south warwickshire general hospitals nhs trust

SOUTH WARWICKSHIRE NHS FOUNDATION TRUST

Meeting Board of Directors

Date 7 December 2016

Subject Care Quality Commission (CQC) Action Plan Update

Enclosure J

Nature of item For information For approval For decision

Decision required (if any)

The Board is asked to receive and note this report.

General Information

Report Author Helen Lancaster, Director of Nursing Karun Thaper, Quality Improvement

Lead Director Helen Lancaster, Director of Nursing

Received or approved by

Meeting Date

Resource Implications

Revenue Capital Workforce Use of Estate Funding Source

Applicable Quality Improvement Priorities

Over 75s Initiative Health Population Home First Service Tertiary Pathways Quality Measures Redesign of Out of

Hospital Services

Nurse Staffing Levels Flow Programme

Freedom of Information

Confidential (Y/N) (if yes, give reasons)

No

Final/draft format

Final

Ownership

Trust

Intended for release to the public

Yes

2

South Warwickshire NHS Foundation Trust

Report to Board of Directors – 7 December 2016

Care Quality Commission (CQC) Action Plan Update

Executive Opinion The action plan provides assurance against all of the actions identified by the CQC. Excellent progress has been made and robust plans and monitoring are in place. Executive Summary This is the quarterly update following the CQC inspection in March 2016. The action plan contains the ‘must do’s’ and ‘should do’s’ and the progress against each. The only outstanding action is the action relating to the locking of treatment rooms. Initial actions of putting doors on all treatment rooms have caused another issue of treatment rooms overheating and then causing issues with drug storage. This is not wide spread across the Trust and therefore a different solution for those areas affected is being considered. The remaining areas are compliant. Therefore a revised date of full completion of the action has been set at the end of March 2017. Recommendation The Board is asked to receive and note this report. Helen Lancaster Director of Nursing

3 SWFT Provider Report (final published) – Improvement Action plan Version 3 Updated 18 November 2016

SWFT Provider Report (final published) – Improvement Action Plan

Incomplete Risks identified

Partially complete No risks identified

On track, no risk to completion

Completed

AREAS FOR IMPROVEMENT Action No.

Action Responsible lead(s)

Completion Date Action Status RAG

Must Do:1

Ensure that regular risk assessments are completed appropriately on admission to medical wards and repeated regularly to identify any changes in patient’s risk of harm. This includes bed rail and mobility assessments for patients receiving end of life care.

Caroline Jackson, Head of Nursing Emergency Division

August 2016

• Monthly audit undertaken by compliance unit includes all patient assessments and bed rail assessment.

• All wards audited for completion of bed rail assessments and whether bedrails are in use if indicated.

• Audit results sent to all ward managers • Individual ward managers met with by

Head of Nursing if compliance drops or if additional actions/support is needed.

• Nurse care indicator results discussed at monthly matron/manager/ ward manager meeting, action plans developed where needed to address shortfalls

• Results analysed monthly and reported in a written document presented at Senior Nurses meeting and Patient Experience Group.

• Results reviewed monthly at falls prevention steering

• All falls prevention training already includes importance of bedrail assessment and all RCAs following any serious incident include investigation of bedrail assessment and compliance where relevant

Completed

4

Action No.



Must Do: 2

Ensure that all staff receive safeguarding children training in line with national guidance.

Helen Lancaster, Director of Nursing

December 2016

• Compliance monitored monthly. • Bespoke training commissioned from

designated nurse • Additional level 3 training

commissioned • Training needs analysis updated

On track

Must Do: 3

Ensure that staff have full understanding of the Mental Capacity Act 2005 and their responsibilities and role in the management of patients with capacity concerns. This includes appropriate formal assessment processes and escalation of concerns.

Helen Lancaster, Director of Nursing

December 2016

• The safeguarding adults face to face training and the e learning package reflect the MCA and the DOLS process.

• Compliance for safeguarding level 2 adults clinical is –97% for 2015-16.

