cog (11/16) item 9.2 - northern lincolnshire and goole ... · responded to the initial feedback...

CoG (11/16) Item 9.2.2

DATE 17 November 2016

REPORT FOR Council of Governors

REPORT FROM Kathryn Helley, Deputy Director of Performance Assurance/Asst Trust Sec

CONTACT OFFICER Kathryn Helley, Deputy Director of Performance Assurance/Asst Trust Sec

SUBJECT

CQC Update

BACKGROUND DOCUMENT (IF ANY)

EXECUTIVE COMMENT (INCLUDING KEY ISSUES OF NOTE OR, WHERE RELEVANT, CONCERN THAT THE COG NEED TO BE MADE AWARE OF)

COUNCIL ACTION REQUIRED

To note the report

CQC Action Plan

Executive Summary October 2016

Progress RAG Rating

RED The action is off plan and cannot be returned to the planned date or it has already missed the planned completion date

AMBER

Current indications are that action is on target OR is off plan but action is being put in place to mitigate the delay and the action is expected to return to the planned completion date

GREEN Action completed

BLUE

Action has been completed and there is now compelling evidence that the action has been embedded in day to day processes so it is unlikely that there will be a recurrence of the issue

1

Our improvement plan & our progress

Background & Introduction

• During October and November 2015 and January 2016, the Trust received announced and unannounced visits by the CQC. The Trust responded to the initial feedback received in respect of the issues identified from these visits including review and follow-up of a backlog of OPD follow-up patients, which the Trust was aware of and already dealing with prior to the CQC inspection, and in respect of the environment in A&E for the management of patients with a mental health problem, and provided assurances to the CQC on the implementation and delivery of plans to address these issues. The final report of the inspection was published on 15 April 2016. An action plan in response to the additional findings and recommendations was submitted to the CQC by the deadline of 6 May 2016. Following feedback received from the CQC, some amendments and additions have been made to the action plan. Support from our Commissioners has also been sought where some actions are outside of our control.

• Whilst this executive summary is intended to provide an overview of the plan progress including risks to delivery and also next steps, the full CQC action plan & associated KPIs are also attached.

• Delivery of the CQC action plan and in turn ensuring ongoing improvement to quality of care is the Trust’s foremost priority.

Oversight & Assurance Arrangements

• Strengthened oversight and assurance arrangements are in place to support the changes required and ensure the early escalation of risks to delivery including monthly 1:1 challenge meetings with Executive leads, weekly monitoring of the action plan and KPIs by the Executive Team (with a monthly CEO challenge meeting) and monthly by the Trust Board (details of the oversight & assurance arrangements are attached).

• The Trust’s CQC action plan has also been strengthened to include a strict BRAG rating. The benefits of the use of a BRAG rating, supported by a robust challenge and escalation process (see details of oversight & assurance arrangements attached), is that it shows both that actions have been completed and that there is clear evidence of embedding in day to day processes.

• In addition to the completion of the immediate actions, the Trust fully understands the need to sustain progress and ensure that the actions are embedded and lead to measureable improvements. To this end and in addition to the above arrangements, Key Performance Indicators (KPIs), each with a clear trajectory and timescale for demonstrating sustained improvements, have also been agreed.

• The Board assurance sub-committees (e.g. Quality & Patient Experience Committee, Trust Governance & Assurance Committee and Mortality Performance Assurance Committee) each has oversight of relevant sections of the CQC action plan and associated KPIs. The sub- committees, in turn, will be required to provide assurance to the Trust Board in respect of delivery and embedding of those elements of the plan and progress against the associated KPIS and / or to escalate any concerns or risks to delivery and the mitigating actions.

• As part of the above arrangements and in order to provide independent assurance in respect of the Trust’s progress with the delivery of its CQC action plan, the Trust has appointed an external ‘Improvement Director’, Eric Morton. It is intended that the Improvement Director will provide the following:

- challenge of the Trust’s delivery of the CQC action plan including through individual challenge meetings with lead Executives;

- independent assurance – internally & externally (including to NHSI and the CQC) as to the progress being made; and / or

- escalation of risks to delivery.

The Improvement Director will provide a monthly formal written progress report to the Trust and that report is attached to this summary).

• ‘On the ground’ testing to ensure embedding of the actions taken occurs via a variety of mechanisms including Announced and Unannounced Director Visits, Chief Nurse and Medical Director walk arounds and internal CQC themed visits.

• The Trust will also continue to commission other external support as the need is identified. This will include both audit and verification of actions put in place but also peer review and visits to other Trusts to learn from good practice elsewhere.

2


Progress / current position including any slippage / risks to delivery and mitigating actions

• Whilst good progress continues to be made with delivery of the CQC action plan, arising from the first two cycles of the revised oversight & assurance arrangements

(including review by the relevant Board assurance sub-committees, a number of actions within the plan have been BRAG rated as red (ie. where timescales have slipped

or where risk to delivery has been identified). For these red rated items, the relevant Board assurance committees were asked to consider mitigation actions and revised

timescales (where appropriate). Action

Number

Action Target

Completion Date

Explanation for Red Rating Expected

Completion Date

CQC3b Introduction of Paediatric Nurses to

the ED.

31 July 2016 As part of a review of establishments the Trust considered the introduction of dedicated

paediatric nurses for ED, not least due to the fact that there was the possibility of redeployment

of some of the paediatric nurses from childrens to A&E. If this had occurred, the nurses would

have required additional training to ensure that they were dual trained in order for them to be

able to see the wide range of patients who come through the door in A&E. Following a review

what other Trust have in place in A&Es and in discussions with NHSI, it was identified that it

would be more effective to adopt a pathway approach, as others have, thereby providing

appropriate care to all groups of patients at all times. These ratified pathways are in place and

plans are in place for them to be reviewed by NHSI for completeness. The pathways allow for

paediatric care that is unable to be delivered by A&E nurses, to be delivered via the paediatric

specialist team on site when required. Evidence to demonstrate the effectiveness of this model

is currently being collated and will be available by the end of October 2016.

31 October 2016

CQC14 The Trust must ensure there are

adequate specialist staff, training and

systems in place to care for

vulnerable people specifically those

with dementia.

31 August 2016 2 substantive appointments made – awaiting employment checks – 1 has 1 month notice

period, the other a 3 month notice period.

Member of staff working temporary hours on the bank from 5th September supporting Quality

Matron. Completion of national dementia audit is on track. All other actions are complete.

31 October 2016

CQC15 The Trust must ensure there are

adequate specialist staff, training and

systems in place to care for

vulnerable people specifically those

with learning disabilities.

31 August 2016 In North Lincolnshire, the NL CCG have commissioned RDash (mental health provider) to

recruit an ALD nurse to work between hospital and primary care (3 days hospital-based).

Recruitment to this post is underway. Following creation of a business case for a post at the

North East Lincolnshire end of the patch, a formal request was made to NEL CCG to

fund/commission a post. This request has not been supported. The business case has been

reviewed by NLAG ET against other priorities. Agreement has been reached to fund a full time

band 6 ALD liaison nurse post. Recruitment to this post is currently underway. The Trust

continues to receive positive feedback from a number of sources in relation to delivery of

person-centred care for patients with a learning disability. In addition to the involvement of the

lead Quality Matron, 2 other members of staff with an Adult LD qualification have been offering

advice and support on an ad-hoc basis. The Chief Nurse has written to neighbouring providers

to seek support in relation to an interim position however at this stage no resource has been

identified in support but advice over the phone may be available to the QM lead re: recruitment

as required. Telephone calls are in the diary to discuss further with Care Plus Group and

Navigo. Recruitment process is now underway. One of the new dementia nurse specialists has

experience of working with LD patients and should be in post by late October/early November

so will be a resource to utilise. Additional resource identified in KPMG review of the

safeguarding team re: supporting MCA/DOLS. Issue identified to ET for reserve list

prioritisation. Recruitment to this post will also provide support for staff in caring for patients with

an LD. Meeting held with Head of Community & Therapies and Lead Superintendant

Physiotherapist for the Adult LD team to consider how to strengthen inter-professional

collaboration.

31 October 2016

CQC25 Resolution of the Ophthalmology

backlog.

31 December

2015

Whilst the December 2015 timescale relates to the earlier work, the RAG rating relates to

current ongoing capacity issues.

Goole - October 2016

Scunthorpe -

November 2016

DPoW - January 2017

CQC26a Resolution of other specialty backlog. 31 December

2015

Whilst the December 2015 timescale relates to the earlier work, the RAG rating relates to

current ongoing capacity issues.

Work being

undertaken to

determine dates as

per ophthalmology

above

CQC50a Estates and Facilities to work with

Community and Therapy Services

Group to ensure all Portable

Appliance Testing (PAT) is

completed.

30 September

2016

There are 2 properties where PAT testing has to be completed. These will be completed by

31st October 16. The 2 outstanding properties are Pilgrim Primary Care Centre and Stirling

Medical Centre. A total of 30 properties have been completed.

31 October 2016

3


• A number of actions have also been BRAG rated as blue during the second round of the cycle (i.e. where the relevant Board sub-

committee was assured that sufficient evidence exists of embedding in to day to day practice).

Action Number

Action Executive Lead

CQC8a Continue to resize available resource and capacity, enact where required on the grounds of safety and look to CCGs for support when issues are 'flushed out' (nursing).

Tara Filby

CQC13 The Trust must stop including newly qualified nurses awaiting professional registration (band 4 nurses) within the numbers for registered nurses on duty.

Tara Filby

CQC17 The Trust must ensure there are always sufficient numbers of radiologists to meet the needs of people using the radiology service.

Karen Dunderdale

CQC44 Processes for ensuring that equipment is included in the Trust replacement plan and on the risk register to be shared again with Associate Chief Operating Officers to ensure compliance.

Karen Dunderdale

CQC52 The Trust must ensure that all substances which could be harmful are stored appropriately, specifically within the Ironstone Centre.

Karen Dunderdale

CQC53 The Trust should ensure that there is a standard operating procedure for the use of the second theatre (anaesthetic room) to maintain patient safety with maternity.

Karen Dunderdale

CQC58 Ensure that staff are aware of the need to ensure that multi-use equipment is cleaned between patients (maternity services).

Karen Dunderdale

CQC60 At DPOW, move to the use of single use monitoring belts (maternity services). Karen Dunderdale

CQC64 Whilst there is a process in place for staff to follow, there are notices displayed and verbal consent is obtained from patients and / or relatives for the use of the cameras / monitors, consent needs to be recorded in patient' notes.

Karen Dunderdale

CQC87 The Trust must review the validation of mixed sex accommodation occurrences, ensure patients are cared for in an appropriate environment and report any breaches. Undertake immediate review.

Karen Dunderdale

CQC94 Update of the Patient Information leaflet – NLAG/Health Watch Karen Dunderdale

CQC114 The Trust must ensure three-monthly safeguarding supervision takes place for health visitors. Karen Dunderdale

CQC132 The Trust should strengthen the support provided to nuclear medicine technologists by the ARSAC (administration of radioactive substances advisory committee) licence holder.

Karen Dunderdale

• These ratings are recommended to the Trust Board for formal ratification. The assurance templates and supporting evidence are

attached to this report to support the Board’s consideration of this recommendation.

• Progress with our overall action plan ‘at a glance’ is shown on pages 6 - 15 of this report. 4


Reporting our progress

• A report on our progress with the delivery and embedding of actions within the CQC action plan will be provided to the Trust Board

monthly.

• The report will include:

- this executive summary

- the detailed CQC action plan

- progress against the associated KPIs

- the monthly report from the Trust’s Improvement Director

• The report will also be shared with Governors and with relevant external stakeholders including:

- CQC

- NHSI

- CCGs

- HealthWatch

- OSCs

- MPs

• Progress against the plan will also be shared with staff through the existing communication and cascade arrangements in place within the

Trust.

5

Our Progress: ‘At a Glance’

Area Summary of Actions Agreed Timescale for Implementation of

Immediate Actions

Progress

Summary

Staffing Levels Review and where appropriate make changes to staffing levels:

- medical staff in A&E - revised rota (CQC1) 31 August 2016 Completed

- medical staff in critical care - annual leave (CQC2) 31 July 2016 Completed

- medical staff in critical care - introduction of rotas (CQC2) 1 October 2016 Completed

- nursing staff within A&E (CQC3a) 31 August 2016 Completed

- introduction of Paediatric Nurses to A&E (CQC3b) 31 August 2016 Some Slippage

- nursing staff within Medicine - establishment review (CQC4) 31 July 2016 Completed

- nursing staff within Surgery (CQC5) 31 August 2016 Completed

- rreview of midwives (CQC6) 31 August 2016 Completed

Continue to develop innovative solutions in partnership with other providers (CQC7) 31 October 2016 On Target

Continue to resize available resource and capacity & enact where required on the grounds of

safety - process in place - nursing (CQC8a)

31 April 2016 Embedded

Continue to resize available resource and capacity & enact where required on the grounds of

safety - enacting as required - medical (CQC8a)

31 August 2016 Completed

Proactively plan for and monitor any gaps in staffing and act accordingly - process in place

(CQC9a)

30 April 2016 Completed

Proactively plan for and monitor any gaps in staffing and act accordingly - enacting as required

(CQC9a)


Review dedicated management time allocated to ward co-ordinators: and managers (CQC10a) 31 August 2016 Completed

Review dedicated management time allocated to ward co-ordinators / shift leaders (CQC10b) 30 September 2016 Completed

Review and ensure adequate out of hours anaesthetic staff (CQC11) 31 October 2016 Completed

Review and ensure adequate consultant cover for AMU - audit) (CQC12a) 31 July 2016 Completed

Recruit additional ACPS to deliver a different model of care / use of locums in interim if no

substantive appointment is made (CQC12b)

30 September 2016 Completed

Cease using newly qualified nurses awaiting professional registration within ward numbers

(CQC13)

30 June 2016: Completed & Ongoing Embedded

Ensure there are adequate specialist staff, training & systems in place to care for vulnerable

patients specifically patients with dementia & learning disabilities (CQC14 & CQC15)

31 August 2016 Some Slippage

Appoint a Practice Development Midwife within Maternity Services (CQC16) 30 April 2016 Embedded

Ensure there are sufficient numbers of Radiologists (CQC17) 31 July 2016 Embedded

6


Area Summary of Actions Agreed Timescale for

Implementation of

Immediate Actions

Progress

Summary

Out-patient capacity Reinforce Access Policy & SOP regarding cancellation of clinic appointments and

requirement for clinical involvement om the process & decision making (CQC18)

Immediate (16 October

2015)

Completed

Monitor compliance with the above requirement (CQC19) Immediate (16 October

2015)

Completed

Undertake RCA to ensure issues identified at CQC visit in respect of the

cancellation of clinic appointments without clinical input is not systemic (CQC20)

31 October 2015 Embedded

Revise, Re-issue and Reinforce Access Policy (CQC21) 10 November 2015 Completed

Appoint overarching lead for with oversight of the clinical administration systems

and processes (CQC22)

2 November 2015 Embedded

Complete the clinical cancellation workshops and ensure ongoing staff

engagement in respect of the changes to clinical administration systems and

processes arising from the clinical admin review (CQC23)


Implement the recommendations from the Clinical Admin Review. (CQC24) 30 November 2015 Completed

Implement the current Patient Admin Action Plan including feedback from SAT /

operational teams and recommendations from KPMG Audit. (CQC30)

30 November 2016 Completed

Address the OPD backlog and ensure there is robust monitoring of these

arrangements going forward and monitor progress and with KPIs through the Executive Team. NB. Whilst immediate action was taken prior to and at the time

of the CQC visit, there has remained a capacity shortfall which has resulted in a

further backlog of out-patient follow-ups in Ophthalmology and other specialties. .

In respect of Ophthalmology, the Trust has agreed a clear improvement plan and

trajectory which has been discussed with CCGs and includes additional further

capacity, consideration of external capacity, validation and discussions with CCGs

in relation to further referral avoidance measures. Improvement plans and

trajectories have and are being agreed for all other specialties (CQC25)

31 December 2016 BRAG Rated as RED Due to

Current OPD Follow-up

Backlog

Improve OPD appointment cancellation rates and DNAs (CQC62) 31 October 2016 Completed

Agree the arrangements for out of hospital cardiology and respiratory services with

Commissioners (CQC31)

31 October 2016 Completed

Support & Guidance for GPs pre-referral to be agreed with Commissioners

(CQC32)

31 October 2016 On Target

MSK pathway to be progressed with commissioners (CQC33) 31 October 2016 Embedded

Assurance visits to OPD to be agreed with commissioners as part of wider

programme of assurance visits (CQC34)


7

Our Progress: ‘At a Glance’ Area Summary of Actions Agreed Timescale for

Implementation of

Immediate Actions

Progress

Summary

Environment & Equipment Make changes to the environment within A&E at SGH:

- to provide a dedicated room for the management of patients with a mental

health condition; (CQC35)

11 March 2016 Embedded

- to ensure treatment rooms are suitable for patients on trolleys; (CQC42) 11 March 2016 Embedded

- To create a separate waiting & treatment area for children that is safe and

secure; (CQC54)

30 September 2016

(commencement)

31 December 2016

(completion)

On Target

- To create separate entrances for patients self-presenting with minor injuries or

illnesses and those conveyed by ambulance with serious injuries (CQC55)

30 September 2016

(commencement)

31 December 2016

(completion)

On Target

Strengthen the risk assessment tool for patients with a mental health condition

(CQC39)

30 November 2015 Completed

Review the current CAMHS Team support to ensure children presenting in the

A&E Department with mental distress receive timely specialist assessment of their

needs including the review of pathways (CQC85b)

29 February 2016 Completed

Provide MHA training for staff within A&E (CQC40) 30 September 2016 (revised

date)

Completed

Install an alarm in both A&E triage areas (CQC41) 29 February 2016 Embedded

Ensure there is sufficient space and seating for patients and their supporters in

OPD (CQC56)


Ensure the premises and location of the Ophthalmology Department is ‘fit for

purpose’ (CQC57)


Ensure that equipment (specifically maternity, resuscitation and critical care

equipment) is checked, is in date and is ‘fit for purpose’ (CQC45)

31 July 2016 Completed

Processes for ensuring that equipment is included in the equipment replacement

plan and on the risk register to be shared with Groups and reinforced (CQC44)

30 June 2016 Embedded

Strengthen Equipment Group Terms of Reference & associated actions (CQC43) 30 September 2016 Completed

Increase staff awareness in relation to the need for checking equipment (CQC46) 31 July 2016 Completed

8



Implementation of

Immediate Actions

Progress

Summary

Environment & Equipment Include equipment checks in existing monitoring arrangements & assurance visits

e.g. internal CQC themed visits (CQC47)

31 May 2016 Completed

Ensure that community equipment and environments are cleaned in accordance

with agreed cleaning schedules (CQC48 & CQC49)


Ensure that community equipment is serviced and tested for electrical safety -

PAT testing (CQC50a)

30 September 2016

(Revised date 31/10/16)

Some Slippage

Ensure the safe storage of intravenous fluids - maternity at SGH (CQC51) 6 May 2016 Embedded

Ensure the safe storage of substances which could be harmful - Ironstone Centre

(CQC52)


Develop a standard operating procedure for the use of the second maternity

theatre (CQC53)


Ensure that within maternity services multiple use equipment and devices are

cleaned or decontaminated between use and records of cleaning are maintained

- instructions to staff and monitoring (CQC58)

31 May 2016 Embedded

Ensure that within maternity services multiple use equipment and devices are

cleaned or decontaminated between use and records of cleaning are maintained

- E&F Teams to evidence cleaning regimes (CQC59)


Implement single use monitoring belts (CQC60) 31 May 2016 Embedded

Consent Strengthen he arrangements for obtaining and recording consent from patients

and / or their families where CCTV and other monitoring systems may be in use

(CQC64)


Amend the CCTV Policy to capture the above arrangements (CQC65) 18 January 2016 Embedded

9



Implementation of

Immediate Actions

Progress

Summary

Medicines Management Ensure the safe storage and administration of medicines; specifically that drug fridge

temperatures are checked daily and minimum and maximum temperatures are recorded

and that staff are aware of the actions to take if the recordings are outside this range:

- Decommission fridge on Ward 23 (CQC66)


Reinforce Trust Policy & Procedure for monitoring of drug fridges (CQC67) 31 March 2016 Embedded

Ensure ongoing monitoring and testing of the above arrangements (CQC68) 30 June 2016 Completed & Ongoing

Implement an electronic system that remotely monitors fridge temperatures (CQC69) 31 October 2016 CQC requirement not

reliance on this action

Ensure the safe storage of oxygen cylinders on ITU at DPOWH (and elsewhere)

- assessment

- remedial works (CQC70)

30 June 2016

31 July 2016

Completed

Ensure the safe storage of oxygen cylinders on ITU at DPOWH (and elsewhere)

- staff awareness (CQC70)


Ensure the Discharge Lounge at DPOWH has a facility and process for the safe storage

of medicines and that there is a programme of education for staff (education) (CQC72)


Ensure the Discharge Lounge at DPOWH has a facility and process for the safe storage

of medicines and that there is a programme of education for staff (review) (CQC71)


Ensure that the procedures for the management of controlled drugs in patients’ homes is

standardised and all relevant staff are aware of and follow these procedures (review of

medicine codes) (CQC73)


Ensure that the procedures for the management of controlled drugs in patients’ homes is

standardised and all relevant staff are aware of and follow these procedures (staff

awareness) (CQC74)

30 June 2016 Completed

Ensure that the Patient Group Directions (PGDs) in the A&E Departments are reviewed

and in date (CQC75)


Mortality Address the mortality outliers and improve patient outcomes in these areas. (CQC76) 16 August 2016 Embedded

Introduce critical care specific morbidity and mortality meetings. (CQC77) 31 July 2016 Embedded

Pressure Ulcers Review the use of pressure relieving equipment and prevention blood clot equipment

within theatres. (CQC78)


10



Implementation of

Immediate Actions

Progress

Summary

Evidence Based Practice

and Monitoring and

Clinical Education

Ensure that the reasons for Do Not Attempt Cardio-Pulmonary Resuscitation

(DNAR) are recorded and implemented in line with best practice. (CQC79)


Ensure that the Five Steps for Surgery & WHO Checklist are consistently applied

and practice audited. (CQC80)


Continue to work towards delivering care and treatment in line with national

guidance and core standards for Intensive Care. (CQC81)

31 March 2018 On Target

Ensure that policies and guidelines in use in clinical areas are compliant with NICE

or other similar requirements and ensure staff are aware of these policies &

guidelines, specifically within maternity, A&E and surgery. (CQC82)

Ongoing On Target

Ensure that all maternity policies are up to date and reflect current guidance and

that staff are aware of these policies. (CQC83)

30 April 2016 Embedded

Develop a standard operating procedures to ensure consistency of the health

visitor role when working with GPs. (CQC84)


Ensure there are effective arrangements in place to assess, monitor and improve

the quality of end of life care including auditing preferred place of care and

outcomes (strategy approved) (CQC85a)


Ensure there are effective arrangements in place to assess, monitor and improve

the quality of end of life care including auditing preferred place of care and

outcomes (KPIs in place) (CQC85a)


Address the continuing gap in clinical education in critical care including the

appointment of a Nurse Educator (CQC86)


Eliminating Mixed Sex

Accommodation (EMSA)

Review and strengthen the Trust’s policy and arrangements to ensure there are

no mix sex accommodation breaches including improved escalation and

monitoring (CQC88)


Increase awareness of the national guidance & Trust policy through training

(CQC89)


Include the testing of the above arrangements in the existing assurance visits e.g.

Director Visit and CQC themed visits (CQC90)


CCG assurance visit to be undertaken to further test these arrangements (CQC93) 30 June 2016 Embedded

Review and agree with commissioners the time period for ‘step down’ patients

ready to leave a specialist unit (CQC92)


Update the Trust’s patient information leaflet to raise patient awareness of EMSA

(CQC94)

31 July 2016 Embedded

11



Implementation of

Immediate Actions

Progress

Summary

Patient Flow & Access Improve on the number of fractured neck of femur patients who receive surgery

within 48 hours (CQC95)

31 July 2016 (revised action

plan) / Timescale for any

additional actions TBC

Completed

Evaluate the medical review of outlying medical patients on surgical wards to

improve consistency of cover arrangements and prevent unnecessary delayed

discharges including;

- implementation of ACP model (CQC96) 31 July 2016 Embedded

- review and re-introduction of the short stay ward (CQC97) 30 June 2016 Completed

- review of weekend discharge process on all 3 sites to ensure best practice

(CQC98)


Review and strengthen the triage system with the A&E Departments including a

visit to a high performing Trust to view best practice with a view to introducing

within NLG (CQC99)


NLAG to visit other Trusts who are outstanding in the area of Triage (CQC100) 31 July 2016 Completed

Continue to monitor the arrangements for patient transport (new contract awarded

by commissioners and n place from September 2016) (CQC101a)


NEL CCG to consider introduction of a 30 day bed model (CQC102) 30 September 2016 Completed

NL CCG to consider whether walk in service would be better led by GPs

(CQC103)


Review patient flow and reduce delayed discharges from ITU. NB. The Trust is

not an outlier in this area (CQC104)


Review access and flow through the SGH angiography catheterisation lab to

reduce last minute cancellations, delays and wasted appointments including a full

capacity & demand review (CQC105)


Review patient flow through the SGH short stay ward to ensure this does not have

an adverse impact on the flow of patients through the Clinical Decisions Unit

(CQC106)


Review the effectiveness of the patient pathway for pre-assessment, the

timeliness of going to theatre and the number of on the day cancellations and

make changes as required (CQC107)


12

Our Progress: ‘At a Glance


Implementation of

Immediate Actions

Progress

Summary

Strategy, Vision &

Engagement

Through the development of a Staff Engagement Strategy, ensure that staff

understand and can communicate the key priorities, strategies and implementation

plans for their areas and are involved in improvements and receive appropriate

support to carry out their duties (CQC108)


Ensure the community teams are engaged in developing the vision and strategy

for their teams (CQC112)


Develop an end of life care strategy and vision and KPIs that reflect national

guidance (CQC110)


Identify patient representatives to join the End of Life Strategy Group (CQC111) 31 May 2016 Embedded

Appraisal & Mandatory

Training

Ensure staff, especially in surgery, have appraisals and supervision (CQC113) Ongoing On Target

Ensure three monthly safeguarding supervision takes place for health visitors

(CQC114)

31 March 2016 Embedded

Ensure the delivery of the targets for appraisal and mandatory training for all staff

groups but specifically in respect of community and end of life care staff and

specifically to improve staff understanding of the assessment of capacity and the

use of restraint (including chemical restraint) (CQC116)

Ongoing On Target

Ensure IR(ME)R training is mandatory for radiology staff (CQC118) 31 July 2016 Embedded

Patient Feedback Seek and act on feedback from patients in radiology in order to evaluate and

improve services (particularly at Goole) (CQC119)

Immediate Embedded

Duty of Candour Ensure that all staff within OPD are aware of their responsibilities in relation to the

Duty of Candour (CQC120)


13



Implementation of

Immediate Actions

Progress

Summary

Learning Lessons Ensure that lessons learned from incidents / SIs / ‘Never Events’ / complaints &

PALS / claims are shared and there is evidence available to demonstrate this

including through the re-launch of the ‘Please Ask’ Campaign (CQC121 & CQC122)


Ensure that staff can access and receive feedback and learning from incidents

(CQC124)


Ensure ‘how staff learn lessons’ is linked to the wider Staff Engagement Strategy and

staff are asked to share their ideas on how the Trust can improve these

arrangements (CQC123)


Agree and implement a standard template for use by all ward/department staff

meetings to ensure there is a standing item so share feedback and learning from

incidents etc. (CQC125)


Review membership of Learning Lessons Group to include consideration of

representation from wards / departments and admin staff (CQC126)

30 June 2016 Completed

KPI to be developed in respect of feedback and learning (CQC127) 30 September 2016 Completed

