king’s lynn nhs foundation · the queen elizabeth king’s lynn nhs foundation trust - our...

Special Measures Action Plan

The Queen Elizabeth Hospital King’s Lynn NHS Foundation

Trust 13th January 2015

KEY

Delivered

On Track to deliver

Some issues – narrative disclosure

Not on track to deliver

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The Queen Elizabeth King’s Lynn NHS Foundation Trust - Our improvement plan & our progress

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What are we doing?

• The Trust entered the special measures programme in October 2013 by Monitor following the publication of two CQC reports in August 2013 and November 2013. The Trust

was non-compliant with twelve of the sixteen CQC outcomes. In addition the Trust was also the subject of a Rapid Responsive Review (RRR) led by NHS Midlands and East

with a site visit in August 2013, making a further 27 recommendations to improve patient care. The Trust was also served with 4 formal warning notice from the CQC.

• The Trust has been given a variety of recommendations from the CQC inspection in July 2014, in line with the re-inspection within 12 months of QEH entering Special

Measures. There were 21 ‘Must’ and 7 ‘Should’ under 4 of the 5 Domains of Safe, Effective, Caring, Responsive and Well-led summarised below:

Safe

- storage and documentation of medicines in clinical areas

- medical and nursing access to education and training

- embedding nursing skill mix review

- emergency planning resilience

- review and audit of infection, prevention and control practices

Effective

- review and improve the environment and storage arrangements for A&E and neonatal unit

- strategically plan to move to MEWS

Responsive

- review cancellation rates and discharge processes

- review the mortuary environment

- review the investigations of incidents process

- ensure there are sufficient staff on duty at all times who are trained in restraint

Well Led

- review the medical leadership for elective and emergency surgery

- ensure an Executive Director is appointed as End of Life Care Lead

• The Trust is also responding to the concerns outlined in the CQC press release concerning

Medical Outliers

Elective Surgical patient cancellations

Physical Restraint training for staff

Embedding a robust governance structure.

• The Trust agreed a summary action plan to deal with these 28 recommendations. We have accepted all of the recommendations and are addressing them through current

actions being taken to improve the quality of services. These improvements will be managed through the PMO with Executive Directors as named leads. The Interim Director

of Quality Improvement is due to leave the Trust in November. The lead for the programme of work will be Louise Stevens, Head of Integrated Clinical Governance. The

Trust will set out a longer-term plan to maintain progress and ensure that the actions lead to measurable improvements in the quality and safety of care for patients.

• This document shows our plan for making these improvements and demonstrates our progress against the plan. While we take forward our plans to address the 28

recommendations, the Trust is in ‘special measures’.

• Oversight and improvement arrangements are in place to support changes required through our monthly Performance Review meetings and signed off by Monitor’s

Improvement Director, David Hill.

The Queen Elizabeth King’s Lynn NHS Foundation Trust - Our improvement plan & our progress

Chair / Chief Executive Approval (on behalf of the Board):

Chair Name: Edward Libbey Signature: Date:13th January 2015

Chief Executive Name: Dorothy Hosein

Signature:

Date: 13th January 2015

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Who is responsible?

• Our actions to address the 28 recommendations have been agreed by the Trust Board.

• Our Chief Executive, Dorothy Hosein, is ultimately responsible for implementing actions in this document. Other key staff are Dr Bev Watson, Medical Director and Patient

Safety Lead and Catherine Morgan, Director of Nursing, who will provide the executive leadership for quality, patient safety and patient experience.

• The Improvement Director assigned to Queen Elizabeth NHS Foundation Trust is David Hill, who will be acting on behalf of Monitor and in concert with the relevant Regional

Team of Monitor to ensure delivery of the improvements and oversee the implementation of the action plan overleaf. Should you require any further information on this role

please contact [email protected]

• Ultimately, our success in implementing the recommendations of the Integrated Quality Improvement plan will be assessed by the Chief Inspector of Hospitals, upon re-

inspection of our Trust.

• If you have any questions about how we’re doing, contact Karon Strong, Head of Quality Improvement, [email protected]

How we will communicate our progress to you

• We will update this progress report every month while we are in special measures.

