OARD OF DIRECTORS 31 AUGUST 2017 CQC Ispectio of Rampto Hospital 1. Itroductio Followig the ispectio of Rampto Hospital o the 6 to 10 March 2017 the ispectio report was published o the 16 th of Jue 2017. The overall ratig for the Hospital is requires improvemet. The Trust has had a actio pla i place sice it received the verbal feedback o completio of the ispectio. The paper details the short term actios to achieve compliace with the fudametal stadards i the areas where improvemet is required. There are additioal strategic ad loger term developmets (which are ot the subject of this paper) related to medical egagemet ad developig people that will uderpi sustaied chage ad improvemet. The short term aim of the pla is to resolve the 6 requiremet otices by the ed of August 2017. 2. Actio required Withi the report there are 6 requiremet otices where the Trust is i breach of a regulatio or has poor ability to maitai compliace with regulatios, but people usig the service are ot at immediate risk of harm. These are detailed i the table below alog with their curret status. Actio Staff were ot calculatig the Natioal Early Warig Scores ad recordig them correctly. The trust audit did ot address this issue. The emergecy major icidet trolley had ot bee checked. The trust did ot have effective systems i place to esure the staff were egaged ad were able to give feedback without fear of victimisatio. This was because staff did ot feel adequately egaged ad reported feelig demoralised ad so further improvemets i commuicatio were eeded. Curret Status G G Actio Staff were ot adherig to the ifectio prevetio cotrol ad dress code policy as we observed staff wearig, rigs, ail varish ad full sleeves. Fire doors were left ope overight o the wome s wards to facilitate observatios. The Trust was ot esurig that there were sufficiet umbers of suitably qualified, competet, skilled ad experieced staff to meet the eeds of patiets. There was regular loe workig at ight. Curret Status Y Status Key G Y A R Evidece of positive impact of improvemet foud. It is embedded ito practice ad has bee siged off by the appropriate forum. Actios required to achieve outcome cosidered complete. Ogoig moitorig arragemets are i place. ig to time, evidece of progress. Delayed, with evidece of improvemet ad agreed actios to get back o track. Cause for cocer. No progress towards improvemet completio. Needs evidece of actio beig take to improve. Page 1 of 16
Chages i status sice the last report to the oard are; progressig from yellow to gree o staff egagemet. There is evidece of actio i the Freedom to Speak up report, the implemetatio of staff focus groups ad the broader pla for cultural developmet at the hospital. Data about staff experiece will be gathered as part of the focus groups beig held i August. The requiremet otice related to bare below the elbows was subject to review by NHSI ifectio cotrol specialist durig August which saw the risk ratig reduced ad o issues i relatio to bare below the elbows, ad a geeral improvemet was oted i ifectio cotrol stadards. There have bee o istaces of loe workig sice the 8 th of July 2017. This will be siged of as complete after 100 clear days (i.e. this beig a rare evet). The report icludes a further 5 must do actios ad 15 should do good practice recommedatios. All requiremets ad actios beig take are provided i the actio pla i Appedix 1. The Trust met with the CQC o the 18 th of July 2017 to agree the provisio of evidece to substatiate that improvemets have bee made this icludes the followig ad a idicatio of the status of each. A audit of NEWs recordig ad actios take due to for re-audit by the 8 th of September 2017. Ifectio cotrol audit report available. Registers of icidet trolley checks - available, Fire doors audit reports - available, Feedback from staff via focus groups or survey due mid September, Freedom to speak up report - available, Loe workig rates - available, Activity provisio ad cacellatio rates - available, Evidece of lessos leart - available, Revised mail moitorig policy - available, Our ow review of the ifluece of staffig o restrictive practice ot completed, Restrictive practice audit - awaited, Ad a revised Seclusio ad Segregatio policy out for cosultatio. The Trust will meet with the CQC o the 26 th of September 2017 to review the evidece. 3. Iteral Goverace & Exteral Assurace Compliace issues cotiue to have icreased emphasis ad oversight withi existig goverace arragemets. The Executive is resposible for deliverig agaist the actio pla ad this reports weekly to the Executive ership Team. There is a specific weekly report o the icidece of loe workig. There is bimothly scrutiy at the Quality Committee of aspects of evidece ad sustaiability. There is mothly reportig ad oversight by the Trust oard util the requiremet otices are closed. Page 2 of 16
