Royal College of Paediatrics and Child Health Service Review Action Plan and Progress Report 26 th May RAG Dark green Light green Amber Red White Definition Action complete and assurance gained Action on track, expected to complete on time Action commenced, some slippage or evidence awaited, expected to complete on time Action commenced but considerable delay Action not yet commenced Ref Areas for improvement Milestone Tasks (Key tasks that need to be carried out to implement actions) Responsible Person Target Date Progress (Details of progress to date, useful information, barriers encountered etc) Status (RAG) WORKFORCE 1 The Trust must implement a split Consultant rota between the NNU and the Paediatric unit to reflect BAPM standards. In the absence of a spilt rota, the Trust may wish to consider implementing a model of hybrid shifts between Consultant and middle grade staff. Review the benefits of the two models of Medical provision for Paediatric and Neonatal services and agree a model between split rota or hybrid Agree provision for identified model and proceed to implementation Clinical Director / Divisional Director Maternity & Neonatal Taskforce March March Review of models undertaken, paper provided at Maternity & Neonatal Taskforce. Agreed to a hybrid model of medical cover (Maternity and Neonatal Taskforce March ) For information The Hybrid model consists of a separate rota for Paediatrics and Neonatal care for Junior Doctor s and acute care consultant, providing on-site out of hours cover and a separate consultant non-resident on-call rota that oversees both services. Hybrid model agreed through provision of Acute Care Consultants Trust Board agreed 4 x Acute Care V3.3 updated 25/0516 Page 1 of 16
Agree Job Descriptions with and advertise posts substantively Implementation of hybrid model complete Clinical Director May October Consultants 3 Locum Consultants have been recruited and are expected to start in September Substantive posts are with the for approval with the expected return date June, date of advertisement July and expected start date October. Internal review of model of medical cover December Review will be undertaken in December once the model has been in place. 2 The unit should review establishment and recruit sufficient nursing staff to meet the BAPM standards and provide adequate support and supervision to new and junior staff. The nurse in charge should not have a patient caseload, to ensure effective supervision of junior staff and to oversee activity whilst managing the NNU and coordinating issues such as transfer or discharge. Benchmark provision of nursing across neighbouring Trusts Agree number of minimum safe nursing staff for the department Paediatric and Neonatal Clinical Support Senior Neonatal Nurse / Delivery Suite Matron / Paediatric and Neonatal Clinical Support 31 st July 31 st May Review of nursing provision and nurse in charge role under progress, the findings of this will be completed in June and will be presented to the July Maternity and Neonatal Taskforce. Agreed through Maternity & Neonatal Taskforce that long term provision of cots will be no more than 20, this has been agreed with the Neonatal Network, the unit currently has provision for 15 cots and staffing for this number (5 recruited since November 2015). It should be noted that the unit often operates at more than 15 cots and still relies on temporary staff when it does so. Work continues through the Taskforce on setting and recruiting to staffing for the increased number of cots V3.3 updated 25/0516 Page 2 of 16
Recruit to the number of staffing agreed as part of the review of safe staffing levels for the Neonatal unit Senior Neonatal Nurse 31 st July Neonatal Workforce listening exercise with the Director of Nursing and Divisional Director, recruitment underway for band 5 roles and Support Workers within the unit. A formal Paediatric and Neonatal Workforce group has been set up, the date for the first meeting is 2 nd June. This will determine long term provision, types of workforce needed and recruitment strategies including Medical, Nursing and support functions. Undertake benchmarking of nurse in charge role across other providers and agree arrangements which are in line with other providers and enables the nurse in charge to support junior staff Paediatric and Neonatal Clinical Support 31 st July Contacted neighbouring trusts and in discussion with BCA, the findings of this will be completed in June and will be presented to the July Maternity and Neonatal Taskforce. Agree developmental strategy, including workforce and training for junior staff on the neonatal unit Paediatric and Neonatal Clinical Support / Practice Development Lead / ANNP s 31 st July Developmental Strategy being addressed through the Deanery Visit action plan. Following the Deanery attendance at the service we have agreed with the Deanery a range of actions to address areas of training and support for Junior Doctors, this ranges from review of clinic structure at Outpatients to recruitment of additional support. A separate plan is being monitored to oversee these actions. First meeting of the Paediatric and V3.3 updated 25/0516 Page 3 of 16