Audit effectiveness of above arrangements as part of Internal Audit Programme

(CQC128)


Promote the use of the Trust’s electronic incident reporting system (DatixWeb) within

Community Dental Service to ensure staff are aware of the requirement to report

incidents and that incidents are investigated and lessons learned (CQC129)


14



Implementation of

Immediate Actions

Progress

Summary

Management of Risk Ensure there are timely and effective governance processes in place in all areas to

identify and actively manage risks throughout the organisation (but specifically in

relation to critical care, staffing and ensuring essential equipment is included in the

Trust replacement programme) and ensure that all identified risks (Trust-wide and

at service level) are identified and recorded on the risk register – review to be

completed (CQC130)


Ensure that there is discussion on the risk register at all Directorate / Group

governance meetings (CQC131)

31 May 2016 Completed

Staff Support Strengthen the support provided to nuclear medicine technologists by the

Administration if Radioactive Substances Advisory Committee (ARSAC) (CQC132)


Record Keeping Ensure that record keeping meets all appropriate registered body standards

(particularly in the community) (CQC133)


15

CQC Action Plan Assurance Process

TRUST BOARD REGULATORY OVERSIGHT

MONTHLY HIGHLIGHT

REPORTS TO THE TRUST

BOARD FROM RELEVANT

BOARD SUB-COMMITTEES

CQC ACTION PLAN & KPIs:

UPDATE REPORT

SUBMITTED TO TRUST

BOARD

CQC ACTION PLAN & KPIs:

UPDATES SHARED WITH

OTHER EXTERNAL

STAKEHOLDERS

BOARD SUB-COMMITTEES EXECUTIVE TEAM / TMB

OVERSIGHT & ASSURANCE

OF CQC ACTION PLAN &

DELIVERY OF KPIs

FORMAL REVIEW OF PERFORMANCE

AGAINST DELIVERY OF CQC ACTION

PLAN & KPIs AND ESCALATION AS

APPROPRIATE (WEEKLY BY EXCEPTION &

MONTHLY ‘DEEP DIVE’ & CHALLENGE)

MONTHLY INDIVIDUAL CHALLENGE MEETINGS WITH

EXECUTIVE & ACTION PLAN LEADS / IMPROVEMENT

DIRECTOR / DIRECTOR OF PERFORMANCE ASSURANCE AND

DEPUTY DIRECTOOR OF PERFORMANCE ASSURANCE WITH

ESCALATION AS APPROPRIATE

DIRECTORATE / GROUP DELIVERY & OVERSIGHT

ON THE GROUND TESTING THAT ACTIONS ARE EMBEDDED

IMP

RO

VEM

ENT

DIR

ECT

OR

CH

ALL

ENG

E &

ASS

UR

AN

CE

INTE

RN

AL

AU

DIT

REV

IEW

OF

REL

EVA

NT

AR

EAS

WIT

HIN

TH

E C

QC

AC

TIO

N P

LAN

CHALLENGE, ESCALATION & ASSURANCE – HOW IT WILL WORK IN PRACTICE

MONTHLY CYCLE:

WEEK 1:

Individual Challenge meetings with Executive & Operational Action Leads / Improvement

Director / Director of Performance Assurance / Deputy Director of Performance Assurance –

with escalation of risks to delivery to ET and / or TMB as required

WEEK 2

CEO / ET / TMB ‘Deep Dive’ & challenge of progress

WEEK 3

Reports to & challenge by Trust Board Assurance Sub-Committees (e.g. Quality & Patient

Experience Committee, Trust Governance & Assurance Committee, Mortality Performance

Committee)

Relationship meeting with CQC / Improvement Director / Director of Performance Assurance

/ Deputy Director of Performance Assurance

WEEK 4

Trust Board oversight and challenge

Stakeholder meeting to review progress. Stakeholder attendees to include:

- NLG

- Improvement Director (Eric Morton)

- CQC

- NHSI

- CCGs

- HealthWatch

- OSCs

- MPs

REPORTING

One report – internally and externally – and combining:

Executive Summary

Detailed CQC Action Plan

Progress Against KPIs

Strengthened Assurance Process (first report)

Monthly Report from Improvement Director

Improvement Director Monthly Report

Trust Board – 25 OCTOBER 2016 Overall Assessed Status: AMBER

Overview (as at 18 OCTOBER 2016)

Monthly iterations of the CQC action plan and the output from the revised assurance process continue to be presented to monthly trust board meetings. This is the third such iteration.

During early October, progress meetings were again held with each executive action owner to review and update progress and to assess the position for reporting through the October cycle of Executive Team meetings, assurance committees and finally to this trust board.

The action plan continues to be reported using a BRAG system of rating, where actions are assessed at a joint meeting between the executive owner of the action, the assurance team and the ID. The position of each action is considered using evidence presented by the executive owner so the status can be determined as either:

o BLUE – action completed and evidence available to present to the appropriate assurance committee and trust board to demonstrate the completed action is now embedded and part of routine practice.

o RED – action is off plan and will not be completed in the target time scale. An explanation of why the action has fallen off track and measures the executive owner is taking to complete the action with a forecast completion date. The action remains RED, until the action is completed.

o AMBER – the action is on plan to complete by the target date. o GREEN – the action has been completed and is now in a period where the action is being embedded as part of routine practice.

Actions which were evidenced as embedded and where the executive owner can provide completing evidence that changes and actions taken are now part of routine practice have been assessed as BLUE and have been submitted to the appropriate assurance committee for consideration and ratification. These actions are reported on to this trust board for confirmation.

There has been a reduction in the number of actions being reported as RED. Plans have been discussed with the appropriate executive director consider measures to mitigate the impact of actions remaining off plan and to understand the measures being taken to bring these to bring these actions back on to plan as soon as practicable.

I remain confident that the action plan remains fit for purpose and provides a sound basis for all actions arising from the CQC inspection to be appropriately addressed, assessed and reported to the relevant assurance committee and trust board and shared with CQC (at the scheduled monthly engagement meetings) and NHSI.

The CQC re-inspection is now only one month away and whilst a significant number of actions are planned to be evidenced as embedded by the end of November, it is important for independent external testing of progress to be carried out. NHSI has made available senior staff to initiate this process and to set a series of reviews to test compliance and to assure that the actions which the trust has accepted as embedded remain fully in place

As the board is aware, it will not be possible to demonstrate embeddedness for a number of actions. In particular the waiting list backlog will not have been fully cleared by the time of the CQC re-inspection. However in such cases, there needs to be evidence of clear and credible plans to address the issue and a demonstration that progress against such plans has been sustained so as to be able to offer confidence that the plan will be delivered.

Actions have already been put in place to reduce the number of patients waiting for follow up appointments and further action is being planned by the trust and a dedicated member of staff to focus on waiting lists has now taken up post. In addition the Intensive Support Team at NHSI have also been to the trust to review, support and assure the actions being taken.

The challenge is significant but the development of clear actions and close working with clinical teams will allow significant in roads to be made. However it is not just a matter of clearing this backlog, it is critically important that the trust can demonstrate sound processes to ensure that such a situation cannot be repeated in the future. The support form the Intensive Support Team will be very helpful for this.

Overview (as at 18 OCTOBER 2016)

Last month, I revised my assessment of the position of the trust from RED/AMBER to AMBER. I am holding to that assessment for October. I have again based this assessment on the quality of the CQC plan, assurance processes and progress to date and the prospect of independent scrutiny of the plan being provided via colleagues from NHSI.

It is important that the trust leadership maintains strong progress on delivering against the CQC action plan in the next few weeks and in the run up to re-inspection. Both in terms of continuing to complete planned actions, evidencing that those actions are part of the day-to-day operation of the trust and preparing the trust and its staff for the inspection itself.

The trust has much to be proud of and the progress it has made over recent months has been significant. These achievements should be positively publicised, shared across the trust and celebrated across the trust and beyond, so that the trust and its staff can demonstrate and be proud of its strengths and achievements.

I have made no changes to my previous assessment of the main risks, which are set out on the following page.

Risks / Concerns Risk level

(High/Medium

/Low)

Recommended actions

Relatively short time available before CQC re-inspection, to complete actions and assemble compelling evidence that the completed actions are embedded as part of standard practice.

HIGH Continued monthly scrutiny and challenge of the CQC action plan.

Build confidence with external regulators CQC and NHSI, and also key stakeholders that good progress is being made and the trust will be in a good state of readiness for re-inspection in November.

HIGH Monthly meetings with CQC representatives where the action plan and progress is being shared will contribute significantly and it is also important to have a regular and open dialogue with senior CQC and NHSI colleagues.

In addition monthly Stakeholder Meetings are now also being held to share progress in a very open and transparent way.

Executive owners having time and resources to address their actions and make rapid progress towards completion and able to evidence that actions are embedded.

HIGH Executive owners must prioritise this work over the next few months to maximise progress and where possible exceed planned expectations.

The appointment of an interim COO will be major contribution to mitigating this risk in relation to the operational agenda.

Waiting lists – patients backlog. HIGH This is the most critical challenge. The recent revised reporting arrangements and the sharing of the position and weekly progress updates with commissioners, CQC and NHSI, demonstrates a clear intention of openness and engagement.

The appointment of an additional resource, dedicated to improving the management of waiting lists and the invitation to the Intensive Support Team is mitigating this risk.

Preparation for CQC inspection. HIGH Colleagues from NHSI are now working with the trust to undertake a series of CQC themed reviews across both main acute sites and raising concerns immediately to allow these to be addressed. In addition a comprehensive review is being developed to be carried out in the coming weeks to robustly test the state of preparedness of the trust for CQC re-inspection.

Date Activity Key work done & meetings attended (22 SEPTEMBER to 17 OCTOBER 2016)

22 Sept 2016 Claire Pacey - NHSI Meeting to develop arrangements for her to support the trust.

23 Sept 2016 NHSI Telephone conversation to agree NHSI support to the trust.

26 Sept 2016 Claire Pacey & Yvonne Evans (NHSI) & Wendy Booth & Kathryn Helley

Preparation meeting to agree scope of support from NHSI.

27 Sept 2016 Trust Board meeting

3 Oct 2016 Pam Clipson

Wendy Booth

CQC progress review meeting.


5 Oct 2016 Lawrence Roberts

Jug Johal

Tara Filby

CQC progress review

meeting. CQC progress

review meeting. CQC

progress review meeting. 6 Oct 2016 Warren Brown & Owen Southgate (NHSI)

Karen Dunderdale, Karen Fanshaw and assistant chief operational officers

Vince Connolly (medical director NHSI)

Meeting with executive team.


Telephone conversation.

11 Oct 2016 Neil Gammon

Executive team meeting

Wendy Booth

Telephone conversation.

CEO challenge on CQC action plan.

Progress meeting.

12 Oct 2016 Karen Dunderdale

Tara Filby

CQC & members of executive team

Chairman

Waiting lists.

Progress meeting.

Engagement meeting.

Progress meeting.

17 Oct 2016 Preparation of Improvement Director’s monthly report.

Key activities planned (for coming month)

Attend trust board meeting.

Attend Stakeholders meeting.

CQC progress review meetings with each executive action owner.

Attend trust board meeting.

Attend other meeting in the trust relating to progress on CQC action plan and preparation fro the re-inspection.

Liaise with NHSI as required.

Liaise with CQC as required.

----------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------

Overall status definitions

Good progress, no significant concerns or risks identified.

Reasonable progress, some concerns and risks that will need to be closely managed.

Progress is not sufficient, significant concerns and risks identified.

Any other comments

CQC Action Update – Assurance Template

CQC Action Number: 8a Current BRAG Rating Target BRAG Rating

CQC Recommendation: The Trust must ensure Achieved 31 August Target date for that there are sufficient skilled, qualified and 2016 evidence of experienced staff in line with best practice and embedding is end of national guidance, taking into account patients' On-going resizing October 2016 dependency levels. This must include but not be capacity according to limited to: medical staff within the emergency demand department (ED) and critical care, nursing staff within ED, medicine and surgery and midwives (DPOW). Action: Continue to resize available resource and capacity, enact where required on the grounds of safety and look to CCGs for support when issues are 'flushed out'.

Progress Update: Agreed standards for nurse staffing in place for inpatient wards with a minimum 1:8 nurse to patient ratio on days. Establishment review timetable in place (April 2016) as part of Sustainability plan. Reviews completed for Surgery & Critical Care, ECC, paediatrics, neonates and medicine and are in the process of implementation (August/September 2016). Maternity establishment currently based on last Birthrate Plus review (2014 data). Temporary uplift recommended to ET approved in

principle (12th August 2016). Birthrate Plus to be recommissioned by Women & Children’s Group.

Effective ward configuration discussed at Strategy & Planning meeting (July 2016) and is being linked into service review schedule (to be completed and pulled together by 3rd October).

Monitoring of short term impact of resizing capacity is reported through the monthly staffing capacity and capability reports with appropriate mitigation evidenced including temporary bed closures (from June 2016), usage of temporary bank/agency staff and redeployment. A whole ward (19 beds) closed 15th August temporarily to redeploy staff across the Medicine wards at SGH. Data for A&E fill rates to be included in the monthly report from September.

Evidence of Compliance and / or embedding * Supporting Documents ** Draft paper – principles discussed and agreed at Strategy & Planning

Further meeting held to review longer term configuration 19th August – follow up meeting to review outstanding queries in September 2016

Nurse staffing for

new bed model June

Temporary staffing establishments for reduced capacity wards agreed at Resource Committee September 2016

New bed model

August 2016.docx

Proposed bed configuration agreed via CEO Sustainability Challenge

meeting September 2016 Temp Staffing for

Reduced Capacity – I

Bed model paper

Sept 2016.docx

Monthly staffing paper to the Board

ECC fill rates included from September Board report onwards

NLG(16)310- Staffing

Capability and Capac

NLG(16)347 -

Monthly Capacity and

NLG(15)400 -

Staffing Capability an

6 monthly staffing report

NLG(16)339 - 6

monthly nurse staffin

Resizing capacity discussed at TMB to raise awareness re: impact and to seek clinician buy-in

FINAL TMB mins - 8th

August 2016.pdf

TMB mins - 22nd August 2016.pdf

On-going Monitoring Arrangements:*** Vacancy rate reported in monthly staffing report to Resource Committee and in staffing capacity and capability report to the Board – monitored by weekly operational delivery group and fortnightly oversight group as part of Nurse Staffing Improvement Sustainability programme KPIs in place for fill rate Agency issues escalated to ET Executive Director Responsible:

Tara Filby Board Sub Committee Responsible for Oversight (as per CQC Action Plan):

Resource Committee

* Describe the evidence you are providing to demonstrate compliance and / or embedding

** Please embed any relevant supporting documents

*** Describe method for ongoing monitoring eg. Group Governance Meetings, Team Meetings,

KPIs, Reports etc


CQC Action Number: 13 Current BRAG Rating Target BRAG Rating

CQC Recommendation: The Trust must stop including newly qualified nurses awaiting professional registration (band 4 nurses) within the numbers for registered nurses on duty.

Achieved June 2016 Embedding by end of September 2016

Action: Ensure that clear guidance is developed and embedded within Trust Policy.

Progress Update: July: KPI in place – weekly report run from the electronic roster, validation by Operational teams with evidence of action taken by the Nurse Staffing Improvement Manager Roster rules revised and templates all updated August: weekly reports have identified a small number of B4 staff allocated in B5 shifts. On investigation this has been due to human error or delay in processing change form/roster template for staff who have received their PiN number – hence do not recommend Blue rating until further KPI monitoring and assurance is received. Evidence is captured weekly. September: weekly review undertaken. No Band 4 working in band 5 shifts. Errors have been made as above but corrected due to weekly comprehensive review and plan changed efficiently and effectively. This will be monitored ongoing via a KPI

Evidence of Compliance and / or embedding * Supporting Documents **

Email communications outlining process

Band 4 nurses.msg

Nurses awaiting

PiN.msg

NMAF assurance

FINAL - NMAF mins

(06 05 16).doc

FINAL NMAF minutes

- June 2016.doc

Sample weekly report and challenge

PRN wrong grade

shifts.msg

RE URGENT re PRN

wrong grade shifts.m

Kimberly Fernie.msg

Pre Pin nurses..msg

Evidence table

Band 4 Pre pin

nurses.docx

Band 4 Pre pin nurses.docx

On-going Monitoring Arrangements:***

Weekly KPI and challenge by Chief Nurse

Executive Director Tara Filby Board Sub Committee Resource Committee Responsible: Responsible for

Oversight (as per CQC Action Plan):




KPIs, Reports etc


CQC Action Number: Number 17

Current BRAG Rating Target BRAG Rating

CQC Recommendation: The Trust must ensure there are always sufficient numbers of radiologists to meet the needs of people using the radiology service.

Action: Continue to work with HR Recruitment teams to source Radiologists on permanent, fixed term, or locum basis.

Completion 31st July 2016 Progress Update: The service has produced a matrix which shows presence of Radiologists in the departments each week from January to September 2016.

In terms of recruitment, two new radiologists were employed in December 2015 and April 2016 with a third person agreeing to a one year fixed contract.

Skype interview held 15/7/16, with Radiologist currently in Singapore – position offered but declined.

Continuing to look at CVs for further candidates. 3 further Skype interviews to be arranged.

Utilising existing links with Indian Teaching Hospitals to assess further interest – promotional literature has been delivered – follow up calls to be made by the recruitment team from October, and further literature to be circulated to other institutes.

Early Humber Coast & Vale (HCV) STP work is indicating potential opportunities, in terms of shared recruitment (split posts offering specialities which may help attract recruits) and also of collaborative ways of working which may help reduce the volume of work outsourced within HCV. Further meeting TBA to offer structured plans.


Radiologist Establishment / Vacancy position

Radiologist Est/Vac Position

Details of Interviews held, job offers pending, status updates etc

Radiologist Recruitment Progress

Evidence of presence of Radiologists within departments, highlighting actions taken

Radiologist presence Jan-Sept

Evidence of reporting backlog with narrative giving context to numbers.

Unreported Position 10.10.16.xlsx

Unreported PTL shows position against TAT targets

Unreported PTL 10.10.16.xls


Weekly Radiologist Rotas produced and circulated 6 weeks in advance to enable lists to be planned accordingly, and to allow for advance planning regarding additional support with Reporting if required

Monitoring of Unreported Radiology Images via daily PTL which shows numbers waiting by modality, priority, and length of time waited. Diagnostic Reporting policy shows standards against which PTL is compared.

Diagnostic Imaging

Reporting Policy (DCP Unreported PTL

10.10.16.xls

Unreported studies are validated on a daily basis via the PTL attached above, and also on a weekly basis when unreported report is circulated to head of clinical support services. Any outliers in terms of patients waiting longer than expected are checked and escalated to radiologists via Soliton messenger – example of messages attached:

Soliton messages to escalate reports.pdf

To put into context regarding the numbers of unreported images - for week commencing 26.9.16, the total number of exams reported was 8110; the total number of outstanding unreported exams (5860) is well below 1 week's reporting capacity. Rather than just looking at the number of studies, the length of time of the backlog is also considered, and the two of these together are the trigger for outsourcing exams for external reporting.

In order to minimise risk, reporting is carried out according to the following:

o IP & A/E CT & MRI; All Cancer imaging; All urgent imaging; Routine work o Routine work is split by source – GP work is prioritised as these images are unlikely

to have been reviewed by anyone prior to the report being available, A/E images should all have been reviewed by a trained A/E doctor so these images carry the lowest risk of delayed diagnosis.

Working closely with NLaG radiologists to maximise reporting capacity, by offering additional sessional reporting.

Maintaining daily contact with external reporting companies to ensure as much reporting as possible is outsourced – capacity is limited at present so all alternatives are being considered.

Undertaking costing exercise to understand requirements to remove all backlog reporting – to be reviewed monthly after month end finance activities completed & reported at Branch Business meeting.

Backlog Reporting

Costs

While it is acknowledged that the NLaG position is not ideal, it is being managed well, and some reassurance is taken from the fact that this is a National concern – see RCR census attachments:

RCR Census

Presentation.pptx RCR Census

Infographic.pdf

Board Sub Committee Responsible for Oversight (as per CQC Action Plan):




KPIs, Reports etc


CQC Action Number: CQC44 Lead: All ACOOs

Current BRAG Rating Proposed BRAG Rating

CQC Recommendation: The Trust must ensure that equipment is checked, in date and fit for purpose, including checking maternity resuscitation equipment and critical care equipment is reviewed and where required, included in the Trust replacement plan.

Action: Processes for ensuring that equipment is included in the Trust replacement plan and on the risk register to be shared again with Associate Chief Operating Officers to ensure compliance.

Completion Date: 30 June 2016

Progress Update:

A 'Medical Device Evaluation and Replacement Process' is in place within the Trust. This has been shared with the ACOOs and will be kept under review at the Equipment Group and will be further discussed at August's Equipment Group.


Equipment Group minutes

Adobe Acrobat

Document

Demonstration that those items on the equipment replacement plan are up to date

Adobe Acrobat Document

Medical Devices Evaluation & Replacement Process

Medical Device

Evaluation and Replac

On-going Monitoring Arrangements:*** Equipment Group to review the replacement process in accordance with documentation control requirements

Executive Director Responsible:

Dr Karen Dunderdale, Deputy Chief Executive/Director of Operations


Trust Governance and Assurance Committee




KPIs, Reports etc


CQC Action Number: 52 Lead: Dawn Daly


CQC Recommendation: The Trust must ensure that all substances which could be harmful are stored appropriately, specifically within the Ironstone Centre.

Action: Ensure that substances which could be harmful are stored correctly.


Progress Update: Ironstone building manager, Kirsty Dale. contacted to ensure the cleaning cupboard is locked at all times. She has confirmed that she has informed the cleaners of this action. Clinical staff do not access this cupboard, but have been asked to escalate immediately if they find the cupboard is unlocked whilst they are carrying our clinical sessions in the building.

Digilock fitted to cleaners cupboard where cleaning fluid stored.

Evidence of Compliance and / or embedding * Supporting Documents ** Team Lead/Lead clinician, responsible for checking that substances are stored correctly when using the clinical rooms at Ironstone. Spot checks carried out on service visits by managers.

Verbal assurance given by Tissue Viability sister and Team Leader. No issues regarding storage of cleaning fluid raised at recent mock CQC visits to the Ironstone.

CQC update for

Ironstone.msg

Confirmation of Digilock fitting to the cleaning cupboard 4. 7.16

FW Chronic wound

clinic.msg

Photo evidence

CQC 52 - photo of

lock on door.docx


Spot checks via mock CQC visits



Board Sub Committee Responsible for Oversight (as per CQC Action Plan)

Trust Governance & Assurance Committee




KPIs, Reports etc


CQC Action Number: 53 Lead: Ashy Shanker


CQC Recommendation: The Trust should ensure that there is a standard operating procedure for the use of the second theatre (anaesthetic room) to maintain patient safety with maternity.

Action: A standard operating procedure to be developed.


Progress Update: SOP agreed and in place. Approved by clinical governance group on 24/6/16.


SOP

Microsoft Word 97 -

2003 Document

Minutes of Governance meeting

Microsoft Word 97 -

2003 Document


Theatre Utilisation report




Quality & Patient Experience Committee




KPIs, Reports etc


CQC Action Number: CQC58, 60 Lead: Ashy Shanker


CQC Recommendation:

The Trust should ensure that within maternity services multiple use equipment and devices are cleaned or decontaminated between uses; that all areas are kept clean and records of cleaning are maintained.

Action: CQC 58 - Ensure that staff are aware of the need to ensure that multi-use equipment is cleaned between patients. Completion date: 31.05.16 CQC 60 - At DPOW, move to the use of single use monitoring belts. 31.05.16

Progress Update:

CQC 58 All managers have been instructed to ensure that multi use equipment is cleaned between patients and required to cascade this information. 1/6/16: Update: This requirement is being formally monitored by the Quality Matron as part of the monthly quality dashboard visits to determine level of staff awareness.

CQC 60 This has been enacted. The Head of Midwifery has confirmed that the use of reusable fabric monitor belts that required washing has now ceased and that disposable belts are now used instead. Disposable belts were ordered via supply chain purchase on 2 May 2016. The team are now on their 3rd box


Audit to demonstrate multi use equipment is cleaned between patients

Audit to demonstrate that single use equipment is being used

Adobe Acrobat

Document

Works order for the monitoring belts – May 16

Reorder of monitoring belts – September 2016

Adobe Acrobat

Document

Advice note - monitor

belts reorder sept16.p


QM monthly audits








KPIs, Reports etc


CQC Action Number: CQC64 Lead: ACOOs


CQC Recommendation: The Trust must have a process in place to obtain and record consent from patients and/or their families for the use of the baby monitors in critical care and for the use of CCTV in coronary care.

Action: Whilst there is a process in place for staff to follow, there are notices displayed and verbal consent is obtained from patients and / or relatives for the use of the cameras / monitors, consent needs to be recorded in patient' notes.

Completion Date: 31 August 2016

Progress Update: The requirements for the recording of consent in patients' notes has been reinforced and will be monitored by the Operational Matron. 1/6/16 Update: Monitoring visit undertaken by LSMS and all processes in place and being used. Additional monitoring visit to continue to test the application of the policy on CCU and Critical care with a Quality Matron visit to take place during June and with input from Operational leads. 'yes when they do the morning round, question the nurse in charge to ensure clearly documented evidence in the patient notes that the monitors are in use and the pt and family have been informed.' Helen Davis undertaking an audit of pts and evidence will be forwarded within the week – 15/9/16

October Update - W&C - There are 2 baby monitors on the neonatal unit at DPOW which are in the 2 rooms that can’t be seen from the nurses station – the isolation room (the door should be shut if baby in isolation therefore staff can’t hear a baby crying) and room 4 which are both situated off the main corridor. Work has been done with John Melville’s team to ensure these monitors are legitimate and signs are up on the unit informing parents that the monitor is in the room and the reasons why. Parents are also told verbally about the monitor if their baby is in the room.

The monitors are like ones you can have at home – two basic cameras, one in the room overlooking the baby in the cot, and the other at the nurses station so nurses can keep an eye on the baby from there. There is also sound on the monitor at the station so noise can be heard coming from the room.


Process for the use of a visual monitor in critical care areas

Process for the use of

a Visual Monitor withi

Audit of consent for camera use in CCU

Audit of consent for camera use in neonatal care

Audit of consent for camera use in ITU

CQC 64 Use of

Camera in ITU audit s

Privacy Impact Assessment

Privacy Impact

Assessment CCTV Ca

Photos of signs confirming monitors are in use in SGH ICU

Shift leader checklist – ongoing monitoring of consent for cameras

CQC 64 - photo

evidence of cameras i

CQC Action 45 - SGH

ICU shift leaders chec

Security Surveillance Report – John Melville (excluding Coronary Care)

Security Surveillance

report


Executive Director Dr Karen Dunderdale, Board Sub Committee Trust Governance & Responsible: Deputy Chief Responsible for Assurance Committee

Executive/Director of Oversight (as per CQC Operations Action Plan):




KPIs, Reports etc


CQC Action Number: 87 Lead: Karen Fanthorpe


CQC Recommendation: The Trust must review the validation of mixed sex accommodation occurrences, ensure patients are cared for in an appropriate environment and report any breaches.

Action: For immediate review and action.

Completion Date: April 2016

Progress Update:

Update @ 29.9.16

The Board considered the position of the Trust in regard to EMSA at its meeting on 26th January 2016. This included feedback from the discussion with Monitor the previous week. As a result, the Board decided that the escalation route for any mixing of sexes would be at director level only and for this to take immediate effect. Communications to this effect were cascaded immediately – evidence attached

The Trust continues to operate this escalation route for the mixing of sexes which requires authorisation at director level, in advance (NB this does not apply to specialist units such as ICU, HDU where the mixing of male & female patients is permitted within the guidance)

The Trust took immediate action with regard to the Acute Medical Unit at DPOW (which was the location for the reported breaches following the CQC visit). With effect from 25th January 2016, the AMU and Short Stay Unit were amalgamated into a single unit which provided the flexibility required to prevent any further risk of breaches occurring on this unit.

