CQC IMPROVEMENT ACTION PLAN Page 1 of 86 CQC Improvement Plan (Published 10/8/15)
Contents FOREWORD FROM THE CHIEF EXECUTIVE... 3 TRFT INSPECTION RATINGS... 4 AREAS FOR IMPROVEMENT... 5 ACTION PLAN MUST do... 16 ACTION PLAN Should do... 54 Page 2 of 86 CQC Improvement Plan (Published 10/8/15)
FOREWORD FROM THE CHIEF EXECUTIVE The Trust Board welcomes the CQC report published in July. This provided rich feedback and valuable insights about the care that we deliver in acute and community settings and how that care was viewed by our patients, their carers and families. In addition the reports contained the views of colleagues working across the organisation regarding the services they deliver, the challenges they face and highlights good practice in their areas. The report reinforced what we know as an organisation about the progress we have made and the challenges we face; and reflects our journey of improvement and culture change. Our journey started in December 2013 when the Trust confirmed its strategic direction to be a stand-alone Trust with collaboration across the wider health and social care economy to achieve improved clinical, financial and operational sustainability. Our strategic objectives set out our focus to move towards a more secure future where we can provide excellence in healthcare, delivered by engaged, accountable colleagues, within sound governance arrangements, based on strong financial foundations and working with partners to deliver sustainable services for the future, together. However, we are not complacent. We recognise that while we have addressed many of the issues raised following our inspection in February and March, we still have much to do. The improvement action plan has been developed based on the need to address the Must Do and Should Do actions highlighted in the Trust s CQC reports. This serves as a document of record to capture the actions that we have taken and sets out clearly our plans for tackling any outstanding issues. It also provides assurance to our board, our colleagues and people in the community of Rotherham, that we are committed to addressing all the issues that the CQC identified. In particular, it sends out a clear message that if we fall short of the high standards we set ourselves we will recognise that honestly, share the lessons we have learned across the organisation and take positive action to improve. We are an open and transparent organisation and our progress towards meeting the objectives set out in this plan will be reported regularly, in public, at our monthly board meetings. We also welcome comments and suggestions on this plan from colleagues, patients and the public. If you have any views you would like to share, I would be delighted to hear them. Please email them to me via Lisa Reid at lisa.reid@rothgen.nhs.uk Louise Barnett Chief Executive Page 3 of 86 CQC Improvement Plan (Published 10/8/15)
TRFT INSPECTION RATINGS To get to the heart of patients experiences of care, the CQC will always ask the following five questions of every service and provider they inspect: Is it safe? Is it effective? Is it caring? Is it responsive to people s needs? Is it well led? Before the inspection the CQC review a range of information including that provided by other agencies such as the Clinical Commissioning Group, the GMC and NHS England. That information is then triangulated with what patients, visitors and staff (colleagues) say during the inspection and considered alongside what the CQC observe. CARE QUALITY COMMISSION OVERALL RATING FOR THE ROTHERHAM NHS FOUNDATION TRUST Are services at the Trust Safe? Requires Improvement Are services at the Trust Effective? Requires Improvement Are services at the Trust Caring? Good Are services at the Trust Responsive to needs? Requires Improvement Are services at the Trust well led? Requires Improvement Overall assessment Requires Improvement Community Dental Services Good Community Health Services for Adults Requires Improvement Community Health Services for Children, Young People and Families Requires Improvement Community End of Life Care Requires Improvement Community Health Inpatient Care Requires Improvement Page 4 of 86 CQC Improvement Plan (Published 10/8/15)
AREAS FOR IMPROVEMENT actions the Trust MUST take In presenting the findings of the inspection the CQC have produced a list of actions which the Trust must take and a list which the Trust should take. Action Actions the Trust MUST take: Regulated Activity: M1 The Trust must ensure there are suitable arrangements in place to ensure all relevant staff receive appropriate training. This must include safeguarding adults and children, resuscitation, mental capacity awareness and living with dementia awareness. (Provider report) Maternity and midwifery services Treatment of disease, disorder or injury M2 The Trust must ensure there are suitable arrangements in place to ensure staff working in the medicine, maternity, children's and young people, critical care and accident and emergency services receive appropriate training. This must include safeguarding adults and children, resuscitation and mental capacity act awareness. (RGH report) The Trust must ensure there are suitable arrangements in place to ensure staff working in the community end of life care service receive appropriate training. This must include safeguarding, resuscitation, and mental capacity awareness. (Community End of Life Care report) The Trust must ensure there are suitable arrangements in place for establishing and acting in accordance with the best interest of patients without the capacity to give consent and treatment in line with the requirements of the Mental Capacity Act (2005) and its associated Deprivation of Liberty Safeguards. (Provider report) Diagnostic and screening procedures Family planning services Maternity and midwifery services Surgical procedures Treatment of disease, disorder or injury Treatment of disease, disorder or injury Diagnostic and screening procedures Surgical procedures Treatment of disease, disorder or injury Page 5 of 86 CQC Improvement Plan (Published 10/8/15)