Neonatal Workforce Strategy Group being held on 2 nd June Agree escalation process and ensure widely communication in times of short staffing to maintain safety of service Paediatric & Neonatal Workforce Start group June Interim arrangements are in place and a local Escalation Policy in place Develop Transitional Care arrangements to release pressure of the Neonatal Unit Transitional Care Group Underway complete July Transitional Care area identified, pathways in development and to be completed end of June Identified as first phase Listening into Action. Determine the required number of cots for the unit and agree plans to move to that provision Maternity & Neonatal Task Force March Maternity & Neonatal Taskforce received paper for number of cots and agreed provision of 20 total cots. The business case for the extension of the unit is being prepared and is expected at the September Trust Board. Agree estates strategy for developing the unit to manage the number of cots required Estates Department (FBC to be presented to TB) Senior Neonatal Nurse August Outline estates paper received by Taskforce, estates solution agreed and full business case in development Dedicated lead to be identified for discharge March Senior Neonatal Outreach Nurse is coordinating the discharges 3 The Trust should benchmark the baseline nursing establishment against the RCN standards and increase nurse staffing to reduce the frequency of reporting Benchmark nursing establishment, understand and agree the number of staff required for Paediatric Unit Agree Paediatric nursing establishment for the Paediatric Unit Matron for Paediatric Service 31 st July 30 th November Benchmarking in progress comparing with similar establishments Paper needs finalising once benchmarking complete Current staffing is monitored daily with the Divisional Management team and staffing is allocated to the unit V3.3 updated 25/0516 Page 4 of 16
and the risk of over stretching the nursing team. based on demand and case mix. In addition, the service has strengthened its clinical support worker capacity to support the nursing staff within the service. An escalation plan is in place to manage times of high demand and to ensure that staffing is adequate for the service. The Trust has also invested in additional Paediatric trained nursing staff within A&E, which supports the Paediatric service by improving patient flow. Implement establishments April 2017 Division support to ensure staffing meets the complexity of the patients, this is reviewed daily through the matron meeting. Workforce, training plan for Paediatrics Nursing Team Division to agree Senior Paediatric Nursing Leadership Divisional Director / Director of Nursing July July First meeting of the Paediatric and Neonatal Workforce Strategy Group being held on 2 nd June. Divisional agreed Professional Head of Paediatric and Nursing. Job Description in draft, to be finalised and recruited to. 4 Set a strategy for development of Physician s Associates or ANNPs to cover the 7-9 pm peak activity and other rota gaps in the Workforce group to be developed to agree future workforce Develop a local strategy for extended roles through the workforce group Clinical Director / Divisional Director / Matron for Paediatric Service / Matron for Neonatal Service 31 st July 31 st July First meeting of the Paediatric & Neonatal Workforce Strategy Group being held on 2 nd June To be commenced at Paediatric & Neonatal Workforce Strategy being held on 2 nd June V3.3 updated 25/0516 Page 5 of 16
absence of sufficient non-consultant medical staff. The service should develop a model for advanced nursing practice within the PAU to improve patient throughput in PAU and to reduce the risk of staffing problems in the future. Develop implementation plan to support the strategy Workforce group to lead the development of new roles within the service Agree short term plan for ensuring stability within junior medial workforce Paediatric & Neonatal Workforce Clinical Director / Associate Medical Director / Divisional Director 31st August 31st August 31 st August The Paediatric & Neonatal Workforce Strategy Group which starts on 2 nd June will lead the development of new posts to support the unit, the agreed workforce plan will be supported by