4. Summary & Recommedatios The Trust oard remais committed to makig the improvemets required ad providig high quality care for the patiets at Rampto Hospital. This will ot be delivered by this actio pla aloe but by loger term sustaiable chage that addresses the cocers of staff ad broader stakeholders. The service cotiues to care for the most complex idividuals i a recovery focused way. The Hospital has i the last moth welcomed the ifectio cotrol re-ispectio by NHSI demostratig improvemet. The Trust oard is cosistet i its support of the delivery of this pla ad the broader leadership ad orgaisatioal developmet approach beig take. The Trust oard is asked to: discuss this report ad pla, cosider ay risks to meetig the requiremets, critically determie the level of assurace received o the actios beig take, ad seek further assurace o specific aspects if it is warrated. Dr Julie Attfield Executive Nursig Page 3 of 16
Pla v8 21.8.17 Title: Executive Director : Peter Wright Seior Maager Co-ordiator: Louise ussell Rampto CQC Ispectio Improvemet Pla Sub-Committee & Group Resposible for Delivery: Rampto Hospital Maagemet Committee Scrutiy at the Executive ership Team Oversight at the Trust Quality Committee ad Trust oard Pla First Approved: 15.6.17 siged off as complete (lue Ratig): evidece of assurace that improvemets are cosidered to be embedded i practice (Gree Ratig): ackgroud: The purpose of this pla is to outlie the improvemets that the Trust is makig to achieve compliace with the Fudametal Stadards at Rampto Hospital. The pla icludes resposes to the requiremet otices (MUST DO) ad the recommedatios (SHOULD DO) i the CQC report issued o the 15 th of Jue 2017 followig the ispectio of Rampto Hospital from 6 10 March 2017. The Trust is also committed to a broader, loger term piece of work etitled Our People ad Culture Strategy. This was developed i collaboratio with a rage of stakeholders ad outlies the trust s overall ambitio for Nottighamshire Healthcare NHS Foudatio Trust to be regarded as a Great Place to Work. It is ot the itetio that the improvemet goals liked to our People ad Culture strategy will be achieved withi the timescales set i this improvemet pla. We are however immediately workig to improve the egagemet of Rampto Hospital staff with our visio ad values. The improvemet pla will be moitored ad through our revised Goverace arragemets with progress reported weekly to the Executive ership Team, mothly to the oard of Directors meetigs ad bi-mothly to the Quality Committee. Requiremet Notices (MUST Dos) from the Ispectio Report The CQC made the followig six Requiremet Notices i the Ispectio Report received o 15 th of Jue 2017: 1. Staff were ot calculatig the Natioal Early Warig Scores ad recordig them correctly. The trust audit did ot address this issue. 2. Staff were ot adherig to the ifectio prevetio cotrol ad dress code policy as we observed staff wearig, rigs, ail varish ad full sleeves. 3. The emergecy major icidet trolley had ot bee checked. 4. Fire doors were left ope overight o the wome s wards to facilitate observatios. 5. The trust did ot have effective systems i place to esure the staff were egaged ad were able to give feedback without fear of victimisatio. This was because staff did ot feel adequately egaged ad reported feelig demoralised ad so further improvemets i commuicatio were eeded. The Trust was ot esurig that there were sufficiet umbers of suitably qualified, competet, skilled ad experieced staff to meet the eeds of patiets. There was regular loe workig at ight. MUST Dos i the ispectio report that are ot traslated ito Requiremet Notices There are a additioal five MUST do actios that the CQC made i the Ispectio Report received o 15 th of Jue 2017: The provider must esure that sufficiet staff are deployed across the hospital The provider must esure that all staff are aware of lessos leart from durig the day so that activities are ot cacelled due to staffig eeds. icidets ad complaits. 6. The provider must esure adherece to the code of practice regardig seclusio ad log term segregatio practices. 7. The provider must esure adherece to the code of practice regardig Sectio 134 mail moitorig. The provider must review whether the staffig situatio is cotributig to staff usig more restrictive itervetios tha would otherwise be required. Page 4 of 16