Action Actions the Trust MUST take: Regulated Activity: The Trust must ensure there are suitable arrangements in place for establishing and acting in accordance with the best interests of patients without the capacity to give consent. this should be in line with the Mental Capacity Act (2005). (RGH report) Diagnostic and screening procedures Surgical procedures Treatment of disease, disorder or injury The Trust must ensure staff are working in accordance with the Mental Capacity Act code of practice (2005). (Community Health Services for Adults report) Treatment of disease, disorder or injury M3A & M3B The Trust must ensure all staff understand their role in relation to the Mental Capacity Act (2005) and its associated code of practice. (Community Health Inpatient Services) The Trust must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons deployed to meet the needs of patients. (Provider report) The Trust must ensure there are sufficient numbers of suitably skilled, qualified and experienced staff. (RGH report) Diagnostic and screening procedures Treatment of disease, disorder or injury Diagnostic and screening procedures Family planning services Maternity and midwifery services Surgical procedures Treatment of disease, disorder or injury Diagnostic and screening procedures Maternity and midwifery services Surgical procedures Page 6 of 86 CQC Improvement Plan (Published 10/8/15)
Action Actions the Trust MUST take: Regulated Activity: The Trust must ensure there are sufficient numbers of suitably qualified and skilled staff to meet the needs of people who uses the services. (Community Health Services for Adults report) Treatment of disease, disorder or injury M4 The Trust must ensure that there are sufficient suitably qualified, skilled and experienced staff in the school nursing service to meet the needs of the local population. (Community health services for children, young people and families report) The Trust must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons deployed to meet the needs of patients. (Community Health Inpatient Services report) The Trust must ensure all do not attempt cardio-pulmonary resuscitation (DNA CPR) forms are completed in line with the trust s policy and that patients capacity is assessed in line with the requirements of the Mental Capacity Act (2005). (Provider report) The Trust must ensure that all 'do not attempt cardio-pulmonary resuscitation' (DNA CPR) forms are completed appropriately. (Community End of Life Care report) The Trust must ensure all do not attempt cardio-pulmonary resuscitation (DNA CPR) forms are completed in line with the trust s policy and that patients capacity is assessed in line with the requirements of the Mental Capacity Act (2005). (RGH report) Treatment of disease, disorder and injury Diagnostic and screening procedures Treatment of disease, disorder or injury Diagnostic and screening procedures Surgical procedures Treatment of disease, disorder or injury Treatment of disease, disorder or injury Diagnostic and screening procedures Surgical procedures Treatment of disease, disorder or injury Page 7 of 86 CQC Improvement Plan (Published 10/8/15)
Action Actions the Trust MUST take: Regulated Activity: M5 The Trust must ensure patients are not cared for in mixed sex wards / departments apart from those areas which are exempt from meeting the national requirements. (Provider report) Diagnostic and screening procedures Surgical procedures Treatment of disease, disorder or injury M6 M7A & M7B The Trust must ensure patients are not cared for in mixed sex wards/departments apart from those areas which are exempt from meeting the national requirements. (RGH report) The Trust must ensure the outpatient appointment validation process is completed and actions taken to assess clinical risks to patients of having overdue appointments. (Provider report) The Trust must ensure the outpatient appointment validation process is completed and appropriate actions are taken to assess the clinical risks to patients from having overdue appointments. (RGH report) The Trust must ensure that children are protected from the risks associated with unsafe or unsuitable premises. The children's ward environment must be safe and appropriate for children and young people. (Provider report) The Trust must ensure the environmental risks on the children's ward are assessed and mitigated so that it is safe and secure. (RGH report) Diagnostic and screening procedures Surgical procedures Treatment of disease, disorder or injury Diagnostic and screening procedures Surgical procedures Treatment of disease, disorder or injury Diagnostic and screening procedures Treatment of disease, disorder or injury Diagnostic and screening procedures Surgical procedures Treatment of disease, disorder and injury Diagnostic and screening procedures Treatment of disease, disorder or injury Page 8 of 86 CQC Improvement Plan (Published 10/8/15)
Action Actions the Trust MUST take: Regulated Activity: M8 The Trust must ensure all incidents are reported and investigated in a timely manner and that learning is shared with all relevant staff. (Provider report) Diagnostic and screening procedures Family planning services Maternity and midwifery services Surgical procedures Treatment of disease, disorder or injury M9 The Trust must ensure all incidents are reported and investigated in a timely manner and that learning is shared with all relevant staff. (RGH report) The Trust must ensure all directorate and corporate risk registers are reviewed so they reflect the current identified risks, contain appropriate mitigating actions and that the risks are monitored and reviewed at appropriate intervals. (Provider report The Trust must ensure all directorate and corporate risk registers are reviewed so they reflect the current identified risks, contain appropriate mitigating actions and that the risks are monitored and reviewed at appropriate intervals. (RGH report) Diagnostic and screening procedures Maternity and midwifery services Surgical procedures Treatment of disease, disorder or injury Diagnostic and screening procedures Family planning services Maternity and midwifery services Surgical procedures Treatment of disease, disorder or injury Diagnostic and screening procedures Maternity and midwifery services Treatment of disease, Page 9 of 86 CQC Improvement Plan (Published 10/8/15)
