worcestershire acute hospitals nhs trust: independent web viewprofessor janice stevenscbe ma rgnjune...

Professor Janice StevensCBE MA RGN

June 2011

Worcestershire Acute Hospitals NHS Trust: Independent Review

Acknowledgements

I have met with patient representatives, nurses, doctors, managers and other health care staff to gather views and information to inform this report and I would like to thank them for their candour and enthusiasm in the way they shared information with me. Everyone I met, without question were deeply saddened by the findings of the CQC, feeling their patients and community had been let down but committed to taking whatever action necessary to rectify and improve services and care for the future.

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IndexPage

Executive Summary 31 Background 132 Findings 153 Reviewers’ Observation 204 Addressing questions posed 245 Recommendations 32

Annex I Terms of reference of review & reporting 34Annex II List of documents used 37Annex III Glossary 39

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Executive Summary

Background

On 22 March 2011 the CQC carried out a review of the Trust as part of a targeted inspection programme in acute NHS hospitals to assess how well older people are treated during their stay, in particular whether they were treated with dignity and respect and whether their nutritional needs were met.

They observed how people were being cared for on wards five and eleven, talked to staff, a visitor and patients and determined that, although people were generally complimentary, overall their assessment was that the Alexandra hospital was not meeting either of the essential standards reviewed. They requested a report to be sent to them within 14 days outlining the actions the Trust planned to take to address the concerns.

At the Trust Board meeting 2 June, it was agreed to commission an independent review to ensure that the wards were now compliant with the CQC standards, that the action taken would be sustainable and in addition provide learning that could be utilised across the trust. During the course of the review, ten wards were visited, 35 one to one meetings held and extensive documentation reviewed.

Conclusions

Throughout the Trust there was a genuine commitment and desire to provide a good patient experience and deliver clinically effective high quality care. All staff were deeply upset about the findings and totally committed to taking whatever action necessary to put things right quickly.

Whilst undertaking this review the Trust was subject to a Quality Review by the Strategic Health Authority (SHA) and Care Quality Commission (CQC) which included 16 people reviewing a range of quality issues. Their report back to the Trust states “At the outset we would wish to make clear that no significant concerns or immediate patient safety risks were highlighted during the visit.” The reviewer, would echo their view.

On 24 June 2011 the CQC undertook a follow-up visit and verbal feedback indicated the trust is now compliant. – This review supports this finding.

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The Trust is undertaking a significant amount of work in order to aspire to its vision of “the safest most patient centred and efficient Trust in the West Midlands” This work had begun prior to the CQC visit. Given this was the case, the review focused on understanding why, despite huge amount of work in progress, when the CQC visit took place the trust failed to meet the required standard.

Overall, it is the Independent Review findings, that a combination of factors, including organisational, systems and cultural factors lead to the Trust failing to meet the CQC standards when they reviewed wards five and eleven. Findings show that whilst the Trust has a good foundation on which to achieve its goals, there are a number of areas which require strengthening or more robust action taken as a matter of urgency.

Culture. The culture of ensuring mealtimes were protected and all staff contributed to patients eating was not embedded prior to the CQC visit. Wards, without doubt are incredibly busy areas with a vast array of constant activity. At mealtimes staff would be giving out drugs, carrying out ward rounds and delivering other aspects of care. This inevitably meant that mealtimes did not receive the level of focus necessary to ensure all patients received adequate nutrition.

Leadership at ward level. It has been difficult to attract senior nurses to the roles of ward sister/charge nurse and as a consequence some are less experienced and less prepared. The Trust does have a number of very experienced, motivated and highly professional Matrons in place to support the ward sister/charge nurses. The organisation has recognised that in order to meet the demanding and complex challenges ward leaders face on a daily basis in their leadership role, the ward leaders need a programme of development and support. A development programme has begun, but it will take some time to take staff through this. In the meantime there are ward sisters with a range of experience and skill who will require on-going support from the Matrons.