• There will be regular updates on NHS Choices and subsequent longer term actions may be included as part of a continuous process of improvement.

• The Trust is planning to undertake a serious of staff and public meetings through October . Further dates will be announced in updates of this progress report

mailto:[email protected]

mailto:[email protected]

The Queen Elizabeth King’s Lynn NHS Foundation Trust - Our improvement plan

Summary of Main Concerns Outstanding

Summary of Urgent Actions Required Agreed timescale for implementation

External Support/

Assurance

Progress against original

timescale

Revised deadline (if required)

Outcome 7 – Safeguarding

people who use the services

from abuse

The Trust commenced mandatory training in Mental Capacity Act in November 2013. A

targeted approach has been applied with an overall trajectory set for Trust wide

completion.

Compliance end of October 73.07% against target of 70%

Compliance end of November 77.05% against target of 70%

Compliance end of December 78.28% against target of 70%

Outcome 13 – Nursing levels - staffing

A large-scale skill mix review was undertaken in April. The Board subsequently approved £3m investment in nurse recruitment. All budgets were updated accordingly in April 2014. Nurse staffing is reviewed 3 times each day and staffing is flexed to meet patient dependency/acuity. Turnover rate in month 31st December: 12.7% against target of <10%. Vacancy rate to current establishment 31st December: 9.3% Registered nurse against target of <6% .

Outcome 14 – Supporting Workers

71% of staff have attended the Trust Values and Behaviours’ workshops and are now

part of the Trust induction training and are being used in recruitment. Mandatory

training -Trust-wide compliance to end of September 2014 86.07% against target of 85%

N.B. excludes newly added subjects.

Outcome 4 – Care and welfare of the people who use the service

Board rounds are embedded on all wards. Focus on Social Services attendance. Current

compliance as of December shows 68% compliance. Weekly random spot checks of 2

wards per week to reinforce compliance.

Outcome 5 – Meeting Nutritional Needs MUST accuracy 89% for November 2014 against a target of 90%

New fluid balance chart introduced in March with many wards now achieving 100%

compliance. Current Trust wide compliance for December 2014 - 91% against target of

90%.

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Summary of Main Concerns


External Support/

Assurance


timescale


Outcome 9 – Management of medicines

Automatic, centralised drug fridge temperature monitoring system:- Installation

commenced 6th October 2014

Installation complete

By 31st October 2014

System calibration and validation date: 15/16 December. 15/16 December 2014

Handover of temperature monitoring to Tutela and inform staff of the change over January 2015

Outcome 9 – Management of medicines

Medicine reconciliation audit completed. 54% compliance. Internal productivity review in

progress to release current pharmacy capacity. CCG and Trust discussed funding to

increase resource to improve compliance . A new Medicines Management technician

has been recruited to help increase compliance.

Monthly compliance audits being undertaken. To be placed on the Medicines

Management action plan.

To be incorporated

into the medicines

management action

plan.

Outcome 21 – Record Keeping

Positive feedback has been received from the new medical documentation. This has

been substantiated by recent audit results. Work has now commenced to modify the

emergency surgical pathway into the same format.

Revised date for completion 1st December 2014

Outcome 21 – Record Keeping

Proposed switch-off of paper system only for in-patient areas. Work commenced with

Project Management office and Business Intelligence and IM&T.

Revised date for completion April 2015

Operational Delivery November 2014 A&E performance 85.58%

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External Support/

Assurance


timescale


Safe Urgent efforts are made to comply with the warning notice issued last year in regard to safeguarding people who use services from abuse, restraint of patients, staffing levels and staff training.

• From 1st July 2013, two Security Guards trained in restraint are available during the day and one during the night.

• From 3rd July 2014, two Security Guards trained in physical restraint on duty 24/7

• Substantive Training Officer (violence and Aggression) in post 22nd September

• 3 day training in physical restraint techniques and relevant laws will commence 17th November 2014 Prioritised clinical staff group to be trained:

- Site management team (7) • 3 members of the site team still to be trained in March 2015 however

training has been rolled out to other teams – 11 trained to date.

By 31st December 2014

Datix reports for each physical restraint incident from 30th January 2014 Mandatory training rates by staff group by month.