Recommedatios (SHOULD Dos) from the Draft Ispectio Report The CQC made 15 Recommedatios i the Ispectio Report received o the 15 th of Jue 2017 as follows: 8. The provider should esure that staff egagemet is icreased (ote related MUST do actio). 9. The provider should esure that therapists are able to atted multidiscipliary team meetigs o a regular basis. 11. The provider should esure that doctors have time to see their patiets outside of multi-discipliary meetigs. 14. The provider should esure that weekly reviews take place of patiets i log-term segregatio ad these are recorded clearly (ote related MUST do actio). 15. 17. The provider should esure there is regular access to fresh air for those patiets i log-term segregatio. 18. 20. The provider should review the process for orderig stock medicatio to esure medicatio charts are ot off the ward for legthy periods of time. 21. 23. The provider should esure there is a more cosistet approach to record keepig across the hospital. 24. 26. The provider should esure all care plas are recovery focused ad reflect the patiets voice. 27. 29. The provider should esure that all staff receive regular supervisio. 30. 10. 12. The provider should esure there is multidiscipliary discussio aroud mail ad phoe moitorig ad the records o the ward are accurate ad reflect the Metal Health Act Code of Practice (ote related MUST do actio). 13. 16. The provider should esure that capacity to coset is assessed ad recorded cosistetly i the patiets otes across the hospital. 19. The provider should esure the meu choices are reviewed o a regular basis. 22. The provider should esure food ad drik is ot passed through observatio hatches above toilets. 25. The provider should esure all the clocks show the same ad correct time. 28. The provider should esure staff receive breaks from cotiuous observatios. The actios defied are iteded to meet legal requiremets, address good practice recommedatios ad achieve sustaied improvemets Key 31. G Y A R Evidece of positive impact of improvemet foud. It is embedded ito practice ad has bee siged off by the appropriate forum. Actios required to achieve outcome cosidered complete. Ogoig moitorig arragemets are i place ig to time, evidece of progress. Delayed, with evidece of improvemet ad agreed actios to get back o track. Cause for cocer. No progress towards improvemet completio. Needs evidece of actio beig take to improve. Page 5 of 16
Idetified (what do we eed to Improvemets to Address Gap ad Achieve Plaed Start Plaed Ed Ratig / Resources / Evidece Ogoig Moitorig ad Evidece Evidece Cosidered Improvemets relatig to Requiremet Notices 1. Staff were ot calculatig all Natioal Early Warig Scores ad recordig them correctly. The trust audit did ot address this issue. Emerald Ward staff were ot calculatig all Natioal Early Warig System (NEWS) Scores. 2. Staff were ot adherig to the ifectio prevetio ad dress code policy as we observed staff wearig rigs, ail varish ad full sleeves. Esure early idetificatio of the physical deterioratio of patiet s health. Review ad trai Assoc. Director staff to esure they of Nursig are competet to measure ad moitor observatios ad calculate scores withi early warig (EW) tools ad uderstad the importace of doig so. Esure moitorig, escalatio ad hadover mechaisms are i place oward. Compliace with the Commuicatio with updated Health & frot lie staff o Social Care Act expectatios of (2008): Code of dress code ad risks Practice o the of log, polished prevetio ad ails ad jewellery. cotrol of Ifectios A full review of the ad related guidace Hospitals (2015). compliace with the DoH are elow the Elbows (2003) iitiative. A full review of dress codes, IPC capacity ad compliace moitorig. Nursig 14/3/17 5/7/17 G All areas across the July August hospital have had NEWS NEWS Rio scores reviewed. A Audit NEWS traier has bee allocated to all services August report ad staff have bee i draft. traied. A further audit has led to targeted work. about esurig oward escalatio. Page 6 of 16 Audit fidigs show sigificat improvemet i completio. September followup audit to review actios take from scores. 13/3/17 31/8/17 Egagemet with Staff Side has commeced to support the required chages. Revised dress code to be drafted. Ifectio Prevetio ad Cotrol Audits completed i July. NHSI Regioal exteral review completed ad actios beig take forward. i the lig campaig to commece 1 st July 201 7 Campaig posters distributed. Draft Dress Code are below the elbow campaig iformatio. NHSI review report 15 th August 2017 demostratig improvemet o bare below the elbows cocers are below the elbows poster. Draft Dress code. NHSI follow up report.