Action Actions the Trust MUST take: Regulated Activity: disorder or injury M10 The Trust must ensure that all community health services for adults staff are able to attend mandatory training and other essential training as required by the needs of the service. (Community Health Services for Adults report) Treatment of disease, disorder or injury M11 The Trust must ensure that patient records are kept securely (Provider Report) Diagnostic and screening procedures Treatment of disease, disorder and injury. M12 M13 The Trust must ensure complaints are dealt with in accordance with the trusts policy, national best practice and guidance and people receive a timely and complete response to their complaint that is sensitive to their situation. (Provider report) The Trust must ensure that children and young people using the short break service, are protected against identifiable risks of acquiring a healthcare associated infection. (Provider report) Diagnostic and screening procedures Maternity and midwifery services Surgical procedures Treatment of disease, disorder or injury Diagnostic and screening procedures Treatment of disease, disorder or injury M14 The Trust must ensure that children and young people using the short break service are protected against identifiable risks of acquiring a health care associated infection. (Community health services for children, young people and families report) The Trust must ensure that children and young people using the short break service are protected against the risks associated with the unsafe use and management of medicines. (Provider report) Diagnostic and screening procedures Treatment of disease, disorder or injury Diagnostic and screening procedures Treatment of disease, disorder or injury Page 10 of 86 CQC Improvement Plan (Published 10/8/15)
Action Actions the Trust MUST take: Regulated Activity: The Trust must ensure that children and young people using the short break service are protected against the risks associated with the unsafe use and management of medicines. Treatment of disease, disorder or injury (Community health services for children, young people and families report) M15 The Trust must ensure that there is effective liaison between the contraception and sexual health service and the school nursing service about individual young people who may be at risk of abuse. (Provider report) Family planning services The Trust must ensure that there is effective liaison between the contraception and sexual health service and the school nursing service about individual young people who may be at risk of abuse. (Community health services for children, young people and families report) Family planning services Treatment of disease, disorder or injury Page 11 of 86 CQC Improvement Plan (Published 10/8/15)
AREAS FOR IMPROVEMENT actions the Trust Should take Emergency department Complete a review of staffing levels so appropriate numbers of suitably qualified nurses, emergency department assistants, and healthcare assistants are on duty to manage surges in demand. Ensure that all staff are able to attend regular staff meetings. Ensure that there are systems in place that allow for professional sign language interpretation of consultations for profoundly deaf patients who use sign language, either in person or via video link. Surgery Improve the 18-week referral-to-treatment targets so that patients have access to timely care and treatment. Improve access and flow for patients attending fracture clinic appointments. Minimise the movement of patients from other specialities onto surgical wards, particularly those wards providing elective orthopaedic surgery. Critical care Make sure that staff have access to up-to-date, evidence-based guidance. Review access to the intensive care unit so it is secure at all times. Ensure that consultant ward rounds take place in accordance with national guidance. Maternity Review guidance so that the time intervals for recording patient observations are sufficiently frequent to ensure patient safety. Make sure that suitably trained staff are available to provide postoperative recovery care for women. Review documentation so that appropriate prompts are available to identify patient safety needs. Review the process for women with social service involvement, who may require an extended stay on the ward after giving birth. Review the rates of elective caesarean section and those performed following an induction of labour, with appropriate implementation of identified learning. Review access and patient flow on the labour and postnatal wards so there is effective use of resources to ensure that mothers and babies are cared for in the most appropriate place. Page 12 of 86 CQC Improvement Plan (Published 10/8/15)
Children and young people Review the internal safeguarding processes and implement identified actions. Review the transition arrangements for children and young people for all pathways. Review the leadership of the service so there is access to senior children s nursing advice. Outpatients and diagnostic imaging Ensure that sharps are managed in a manner which protects staff and patients from the risk of needle-stick injuries. Trust- wide Ensure that information about how to make a complaint or leave a comment is available in alternative formats and languages. Ensure that nursing staff have access to clinical supervision. Ensure that patients who are living with dementia and/or their relatives have the opportunity to give information about their personal circumstances, their preferences and likes and dislikes. Patients records are kept securely at all times. Community Health Services for Adults Strengthen the engagement with community health services for adults staff. Ensure community staff have access to information relating to people before providing care and treatment. Ensure staff are accessing interpreter services where appropriate. The provider should support community and district nursing staff to report patient safety incidents appropriately. The provider should ensure staff are involved in learning from incidents and good practice is shared across teams and departments. Community End of Life Care Services Provide support to staff delivering community end of life and palliative care to report patient safety incidents appropriately and ensure they are able to access training in incident reporting on a regular basis. Strengthen ways of learning from incidents and sharing good practice across the community end of life and palliative care services. Ensure that staff visiting patients in their homes to deliver end of life and palliative care are able to access the complete information they need before providing care and treatment. Page 13 of 86 CQC Improvement Plan (Published 10/8/15)
