RBCH Actions to meet CQC Essential Standards REGULATION 17 How the regulation was not being met Patients, their relatives, and staff told us about incidents where people had not been treated with dignity and respect. Patient s requests for assistance to use the toilet had not been met in a timely manner causing them to be incontinent. People told us that they had seen a patient exposed with no consideration for their dignity. Action to meet regulation What the action intends to achieve Who is responsible? Action Lead 1.1 Trust wide daily review and authorisation of ward staffing levels by ward sisters, daily review of compliance to templates by Senior Nurse by shift. Weekly retrospective compliance report to Chief Operating Officer and and prospective plan for following week 1.2 Implement recruitment plan to establish a substantive workforce across all in patient wards and create capacity to manage short term sickness and expected levels of staff turnover including: Targeted Journals Overseas recruitment plan. Local recruitment fare Formal assurance and risk mitigation process for all inpatient wards to ensure appropriate staffing levels Management of staff turnover and short term sickness via over recruitment and effective and timely recruitment processes Ward Sisters & Senior Nurses Trust overview by How to ensure improvements have been made & sustained? What measures to check this? Daily review of templates and allocations, including sign off by ward sisters and senior nurses and escalation to as required Weekly review by Executive Team Weekly review and assurance of escalation process used to ensure compliance or mitigation Review of milestones for recruitment process. Vacancy template report weekly and fill rates Who is responsible? Monitoring lead Chief Operating Officer and Board of to review monthly report on compliance and forecasts HR Director Resources needed to implement the changes On-going recruitment plus bank and agency staffing to fill shifts. Action plans restricted by the current national availability of experience trained nurses. Overseas recruitment included in Trust recruitment plan (see below) Successful recruitment campaign Date actions will be completed 28/2/14 Interviews 30/1/14 Advertise 30/01/14 30/03/14 1.3 As a priority ensure Wards 3 and 26 are fully staffed to template New established ward leadership Staffing and skill mix to recommended templates for all shifts To ensure strong leadership and develop new team culture to Ward sisters / Senior Nurse Care of the Elderly 1 Daily review of compliance with templates Senior Nurses Care of the Elderly Review of use of bank and agency to maximise staffing opportunities 4/12/13 (Ward 26 sister) 6/1/14 (Ward
on Ward 26 and Ward 3 support high standards of patient care and safety 3 sister) 1.4 Additional senior nurse cover for hospital site at weekends and bank holidays 1.5 Recruitment of Senior Nurse Elderly Care Directorate Increased and enhanced nursing leadership to support improved and consistent nursing standards at ward level out of hours Specialist nurse leadership for Elderly Care General Manager Elderly Care Weekly review of senior nurse cover. Audit of activity, stakeholder views and quality improvement as a result of senior cover Monthly review of standards via CARE and Safety Thermometer audits Budget to support extra cover Availability and recruitment of high calibre candidate 4 th Dec 2013 Appoint by 1.6 Senior nurses in elderly care directorate to implement a weekend rota to support consistent approach and scrutiny of high standards of care across all wards 1.7 Engage expertise and support from external consultant nurse practitioner in elderly care and dementia and dignity, for leadership training 1.8 Public display of staffing template and shift staffing levels on all wards 1.9 Implementation of new Privacy and Dignity Policy and education programme to support embedding. Focus on key standards to include: response to call bells, provision of suitable gowns, communication, noise at night, use of curtains and privacy of conversations 1.10 Monthly Patient Association CARE audit of 20 patients per ward across all Elderly Care and Medical wards Senior nursing leadership provided 7 days per week to provide on-site support and leadership Increased and enhanced specialist nursing leadership and training needs assessment to support improved and consistent nursing standards Increased public confidence with regard to staffing levels Cascade of corporate and directorate actions at ward level. Greater staff awareness of Trust action plans for Privacy and Dignity. Consistency of approach and compliance across the Trust Reducing variation in practice and spreading good practice via: audit of wound care, call bell response, communication and nutrition General Manager Elderly Care Senior Nurse Elderly Care Ward sisters/senior Nurses Ward sisters Trust overview by Ward Sisters/Senior nurses Medicine and Care of Elderly Monthly review of standards via CARE and Safety Thermometer audits Weekly review of effectiveness of external support Daily review of compliance and weekly report to Executive Team Repeat Privacy and Dignity Observational Audit across all wards. Tool to be refined to assess impact of previous actions implemented. Audit to include assessment of staff awareness of actions implemented Results and actions to be reviewed monthly at ward sister and Senior Nurse meetings, and Executive Team of nursing monthly report to execs and Board of to provide monthly report to Executive Team Availability and recruitment of high calibre candidate Appointment of external consultant with specialist knowledge and experience Implementation of new Display Boards Staff time to understand and implement. Education and communication with staff Re-audit following policy implementation via CARE Audit. Patient Association contract. Availability of Volunteers to undertake interviews and data collection Rota to start Starts 6/1/14 for 3 months initially 31/1/2014 Implement policy by Complete re audit by Start by 2