Idetified (what do we eed to Improvemets to Address Gap ad Achieve Plaed Start Plaed Ed Ratig / Resources / Evidece Ogoig Moitorig ad Evidece Evidece Cosidered 3. The emergecy major icidet trolley had ot bee checked. Compliace with Weekly check ad major icidet policy maiteace of the regardig checkig Trolley ad its ad stockig cotets. equipmet. Matro Physical Healthcare 01/5/17 30/5/2017 1/6/2017 Weekly checks evideced by register. Weekly receipt 15.6.17 of register to Registers logged i evidece Nursig base. Fire doors were left ope o the womes wards to facilitate observatios. The trust did ot have effective systems i place to esure the staff were egaged ad were able to give feedback without fear of victimisatio. This was because staff did ot feel adequately egaged ad reported feelig demoralised ad so further improvemets i commuicatio were eeded. Ay fire resistig doors ot fitted with approved automatic release devices will ot be wedged or held ope, Establish a Trust wide culture based o itegrity ad trust All staff to be familiar with all of the routes ope to them to raise cocers. Improve medical egagemet. Immediate actio with fire safety advisors, seior staff ad site maagers to remid ad istruct all staff that fire safety advisors doors, which are ot fitted with approved automatic release devices must remai closed. Fire Safety Advisors, ad Site Maagers to address this. Staff focus groups have commeced to facilitate dialogue. Cotiue to promote ad share iformatio o the Trusts People ad Culture Strategy (2017 20122) Idetify barriers to staff egagemets ad improve uderstadig as to why staff feel demoralised. Implemet a medical egagemet strategy. Nursig Deputy Director: Servic es 28/4/17 31/5/17 12/6/17 CCTV audit for 1 moth May/Jue of the 4 doors betwee hours of 10.30 pm ad 6 am foud that o doors were ope. 10/317 31/717 for shorter term work improvig egageme t liked to loger term strategy to support cultural chage. G 2 audits coducted i July other doors sampled ad issues foud rectified ad reaudited. Itroduced dedicated Staff Voice pages which provide iformatio o sharig cocers. Freedom to speak up guardia ow has a weekly presece. Posters provided i each cliical area. The Discovery, Desig ad Delivery phases of the Trusts People ad Culture Strategy have bee iitiated ad will be used to explore staff morale at Rampto Hospital. July staff egagemet evets booked. Mothly audit to cotiue for the ext quarter reportig directly to the Nursig. Desig ad discovery role out pla. Egagemet ad orgaisatioal developmet metrics ic egagemet measures to be collected via focus groups & survey. Freedom to speak up reports. May/Jue Audit i evidece file/ Freedom to Speak Up Guardia Report. Part 2 Cultural Developmet Pla paper for the Trust oard Page 7 of 16
Idetified (what do we eed to Improvemets to Address Gap ad Achieve Plaed Start Plaed Ed Ratig / Resources / Evidece Ogoig Moitorig ad Evidece Evidece Cosidered 4. Sufficiet staff eed to be deployed across the hospital at ight to avoid loe workig. Effective oversight ad use of available staffig ad resources ad escalatio of actual ad potetial breaches of Regulatio 18 - Staffig Redeploymet resultig i loe workig is a rare exceptio. Stregthe the goverace ad oversight of all aspects of safe staffig ad roster maagemet Effectively maage staff absece. Reduce the ecessity for out of grouds escorts by icreasig availability of physical healthcare iterally. Executive 10/3/17 30/7/17 Y July/August Focus groups booked. 