• New First Aid Mental Health training course has been commissioned from Coventry University

• Monthly audit commenced re compliance to MCA and DOLs

• Monthly monitoring of numbers of applications in place

On track

1 Ensure that staff in the outpatients department record all incidents.

Dee Dunne, Outpatients Manager

July 2016

• Department manager to raise issue at team meeting re incident reporting.

• Monitored though Director of Nursing Monday incident meeting

• The requirement to report incidents in line with the Trusts Incident Management Policy is communicated to staff through monthly Team Meetings.

Completed.

2 Staff having a clear understanding of the Duty of Candour.

Andy Butters, Head of Governance

September 2016

• Internal Audit review of Duty of Candour to include staff questionnaire

• Regular program of Duty of Candour

Completed

5

Action No.



training commenced • Leaflet re distributed • Patient safety newsletter re published

containing Duty of Candour information • Compliance to Duty of Candour

continues to be monitored monthly • Already in the mandatory training for

staff

3 Ensure that defined cleaning schedules and standards are in place to comply with the Department of Health 2014 document ‘Specification for the planning application, measurement and review cleanliness services in hospitals’.

Claire Hinds, Assistant Director of Operations

September 2016

Evidence has been provided that these were in place at the time of the inspection The document referred to states the following in its Introduction section 0.2 – ‘The DH has sponsored this revision of PAS 5748:2011 only in relation to its use in hospitals in the NHS in England. Any use of this PAS outside NHS hospitals in England is not a matter for the DH. NHS hospitals are entirely free to choose whether or not to use this PAS. There are currently no central statutory or procedural requirements that they do so. Organizations might choose to adopt the PAS to provide evidence of an intention to comply with part of the CQC’s registration requirements in relation to cleanliness and infection control.’

• This Trusts feels that its cleaning specification is robust and is based on the NCS/the Revised Healthcare Cleaning Manual.

• All risk levels are agreed by Infection Prevention Matron and Hospital Matrons and all areas within that area cleaned to

Completed

6

Action No.



the agreed level. • Some of the Trust areas could be in a

lower risk level but for assurance they have been placed in the higher level.

• Areas are reviewed with the above team if deemed necessary.

• There is a plan of each area available Further evidence via the full

• Role plan for cleaning schedule compliance and audit

Rollout Plan for the Ward Checklist for the

Supervisor ward checksheet.xls

Ward Check Sheet.xls

4 Ensure that infection control

and prevention policies are embedded into practice, particularly on the medical wards.

Christine Georgeu, Infection Prevention Matron

30 October 2016

• External auditor undertaking hand hygiene assurance audits in all in-patient areas. Each ward will have one annual external review.

• Wards and departments continue to self-audit hand hygiene compliance on a monthly basis. Re-training has been delivered to auditors who have also been advised to ensure that the WHO’s “5-moments of Hand Hygiene” are fully audited.

• Compliance is checked by the IP Team, who conduct monitoring audits on all wards and departments. Each area will have 2 review audits per year. In addition, a re-audit will be conducted if compliance drops below 80%, or in

Completed

7

Action No.



response to any infection-related incidents.

• Results are reported to the Infection Prevention Board and Divisional audit groups monthly

• Training continues to be delivered to all trust staff on a mandatory basis. The 5-moments of Hand Hygiene and compliance audit findings are discussed during this training.

• Hand Hygiene Awareness Week undertaken during the week of 17th October, which was supported by the Trust’s Executive Team. A unique interactive hand hygiene training machine was used during this week. This guided staff in perfecting their hand hygiene technique. Agar plates used for showing staff what is growing on their hands!

• MRSA positive status recorded on Lorenzo with follow up by the Infection Prevention team.

• All positive laboratory results are analysed by the IP team twice a day. Positive MRSA results are reported to ward staff and appropriate advice given on a patient-by-patient basis in line with Trust Guidelines. Records of this are held by the IP Team for patient monitoring purposes

• All patients with a history of MRSA have

8

Action No.



an infection “alert” on the Lorenzo system. All alerts are reviewed by ward staff daily. In addition, all alerts are reviewed by the IP Team and ward staff are informed of any patients with a history or MRSA.