Ensure that all staff delivering community end of life and palliative care are able to access appropriate one to one supervision on a regular basis. Strengthen the engagement with staff delivering community end of life and palliative care, and improve communication about service design and strategy. Community Health Inpatient Services Review the care being provided in The Oakwood Unit so that patients have the opportunity to engage in social activities as well as promoting their independence. Review reasons for staff working in the community in-patient areas feeling isolated and distanced from the senior leaders in the trust. Review the delay in discharges caused by lack of access to prompt assessments for receiving social care and continuing healthcare and lack of availability of specialist packaging for medicines. Community Children & Young People s Services Ensure that systems for reporting and recording safety concerns, incidents and near misses are used effectively and consistently. Safeguarding supervision should be reviewed to make sure it is robust and effective for all staff that need this. The provider should ensure that the substance misuse pathway is effective in providing appropriate intervention for young people under 16. The provider should ensure that handovers from midwives to health visitors are taking place in a timely and effective way. Review the early attachment service to ensure it is not over reliant on one practitioner. The provider should ensure that discharge criteria for the early attachment service are fully defined. Review the IT requirements of staff working in the community so that staff are not hindered by old and inefficient IT equipment. Ensure that all staff working with children, young people and families have received training about the identification and prevention of child sexual exploitation. Ensure that young people have access to contraceptive and sexual health clinics during school holidays. Page 14 of 86 CQC Improvement Plan (Published 10/8/15)
Ensure that waiting time targets are met for physiotherapy non-urgent appointments and child development centre appointments. Ensure that letters to parents and carers include how to get the information in languages other than English. Ensure that information about complaints is captured and shared, including when they are dealt with locally and not recorded on the reporting system. The provider should ensure that risks and concerns within the service are dealt with in an appropriate and timely way. Ensure a consistent approach to obtaining the views of children, young people and families using the service. Strengthen the engagement with staff delivering community health services for children and young people and improve communication about service design and strategy. Page 15 of 86 CQC Improvement Plan (Published 10/8/15)
ACTION PLAN MUST do Based on high level feedback at the end of the inspection the Trust was aware of some of the concerns held by the CQC and was therefore able to take some immediate actions. All the actions described in this plan have: An executive lead An operational lead A timescale for delivery An assigned Committee of the Board which will monitor delivery and provide assurance to the Board of Directors A descriptor of expected outcome A standard of measurement / evidence On the basis that some actions have already been started / completed the following key is applied: Action complete and evidence available Action complete; evidence being compiled Action on track; will progress to timescale Action off track and subject to executive escalation Not scheduled to have started yet. This action plan was approved by the Board of Directors at their meeting on 28 July. The Board of Directors will monitor progress monthly. Page 16 of 86 CQC Improvement Plan (Published 10/8/15)
Unique Id M1 - Training Executive Lead Director of Human Resources Operational Lead Head of Learning, Development and Well Being Timescale 26/05/15 to 31/03/16 Committee oversight Strategic Workforce Committee Overall status as at 26 June CQC requirement: The Trust must ensure there are suitable arrangements in place to ensure all relevant staff receive appropriate training. This must include safeguarding adults and children, resuscitation, mental capacity awareness and living with dementia awareness. (Provider report) The Trust must ensure there are suitable arrangements in place to ensure staff working in the medicine, maternity, children's and young people, critical care and accident and emergency services receive appropriate training. This must include safeguarding adults and children, resuscitation and mental capacity act awareness. (RGH report) The Trust must ensure there are suitable arrangements in place to ensure staff working in the community end of life care service receive appropriate training. This must include safeguarding, resuscitation, and mental capacity awareness. (Community End of Life Care report) Action already taken since the CQC inspection: The Trust has ensured that staff within the paediatric environment have received training in risk assessment and care planning for the needs of children admitted with mental health problems. Thirty-two staff have been trained by the local mental health provider of CAMHs services The Trust has commissioned Professor Sue Proctor to deliver a presentation on 22 June. This will address the learning from the investigations into the acts of Jimmy Savile and the messages for NHS providers of acute and community services in relation to safeguarding vulnerable adults and children. The Trust has formally signed off the /16 Quality Improvements linked to the Quality Account and this includes further training in the care of patients living with dementia. Page 17 of 86 CQC Improvement Plan (Published 10/8/15)