12 additioal ight staff deployed 1 st of April 2017. 30.05.2017. Extra staffig ight pool commeces o 17 th of Jue. Executive Team review 23 rd Jue 2017. Traiig to reduce reliace o DGHs. More strategically we are part of the Carter Pilot ad are startig the 90 day collaborative to improve our rosterig/use of resources ad our staff are beig traied o the 28 th Jue to use the Hurst model to evaluate their establishmets. Modellig commissioed ad staffig icreased. Istaces of loe workig March 39 April 74 May-13 Jue - 19 July 6 Aug oe to date Sickess rates March 5.59% April 5.82% May 5.9% Jue - 6.3% July 7.1% Registered Nurse Vacacy Rates March 9.9% April 3.8% May 5.2% Jue - 4.9% July 8.9% Emergecy Out of Grouds Escort (Hrs) March - 329 April - 1234 May 156 Jue - 195 July - 532 Page 8 of 16
Idetified (what do we eed to Improvemets to Address Gap ad Achieve Plaed Start Plaed Ed Ratig / Resources / Evidece Ogoig Moitorig ad Evidece Evidece Cosidered Improvemets relatig to MUST DOs that are ot traslated to eforcemet otices 5. Sufficiet staff eed to be deployed across the hospital durig the day so that activities are ot cacelled due to staffig eeds. The provider must esure that all staff are aware of lessos leared from icidets ad complaits. Activities ad plaed out of groud escorts are ot cacelled due to routie staffig issues ad oly for uforeseeable cliical activity or emergecy situatios Daily hospital wide coordiatio of all activities i collaboratio with the site maager to esure best use of resources All staff to use Review efficacy of learig from patiet systems employed feedback, to dissemiate complaits, learig from cocers ad icidets ad icidets as a complaits to frot opportuity to lie staff. Cosult improve patiet with staff to obtai experiece. feedback o the Followig curret system of complaits ad dissemiatig icidet policies learig from focus o learig icidets ad ad service complaits to all improvemet ad staff to determie the Trust`s whether staff are Deputy Director Head of Goverace ad Risk 10/3/17 12/6/17 30.5.17 Daily plaig commeced with liaiso with the Site Maager to esure best use of resources ad to miimise ay cacellatios. Daily o call maager oversight at follow up daily meetig with site maager. Weekly forward plaig meetigs icludig cross site represetatio. Clear structure for esurig activities are effectively achieved. Publicatio of cacellatio rates for patiets ad staff. 01/5/17 31/7/17 Page 9 of 16 G We have eabled reporter requested feedback o the icidet form. All staff (at every level) reportig a icidet ow have the optio of requestig that their maager provides feedback this becomes madatory for the maager. This has bee commuicated to all users. Wider comms strategy implemeted. Activity cacellatio rates due to staffig April 2.1% May 2.1% Jue 1.7% July- 2.9% Mothly activity reports from RHMC. Learig the Learig the lessos lessos bulletis sice bulletis sice ispectio. ispectio. Lessos Lessos leart booklet. leart booklet. Ward by ward feedback report o lessos leart egagemet durig Jue/July - awaited Complaits reports to RHMC.