• The IP team continues to advise daily on these patients throughout their hospital stay. This advice includes barrier nursing requirements, MRSA decolonisation and re-screening requirements. There is evidence of this on the “Daily monitoring” forms held by the IP Team.

• When the IP Team inform wards of a patient being MRSA positive, they are now ensuring that staff accurately record this in the patients’ records. A Trust-wide audit of MRSA decolonisation compliance will be undertaken in November 2016. This will be reported to both the Antimicrobial Steering Group and the Infection Prevention Board

5 Ensure medicine fridge temperatures are recorded accurately and any deviation from temperature controls acted upon.

Martin Phillips, Head of Pharmacy

December 2016 Immediate actions now complete. Long term actions to be completed by December 2016

We have replaced Min/Max fridge thermometers with easy to use data loggers that provide continual monitoring of fridge temperatures. The new loggers have a visible alarm triggered if temperature goes out of limits, and this alerts staff and therefore makes a quick response easier.

On track

9

Action No.



Evidence of the embedment of our processes is demonstrated in the following documents: 1. Temperature monitoring (data loggers) SOP for non-pharmacy staff 2. Temperature monitoring (data loggers) SOP for pharmacy staff 3. Record of temperature monitoring interventions by pharmacy staff

Data logger instructions for NON-P

Data logger instructions for pharm

Record of temperature monitorin

We believe Document 3 above demonstrates this system is being used and appropriate responses are being made regularly. Pharmacy staff have had training on dealing with temperature deviations, and our MI team support the wider team with collating evidence to support expiry date changes where required. occasions when temperature deviations are not notified to pharmacy staff by ward staff carrying out the checks. Are monitored by receiving monthly the temperature monitoring record forms. Audit temperature record forms returned monthly regarding deviations escalated to the

10

Action No.



pharmacy team and report results to HoN / DTC.

6 Ensure all medicines are stored safely in locked cupboards.

Martin Phillips, Head of Pharmacy Heads of Nursing

December 2016 Revised to March 2017

This is acknowledged as a risk on the Trust risk register [Risk ID: 1058] Our process for drugs security on Theatres, is compliant with the June 2016 Royal College of Anaesthetists guideline All clean utilities across the Trust have been reassessed and doors have been fitted with locks. Where it is not possible to fit all IV fluids in these treatment rooms these have been decanted to storage areas with locks fitted. Specific area risk assessments are to be completed and placed on the risk register for those areas that are non compliant. Where due to space or overheating a door cannot be fitted a different solution needs to be found or risk assessment in place. Awaiting options appraisal on solutions in relation to rooms overheating and the potential for drugs to be stored at temperatures not in line with manufacturer’s guidance. A revised completion date of March has been agreed for full compliance to be achieved

On track for new compliance date

7

Ensure that facilities in the emergency department are suitable for caring for patients with mental health needs.

Claire Weatherhead, A&E Clinical Nurse Lead

August 2016 Risk assessment and SOP in place. All available on A&E intranet. Embedded below;

Adult Mental Health Triage and Assessmen

Complete

11

Action No.



Paediatric Mental Health Triage and Ass Wording to adult/paeds mental health assessment amended to reflect practice.19/08 Emma Ratley/Pat Morris emailed regarding these amendments and the correct process for getting the originals on intranet amended.

8 Ensure that all mandatory training is completed in line with the trust target.

Jackie Farrington, Head of Learning and Development

Monthly monitoring for completion in December 2016

A report on mandatory training has be run and all managers where team member are not compliant have been informed and are required to ensure compliance by the 15/8/2017 Monitor monthly at CQC monitoring group

On track

9 Ensure that staff have completed the relevant safeguarding adult training to ensure staff are aware of their roles and responsibilities in the identification of safeguarding needs and how to escalate concerns.