1.11 New patient gowns to be used across the Trust with improved design 1.12 Implementation of standard checklist for daily ward safety briefing and handover by ward sisters at start of each shift with all available staff. To include discussion on staffing levels, risk issues, patient safety issues, staff questions and concerns for shift 1.13 Remove escalation beds in ED Remove escalation beds in AMU 1.14 Implementation of a Code of Conduct for Healthcare Assistants supported by training and appraisal processes To improve patient dignity and protect patients privacy To improve clarity and consistency of safety briefing and handover information to support patient care and patient safety. To ensure ward teams receive consistent daily information of ward safety and staffing. To ensure wards consistently communicate key actions to all staff and staff are engaged and aware of safety issues and responsibilities To improve privacy, dignity and safety for emergency patients To implement consistent standards, responsibilities and accountabilities for healthcare assistants across all wards. To support further development of Healthcare Assistants roles Trust overview by Ward sisters / General Manager Medicine Trust overview by Training Manager and Senior nurses meeting Repeat Privacy and Dignity Audit across all wards. Tool to be refined to assess impact of previous actions implemented. Audit to include assessment of staff awareness of actions implemented Audit of safety briefing implementation Daily bed state report Ward and directorate compliance report confirming all Healthcare assistants have received and signed a copy of the Code of Conduct and Board of Senior Nurses. to provide report to Executive Team and Board of Chief Operating Officer Procurement and laundry contract to ensure gowns fully available Design of checklist and support for roll out Appropriate bed base and emergency care measures No additional resources beyond time for training 1/3/14 1/3/14 ED 1/12/13 AMU 14/1/14 28/2/14 3
REGULATION 9 How the regulation was not being met Patients and their relative reported that they were restricted from eating and drinking by mistake. Planned care was not being delivered in respect to wound care. People reported that their relative was not supported to eat and drink on the ward Action to meet regulation 2.1 Generate 50% supervisory time for ward sisters releasing time to ensure all inpatients in their area have their needs assessed, then met in a safe and timely way 2.2 Monthly Patient Association CARE audit of 20 patients per ward across all Elderly Care and Medical wards 2.3 Implementation of a Wound Care Plan Documentation Audit across all wards What the action intends to achieve Enhanced leadership time to monitor and ensure high and consistent standards of nursing care are delivered across the ward. To improve risk assessment and audit compliance. To support a learning culture from additional review and feedback of learning from adverse events and complaint Reducing variation in practice and spreading the good practice via: Monthly care audit of wound care, call bell response, communication and nutrition Assess compliance with Wound Formulary and the Standard Operating Procedure (SOP) for stock dressings. Highlight areas for additional Wound Care and Pressure Ulcer Prevention training Who is responsible? Action Lead Ward Sisters/ Lead Tissue Viability Nurse How to ensure improvements have been made & sustained? What measures to check this? Agreed plan with each ward sister Results and actions to be reviewed monthly at ward sister and Senior Nurse meetings, and Executive meetings Monthly audit report Who is responsible? Monitoring lead Senior Nurses to provide monthly report to Executive Team and Board of to provide monthly report to Board of Resources needed to implement the changes 350k fund allowing recruitment and backfill Patient Association contract. Availability of Volunteers to undertake interviews and data collection Additional nursing / HCA time in place Date actions will be completed AMU and Stroke from 1/11/13 Ward 3 and 26 from All wards by Start by To start by 2.4 Develop Standard Operating Procedure to implement, in addition to daily review and care planning, twice weekly pressure ulcer ward rounds by Ward sisters of all inpatient with recorded pressure damage (hospital or externally developed). Ensuring appropriate wound care Assess compliance with SOP for Pressure Ulcer ward rounds and Pressure Ulcer policy Highlight areas for additional Wound Care and Pressure Ulcer Prevention training Ward sister using supervisory time. Lead Tissue Viability Nurse Audit of compliance as part of monthly report to Board to provide monthly report to Board of See supervisory time action Ward rounds to be supported by ward consultant and Tissue Viability Team where high patient acuity, risk factors or clinical need. Initial To start by 4