TRFT outcome descriptor: The Trust will be able to evidence that the number of staff requiring access to safeguarding adult and children training, resuscitation training and Mental Capacity Act awareness within all services is understood. The Trust will be able to evidence capacity plans consistent with trainers being available to deliver the required levels of training by 31 March 2016. Each division and the corporate teams will be able to evidence how they have prioritised their plans for release of staff to undergo training / awareness. The Trust will be able to evidence a risk assessment of any other gaps in appropriate training. Actions Source of Evidence Current status 1.1 A training needs analysis of each service in relation to the numbers of staff who require safeguarding, resuscitation, dementia awareness and Mental Capacity Act training / awareness will be carried out. 1.2 Once the level of training during /16 is understood, a capacity analysis of the availability of Trust trainers will be carried out. 1.3 The Corporate Workforce Committee will advise the Trust Management Committee on whether training needs can be met from additional training needs or not, and if not, solutions will be produced. 1.4 Each division will lead a piece of work to plan staff release for training consistent with the needs analysis and capacity plans described above. A service level analysis for all services including corporate teams will be presented to the Corporate Workforce Committee A capacity analysis of TRFT Trainers will be presented to the Corporate Workforce Committee Corporate Workforce Committee and Trust Management Committee minutes. A written plan from each division and corporate team signed off by the divisional / corporate director. Combined Education Strategy to be jointly written by PGME and Learning & Development dept. Page 18 of 86 CQC Improvement Plan (Published 10/8/15)
1.5 The Executive Director of HR will lead a risk assessment of any other gaps in training from which a priority training plan for the remainder of 15/16 and 16/17 will be devised. 1.6 The training plans will be monitored by the Corporate Workforce Committee monthly leading to suitable intervention if the plans de-rail 1.7 In relation to 3.18 the Trust will develop further training plans for colleagues caring for children and young people with mental illness. Evidence of the risk assessment and the priority plan being presented to the Strategic Workforce Committee Minutes of the Corporate Workforce Committee. Training Plan Page 19 of 86 CQC Improvement Plan (Published 10/8/15)
Unique Id M2 - MCA Executive Lead Chief Nurse Operational Lead Named Nurse Adult Safeguarding Timescale 26/05/15 to 01/12/15 Committee Oversight Quality Assurance Committee Overall status as at 26 June CQC requirement: The Trust must ensure there are suitable arrangements in place for establishing and acting in accordance with the best interest of patients without the capacity to give consent and treatment in line with the requirements of the Mental Capacity Act (2005) and its associated Deprivation of Liberty Safeguards. (Provider report) The Trust must ensure there are suitable arrangements in place for establishing and acting in accordance with the best interests of patients without the capacity to give consent. This should be in line with the Mental Capacity Act (2005). (RGH report) The Trust must ensure staff are working in accordance with the Mental Capacity Act code of practice (2005). (Community Health Services for Adults report) The Trust must ensure all staff understand their role in relation to the Mental Capacity Act (2005) and its associated code of practice. (Community Health Inpatient Services) Action already taken since the CQC inspection: The Trust has engaged with the Rotherham Metropolitan Borough Council to introduce an e- Deprivation of Liberty Safeguards form, and initiated recruitment of additional resource to the Safeguarding and Vulnerabilities Team. The additional resource will facilitate training and audit. TRFT outcome descriptor: The requirement for MCA training / awareness and corresponding plans will be evidenced through actions related to M1-Training. The Trust will be able to evidence audit of practice and the development of a second level action plan based on audit findings. Page 20 of 86 CQC Improvement Plan (Published 10/8/15)
Actions Source of Evidence Current status 2.1 The Trust will recruit to a Band 4 MCA / Deprivation of Liberty Safeguards administrator by 31 July. Recruitment file 2.2 The Trust will provide each clinical area / community team with an MCA resource file Receipts from each clinical area confirming the delivery of a resource file 2.3 The Trust will undertake an MCA audit (involving the SAS doctors in conducting the audit) in October. 2.4 The Trust will hold two focus groups in September ; one of clinicians assessing capacity to consent and one of families. This will provide an opportunity to hear the voice of families and colleagues, and inform the planned audit. 2.5 The Trust will publish the improvement journey in the /16 annual safeguarding report 2.6 The Trust will develop a second level action plan based on audit findings. Audit undertaken and reported to the Strategic Safeguarding Group in December, with an action plan describing further improvement steps Signing in sheet and high level notes of the focus groups Publication of the report with relevant content Audit and action plan reported to the Strategic Safeguarding Group in December Page 21 of 86 CQC Improvement Plan (Published 10/8/15)