an implementation plan with timescales and leads. Agreed short term locums to provide greater stability within the Junior Medical Team The short term solution includes the recruitment of 4 post holders for a period of three months, this will be reviewed at two months to agree an extension. The medium plan is to look at alternative roles which could support the unit and release medical time. We have recently agreed a dedicated medical PAU lead who will support us with the implementation of this plan. 5 Consider appointing a lead Paediatric Consultant in ED Consider looking at the need for a lead Paediatric Consultant and Paediatric cover in ED Review previous Paediatric attendance, to determine the need of a Paediatric lead Consultant in ED ED Consultant 31st May Number of Paediatric attendance in ED has been considered Between 2014-2015 11,000 children were seen in ED, according to 2012 Paediatric Guidelines there is not a requirement for a lead Paediatric Consultant in ED However when next recruiting, will request Paediatric experience V3.3 updated 25/0516 Page 6 of 16
Currently reviewing the children s pathway in ED Increased children nursing complete in ED Next stages of consideration of Paediatric Services in development with ED Taskforce. Discuss with Community Paediatricians rota for OOH In discussion with Community Paediatrician to cover peak OOH, agreed in principle and finalising. 6 Child Protection medicals should be dealt with through a separate rota to avoid depleting the on take team. This could be through increasing the capacity of the community Paediatric team to work out of hours. Agree peak OOH rota to complete Child Protection Medicals Advertise and recruit a fourth Consultant by September The new appointed Consultant to work alongside Community Paediatricians to cover peak OOH Clinical Director 30 th June September Peak hours cover will be provided by Community Paediatricians up to 8.30 pm Plan has been devised and the working rota will be in place by the end of June. Community Paediatrics has been increased to 4 Consultants and 1 associate specialist Recruitment in progress - Locum consultant posts are out to advert and it is expected that they will be in post in July, substantive posts with approval expected return date June, date of advertisement July and expected start date October. Review current location for delivery of Child Protection Medicals 30 th June 2015 Child Protection Medicals moved from PAU to Starfish Suite (purpose built facility) V3.3 updated 25/0516 Page 7 of 16
The rota for in-hours dedicated Child Protection Medicals is now in place V3.3 updated 25/0516 Page 8 of 16
CLINICAL PATHWAYS 7 It is recommended that one nurse is always present in the intensive care room to monitor and detect changes in the condition of infants. Review the nursing rota Ensure the rota supports a minimum of 2 nurses to work within the intensive care area Look at interim Transitional Care facility within current Estate Senior Neonatal Matron 30 th April Nursing rota reviewed Nursing cover is now present to ensure the intensive care room is covered and rota has been devised Stakeholder meeting in progress to finalise facility. Progress report to be provided to Maternity & Neonatal Taskforce in June. 8 Work with commissioners and the maternity team to plan for a transitional care service when the unit is developed, to reduce pressure on the NICU. Identify workforce policies and processes to support implementation Agee implementation model and date Neonatal Consultant 30 th June Suitable area identified for Transitional Care facility to support 4 cots, clinical pathways currently in development. First meeting taken place on 20 th May and a number of work streams are underway, including the workforce, pathways, policies equipment and criteria. A project lead has been assigned to the development of the Transitional care unit. 9 Expand existing Consultant-led rapidaccess service to manage urgent Work with Estates Team to ensure Transitional Care provision in long term strategic Estate Plan for Maternity and Neonatal Services Agree the required number of medical staff to expand service Clinical Director and Matron for Paediatric Service 30 th September Listening in to Action team also supporting Transitional Care facility Medical staffing reviewed and agreed to recruit to 4 x Acute Care Consultants see detail already provided above. V3.3 updated 25/0516 Page 9 of 16