The Trust has submitted a zero return for breaches every month since January 2016 – evidence is provided of the monthly returns

The WebV system has been developed to provide an automated alerting function – this system provides the assurance for the Trust to be able to declare compliance in the monthly returns – a screenshot of the WebV screen is attached as evidence. A flow chart showing how this system operates is attached. An analysis of the trigger alerts for September 2016 will follow

QPEC is the route by which the ongoing actions for Eliminating Mixed Sex Accommodation are monitored and reviewed. The latest report (July 2016) is attached as evidence. The next report is due in October 2016.

Evidence of Compliance and / or embedding * Supporting Documents ** Briefing issued to instigate zero tolerance approach to the mixing of

sexes plus instructions re new escalation process – issued on 26th

January 2016

CQC 87 EMSA - email

to directors from KG 2

QPEC report (July 2016)

mailto:[email protected]

Monthly UNIFY reports (January – August 2016 inclusive)

MSA unify returns

Jan-Aug16.zip

WebV trigger alerting flow chart

Analysis of trigger alerts for Sept 2016 – to follow

WebV icon snapshot

MSA Trigger

Response flowchart 2

CQC 87 MSA screen

shot - red & blue beds

Spot checks of staff in AMU re Mixed Sex occurrences, reporting and escalation process – to follow

On-going Monitoring Arrangements:*** QPEC is the route by which the ongoing actions for Eliminating Mixed Sex Accommodation are monitored and reviewed.








KPIs, Reports etc


CQC Action Number: Numbers 94 Lead: Karen Fanthorpe

Current BRAG Rating Target BRAG Rating

CQC Recommendation: The Trust must review the validation of mixed sex accommodation occurrences, ensure patients are cared for in an appropriate environment and report any breaches.

Action: Update of the Patient Information leaflet – with input/support from Health Watch

Completion date: 30 September 2016

Progress Update: June 2016: Draft of a revised leaflet has been completed for discussion via Task and Finish Group. This has been shared with commissioners for their comments – in the interim, Commissioners have requested that the existing leaflet is provided to all patients in critical care areas and this has been actioned.

10.8.16: Final version of the new leaflet for patients has been to both the Healthwatch groups in NL and NEL and suggested amendments incorporated

8.9.16: The Eliminating Mixed Sex Accommodation (IFP-704) leaflet was approved via the Trust’s IFP Group

Order for new leaflets (x500) has been placed

29.9.16: copies of the leaflet have been distributed to the specialist wards/units for distributing to patients as an interim measure until the printed leaflets are received


Final version of the new leaflet

FINAL patient Leaflet

Single Sex Accommod


Leaflet will be reviewed in Sept 2019 in line with document control process








KPIs, Reports etc


CQC Action Number: Numbers 114 Lead: Dawn Daly


CQC Recommendation: The Trust must ensure three-monthly safeguarding supervision takes place for health visitors.

Action: Ensure three-monthly safeguarding supervision takes place.

Completion date: 31 March 2016

Progress Update: All early help champions and practice teachers were trained as peer safeguarding supervisors in

October 2015

Three monthly peer safeguarding supervision has been implemented within the HV service

In addition, six monthly named nurse supervision is undertaken which provides external challenge

An early warning mechanism has been developed to flag when someone is due to go out of compliance in order that this can be addressed so that applicable compliance remains at 100%.

14.9.16 – All HV’s are compliant with 3 monthly supervision –verbal September report 100%


Evidence from OLM that all eligible HV’s are compliant 3 monthly supervision has moved from 0% at the beginning of the year to 88% this month.

OLM report

All staff inform clinical development team of completion Group supervision summaries of discussions are added to personnel files

1:1 supervision evidence completed and attached to child’s electronic record

Staff email clinical development practitioner regarding completion of supervision so can be uploaded onto OLM

Personnel files SystmOne

Please find attached the safeguarding supervision compliance record. Report as of 12/08/2016 is at 88%. This equates to 5 staff members who have fallen out of compliance on 31.7.16, active management follow up occurring, (1 due to sickness)

OLM/ESR report from training and development

Recent safeguarding supervision audit demonstrates the embedding of the peer supervision in practice of those who undertook the audit and evaluates well. Please see below the relevant 3 monthly peer safeguarding supervision standards from the audit which evidence embedding. N=16

Safeguarding supervision audit-not yet published.

Standard 5 Achieved

For Early Help Peer Supervision the Supervisor should:

- Complete a practitioner supervision record that is signed off by both supervisor / supervisee during the session

- Retain a copy of the record for their records, kept in the supervisee’s supervision record.

13/13 (100%)

16/16 (100%)

Standard 12 Peer

For the Safeguarding Supervision meeting, this should:

Have protected time given 9/16 (56%)

Take place at a quiet venue with no interruptions 15/16 (94%)

Have mobile IT equipment and access be available 16/16 (100%)

Be supportive for the Supervisee 16/16 (100%)

Provide constructive feedback from the Supervisor to the Supervisee

16/16 (100%)

Review the progress of previously made initial or review supervision plans.

12/14 (86%)

Evidence from OLM – 3 monthly supervision Training programme for peer safeguarding supervision Six monthly named nurse supervision Evidence of early warning mechanism which flags out of compliance position Current position for safeguarding supervision as at end August

Training programme for peer safeguarding supervision

Microsoft Word 97 - 2003 Document

Six monthly named nurse supervision

Evidence of early warning mechanism which flags out of compliance position

Current position for safeguarding supervision as at end August

Microsoft Excel

97-2003 Worksheet

Standard 11 Peer

A copy of the supervision record should be:

- Retained by the practitioner for their records

- Kept In the supervisee’s supervision record in the Safeguarding Children Team office.

16/16 (100%)

16/16 (100%)

On-going Monitoring Arrangements:*** Clinical development practitioner/early help lead, head of CYPS service ,CYPS operational matron &

team leader and the head of safeguarding and named nurses are sent a report monthly which flags RAG compliance

The report is forwarded to the peer supervisors to monitor and ensure compliance of all team members

Amber compliant staff are emailed to remind regarding compliance

Once supervision has taken place staff send or email relevant documents to the clinical development practitioner/early help lead for uploading to OLM and placing in personnel file

Clinical development report during the HV professional meetings includes reminders for all staff regarding the compliance and process

Compliance and maintenance discussed at Early help champion meetings




Trust Governance and Assurance Committee




KPIs, Reports etc


CQC Action Number: CQC132 Lead: Tracey Broom


CQC Recommendation: The Trust should strengthen the support provided to nuclear medicine technologists by the ARSAC (administration of radioactive substances advisory committee) licence holder.

Action: Strengthen support as outlined in CQC action.

Completion date: 30 June 2016

Progress Update: A Consultant Radiologist from HEY is now our ARSAC Licence Holder – contract runs until March

2019. He provides support both remotely and in person when required. Consultant Radiologist &

ARSAC support will include:

reporting nuclear medicine scans for NLaG

documentation review 1-2 hours weekly

advice and guidance

Governance arrangements will include weekly visits by Hull physicists to NLaG

hospital sites

Audits as required

adhoc visits when required

training of NLaG Radiologists to report nuclear medicine scans


Final Service Specification

CQC 132 - Nuclear

med Service Spec inc

ARSAC Certificate for Dr Ged Avery

CQC 132 - ARSAC

licence certificate for

Contract monitoring action plan

CQC 132 NLaG - HEY

Contract Meeting Sept

On-going Monitoring Arrangements:*** Ongoing contract meetings – if issues arise, 1:1 meetings with HEY will be set up to discuss and resolve issues


Karen Dunderdale Board Sub Committee Responsible for Oversight (as per CQC Action Plan):

TGAC




KPIs, Reports etc

CQC Visit October 2015 - v24 - 19 10 2016

Progress RAG

Rating

RED

The action is off plan and cannot be returned to the planned date or it

has already missed the planned completion date

AMBER

Current indications are that action is on target OR is off plan but action

is being put in place to mitigate the delay and the action is expected to

return to the planned completion date

GREEN

Action on plan or completed

BLUE

Action has been completed and there is now compelling evidence that

the action has been embedded in day to day processes so it is unlikely

that there will be a recurrence of the issue

ACTION PLAN

NUMBER

SOURCE RECOMMENDATION ACTION PROGRESS EXECUTIVE LEAD OPERATIONAL LEADS TIMESCALE IMPLEMENTATION AND

EMBEDDING OF ACTIONS

BRAG RATING

VERIFICATION OF

ACHIEVEMENT/

EVIDENCE OF IMPACT

METHOD OF

MEASUREMENT

BOARD SUB

COMMIITTEE

OVERSIGHT

Safe

Staffing Levels

CQC1 CQC 2015 The Trust must ensure that

there are sufficient skilled,

qualified and experienced staff

in line with best practice and

national guidance, taking into

account patients' dependency

levels. This must include but

not be limited to: medical staff

within the emergency

department (ED) and critical

care, nursing staff within ED,

medicine and surgery and

midwives (DPOW).

Review of medical staff within the

emergency department to be

undertaken - both short and long term.

Rotas in place. Longer term plan being discussed across STP. Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

Peter Bowker, Associate

Chief Operating Officer

(Medicine), Stuart

Baugh, Associate

Medical Director, Paul

Kirton-Watson,

Associate Chief Nurse

(Medicine)

31 August 2016

(Revised rota to be

implemented)

31 March 2017

(HLHF work)

Date expected to be

fully embedded - 30

November 2016

Completed Appropriate staff in place

to deliver services

KPI308

Vacancy rate for doctors

KPI302

Number of shifts not

filled

Rotas

Resources

Committee

CQC2 Review of medical staff within critical

care to be undertaken and revised

arrangements implemented as

appropriate.

Terms of Reference for review agreed. Meetings taken place throughout September

around middle grade rota. DRS pattern has been fixed, however due to complexities

and nuances of anaesthetics training and cross skill mix, this is altered on a week by

week basis to enable training and activity cover as appropriate. Evidence demonstrates

that rotas are filled appropriately. Anaesthetics have also come up with a list of

improvements and best practice which will improve the rota further and this will enable

the activity planner to improve the process.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

Maureen Georgiou,

Interim Associate Chief

Operating Officer

(Surgery),

31 July 2016

(annual leave)


to deliver services

KPI309


KPI303


filled

KPI362

On the day cancellation

rates

Rotas

Resources

Committee

01/10/2016

(introduction of rotas)

Date expected to be

fully embedded - 31

December 2016

Completed

CQC3a Review of the nursing staff within the

emergency department to be

undertaken and revised arrangements to

be implemented as appropriate.

1Nursing establishment review for ECCs completed. Ambulance handover nurse in

place which has significantly improved position in both EDs. Daily & Weekly meeting

held to review staffing levels and patient throughput. At known exceptional times

plans put in place to increase staffing levels ie Bank Holiday Weekends. A monthly

retrospective review to be introduced July to ensure fill rates are maintained.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations



(Medicine), Stuart

Baugh, Associate

Medical Director, Paul

Kirton-Watson,


(Medicine)

31/08/2016

Date expected to be

fully embedded - 31

October 2016


to deliver services

KPI310 & KPI311 Vacancy

rate for nurses

KPI306


filled

KPI334

Resources

Committee

1

2

Introduction of Paediatric Nurses to the

ED.

As part of a review of establishments the Trust considered the introduction of

dedicated paediatric nurses for ED, not least due to the fact that there was the

Karen Dunderdale,

Deputy Chief



31/08/2016 Some slippage on original

date for completion

Datix incidents re capacity

Resources

Committee

possibility of redeployment of some of the paediatric nurses from childrens to A&E. If

this had occurred, the nurses would have required additional training to ensure that

Executive and

Director of

(Medicine), Stuart

Baugh, Associate

Date expected to be

fully embedded - 31 Rotas

they were dual trained in order for them to be able to see the wide range of patients Operations Medical Director, Paul January 2017 who come through the door in A&E. Following a review what other Trust have in place Kirton-Watson, in A&Es and in discussions with NHSI, it was identified that it would be more effective Associate Chief Nurse to adopt a pathway approach, as others have, thereby providing appropriate care to all (Medicine) groups of patients at all times. These ratified pathways are in place and plans are in place for them to be reviewed by NHSI for completeness. The pathways allow for paediatric care that is unable to be delivered by A&E nurses, to be delivered via the paediatric specialist team on site when required. Evidence to demonstrate the effectiveness of this model is currently being collated and will be available by the end of October 2016.

Review of the nursing staff within Nursing establishment process for Medicine Group has been completed in terms of Karen Dunderdale, Peter Bowker, Associate 31/07/2016 Completed Appropriate staff in place KPI316 & KPI317 Vacancy Resources

medicine to be undertaken. staffing profile. Engagement with ward managers has taken place. Deputy Chief Chief Operating Officer to deliver services rate for nurses Committee

Establishment review has been approved at Resources Committee in August. All Executive and (Medicine), Stuart Date expected to be rosters have been amended to commence 12th September 2016. Director of Baugh, Associate fully embedded - 31 KPI304 Operations Medical Director, Paul December 2016 Number of shifts not Kirton-Watson, filled Associate Chief Nurse (Medicine) KPI335 Datix incidents re capacity

Rotas

Review of the nursing staff within Following establishment reviews in May the new ward templates have been adjusted Karen Dunderdale, Maureen Georgiou, 31/08/2016 Completed Appropriate staff in place KPI314 & KPI315 Vacancy Resources

surgery to be undertaken. as from 15/8/16. Ward managers all refreshed regarding the reporting mechanism for Deputy Chief Interim Associate Chief to deliver services rate for nurses Committee

staff discussion at joint ward managers meeting on 20/6/16 – minutes available. Executive and Operating Officer Date expected to be Discussion of concerns re filling the rotas is resulting in reduction of beds within Director of (Surgery), fully embedded - 31 KPI305 surgical areas. Ongoing reassessment and review of occupancy, acuity and staffing Operations October 2016 Number of shifts not throughout the day with a daily and weekly review. Rosters now in place. filled

KPI336

Datix incidents re capacity

Rotas Review of number of midwives to be The midwifery staffing numbers have been reviewed against Birthrate Plus and meet Karen Dunderdale, Ashy Shanker, Associate 31 August 2016 Completed Appropriate staff in place KPI319 Resources

undertaken Trustwide. the requirements under this methodology. However, due to recent activity pressures Deputy Chief Chief Operating Officer (staffing changes to deliver services Vacancy rate for Committee

and the implementation of Trust policy to move to increased shift breaks, it has been Executive and implemented) Midwives identified that an additional 4.88 midwives are required. A proposal was presented to Director of ET in early June at which time, further information was requested. The revised paper Operations KPI307 will be discussed at the meeting on 19 July. The paper also recommends that the Trust Number of shifts not re-commissioners Birth-rate Plus to undertake a further review of the establishment. filled In the meantime, the additional shift required continues to be filled by substantive staff undertaking additional hours to ensure the safety of women within maternity wards. It KPI337 was approved by the executive team to support the increase in establishment on a Datix incidents re short term basis, and to support Birthrate plus being recommissioned. This however capacity would need to be reviewed against the trust reserve list and prioritised accordingly. Awaiting decision. KPI364 Ratio of midwives to births 31/12/2016

(Birth-rate Plus review

to have been

undertaken)

On Target

KPI365

1:1 figures for births

Maternity Dashboard

CQC3b

CQC4

CQC5

CQC6

CQC7 NLAG to continue to develop innovative

recruitment solutions in partnership with

other providers. NB: the Trust will

continue to seek support and advice

from national agencies to help with

recruitment.

Recruitment activities continue. Recruitment Strategy being developed at present, will

be circulated for comments across the Trust through November.

Jayne Adamson,

Interim Director of

People and

Organisational

Effectiveness

Claire Smaller, Head of

Employment Services

31 October 2016

Date expected to be

fully embedded - 31

March 2017

On Target Appropriate staff in place

to deliver services

KPI52


KPI319

Vacancy rate for

midwives

KPI51

Vacancy rates for nurses

KPI53

Vacancy rates for AHPs

KPI318

Vacancy Rate for

Unregistered Nurses

Resources

Committee

CQC8a Continue to resize available resource and

capacity, enact where required on the

grounds of safety and look to CCGs for

support when issues are 'flushed out'.

Agreed standards for nurse staffing in place for inpatient wards with a minimum 1:8

nurse to patient ratio on days. Establishment review timetable in place (April 2016) as

part of Sustainability plan. Reviews completed for Surgery & Critical Care, ECC,

paediatrics, neonates and medicine and are in the process of implementation

(August/September 2016). Maternity establishment currently based on last Birthrate

Plus review (2014 data). Temporary uplift recommended to ET approved in principle

(12th August 2016). Birthrate Plus to be recommissioned by Women & Children’s

Group.

Effective ward configuration discussed at Strategy & Planning meeting (July 2016) and

is being linked into service review schedule (to be completed and pulled together by

3rd October). Monitoring of short term impact of resizing capacity is reported through

the monthly staffing capacity and capability reports with appropriate mitigation

evidenced including temporary bed closures (from June 2016), usage of temporary

bank/agency staff and redeployment. A whole ward (19 beds) closed 15th August

temporarily to redeploy staff across the Medicine wards at SGH. Data for A&E fill rates

to be included in the monthly report from September.

Tara Filby, Chief

Nurse

Sue Peckitt, Deputy

Chief Nurse/ Associate

Chief Nurses

31 August 2016

Date expected to be

fully embedded - 31

October 2016

Ratified in principle at

Resources Committee on 19

October 2016

Appropriate staff in place

to deliver services

KPI52, KPI319, KPI151 &

KPI53

Vacancy rate for Nurses/

AHPs/ Doctors/ Midwives

KPI350

Number of service

reviews undertaken

KPI351

Number of services with

capacity plans

Rotas showing fill rates

Resources

Committee

CQC8b The MD office continues to provide oversight and scrutiny on the job plan project.

Concerns were raised in August Private Board regarding shortage of microbiologists

available in September. 93% of medical staff have a draft job plan, 30% have a signed

off job plan. Man marked job plan progress chart established to enable identification of

non-engagers

Lawrence Roberts,

Medical Director

Jane Heaton, Assistant

to the Medical Director

31 April 2016

Date expected to be

fully embedded - 31

March 2017

Completed Resources

Committee

CQC9a Processes need to be in place to

proactively plan for and monitor any

gaps in staffing.

As part of ‘Nurse Staffing Improvement’ Sustainability programme, processes have

been reviewed including: Establishment reviews – to match patient need to staffing in

terms of numbers and acuity/dependency – policy under development but reviews

undertaken at least annually with a review at 6 months – this uses Safer Nursing Care

Tool and a local model based on RCN & NICE guidance – output approved at Resources

Committee

SOP developed to archive approved rosters - archive created on shared drive. Roster

policy in place with KPIs to monitor compliance of e-Rostering – approved by Matrons.

Competency framework built into background of roster template – to be rolled out to

all areas to support effective skill mix distribution. Short term staffing policy in place -

New process under development for escalating “red” shifts and authorisation of ‘break

glass’ agency use – looking to include a strengthened proactive process as part of the

revised policy. Facility for identifying “red flag” events included on DATIX. Recruitment

plan and retention plan in place and monitored through oversight/stocktake. Head of

Clinical Rostering & Bank Services and e-Rostering Systems Manager part of Managing

Absence HR work stream. Deputy Chief Nurse has milestone plan in place to ensure

establishments reviewed at agreed intervals

Tara Filby, Chief

Nurse

Associate Chief Nurses

and Associate Medical

Directors (All

Groups)/Claire Smaller -

Head of Recruitment

31 August 2016

Date expected to be

fully embedded - 31

October 2016


to deliver services

KPI52, KPI319, KPI151 &

KPI53

Vacancy rate for Nurses/

AHPs/ Doctors/ Midwives

Staff rosters

Use of bank and agency

staff

Board Papers

Resources

Committee

CQC9b Recruitment is part of the weekly directorate meetings covering clinical areas which are

governed to review establishments, approve vacancies and review priorities for each

area. This is a business partner model of working which is joined up in its approach to

ensure the recruitment team target the right skills and candidates needed to be

recruited working to local and national best practice. Minutes and notes of these

meetings are available. This is also managed within the sustainability meetings to which

recruitment report progress and escalate concerns. Current priority lists are under

review to ensure that the recruitment team are targeting the right skills and roles. A

number of posts have been offered and the team are currently working on the

conversion of these roles to ensure a quick and effective pre-employment phase

leading to a start date.

Lawrence Roberts,

Medical Director

Jane Heaton, Assistant

to the Medical Director

31 April 2016

Date expected to be

fully embedded - 31

October 2016

Completed Resources

Committee

3

4

CQC10a CQC 2015 The Trust must include a A review of this requirement was already All nurse managers have a proportion of protected time within their roster to support Tara Filby, Chief Associate Chief Nurses 31/08/2016 Completed Ward leaders report Staff Rosters Quality and Patient

review of dedicated underway prior to the CQC visit. managerial duties including PADRs, sickness support meetings etc. This is a minimum of Nurse (All Groups) having dedicated Experience

management time allocated to 9.5 hours and increases in accordance with number of areas managed and size of Date expected to be management time Feedback from Ward Committee

ward co-ordinators and nursing team. The Trust has prioritised a review of shift leader status but has the fully embedded - 31 Leaders managers. aspiration of increasing the proportion of protected time for managers in addition to October 2016 shift leaders within the next 12-24 months as evidenced in the paper to ET & Resource KPI349 Committee (April 2016). Number of wards with Amount of protected time has been reviewed as part of the establishment review dedicated management process – completed by end of August 2016. It has been identified that maternity is an time outlier as only has 7.5 hours currently. Paper to ET 14 August 2016 approved in principle to move towards standard minimum of 9.5 hours for equity with other inpatient areas.

CQC10b CQC2015 CQC Recommendation: The A review of this requirement was already April 2016: Resource Committee approved the first phase of implementation of shift Tara Filby, Chief Associate Chief Nurses 31/12/2015 Completed Ward leaders report Staff Rosters Quality and Patient

Trust must include a review of underway prior to the CQC visit. leaders on 5 wards. June 2016: Risk assessment completed with mitigation actions Nurse (All Groups) (options paper having dedicated Experience

dedicated management time identified including: daily staffing reviews, bay nursing, hourly care rounds, other roles presented to ET management time Feedback from Ward Committee

allocated to ward co- under development/pilot, identification of nurse in charge (red badge), Quality Matron 05/01/16 -completed) Leaders ordinators/shift leaders. nursing dashboard audits (care & patient experience), use of Safe Care Live tool and monthly oversight at the Board of fill rates and quality impacts on care. July 2016: shift 22/03/16 KPI349 leader for AMU/CDU in place on early and late shift, planned roll out of shift leaders (approval of proposed Number of wards with affected by recruitment difficulties and staff shortages on ward 22 and 25 so temporary way forward - dedicated management bed closures have been initiated. A shift leader on the early shift has been factored into completed) time the refreshed template. B2 shift leader to be rolled out July/August along with agreed establishment. September: shift leaders have been built into 5 ward areas as agreed in addition to ECC and ED however there have been difficulties with consistency of fill rate. Due to bed reductions it was agreed to move the pilot from ward 25 to ward 28 – this was only commenced on the September roster period. Feedback from each ward has been collated and is extremely positive as expected from front-line staff and ward sisters however it is limited due to time taken to recruit and fill the shifts. Medicine establishments for the 30 bed wards at SGH have had an agreed funded uplift to their establishment to 5 RNs which will give a 1:8 nurse to patient ratio plus a shift lead on days. A new bed reconfiguration has been reviewed at CEO challenge 28 September 2016 which proposes a move to a 24 bed model – with 4 RNs on Early and Late shift. This would ensure a 1:8 nurse to patient ratio plus a dedicated shift lead.

30 September 2016

(further actions to be

agreed following pilot)

Completed

CQC11 CQC 2015 The Trust must ensure Establishment review to be undertaken. Terms of Reference for review agreed. Meetings taken place throughout September Karen Dunderdale, Maureen Georgiou, 31/10/2016 Completed Shifts filled as per Trust Staff Rosters Resources

adequate out of hours Medical Director to source outside around middle grade rota. DRS pattern has been fixed, however due to complexities Deputy Chief Interim Associate Chief requirement Committee

anaesthetic staffing to avoid consultant to assist with this. Timescale and nuances of anaesthetics training and cross skill mix, this is altered on a week by Executive and Operating Officer Date expected to be KPI332 delays in treatment. estimated to be October 2016. In week basis to enable training and activity cover as appropriate. Evidence demonstrates Director of (S&CC)/ Dr Krishnan, fully embedded - 31 Incident reports due to addition meeting taking place by end of that rotas are filled appropriately. Anaesthetics have also come up with a list of Operations Clinical Lead for December 2016 lack of anaesthetist May 2016 with middle grade improvements and best practice which will improve the rota further and this will enable Anaesthetics anaesthetics to confirm new rota and the activity planner to improve the process. KPI367 (a-e) reinforce annual leave policy. On the day cancellations

CQC12a CQC 2015 The Trust should evaluate the Baseline data to be drawn from 7 day Trust has been able to access & analyse our data from national 7 day services survey Karen Dunderdale, Peter Bowker, Associate 31/07/2016 Completed Gap analysis in place Audit Data Resources

arrangements for consultant working audit to determine the gap in held in April 2016. Deputy Chief Chief Operating Office Committee

cover of the AMU to ensure a cover arrangements. Executive and (Medicine)/ Stuart consultant reviews all patients Director of Baugh, Associate daily, irrespective of length of Operations Medical Director stay. (Medicine)

CQC12b Programme of recruitment of ACPs to DPOW now has 5 long term locum ACPs operating from AMU additionally ACPs cover Karen Dunderdale, Peter Bowker, Associate 30/06/2016 Completed Patients reviewed KPI300, KPI301, KPI302, Resources

deliver a different model of care. from rotational basis at the weekend discharging alongside the junior doctor. The Deputy Chief Chief Operating Office (for recruitment to be appropriately KPI303, KPI304, KPI305, Committee

length of stay has reduced by 1 day. Executive and (Medicine)/ Stuart agreed) KPI306 & KPI307 Director of Baugh, Associate Clinical shifts unfilled Operations Medical Director (Medicine) KPI52, KPI319, KPI151 & KPI53 30 September 2016 Completed Vacancy rate for Nurses/ AHPs/ Doctors/ Midwives

5

CQC13 CQC 2015 The Trust must stop including

newly qualified nurses

awaiting professional

registration (band 4 nurses)

within the numbers for

registered nurses on duty.

Ensure that clear guidance is developed

and embedded within Trust Policy.

July: KPI in place – weekly report run from the electronic roster, validation by

Operational teams with evidence of action taken by the Nurse Staffing Improvement

Manager

Roster rules revised and templates all updated

August: weekly reports have identified a small number of B4 staff allocated in B5 shifts.

On investigation this has been due to human error or delay in processing change

form/roster template for staff who have received their PiN number – hence do not

recommend Blue rating until further KPI monitoring and assurance is received.

Evidence is captured weekly.

September: weekly review undertaken. No Band 4 working in band 5 shifts. Errors have

been made as above but corrected due to weekly comprehensive review and plan

changed efficiently and effectively. This will be monitored ongoing via a KPI

Tara Filby, Chief

Nurse


(All Groups)/ Helen

Clarke, Clinical Lead for

E-roster Team

30/06/2016

Date expected to be

fully embedded - 30

September 2016



October 2016

Rosters filled

appropriately

Staff Rosters

Establishment Reviews

KPI207

Pre pin usage

Resources

Committee

CQC14 CQC 2015 The Trust must ensure there

are adequate specialist staff,

training and systems in place

to care for vulnerable people

specifically those with

dementia.

Scope staffing requirements and develop

business case to take to Strategy &

Planning and for discussion with CCGs.

2 substantive appointments made – awaiting employment checks – 1 has 1 month

notice period, the other a 3 month notice period.