Jackie Farrington, Head of Learning and Development and Safeguarding Leads

Monthly monitoring for completion in December 2016

Safeguarding adult training has been reviewed and up to date , any noncompliance is being addressed in the Mandatory training communication to managers Monitored monthly at CQC monitoring group

On track

10 Establish formal cover arrangements for acute palliative care consultant post when they were on leave.

Charles Ashton, Medical Director

December 2016 Wider health economy engagement and strategy is required.

On track

12

Action No.



11 Continue to implement and monitor use of the swipe card access of the corridor and clean utility room in critical care to ensure safe storage of medicines, records and equipment on critical care.

Jon Henry, Senior Compliance and Contracts Manager (Estates)

October 2016 Swipe card access to the medicines storage room (clean utility) in critical care is implemented. All medicines remain locked away. New bedside lockable Patient Own Drug lockers have just been installed improving secure storage of medicines on ITU. Renal replacement fluids are a large bulk requiring storage outside of the clean utility in the equipment store due to space restrictions. Swipe access to this will be implemented to ensure that access is limited. Swipe access as a whole will be reviewed by the ward managers to ensure that only those with need gain swipe access to the ITU area. Swipe doors will be implemented on the doors that link Main Theatres and ITU as well.

Complete

12 Investigate and share learning from the controlled drugs incident on critical care and ensure any corrective actions are completed.

Martin Phillips, Head of Pharmacy and CD Accountable officer

Immediate action taken. On-going monitoring

This incident refers to Datix Web 30474

Datix Web30474.pdf

This incident was reviewed and investigated by both the Controlled Drug [CD] Accountable Officer and the ward manager for ITU and closed. The register entry has been corrected appropriately. Learning from the incident was identified by the investigators as development of transit/emergency bags for intubations away

Complete

13

Action No.



from the unit. A bag containing CD’s required from in these situations in stored in the CD cupboard. The bag is signed out in the CD book in its own page, and any CD’s used then accounted for on their respective pages after the event. This action is approved by the CD Accountable Officer, and is modelled on a system used by the West Midlands Ambulance Service and was approved by CQC when WMAS was inspected recently. Monitoring by quarterly CD audits as part of rolling programme, and reporting up to the Elective AOGG of any deviation in practice.

13 Ensure that all staff working in critical care receive training and guidance regarding their responsibilities outlined in the major incident plan.

Marian Penny, ITU Ward manager

September 2016

Annual training in place Further training planned with emergency planning lead for September

Complete

14 Ensure that staffing levels meet patient demand, enable adequate care of children by a qualified paediatric nurse and allow monitoring of all patients within the Emergency department at all times of day.

Claire Weatherhead, A&E Clinical Nurse lead

On-going monitoring and recruitment review

Risk assessment Active recruitment in place Vacancies monitored via Recruitment and Retention group SOP in place to monitor children in the department

SWH 01422 Segregation of Paedia

ED Paediatric Nurse Staffing V1.docx


14

Action No.



15 Ensure that patient records are stored securely and completed in line with legislation.

Maureen Cooper, Records manager

August 2016

• Notes storage has been reinforced with all staff.

• Signage provided to remind staff not to leave notes accessible on nurse’s station or reception.

• Notes trolleys move to areas less accessible wherever possible (behind nurses stations and into offices etc.)

• Additional storage boxes and shelving provided to store notes awaiting coding/return to medical records department.

• In ED, folders now in place for each cubicle to store charts and personal information

• Compliance checked on weekly walk round by Corporate Nursing Team

• Where this is not possible to move trolleys to a different area new notes trollies have been ordered.

complete

16 Review the high number of caesarean sections developing an action plan to reduce these.

Wendy Jones, Associate Director of Women’s and Childrens Division Mel Crockett, Head of Midwifery,

The normal birth rate and caesarean section rates remain consistent and continues to red flag. Although the maternity service will continue to develop initiatives to reduce the caesarean section rates, there is to be a renewed focus on improving the normal birth rate. A number of initiatives have been put in place:

• A home birth group that is led by the community midwifery team and supported by a Supervisor of Midwives

15

Action No.