referrals and reduce unscheduled workload on PAU. This could be an urgent out-patient clinic more frequently. Consider running review clinics from outpatients, rather than the PAU to improve the flow through the children s service Advertise and appoint 4 Acute Care Consultants and 3 Locum Registrars in the interim Clinic appointments and clinic rooms to be reviewed Once 4 Acute Care Consultants appointed there will be an increase in Rapid Access, Prolonged Jaundice and Routine clinics Liaise with the CCG regarding outpatient appointments and integration between Acute and Primary Care Recruitment taking place W/C 23 rd May Review of consultants and clinics complete Additional outpatients clinics planned as part of recruitment of Acute Care Consultants Monthly Paediatric Clinical Pathways meeting in place. 4 Clinical Pathways in development to support flow on PAU. Division sourcing Primary Care venues for outpatient Paediatric Clinics to support management of children in Primary Care. 10 Address the lack of clarity regarding the bleep system to ensure timely access to appropriate medical support in an emergency. Review the bleep system Identify systematic and operational issues Implement a robust system to ensure appropriate staff are directed to the emergency in a timely manner ANNP / Neonatal Consultant 31 st May A review of the bleep system has taken place, following the review the lead met with switchboard and identified that the issue was due to poor communication within the service. Signs informing all staff of the correct emergency bleep numbers for appropriate medical staff have been put in place Develop a Standard Operating Procedure Standard Operating Procedure in development Communicate to all staff Training and communication in place V3.3 updated 25/0516 Page 10 of 16
Audit new system 31 st August Audit of the bleep system in use is planned for June V3.3 updated 25/0516 Page 11 of 16
TRAINING 11 The Trust should explore opportunities with the Network to allow Consultants to gain experience working/refreshing skills at a Level 3 unit in the Network. Clinical Director at Level 3 hospital to arrange for Consultants to gain experience and refresh skills within the network Walsall Healthcare will agree a plan to ensure Consultants work with the level 3 hospital to gain more experience Put in place a sharing agreement document outlining requirements to support the service Clinical Director 31 st October Discussion between Clinical Director at Level 3 hospital and Walsall Healthcare Clinical Director has been undertaken Level 3 Hospital have appointed a Consultant who will carry out 1 SPA at Walsall Healthcare. Walsall Healthcare have devised and agreed a plan to ensure Consultants work with the level 3 hospital to gain more experience. The Clinical Director is in discussions with the Level 3 units to agree the terms of the arrangements, it is expected that the agreement will be finalised in June. 12 A programme of regular training opportunities should be developed on the neonatal unit. This should include NLS refresher/update sessions, MDT simulation sessions and advanced airway practice including use of the Glidoscope, these sessions should be led by Arrange NLS refresher sessions for nursing and medical staff Arrange 4 sessions per year for advanced/update session for Consultants and trainees Clinical Director 30 th June ANNP provides training report for the Weekly Divisional Governance Assurance meeting: Currently 70% of staff Qualified in Speciality have had NLS refresher training, in 6 months this should increase to 87% and 100% by December. Dates have been identified for advanced/update sessions Deep Dive review into Tube related incidents commenced in May and will be completed by the end of June Audit against training and compliance V3.3 updated 25/0516 Page 12 of 16
Consultants with the assistance of other staff. against policy underway Keep a log for advanced/update session for Consultants and trainees and those due for an update All training logs to be reported at the Paediatric Governance meetings, initial report to be presented at Paediatric Governance on 10 th June GOVERNANCE AND PROCESSES 13 The Trust should strengthen its arrangements for Board oversight of Quality and Clinical Governance Review the Trusts Governance processes Establish Quality and Clinical Governance meetings for Board Oversight Divisional Governance Team 31 st March Governance was a key area for development post CQC Inspection Board processes have been strengthened by Monthly updates to Quality Executive / Quality & Safety since March 16 A Quality and Clinical Governance Improvement Facilitator has been appointed The Trust s Risk Management processes have been reviewed and training is being undertaken There is a new Risk Management Strategy in draft - June There are new RCA in processes in place, supported by external training commencing 23 rd June Monthly Risk Management meetings are taking place Interim arrangements are in place to oversee the Quality and Clinical Governance Organisational Governance framework designed 01/02/16 V3.3 updated 25/0516 Page 13 of 16