In the normal working week, Ward sisters/charge nurses will be “in the numbers” caring for their own group of patients three days a week. One day a week they carry the bleep to help co-ordinate bed management across the Trust and one day a week is classed as an office day which is when they will do tasks such as deal with recruitment, off duty, input audit data. During that time they will have to also deal with several doctors’ rounds, specialist nurses visiting, bed management teams asking about admissions and discharges, speak to relatives and answer phone calls. As part of their role as leaders they are also responsible for ensuring their staff have the knowledge and skills necessary to practice safely and that they

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behave in a way in keeping with their professional code of practice. It is genuinely hard to see how they can effectively fulfil their role as leaders when they are unable to be “in-charge” of their ward on a daily basis.

Individual clinical practice: Nurses operate within a Code of Conduct, performance and ethics agreed by the nursing regulator the Nursing and Midwifery Council. This Code places personal and professional accountability for individuals actions. To ensure nurses operate in this way, the Trust has in place a range of development and training programmes and operates an appraisal system for staff. Information from complaints and the findings of the CQC clearly demonstrate that not all practitioners operate at this level all of the time. The review finding identified:

The programmes of training appears to be quite traditional and focus on theory and concepts. They do not clearly state expectations of behaviour.

There does not appear to be a focus on assuring competence, which is necessary to “close the loop” and ensure theory is consistently applied in practice.

A process of appraisal is in place. It does however appear to be viewed as something that “has to be done” rather than staff seeing it as a crucial and integral part of assuring individuals are clear about their objectives, expectations and development needs.

Documentation – All staff commented on the huge amount of paperwork, how time consuming it was and how much repetition there was. The need for comprehensive assessment, planning, evaluating and recording the care of each patient is important both clinically and legally. Although incomplete documentation cannot be condoned, practically, it is unsurprising that there were omissions given the time it takes to complete this documentation and the amount of duplication that exists. For example current documentation requires a patient label to be put on each patients nursing records 26 times.

Action Plans – There are a number of action plans for a range of programmes of work). The existing plans are detailed in content, but not sufficiently outcome focussed, or as effectively project managed to ensure implementation with pace and grip. This problem is not unique to this Trust and highlights a gap in the skills of effective project management.

Why were the Board not alerted to the problems prior to the CQC visit?

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Until April the Board met quarterly and relied on committees at sub-board level to provide assurance to the Board. The Board received a range of quality reports in the main from the Nurse Director. Whilst there was indeed a plethora of information available and discussed, it was not organised into a robust performance framework that would have made it easy to alert the Board to a problem. Fundamentally data and intelligence is not underpinned by an infrastructure including hard and soft-ware to capture the evidence it needs to monitor and track trends and progress at Trust, hospital and ward levels in an organised and structured way.

Audits. Large numbers of audits are undertaken as a means of monitoring quality. There is however, significant duplication and the lack of an IT system makes the task hugely time-consuming. In addition it was not always easy to see how “the loop is being closed and where the process of audit consistently leads to improvement action.

Committee Structure and function. There currently are a range of committees and sub-committees in place in order to support clinical and corporate governance. It has been recognised that their current organisation, terms of reference and ways of working do not effectively support robust governance and assurance. Therefore a new Quality Assurance and Scrutiny has been established and will report to the Board. Its terms of reference and key responsibilities should enhance the current approach. In addition the Trust is reviewing its other committees to ensure they add value and support the Trusts future governance and assurance process.

Actions taken on the two wards since the CQC visit and sustainability of those actions.

The actions taken on both wards have resulted in significant improvements and the wards have achieved the criteria necessary to achieve compliance to the standards. The teams on the two are totally committed to regaining the confidence of both patients and the public by demonstrating high standards of care.

Sustainability. Evidence would suggest that it is too early to assess whether these changes will sustain, however the NHS Institute has developed an evidence based tool to help organisations predict the likelihood of an improvement sustaining. Having reviewed this, a number of the features are relevant to this review:

Benefits beyond helping patients including improving efficiency, reducing duplication.

Effectiveness of the systems to monitor progress

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Having effective feedback systems to reinforce progress and initiate action

Effective communication of results to patients staff, the organisations and beyond

Given these features have already been mentioned as potential contributors to the problems that occurred; unless they are addressed it would not be possible to assure the Board that the changes made will be sustainable.