Member of staff working temporary hours on the bank from 5th September supporting

Quality Matron. Completion of national dementia audit is on track.

Tara Filby, Chief

Nurse

Rachel Greenbeck,

Quality Matron, Craig

Ferris, Head of

Safeguarding.

31 August 2016 Some slippage on original

date for completion

Revised Completion Date

31 October 2016

Appropriate care

delivered to vulnerable

patients

National Audit of

Dementia

KPI62

Dementia Training

Quality and Patient

Experience

Committee

CQC15 CQC2015 The Trust must ensure there

are adequate specialist staff,

training and systems in place

to care for vulnerable people

specifically those with learning

disabilities.

In North Lincolnshire, the NL CCG have commissioned RDash (mental health provider)

to recruit an ALD nurse to work between hospital and primary care (3 days hospital-

based). Recruitment to this post is underway. Following creation of a business case for

a post at the North East Lincolnshire end of the patch, a formal request was made to

NEL CCG to fund/commission a post. This request has not been supported. The

business case has been reviewed by NLAG ET against other priorities. Agreement has

been reached to fund a full time band 6 ALD liaison nurse post. Recruitment to this post

is currently underway. The Trust continues to receive positive feedback from a number

of sources in relation to delivery of person-centred care for patients with a learning

disability. In addition to the involvement of the lead Quality Matron, 2 other members

of staff with an Adult LD qualification have been offering advice and support on an ad-

hoc basis. The Chief Nurse has written to neighbouring providers to seek support in

relation to an interim position however at this stage no resource has been identified in

support but advice over the phone may be available to the QM lead re: recruitment as

required. Telephone calls are in the diary to discuss further with Care Plus Group and

Navigo. Recruitment process is now underway. One of the new dementia nurse

specialists has experience of working with LD patients and should be in post by late

October/early November so will be a resource to utilise. Additional resource identified

in KPMG review of the safeguarding team re: supporting MCA/DOLS. Issue identified to

ET for reserve list prioritisation. Recruitment to this post will also provide support for

staff in caring for patients with an LD. Meeting held with Head of Community &

Therapies and Lead Superintendant Physiotherapist for the Adult LD team to consider

how to strengthen inter-professional collaboration.

Tara Filby, Chief

Nurse

Rachel Greenbeck,

Quality Matron, Craig

Ferris, Head of

Safeguarding.

31 August 2016 Some slippage on original

date for completion


31 October 2016

Appropriate care

delivered to vulnerable

patients

KPI355

Vulnerable Adults

Training

Quality and Patient

Experience

Committee

CQC16 CQC 2015 The Trust must ensure it acts

on its own gap analysis of

maternity services across the

Trust to deliver effective

management of clinical risk

and practice development.

At the time of the visit the Trust had put

together a business plan to support the

appointment of a dedicated Practice

Development Midwife to support risk

and practice development.

The Practice Development Midwife has been appointed to and commenced during April

2016. This post encompasses the requirements for Risk and Governance into one

combined post.

Initial feedback on the impact of the post is positive in terms of:

- Backlog of RCAs have been dealt with ( had about 40)

- New RCAs progressed quickly

- Complaints dealt with more responsively

- Policies and guidelines( incl NICE) for the group updated in time

- CTG training for midwives and medics implemented

- Additional workload on matrons eased

- Specific service development /quality improvement initiatives championed ( E.g

Bereavement room etc.)

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

Ashy Shanker, Associate


(W&C)/ Julie Dixon,

Head of Midwifery

(W&C)

31 April 2016 Ratified at QPEC 10 August

2016

Governance & Practice

Development Midwife in

post

KPI342

Document control

KPI333

Incident RCAs

Quality and Patient

Experience

Committee

CQC17 CQC 2015 The Trust must ensure there

are always sufficient numbers

of radiologists to meet the

needs of people using the

radiology service.

Continue to work with HR Recruitment

teams to source Radiologists on

permanent, fixed term, or locum basis.

The service has produced a matrix which shows presence of Radiologists in the

departments each week from January to June 2016. In terms of recruitment, two new

radiologists were employed in December 2015 and April 2016 with a third person

agreeing to a one year fixed contract. Skype interview held 15/7/16, with Radiologist

currently in Singapore – position offered - currently negotiating salary & start date etc.

Continuing to look at CVs for further candidates. Utilising existing links with Indian

Teaching Hospitals to assess further interest – promotional literature to be delivered in

person over next 3 weeks.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

Tracey Broom,

Associate Chief

Operating Officer (CSS)/

Oltunde Ashaolu,

Associate Medical

Director (CSS)

31 July 2016

Date expected to be

fully embedded - 31

October 2016



October 2016

Reduction in the

radiology vacancy rate

KPI326, KPI327, KPI328,

KPI329, KPI330 & KPI331

Radiology reporting times

KPI363

Radiologist Vacancy Rate

Resources

Committee

Outpatient Capacity

CQC18 CQC 2015 The Trust must ensure that the

significant outpatient backlog

is promptly addressed and

prioritised according to clinical

need. It must ensure that the

governance and monitoring of

outpatients' appointment

bookings are operated

effectively, reducing the

Whilst the capacity issues within OPD are

known to the Trust and actions were

underway prior to the CQC visit to

resolve the backlog and there is

monitoring of the follow-up position and

actions through the Executive Team,

immediate steps to be taken ensure that

appointments are not being cancelled

without clinical input in to decision

In accordance with the Trust’s existing Access Policy and SOPs, an immediate

instruction was issued on Friday, 16th October 2015 to all clinical administration teams

that clinic appointments must not be cancelled without a clinical opinion (i.e.. existing

requirements were reinforced). Staff are also being empowered to escalate any

concerns or where they feel they are being asked to take actions which are outside of

this requirement. This latter requirement was reinforced as part of the above

instruction / briefing. Process continues to be followed with spot checks undertaken

by teams.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations


Chief Operating Officer,

(Medicine)/ Maureen

Georgiou, Interim

Associate Chief

Operating Officer

(S&CC)/ Ashy Shanker,

Associate Chief

Operating Officer

16 October 2015

Date expected to be

fully embedded - 31

November 2016

Completed Improved quality &

safety

Reduction in incidents

Reduction in complaints

& concerns

Waiting List Reports

Observational Audit

Director / ACOO Walk

rounds

KPI195

Reduction in Hospital

Quality and Patient

Experience

Committee

numbers of cancelled clinics

and patients who did not

attend, and ensuring

identification, assessment and

action is taken to prevent any

potential system failures, thus

protecting patients from the

risks of inappropriate or unsafe

care and treatment.

making. outpatient Cancelled

Appointments (by

patients)

KPI361

Outpatient Clinic Slot

Utilisation Rate

6

CQC19

CQC20

CQC21

CQC22

CQC23

CQC24

Compliance with the above instruction will be monitored daily through the clinical

administration supervisory staff and will be tested weekly by the Assistant Chief

Operating Officers (ACOOs). There will be further monitoring through observational

audit and KPIs.

(W&C) 16 October 2015

Date expected to be

fully embedded - 31

November 2016

Completed

A Root Cause Analysis (RCA) exercise was completed immediately this issue came to

light and in order to demonstrate that this practice was not systemic. The actions

arising from the RCA are included within the wider CQC action plan.

Wendy Booth,

Director of

Performance

Assurance & Trust

Secretary

Jill Mill, Group Manager

Planned Care / Sarah-

Jayne Thompson,

Assistant General

Manager - Head & Neck

31/10/2015 Ratified at QPEC 10 August

2016

The Trust Access Policy was approved 10th November with a caveat to check clinical

involvement regarding cancellations. This is included in section 5.7.2

Pam Clipson,

Director of Strategy

and Planning

Kerry Carroll, Interim

Associate Director of

Strategy and Planning

10/11/2015

Date expected to be

fully embedded - 31

January 2017

Completed

In order to ensure consistency and oversight of the clinical administration systems and

processes which span the clinical groups, a senior over-arching lead has been identified

to co-ordinate and drive the required improvements proposed as part of the clinical

administration review. This post holder was in place from Monday, 2 November 2015.

Pam Clipson,


and Planning

Sarah Coombs, Service

Development &

Performance Manager

02 November 2015 Ratified at QPEC 10 August

2016

The series of Clinic Cancellation Workshops which were arranged as part of the

implementation of the Clinical Administration Review during 2015 and as part of the

wider series of staff engagement and awareness events were completed. However,

there are ongoing engagement events to test implementation of actions and as part of

the current Patient Admin Action Plan and these are in place until the end of 2016.

Progress against these actions are captured in CQC 24. There is good engagement from

SAT & Operational Management Teams at these events.

Wendy Booth,

Director of

Performance

Assurance & Trust

Secretary

Kate Conway,

Improvement Delivery

Manager

30/11/2015 Ratified at QPEC 10 August

2016

The Clinical Administration Review (CAR) was implemented by the end of November

2015. Monitoring and reporting on the impact of the changes has continued through

the weekly Sustainability Programme Stocktake Meeting and weekly by the Executive

Team. Oversight and challenge (and in turn assurance to the Trust Board) is also

provided through the monthly Resources Committee. The CAR has also been (and

continues to be) a standing item on the Trust Board agenda since August 2015.

Engagement events with staff continue including monthly time-outs. The time-outs

have provided the opportunity for further evaluation to changes and agreement of

further actions in response. Actions from the time-outs have been incorporated in to

the current patient admin action plan which will provide the work plan for the next 3 - 6

months. Oversight arrangements remain in place and recently strengthened. The

actions agreed and being progressed will further strengthened the arrangements in

place. Monitoring of the impact of the changes made continue via a range of

mechanisms e.g. incident reporting, KPIs etc. The Trust has also increased the

communications around this issue including briefings to MAC and HCC and TMB.

Weekly communications detailing progress also continue to be shared with the SAT /

operational teams. The key action remains to implement the current patient admin

action plan.

Wendy Booth,

Director of

Performance

Assurance & Trust

Secretary

Karen Fanthorpe,

Interim Chief Operating

Officer

30/11/2015

(implementation of

CAR)

Completed

30 November 2016

(Implementation of

current patient admin

action plan)

Date to be fully

embedded - 28

February 2017

On Target

Quality and Patient

Experience

Committee

Quality and Patient

Experience

Committee

Quality and Patient

Experience

Committee

Quality and Patient

Experience

Committee

Quality and Patient

Experience

Committee

Quality and Patient

Experience

Committee

7

Quality and Patient

Experience

Committee

Quality and Patient

Experience

Committee

Resources

Committee

Quality and Patient

Experience

Committee

Quality and Patient

Experience

Committee

Resolution of the Backlog: Ophthalmology: validation of the ophthalmology patients Karen Dunderdale, Peter Bowker, Associate 31/12/2015 Some slippage on original

on the OPD waiting list whose appointment were overdue is already complete (please Deputy Chief Chief Operating Officer date for completion

refer to the Ophthalmology Recovery Plan and Dashboard). Of those patients Executive and (Medicine)/ Maureen Ongoing validated, a significant number were discharged and there are 431 patients left to see. Director of Georgiou, Interim Appointment dates will be offered to all of these patients by no later than the 31 Operations Associate Chief Revised timescale for December 2015. There is clinical input in to this process in order to assess and manage Operating Officer completion - 30 the clinical risks involved. Update as at 17/11/15: Appointment dates will be offered to (S&CC)/ Ashy Shanker, November 2016 all outstanding patients and all patients will be seen by 31 December 2015.Update as Associate Chief at 4/12/15: There are 150 patients left to see and all patients will be seen by 31 Operating Officer Date expected to be December 2015. Update as at 5/1/16: All patients now seen. Note: Whilst the Trust (W&C) fully embedded - 31 took action as above, there has remained a capacity shortfall which has resulted in a March 2017 further backlog in outpatient follow ups. The Trust has a clear improvement plan and trajectory which is being agreed with the CCGs and will include additional further capacity, consideration of external capacity, extensive validation of the list and discussions with the CCGs in relation to further referral avoidance measures. Progress against this plan will be reviewed weekly and shared with commissioners and the CQC.

Resolution of the Backlog: All Other Specialties: validation of all other patients on our 31/12/2015 Some slippage on original

OPD waiting list whose appointments are overdue is underway. The validation exercise date for completion

(administrative and clinical) will be completed and, all patients appointed by 31 Ongoing December 2015. There is clinical input in to this process in order to assess and manage the clinical risks involved. The Medical Director and Chief Operating Officer have met Revised timescale for with the consultant body to ensure they are cited on the above exercise and are fully completion - 31 engaged in the process. Update as at 5/1/16: First line validation complete - see December 2016 separate breakdown. Revised booking rules have been introduced. This means that patients requiring an appointment will only now be offered an appointment within 4 Date expected to be weeks of their due date. This will minimise the number of repeat appointment fully embedded - 31 cancellations. From the backlog, patients in need of an appointment within 4 weeks March 2017 have now been offered an appointment date. Those patients in need of an appointment 4 weeks+ have been flagged on the system and will be tracked through to appointment - capacity has been identified to see these patients. Note: Whilst the Trust took action as above, there has remained a capacity shortfall which has resulted in a further backlog in outpatient follow ups in some specialties. Plans have been developed as in ophthalmology and progress against these plans will be reviewed weekly and shared with commissioners and the CQC.

The risks identified in the September update still remain key risks however a number of

actions have been completed over the last month to ensure we are able to;-

• Quantify the outpatient supply and demand gap

• Progress with the job planning process at a quick a pace as we are able

• Some of the key actions identified through specialty specific business summaries have

come to fruition. This includes

- The commencement of the external sub contractor for ophthalmology services

- The consultant Orthodontist commenced in post during September as forecast

- Revised booking rules to increase throughput per session commenced in Cardiology

and initial areas in Ophthalmology

All of the above run in parallel to the immediate actions being taken by the Operations

Directorate to increase capacity albeit through premium rate sessions.

With the supply and demand gap quantified in outpatients and the critical specialties,

delivery of the key actions to increase capacity or reduce demand in the medium term

are being taken. A sample business summary which demonstrates the core actions is

embedded below as is the outpatient summary position. The Trust has raised with its

two main commissioners the need to deliver outpatient care differently and have

requested this be contained within their commissioning intentions with real actions to

deliver. The Trust has also compiled an action plan to aid delivery of this which

commences with a survey which will run through October.

Pam Clipson,


and Planning





There is improved reporting and monitoring in place in respect of the live waiting list Wendy Booth, Karen Fanthorpe, Immediate & Ongoing Completed

position including patients who are overdue their follow-up appointments. The new Director of Interim Chief Operating weekly waiting list report is shared extensively internally and with relevant external Performance Officer / Pam Clipson, Date expected to be stakeholders. Assurance & Trust Director of Strategy & fully embedded - 31 Secretary Planning November 2016

With effect from week commencing 26 October 2015, the Executive Team received 27 October 2015 Completed

weekly OPD appointment cancellations including repeat cancellations. Date expected to be fully embedded - 30 November 2016

CQC25

CQC26a

CQC26b

CQC27

CQC28

CQC29 Trust systems were also strengthened to more accurately capture and report on short

notice / on the day cancellations. This latter report will be in place from November

2015.

1 November 2015

Date expected to be

fully embedded - 30

November 2016

Completed Quality and Patient

Experience

Committee

CQC30 Whilst there is ongoing of actions in place, external audit of the Trust’s actions was

undertaken by KPMG. The findings and recommendations from the audit have been

captured within the Trust’s patient admin action plan which is ongoing. No significant

concerns were highlighted from that audit but need for pace in delivery actions

reinforced. KPMG have more recently been asked to audit the Trust’s management of

its waiting list.

Wendy Booth,

Director of

Performance

Assurance & Trust

Secretary

Sarah Coombs, Service

Development &

Performance Manager /

Claire Jenkinson, Head

of Performance

30/11/2015

(completed & ongoing)

NB. TOR for 'external'

audit being finalised.

Auditors on site w/c 7 &

14 December 2015)

Completed Quality and Patient

Experience

Committee

31/03/16

(date for completion of

audit and receipt of

report)

Completed

30 November 2016

(implementation of

current patient admin

action plan)

Date to be fully

embedded - 28

February 2017

On Target

CQC31 CQC 2015 NEL CCG have placed a focus upon

mobilising Cardiology and Respiratory

services out of hospital and this could be

a pilot. NELCCG to confirm structure for

out of hospital cardiology and

respiratory service to enable NLAG to

understand how it could develop

accordingly.

North East Lincolnshire CCG have commissioned provision of these services external to

NLaG. Care Plus group deliver community cardiology services from Weelsby View

Primary Care Centre. The out of hospital service is due to go live during October. The

Trust has given a commitment to support in terms of joined up systems. This will be

monitored as the service mobilises and embeds. During September, a Trust Respiratory

Consultant (Dr O’Flynn) commenced training of primary care nursing staff to deliver

community based COPD clinics. The impact upon secondary care will be monitored as

the service embeds

Pam Clipson,


and Planning (Trust

Lead)

Accountable

Officers (External

Lead)

Jan Haxby (NELCCG)

Jane Ellerton (NLCCG)

31/10/2016 Completed Plans in place for

cardiology and

respiratory

Reduction in the number

of patients treated in

hospital

KPI356 (a&b)

Reduction in Cardiology

referrals

KPI357 (a&b)

Reduction in Respiratory

referrals

Resources

Committee

CQC32 Potential for support and guidance for

pre referral to be explored.

This was linked to outpatients access, if

support/guidance was available for GPs,

content of the physical referrals would

be improved and may not be needed at

all. Requested by CCG at Quality

Summit.

At the Quality Summit on 25 April 2016, the health community agreed to work together

on these actions. A meeting has been arranged with representatives from medicine

and general practice at North Lincs. Jan Haxby to discuss internally the possibility of

being part of this work to ensure a co-ordinated approach across the patch. GPs may

contact any consultant by phone for advice. A proof of concept project is working with

Market Hill and Roxton practices on a central referral pathway. Dir of Strategy and

planning will today offer the ability to request a pre-referral opinion, which should be

electronic and written to maintain an audit trail. The proof of concept runs through

September and if successful will roll out on a wider basis from October.

Lawrence Roberts,

Medical Director

Robert Jaggs-

Fowler, NLCCG

Jan Haxby

(NELCCG)

Stuart Baugh, Associate

Medical Director

(Medicine) (NLAG)/

Clinical Leads/ GPs

31/10/2016

Date expected to be

fully embedded - 31

March 2017

On Target Reduction in referrals to

the Trust

KPI347 (a&b)

Reduction in the number

of referrals to the Trust

Quality and Patient

Experience

Committee

CQC33 MSK pathway to be progressed,

including therapy services at North

Lincolnshire.

Suggest this action is closed. It is the Trust understanding that NL CCG awarded MSK to

a private provider during quarter 4. Unsure why this was raised at the quality summit

in April.

Pam Clipson,


and Planning (Trust

Lead)

Accountable

Officers (External

Lead)

Jane Ellerton (NLCCG) 31/10/2016 Ratified at Resources

Committee on 21 September

2016

MSK Pathway in

operation

Not Applicable - service

not provided by the Trust

Resources

Committee

CQC34 Enter and View' patient surveys within

out-patients to be undertaken to assess

the impact of the changes the Trust has

made.

Report received and shared with OPD management team. Response received re:

actions in train and development of a written response.

Tara Filby, Chief

Nurse (Trust Lead)

Stakeholder

Executive Quality

Leads (External

Lead)

Stakeholder Operational

Quality Leads

31/10/2016 Completed Improvement in patients

experience of out patient

services

Results of the Quarterly

Out Patient Survey

Quality and Patient

Experience

Committee

Environment and Equipment

8

CQC35 CQC 2015 The Trust must ensure that all

risks to the health and safety

of patients with a mental

health condition are removed

in Scunthorpe emergency

department (ED). This must

include the removal of all

ligature risks, although must

not be limited to the removal

of such risks. The Trust must

undertake a risk assessment of

the facilities (including the

clinical room and trolley areas,

but not be limited to those

areas), with advice from a

suitably qualified mental

health professional.

For immediate review and action to

mitigate the risks in the short and longer

term including completion of risk

assessment in conjunction with RDASH.

The works to create the ligature free room 10 on ECC was completed in March 2016. Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

Kay Newton,

Operational Matron

(Medicine) / Claire

Thirwall, Lead Planning

Co-ordinator

13/11/15

(Risk Assessment -

completed)

20/11/15

(costings to be available

- completed)

11/03/16

(completion of works* -

completed)

Ratified at TGAC 18 August

2016

Improved safety Risk Assessment

Observational audits /

spot checks

KPI353

Incidents in A&E relating

to health and safety of

mental patients

KPI352

SIs in A&E relating to

health and safety of

mental patients

Trust Governance

and Assurance

Committee

CQC36 Low risk patients with sitter: (current) visitors room to be utilised. Steps have been

taken to remove, as far as reasonably possible, the ligature risks from this room.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

Kay Newton,

Operational Matron

(Medicine)

13/11/2015 Ratified at TGAC 18 August

2016

Trust Governance

and Assurance

Committee

CQC37 Low risk patient who do not consent to a sitter: Room 10 to be utilised. Whilst work is

undertaken on Room 10, Cubicles 2 & 3 which are directly opposite the nurses' station,

to be utilised. In the event that these cubicles get full, Cubicles 6 & 7 to be utilised. All

ligature risks to be removed in accordance with the agreed guidance and process which

has been shared with all staff in the department.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

Kay Newton,

Operational Matron

(Medicine)


2016

Trust Governance

and Assurance

Committee

CQC38 For those patients who are considered to be high risk (and until the required

modifications have been made to Room 10: Cubicles 2 & 3 to be utilised. In addition a

sitter will be with the patient at all times. At the point the patient is admitted to the

cubicle, all ligature risks will be removed in accordance with the guidance and process

which has been shared with all staff in the department.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

Kay Newton,

Operational Matron

(Medicine)


2016

Trust Governance

and Assurance

Committee

CQC39 Introduce mental health risk assessment

tool.

A 'mental health assessment in self-harm patients' tool' has been developed by NLG in

conjunction with the Lead Consultant Psychiatrist in Mental Health at RDASH. The tool

has been shared for comment. Linked to this action - consideration is also being given

to comments within the MHA Monitoring Report on the absence of an 'observation

policy'. Update as at 4/12/15: Tool in use.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

Kay Newton,

Operational Matron

(Medicine)

30/11/2015

(Review and

consultation to be

completed)

Completed Trust Governance

and Assurance

Committee

CQC40 Provide dedicated awareness training for

staff.

All mandated staff have now received training with the exception of long term sick and

overseas nurse.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

Kay Newton,

Operational Matron

(Medicine)

20/11/15

(Schedule of Training

Dates - confirmed)

29/02/16

(Date for Completion of

Training)

Revised completion

date 31/8/2016

Revised completion


and Assurance

Committee

CQC41 Install an alarm in both triage rooms. Blick Minder System is already in use within A&E. The Blick Minder System is a portable

alarm system which enables staff to take an alarm into any area within A&E and

radiology and will inform security of the member of staff’s location. This system can be

used for staff working in lone working areas, when dealing with violent patients,

patients with MH issues etc. Advice was sought from the Trust’s Local Security

Management Specialist, who confirmed that this system would be suitable to address

the recommendation above. There are currently 10 alarms within A&E, but a further

10 alarms are due to be moved from blue sky unit imminently.

Staff have had training updates on the system to ensure they feel confident using the

system, and this training is ongoing.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

Kay Newton,

Operational Matron

(Medicine) / Claire


Co-ordinator / John

Melville, LSMS

30/11/15


- completed)

11/03/16


upgrade work) -

completed

29/02/16


staff training-

completed)

Ratified at TGAC on 15

September 2016

Trust Governance

and Assurance

Committee

9

CQC42 CQC 2015 The Trust must ensure that the

recently constructed treatment

rooms at Scunthorpe ED that

were previously used as

doctors' offices are suitable for

the treatment of patients on

trolleys. This must include

ensuring that such patients can

be quickly taken out of the

room in the event of an

emergency.

Risk assessment to be completed. All completed and handed over. Pam Clipson,


and Planning

Kay Newton,

Operational Matron

(Medicine) / Claire


Co-ordinator

20/11/15


- completed)

11/03/16

(completion of works -

completed)


2016

Improved safety and

patient experience

Risk Assessment Trust Governance

and Assurance

Committee


equipment is checked, in date

and fit for purpose, including

checking maternity

resuscitation equipment and

critical care equipment is

reviewed and where required,

included in the Trust

replacement plan.

The Equipment group to review the

Terms of Reference to ensure they are fit

for purpose.

Equipment Group Terms of Reference have been reviewed and approved. Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations


(All Groups)/ Chair of

the Equipment Group

(Nicola Parker)

30/06/2016

(Review of terms of

reference)

Completed Equipment clean and fit

for purpose

Spot Checks

Cleaning/ maintenance

schedules

Trust Governance

and Assurance

Committee

20 September 2016

(Additional actions

completed and

feedback to TGAC)

Date expected to be

fully embedded - 31

Completed

CQC44 Processes for ensuring that equipment is

included in the Trust replacement plan

and on the risk register to be shared

again with Associate Chief Operating

Officers to ensure compliance.

A 'Medical Device Evaluation and Replacement Process' is in place within the Trust.

This has been shared with the ACOOs and will be kept under review at the Equipment

Group.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

Associate Chief

Operating Officers

30 June 2016

Date expected to be

fully embedded - 30

September 2016


October 2016

Equipment clean and fit

for purpose

Spot Checks


schedules

Trust Governance

and Assurance

Committee

CQC45 Confirmation of processes for checking

that equipment is checked, in date and

fit for purpose to be reviewed and

shared with relevant staff with particular

emphasis on maternity resuscitation

equipment and critical care equipment.

S&CC are piloting named individuals per shift to complete the wards

daily/weekly/monthly checklist. Matrons are undertaking a secondary weekly check to

ensure wards are following process, and the pilot will end July 2016. Any amendments

will then be made and taken to August's Equipment Group for review and approval and

then rolled out to other groups.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

Associate Chief

Operating Officers

31/07/2016

Date expected to be

fully embedded - 31

October 2016


for purpose

Spot Checks


schedules

Trust Governance

and Assurance

Committee

CQC46 Raise awareness with staff in relation to

the need for checking equipment, e.g.,

monthly 'Check It' date.

All medical equipment is checked by Medical Engineering and the Equipment group

ensures that they are represented at every meeting. Any issues with broken or end of

life equipment is always picked up by them if not by the clinical area. Work is underway

with wards and departments to ensure that equipment checks are embedded in to

practice. Compliance with this is monitored via the daily/weekly/monthly checklist and

the matron's audit. It is also included in the CQC Mock Visits.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations


(All Groups)/ Sarah

Mainprize/ Chair of

Equipment Group

(Nicola Parker)

31/07/2016

Date expected to be

fully embedded - 31

October 2016

Completed Evidence of awareness

raising campaign

Spot Checks


schedules

Trust Governance

and Assurance

Committee

CQC47 Build in monitoring processes to existing

assurance visits, e.g., CQC Mock visit.

This has been actioned. Equipment checks have been included in the internal CQC

themed visit process which is ongoing. These arrangements will be further tested

through the themed inspection visits being undertaken by NHSI during October 2016

and again during the CQC visit in November 2016.

Wendy Booth,

Director of

Performance

Assurance & Trust

Secretary

Kathryn Helley, Deputy

Director of Performance

Assurance

31/05/2016

Date expected to be

fully embedded - 31

October 2016


for purpose

Spot Checks


schedules

Quality and Patient

Experience

Committee


community EQUIPMENT is

cleaned in line with cleaning

schedules.

Continue to ensure that medical

equipment in community bases is

cleaned to manufacturers guidelines.

A Decontamination Policy is in place. All areas have Infection Control Link Workers who

are responsible for doing monthly audits, which are reported centrally. Cleaning

Schedules are required in all clinical areas which have multiple use. Items of equipment

which are re-used have the green tape applied to show when they were cleaned and by

whom. All these are monitored through Mock CQC visits & infection control audits.