September 2016 30th November 2016

• Specific clinics for women who are aiming to achieve a Vaginal Birth After Caesarean Section (VBAC)

• •Specific midwifery led groups for women aiming to achieve a VBAC that focus on approaching birth with confidence and promoting a more physiological approach to birth rather than a medicalised approach

Actions to follow:

• Revision of ways to promote water for labour including water birth classes for women

• •Review of the Induction of Labour pathway including the location and environment where the induction of labour care is provided

• •Strategy and business plan for the development of a midwifery led unit has been approved by Management Board a Business Case is being formulated and work is in progress with regards to the service development.

17 Ensure that there is an early warning score tool for babies on SCBU to ensure that any deterioration of a patient’s condition is recognised.

Wendy Jones, Associate Director of Women’s and Childrens Division

September 2016

• Review of Neonatal Observation chart (NOBS) early warning score chart conducted

• Updated Neonatal Observation chart (NOBS) early warning score chart to be used for neonates in Maternity and

Complete

16

Action No.



Mel Crockett, Head of Midwifery,

SCBU • Reporting as per monthly Nurse care

indictors

18 Ensure all trust policies are up to date and relevant.

Andy Butters, Head of Governance


The Development and Control of Trust Documents Procedure (SWH 00306) sets out the process for developing, agreeing, approving/ratifying and disseminating Trust documents such as policies, protocols, procedures, strategies guidelines and Standard Operating Procedures [SOPs]. This includes how documents are developed, controlled, stored, approved and ratified, disseminated and reviewed. It is the authors responsibility to ensure that documents are kept up-to-date. Review The original review period for documents set out in the Trust’s document procedure was 3 years with proviso that: • Another time frame is specified by an

external agency e.g. the Health and Safety Executive, in which case the review date should reflect these requirements

• Publication of new evidence necessitates change

• Legislation dictates • New systems of working are introduced • Practice changes e.g. as a result of a

notifiable incident, claim or complaint

Immediate action taken. On-going monitoring in place

17

Action No.



As authors were finding it increasingly difficult to meet the 3 years review when the procedural document (SWH 00306) was reviewed in January 2016 the Policy Review group extended the review period to 5 years. Publication of NICE Guidance and NCEPOD Reviews The Trust has a process in place so that when new NICE Guidance/NCEPOD reviews are published they are circulated to the appropriate clinicians and the Divisional Audit and Operational Groups. Clinicians are required to complete an action plan, which asks them: Does existing Trust guidance reflect this NICE guidance? If ‘No’ has Trust guidance been updated? Is latest version of Trust guidance available on the intranet? The expectation is that these questions will prompt a review of the document and the necessary updates made as required.

19 Ensure there are appropriate polices and operating procedures to support processes within the emergency department.

Claire Weatherhead, A&E Clinical Nurse Lead

August 2016 Triage Childrens area and escalation MIU SOPs and guidelines in place

Triage of Patients in the ED SOP.pdf

paed segregation SOP March 2016 vers

Adult Mental Health Triage and Assessmen

Completed

18

Action No.



Paediatric Mental Health Triage and Ass

20 Monitor pain scores in a consistent manner in the emergency department and ensure that there are formal pain tools used across SCBU and Macgregor ward.

Wendy Jones, Associate Director of Women’s and Childrens Division Linda Holland, Women and Childrens General Manager

Originally, 31st October 2016 Revised to December 2016

Review of Pain score process and procedure conducted Develop and implement a formal Pain score for use in SCBU and Macgregor –

• Formal pain score with BWH to be shared

• Adapt for SWFT neonatal and paediatrics

On track

21 Ensure that advance care plans (a plan that documents patients’ views, preferences and wishes about their future care) are in place for patients receiving end of life care.

Dr. Carole Tallon, Palliative Care Consultant

December 2016

• Commence pilot of RESPECT tool to facilitate advance care planning and discussions regarding DNACPR and ceiling of care.

• The specialist palliative care team Consultants and Macmillan GP to deliver education and training across acute and community services about the recognition of palliative care and dying and sensitive communication about advance care planning.