Review of Outcomes from actions taken

There has been real and tangible change in the way nutrition is being dealt with. It is receiving the focus and attention it rightly deserves. Audits have shown improvement in compliance. The completion and quality of documentation is good. The actions outlined in this report show real progress in a short time. The follow- up visit by the CQC indicated (verbal feedback) that the Trust is now compliant.

Clarity of roles and responsibilities

There have been a number of organisational changes over the recent years, with the latest reorganisation occurring at the start of the year. Discussion with staff revealed that there was varying clarity about roles and responsibilities for with regard to quality, which they attributed to the most recent changes not having chance to “bed-in.”

There is a lack of clarity about how this new structure aligns with the current nursing structure. This structure was described as “running alongside” the new arrangements rather than being “aligned to.Bed management appears to occupy the time of many staff and especially matrons and ward sisters and prevents them being able to devote sufficient time to the quality component of their role. This occurs, despite the organisation having a range of roles dedicated to capacity and bed management.

Administration – Ward sisters and matrons appear to be responsible for the majority of administrative tasks concerned with recruitment including organising venues and sending out letters to candidates. This may be an area that could be reviewed if seeking ways to free up time to enable them to take responsibility for quality

Recommendations

The following recommendations are made based on the findings of the review, the authors’ experience of working with 40 NHS

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organisations and known good practice across the NHS. The findings of the review do show that the Trust has a range of activities and good practice in place but these need to be built on, strengthened and enhanced.

In accepting the recommendations, the Trust should actively seek out known good practice, tools and techniques already available in the NHS and avoid “reinventing the wheel.”

The recommendations are weighted on the basis of “early wins,” to increase the likelihood of achieving sustainable change and the recognition that some actions are complex and will take longer to plan and implement.

In the next four weeks,

1. Agree the set of nursing and quality indicators and review the range of nursing audits undertaken. Make sure they are aligned to the Trusts nursing strategy and agreed indicators. This is not just about reducing the number but reducing duplication. Whilst waiting to procure a new electronic system – access some information/ IT expertise and ensure any audits undertaken use excel instead of word to enable the production of graphs and charts to track progress.

Suggested goal – One audit that can be undertaken to capture all necessary information, that can be done in one day. implemented within two months.

2. Review the process of audit feedback and action and agree approach to ensure “the loop is closed” and action follows promptly. This is applicable to all professional clinical audits.

3. The recommendations from the review should not generate an additional action plan, instead review and simplify your current action plans to incorporate additional actions. Be clear about the actions required at corporate level and those at hospital level to help clarify roles and responsibilities

Suggested goals. Clear understanding of corporate and divisional responsibility, outcome focused plans and that they are implemented with focus, pace and grip.

4. Identify Trusts that have already implemented new streamlined and simplified nursing documentation and acquire copies. Review

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with a view to minimal adjustment (if any) and develop an adoption and implementation plan for Trust.

Suggested goal. Documentation no duplication, used by Trust, that combines assessment tools, reduces significantly the time it takes to complete

Within 3 months

5. Review goals of Exemplar Ward project (being used to test value of the sister charge nurse not being “in the numbers”) to help determine implications of new ways of working and resources necessary to progress .

6. Progress the review and implementation of a more robust governance and assurance process and ensure staff fully understand the relationship between controls (policies and procedures), risk management, performance monitoring, performance reporting and provision of high level assurance information.

7. Progress the acquisition of an electronic system to enable all information to be pulled together into one area, follow this with comprehensive implementation plan.

8. Review and strengthen the Sisters/Charge Nurse and Matrons development programmes. Articulate the leadership and management behaviours and competences sought. Include a method to assess individuals against these and ensure the programme of development is tailored to meet individual needs.

Within 3-6months

9. Review current training programmes and methods of delivery to ensure they include a process of clarifying and testing the competences required (skills and behaviour) N.B this is relevant to all professional training programmes

10. Review and identify the preferred (and simple) process for appraisal and set clear measurable expectations of performance, behaviour, care delivery and competence required. Build into this a process of assurance to be confident staff meet expected standards.