Idetified (what do we eed to Improvemets to Address Gap ad Achieve Plaed Start Plaed Ed Ratig / Resources / Evidece Ogoig Moitorig ad Evidece Evidece Cosidered The Hospital must esure adherece to the Code of Practice regardig seclusio ad logterm segregatio practices. The provider must esure adherece to the code of practice regardig Sectio 134 mail moitorig. POSITIVE values ad culture. Feedback cofirms staff at all levels receive iformatio about learig from adverse evets. A commitmet to the reductio of restrictive practice ad to the applicatio of the least restrictive priciple i all aspects of service delivery. Implemetatio of good practice guidace developed i partership with other High Secure hospitals (February 2017 The hospital maagers have powers uder Sectio 134 to restrict outgoig mail i certai circumstaces ad icomig mail i high secure hospitals oly. receivig feedback from adverse evets ad if ot what their preferred method would be. Esure staff have access to learig from a rage sources ad a rage of formats which meets their eeds. There eeds to be a review of the policy ad practice for Idepedet Reviews. The policy implemetatio eeds to be audited oward. aselie audits of the use of powers uder Sectio 134. Cliicias remided to keep decisios to withhold mail ad moitor phoe calls uder review with the multi- Medical Director ad Nursig 3/5/17 25/7/17 18/8/17 Y 3/5/17 20/7/17 31/8/17 Page 10 of 16 Seclusio ad Segregatio Policy review completed by the 5 th of July, ad the for audit i October 2017. This specifically relates to the coduct of reviews. Audit of baselie i Jue 2017. Discussed at MSC ad legal advice ad bechmarkig doe. Revised policy out for cosultatio Audit completed ad revised mail maagemet procedure to be issued by the ed of July August 2017. FOR8 to be ameded. Stadard letter to be revised. RCs ivolved i FOR8 revisio. Complaits reports to RHMC. Iteral Audit Report. Revised policy ad implemetatio pla. Segregatio ad seclusio rate moitorig ad HSH bechmarkig. Report requested - awaited Policy FOR8 Revised template letter Policy FOR8 Revised template letter
Idetified (what do we eed to Improvemets to Address Gap ad Achieve Plaed Start Plaed Ed Ratig / Resources / Evidece Ogoig Moitorig ad Evidece Evidece Cosidered The provider must review whether the staffig situatio is cotributig to staff usig more restrictive itervetios tha would otherwise be required. Staffig does ot impact o patiets rights to always receive care which is delivered i accordace to the least restrictive priciple. discipliary team. Guidace to be issued to cliicias regardig the reportig covetio i patiets records. Udertake a aalysis of the possible impact staffig issues have o restrictive practice. All staff ivolved i reviews prompt to review whether all restrictios are cliically warrated. The idepedet review coducted ito segregatio i March 2017 is positive evidece that this does happe. Deputy Director of 01/5/17 31/7/17 Y The idepedet review of mechaical restrait will draw upo this i its fidigs. ADoN & AMD weekly scrutiy of segregatio cases. Report from the March 2017. Idepedet review of segregatio. Report form the idepedet review of Mechaical Restrait. March 2017. Idepedet review of segregatio. SHOULD DO recommedatios from the Ispectio Report 6. The provider should esure that staff egagemet is icreased. The hospital should esure that doctors have time to see their patiets outside of multi-discipliary meetigs. Refer to the previous actio related to staff experiece. Drs to be give sufficiet time to see patiets outside the MDT review meetig. Hospital to udertake a review of medical time commitmets through case review (curretly operatig a caseload of 25 Executive 8/5/17 30/9/17 Page 11 of 16 Y Fact fidig review beig udertake with key staff to uderstad ad agree actios. For the workload review project reviewig Agreemet o capacity, cliical priorities ad ay gaps i resource.