Safe Concerns around the management of medical outliers are addressed. The trust was not effectively tracking outliers, and therefore appropriate monitoring and follow-up care was not always being provided

• Medical outlying patients reviewed every morning by dedicated Medical

Consultant Monday – Friday from 1st July 2013.

• Reduction in total number of outlying medical patients as a result of

Emergency Flow Programme.

• 3 times daily monitoring through operations centre at bed meetings.

On going

• Frailty Ward model planned for Pentney w/c 6th October. We expect this

will reduce the length of stay for Care of Elderly patients by 1 day and will

also contribute to reducing the conversion rate in A&E by 30%

• Patients moves are tracked and electronically recorded out of hours by

the Hospital at Night Team and during the day by the Site Practitioner

team. MAU to have 24 hour ward clerk cover to ensure a robust system

for tracking going forward.

31st March 2015

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External Support/

Assurance


timescale


Responsive Improvements are made within the trust’s surgery service. Several elective surgeries were cancelled due to capacity and low availability of beds

• As a result of the Emergency Flow Programme commenced 31st July, cancelled

operations did continue to reduce (July = 52; Sept = 16; Oct = 25; Nov = 46 Dec = 14).

However due to severe bed pressures and an early outbreak of Noro Virus this

number significantly increased in November.

• Monitoring is through Divisional Managers who attend Trust bed management

meetings 3 times daily to assess outlying patients and capacity for elective admissions

• The Board receives a monthly Integrated Report with aggregated numbers of

cancelled operations

On going Governance Structure

Effective Progress is made towards embedding a robust governance structure. The trust’s governance system must work more effectively to provide assurance to the board that the services being provided are safe and effective. This included ensuring that the trusts policies are up to date as during the inspection CQC inspectors found almost 200 polices were out of date.

• All Substantive Executive Directors including CEO and Non-Executive Director’s

appointments will be made by 8th October. The Medical director, Director of Nursing,

Chair and NEDs are in post, Chief Operating Officer from 1st November and Human

Resource and Organisational Development Director from 1st December.


KPMG

• The head of Integrated Governance has been in post since 6th June 2014. 2 of 3

Divisional Governance and Risk Managers are in place from 1st October.

Interview for the 3rd post 15th October 2014.

• A policy management system (Hadron) is planned to be in place by 31st March 2014.

• All RCA investigation outcomes and action plans to be uploaded to the Patient Safety

intranet site to enable shared learning

• Revised Committee Structure agreed at Audit Committee 8th April 2014

• Terms of References of every committee reviewed.

• Chairs changed where requested and Clinical Chair numbers increased to 17

• Work has commenced to review and implement a new Quality Strategy.


• KPMG commenced a second Monitor GQF review of November 2013 on 30th

September 2014.

• KPMG’s second GQF results published – Action Plan currently being compiled.

30th June 2015


Summary of Main Concerns Summary of Urgent Actions Required Agreed timescale for implementation

External Support/ Assurance

Progress against original timescale


Musts SM1 –Ensure that resuscitation support, equipment and training is consistent throughout the trust, and compliance with Resuscitation Council guidance is achieved. We found several examples of different equipment on resuscitation trolleys, lack of training and audit especially in A&E and outpatients.

The equipment on all trolleys is now standard across the trust and complies with current guidelines. Delivery of 2 new defibs still awaited to ensure trolleys are situated in all inpatient areas.

31st December 2014

Compliance audits are currently undertaken 3 monthly which will increase to monthly when the Resus administrator commences post on 3rd November 2014

31st December 2014

Training is currently at 86.07% which is above the trust target of 85%. A second Resus officer was appointed on 6th October2014 and will commence in post 2nd February 2015, with specific role for monthly audits.

2nd February 2015

SM2 – Ensure that the management of medicines, including storage and recording of temperatures, is done in accordance with national guidelines.

A weekly compliance tool has given to ward Sisters 13th October 2014 with a communication from the Director of Nursing to launch the tool.

13th October 2014

The importance of daily fridge temperature checks to be reiterated by Chief nurse in newsletter. Centralised monitoring system to be fully functional by end January 2015.