Special Measures Oversight Quality Group commenced on 23/02/16 Arrange weekly Assurance meetings to discuss Incidents and Complaints with the Divisional Director and Associate Medical Director An independent member of staff has been appointed to support the development of the Paediatric and Neonatal Service A newly appointed Quality and Clinical Governance Lead is due to start in July Independent review of Divisional Governance is complete and presented to Maternity & Neonatal Taskforce, recommendations are being implemented Quality and Safety Assurance meetings are in place within the Division, co-chaired by the AMD/DD Monthly Divisional Quality Teams and Care Group and divisional level Agendas and structures of Divisional Governance meetings have been reviewed. 14 The Trust should record action taken relating to both formal and informal complaints to ensure learning. Divisional Standard Operating Procedure to be developed for dealing with complaints Methods of addressing complaints to be developed Coordinate meetings aimed at identifying and investigating Divisional Governance Team 31 st March Divisional Standard Operating Procedure is in draft and awaiting approval 10 th June Trust wide complaints processes were recently reviewed. Divisional process agreed as part of SOP and being reviewed weekly Quality and Safety Assurance meetings Internal processes have been strengthened, with weekly Assurance V3.3 updated 25/0516 Page 14 of 16
15 External input should also be sought from within regional networks to the RCA and investigation process until there is confidence that all issues have been considered. complaints Lessons learned and actions plans to be monitored at local monthly governance meetings Action Plans to be shared at local service meetings and disseminated to all relevant staff. Develop clear guidelines for devising action plans following investigations of complaints Identify an interim measure with input from local expertise, but external to the department Long term BCA and SSBN Clinical Director to liaise with Clinical Director in Level 2 Hospital Associate Medical Director 30 th April September meetings and Monthly Divisional Quality Team meetings The Divisional Quality Team monitor all actions ensuring implementation, collecting evidence and escalating to DD/AMD when required All relevant learning fed back via Divisional/speciality/Governance meetings. Wider learning to be fed back to the taskforce and also at clinical teachings/grand rounds Part of the Standard Operating Procedure As part of the RCA process, agreed clinicians external to the Division to support with RCAs As part of SSBN network, agreed to support Wolverhampton (local level 3 NNU) with mutual Governance support by each provider giving 1 SPA per week to its partner organisation. Clinical Director in discussion with Clinical Director in another Level 2 hospital within the network Agreed to support mutual Governance opportunities V3.3 updated 25/0516 Page 15 of 16
ASSURANCE 16 The team should review its compliance with the Together for Child Health recommendations and develop a plan to implement and consequently reduce pressure on the urgent care service. Identify a lead to develop a plan on the reduction on the urgent care service Review the Together for Child Health document and present a current position statement at the Paediatric Governance meeting Paediatric Consultant / Registrar 30 th June Paediatric Registrar identified as lead Being presented as a scoping exercise at the Paediatric Governance meeting on 10 th June 17 Audit and strengthen postnatal check arrangements to ensure suitably qualified staff are conducting the checks in a timely manner. Audit to take place to ensure checks are taking place in a timely manner by suitably qualified staff Recommendations to be made following the audit Identify appropriate staff to carry out the postnatal checks ANNP 31 st May 30 th June Audit in progress and is expected to be completed by the end of May Recommendations to be implemented once audit completed To be identified once audit has been completed. 18 It would be prudent to invite a further review of the neonatal unit in 8-10 months time once the new Consultant has developed and begun to implement a strategy. A Black Country Alliance supported external audit to take place Liaise with the Clinical Director from a Level 2 hospital to support a further review Associate Clinical Director / Clinical Director 30 th November Clinical Director has liaised with the Clinical Director from a Level 2 hospital, agreement is expected to be reached at the end of June V3.3 updated 25/0516 Page 16 of 16