Unique Id M3A Nurse Staffing Executive Lead Director of Human Resources (HR specific elements) Chief Nurse (Professional Nursing Leadership) Operational Lead Heads of Nursing, Midwifery & Clinical Professions & Deputy Director of Human Resources Timescale 26/05/15 to 31/03/16 Committee Oversight Strategic Workforce Committee Overall status as at 26 June CQC requirement: The Trust must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons deployed to meet the needs of patients. (Provider report) The Trust must ensure there are sufficient numbers of suitably skilled, qualified and experienced staff. (RGH report) The Trust must ensure there are sufficient numbers of suitably qualified and skilled staff to meet the needs of people who uses the services. (Community Health Services for Adults report) The Trust must ensure that there are sufficient suitably qualified, skilled and experienced staff in the school nursing service to meet the needs of the local population. (Community health services for children, young people and families report) The Trust must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons deployed to meet the needs of patients. (Community Health Inpatient Services report) Action already taken: The Trust has already taken action to reduce bed numbers in paediatrics, initiate an external review of paediatric nursing services (in-patients), devise a nurse staffing matrix for use on the paediatric ward, benchmark paediatric nurse staffing with other units across the Yorkshire and the Humber region, speak with the strategic clinical network lead and procure PANDA to review the paediatric nurse staffing levels. Page 22 of 86 CQC Improvement Plan (Published 10/8/15)
Secondly, the Trust plans to visit Croatia during June as part of the existing recruitment plans. To date 40 registered nurses have joined the Trust from Spain, Italy and Romania. Thirdly, the Trust has liaised with the Rotherham, Doncaster and South Humber Mental Health Trust in relation to the provision of Child and Adolescent Mental Health services within the Trust; this includes the provision of one-to-one staffing levels for children admitted to the children s ward. Fourth, the Trust has reviewed the structure of nursing and midwifery leadership within the Division of Family Health and will be recruiting to a Deputy Head of Nursing / Midwifery with a children s qualification. Similarly, the Trust has reviewed the structure of nursing and midwifery leadership within the Division of Medicine and will be recruiting to a Deputy Head of Nursing with community leadership experience. The Trust has rolled out the use of the Safer Nursing Care Tool and will next report as full nursing establishment review, to the Board of Directors in July. TRFT outcome descriptor: Each clinical service, team, department, ward will have an agreed staffing establishment and there will be one version of the truth, i.e. the establishment will be recognised by the operations team, HR and finance and published at the entrance to each department. The Trust will have an agreed set of workforce indicators that are reported in the integrated performance report to Board. These will enable the Trust to determine whether it has sufficient numbers of suitably skilled, qualified and experienced staff. The staffing risk on the risk register will be reduced. Actions Source of Evidence Current status 3A.1 A joint operations, HR and finance team will systematically work through coming to one version of the truth on staffing establishments for all clinical areas. For areas employing nurses / midwives, appropriate tools will be used and the establishments will be signed off by the Chief Nurse and reported to the Board. 3A.2 Vacancies against establishment will be prioritised for recruitment based on a risk assessment and a recruitment plan will be generated. The risk assessment will be formally reviewed at the Trust Management Committee alternate months. The payroll system, ESR and finance ledger all agree on the establishment. Nursing establishments are presented to the Board by the Chief Nurse at least every 6 months Risk assessment. Trust Management Committee notes Page 23 of 86 CQC Improvement Plan (Published 10/8/15)
3A.3 Changes in skill mix influenced by whether the Trust is able to recruit experienced staff, or not, will be formally risk assessed and influence the recruitment plan. 3A.4 The Trust will appoint vendors for nursing agency staff and agree key performance measures which will be managed via regular business meetings. 3A.5 The Trust will procure an e-roster system which will enable real time analysis of staffing and provide a valuable tool to achieve staffing management Risk assessment Vendor appointments Minutes of business meetings at least quarterly. Procurement and implementation of e-roster 3A.6 The executive team will agree a set of HR / Workforce KPIs Monthly report to Board with decisions captured in the minutes 3A.7 The Trust will hold a Band 7 sister / charge nurse two day event in September and use the event to provide training on budget management, staffing establishment reviews, the use of flexible staffing, risk assessment techniques, good people management etc. This will assist in addressing exit interview feedback about some people management practices. 3A.8 All staffing establishments will be published at the entrance to wards / departments. These will be clearly dated and refreshed as a minimum, every 6 months. 3A.9 The Trust will offer every person resigning from position the opportunity of an exit interview with a member of the Trust Management Committee (TMC) 3A.10 The Trust will establish minimum and optimal staffing levels for all in-patient ward areas 3A.11 The Trust will review School Nursing and Community Nursing caseloads using recommended tools and / or benchmarks 3A.12 The Trust will agree maximum caseload sizes for community practitioners, Training programme and signing in sheet showing minimum of 70% of eligible band 7 attendances. Assurance visits Exit interview analysis Agreed levels Caseloads published in the nurse staffing report to Board Agreed caseloads Page 24 of 86 CQC Improvement Plan (Published 10/8/15)
3A.13 The Trust will continue to publish nursing and midwifery staffing data in accordance with hard truths on the website monthly 3A.14 The Trust will strengthen the analysis of planned versus actual nurse / midwife staffing levels and continue to report to Board monthly 3A.15 The Trust will continue to pursue a reduction in sickness / absence levels, achieving best in sector performance during 2016/17, and a rate no greater than 4% by March 2016. 3A.16 The Trust will evaluate the success of the overseas recruitment and make a decision by mid-july on the frequency with which an overseas programme might be repeated and the opportunity to partner with an overseas education establishment to become a UK provider of choice for registrants. 3A.17 The Trust will initiate a dedicated School Nursing recruitment campaign 3.18 Whilst not singularly a result of staffing levels the Trust will work with the Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH) to review all aspects of the Child and Adolescent Mental Health Service provision here in the Rotherham NHS Foundation Trust. The Trust will seek a service which achieves timely specialist CAMHS assessment, a CAMHS care plan and risk assessment and follow up response relevant to the needs of each individual child. Monthly uploads on the Trust website Monthly reports to Board Integrated performance report Paper to the Strategic Workforce Committee Campaign materials A quarterly audit of the records of each child admitted to the Children s Ward subject to shared care. Page 25 of 86 CQC Improvement Plan (Published 10/8/15)
