Final Copy @ 18/8/09 August 2009(9) Northern Trust Corporate Register of Top s Existing 1 To improve services as set out in TDP in response to PFA. Failure to discharge statutory Child Care functions, ie Not allocating child care cases in a timely manner. Insufficient adequate capacity to monitor children deemed at risk. Use of unregulated places for 16-18 year olds outside the care system. NHSCT Multi- Agency Child Protection Panel. DMT Sub-Group for and Governance in Child Care. Exec- of Social Work receives weekly report of unallocated cases and of cases allocated but not receiving a service. 89 unallocated cases at 17/7/09 in the 3 sectors. In Disability there were 201, of which 169 are in receipt of services. There are no unallocated child protection cases. Bi-annual Parenting Report to TB and DHSSPS. Annual Report to RQIA. RQIA inspections announced and unannounced. NED visits to children s homes. Monthly review DHSSPS. 20 16 16 16 March 2010 Mr Worthington Assessment of new investment for 2009/10 to prioritise where resources are to be deployed. Increasing capacity to accommodate 16+ young people as part of the joint commissioning agenda. 1
2 Statutory duty to break even Costs associated with mgt of C Difficile. Community Packages of Care (linked to PFA targets) Energy Costs Maintaining smaller hospitals PFA targets Existing Financial Reports/ budgetary reports Contingency Plan approved at October Trust Board Financial Strategy Revised Recovery Plan required for Trust Board in June 2009 with Plans to be submitted to Health and Social Care Board thereafter. Internal Audit. Accountability Meetings Economy Meetings. Monitoring of implementaction of Recovery & Contingency Plans SMT & Trust Board. 25 20 Ongoing Mr Guckian & SMT TDP financial projection for 2009/10 identifies a deficit of 30M plus any shortfall in Elective Care Reform. Shortfalls in CSR savings: General Efficiency Frontline Admin Reform Projects 2
3 Develop and implement informatics strategy and annual action plan as a key enabler of reform and modernisation. Insufficient resources to support core function and support modernisation. Existing Regional ICT programme. Informatics strategy 2008/2009 2011 programmes developed for Trust as part of planning process. Annual Informatics Work Programme that identifies top priorities. Information Governance Work Programme Assurances on Accountability Review ICT Assurance Standard Annual Report on Work Programme 20 20 Ongoing Chief Executive In March 2008 the Trust committed to provide additional funding for 2 years for staff to maintain the current rate of development / level of support. Some of this funding has been made permanent and this will help to secure expertise in key areas. In July 2008 funding for a further post on a 2-year basis was made available to support essential IT Security developments. The Trust has been successful in securing funding associated with new regional developments (eg Cancer Information system, Theatre, NIPACS) and will continue to lob for inclusion of set-up and recurring support staffing costs in bids. A number of projects are in hand that will improve core ICT services (eg single service desk, network standardisation and enhancement, 3
Develop and implement informatics contd. Existing Assurances on consolidation of systems, data warehouse/information portal) and, in time, will enhance productivity. DIS has been successful in securing capital funding for a range of projects, including desktop infrastructure. This funding will assist with the harmonisation and standardisation essential to future development. Change to definitions of capital and revenue funding are scheduled for April 2009 although the impact for ICT is not clear. Finance ate will keep Informatics Dept apprised. While the actions in hand will secure the current position, the risk is not significantly reduced at this stage. A paper outlining proposals for significant mitigation of this risk is under development. 4
4 Ensure patient and client safety has the highest priority in the Trust implementing patient/client safety improvement plan and develop strategy to introduce IHI improvement methodology Trust-wide. Health Care Associated Infection (HCAI) Lack of isolation facilities. Subject to findings from Public Inquiry into C. Diff outbreak in Northern Trust in 2008 adverse criticism and loss of public confidence in Trust. Existing HCAI Corporate Plan. DH supported task force. Infection Prevention & Control and Environmental Hygiene Committee. RQIA review. HSC Board monitoring. Performance monitoring to Trust Board. 20 16 September 2009 Dr Flanagan Corporate plan developed with the support of DH to reduce HCAI. Supported implementation of plan. Assurance process being developed. 5 Ensure patient and client safety contd. Inadequate acute inpatient psychiatric bed capacity resulting, on occasions, in Trust being unable to admit patients promptly. Resultant increased risk of patients being involved in Serious Adverse Incidents(SAI) Bed management/ Admission policy. Bed escalation policy. Daily review of bed state. Crisis Response provision in community. Management Reports. Reporting Mechanisms to SMT & regionally. SAI reporting to DHSS&PS & NHSSB and investigation. 20 16 Jan 2009 onwards Mr Donnelly treatment plan includes continued provision of 9 beds at annex, Holywell Hospital. Plans to develop Home Treatment Service. Participation in regional bed management arrangements. Crisis Resolution Service rolled out across Causeway 5