C&TS are currently producing an audit tool for staff to use themselves when in

community clinic areas, to be processed at the next governance meeting.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

Dawn Daly, Head of

Therapy Services,

Community and

Therapy Services

31/07/2016

Date expected to be

fully embedded - 31

October 2016


for purpose

Spot Checks


schedules

Quality and Patient

Experience

Committee


community ENVIRONMENTS

are cleaned in line with

cleaning schedules.

Estates and Facilities to assess all

properties to ensure cleaning contract is

in place.

All community venues, staff to ensure

cleaning schedules updated at the end of

all treatment sessions

All multiple use areas have cleaning schedules which are monitored through infection

control audits & mock CQC visits. Audit tool being presented to governance for

clinicians to reassure that all clinical areas in total meet requirements. Lines of

responsibility for cleaning schedules being requested at SMT 27/06/16. Confirmation

received that all cleaning schedules in place and named people identified for

monitoring.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

Dawn Daly, Head of

Therapy Services,

Community and

Therapy Services

31/07/2016

Date expected to be

fully embedded - 31

October 2016


for purpose

Spot Checks


schedules

Quality and Patient

Experience

Committee

10

CQC50a CQC 2015 The Trust must ensure that all

community equipment is

tested for electrical safety and

evidence is available to show

that equipment is serviced in

line with manufacturers

recommendations.

Estates and Facilities to work with

Community and Therapy Services Group

to ensure all Portable Appliance Testing

(PAT) is completed.

Update: There are 2 properties to conduct PAT, these will be completed by 31st

October 16. The 2 outstanding properties are Pilgrim Primary Care Centre and Stirling

Medical Centre. A total of 30 properties have been completed.

Jug Johal, Director

of Estates and

Facilities

Simon Tighe, Deputy

Director of Estates and

Facilities

30/09/2016

Date expected to be

fully embedded - 31

December 2016

Some slippage on original

date for completion.


31 October 2016

All equipment tested

appropriately

Spot Checks

Maintenance Schedules

Register

KPI348

Buildings where PAT

testing complete

Trust Governance

and Assurance

Committee

CQC50b Medical Engineering to continue to work

with Community and Therapy leads to

ensure equipment is retrieved for

routine service & electrical safety testing

Medical Engineering test the medical equipment listed in the Trust spreadsheet. The

external contractor PAT tests everything else. They also test the electrically powered

plinths and chairs which are not listed on the medical equipment spreadsheet. The

contractor is able to identify what requires testing by Medical Engineering as

everything they maintain will have the blue equipment control number sticker and next

test due sticker. Under the Trust system the next test due sticker indicates that the

equipment has been serviced, tested and or calibrated and the appropriate electrical

safety test is carried out as part of the inspection. The Trust do not attach dedicated

PAT stickers to the equipment, only a next test due label as per Trust policy. This will

be monitored at CQC Mock Visits.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

Gavin Cogley, Head of

Medical Engineering

30 September 2016

Date expected to be

fully embedded - 31

October 2016

Completed All equipment tested

appropriately

Spot Checks

Maintenance Schedules

Register

KPI348

Buildings where PAT

testing complete

Trust Governance

and Assurance

Committee

CQC51 CQC 2015 The Trust should ensure the Ensure that the intravenous fluid room in This has been addressed and locks are now on the doors in Scunthorpe. The doors Karen Dunderdale, Ashy Shanker, Associate 06/05/2016 Ratified at TGAC on 15 Fluids stored safely and Spot Checks Trust Governance

lock on the intravenous fluids maternity at Scunthorpe General have also been checked at Diana, Princess of Wales Hospital and this is also secure. Deputy Chief Chief Operating Officer September 2016 securely and Assurance

room in maternity at Hospital is secure. Executive and (W&C)/ Julie Dixon, Committee

Scunthorpe hospital is in Director of Head of Midwifery/ working order to ensure safe Operations Simon Tighe, Deputy storage of fluids. Director of Estates and Facilities

CQC52 CQC 2015 The Trust must ensure that all Ensure that substances which could be The cleaning fluids are now kept in the cleaners cupboard as this is the appropriate Karen Dunderdale, Tina Sykes, Associate 30/06/2016 Ratified at TGAC on 17 Review undertaken Spot Checks Trust Governance

substances which could be harmful are stored correctly. place for them to be stored. The cupboard is locked at all times and the cleaners and Deputy Chief Chief Nurse (C&TS)/ Bill October 2016 and Assurance

harmful are stored the NHS Property Estates Co-ordinator have a key to the cupboard. The Chronic wound Executive and Parkinson, Head of Fire, Date expected to be Committee

appropriately, specifically Sister also confirmed that after speaking to the cleaners following the issue being Director of Health and Safety fully embedded - 30 within the Ironstone Centre. raised they have removed the floor cleaning solution bottle and this is now in a Operations September 2016 permanently locked store cupboard.

CQC53 CQC 2015 The Trust should ensure that A standard operating procedure to be SOP agreed and in place. Approved by clinical governance group on 24/6/16. Karen Dunderdale, Ashy Shanker, Associate 30/06/2016 Ratified at QPEC on 12 Standard Operating Theatre Utilisation Quality and Patient

there is a standard operating developed. Deputy Chief Chief Operating Officer October 2016 Procedure in place Report Experience

procedure for the use of the Executive and (W&C)/ Maureen Date expected to be Committee

second theatre (anaesthetic Director of Georgiou, Interim fully embedded - 30 room) to maintain patient Operations Associate Chief September 2016 safety with maternity. Operating Officer (S&CC)/ plus AMDs

CQC54 CQC 2015 The Trust should undertake Address the environment issues as Works were scheduled to commence 30th August 2016, complete 2nd December 2016 Pam Clipson, Alex Afifi, Group 30 September 2016 On Target Works undertaken Observation Resources

work in a reasonable time- identified by the CQC. however as the cost for the building works on this project were over £250k (After a Director of Strategy Manager, Unplanned (Building work to have Committee

frame that will lead to the full cost analysis) authorisation was needed from monitor, a paper with a full and Planning Care (Medicine), Kay commenced by) Board Minutes creation of separate waiting breakdown of costs was sent to monitor and this was approved, the final decision was Newton, Operational and treatment areas for then taken to the Trust Board on Tuesday 30th August 2016 where final approval was Matron (Medicine)/ 30 November 2016 children in the Scunthorpe ED given. Due to the financial value the director of finance signed the order on Thursday 1s Claire Thirwall, Lead (Building work that are safe and secure. September 2016 and clugstons have confirmed receipt of this and agreed a start date Planning Co-ordinator completed) of Monday 19th September with completion on 23rd December 2016. Programme will be as follows: Phase 1 – 19th September – 17th October 16 - Creates a new majors entrance, New consulting room, consulting room 3 (Children’s room) and works to the security wall – works commenced on schedule Phase 2 – 18th October 16 – 29th November 16– Creating a dedicated children’s waiting area/play area and toilet Phase 3 - 30th November 16 – 23rd December 16 – modifications to the reception desk to bring to DDA compliant (not part of the CQC need but because area is changing, need to be DDA compliant)

11

CQC55 CQC 2015 The Trust should undertake

work in a reasonable time-

frame that will lead to the

creation of separate entrances

in Scunthorpe for ED for

patients self-presenting with

minor injuries or illnesses, and

those conveyed by ambulance

with serious injuries.

Address the environment issues as

identified by the CQC.

Works were scheduled to commence 30th August 2016, complete 2nd December 2016

however as the cost for the building works on this project were over £250k (After a

full cost analysis) authorisation was needed from monitor, a paper with a full

breakdown of costs was sent to monitor and this was approved, the final decision was

then taken to the Trust Board on Tuesday 30th August 2016 where final approval was

given. Due to the financial value the director of finance signed the order on Thursday 1s

September 2016 and clugstons have confirmed receipt of this and agreed a start date

of Monday 19th September with completion on 23rd December 2016.

Programme will be as follows:

Phase 1 – 19th September – 17th October 16 - Creates a new majors entrance, New

consulting room, consulting room 3 (Children’s room) and works to the security wall –

works commenced on schedule

Phase 2 – 18th October 16 – 29th November 16– Creating a dedicated children’s

waiting area/play area and toilet

Phase 3 - 30th November 16 – 23rd December 16 – modifications to the reception desk

to bring to DDA compliant (not part of the CQC need but because area is changing,

need to be DDA compliant)

Pam Clipson,


and Planning

Alex Afifi, Group

Manager, Unplanned

Care (Medicine), Kay

Newton, Operational

Matron (Medicine)/

Claire Thirwall, Lead

Planning Co-ordinator

30 September 2016

(Building work to have

commenced by)

30 November 2016

(Building work

completed)

On Target Works undertaken Observation

Board Minutes

Resources

Committee

CQC56 CQC 2015 The Trust should ensure there

is sufficient space and seating

for patients and their

supporters in the outpatients

department.

OPD Managers to discuss with Strategy

and Planning Team and offer areas

identified as a risk with seating,

mitigating plans and longer term

solutions that will require working up

and plans agreeing.

Additional outpatient space has been identified in zone 4 with funds agreed through

Charitable Funds.

Order placed

Pre-start meeting – Wed 7/9/16, contractors will present programme detail.

Works commence – Mon 19/9/16

Completion due – 10/10/16

Update: the contractor has found a gas pipe hidden behind a kitchen unit that will

require removing. A gas shutdown is being organised to remove pipe asap, current

indication is that this will not affect programme schedule however this will be kept

under review whilst pipe is removed.

Pam Clipson,


and Planning

Tracey Broom,

Associate Chief

Operating Officer (CCS)/

Louise Hobson, Planned

Care Manager (CSS)/




30/06/2016

(additional seating

identified)

31 October 2016

(Completion of

additional works)

On Target Increase in seating

available

Patient experience

surveys

Quality and Patient

Experience

Committee

CQC57 CQC 2015 The Trust should ensure the

premises and location of the

ophthalmology department is

suitable for the purpose for

which it is being used.

To meet demand the Trust needs to

increase its workforce. This is not

possible due to space. Working with

strategy and planning to identify a new

location in order to expand the service to

meet the demand.

An area has been identified to increase the clinical footprint by a further clinic room on

the Grimsby site. This is to accommodate the workforce strategy in place within the

team. Works commenced 12th September and completed 23rd September 16. Room

now available. Mobilisation plan in progress for clinic room to become live (staffing

and equipment).

Pam Clipson,


and Planning

Maureen Georgiou,


Operating Officer

(S&CC), Kerry Carroll,

Interim Associate

Director of Strategy and

Planning

31/10/2016 Completed Patients receive care in

appropriate environment

Patient experience

surveys

Ophthalmology Action

Sheet

Resources

Committee

CQC58 CQC 2015 The Trust should ensure that

within maternity services

multiple use equipment and

devices are cleaned or

decontaminated between

uses; that all areas are kept

clean and records of cleaning

are maintained.

Ensure that staff are aware of the need

to ensure that multi-use equipment is

cleaned between patients.

All managers have been instructed to ensure that multi use equipment is cleaned

between patients and required to cascade this information. 1/6/16: Update: This

requirement is being formally monitored by the Quality Matron as part of the monthly

quality dashboard visits to determine level of staff awareness.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations



(W&C), Julie Dixon,

Head of Midwifery

(W&C)

31/05/2016

Date expected to be

fully embedded - 30

October 2016


October 2016

Improved patient

experience

Spot checks

Ward Reviews

CQC Mock Visits

Trust Governance

and Assurance

Committee

CQC59 E&F teams to evidence cleaning regimes. All complete. Jug Johal, Director

of Estates and

Facilities

Simon Tighe, Deputy


Facilities

31/05/2016

Date expected to be

fully embedded - 31 July

2016


2016

Cleaning Regimes FLO audits

PLACE

Environmental Audits

Trust Governance

and Assurance

Committee

CQC60 At DPOW, move to the use of single use

monitoring belts.

This has been enacted. The Head of Midwifery has confirmed that the use of reusable

fabric monitor belts that required washing has now ceased and that disposable belts

are now used instead. Disposable belts were ordered via supply chain purchase on 2

May 2016. The team are now on their 3rd box

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations



(W&C), Julie Dixon,

Head of Midwifery

(W&C)

03/05/2016

Date expected to be

fully embedded - 30

September 2016


October 2016

Improved patient

experience

Spot checks

Ward Reviews

CQC Mock Visits

Trust Governance

and Assurance

Committee

CQC61 Ensure that all areas are kept clean and

records of cleaning are maintained.

Monitoring processes have demonstrated that there are pockets of areas where

cleaning needs to be improved. For this reason, it was decided at the Executive

Chellenge meeting that this action should be revised to green until monitoring

processes demonstrate that this has been embedded.

Jug Johal, Director

of Estates and

Facilities



(W&C), Julie Dixon,

Head of Midwifery

(W&C)

31/05/2016

Date expected to be


2016

Revised to Completed at

October Challenge Meeting

Improved patient

experience

Environmental Audits

CQC Mock Visits

Trust Governance

and Assurance

Committee

CQC62 CQC 2015 The Trust must review the rate

of cancellations of outpatient

appointments and rates of 'did

not attend' at Goole and take

action to improve these in

order to ensure safe and timely

care and to meet the Trust's

own standards of 6%.

Please note: this work is taking place

Trustwide.

Clinic Cancellations & DNAs are part of

the work contained within the

Sustainability plan for OPD Trust wide.

An A3 report is published monthly and

shared with the OPD Sustainability

Group. A dashboard of group KPI

summary reports is shared by

Sustainability Programme Governance

Office for Medicine, Surgery and Women

and Children.

The average number of attendances and DNAs in the last 12 months was 35,781. July

16 saw a figure of 32,789 Attendances and DNAs and therefore lower than the average

of the last 12 months, for all sites, including Goole, which is currently just above 8%.

DPOW current position, 12 months to end July 16 = 15.0% (9.5% in July 16 compared

with 8.9% in June 16). Increase in most recent month but overall 12 month trend =

decreasing.

SGH current position, 12 months to end July 16 = 12.9% (10.6% in July 16 compared

with 7.9% in June 16). Increase in June and July but overall 12 month trend =

decreasing.

GDH current position, 12 months to end July 16 = 13.5% (14.6% in July 16 compared

with 8.5% in June 16). Increase in most recent month but overall 12 month trend =

decreasing

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

Tracey Broom,

Associate Chief


Louise Hobson, Planned

Care Manager (CSS)

30/06/2016

(review undertaken)

31 September 2016

(Data collection to be

completed)

31 October 2016

(Decision taken re pilot

rollout)

Date expected to be

fully embedded - 31

December 2016

Completed Improved patient

experience

Decrease in DNA rate

KPI182 & KPI338

DNA rate

KPI322 & KPI323

Cancellation rate

Trust Governance

and Assurance

Committee

Consent

12

CQC63 CQC 2015 The Trust must have a process

in place to obtain and record

consent from patients and/or

their families for the use of the

baby monitors in critical care

and for the use of CCTV in

coronary care.

For immediate review and action as

appropriate.

Cameras/monitors in use are commercial baby monitors which have visual and sound

capability but no recording capacity. Following the receipt of earlier legal advice, the

Trust is alive to the potential issues surrounding the use of cameras including the need

to consider alternatives wherever possible and also in relation to issues such as privacy

and dignity and consent to their use in terms of being compliant with Article 8 of the

ECHR. The current legal advice and advice from the Trust's Health & Safety Manager

and LSMS is that this type of "visualisation", rather than the monitoring and/or

gathering of information, is a ‘grey area’ for the purposes of the current legislation on

surveillance. The Trust does recognise that the previous legal advice obtained in 2007

pre-dates the current legislation, and in light of this, intends to be proactive and treat

the cameras as "surveillance" for the purposes of the current legislation. To this end, a

Privacy Impact Assessment and related actions has been undertaken. The Policy has

also been updated. Regular walk rounds are undertaken by the LSMS to monitor

compliance. A register is also in place outlining areas of the Trust where cameras/

monitors are in place and this is maintained by the LSMS. The LSMS monitors these

arrnagements.

Wendy Booth,

Director of

Performance

Assurance & Trust

Secretary

Bill Parkinson, Health &

Safety Manager / John

Melville, Local Security

Management Specialist

(LSMS)

31/10/2015

(completion of Privacy

Impact Assessment)

16/11/2015

(approval of Privacy

Impact Assessment by

Trust Governance &

Assurance Committee

(TGAC)

Date expected to be

fully embedded - 31

August 2016


September 2016

Improved patient

experience (privacy &

dignity)

Audit of Consent

Director Visits & Walk

rounds

Register of CCTV

Trust Governance

and Assurance

Committee

CQC64 Whilst there is a process in place for staff

to follow, there are notices displayed

and verbal consent is obtained from

patients and / or relatives for the use of

the cameras / monitors, consent needs

to be recorded in patient' notes.

The requirements for the recording of consent in patients' notes has been reinforced

and will be monitored by the Operational Matron. Monitoring visit undertaken by

LSMS and all processes in place and being used. Additional monitoring visits continue

to test the application of the policy on CCU and Critical care with a Quality Matron visit

to take place during June and with input from Operational leads.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

Operational Matrons,

Medicine and Surgery &

Critical Care

November 2015

Date expected to be

fully embedded - 30

September 2016


October 2016

Improved patient


dignity)

Audit of Consent

Observational Audits

Director Visits & Walk

rounds

Trust Governance

and Assurance

Committee

CQC65 CCTV Policy to be amended to capture

the above requirements.

Policy updated (incorporating legal advice) and approved at Trust Governance and

Assurance Committee in February 2016.

Wendy Booth,

Director of

Performance

Assurance & Trust

Secretary

Bill Parkinson, Health &

Safety Manager / John

Melville, Local Security

Management Specialist

(LSMS)

02/12/2015

(policy updated -

completed)

18/01/16

(final approval -

completed)

Date expected to be

fully embedded - 31


September 2016

Improved patient


dignity)

Compliance with

statutory and good

practice requirements

KPI183

Document Control

Trust Governance

and Assurance

Committee

Medicines Management

CQC66 CQC 2015 The Trust must ensure the safe

storage and administration of

medicines. The Trust must

ensure staff check drug fridge

temperatures daily and record

minimum and maximum

temperatures. Additionally it

must ensure staff know that

the correct fridge

temperatures to preserve the

safety and efficacy of drugs

and what action they need to

take if the temperature

recording goes outside of this

range.

For immediate review and action. The drug fridge on Ward 23 was immediately decommissioned and alternative

arrangements made. A new fridge has been purchased.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

Michelle Long,

Operational Matron -

Medicine

01 November 2015 Ratified at TGAC 18 August

2016

Improved quality &

safety

CQC Mock Visits

Weekly Monitoring

Trust Governance

and Assurance

Committee

CQC67 Reinforce Trust policy and procedure. March 2016: drug fridge audit reviewed. Revised drug fridge checklist approved for use

March 2016 via NMAF. Drug fridge checklist rolled out to all clinical areas. Process in

place for Quality Matron review monthly on environmental audit. June 2016 –

commenced spot check audit weekly with zero tolerance escalation to ET/TMB.

Tara Filby, Chief

Nurse

Associate Chief Nurses/

Sue Peckitt, Deputy

Chief Nurse

31 March 2016 Ratified at TGAC 18 August

2016

Improved compliance

with Trust Policy

Improved quality &

safety

CQC Mock Visits

Weekly Monitoring

Trust Governance

and Assurance

Committee

CQC68 Ensure ongoing monitoring and testing. March 2016: drug fridge audit reviewed. Revised drug fridge checklist approved for use

March 2016 via NMAF. Drug fridge checklist rolled out to all clinical areas. Quality

Matrons review on environmental audit. June 2016 – commenced spot check audit

weekly with zero tolerance escalation to ET/TMB. ACOOS/TMB reminded of zero

tolerance process. Nil return process initiated for robust assurance – not all returns in

place – being followed up by relevant ACN.

Tara Filby, Chief

Nurse

Mike Urwin, Chief

Pharmacist / Quality

Matrons

30 June 2016

Date expected to be

fully embedded - 30

October 2016

Completed Improved compliance

with Trust Policy

Improved quality &

safety

CQC Mock Visits

Weekly Monitoring

Trust Governance

and Assurance

Committee

CQC69 Consider longer term solution. The CQC action is to ensure that the safe storage and administration of medicines

especially drug fridge temperatures. The immediate action has been taken to ensure

there is a manual check operating across the Trust, CQC reference 68. As part of the

Trusts IM&T strategy, where a manual process can be developed electronically to

improve efficiency and/or alleviate non clinical workload given the recruitment

challenges faced, drug fridge monitoring is an area where the Trust has agreed to

compliment the current manual process with an electronic monitoring system. The

CQC action is to ensure drug fridge temperatures are monitored. A manual process is

in place which satisfies this need with oversight through the Chief Nurse (CQC68). The

electronic solution provides an additional fail safe for monitoring drug fridge

temperatures. The BRAG rating is n/a as the manual process meets the CQC

requirement. The electronic solution enables the Trust to go a step further.

Pam Clipson,


and Planning

Mike Urwin, Chief

Pharmacist / Hazel Tait,

Medicines Manager

31/10/2016

Date expected to be

fully embedded - 28

February 2017

Not Applicable Improved compliance

with Trust Policy

Improved quality &

safety

CQC Mock Visits

Weekly Monitoring

Trust Governance

and Assurance

Committee

13

CQC70 CQC 2015 The Trust must ensure the safe

storage of oxygen cylinders on

the intensive care unit at

DPOW hospital.

Estates and Facilities team to assess

cylinder storage.

Assessment currently underway. Update as at 27/5/16: This piece of work has been

expanded to cover all three sites and therefore timescale has been extended. In the

interim, monitoring is taking place via the Health and Safety team and via CQC Mock

visits. Update: Review complete and areas for action identified. The full report from

BOC is awaited. For the majority of the wards the ward sister/charge nurse was in

attendance for the walk around and so any issues were feedback at the time of the visit

and this also acted as a learning opportunity. As part of the review, the Assistant

Director of Nursing and BOC attended ITU at DPOW and were shown the cylinder

storage and they were all stored in suitable containers and in one area of the unit. It

was agreed to obtain clear signage that medical gases are stored. There were no issues

with the storage. A lead clinician (Mr Chambers) has been identified to help develop

and engage staff. This will be complete by 31st August 2016.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

Jen Orton, Interim

Deputy to the Associate

Chief Nurse (S&CC),

Simon Tighe, Deputy


Facilities.

30 June 2016

(Assessment to be

completed)

To be ratified at TGAC once

all elements complete

Improved safety CQC Mock Visits Trust Governance

and Assurance

Committee

31 July 2016

(Remedial work in ITU

to be complete)

To be ratified at TGAC once

all elements complete

31 August 2016

(Awareness raising with

staff complete)

Date expected to be

fully embedded - 31

October 2016

Completed

CQC71 CQC 2015 The Trust must ensure the

DPOW hospital discharge

lounge has a facility and

process for safe storage for

medicines.

A review of the current storage

processes to be undertaken in

conjunction with pharmacy management

to identify any changes required.

A new cabinet is in place. All staff have received training by the medicine management

team on correct storage procedure

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations



(Medicine), Paul Kirton-

Watson, Associate Chief

Nurse (Medicine)

30/06/2016 Ratified at TGAC on 15

September 2016

Improved safety Spot checks

Ward Reviews

CQC Mock Visits

Trust Governance

and Assurance

Committee

CQC72 Education of staff to take place to ensure

that they are aware of correct storage

procedures.

A new cabinet is in place. All staff have received training by the medicine management

team on correct storage procedure

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations



(Medicine), Paul Kirton-

Watson, Associate Chief

Nurse (Medicine)

31/05/2016

Date expected to be

fullly embedded - 31

October 2016


September 2016

Improved safety Spot checks

Ward Reviews

CQC Mock Visits

Trust Governance

and Assurance

Committee


procedures for managing

controlled drugs in patients'

homes are standardised and all

staff follow guidelines for the

safe management and

documentation in relation to

controlled drugs.

Review of the Medicines Code to be

undertaken to ensure that it captures

requirements for management of

controlled drugs in patients' homes.

Medicine code amendments ratified at the Safer Medicine Business Group meeting on

17 May 2016. The newly amended code e-mailed out to all registered Community

Nurses within C&T group. Read receipts being collated by admin team, also discussed

within network teams by the EOL lead nurse. Copy available on the C&T intranet site.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

Tina Sykes, Associate

Chief Nurse (C&TS)


2016

Improved safety Audit Trust Governance

and Assurance

Committee

CQC74 CQC 2015 Ensure that staff are aware of the

processes for the management of

controlled drugs in patients' homes.

All registered community nurses who are involved in prescribing or administering

medication complete the medicine management self-assessment work book which has

a section regarding disposal of controlled drugs in the patient home. The July

mandatory training report shows that there are 3 staff requiring completion of the

booklet out of 110 community nurses. They have been contacted by their team leader

and have been given until 31.8.16 to complete. The mandatory training report will be

run again at this time to verify completion. The revised Medicine Code with section

5.17, community services has been uploaded to the Intranet and shared and reinforced

with all staff. The revised policy has been e-mailed out to all community nurses with a

requirement to return a signed receipt that they have read and understood the

amended code. This was sent out on 25th July, 36 read receipts have been returned as

of 31st July these are being monitored and any outstanding will be followed up by the

team leader at the end of August.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations


Chief Nurse (C&TS)

30/06/2016

Date expected to be

fully embedded - 31

October 2016

Completed Improved safety Staff experience survey Trust Governance

and Assurance

Committee

CQC75 CQC 2015 Patient Group Directions for

medication within ED must be

reviewed and in date.

PGDs to be reviewed to ensure that they

are in date.

PGDs updated and in date. Staff made aware through A&E Huddle and Senior Nurse

Meetings.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

Alex Afifi, Group

Manager, Unplanned

Care (Medicine), Tess

Tasker, Operational

Matron (Medicine)

31 August 2016 Ratified at TGAC on 15

September 2016

Improved safety KPI183

Document control

Trust Governance

and Assurance

Committee

Mortality

14


action is taken to address the

mortality outliers and improve

patient outcomes in these

areas.

The Mortality Performance Assurance

Committee meets on a monthly basis. A

monthly mortality report is presented at

this meeting to provide updates on the

areas that have been identified as having

the highest numbers of people dying

within the trust. These areas have

clinically led groups that meet regularly

and work towards action plans that have

been generated through notes reviews

and observations of where pathways of

care can be improved.

Monthly meetings monitor both crude mortality as well as being aware of the quarterly

SHMI report. Whilst the focus has been on being sighted on areas of high mortality, the

focus is shifting to areas where quality of care can be identified as being improved. This

work is ongoing, with introduction of Quality Improvement work across the

organisation which will be an additional tool for improving patient outcomes. The

mortality outliers report was written and minutes and improvement plans from

speciality specific M&M meetings are produced for MPAC. There is now a move to

monitor and view these minutes and improvement plans through the group specific

business and governance meetings. This allows groups focus on the improvements that

need to be made to pathways that are relevant to the individual specialities. Any

problems identified that are not easily changed/dealt with are escalated to the

respective overarching clinical governance groups (and then TGAC) as well as MPAC.

August MPAC received a worksatream 7 update and the stroke mortality report

Lawrence Roberts,

Medical Director

Kate Wood, Deputy

Medical Director

16 August 2016

Date plan signed off at

MPAC

Ratified at MPAC on 20

September 2016

Improved mortality and

morbidity of patients

KPI01

SHMI

Minutes of MPAC

Mortality

Performance and

Assurance

Committee

CQC77 CQC 2015 The Trust should introduce

critical care specific morbidity

and mortality meetings.

Introduce critical care specific morbidity

and mortality meetings.

These meetings commenced in July 2016 and there will be 2 meetings per month, one

for SGH and one for DPOW.