31st January 2015

SM3 – Ensure that patients are protected from the risks associated with the unsafe use and management of medicines, by means of ensuring that appropriate arrangements for the recording and use of medicines are in place.

The Trust is to be involved in a pilot of the regional drug chart. Pilot to commence on West Raynham Ward 5th January 2015. The Trust will also adopt the medicines safety thermometer.

On going

SM4 – Review and improve medical staffing levels, education and training to ensure patient safety.

Acute medicine Consultant and junior establishment and inpatient consultant staffing establishment and job planning is being reviewed as part of the Emergency Flow Improvement Plan. Educational supervisors and clinical supervisors have undertaken a training day 1st October2014, to improve the support for trainees accessing study leave. Simulation Suite – space has been identified, funding agreed , funding agreed, faculty established and programme for courses being developed.

31st December 2014

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SM5 – Embed skill mix assessments for nursing staff and review nursing establishments and adjust as required to ensure patient safety.

Establishment will be reviewed every 6 months after initial baseline in April 2014. Tracking of staff turnover is undertaken monthly. HR support has been increased to support recruitment and retention.

On going

SM6 – Review nursing staffing levels in both the neonatal and paediatric units to ensure patient safety.

The skill mix review is to be presented to Board 28th October 2014. Increased funding has been agreed for 2.75 WTE nurses in both areas. Posts have been offered to 5 nurses, HR currently processing.

28th February 2014

SM8 – Improve access to training both mandatory and required to undertake the role to ensure that the staff have the knowledge to care for patients for example those at the end of their life

September compliance of mandatory training, 87.59% against target of 85%. “Hot spot” wards identified for additional support.

On Going

All enhanced skills training information available on the Practice Development intranet site. All Ward sisters are aware of dates.

On going

Template sent to band 7’s

All Ward Sisters to undertake a training needs analysis. 31st January 2015

EM3 – Improve the environment in the emergency department, including paediatric A&E, and outpatients; the mortuary also required improvement.

Estates have reviewed the footprint of the plans have been approved. See implementation plan below.

Plan agreed to incorporate new waiting areas for under 16’s, High Acuity area and outside play space

31st March 2015

Mortuary refurbishment design completed , construction work to commence 20th April 2015

3rd July 2015

An outpatient work stream programme has been created by the PMO, to ensure that the right patient is seen in the correct place to meet best practice guidelines and enhance the patient journey. Timescales for delivery to be scoped Wednesday 15th October . Phase one to be completed by 31st March 2015

31st March 2015.

RM3 - Review the elective surgery cancellation rates, and review the elective surgery service demand

As a result of the Emergency Flow Programme commenced 31st July. Cancelled operations continue to reduce (July = 52; Sept = 16, Oct = 25, Nov = 46, Dec = 14).

On going

RM4 – Ensure that patients are discharged in a timely manner across all wards and, in particular, at the end of their life.

Monitoring discharges before midday continues weekly. October Trust-wide compliance 17% against target of 30% (with a variance between wards between 3.1% and 30%). Focus on poor performing wards by project team.

On going


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RM5 – Review and improve cancellation rates within outpatients

RM1 - Ensure that outpatient clinics are not overbooked, and cancellations are minimalized

An outpatient work stream programme has been created by the PMO to ensure the right patient is seen in the correct place to meet best practice guidelines and enhance the patient journey. Phase 1 to be initiated 19th January 2015 and is due to be delivered by 12th June 2015.

12th June 2015

RM 6 – Ensure there are sufficient staff on duty at all times who are trained to restrain patients.

Substantive Violence and Aggression Training Officer in post 22nd September. 3 day training in physical restraint techniques and relevant laws will commence mid October. Staff group to be trained:- Site management team (7) 3 members of staff still to be trained and are booked for March 2015. Training of other groups has commenced, 11 people currently trained.

March 2015

WLM1 – Review medical leadership for elective and emergency surgery.

Clinical Director structure discussed at EDs 11th November.

31st December 2014

WLM2 – Ensure an Executive Director is appointed to champion End of Life Care as directed by Norman Lamb in his letter to NHS chief executives.