• The specialist palliative care team to review current documentation to strengthen the documentation of advance care plans and preferred place

On track

19

Action No.



of care. • To explore if preferred place of death

and care can be incorporated in Lorenzo as a mandatory field.

• The Macmillan Specialist Palliative Care Team will create and deliver a structured Education and Support Programme across Acute and community services that includes advance care planning, DNACPR decision making and communication. To commence the implementation of the use of the electronic register of patients who are recognised to be at the end of life (EPACCs).

22 Ensure the annual audit plan for maternity is formally approved, that recommendations address the issues identified and action plans for improvement are developed.

Wendy Jones, Associate Director of Women’s and Childrens Division Linda Holland, Women and Childrens General Manager

September 2016 September

A review of the current audit process and procedure has been conducted and improvement actions have been outlined below: • All the maternity units’ audits for 2016/17 are

to be registered with the required proposal form on the trust database that the audit department has helped create.

• A review of audits from 2015/16 to be carried out and registered retrospectively on the trust database by the audit midwife. This task is near completion

• Re-register the audit with a new date (only if the audit has not been started)

• Provide rationale for the audit and the reason it may be overdue and consider withdrawal

Complete On-going monitoring

20

Action No.



2016 e.g. auditor left the trust/on maternity leave etcetera

• A progress report will be produced for the clinical governance committee for Q2

• The audit midwife to meet regularly with the audit manager to report on progress with the registering process.

• Audits to be allocated to a consultant obstetrician who would be accountable/responsible for the audit to be in line with trust requirements

• The audit department will participate and give training on clinical audit for obstetricians and midwives as necessary

• Audit plan to be re-designed to be in line with the live guidelines that are on the intranet at the present time, plus any long standing continuous audits that occur in maternity

• The completed proposals database will be presented to Women and Children’s AOGG.

• The Maternity Department will ensure the full audit cycle is complete

23 Develop, approve and

implement an annual audit plan for gynaecology.

Gynae Governance Lead

30th November 2016

A review of the current audit plan and review process has been conducted and improvement actions have been outlined below:

• Women and Children’s Division developing structures and an annual audit plan for gynaecology to be presented and approved at Women and Children’s AOGG

Complete

21

Action No.



24 Ensure that outcomes for gynaecology patients are clearly presented and reviewed.


September 2016 30th November 2016

A review of the existing outcome measures and reporting mechanisms has been conducted and improvement actions have been outlined below:

• Women and Children’s Division developing structures AOGG in place to outcome data for gynaecology to be presented and monitored at Women and Children’s AOGG.

• Gynaecology dashboard being developed and agreed, to be presented at Women and Childrens AOGG.

Complete Complete

25 Ensure that nurses on the gynaecology ward receive training relevant to the specialism and acuity of patients admitted to the Beaumont ward.


31st October 2016

Following discussion with the manager of this area, it has been established that the current area specific competencies will be added to part 2 of the Band 5 Preceptorship Programme to formalise the speciality training. This includes

• Delivery of misoprostol • Vaginal examination • Management of early pregnancy loss.

These would be considered as extended practice so need to be completed following satisfactory completion of part 1 of the Preceptorship programme. Senior members of the team have been allocated to coach junior staff in the management of telephone consultations including patient information and early pregnancy loss and the ward manager is ensuring that all staff have the opportunity to undertake this.

Complete

22

Action No.



The electronic EPAU electronic patient record is to be implemented. There is a form in this system for telephone consultations that will prompt staff to request the correct information. There is a plan to reduce/remove the ortho/geriatric outliers from the ward area Bed capacity reduced by 6 beds

Completed Completed

26 Ensure privacy of in patients attending radiology department is maintained.

Caroline Robertson, Head of Nursing

August 2016 • All trolley spaces have curtains • Ensure patients are managed through

these cubicles • Monthly spot checks to ensure

compliance

Complete

27 Ensure that the use of the individual plan for the dying person is embedded.

Dr. Carole Tallon, Pallative care consultant

December 2016- Revised to January 2017

• Increase the number of wte end of life practice educator post holders

• Increase face to face education provision

• Visit to Salford arranged to learn best practice

• Review and amend individual care of the dying care plan to make user friendly for community and acute sector

• Engage General practice and district nursing in its use.