Existing locality in 2008. Phase 1 Home Treatment Service commenced in April 2009. Roll-out of Phase 2 initially scheduled to commence in 2010 now brought forward to September 2009 to help address bed pressures in Causeway locality. Commissioners have agreed partial funding for 9 Annex beds for 09/10. 6 Ensure patient and client safety contd. Ensure patient and client safety contd. Ageing clinical equipment. Management Reports. Asset Register. Capital allocation. Trust Medical Devices Policy in draft form. Monitoring and discussion at Trust & Accountability review. SAI reporting to DHSSPS & NHSSB and investigation. Governance and Service User Feedback Committees 25 16 Ongoing Dr Flanagan (Dr Scott) Senior Management Team Assessment for relevant equipment. Additional capital allocation being utilised. Anaesthetic machines ordered. Requests for replacement of medical equipment are now being 6
Existing Governance Coordinating Group and other forums within Governance Accountability Framework. prioritised Trust Medical Devices and Capital Scrutiny Committee using DHSSPS approved matrix. By linkage with capital allocations this assessment enables requests to be categorised as either Definite, Possible or Unlikely. Consequently, and subject to the availability of funding, this approach enables the procurement process to be speeded-up and provides the Trust with a robust and transparent prioritisation system. A total of 1088k has been allocated to the Acute/Elective ate out of general 7
7 Ensure patient and client safety contd. Acute hospital profile at Mid Ulster and Whiteabbey Hospitals. Existing Reconfiguration of acute hospital services within the Trust has an established project management infrastructure in place. Senior Clinicians and managers are involved and leads identified for various subgroups established. Changes made previously to acute services at Mid Ulster and Whiteabbey Hospitals remain in place. Report of project team. Accountability review. 25 16 Ongoing March 2009 Mr Sloan capital for equipment. Ms Donaghy leading a group to develop proposal for way forward. Consultation regarding CSR proposals has been completed. Approval from Minister for implementation of the proposals awaited. 8 Patient safety and financial breakeven. Ongoing medical staff vacancies (mainly in training posts) across the Trust. These vacancies impact upon medical training in the Trust. Creates adverse patient safety and financial Induction programmes Monitoring Trust s Head of Medical Education Monitoring ates. Accountability review. Incident reporting. 20 16 Ongoing Dr Flanagan Chief Executive has written to the Chief Medical Officer (and copied to Permanent Secretary and other Chief Executives) regarding seriousness of the recruitment situation. 8
implications in the increased engagement of Locum staff for the Trust. Existing Trust is engaging with locum agencies to seek additional locum staff. Trust is supporting a regional initiative (led NIMDTA) to recruit medical staff from outside the EU. 9 Ensure patient and client safety contd. Difficulties in maintaining adequate Midwifery staffing levels in Antrim Hospital due to ongoing staff absence difficulties. Birth Rate Plus. Independent review of service. Management Reports. Register. Management Absence Management Policy and monitoring of absence levels. NHSSB agreement to fund three additional posts has enabled recruitment process to commence with appointments expected to take-up post in March 2009. Reports to Governance and Service User Feedback Committees. 20 16 Mr Sloan Monthly Meetings with O&G Forum with Staff side reps and midwives to review staffing levels sickness absence reports chaired Assistant from Human Resources. Incident reports relating to absence. Actively using absence policy. 9
Existing New staff commence 1 st May. Review of midwifery bank system. 10 Ensure patient and client safety contd. High incidence of falls resulting in serious injury within in-patient wards. Existing risk assessment tools. Incident reporting and monitoring. Registers. 20 16 Dec 09 Ms Scott Establishment of ate Acute Falls Prevention Reference Group and Working Group which has prepared an Plan which was presented to GMB on 31 March 2009. Review of existing Falls Care Plan and Matrices. Review of current best practice including NPSA Report on Slips, Trips & Falls. Development of Trust Policy on use of bed rails. October Roll-out of new 10