Unique Id M3B - Staffing Executive Lead Director of Human Resources (HR specific elements) Medical Director (Professional Medical Leadership) Operational Lead General Managers & HR Manager Medical Staffing and Recruitment Timescale 26/05/15 to 31/03/16 Committee Oversight Strategic Workforce Committee Overall status as at 26 June CQC requirement: The Trust must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons deployed to meet the needs of patients. (Provider report) The Trust must ensure there are sufficient numbers of suitably skilled, qualified and experienced staff. (RGH report) The Trust must ensure there are sufficient numbers of suitably qualified and skilled staff to meet the needs of people who uses the services. (Community Health Services for Adults report) The Trust must ensure that there are sufficient suitably qualified, skilled and experienced staff in the school nursing service to meet the needs of the local population. (Community health services for children, young people and families report) The Trust must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons deployed to meet the needs of patients. (Community Health Inpatient Services report) Action already taken: The Trust has commissioned ATOS to undertake a capacity and job plan review. This is being used by the Divisional Directors, supported by the Medical Director, to review job planning. The Quality Assurance Committee has been receiving medical staffing reports on alternate months for the past 6 8 months. Recent discussions have led to a request for the data to be enriched and for the reports to provide a similar level of depth and analysis to that which is available in the nurse staffing reports. Page 26 of 86 CQC Improvement Plan (Published 10/8/15)
TRFT outcome descriptor: Each clinical service will have an agreed medical staffing establishment and there will be one version of the truth. The Trust will have an agreed set of workforce indicators that are reported in the integrated performance report to Board. These will enable the Trust to determine whether it has sufficient numbers of suitably skilled, qualified and experienced staff. The staffing risk on the risk register will be reduced. Actions Source of Evidence Current status 3B.1 A joint Division, HR and finance team will systematically work through medical staffing data coming to one version of the truth on medical vacancies. The payroll system, ESR and finance ledger all agree on the establishment. 3B.2 The medical staffing report will be strengthened in line with the discussion at QAC in June and continue to be submitted to QAC every other month. 3B.3 The Trust will appoint vendors for medical agency staff and agree key performance measures which will be managed via regular business meetings. 3B.4 The Divisional Directors and Medical Staffing Manager will influence the forward-looking workforce plan to identify opportunities for the development of Advanced Nurse Practitioner roles and Physician Assistants to replace traditional medical roles not least in those hard to fill vacancies. 3B.5 The Medical Director will ensure that all Consultant and Specialist / Associate Grade Doctors job plans are completed by August and agree the timescale for completing the 2016/17 job plan review. 3B.6 The Divisional Directors will work together to define medical red flags and ensure that all medical staff report against them. Medical Staffing report to QAC Vendor appointments Minutes of business meetings at least quarterly. Workforce plan Report to Board of Directors September Included in the medical staffing report to QAC by October. Page 27 of 86 CQC Improvement Plan (Published 10/8/15)
3B.7 The executive team will agree a set of HR / Workforce KPIs Monthly report to Board with decisions captured in the minutes 3B.8 The Trust will offer every person resigning from position the Exit interview analysis opportunity of an exit interview with a member of the Trust Management Committee (TMC) to all Trust-employed staff. 3B.9 The Trust will publish medical staffing data alongside nursing and midwifery staffing data exceeding the hard truths recommendations on the website on alternate months 3B.10 The Trust is considering how we input medical vacancy data into the existing quality metrics. 3B.11 The Trust will continue to pursue a reduction in sickness / absence levels, achieving best in sector performance during 2016/17, and a rate no greater than 4% by March 2016. 3B.12 The Trust will initiate a medical staffing campaign linked to the development of the Emergency Centre. Monthly uploads on the Trust website Alternate month report to QAC Integrated performance report Campaign materials Page 28 of 86 CQC Improvement Plan (Published 10/8/15)