Lawrence Roberts,

Medical Director

Dr Dharmarajah,

Clinical Lead for Critical

Care

31 July 2016 Ratified at MPAC 16 August

2016

Improved mortality and

morbidity of patients

KPI01

SHMI

Minutes of M&M

Meeting

Mortality

Performance and

Assurance

Committee

Pressure Ulcers

CQC78 CQC 2015 The Trust should review the

use of pressure relieving

equipment and prevention

blood clot equipment within

theatres.

Review the availability of suitable

equipment and make recommendations

for improvements.

Review complete. All equipment deemed to be appropriate. The review has been

written and awaiting comments from Surgery & Critical Care re: recommendations. The

VTE policy and pressure ulcer policy will be reviewed to identify any implications for

theatre. Review of DPOW undertaken – minimal action required (see attachment).

Incident data requested re: harm attributable to Theatres. Review of Goole requested

for complete assurance. Full review completed. Inventory of equipment being

catalogued by Theatre managers. Guidance and RCA tool to be amended following

review at PUG.

Tara Filby, Chief

Nurse

Denise White, Associate

Chief Nurse/ Brendan

Forman, Quality Matron

31/07/2016

Date expected to be

fully embedded - 30

September 2016


experience

KPI05

Pressure Ulcers

Trust Governance

and Assurance

Committee

Effective

Evidenced Based Practice and Monitoring

CQC79 CQC 2015 The Trust must ensure the

reasons for Do Not Attempt

Cardio-Pulmonary

Resuscitation (DNACPR) are

recorded and is implemented

in line with best practice within

surgical services.

Training with staff

dissemination through clinical leads and

business meetings. Audit of DNACPR to

be undertaken.

Training continues with both medical and nursing staff.. Additional training and support

has already taken place within the Anaesthetic Business meetings and further

dissemination continues through clinical leads and identified via the surgical specialty

business meetings. S&CC participate in the audit of DNACPR to ensure increased

compliance with DNAR policy. This will be monitored via the Trust Governance and

Assurance Committee.

Lawrence Roberts,

Medical Director

Jen Orton, Interim


Chief Nurse (S&CC)/

Steve Heath,

Resuscitation Officer/

Kelly Burcham, Head of

Risk and Clinical Audit

31/07/2016

Date expected to be

fully embedded - 31

March 2017

Completed Increased compliance

with DNAR policy

Audit Trust Governance

and Assurance

Committee

CQC80 CQC 2015 The Trust must ensure the Five

Steps for Safer Surgery

including the WHO checklist is

consistently applied and

practice is audited.

This is included in the audit calendar. Re audit currently underway, improvement plan in place through a Task and Finish

Group, an example of one of the actions is a planned qualitative survey of staffs

attitude to the ability to challenge in theatres should the WHO not be started.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

Tracey Broom,

Associate Chief


Maureen Georgiou,


Operating Officer

(S&CC)/ Kelly Burcham,

Head of Risk and Clinical

Audit

31/08/2016

Date expected to be

fully embedded - 31

October 2016

Completed Increased compliance

with WHO

Notes audit

Observational Audit both

announced and

unannounced

Trust Governance

and Assurance

Committee

CQC81 CQC 2015 The Trust should continue to

work towards delivering care

and treatment that is in line

with national guidance and

Core Standards for Intensive

Care.

Long and short term critical care strategy

document has been developed taking

account of necessary guidance. Working

towards longer term measures which

cover core standards for intensive care.

The strategy document has a number of

milestones within it which are spread

across the next 3 financial years.

Consultant Intensivist Expansion by 1 per year on each site over 3 years after which the

rota can be split. Job descriptions submitted to college and awaiting approval. In the

interim, Locum Consultant posts have been advertised and awaiting appointments.

Nursing establishment being expanded to meet standards. Policies being updated.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

Jen Orton, Interim


Chief Nurse (S&CC)/ Dr

Dharmarajah, Clinical

Lead for Critical Care

31 March 2018

(with milestones

throughout the period

of the strategy. These

will be monitored

through the monthly

updates)

Date expected to be

fully embedded - TBC at

monthly 1:1 challenge

meeting

On Target Compliance with Care

Standards of Intensive

Care

Minutes of critical care

provision meeting

Quality and Patient

Experience

Committee

15

CQC82 CQC 2015 The Trust must ensure policies

and guidelines in use within

clinical areas are compliant

with NICE or other similar

bodies. The Trust must ensure

that staff are aware of the

updated policies, especially

within maternity, ED and

surgery.

Continue to ensure that Trust complies

with NICE guidance and that policies

remain in control.

Document control and implementation of NICE guidance is a regular item on the Group

and Directorates Governance Meetings. Monthly reports demonstrating compliance

are provided and KPIs for both areas form part of the Trust Performance Framework.

Current compliance for NICE stands at 77.6% and document control 78.2%.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

Jeremy Daws, Head of

Quality Assurance

31/03/2017

Date expected to be

fully embedded - 30

June 2017

On Target Compliance with

necessary best practice

guidance

KPI183

Document control

KPI342

Document control -

maternity

KPI343

Document control - ED

KPI03 (a&b)

NICE

Trust Governance

and Assurance

Committee

CQC83 CQC 2015 The Trust should ensure all the

maternity policies are up to

date and reflect current

guidance and that staff are

aware of the up dated policies.

Develop process for ensuring that

guidelines are identified 6 months prior

to the review date in order that they

remain in date.

Action plan is kept by the governance secretary of any outstanding guidelines.

Reminders sent out 6 months prior to review date. Update as at 27/04/16: Currently

stands at 90%. Update: Guidelines are uploaded to the intranet as soon as they are

approved in order that staff only have access to the most up to date versions. The

Service has a Clinical Standards Review Group which undertakes the review of the

documents prior to the sign off at the Governance Meetings. Consultants, midwives

and any other relevant staff attend the CSRG to ensure a wider discussion can take

place. When a policy has been written or amended, all relevant staff are made aware

via email and it is reported in the group newsletter. Update September 16: Current

policy recommends a review at 3 months in advance, and the current figures are 132

maternity documents of which 122 are in date making a percentage of 92.4. The

target is for 90%.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations



(W&C), Julie Dixon,

Head of Midwifery

(W&C)/ Mahadeva

Manohar, Associate

Medical Director

30/04/2016 Ratified at TGAC on 15

September 2016

Compliance with

necessary best practice

guidance

KPI183

Document control

KPI342

Document control -

maternity

KPI03 (a&b)

NICE

Trust Governance

and Assurance

Committee

CQC84 CQC 2015 The Trust should ensure

consistency with the role of the

health visitor link to GP

practices.

Standard Operating Procedure to be

developed for the HV role when working

with GPs.

SOP currently being consulted on and will then go through clinical governance to

ensure a consistent approach is adopted. SOP approved. Discussions taken place with

the CCG to ensure that primary care are aware of changes and SOP shared with staff.

The SOP will be audited twice a year.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations


Chief Nurse (C&TS)

31/07/2016

Date expected to be

fully embedded - 31

October 2016

Completed SOP in place Audit data Quality and Patient

Experience

Committee

CQC85a CQC 2015 The Trust must have effective

systems in place to assess,

monitor and improve the

quality of the end of life care

services, including auditing

preferred place of care and

other patient outcomes.

An end of life care strategy is being

written encompassing the whole of the

care pathway for patients approaching

end of life (regardless of location).

Within this strategy are a number of

work streams, each with specific actions

and KPIs that are being developed and it

is being ascertained that these can be

robustly measured

The final version of the strategy was ratified in July (with review date in October). KPIs

are under development but have not yet been finalised. Target date for agreement of

KPIs is end of August 2016. The Trust is also engaged in the national audit, but is also

undertaking a local audit EOL KPIs developed and mechanism for monitoring is in

place.

Tara Filby, Chief

Nurse

Kate Wood, Deputy

Medical Director/ Sue

Peckett, Deputy Chief

Nurse/ Tina Sykes,


(C&TS)

31/07/2016

Strategy Approved

Completed Monitoring processes in

place

Audit

KPI345

End of Life Care

Complaints

Quality and Patient

Experience

Committee

31 August 2016

KPIs developed and in

use

Date expected to be

fully embedded - 31

October 2016

Completed

CQC85b CQC 2015 Concern raised in respect of

the service provided to

patients with a mental health

condition in A&E at SGH

NLG to work with CAMHS provider to

review the current CAMHS Team Support

to ensure children presenting in the A&E

Department with mental distress receive

timely specialist assessment of their

needs.

Pathways revised and revised and due to be ratified at the ECC Governance & Business

Meeting on 23 February 2016. Training for staff has been arranged for 22 February, 1

March and 22 March 2016.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

Pete Bowker, Associate

Chief Operating Officer -

Medicine / Ashy

Shanker, Associate Chief

Operating Officer,

Women's' & Children's'

3/11/15

(Date of meeting with

CAMHS)

29/02/16

(Final resolution plan

including

implementation of

revised pathways -

completed)

Date expected to be

fully embedded - 31

October 2016

Completed Improved patient safety Risk Assessment

Incident/SIs

Pathways in place

Quality and Patient

Experience

Committee

Clinical Education

CQC86 CQC 2015 The Trust should, as a matter

of urgency, address the

continuing gap in clinical

education in critical care.

This specific action relates to the

appointment of a Nurse Educator post

within critical care.

Educators now appointed Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

Jen Orton, Interim


Chief Nurse (S&CC)/

Nick Harrison, Nurse

Consultant for the

Deteriorating Patient

31 August 2016

Date expected to be

fully embedded - 31

October 2016

Completed Improved training

experience for staff

Training reports Quality and Patient

Experience

Committee

Caring

Please note: no actions relating to the domain of Caring were identified during the October 2015 visit.

Responsive

Eliminating Mixed Sex Accommodation

16

17

CQC87 CQC 2015 The Trust must review the For immediate review and action. The Board considered the position of the Trust in regard to EMSA at its meeting on Karen Dunderdale, Paul Kirton-Watson, 01 April 2016 Ratified at QPEC on 12 Zero Mixed Sex KPI346 Quality and Patient

validation of mixed sex 26th January 2016. This included feedback from the discussion with Monitor the Deputy Chief Associate Chief Nurse - October 2016 Accommodation MSA Experience

accommodation occurrences, previous week. As a result, the Board decided that the escalation route for any mixing Executive and Medicine Breaches leading to Committee

ensure patients are cared for in of sexes would be at director level only and for this to take immediate effect. Director of improved patient an appropriate environment Communications to this effect were cascaded immediately – evidence attached. The Operations experience (privacy & and report any breaches. Trust continues to operate this escalation route for the mixing of sexes which requires dignity) authorisation at director level, in advance (NB this does not apply to specialist units such as ICU, HDU where the mixing of male & female patients is permitted within the guidance). The Trust took immediate action with regard to the Acute Medical Unit at DPOW (which was the location for the reported breaches following the CQC visit). With effect from 25th January 2016, the AMU and Short Stay Unit were amalgamated into a single unit which provided the flexibility required to prevent any further risk of breaches occurring on this unit. The Trust has submitted a zero return for breaches every month since January 2016 – evidence is provided of the monthly returns. The WebV system has been developed to provide an automated alerting function – this system provides the assurance for the Trust to be able to declare compliance in the monthly returns – a screenshot of the WebV screen is attached as evidence. A flow chart showing how this system operates is attached. An analysis of the trigger alerts for September 2016 will follow. QPEC is the route by which the ongoing actions for Eliminating Mixed Sex Accommodation are monitored and reviewed. The latest report (July 2016) is attached as evidence. The next report is due in October 2016.

CQC88 Review of existing training opportunities i) presentational material finalised through task & finish group (27.9.16) – attached as Karen Dunderdale, MSA Task and Finish 30/06/2016 Completed Zero Mixed Sex KPI346 Quality and Patient

for staff, including new starters who join evidence. Deputy Chief Group Accommodation MSA Experience

the Trust, e.g., Care Camp, to be ii) there are 4 cohorts of new staff who will be returning to care camp for follow up Executive and Breaches leading to Committee

undertaken. sessions. These sessions are arranged to run between 4th November and 16th Director of improved patient December 2016. Training on MSA has been included as part of the programme for this Operations experience (privacy & session and will be delivered by Ops Matrons/Quality Matrons. A copy of the EMSA dignity) presentation is attached as evidence. iii) Existing staff will receive training via a cascade method from ward managers. Arrangements have been made for the HoN for each of the three service groups to deliver the training to ward manager meetings in October/November. iv) on call manager training has been arranged for 21st October and 4th November – the training presentation will be used for the session on EMSA

CQC89 Gaps in training opportunities to be i) presentational material finalised through task & finish group (27.9.16) – attached as Karen Dunderdale, MSA Task and Finish 30/06/2016 Completed Zero Mixed Sex KPI346 Quality and Patient

identified and a plan to close the gaps to evidence. Deputy Chief Group (Initial Scoping) Accommodation MSA Experience

developed. ii) there are 4 cohorts of new staff who will be returning to care camp for follow up Executive and Breaches leading to Committee

sessions. These sessions are arranged to run between 4th November and 16th Director of 30 September 2016 improved patient December 2016. Training on MSA has been included as part of the programme for this Operations (Awareness Raising) experience (privacy & session and will be delivered by Ops Matrons/Quality Matrons. A copy of the EMSA dignity) presentation is attached as evidence. iii) Existing staff will receive training via a cascade method from ward managers. Arrangements have been made for the HoN for each of the three service groups to deliver the training to ward manager meetings in October/November. iv) on call manager training has been arranged for 21st October and 4th November – the training presentation will be used for the session on EMSA

CQC90 Include the need to review mixed sex The revised Director Visit pro-forma was updated and approved at the Trust Board Wendy Booth, Kathryn Helley, Deputy 31/05/2016 Ratified at QPEC on 14 Zero Mixed Sex KPI346 Quality and Patient

accommodation and test staff meeting in May 2016. This is now in use. Reports from all visits are shared with the Director of Director of Performance September 2016 Accommodation MSA Experience

knowledge in existing assurance visits, relevant Managers / Directors for follow-up and summary reports are also shared Performance Assurance Date expected to be Breaches leading to Committee

e.g., Director Visits. through QPEC and the Trust Board Assurance & Trust fully embedded - 31 improved patient Secretary August 2016 experience (privacy & dignity) CQC91 Further explanation required on how the Head of Children's Services working with operational leads to ensure guidance is Karen Dunderdale, Amanda Jackson, Head 30/06/2016 Completed Zero Mixed Sex KPI346 Quality and Patient

national guidance applies to children and appropriately applied to children. Update: Practical application been reviewed with Deputy Chief of Children's Services Accommodation MSA Experience

the practical application of the policy wards, process being applied in line with guidance. Discussed the paragraph within the Executive and Date expected to be Breaches leading to Committee

locally. trust policy for children, young people and adults which has been shared with Director of fully embedded - 31 improved patient commissioners to ensure it is clear in relation to accommodating parents and ensuring Operations October 2016 experience (privacy & the privacy and dignity is maintained. dignity)

CQC92 Review, agree and implement the time Assurance visits by commissioners regarding mixed sex accommodation took place Karen Dunderdale, Jenn Orton, Interim 31/07/2016 Completed Zero Mixed Sex KPI346 Quality and Patient

period for “step down” patients when during June 2016 and the outcome was shared at the Quality Contract Review meeting Deputy Chief Deputy to the Associate Response from Accommodation MSA Experience

ready to leave a specialist unit in July 2016. The Commissioners’ stance is that the Trust must comply with the Executive and Chief Nurse Commissioners Breaches leading to Committee

(agreement is for local determination) – national critical care guidance that patients are transferred within 4 hours of being Director of improved patient agreement for CCGs to work with the deemed medically fit (this is different to the current, locally agreed arrangement, of Operations 31 August 2016 experience (privacy & Trust to agree a common approach. transfer within 24 hours). The policy is at a final stage but is awaiting agreement with Implemented dignity) CCGs & NLAG commissioners regarding the status of the HOBs unit as a specialist unit. The final draft includes comments are shown in red as it is still a working document and it is essential Date expected to be that the outstanding issues are clearly identified. Work is underway to amend the fully embedded - 31 HOBs documentation in anticipation that commissioners will then agree this is a October 2016 specialist unit. The policy will then need to be shared with commissioners in its entirety – this will include the opportunity to confirm whether there is a “clock stop” arrangement over night. Then it can proceed through the normal governance approval routes.

CQC93 Agree date for commissioners to visit the

Trust to undertake an assurance visit

These visits were undertaken on 17/6/16 to Scunthorpe General Hospital and on

20/6/16 to Diana, Princess of Wales Hospital.

Wendy Booth,

Director of

Performance

Assurance & Trust

Secretary

Kathryn Helley, Deputy

Director of Performance

Assurance/ CCG Leads

to be identified

31/05/2016

(date to be agreed)

30 June 2016

(first visit to be

undertaken)

Date expected to be


2016

Ratified at QPEC 10 August

2016

Zero Mixed Sex

Accommodation

Breaches leading to

improved patient


dignity)

KPI346

MSA

Quality and Patient

Experience

Committee

CQC94 Update of the Patient Information leaflet

– NLAG/Health Watch

Draft has been completed for discussion at Task and Finish Group in July 2016. This has

been shared with commissioners for their comments who have requested all patients

in critical care areas receive the leaflet. The Eliminating Mixed Sex Accommodation (IFP

704) leaflet was approved at the IFP Group on 8th September 2016.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

MSA Task and Finish

Group

31/07/2016

Date expected to be

fully embedded - 30

September 2016

Ratified at QPEC on 12

October 2016

Zero Mixed Sex

Accommodation

Breaches leading to

improved patient

experience (privacy & dignity)

KPI346

MSA

Quality and Patient

Experience

Committee

Patient Flow and Access

CQC95 CQC 2015 The Trust must ensure it

continues to improve on the

number of fractured neck of

femur patients who receive

surgery within 48 hours.

The Trust to review the fractured neck of

femur action plan and ensure that all

necessary actions are taken.

Daily trauma meetings are facilitated on both sites consistently. The business case for

the Saturday Trauma list is now completed and awaiting decision. The fractured neck

of femur action plan has been reviewed and the majority of actions have been

completed. Therefore a full refresh of the plan is currently being undertaken and this

will be complete by 31 July 2016. At this point, a revised timescale will be provided for

the completion of any new actions identified. The Trauma Co ordinator has

commenced in post in DPOW. With this in mind we should see an improvement in our

compliance of this target and close monitoring is on going monthly.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

Maureen Georgiou,


Operating Officer

(S&CC)/ Sairam Alavala,

Clinical Lead

30/06/2016

Review of action plan


experience

KPI19

#NOF

Quality and Patient

Experience

Committee

31 July 2016

(revised action plan to

be developed)

Completed

Implementation of

actions - 30 September

2016

Date expected to be

fully embedded - 31

December 2016

Completed

CQC96 CQC 2015 The Trust should evaluate the

medical review of outlying

medical patients on surgical

wards to improve consistency

of cover arrangements and

prevent unnecessary delayed

discharges.

To implement the ACP model across the

DPOW site.

The DPOW leave calendar shows that from 15th August we have increased to 5 ACPs

(Dr Hamod, Dr Sanyal, Dr Abdelgabar, Dr Adebayo, Dr Abu Subhu). We increased to 5

ACPs to ensure we have cover for annual leave so at any time of year there should be 4

ACPs.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations


Chief Operating Officer/


Medical Director/ Paul

Kirton-Watson,


31/07/2016

Date expected to be

fully embedded - 31

August 2016

Ratified at QPEC on 14

September 2016

Improved patient

experience

Reduction in number of

outlying patients

Reduction in delayed

KPI18

Reduction in patient

outliers

KPI17


transfers of care

Quality and Patient

Experience

Committee

CQC97 Review and reintroduction of the short

stay ward.

As part of the ACP model and successful recruitment to the 4 positions the Short Stay

Ward function will re-established. Expected date for implementation is 31st July.

Following review it has been agreed that short stay patients arrangements to remain as

is on AMU and Icon to be put on Web V to identify 'short stay' patients so they can be

prioritised. This will be monitored on a monthly basis by patient length of stay on Unit.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations


Chief Operating Officer/


Medical Director/ Paul

Kirton-Watson,


30/06/2016

Date expected to be

fully embedded - 31

October 2016


experience


outlying patients


KPI18


outliers

KPI17


transfers of care

Quality and Patient

Experience

Committee

CQC98 Review the weekend discharge processes

in place at all three sites and ensure

consistency with best practice.

Discussions held with physicians on both main sites and agreement in principle to

review rotas with the view of introducing a second 1:8 weekend rota. Target date for

implementation of new rota is the end of October 2016. In the interim the current

arrangements will remain in place. Agreed at meeting with commissioners to organise

a joint event where issues surrounding the discharge process would be discussed. Out

of hours services, social care and community services would also be involved in this

event.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations



(Medicine)

Richard Young (NLCCG)

31/07/2016

review complete

31 October 2016

(implementation of

rotas)

Date expected to be

fully embedded - 31

On Target Improved patient

experience


outlying patients

KPI18


outliers

KPI17


transfers of care

Quality and Patient

Experience

Committee

CQC99 The Trust to consider having more senior

staff on triage and directing patients to

more appropriate services if not an

emergency.

Interim arrangements of Triage Nurse at A&E reception introduced. This will remain in

place until the visit to Derby takes place and any additional actions for the Trust are

identified. Ambulance Handover nurses introduced and creation of 'pit-stop' facility.

Ambulance handover data is currently showing SGH and DPOW as high achieving in

terms of handover times across the region.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations



(Medicine)

Richard Young (NLCCG)

31/07/2016

Date expected to be

fully embedded - 31

October 2016


experience


outlying patients

KPI18


outliers

KPI17


Quality and Patient

Experience

Committee

18

CQC100 NLAG to visit other Trusts who have

been rated as outstanding in the area of

triage.

Visit to Derby proposed due to Strike Action rearranged for 13 October. Several staff

have attended NHSI meetings and national study days and shared their learning

experience within the units. RAT model and front loading triage(nurse on reception)

have been introduced as trial at DPOW. Greater use of ENPs to share triage role

implemented SGH. Other areas of good practice being examined include amb care in

reach and consultant decision making front hospital (this will form part of PDSA and

shared at NHSI study day 14/10/20.) Following visit to Derby it is expected that further

chages will be considered and potentially introduced.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations



(Medicine)

31/07/2016

Date expected to be

fully embedded - TBC at

monthly 1:1 challenge

meeting


experience


outlying patients

KPI18


outliers

KPI17


transfers of care

Quality and Patient

Experience

Committee

CQC101a CQC 2015 Issues identified regarding patient New contract awarded. Both North and North East Lincolnshire CCGs have confirmed Pam Clipson, Jane Ellerton (NLCCG) 31/10/2016 Ratified at Resources Improved patient Improved patient Resources

transport after 6pm. Need to consider award to commence 1st October 2016. Director of Strategy Committee on 21 September outcomes. experience Committee

whether the service needs to go out to and Planning (Trust 2016 tender. Lead) KPI18 Reduction in patient Accountable outliers Officers (External Lead) KPI17 Reduction in delayed

transfers of care CQC101b The CCGs have commissioned Thames transport to provide this service.

Planned discharge service Monday to Friday 0900 – 2100 / Saturday 10.00 – 19.00.

Karen Dunderdale,

Deputy Chief

Graham Jaques,

Operations Centre

30/09/2016 Completed Quality and Patient

Experience

Same day discharge service 7/7 11.00 – 23.00 ( 2 x double crew stretcher vehicle. This

will commence on 1 October 2016.

Executive and

Director of

Operations

Manager Date expected to be

fully embedded - 31

December 2016

KPI320 & KPI321

Decrease in on the day

cancellations

Committee

CQC102 North East Lincolnshire CCG to consider North East Lincolnshire CCG has not commissioned the Trust to deliver a 30 day bed Pam Clipson, Jan Haxby (NELCCG) 30/09/2016 Completed Resources

the introduction of a 30 day bed model. model. The Trust Board believe it is not appropriate for people to continue to reside in Director of Strategy Committee

an acute bed when they are ‘acute fit’. Direct negotiations by the Trust therefore and Planning (Trust Date expected to be commenced with a local residential home. This agreement is to ensure people who are Lead) fully embedded - 28 acutely fit receive the social care they need within the appropriate setting. The service February 2017 is planned to go live week commencing 3rd October. Accountable Officers (External Lead)

CQC103 Consideration to be given in North CCG feedback from the July stakeholder meeting was that a proposal could come from Pam Clipson, Jane Ellerton (NLCCG) 31/10/2016 Ratified at Resources Resources

Lincolnshire as to whether the walk-in either provider or CCG. Provider is not looking to increase the GP provision in the front Director of Strategy Committee on 21 September Committee

service would be better led by GPs. door currently however will keep under review as out of hospital and the A&E and Planning (Trust 2016 workforce strategy develops. Suggest closure given no party can see additional benefit Lead) in changing the structure in advance of the UEC system recommendations being taken forward as part of the STP. Accountable Officers (External Lead)

CQC104 CQC 2015 The Trust should review Continue to review ICNARC data at the Numbers reviewed through ICNARC and discussed monthly at critical care provision Karen Dunderdale, Jen Orton, Interim 31 August 2016 Completed Improved patient KPI17 Quality and Patient

patient flow and reduce the Critical Care Provision Meeting. meeting. Data is reviewed to see if the Trust is in an outlying position. A member of Deputy Chief Deputy to the Associate experience Reduction in delayed Experience

number of delayed discharges the Network attends these meetings. Update as at 10/6/2016: Data demonstrates Executive and Chief Nurse Date expected to be transfers of care Committee

from ITU. that the Trust is not an outlier. Update: The Critical Care Strategy plans to increase Director of fully embedded Reduction in number of beds. Building work commences January 2017 with a completion date of August 2017. Operations 31 October 2016 delayed discharges KPI339 This will increase capacity and allow flow into the service to improve. In the meantime, Delayed discharges from the Trust is concentrating on flow out of the service in order to reduce delayed ITU discharges. Latest data demonstrates DPOW at 4.7% with national average being 4.8% and SGH 5.8% - this is an improving picture over the last 6 months. For both these parameters the Trust is within 2 Standard Deviations and therefore not an outlier. The Critical Care Strategy plans to increase beds. Building work commences January 2017 with a completion date of August 2017. This will increase capacity and allow flow into the service to improve. In the meantime, the Trust is concentrating on flow out of the service in order to reduce delayed discharges

CQC105 CQC 2015 The Trust should review access Full review of capacity & demand being Activity flows through the catheter labs currently under review to ensure improved use Karen Dunderdale, Alistair Wickham, 31/07/2016 Completed Improved patient KPI324 Quality and Patient

and flow through the undertaken within the Cath Labs at both of available capacity. Audit of start finish times underway. Process mapping session to Deputy Chief Planned Care Manager experience Complaints relating to Experience

Scunthorpe angiography DPoWH and SGH be arranged to review flow through department. Pre and post Bank Holidays and Executive and (Medicine), Tony Date expected to be delays and cancellations Committee

catheterization lab to reduce weekend sessions to prioritise inpatient demand. All referrals carefully vetted by Director of Dawson, Operational fully embedded - 30 Reduction in in Cath Lab last minute cancellations, medical staff to ensure patients are seen in strict priority order. Monday and Friday Operations Matron/ Cardiology November 2016 cancellations delays and wasted reduced elective lists have been reduced and inpatients clinically prioritised to ensure Lead KPI325 appointments. minimal delays. Reprioritising of lists / sessions, planned increase of number of Incidents relating to sessions provided per week on the DPoWH site. Introduction of formal MDTs on each delays and cancellations site. The additional sessions and MDTs will support with the reduction of last minute in Cath Lab cancellations, delays and wasted appointments. In addition to this, elective cases are no longer planned on Fridays and Mondays in order to allow for non-elective cases to be prioritised, again, meaning less delays and last minute cancellations. The Critical Care Strategy plans to increase beds. Building work commences January 2017 with a completion date of August 2017. This will increase capacity and allow flow into the service to improve. In the meantime, the Trust is concentrating on flow out of the service in order to reduce delayed discharges

19

20

CQC106 CQC 2015 The Trust should review Work with ACPs and the Operations Initial indications are that the Improved management of the short stay patients via the Karen Dunderdale, Peter Bowker, Associate 31/07/2016 Completed Improved patient KPI18 Quality and Patient

patient flow through the Centres to ensure the appropriate use of site managers to ensure the appropriate patients are placed on the short stay ward is Deputy Chief Chief Operating Officer/ experience Reduction in patient Experience

Scunthorpe short stay ward to short stay. proving positive. Monthly review of length of stay for patients on Ward 2 will be Executive and Alex Afifi, Group Date expected to be outliers Committee

ensure this does not have an monitored through Medicines Operations and Performance Meetings. NB recent data Director of Manager, Unplanned fully embedded - 31 impact on the flow of patients published internally shows the significant improvement in the average LOS for non- Operations Care (Medicine)/ Kay November 2016 through the clinical decisions elective patients in the Medicine Group at SGH. For the 12 months up to June 2015, Newton, Operational unit. the average LOS for this cohort was 6.3 days. For the 12 months up to June 2016, the Matron/ Kerry Carroll, average LOS is now 5.6 days. This compares to the local peer average of 5.7 days and Interim Associate the national average of 5.8 days. The short stay ward at SGH has been closed to Director of Strategy and support nurse staffing across Medicine. This has provided an opportunity to integrate Planning the short stay service and an additional opportunity to test out two models of delivery across the organisation

CQC107 CQC 2015 The Trust must review the Review is ongoing of pathway looking at Pre-assessment review completed. Due to complexity of pathway’s implementation Karen Dunderdale, Denise White, Associate 31/08/2016 Completed Improved patient KPI320 & KPI321 Quality and Patient

effectiveness of the patient improvements in: has slipped to the middle of October. Approximately 6 week’s slippage. New Deputy Chief Chief Nurse/ experience On the day cancellation Experience

pathway from pre-assessment - Booking into Preassessment preassessment documentation has been shared with clinical staff and comments Executive and Improvement Delivery Revised completion rate Committee

through to timeliness of going - Accuracy and Capacity of received. DPOW feedback due 14th September. Director of Facilitator date - 30 September Reduction in on the day to theatre, and the number of Preassessment Feedback from Surgery Ops Teams prefers allocated clinic slots divided by speciality. Operations 2016 cancellations on the day cancellations for - Information output from Capacity and demand of preassessment shows shortfall in clinics and staffing required patients awaiting operations. preassessment to meet number of patients requiring elective surgery. Business case prepared to meet Date expected to be On the Day cancellations are reviewed capacity shortfall. Accommodation increase identified at DPOW. Preassessment Nurse fully embedded - 31 on a weekly basis and additional support banding at DPOW was not in line with both trust and national profile. Consultation has December 2016 and training is being given to Service been undertaken, completed and pay protection has been applied. Managers to ensure RCA's are robust.