2.5 Highlight all Nutrition and Hydration Standard Operating Procedures to ward staff Further education around utilisation of the nutrition risk assessment scoring (MUST score) Implement standard signs and operating procedures for nil by mouth on all wards 2.6 Expand use of meal time companions to encourage and support relatives, carers and volunteers to support patient s nutritional intake in elderly care 2.7 Review visiting times to remove any unnecessary restrictions that may deter relatives, carers and volunteers to support meal times To ensure practice is research based and uniform throughout the Trust To improve awareness of methods to calculate a MUST score and ensure appropriate referrals, nutrition plans and provision To have a corporate approach and standard Mealtime companions can give greater support for nutrition Facilitate carers feeding patients if they wish, and greater visiting times to allow this and provide companionship Dietetic Team Nutrition team Senior nurse elderly care MUST score reports Audit of compliance, using patient and carers views: CARE Audit. Monitor implementation and views of patients, carers and volunteers via CARE Audit Monthly CARE audit results reported to Wards Sisters and Senior Nurses meetings Monitoring by Nutrition Steering Group to provide monthly report to Healthcare Assurance Committee and Board of Senior nurse elderly care targeted approach and focus with audit of implementation in Vascular and Elderly Care n/a 28/2/14 28/2/2014 Recruitment of volunteers n/a All actions by 2.8 Implementation of bay based nurse stations to all wards staff to be based in bays to provide increased visible presence 2.9 Extend Speech and Language Therapy (SALT) service Basing staff within a bay to reduce need for call bells use and ensure more proactive and visible nursing care To improve access to documentation and nurses based in bays directly inputting and reviewing risk assessments and care plans. Ensuring patients have sufficient care, nutrition and communication More rapid swallow assessment Ward Sisters / Senior nurses General Manager Specialist Services Monthly Board report on implementation by ward Audit of response times Chief Operating Officer Mobile trolleys to be ordered to support phased roll out. Extra funding for SALT team Ward 3 & 26 by All medical wards by All wards by 30/6/14 6 day service by Phased approach to 6 and then 7 day 7 day service 5
service by 30/6/14 2.10 Implement new Pressure Area Care Together (PACT) strategy for pressure ulcer prevention and management To raise awareness of appropriate standards of care and support consistent approach to implementation Tissue viability lead nurse Monthly audit of implementation, Safety Thermometer data collection, AIRS Training and communication time and compliance Monthly newsletter (PACT sheet). Resource folder (PACT file) Monthly programme of training and resource materials for ward staff to produce monthly report to Healthcare Assurance Committee and Board of 6
REGULATION 10 How the regulation was not being met The overall governance of the trust had not taken account of the experiences of patients and staff to improve the service provision. The Trust had not ensured all reporting systems were robust and findings acted upon in a timely way to improve patient care. Action to meet regulation 3.1 Strengthen governance framework to support a more open, learning culture for clinical governance and quality assurance and quality improvement 3.2 Consistent governance framework across all directorates 3.3 Creation of Care of the Elderly Directorate 3.4 Three new Non-Executive appointments including one with clinical background 3.5 Review of Directorate management and nursing leadership structure and accountabilities 3.6 Develop Quality Dashboard to provide Board with overview of ward level metrics, trends and quality assurance 3.7 Undertake an in-depth focus group for patients, carers and relatives who have previously made a complaint. Repeat 6 monthly What the action intends to achieve Clearly defined roles and responsibilities for quality and patient safety at directorate level Increased focus on learning and quality improvement in relation to serious incidents, audits and NICE guidance, including Weekly Grand Round presentation on SI or RCA Increased accountability and clinical leadership with feedback on actions taken To provide greater focus and transparency for frail elderly care To provide new challenge to the board and organisation To provide better governance and responsiveness to patient and service needs To increase transparency at Board level and ensure early action and mitigation plans discussed and implemented To understand the important issues for complainants and relatives with the aim to improve our responsiveness processes for communication and build positive relationships to support patient care and patient experience Action Lead Monitoring Monitoring lead Resources needed to implement the changes Clinical Associate Medical Director Clinical Director and General Manager Elderly Care HR Director Chief Operating Officer Associate Director Clinical Governance Head of Patient Engagement 7 Clinical Governance Risk Committee (reporting into Healthcare Assurance Committee) Overview by Board of Undertake audit of governance frameworks and implementation in Q1 14/15 Directorate Governance Committee minutes and action plans Council of Governors scrutiny committee will review outcome Staff consultation and reporting to Trust Management Board and Board of Healthcare Assurance Committee, Board of Stakeholder feedback Report to Patient Engagement and Communication Committee (PECC) Chief Executive Agreement of dedicated time for governance lead functions in consultant job plans Date actions will be completed Medical Director n/a Chief Operating Officer Additional senior leader resources 27/10/13 Chairman n/a Chief Executive n/a 30/6/14 No external resources required Stakeholder participation and support 3.8 Implement a new Complaints Policy Policy changes to include Complaints Audit of Additional resource in 28/2/14 9/1/14