Idetified (what do we eed to Improvemets to Address Gap ad Achieve Plaed Start Plaed Ed Ratig / Resources / Evidece Ogoig Moitorig ad Evidece Evidece Cosidered patiets) ad time allocatio i order to determie capacity ad demad caseloads ad weightig. Actios to be iformed by the fidigs of the wome s service review. The provider should Practice is code esure that weekly compliat. reviews take place for patiets i log term segregatio ad these are clearly recorded. The geeral maager reviews this weekly ad reports to the Moday Operatioal meetig ad directly to the Deputy completio or exceptios. The hospital should All patiets i Log Fresh air access esure there is regular term segregatio are plaig for LTS access to fresh air for able to access fresh patiets to be those patiets i logterm segregatio. air daily icorporated i daily hospital-wide activity plaig meetig to esure access is prioritised. 7. The provider should review the process for orderig stock medicatio to esure medicatio charts are ot off the ward for legthy periods of time. There are safe systems ad processes to support the effective maagemet of medicies. Medicie cards must be available to esure medicies are admiistered accurately, i accordace with ay prescriber istructios ad at suitable times to make sure that people who use the service are ot placed Deputy Moder Matros for MHNLD, Peaks ad WS/PD Directorates Assoc Dir of Nursig 25/6/17 Cotiuou s G CC is udertakig a exercise to clarify what the timetable of each doctor looks like base o their job plas. Jue audit to be completed ad report beig compiled. Weekly reportig i place. 3/5/17 10/7/17 Y Fresh air data reportig beig put i place from ed of July. 10/3/17 31/5/17 14/6/17 Practice reviewed immediately. Verificatio for 1 moth audit completed by Pharmacy with evidece that il cards were held i pharmacy at dispesig times. Audit report ad actio pla. Weekly report examples throughput July. Report awaited Report awaited. Audit of compliace over see by the Chief Pharmacist. Audit report i evidece base. Page 12 of 16
Idetified (what do we eed to Improvemets to Address Gap ad Achieve Plaed Start Plaed Ed Ratig / Resources / Evidece Ogoig Moitorig ad Evidece Evidece Cosidered at risk. 8. The provider should esure there is a more cosistet approach to record keepig across the hospital. The Hospital should esure all care plas are recovery focused ad reflect the patiets voice. A cosistet approach to the maagemet of patiet records across the wards i the Hospital. All care plas are idividualised, coproduced ad set out clearly the patiet s ow stated goals i his / her ow words The Trust strategy is Deputy to reduce reliace o paper records ad icrease the use of electroic systems across sites. Creatio of a summary guidace documet specifyig what records should be stored ad where Commuicatio strategy emphasisig this requiremet All care plas to be reviewed with patiets ad ameded to esure these priciples are adopted. Audit tool to be developed ad deployed for use. Nursig 01/5/17 31/7/17 8/5/17 12/6/17 9/8/17 G Y Dissemiate guidace o records maagemet. Provide followig up advice, guidace ad istructio. Audit use of systems to show improvemets. Navigatio sheet for cliical records at Rampto (icludig paper ad electroic). 30.05.2017 The ew Recovery strategy has bee lauched. Support through traiig ad guidace o the implemetatio of recovery focussed care plas is beig developed ad will be used over Jue 2017. Audit report completed. Results to be preseted to both Seior Nurses Forum ad Cliical Audit Committee. Actio pla to be developed to address the recommedatios made. Record keepig guidace. Records Maagemet Group Reports. Care Pla Recovery recovery Report. Report Jue 2017. Report is i draft with lessos leart. Awaited Recovery College summary report as evidece of recovery based work. Page 13 of 16