Well-Led

Strategy, Vision and Engagement

CQC108 CQC 2015 The Trust must ensure that Staff engagement strategy is being Discussions are being held with Executive leaders and their senior teams to capture Jayne Adamson, Angie Davies, Assistant 31/10/2016 Completed Staff aware of Trust/ Staff Experience Surveys Quality and Patient

staff at core service/ divisional developed, alongside the how they communicate the key priorities, strategies and implementation plans for their Interim Director of Director Organisational, Service vision and Experience

level understand and are able communications strategy and workforce directorates. Following discussions a plan will be created to produce work streams and People and Quality ＆ Staff Date expected to be strategy Committee

to communicate the key planning and all are a part of the support given to the groups Engagement events are being held with admin and theatre Organisational Development fully embedded - 31 priorities, strategies and overarching P&OD Strategy. staff, as a result of which a number of service improvements have been captured, Effectiveness March 2017 implementation plans for their which has placed staff at the heart of change, making staff agents of change. Senior areas. Leaders within Directorates have been asked to cascade the staff engagement policy to their teams across the Trust. The comms team continue to support directorates with service improvements and organisational changes though comms channels i.e. direct mailing, weekly bulletins, CEO cascade, Podcasts, twitter and Facebook.

CQC109 CQC 2015 The Trust must improve its Staff engagement strategy is being Staff engagement activities as noted above and detail captured through the Directorate Jayne Adamson, Angie Davies, Assistant 31/10/2016 Completed Staff aware of Trust/ Staff Experience Surveys Quality and Patient

engagement with staff to developed, alongside the Delivery Plan. Involvement in service improvements to be captured through Director Interim Director of Director Organisational, Service vision and Experience

ensure that staff are aware, communications strategy and workforce walkabouts, mock cqc visits, senior team walkabouts and reflected through staff People and Quality ＆ Staff Date expected to be strategy Committee

understand and are involved in planning and all are a part of the stories. further staff feedback to be captured through staff stories and other staff Organisational Development fully embedded - 31 improvements to services and overarching P&OD Strategy. feedback. staff engagement workshops have been undertaken with community nursing Effectiveness March 2017 receive appropriate support to and therapy staff, themes have been captured and reported to the interim ACOO for carry out the duties they are the Group, awaiting a steer from her re: further actions to be undertaken, proposed employed to perform. that the report is shared in the first instance with the community staff to agree actions going forwards. OD team will continue to support. ET discussion re: organisational strategy for service / quality improvement to be taken forwards by Exec Lead.

CQC110 CQC 2015 The Trust must ensure it has an The end of life care strategy and vision is The final version of the strategy was ratified in July (with review date in October). All Tara Filby, Chief Kate Wood, Deputy 30/06/2016 Ratified at QPEC 10 August Staff aware of Trust/ Staff Experience Surveys Quality and Patient

end of life care vision and currently being developed with input staff members who had previously been engaged in EOL care were able to be involved Nurse Medical Director/ Sue 2016 Service vision and Experience

strategy in place supported by from all stakeholder groups involved in in the development of the strategy. Social media videos are to be developed to try and Peckett, Deputy Chief strategy Committee

key performance indicators care towards the end of life. This has get more info out to colleagues in addition to the traditional methods such as the staff Nurse/ Tina Sykes, that reflects national guidance been written in conjunction with the bulletin and roadshows. Associate Chief Nurse and ensure staff are included in national guidance available. (C&TS)/ Jane Ellerton the development of these. (NLCCG)

CQC111 Local Healthwatch and CCG Healthwatch and CCG are attending the EOL meetings and are representing the Tara Filby, Chief Kate Wood, Deputy 31 May 2016 Ratified at QPEC 10 August Staff aware of Trust/ Staff Experience Surveys Quality and Patient

representatives to support the Trust in patient/carer perspective. Request made for stakeholders to identify and co-opt Nurse Medical Director/ Sue 2016 Service vision and Experience

identifying patients to join the End of Life appropriate lay representation for strategy group/subgroups as appropriate due to the Peckett, Deputy Chief strategy Committee

Strategy Group. sensitivities involved in this area of work Nurse/ Tina Sykes, Associate Chief Nurse (C&TS)/ Kirsten Spark (Healthwatch/ Jane Ellerton (NLCCG)

CQC112 CQC 2015 The Trust should ensure the DEPCEO team to undertake specific Workshops have been undertaken, report compiled of the themes gathered from staff Jayne Adamson, Angie Davies, Assistant 31/07/2016 Completed Staff aware of Trust/ Staff Experience Surveys Quality and Patient

community teams are engaged piece of work with the Community and views, and shared with Interim ACOO for C&TS. Awaiting a steer from her re actions to Interim Director of Director, Deputy Chief Service vision and Experience

in developing the vision and Therapy Group re staff engagement. take forwards, have proposed the report is shared with staff and they are involved in People and Executive/ Tine Sykes, Date expected to be strategy Committee

strategy for their team(s). crafting the solutions. Organisational Associate Chief Nurse fully embedded - 31 Effectiveness (C&TS)/ Dawn Daly, March 2017 Head of Therapies Appraisal and Mandatory Training

21

CQC113 CQC 2015 The Trust must ensure that Monthly reporting received identifying Requirement for appraisal for all staff being reinforced via Executive Team and is a Karen Dunderdale, Maureen Georgiou, Work in progress - On Target Achievement of Trust KPI63 Trust Governance

staff, especially within surgery, percentage of staff trained. Action plan monthly item on their agenda. Monthly reports are in place for appraisal and Deputy Chief Interim Associate Chief ongoing targets for mandatory Mandatory Training and Assurance

have appraisals and to be developed for all areas to have supervision compliance, across the Trust for all Groups. Further training or access to Executive and Operating Officer training, PADR and compliance rate Committee

supervision, and that actions robust plans to release staff and/ or to alternative support to be fed into the Education Training & Development team from Director of (S&CC)/ Harriet Date expected to be supervision identified in the appraisals are utilise online training and workbooks in Surgery and Critical Care Group to enable progress of actions. Operations Stephens, Head of fully embedded - 30 KPI64 acted upon. order to embed mandatory training. Education, Training and June 2017 with stepped PADR compliance rate Managers must also diarise PADRs over Development targets of 85% by 31 the full year. December 2016 and KPI156 95% by 31 March 2017. Clinical Supervision

CQC114 CQC 2015 The Trust must ensure three- Ensure three-monthly safeguarding All early help champions and practice teachers were trained as peer safeguarding Karen Dunderdale, Tina Sykes, Associate 31/03/2016 Ratified at TGAC on 17 Trust Governance

monthly safeguarding supervision takes place. supervisors in October 2015. Three monthly peer safeguarding supervision has been Deputy Chief Chief Nurse (C&TS) October 2016 and Assurance

supervision takes place for implemented within the HV service. In addition, six monthly named nurse supervision Executive and Committee

health visitors. is undertaken which provides external challenge. An early warning mechanism has Director of been developed to flag when someone is due to go out of compliance in order that this Operations can be addressed so that applicable compliance remains at 100%.

CQC115 CQC 2015 The Trust must ensure all staff Continue to monitor compliance with Requirement for appraisal and mandatory training for all staff being reinforced via Karen Dunderdale, Tina Sykes, Associate Work in progress - On Target Trust Governance

are up to date with appraisal mandatory training and PADR Executive Team and is a monthly item on their agenda. Mandatory training and PADR Deputy Chief Chief Nurse (C&TS)/ ongoing and Assurance

and mandatory training compliance. is a standard agenda item on staff meetings. Team Leaders/Service leads access the Executive and Dawn Daly, Head of Committee

(particularly in community monthly report and support staff to attend mandatory training and complete Director of Therapies (C&TS)/ Date expected to be services). The Trust should workbooks and PADR's proactively. Mandatory training and appraisal are also Operations Harriet Stephens, Head fully embedded - 30 continue to improve against monitored at the Community and Therapy governance meeting. Mandatory training of Education, Training June 2017 with stepped the target of all staff receiving and appraisal are also monitored at the Team Performance Meetings with analysis of and Development targets of 85% by 31 an annual appraisal. plans to achieve. December 2016 and 95% by 31 March 2017.

CQC116 CQC 2015 The Trust should continue to Continue to monitor compliance with MT reports continue to be shared across the groups and Directorates twoice weekly Jayne Adamson, Rachel Greenbeck, Work in progress - On Target Trust Governance

improve on its mandatory mandatory training. which can be drilled down to staff member level. Reported at several Meetings. Interim Director of Quality Matron/ Craig ongoing and Assurance

training targets to achieve its Proposal to be taken to TGAC and Trust Board re interim targets to be set for People and Ferris, Head of Committee

own compliance level of 95% achievement - 85% by end of December 2016 and 95% by the end of January 2017. Organisational Safeguarding/ Harriet Date expected to be and specifically ensure that Effectiveness Stephens, Head of fully embedded - 30 staff have a better Education, Training and June 2017 with stepped understanding of the Development targets of 85% by 31 assessment of capacity and the December 2016 and use of restraint (including 95% by 31 March 2017. chemical restraint).

CQC117 CQC 2015 The Trust should ensure all end Continue to monitor compliance with Appraisal system in place. Need to ensure that team are clearly labelled on ESR to Karen Dunderdale, Tina Sykes, Associate Work in progress - On Target Trust Governance

of life care staff are up to date mandatory training and PADR provide the correct data. As at 31.03.16 - Macmillan Health care team - Mandatory Deputy Chief Chief Nurse, Community ongoing and Assurance

with managerial appraisal of compliance. training 89%, Macmillan specialist Nurses community 86%. PADR Macmillan HHCT Executive and and Therapy Services. Committee

their work performance and 96%, Macmillan specialist nurses 86%. Monitored monthly at SMT and Governance Director of Date expected to be mandatory training. meeting. Service Leads, Operational Matrons and team leaders liaising with staff Operations fully embedded - 30 individually regarding mandatory training and PADR compliance. June 2017 with stepped targets of 85% by 31 December 2016 and 95% by 31 March 2017.

CQC118 CQC 2015 The Trust should ensure Continue to monitor compliance with Current position 95% compliance as of 16/8/16. This will be monitored ongoing via Karen Dunderdale, Tracey Broom, 31/07/2016 Ratified at TGAC on 15 Trust Governance

IR(MER) training is mandatory mandatory training. regular mandatory training reports. Deputy Chief Associate Chief September 2016 and Assurance

for radiology staff. Executive and Operating Officer (CSS)/ Committee

Director of Ruth Kent, Head of Operations Radiology Services/ Harriet Stephens, Head of Education, Training and Development Patient Feedback

CQC119 CQC 2015 The Trust must seek and act on CSS has a patient survey on satisfaction The survey results from Goole were overwhelmingly positive. Results have been fed Karen Dunderdale, Tracey Broom, 30 June 2016 Ratified at QPEC on 14 Increase in patient Patient experience Quality and Patient

feedback from patients in of services throughout the year. Patient back to staff during team brief and discussed at governance meetings. The service has Deputy Chief Associate Chief September 2016 satisfaction surveys Experience

radiology in order to evaluate feedback requiring actions will be an annual timetable for patient satisfaction surveys showing when they will be Executive and Operating Officer (CSS)/ Date expected to be Committee

and improve the services incorporated into an action plan completed and the month they will go to governance for discussion. Director of Ruth Kent, Head of fully embedded - 31 (particularly at Goole). monitored at governance meeting Operations Radiology Services August 2016

Duty of Candour

CQC120 CQC 2015 The Trust should ensure that Being Open Policy to be given to each All staff have received the Being Open Policy and have signed to say that they have Wendy Booth, Tracey Broom, 30/06/2016 Completed Duty of Candour Results of Quiz Trust Governance

all staff within outpatients are member of staff with an explanation read and understood the duty of candour briefing. In order to measure staff Director of Associate Chief (Training Complete) undertaken and Assurance

aware of their responsibilities about it at the team brief and/or knowledge a quiz is being carried out at team brief to test out understanding. In Performance Operating Officer (CSS), appropriately KPI359 & KPI360 Committee

in relation to the Duty of individually if required. Signatory list to addition to this, the Head of Complaints has undertaken some walk rounds in the Assurance & Trust Louise Hobson, Planned 31 July 2016 Duty of Candour Candour. be kept from staff signing to agree "read department to discuss with staff and test understanding. There is also monitoring of Secretary Care Manager (CSS) (staff awareness Increase in staff and understood" wider Duty of Candour requirements via a related KPI. testing) knowledge regarding Duty of Candour Date expected to be fully embedded - 31

Learning Lessons

CQC121 CQC 2015 a) The Trust should ensure that

more robust evidence is

available to show that sharing

of lessons learned from

incidents/ never events/ safety

thermometer outcomes/

audits/ actions plans

(communication in general) are

shared across the teams.

b) The Trust must ensure staff

can access and receive

feedback and learning from

incidents.

c) The Trust must ensure there

is a robust process for

providing consistent feedback

and learning from incidents.

d) The Trust should ensure that

robust processes are in place

for sharing lessons learned

from complaints within

community services.

Reinforce existing policy requirements

(Please ASK Campaign). Staff have a

responsibility to ask for feedback from

incidents as much as managers have a

responsibility to be given it.

A mandatory field has been added to Datix which requires Managers to input the

feedback information they have given staff who have requested it. This has been

developed into a KPI and was reported on for the first time in the July 2016 Integrated

Performance Report. Communication plan developed and campaign has commenced.

Incident leaflet attached to July 2016 payslips. Frequently asked questions leaflet

developed. Updates provided in weekly bulletin. Serious Incident One Page Learning

the Lessons is part of Hot Topics on intranet. Further communications planned i.e. staff

newsletter (weekly bulletin) at a later date to keep up the momentum. Key messages

delivered via training and induction relevant to Risk and Governance Team. Junior Dr

Patient Safety Forum attended and incident reporting discussed with Junior Doctors.

Update 25/08/16: Incident leaflet is handed out at inductions to capture new starters

to the Trust. Care Camp are changing the way the training is delivered and the

expected format is to have 1 week for Care Camp followed by 3 hours sessions that are

delivered 1 per month over 6 months. As part of the programme, the lead tutors are

considering input from the Governance Team on learning lessons at one of the 3 hour

sessions and will notify the team following a meeting on 1 September 2016. A

presentation on the actions to strengthen the Trust’s mechanisms to feedback /

learning lessons has been provided to commissioners through the Quality Contract

Review and SI Collaborative groups.

Wendy Booth,

Director of

Performance

Assurance & Trust

Secretary


Risk and Clinical Audit/

Learning Lessons

Review Group (How

Staff Learn Lessons)

30/06/2016

(Campaign Planned)

31 July 2016

(Campaign

Implemented)

Date expected to be

fully embedded - 31

October 2016

Completed Increase in staff who

report receiving

feedback from incidents

Trust continues to be a

high reporting

organisation

KPI341

Staff receiving feedback

ASK Campaign

Promotional Literature

Learning Lessons

Newsletters

Minutes of Learning

Lessons Review Group

Decrease in numbers of

incidents relating to sub

groups of Learning

Lessons Review Group

Trust Governance

and Assurance

Committee

CQC122 Awareness of the above campaign to be

communicated:

a) re-issue Please ASK Campaign

b) promote above message through

intranet, all staff email and through

incident reporting training

c) where appropriate, incorporate the

above message into other existing

training, e.g., Care Camp.

A mandatory field has been added to Datix which requires Managers to input the

feedback information they have given staff who have requested it. This has been

developed into a KPI and was reported on for the first time in the July 2016 Integrated

Performance Report. Communication plan developed and campaign has commenced.

Incident leaflet attached to July 2016 payslips. Frequently asked questions leaflet

developed. Updates provided in weekly bulletin. Serious Incident One Page Learning

the Lessons is part of Hot Topics on intranet. Further communications planned i.e. staff

newsletter (weekly bulletin) at a later date to keep up the momentum. Key messages

delivered via training and induction relevant to Risk and Governance Team. Junior Dr

Patient Safety Forum attended and incident reporting discussed with Junior Doctors.

Update 25/08/16: Incident leaflet is handed out at inductions to capture new starters

to the Trust. Care Camp are changing the way the training is delivered and the

expected format is to have 1 week for Care Camp followed by 3 hours sessions that are

delivered 1 per month over 6 months. As part of the programme, the lead tutors are

considering input from the Governance Team on learning lessons at one of the 3 hour

sessions and will notify the team following a meeting on 1 September 2016. A

presentation on the actions to strengthen the Trust’s mechanisms to feedback /



Wendy Booth,

Director of

Performance

Assurance & Trust

Secretary



Sarah Mainprize, Head

of Communications and

Marketing

30/06/2016

(Campaign Planned)

31 July 2016

(Campaign

Implemented)

Date expected to be

fully embedded - 31

October 2016


and Assurance

Committee

CQC123 How Staff Learn Lessons' to be linked to

the wider staff engagement strategy,

e.g., staff to be asked to share their ideas

as to how we can improve the current

arrangements and how they would like

to receive feedback, e.g., text,

automated e-mail message, etc.

A presentation on the actions to strengthen the Trust’s mechanisms to feedback /



Wendy Booth,

Director of

Performance

Assurance & Trust

Secretary



Karl Roberts, Clinical

Quality & Patient

Experience Lead

30/06/2016

(Method identified)


and Assurance

Committee

30 September 2016

(Monitoring of

Effectiveness)

Date expected to be

fully embedded - 31

October 2016

Completed

CQC124 Ensure that staff are clear that they may

be asked to share their experiences of

receiving feedback and learning and

ensure staff are clear on the use of

language, i.e., how the question may be

asked.

Key messages have been developed around how lessons will be shared and feedback

provided from reported incidents. This is being shared as part of wider communication

campaign outlined below. Communication plan developed and campaign has

commenced. Incident leaflet developed and attached to July 2016 payslips. Also given

to new starters at Corporate inductions and Junior Dr inductions. Frequently asked

questions leaflet developed and available on the intranet. Updates provided in weekly

bulletin and learning the lessons newsletters – signposted to FAQ leaflet on incident

reporting. Key messages reinforced through training. Key questions for staff to

consider regarding feedback from incidents and learning lessons have been

incorporated into the CQC leaflet.

Wendy Booth,

Director of

Performance

Assurance & Trust

Secretary



Learning Lessons

Review Group (How

Staff Learn Lessons)

30/06/2016

(Campaign Planned)

31 July 2016

(Campaign

Implemented)

Date expected to be

fully embedded - 31

October 2016


and Assurance

Committee

22

CQC125 Agree a standard template for use by all

ward/department staff meetings to

include an item on sharing feedback and

lessons learnt from incidents/SIs,

complaints/PALs and claims. This will

ensure consistency of approach and

provide auditable evidence that this is

happening or not. Include a review of

this requirement as part of Director

Visits or other ward visits and

inspections.

The “Standards for providing feedback to Staff following incidents / Clinical Audit /

Complaints & Claims including the Production of Local Level (Directorate / Group)

‘Learning Lessons’ Newsletters” and Newsletter template were approved at TGAC on

18 August 2016. A communication brief will be provided in the Staff Weekly Bulletin.

The documents will also be added to the Governance Group agendas for discussion

with an action to disseminate accordingly and ensure the key messages within the

standards documents are communicated effectively. The Trust Wide Learning the

Lessons Newsletter will include them as one of the main topic areas with a focus on

providing feedback to staff. The requirement for feedback to staff following incidents

continues to be promoted Trust-wide.

Wendy Booth,

Director of

Performance

Assurance & Trust

Secretary



30/06/2016

(Template Developed)

31 July 2016

(Template Issued)


and Assurance

Committee

30 September 2016

(In place for meetings)

Date expected to be

fully embedded - 31

October 2016 2016

Completed

CQC126 Learning Lessons Review Group to be

asked to review its membership to

include consideration of representation

from wards/departments and from

admin staff.

Terms of Reference reviewed at 7 June 2016 and agreed that membership was

appropriate as staff are involved in the working groups for each of the themes

identified and it was felt that this was more appropriate. Update 25 August 2016: A

learning the lessons event is currently being organised that will include representation

from different wards / departments / specialities and will include clinical, managerial

and admin staff. All in attendance will be able to contribute to understanding the

issues in respect of the 5 key themes and help to determine solutions to the identified

problems.

Wendy Booth,

Director of

Performance

Assurance & Trust

Secretary



30/06/2016

Date expected to be

fully embedded - 31

October 2016


and Assurance

Committee

CQC127 KPI to be developed in respect of

feedback and learning. For example,

when staff report an incident they are

required to tick to indicate whether they

require feedback. A separate field will be

added to datix to include feedback

provided. This KPI will be included in the

Integrated Performance/ KPI Report and

will be formally reported through

appropriate forums and will inform

Group Performance Reviews.

Central testing on July’s incidents has commenced and will be completed by the end of

September 2016 including identifying any actions to improve the process and

compliance.

Wendy Booth,

Director of

Performance

Assurance & Trust

Secretary



Sarah Davy, Legal

Services Manager/

Claire Jenkinson, Head

of Performance

30/06/2016

(amendments to datix

and development of

KPI)

31 July 2016

(Reporting of KPI as

part of integrated

performance report)

Date expected to be

fully embedded - 31

October 2016


and Assurance

Committee

CQC128 Independent re-audit to be requested to

validate actions taken, e.g., Verita, KPMG

as part of Internal Audit Programme

Further review / strengthening of the Trust’s arrangements for managing SIs including

interface with stakeholders to be undertaken further to QSG discussion – meeting to be

held on Friday 14 October 2016, facilitated by NHSE.

Wendy Booth,

Director of

Performance

Assurance & Trust

Secretary



31/08/2016

Scope to be agreed


and Assurance

Committee

30 September 2016

Audit to be undertaken

Date expected to be

fully embedded - 31

October 2016

Completed

CQC129 CQC 2015 The Community Dental Service

should promote the use of the

Trust electronic incident

reporting system to ensure

proper investigation of

incidents and sharing of

lessons learnt across the Trust.

Ensure that staff in the Community

Dental Service are aware of and

appropriately using the Trust incident

reporting system.

This is now embedded and uptake will be monitored through quarterly incident

analysis reports. Update: Monthly team meetings are being used to monitor & discuss

lessons learnt.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

Dawn Daly, Head of

Therapies (C&TS)/ Kelly

Burcham, Head of Risk

and Clinical Audit

31/05/2016

Date expected to be

fully embedded - 31

August 2016


September 2016

Increase in staff

knowledge of incident

reporting systems

Staff Feedback

Incident Reports

Trust Governance

and Assurance

Committee

Management of Risk

CQC130 CQC 2015 a) The Trust must ensure there

are timely and effective

governance processes in place

to identify and actively manage

risks throughout the

organisation, especially in

relation to critical care, staffing

and ensuring the essential

equipment is included in the

Trust replacement programme.

Full review of Risk Register to take place. Risk Register Confirm and Challenge Meeting Terms of Reference and Risk Register

Policy updated and approved by TGAC. Work ongoing with groups/ departments to

ensure that the register is complete.

Karen Dunderdale,

Deputy Chief

Executive and

Director of

Operations

All Associate Chief

Operating Officers/




Lead to be identified

30/06/2016

strategic risks

Completed Risk Register Complete

and updated Monthly

Minutes of Governance

Meetings

Trust Governance

and Assurance

Committee

31 July 2016

directorate/groups

Date expected to be

fully embedded - 31

October 2016

Completed

23

CQC131 b) The Trust should ensure that

all identified risks for the

services are held on the risk

register.

Review of Terms of Reference for

Group/Directorate Governance Meetings

to take place to ensure review of risk

register is on the agenda.

Groups/directorates have confirmed that discussion of the risk register is discussed at

their governance/business meeting. This will be audited. Full review of Terms of

Reference taking place to review other governance requirements.

31/05/2016

Date expected to be

fully embedded - 30

September 2016

Completed Risk Register Complete

and updated Monthly

Minutes of Governance

Meetings

Trust Governance

and Assurance

Committee

Staff Support

CQC132 CQC 2015 The Trust should strengthen Strengthen support as outlined in CQC A Consultant Radiologist from HEY is now our ARSAC Licence Holder. He provides

support both remotely and in person when required. An SLA is in the process of being

drawn up to formalise the agreement. Case of need to be presented at Strategy and

Planning on 9th May outlining request for funding requirements to support service as

per budget setting agreement. Update as at 27/5/16: Support arrangements in place.

Dr Avery now performing the role formally. Funding agreed on 9/5/2016 for 1 year

including training of NLAG Radiologists for reporting. Update as at 7/6/16: A

Consultant Radiologist from HEY is now our ARSAC Licence Holder. He provides

support both remotely and in person when required. Support arrangements in place.

Dr Avery now performing the role formally in line with SLA with HEY. Funding agreed

on 9/5/2016 for 1 year including training of NLAG Radiologists for reporting.

Karen Dunderdale, Tracey Broom, 30/06/2016 Ratified at TGAC on 17 Support arrangements in Staff Experience Surveys Trust Governance

the support provided to action. Deputy Chief Associate Chief October 2016 place and Assurance

nuclear medicine technologists Executive and Operating Officer/ Ruth Date expected to be Committee

by the ARSAC (administration Director of Kent, Head of Radiology fully embedded - 30 of radioactive substances Operations Services (CSS) September 2016 advisory committee) licence holder.