and process, considering views from independent external review by former Deputy Parliamentary Health Service Ombudsmen and stakeholder listening event 3.9 Governors Scrutiny Group audit of patient and staff views on all Elderly Care wards 3.10 Undertake six monthly public listening events 3.11 Undertake six monthly listening events, starting with a Developing our Values Workshops and surveys. Development of on-going employee engagement strategy revised process to ensure more timely discussion with complainant, improved communication and earlier resolution To understand the important issues for patients, relatives, carers and the public. To involve stakeholders in development of the Trust Strategy for Elderly Care and quality priorities for 2014/15 To understand the important issues for patients, relatives, carers and the public. To involve stakeholders in development of the Trusts Quality priorities, objectives and action plans for 2014/15 To understand the important issues for our employees and to act on feedback. To involve all our employee groups in development of the Trust s new Values and behaviours To ensure employees understand the Trust s Quality priorities, objectives and action plans for 2014/15 Manager Lead governor Sharon Carr- Brown Head of Communications OD Lead acknowledgement and response times, complainant feedback and implementation of action plans from reviews Monthly report to Board of Council of Governors Board of Patient Engagement and Communication Committee (PECC) Staff Survey results Developing our Values Workshops & survey outputs Workforce Committee Service Development Human Resources Complaints team Governor and volunteers support Public and stakeholder participation via Patient Association and Healthwatch Employees need to be released to get involved Individual business cases to be submitted for launch & embedding Change Leaders to support Interim Apr 14 Re-audit Jul 14 Final report Oct 14 To start by 28/2/14 To start by 3.12 Improving incident reporting levels. Implementation of Datix web to improve incident reporting, tracking, feedback and learning To support and role model the new Trust Values and behaviours and be a part of the employee engagement programme Improve availability and ease of reporting across the Trust Improve feedback mechanisms to provide staff with assurance Associate Director Clinical Governance AIRS reporting profiles, NRLS data set via Healthcare Assurance Committee Datix web installation Later stage integration with current IT systems (e.g. PAS, ESR) To start phased implementati on on 1/4/14 8
Implement additional training and awareness to support open culture for reporting, investigation and learning 3.13 External peer review of mortality with Frimley Park for internal and external alerts that reports have been received and appropriate actions taken, as part of roll out Reformed approach to internal mortality reviews deficiencies in care, avoidable deaths (Nick Black paper) and if death in acute hospital was appropriate Medical Director E-mortality, M&M actions logs and completion, HSMR/SHMI via Trust Mortality Group Medical Director Time for external peer review 3.14 Improve mortality reporting and learning via: Further develop framework for e- mortality at Directorate and specialty Mortality and Morbidity meetings 3.15 Ensure SIs resulting in death are discussed at Grand round, with learning points promoted and shared across all specialties and directorates 3.16 Initiate Carers café in elderly care directorate 3.17 Initiate regular forum for staff governors to meet with Trust Chairman to discuss any issues or concerns 3.18 Establishment of an Improvement Board structure and programme to support quality improvement initiatives, innovation, service redesign Board to include stakeholder engagement (patients, carers, staff) and learning from best practice outside of the organisation 3.19 External review of Trust governance arrangements by Beachcrofts solicitors Reformed approach to internal mortality reviews deficiencies in care, avoidable deaths (Nick Black paper) and if death in acute hospital was appropriate To promote learning and implementation of actions To improve direct feedback from relatives and carers of current inpatients Enable early resolution of any issues and signposting support services available To involve carers in developing services for the future To increase engagement of staff governors Wider improvement and learning systems to be developed Learning from best practice. Recent initiatives include: ECIST and Professor David Oliver reviews of Urgent care and Care of the Elderly To ensure effective structures, reporting lines systems and processes in place to meet requirements of condition FT4 of NHS Foundation Trust Clinical / Directorate Mortality leads Associate Medical Director Head of Patient Engagement Senior Nurse Care of the Elderly Trust Chairman Interim Director of Improvement Trust Secretary E-mortality, M&M actions logs and completion, HSMR/SHMI via Trust Mortality Group Via Trust Mortality Group Stakeholder feedback from event to Patient Engagement and Communication Committee (PECC) Report to Board of Monthly Improvement Board reporting Report to Board of Council of Governors Medical Director Time for external peer review Medical Director n/a Senior Nurse Care of the Elderly Stakeholder time Trust Chairman n/a Chief Executive Stakeholder engagement Endorsed by Clinical Management Board 3/1/14 Inaugural board meeting 19/2/14 Chief Executive To be finalised To start by 9
3.20 Independent review of the implementation of CQC actions, via Sir Ian Carruthers Conditions of the Trust s provider licence Independent assurance and challenge of the Board Chief Executive Report to Board of Trust Chairman Availability of external resource To start by 10