Unique Id M4 - DNACPR Executive Lead Medical Director Operational Lead Associate Medical Director, Standards of Medical Care Timescale 26/05/15 to 01/01/16 Committee Oversight Quality Assurance Committee Overall status as at 29 May. CQC requirement: The Trust must ensure all do not attempt cardio-pulmonary resuscitation (DNA CPR) forms are completed in line with the trust s policy and that patients capacity is assessed in line with the requirements of the Mental Capacity Act (2005). (Provider report) The Trust must ensure that all 'do not attempt cardio-pulmonary resuscitation' (DNA CPR) forms are completed appropriately. (Community End of Life Care report) The Trust must ensure all do not attempt cardio-pulmonary resuscitation (DNA CPR) forms are completed in line with the trust s policy and that patients capacity is assessed in line with the requirements of the Mental Capacity Act (2005). (RGH report) Action already taken since the CQC inspection: The Trust has completed a Patient at Risk (PAR) audit and a review of all deaths during December 2014. This audit and mortality review included consideration of the DNA CPR status of the patient. The results of the audit have been shared with clinical teams and the mortality review has been presented at the consultants conference held on 21 May and subsequently at the Board of Directors on 26 May. The Medical Director and Chief Nurse have committed to writing to all consultants, ward and community leaders outlining expectations in regard to participation in mortality reviews as part of annual appraisal and revalidation. TRFT outcome descriptor: The Trust will be able to evidence point prevalence audit of completion and compliance with Trust policy, including the assessment of patients capacity in line with the MCA (2005). The Trust will agree a baseline position from which improvement will be reported. The Trust will be able to evidence improved levels of completion. The Trust will be able to evidence 2016/17 improvement and audit plans Page 29 of 86 CQC Improvement Plan (Published 10/8/15)
Actions Source of Evidence Current status 4.1 The Trust will establish the opportunity for a point prevalence audit on one set date each month 4.2 Feedback will be given to the clinical teams on the day of the audit 4.3 The DNACPR policy will be reviewed to ensure it is in line with best practice 4.4 The basic life support resuscitation training package will be reviewed to incorporate DNA CPR 4.5 Divisional performance will be discussed in the performance meetings 4.6 The Medical Director will write to all consultants outlining the plans 4.7 The Chief Nurse will write to all ward and community team leaders / sisters / charge nurses outlining the plans Arrangements minuted in the Resuscitation Group records Signed feedback forms Policy review minuted in the Resuscitation Group records Copy of training package Performance meeting action logs Letter to consultants Letter to all relevant nurse leaders Page 30 of 86 CQC Improvement Plan (Published 10/8/15)
Unique Id M5 - EMSA Executive Lead Chief Operating Officer Operational Lead Deputy Director of Operations Timescale 26/05/15 to 01/09/15 Committee Oversight Quality Assurance Committee Overall status as at 26 June CQC requirement: The Trust must ensure patients are not cared for in mixed sex wards / departments apart from those areas which are exempt from meeting the national requirements. (Provider report) The Trust must ensure patients are not cared for in mixed sex wards/departments apart from those areas which are exempt from meeting the national requirements. (RGH report) Action already taken since the CQC inspection: The Trust has already established a zero tolerance for mixed gender sleeping accommodation and only had two occurrences of a breach of this standard since 01 April (1 on SAU and 1 on HDU both for less than 1 hour). TRFT outcome descriptor: The Trust will develop plans for improving pass-by breaches The Trust will establish a trajectory for achieving compliance with the ITU/HDU 8 hour rule, i.e. transfer out of the unit within 8 hours of the clinical decision being made (to be operated between the hours of 10:00 and 20:00 hours only) The Trust will be able to evidence improved patient reported experience in the in-patient survey on related questions. Actions Source of Evidence Current status 5.1 The Trust will continue to reinforce the requirement to Site manager records escalate to the director on call before any anticipated breach of the mixed gender sleeping standard thereby affording the director the opportunity to prevent the breach 5.2 The Trust will continue to report to Board monthly Integrated Performance Report Page 31 of 86 CQC Improvement Plan (Published 10/8/15)
5.3 The Trust will devise a standard operating procedure for the avoidance and management of pass-by breaches and ensure that compliance is managed and audited by the Matrons 5.4 An audit of compliance with the national requirements will be undertaken across the main hospital site, RCHC, breathing space, the Flying Scotsman and the community unit 5.5 The Trust will agree and manage a trajectory for achieving compliance with the ITU/HDU 8 hour rule by 01 September and then develop a plan for achieving compliance with a 4 hour rule by 31 March 2016. SOP and weekly reports from all in-patient matrons Audit report to TMC Agreed trajectory and weekly reports from critical care Page 32 of 86 CQC Improvement Plan (Published 10/8/15)
Unique Id M6 - Out-patients Executive Lead Chief Operating Officer Operational Lead General Manager, Clinical Support Services Timescale 26/05/15 to 01/09/15 Committee Oversight Divisional Performance Meetings Overall status as at 26 June CQC requirement: The Trust must ensure the outpatient appointment validation process is completed and actions taken to assess clinical risks to patients of having overdue appointments. (Provider report) The Trust must ensure the outpatient appointment validation process is completed and appropriate actions are taken to assess the clinical risks to patients from having overdue appointments. (RGH report) Action already taken since the CQC inspection: The Trust has reviewed 13,500 patient pathways, and confirmed that 10 patients breached the 52 week rule. The details of the review have been shared with commissioners, Monitor and the Board of Directors (26 May ). There has been no direct patient harm as a result of the delays. As a result of the deep dives undertaken, further pathway reviews have been conducted and 4 additional patient delays have been identified. This brings the total as at 29 May to 14 patients. All patients have been contacted and individual pathways management agreed. TRFT outcome descriptor: The Trust will be able to evidence that the pathway review / validation is complete and that the clinical risks have been assessed for all patients affected. Actions Source of Evidence Current status 6.1 The Trust will scope out the full patient backlog delays across all specialities. Backlog Update Report Page 33 of 86 CQC Improvement Plan (Published 10/8/15)