Idetified (what do we eed to Improvemets to Address Gap ad Achieve Plaed Start Plaed Ed Ratig / Resources / Evidece Ogoig Moitorig ad Evidece Evidece Cosidered 9. The Hospital Therapists are able should esure that to atted multidiscipliary team therapists are able to atted multidiscipliary team meetigs o a regular basis. meetigs o a regular basis. Review of therapists time commitmets through case review ad time allocatio. Executive 8/5/17 15/7/17 Fact fidig review of therapist activity icludig case load size ad provisio of structured group work. Audit has foud that attedace stadards have geerally bee met. Review of capacity, cliical priorities ad ay gaps i resource. Attedace audit The provider should esure there is multidiscipliary discussio aroud mail ad phoe moitorig ad the records o the ward are accurate ad reflect the Metal Health Act Code of Practice. 10. The provider should esure that capacity to coset is assessed ad recorded cosistetly i the patiets otes across the hospital. Refer to previous actios o mail moitorig Meet the requiremets of the Metal Capacity Act ad Metal Health Act Codes of Practice. Patiet coset to medical treatmet should always be sought ad full assessmets of discussios ad judgemets about capacity must be recorded. Assoc. Medical Director/ 27/4/17 30/6/17 Y 30.05.2017 Review medical staff practice. Implemet system to track compliace ad respod accordigly. Report to the Metal Health Act Operatios Group ad Committee Report to be discussed at July MSC, ad idividual issues to be addressed. Jue audit of capacity recordig. MSC Miutes Actios from Dr Wood s report to be take forward especially regardig use of S62 for Page 14 of 16
Idetified (what do we eed to Improvemets to Address Gap ad Achieve Plaed Start Plaed Ed Ratig / Resources / Evidece Ogoig Moitorig ad Evidece Evidece Cosidered emergecy treatmet. This will iclude educatioal evet ad revisio of the paperwork (the latter eeds to be cosidered Trust wide). Evidece awaited The hospital should esure the meu choices are reviewed o a regular basis. The Trust should esure food ad drik is ot passed through observatio hatches above toilets i Metal Health wards The hospital should esure all the clocks show the same ad correct time. A icrease i the rage of meals available ad the frequecy of meu chages to esure variety The practice of passig food through hatches above toilets will cease All Clocks show accurate time Meus are reviewed quarterly. Caterig maager to egage further Patiets Coucil i meu plaig takig these priciples ito accout Commuicatio to all staff advisig that this practice must cease. Egage with staff o alterative methods of servig driks ad meals. Deputy Nursig Checks to be Deputy itroduced to esure clocks show accurate times. Cosider: Iitiatio of a maual checkig process. 30/4/17 31/6/17 30/4/17 31/6/17 19/5.17 8/5/17 31/7/17 G Revised meu i beig itroduced o 12 Jue 2017. Oward meu quarterly review pla shared with the ext patiets coucil. 30.05.2017 Keys to the hatches are ow held cetrally o the Metal Health wards. Doors are opeed to serve meals ad refreshmets to patiets, withi a risk maagemet framework. 100 radio cotrolled clocks i place ad 100 further o order. Radio cotrol clock performace is ot guarateed ad daily checks are required. Revised Meu Ad quarterly report to the RHMC. 19 th May 2017 Executive ursig review of all metal health wards Spot checks hospital wide 14 th of August 2017. Revised meu Eyesight review otes Page 15 of 16
Idetified (what do we eed to Improvemets to Address Gap ad Achieve Plaed Start Plaed Ed Ratig / Resources / Evidece Ogoig Moitorig ad Evidece Evidece Cosidered The hospital should esure staff receive breaks from cotiuous observatios. The Hospital must esure that all staff receives regular cliical supervisio. Ay period of observatio should ot be for more tha oe hour uless deemed appropriate ad therapeutic. Allocatio of staff to udertake these observatios should be recorded o Observatio ad Egagemet Procedure FO/R/29 issue 9 Jauary 2017 Each idividual will receive a miimum of oe hour group or idividual cliical supervisio every four to six weeks. Geeral Maagers to establish a daily iteral review process which is resposive to the fluctuatios i patiet depedecy. The allocatio of staffig per duty should take ito accout the eed for staff to be relieved from cosecutive periods of observatio i excess of oe hour. Directorates to esure staff are able to access cliical supervisio a miimum of every 6 weeks ad for the Directorate to meet the target uptake of 80%. Nursig Director Nursig 8/5/17 30/6/17 30.7.17 Y 8/5/17 31/5/17 Patiet/staff observatio review uderway. Awaited 30.05.2017 Cliical Supervisio Policy Issue 5 March 2017 Evidece collated for the year 2016/2017 shows compliace i excess of 80% i respect of cliical supervisio each moth. Cliical Supervisio Rates (%) April -84.8 May -82.5 Jue 82.3 July 81.8 Divisio mothly performace reports. Nursig commissioig qualitative evaluatio. Page 16 of 16