Dr Watson, Medical Director appointed to role. End of Life Care Strategy task and finish group has been developed. Strategy has been written and will be presented to Board 27th January 2015

31 October 2014

Shoulds ES1 – Ensure that equipment storage, within A&E resuscitation areas, is improved.

A task and finish group has been set up to review and streamline resus. First meeting planned 13th October. Initial work has already been undertaken to move some equipment and stores to a more appropriate area.

31st December 2014

Compliance with daily equipment checks is being monitored weekly. Oct – Non compliant Nov – Non compliant Dec – Non compliant

On going

Paediatric resuscitation equipment to be checked daily

Resuscitation officer to standardise resuscitation folders

ES2 –Ensure that the environment and storage of equipment in the neonatal unit is more organised.

Ward stock has been reduced and a housekeeper has commenced in post to manage stock levels and storage.

31st October 2014

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ES4 – Review the equipment used to transport the deceased from the wards to the mortuary to ensure it respects people’s privacy and dignity.

Company to supply trial unit 12th November. Plan to purchase 2 new concealment trollies. Part funding secured from MacMillan

31st December 2014

Trolleys not suitable – to source alternative

Alternative trialled - order to be placed

SS1 – Ensure that there are sufficient numbers of staff who are CBRN trained. (CBRN refers to chemical, biological, radiological and nuclear equipment and policies.)

52 staff have been trained as of end of October 2014. Training will continue every month going forward by the three trained trainers in A&E. This equates to 60% of staff in the department trained against a 60% trajectory for 31st December 2014.

31st March 2015

ES3 – Ensure that plans to strategically move over to NEWS are agreed and implemented. (The NEWS system relates to the management of deteriorating patients)

The Trust will review the move to NEWS in April 2015. April 2015

SS2 – Review the availability of hydration on Pentney, Oxborough and Necton Wards.

The senior nurse in charge on all wards is responsible for coordinating nutrition and hydration. 3 new patient comfort and support workers are currently in post with another 3 commencing in post February 2015. Housekeeper hours have been increased on all wards to support nutrition and hydration.

On going

RS1 – Ensure that all serious incident investigations are undertaken by trained investigators

Funding has been identified for external training of key divisional teams on investigation training. Training dates agreed 4th and 5th March 2015 with 22 people booked to attend. There will be further training sessions rolled out throughout the year.

December 2014 Date slipped to March 2015

All RCA investigation outcomes and action plans to be uploaded to the Patient Safety intranet site to enable shared learning

January 2015

WLS3 - Ensure that all Board members have received training in emergency planning, business continuity and local security specialists

All substantive EDs have undertaken training. New EDs training booked 30th January 2015

January 2015

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ES4 - Ensure that all staff work together effectively to enhance the experience of the patients, ensuring effective communication at all levels.

Substantive board will continue to drive forward the Trust Values and Behaviours

On going

WLS1- Ensure that its governance systems, including committee structures, divisional structures, shared learning and incident investigation, are improved and embedded.

KPMG QGF review November 2013 resulting 25 actions, managed through the NHS Choices reporting process.

November 2013

KPMG QGF review November 2014 November 2014

Divisional Structure consultation commenced on 12th September with 3 appointments made.

September 2014

WLS2 - Ensure that there are clear reporting processes and risk monitoring in place for the emergency planning and local security work, including the testing of resilience plans.

Head of Emergency Planning monitors risk locally, regionally and nationally

On going

Table –top and live emergency preparedness exercises carried out as planned throughout the year including: Viral Haemorrhagic Fever; Child Abduction; Loss of IT and Loss of electric supply.

On going

The Queen Elizabeth King’s Lynn NHS Foundation Trust - How our progress is being monitored and supported

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Oversight and improvement action Agreed Timescale for Implementation

Action owner Progress

Monitor appointed Improvement Director, David Hill Appointed 6th January 2014 Monitor Completed

Guys and St Thomas NHS Foundation Trust appointed as ‘Buddy’ Trust Commenced December 2013. QEHKL

A review of our support from a number of different Trusts as appropriate is currently under review to enable support going forward.

End February 2015 QEHKL

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