• Six monthly case note review to commence January 2017

On track

23

Action No.



28 Audit the effectiveness of the end of life care service, including collecting information on the number of patients who have been discharged to their preferred place of care, collecting information on those patients who died in their preferred place of death and audit the effectiveness of the rapid discharge process.

Dr. Carole Tallon, Pallative care consultant

December 2016 • Monthly dashboard being developed to include operational and quality indicators

• End of life audit plan developed including 1. National End of Life audit 2. Six monthly case note review 3. Anticipatory Prescribing audit 4. Annual CODE survey 5. Place of care and death monthly

data reports 6. Rapid discharge home to die

process review and evaluation 7. Training and Education KPI delivery

On track

29 Ensure arrangements are in place to monitor how quickly women attending midwifery assessment unit are seen and treated.

Wendy Jones, Associate Director of Women’s and Childrens Division Head of Midwifery,

31st August 2016

A review of the existing process and auditing mechanisms has been conducted and improvement actions have been outlined below:

• Additional criteria of time seen to be included in admission book

• Audit of time seen to be included Audit registered with Audit Department

Complete

30 Ensure specialist palliative care team referral guidelines are in place, and circulated to all wards and departments.

Heather Goding, Lead Macmillan Nurse

August 2016

The palliative Care Team will implement the Community referral form and audit effectiveness on a monthly basis


31 Reduce the delays for patients being discharged from critical care to the wards.

Fiona Stevens, General

July 2016

• SOP for delayed discharges in place • Standing tem on bed management

meetings

Complete

24

Action No.



Manager Critical Care

• Monitored through ICNBARC data

SWH 01414 Delayed ITU Discharges and S

32 Ensure that leaflets and interpreters are available and used for non- English speaking patients.

Helen Lancaster, Director Of Nursing

July 2016 December 2016

• Interpreting services available • Leaflets can be made available on

request. • Please See accessible information

action plan embedded below;

Accessible Information Implemen

• Review of most commonly used languages undertaken.

• Key leaflets to be identified for translation

Complete

33 Ensure that all complaints are reported to ensure themes are identified and lessons learnt cascaded to staff.

Helen Lancaster, Director Of Nursing

August 2016

• Monthly divisional patient experience report with lessons learnt included

• Next issue of ‘Quality First’ newsletter to contain lessons learnt

Complete

34 Ensure that there is clear leadership and overall oversight of care for neonates, children and young people.

Chief Executive Glen Burley

July 2016 • New Women and Childrens Division established with monitoring and reporting arrangements in place

Complete

35 Ensure that the arrangements for governance and performance management operate effectively in the services for children and young people.

Glen Burley, Chief Executive

July 2016 • New Women and Childrens Division established with monitoring and reporting arrangements in place

Complete

25

Action No.



36 Ensure that all risks are identified on the risk register and appropriate mitigating actions taken.

Jo Beales, Health Safety and Risk Manager

September 2016 December 2016

• A review of the risks management of and reporting process has been conducted and improvement actions have been outlined:

• Amend the Risk Management Strategy (RMS) to include local risk management processes for the divisions.

• Divisions to implement relevant local risk management processes, to include, local and divisional risk registers

•

Complete

37 Ensure there is a clear process for the documentation and review of risks within the gynaecology service.

Governance Lead for Gynae

31st October 2016

• Risks will be reviewed at the Women and Children’s Risk, Health and Safety Group and quarterly reports will be reviewed at the Risk Management Board

Complete

38 Ensure that each service has a local vision and strategy which is disseminated and understood by all staff so that it is embedded within the service.

Glen Burley July 2016 • We will continue with our single vision or strategy moving forward. Service plans will be developed, where we are implementing major change or making a major investment.

• In the case of EoL, we need a system strategy

Complete