11 Review and continue to develop and implement the Organisational Development Strategy and Plan. Corporate reputation has been damaged media coverage of high profile incidents. 12 Limitations in Trust s arrangements for commissioning and managing services being purchased from third-party providers on behalf of the Trust putting it at risk of being unable to: secure and maintain social care and other provision at required levels Existing Communications Strategy. Media Strategy. Management Reports RQIA Contracting Process Permanent Review team Care Management Process Vulnerable Adult Process Report to Trust Board on media activity. Reports to Governance and Service User Feedback Committees. SAI reporting to DHSSPS & NHSSB and investigation. ate and Trust Contracts Renewal Reports reporting progress implemented March to November 2008. 20 16 March 09 2009 Falls In-Patient Care Plan following evaluation of pilot. Jan 09 Chief Executive, Chairman & Ms Margaret Mulholland Communications Strategy has been consulted on. Reform and Efficiency Stakeholder engagement plan in draft. Proactively managing positive news about the Trust. 20 16 Ongoing Ms Donaghy Trust staff working intensively with poorly performing homes to raise standards of care. plan for strengthening contracting process is being implemented and draft Quality Assurance Framework issued for discussion. 11
of demand, quality, and/or cost; be assured regarding the safety of service users, including vulnerable clients, on whose behalf services are being commissioned; Existing Receipt of Regional guidance also expected in near future. be assured that appropriate governance arrangements are in operation within organisations from which services are being purchased; and being subject to criticism, financial loss or other adverse outcome arising from the above. 13 Compliance with RQIA Inspection reports on Non-compliance with RQIA requirements and recommendations Those requirements/ recommendations that could be 25 15 Ongoing Miss Scott Development of links with Estates and RQIA to 12
Trust Residential Care Homes 14 Compliance with Regional Guidance on Protection of Vulnerable Adults with respect to Estates Inspections of Trust residential care homes could potentially result in issuing of Failure to Comply Notice of noncompliance with Regional procedures and risk of abuse not being identified and investigated due to the increase in the volume of adult protection cases/ allegations within independent nursing and residential homes accompanied Trust responsibility to apply Regional Adult Protection procedures under scrutiny of RQIA. Existing actioned due to management actions have been addressed. ate managers and Estates dept met June, Sept & Dec 2008 to identify remaining outstanding issues. Limited resource dedicated to adult protection procedures in respect of allegations in independent sector has resulted in diverting staff from other areas of responsibility. Level of current resource is inadequate. Protection of Vulnerable Adults a standing item on Professional Social Work agenda. Asst Forum (cross PCOPS/MHLD ates) established to identify/ address adult protection issues. Vulnerable Adults is a standing item 25 15 Ongoing Miss Scott, Mr Donnelly & Mr Worthington minimise identification of issues as requirements arranging Estates Officer attendance at future RQIA Estates Inspections. Requirements to be given priority within ate capital allocation for 2009/10. Volume of referrals remains at significant level. PCOPS ate has identified funding for a further post to oversee allegations of abuse in nursing/ residential homes. Appointment made April 2009. Draft Vulnerable Adults 13
15 Provide and maintain safe patient and client care No additional resource transferred to Trust from RQIA to undertake this new role. Impact of predicted surge in Swine Flu cases. Existing Trust Pandemic Flu Plan Pandemic Strategic Coordinating Team on monthly PCCOPS ate Governance Team meetings. Reports to Trust Board Liaison with Public Health Agency Desktop exercises Assurance Work developed and Plan. PCCOPS ate coordinating responses to incidents involving vulnerable adults within other ates. 25 16 Ongoing Dr Flanagan Corporate Pandemic Flu Plan supported detailed ate Plans. Ongoing review and updating of plans as pandemic flu situation develops. Please note print in red indicates changes since previous version. 14
Deleted s Ensure patient and client safety contd. Managing peaks of demand for access to the 16 neo natal cots in Antrim Hospital when demand exceeds availability. Increased risk of harm being caused to ill babies when then having to be transferred to an available cot at another hospital either in NI or, on occasions in GB. Also reduced level of medical and nursing resource when otherwise engaged in Existing Clinical staff take appropriate steps to identify antenatal mothers who are at risk of premature/ complex deliveries and attempts; as far as is possible, to co-ordinate admissions to a unit in NI which can offer access to a neonatal cot in an emergency. Trust participates in, and works closely with the Regional Neonatal Network to facilitate closer working between the 4 neonatal services in Assurances on 20 16 Mr Worthington 15
facilitating that inter hospital transfer. Existing NI and to access neonatal provision whenever the Neonatal Unit in Antrim Hospital is at full capacity. Assurances on When all NI options have been exhausted the Trust will search across wider GB to locate a suitable cot. Daily status reporting to Jubilee Hospital of cot availability for regional coordination. 16