Record Keeping

CQC133 CQC 2015 The Trust must ensure that This related to a specific issue regarding Staff concerned at the CDC centre were informed to immediately stop this practice at Karen Dunderdale, Dawn Daly, Head of 31 April 2016 Completed Record Keeping Policy Results of Record Quality and Patient

record keeping meets all the use of records for MDT meetings. their MDT meetings. The process for case conferences follows LSCB guidance in that Deputy Chief Therapies (C&TS)/ Tina Keeping Audit Experience

appropriate registered body any case conference information is sent to the chair electronically and any copies Executive and Sykes, Associate Chief Date expected to be Achievement of Record Committee

standards (particularly in the printed stay at the meeting for destruction, not transported outside. All community Director of Nurse (C&TS) fully embedded - 31 Keeping Standards community). staff have mobile solutions (laptops). Operations October 2016

24

QUALITY DEVELOPMENT PLAN INDICATORS

For The Period 1st April 2016 to 31st August 2016

For The Period

Performance Metric

Threshold

Threshold

Type

Apr 16

Performance

May 16

Performance

Jun 16

Performance

July 16

Performance

Aug 16

Performance

In month

movement

Month End

Position

August 16

Trend line Comments

Staffing Levels KPI300 Drs Unfilled Shifts - Medicine 0 61 42 38 ↑ Medicine shifts are an accumulation of medicine and ED shifts.

KPI301 Dr Unfilled Shifts - Surgery 0 0 7 9 ↓ KPI302 Drs Unfilled Shifts - ED 0 13 22 32 ↓ KPI303 Drs Unfilled Shifts - CC 0 0 0 4 ↓ KPI304 Registered Nursing unfilled working hours - Medicine 80% 91.6% 90.6% 87.9% 87.8% 101.2% ↑ The KPI is monitoring is monitoring unfilled working hours for inpatients

areas which is extracted from the monthly Safer Staffing Unify submission

apart from ED shifts which isn't a requisite for the submission therefore is

sourced from e rostering data. The performance target is the actual

percentage where as the Unify return is the average percentage of day and

night shifts.

KPI305 Registered Nursing unfilled working hours - Surgery 80% 96.7% 95.0% 93.8% 92.5% 109.7% ↑

KPI306 Registered Nursing unfilled working hours - ED 80% 92.4% 91.3% 88.4% 88.4% 87.9% ↓

KPI307 Midwife unfilled working hours 80% 94.9% 94.5% 93.2% 92.7% 98.4% ↑ KPI207 No Band 4s are rostered to RN shifts at roster approval stage 0 0 0 → KPI53 Reduction in AHP vacancy rate 6.86% 6.87% 7.44% 6.12% 6.12% 6.12% → KPI52 Reduction in medical staffing vacancy rate 14.17% 16.3% 18.9% 19.1% 19.8% 20.7% ↓ KPI308 Doctors Vacancy Rates - ED 14.17% 28.9% 33.9% 31.9% 34.0% 34.4% → KPI309 Doctors Vacancy Rates - CC 14.17% 1.73% 1.45% 3.55% 1.93% (10.3%) ↑ KPI310 Nursing Vacancy Rates - ED Registered 6% 16.8% 6.9% 10.3% 14.5% 9.8% ↓ KPI311 Nursing Vacancy Rates - ED Un registered 6% (12%) (17.6%) (28.76%) (24.45%) (21.48%) ↓ KPI312 Nursing Vacancy Rates - CC Registered 6% 3.0% 6.9% 4.3% (0.72%) (0.72%) → KPI313 Nursing Vacancy Rates - CC Un registered 6% 33.6% 33.6% (0.14%) 19.4% 13.0% ↑ KPI314 Nursing Vacancy Rates - Surgery Registered 6% 10.6% 11.0% 12.2% 13.2% 14.2% ↓ KPI315 Nursing Vacancy Rates - Surgery Un Registered 6% (6.68%) (16.53%) (5.76%) (3.89%) (3%) ↓ KPI316 Nursing Vacancy Rates - Medicine Registered 6% 15.0% 15.3% 15.8% 17.1% 16.5% ↑ KPI317 Nursing Vacancy Rates - Medicine Un registered 6% (2.58%) (2.07%) (2.23%) (0.26%) 1.1% ↓

KPI51

Reduction in nursing vacancy rate - Registered

6%

9.7%

10.0%

10.4%

10.4%

10.9%

↓ Review meetings held every week. Recruitment incentive packages

developed and agreed, European recruitment ongoing, University

partnerships developed, Retention plan progression including band 5+,

Nursing academies and return to practice, Enhanced pay for bank staff

within ‘specialist areas’.

KPI318

Reduction in nursing vacancy rate - Un registered

6%

(1.62%)

(1.65%)

(1.44%)

0.9%

1.5%

↓

KPI319 Midwife Vacancy Rates 6% (0.75%) 3.2% 2.6% 2.3% ↑ KPI363 Reduction in Radiologist vacancy rates 14.17% 45.7% 41.1% 41.1% 36.5% 36.5% → Clinical Strategies & Pathways KPI320 Theatre 'On the Day' Cancellation Rate (Hospital only for clinical reason) 4.30% 3.9% 4.5% 3.4% ↑ July and August data is not currently available due to the transition of

theatre systems from ORMIS to WEBV which is impacting on monthly

reporting. KPI321 Theatre 'On the Day' Cancellation Rate (Hospital only for non-clinical reason) 2.50% 2.2% 2.6% 3.1% ↓ KPI362 Theatre 'On the Day' Cancellation Rate - Surgery 5% 8.9% 11.5% 8.9% ↑ KPI367(a) Theatre 'On the Day' Cancellation Rate due to lack of Anaesthetist Cover - Elective Surgery 0 0 0 0 →

These measures are to monitor any theatre lists that have been stood down

due to lack of medical cover in Surgery for Elective, Emergency and Urgent

operations. July and August data is not currently available - Transition of

theatre systems from ORMIS to WEBV is impacting on monthly reporting

KPI367(b) Theatre 'On the Day' Cancellation Rate due to lack of Anaesthetist Cover - Emergency Surgery 0 0 0 0 → KPI367(c) Theatre 'On the Day' Cancellation Rate due to lack of Anaesthetist Cover - Urgent Surgery 0 0 0 0 → KPI367(d) Theatre 'On the Day' Cancellation Rate due to lack of Surgeon Cover - Elective Surgery 0 0 5 2 ↑ KPI367(e) Theatre 'On the Day' Cancellation Rate due to lack of Surgeon Cover - Emergency Surgery 0 8 4 1 ↑ KPI367(f) Theatre 'On the Day' Cancellation Rate due to lack of Surgeon Cover - Urgent Surgery 0 0 0 0 → KPI322 Hospital Outpatient Cancelled Appointments - Trust wide 5% 13.1% 8.5% 8.5% 10.3% 8.5% ↑ KPI323 Hospital Outpatient Cancelled Appointments - Goole 5% 15.2% 8.3% 8.5% 14.4% 10.5% ↑ KPI324 Complaints relating to delays or cancellations in Angiography Catherization Lab SGH 1 0 0 0 0 0 → KPI325 Incidents relating to delays or cancellations in Angiography Catherization Lab SGH 1 0 0 0 0 0 → KPI326 Rdlgy Reporting times Urgent CT/MRI GP Referrals within 72 hours 90% 32.1% 28.9% 41.9% 31.5% 29.9% ↓ KPI327 Rdlgy Reporting times Urgent CT/MRI Outpatients within 72 hours 90% 27.4% 30.9% 43.1% 44.9% 46.3% ↑ KPI328 Rdlgy Reporting times CT/MRI Inpatient within 24 hours 90% 91.1% 91.7% 92.7% 93.4% 93.3% ↓ KPI329 Rdlgy Reporting times 31/62 GP Referrals within 24 hours 90% 54.1% 60.5% 66.3% 65.0% 74.3% ↑ KPI330 Rdlgy Reporting times Outpatients within 24 hours 90% 43.2% 50.1% 53.1% 67.2% 75.6% ↑ KPI331 Rdlgy Reporting times Routine within 168 Hours (7 days) 90% 68.3% 73.4% 78.1% 87.0% 79.4% ↓ KPI195 Reduction in Hospital Outpatient Cancelled Appointments rates by Patients 1% 0.0% 0.2% 0.5% 0.0% 0.5% ↓ KPI361 Out Patient Clinical Slot Utilisation Rate 94% 82.8% 85.3% 84.4% 83.3% 85.1% ↑ KPI356 (a) Reduction in the number of Cardiology Referrals NE Lincolnshire 5% 2.3% (-12%) 7.6% 5.7% 16.5% ↓ New referrals only includes accepted referrals in the data set. Measure is

monitoring the reduction of referrals based on the same monthly period

the previous year to allow for seasonal variations. This is to monitor what

impact the new GP referral protocol is having on referral numbers. Figures

in red signify a reduction on last years returns. Figures in red represents the

KPI356 (b) Reduction in the number of Cardiology Referrals North Lincolnshire 5% 32.6% 35.9% 24.3% 22.8% 46.0% ↓ KPI357 (a) Reduction in the number of Respiratory Referrals - NE Lincolnshire 5% (-8.9%) (-27%) 1.8% 15.5% 22.0% ↓ KPI357 (b) Reduction in the number of Respiratory Referrals - North Lincolnshire 5% 7.6% 34.2% 18.6% (-11.1%) 47.3% ↓ Safety KPI332 Emergency Care Incidents - no anaesthetic staff 0 1 0 0 0 0 → KPI368 Pressure Ulcers - Theatres harm free care 0 0 0 0 0 0 → KPI333 Maternity Incidents that have an RCA 5 11 12 12 7 5 ↑ KPI334 Nursing Capacity incidents - ED 7 2 1 2 3 19 ↓

Increase in incidents could be attributed new additional l 'red flag' triggers,

historically there was only 1 trigger 'staffing levels'

KPI335 Nursing Capacity incidents - Medicine 41 10 7 3 63 77 ↓ KPI336 Nursing Capacity incidents - Surgery 2 6 1 2 13 16 ↓

Performance Metric

Threshold

Threshold

Type

Apr 16

Performance

May 16

Performance

Jun 16

Performance

July 16

Performance

Aug 16

Performance

In month

movement

Month End

Position

August 16

Trend line

Comments

KPI337 Midwife Capacity incidents 5 10 0 2 5 11 ↓

Performance Metric

Threshold

Threshold

Type

Apr 16

Performance

May 16

Performance

Jun 16

Performance

July 16

Performance

Aug 16

Performance

In month

movement

Month End

Position

August 16

Trend line

Comments

KPI348 Community Buildings where PAT testing is completed 70% 26.9% 38.5% 100% ↑ KPI364 (a) Ratio of midwives to births - DPoW 01:28 1.34 1.34 → KPI364 (b) Ratio of midwives to births - SGH 01:28 1.30 1.30 → KPI365 1:1 figures for births 100% 100% 99.5% 98.7% 99.5% 98.5% ↓ Responsive

KPI19

Fractured Neck of Femur patients operated on within 36 hours

75%

64.3%

60.0%

73.7%

52.9%

56.1%

↑

There is discrepancy currently e around conciliating data on the National Hip

Fracture Database compared to PAS. The operation group is in the process

of procuring more administration support into #NOF validation. The

performance is representative of the current information available.

KPI182

DNA Rate - Trust wide

6%

8.6%

9.2%

9.9%

9.7%

9.1%

↑

Call reminder service resources allocated to specific specialities to be rolled

out to all specialities following implementation of the new clinical admin

structure. Monthly data is rebased to reflect historic changes. KPI338 DNA Rate - Goole 6% 7.1% 8.5% 9.5% 8.4% 8.5% ↓

KPI339

Delay Discharges Intensive Therapy Unit DPoW - Intensive Care Unit SGH

67.8%

50.0%

43.9%

44.4%

↓ Performance is based on medically fit patients that have a delayed

discharge onto another ward of more that 4 hours. This data is extracted

quarterly and presented to the Critical Care Provision Group. Updated data

will be available in September.

KPI17 Delayed transfer of care at or below national benchmark rate 3.8% 3.3% 2.1% 2.5% 3.1% 2.6% ↑ KPI 18 Outliers on medical and surgical wards 3.0% 5.6% 4.4% 4.3% 4.3% 3.8% ↑ KPI359 Duty of Candour - SUIs - met in all relevant instances 100% 100% 100% 100% 100% 100% → KPI360 Duty of Candour - Moderate Harm (non SUIs) - met in all relevant instances 100% 100% 100% 100% 100% 100% → Well Led KPI340 Health Visitors - 3 monthly peer supervision 92% 88.9% 86.1% 88.9% 84.7% 74.3% ↓

KPI56

Nurses to have received supervision

95%

76.7%

77.4%

76.5%

78.0%

77.4% ↓ Compliance with supervision requirements continues to be monitored at all

levels of the Trust.

KPI341 Learning Lessons - Feedback on incidents to be provided 100% 86.0% 79.9% 76.3% ↓

KPI63

Mandatory training compliance rate

95%

93.3%

93.1%

91.8%

91.6%

92.3%

↑

Failure to achieve this indicator has been escalated to and discussed at the

Trust's Governance & Assurance Committee. A range of actions were

identified and these will be undertaken over the coming months. Monthly

reports are distributed to group managers highlighting staff who are

nearing the cut off point for training compliance.

KPI64

Staff to have undertaken an annual Vision & Values PADR

95%

85.3%

77.9%

78.4%

76.3%

76.3%

→ This continues to be monitored at all levels of the Trust. Monthly reports

are distributed to group managers highlighting staff who are nearing the cut

off point for PADR compliance.

KPI349

Number of wards with dedicated management time

100%

42.9%

26.0%

46.9%

37.3%

29.4%

↓

KPI349 (a) Provision of protected management time for ward charge nurses 100% 90.2% 71.1% 61.6% ↓

KPI349 (b) Dedicated shift leader on days 80%

KPI355

Relevant staff have received training in managing patients with a learning disability

A local Education and Training Strategy for LD care to reflect the new Health

Education England training for learning disability guidance is currently being

developed. Once this has been sanctioned a training programme with be

delivered Trust wide.

KPI62 Relevant staff have received dementia awareness training 60% 67.6% 68.7% 70.0% 71.1% 84.4% ↑ Effectiveness

KPI01

SHMI - hospital within expected range

95

109

(Dec - 15)

107

(Jan - 16)

107

(Feb - 16)

107

(Mar - 16)

108

(Apr - 16)

↓

This is a Trust quality priority which is monitored at monthly QPEC and

MPAC meetings. A range of work streams have been implemented focusing

on: care for patients at the end of life, accuracy of information and coding,

6 clinical led Multi Disciplinary Teams looking at quality/morality agenda.

Case note reviews are also looking at care quality and a monthly detailed

Mortality report is overseen by MPAC and Trust Board.

KPI02

SHMI - weekend within expected range

95

114

(Dec - 15)

109

(Jan - 16)

110

(Feb - 16)

109

(Mar - 16)

112

(Apr - 16)

↓

KPI342 Documents in compliance within the Document Control System - Maternity 90% 91.1% 93.4% 94.9% ↑ KPI343

Documents in compliance within the Document Control System - Patient Group Directions for

Medication within ED 90% 100% 100% 100% 100% 83.7% ↓

KPI183

Documents in compliance within the Document Control System

90%

78.6%

79.3%

77.9%

79.5%

81.2%

↑

Operational groups have implemented various work streams to improve

such as using trackers, dedicated section on governance agenda and general

management direct control.

KPI03a Adherence to NICE guidance TAG 100% 92.3% 93.2% 90.0% 88.9% 82.2% ↓ Work streams implemented to support healthcare professionals to assess

the increasing numbers of guidelines within the required timescales. TGAC

monitoring monthly performance. KPI03b Adherence to NICE guidance - CG & NG 90% 76.5% 75.7% 80.8% 68.4% ↓ KPI350 Number of service reviews undertaken 14.3% 14.3% 14.3% → KPI351 Number of services with capacity plans 46.2% 46.2% 46.2% → Patient Experience KPI344 Complaints/PALS - Midwifery 5 8 2 3 5 2 ↑ KPI345 End of life Care (Complaints) 1 0 0 0 1 2 ↓ KPI346 MSA - sleeping breaches 0 0 0 0 0 0 → KPI352 Sis in A&E Department - anti-ligature risks 0 0 0 0 0 0 →

Performance Metric

Threshold

Threshold

Type

Apr 16

Performance

May 16

Performance

Jun 16

Performance

July 16

Performance

Aug 16

Performance

In month

movement

Month End

Position

August 16

Trend line

Comments

KPI353

Incidents in A&E Department - anti-ligature risks

0

0

0

0

0

1

↓

Incident escalated to Matron for further investigation. Appropriate action

taken by staff, staff were reminded of the importance of 1:1 consultations

with mental health patients.

Threshold Apr-16 May-16 Jun-16 Jul-16 Aug-16 Trend Analysis

Staffing Levels

KPI300 Drs Unfilled Shifts - Medicine 0 61 42 38 KPI301 Dr Unfilled Shifts - Surgery 0 0 7 9

KPI302 Drs Unfilled Shifts - ED 0 13 22 32 KPI303 Drs Unfilled Shifts - CC 0 0 0 4

KPI304 Registered Nursing unfilled working hours - Medicine 80% 91.6% 90.6% 87.9% 87.8% 1.012 KPI305 Registered Nursing unfilled working hours - Surgery 80% 96.7% 95.0% 93.8% 92.5% 1.097

KPI306 Registered Nursing unfilled working hours - ED 80% 92.4% 91.3% 88.4% 88.4% 87.9% KPI307 Midwife unfilled working hours 80% 94.9% 94.5% 93.2% 92.7% 98.4% KPI207 No Band 4s are rostered to RN hours at roster approval stage’ 0 0 0

KPI53 Reduction in AHP vacancy rate 6.86% 6.9% 7.4% 6.1% 6.1% 6.1% KPI52 Reduction in medical staffing vacancy rate 14.17% 16.3% 18.9% 19.1% 19.8% 20.7%

KPI308 Doctors Vacancy Rates - ED 14.17% 28.9% 33.9% 31.9% 34.0% 34.4%

KPI309 Doctors Vacancy Rates - CC 14.17% 1.7% 1.5% 3.6% 1.9% (10.3%) KPI310 Nursing Vacancy Rates - ED Registered 6% 16.8% 6.9% 10.3% 14.5% 9.8% KPI311 Nursing Vacancy Rates - ED Un registered 6% (12%) (17.6%) (28.76%) (24.45%) (21.48%)

KPI312 Nursing Vacancy Rates - CC Registered 6% 3.0% 6.9% 4.3% (0.72%) (0.72%)

KPI313 Nursing Vacancy Rates - CC Un registered 6% 33.6% 33.6% (0.14%) 19.4% 13.0% KPI314 Nursing Vacancy Rates - Surgery Registered 6% 10.6% 11.0% 12.2% 13.2% 14.2% KPI315 Nursing Vacancy Rates - Surgery Un Registered 6% (6.68%) (16.53%) (5.76%) (3.89%) (3%) KPI316 Nursing Vacancy Rates - Medicine Registered 6% 15.0% 15.3% 15.8% 17.1% 16.5%

KPI317 Nursing Vacancy Rates - Medicine Un registered 6% (2.58%) (2.07%) (2.23%) (0.26%) 1.1%

KPI51 Reduction in nursing vacancy rate - Registered 6% 9.7% 10.0% 10.4% 10.4% 10.9% KPI318 Reduction in nursing vacancy rate - Un registered 6% (1.62%) (1.65%) (1.44%) 0.9% 1.5%

KPI319 Midwife Vacancy Rates 6% (0.75%) 3.2% 2.6% 2.3% KPI363 Reduction in Radiologist vacancy rates 14.17% 45.7% 41.1% 41.1% 36.5% 36.5%

Clinical Strategies & Pathways

KPI320 Theatre 'On the Day' Cancellation Rate (Hospital only for clinical reason) 4.30% 3.9% 4.5% 3.4% KPI321 Theatre 'On the Day' Cancellation Rate (Hospital only for non-clinical reason) 2.50% 2.2% 2.6% 3.1% KPI362 Theatre 'On the Day' Cancellation Rate - Surgery 5% 8.9% 11.5% 8.9%

KPI367(a) Theatre 'On the Day' Cancellation Rate due to lack of Anaesthetist Cover - Elective Surgery 0 0 0 0 KPI367(b) Theatre 'On the Day' Cancellation Rate due to lack of Anaesthetist Cover - Emergency Surgery 0 0 0 0 KPI367(c) Theatre 'On the Day' Cancellation Rate due to lack of Anaesthetist Cover - Urgent Surgery 0 0 0 0

KPI367(d) Theatre 'On the Day' Cancellation Rate due to lack of Surgeon Cover - Elective Surgery 0 0 5 2

KPI367(e) Theatre 'On the Day' Cancellation Rate due to lack of Surgeon Cover - Emergency Surgery 0 8 4 1 KPI367(f) Theatre 'On the Day' Cancellation Rate due to lack of Surgeon Cover - Urgent Surgery 0 0 0 0

KPI322 Hospital Outpatient Cancelled Appointments - Trust wide 5% 13.1% 8.5% 8.5% 10.3% 8.5% KPI323 Hospital Outpatient Cancelled Appointments - Goole 5% 15.2% 8.3% 8.5% 14.4% 10.5% KPI324 Complaints relating to delays or cancellations in Angiography Catherization Lab SGH 1 0 0 0 0 0 KPI325 Incidents relating to delays or cancellations in Angiography Catherization Lab SGH 1 0 0 0 0 0

KPI326 Rdlgy Reporting times Urgent CT/MRI GP Referrals within 72 hours 90% 32.1% 28.9% 41.9% 31.5% 29.9%

QUALITY DEVELOPMENT PLAN INDICATORS

For The Period 1st April 2016 31st August 2016


KPI327 Rdlgy Reporting times Urgent CT/MRI Outpatients within 72 hours 90% 27.4% 30.9% 43.1% 44.9% 46.3%

KPI328 Rdlgy Reporting times CT/MRI Inpatient within 24 hours 90% 91.1% 91.7% 92.7% 93.4% 93.3%

KPI329 Rdlgy Reporting times 31/62 GP Referrals within 24 hours 90% 54.1% 60.5% 66.3% 65.0% 74.3%

KPI330 Rdlgy Reporting times Outpatients within 24 hours 90% 43.2% 50.1% 53.1% 67.2% 75.6%

KPI331 Rdlgy Reporting times Routine within 168 Hours (7 days) 90% 68.3% 73.4% 78.1% 87.0% 79.4%

KPI195 Hospital Outpatient Cancelled Appointments rates by Patients 1% 0.0% 0.2% 0.5% 0.0% 0.5%

KPI361 Out Patient Clinical Slot Utilisation Rate 94% 83.0% 82.8% 82.8% 82.7% 0.0%

KPI356 (a) Reduction in the number of Cardiology Referrals NE Lincolnshire 5% 2.3% (-12%) 7.6% 5.7% 16.5%

KPI356 (b) Reduction in the number of Cardiology Referrals North Lincolnshire 5% 32.6% 35.9% 24.3% 22.8% 46.0%

KPI357 (a) Reduction in the number of Respiratory Referrals - NE Lincolnshire 5% (-8.9%) (-27%) 1.8% 15.5% 22.0%

KPI357 (b) Reduction in the number of Respiratory Referrals - North Lincolnshire 5% 7.6% 34.2% 18.6% (-11.1%) 47.3%

Safety

KPI332 Emergency Care Incidents - no anaesthetic staff 0 1 0 0 0 0

KPI368 Pressure Ulcers - Theatres harm free care 0 0 0 0 0 0

KPI333 Maternity Incidents having an RCA 5 11 12 12 7 5

KPI334 Nursing Capacity incidents - ED 7 2 1 2 3 19

KPI335 Nursing Capacity incidents - Medicine 41 10 7 3 63 77

KPI336 Nursing Capacity incidents - Surgery 2 6 1 2 13 16

KPI337 Midwife Capacity incidents 5 10 0 2 5 11

KPI348 Community Buildings where PAT testing is completed 70% 26.9% 38.5% 100%

KPI364 (a) Ratio of midwives to births - DPoW 1.28 1.34 1.34

KPI364 (b) Ratio of midwives to births - SGH 1.28 1.30 1.30

KPI365 1:1 figures for births 100% 100% 99.5% 98.7% 100% 98.5%

Responsive

KPI19 Fractured Neck of Femur patients operated on within 36 hours 75% 64.3% 60.0% 73.7% 52.9% 56.1%

KPI182 DNA Rate - Trust wide 6% 8.6% 9.2% 9.9% 9.7% 9.1%

KPI338 DNA Rate - Goole 6% 7.1% 8.5% 9.5% 8.4% 8.5%

KPI339 Delay Discharges ITU DPoW - ICU SGH 3.8% 67.8% 50.0% 43.9% 44.4%

KPI17 Delayed transfer of care at or below national benchmark rate 3.8% 3.3% 2.1% 2.5% 3.1% 2.6%

KPI18 Outliers on medical and surgical wards 3.0% 5.6% 4.4% 4.3% 4.3% 3.8%

KPI359 Duty of Candour - SUIs - met in all relevant instances 100% 100% 100% 100% 100% 100%

KPI360 Duty of Candour - Moderate Harm (non SUIs) - met in all relevant instances 100% 100% 100% 100% 100% 100%

Well Led

KPI340 Health Visitors - 3 monthly peer supervision 92% 88.9% 86.1% 88.9% 84.7% 74.3%

KPI56 Nurses to have received supervision 95% 76.7% 77.4% 76.5% 78.0% 77.4%

KPI341 Learning Lessons - Feedback on incidents to be provided 100% 86.0% 79.9% 76.3%

KPI63 Mandatory training compliance rate 95% 93.3% 93.1% 91.8% 91.6% 92.3%

KPI64 Staff to have undertaken an annual Vision & Values PADR 95% 85.3% 77.9% 78.4% 76.3% 76.3%

KPI349 Number of wards with dedicated management time 100% 42.9% 26.0% 46.9% 37.3% 29.4%

KPI349 (a) Provision of protected management time for ward charge nurses 100% 90.2% 71.1% 61.6%

KPI349 (b) Dedicated shift leader on days 80%

KPI355 Relevant staff have received training in managing patients with a learning disability

KPI62 Relevant staff have received dementia awareness training 60% 67.6% 68.7% 70.0% 71.1% 84.4%

Effectiveness

KPI01 SHMI - hospital within expected range 95 109

(Dec - 15)

107

(Jan - 16)

107

(Feb - 16)

107

(Mar - 16)

108

(Apr - 16)

KPI02 SHMI - weekend within expected range 95 114

(Dec - 15)

109

(Jan - 16)

110

(Feb - 16)

109

(Mar - 16)

112

(Apr - 16)

KPI342 Documents in compliance within the Document Control System - Maternity 90% 91.1% 93.4% 94.9%


KPI343 Documents in compliance within the Document Control System - Patient Group Directions for

Medication within ED 90% 100% 100% 100% 100% 83.7%

KPI183 Documents in compliance within the Document Control System 90% 78.6% 79.3% 77.9% 79.5% 81.2%

KPI03 a Adherence to NICE guidance TAG 100% 92.3% 93.2% 90.0% 88.9% 82.2%

KPI03 b Adherence to NICE guidance - CG & NG 90% 76.5% 75.7% 80.8% 68.4%

KPI350 Number of service reviews undertaken 14.3% 14.3% 14.3%

KPI351 Number of services with capacity plans 46.2% 46.2% 46.2%


Patient Experience

KPI344 Complaints/PALS - Midwifery 5 8 2 3 5 2

KPI345 End of life Care (Complaints) 1 0 0 0 1 2

KPI346 MSA - sleeping breaches 0 0 0 0 0 0

KPI352 Sis in A&E Department - anti-liagture risks 0 0 0 0 0 0 KPI353 Incidents in A&E Department - anti-liagture risks 0 0 0 0 0 1