11. Build on work done to improve the handling and learning from complaints. Ensure the system in development will enable Trust to easily monitor numbers, types and trends. Ensure learning is shared

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across Trust and that actions taken are outcome focused and are monitored to ensure completed.

12. Consider undertaking volunteer recruitment programme to help at mealtimes, in areas where significant numbers of patients require assistance.

13. Review process for patients obtaining snacks to: meet patient needs, achieve consistent approach across Trust, and utilise expert advice from dietician.

14 .Undertake a full sustainability assessment using the NHS Institute tool. This will help you focus effort in the areas of higher risk of hindering sustainability.

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1 Background

On 22 March 2011 the CQC carried out a review of the Trust as part of a targeted inspection programme in acute NHS hospitals to assess how well older people are treated during their stay, in particular whether they were treated with dignity and respect and whether their nutritional needs were met.

They observed how people were being cared for on wards five and eleven, talked to staff, a visitor and patients and determined that, although people were generally complimentary, overall their assessment was that the Alexandra hospital was not meeting either of the essential standards reviewed. They requested a report to be sent to them within 14 days outlining the actions the Trust planned to take to address the concerns.

The two standards reviewed were:

1. People should be treated with respect, involved in discussions about their care and treatment and able to influence how the service is run.

2. Food and drink should meet peoples’ individual dietary needs.

Following the visit, a range of activities and actions were initiated in March and continued through April and May prior to the publication of the report. These were outlined at the Trust Board Meeting on 2 June in a report provided by the Nurse and Medical Director.

The Board at this meeting, agreed to commission an independent review to ensure that the wards were now compliant with the CQC standards and that the action taken would be sustainable and in addition provide learning that could be utilised across the trust. This review is to be overseen by a working group chaired by non-executive director Lynne Todd. The terms of reference can be found in Annex II.

In order to undertake the review, draw conclusions and make recommendations, the reviewer:

Visited 10 wards at all three hospitals to talk to ward staff, patients, observe practice and review documentation.

Carried out 35 one to one meetings with a range of clinicians, managers and hospital staff spanning ward to board.

Met and sought views from members of the PPI forum and LinkS Reviewed extensive documentation – listed in Annex I

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This combination of action aims to ensure wherever possible that findings, can be supported either by data, information or observation and therefore could not be considered anecdotal. It aimed to provide a balanced view and highlight both the strengths of the organisation as well as identify areas for further action.

Throughout the Trust there was a genuine commitment and desire from staff to provide a good patient experience and deliver clinically effective high quality care. All staff were deeply upset about the findings and totally committed to taking whatever action necessary to put things right quickly.

During the course of this review on 9 June, the Trust was subject to a Quality Review by the Strategic Health Authority (SHA) and Care Quality Commission (CQC) which included 16 people reviewing a range of quality issues as part of a process to potentially aspire to become a Foundation Trust. Their report back to the trust states “at the outset we would wish to make clear that no significant concerns or immediate patient safety risks were highlighted during the visit.”The reviewer, would echo their view.

On 24 June the CQC made a return visit to review progress and verbal feedback indicates that the Trust is now compliant with the two standards. The findings of this review also support this.

2.Findings

Prior to the CQC visit it is evident from both discussion and reviewing documentation that the Trust was undertaking a range of activities focussed on delivering the best patient experience, This included;

The strategy for nurses and nursing 2010 – 2013 was launched which set the strategic goals to

o offer a better patient experience, o improve patient safety, o enhance professional and traditional valueso Educating and developing the workforce.o Leading in the clinical areas

An update on progress towards implementation will be given to the Board in June and early sight of this highlights a range of action that have been implemented and others in progress which will support the actions identified in the CQC report. Relevant examples include:

o Establishing an education programme for nutritional link nurses

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o Expansion of visiting times to enable relatives and carers to participate more fully in aspects of care.

o Establishing a development programme for ward sisterso Pledge posters for nurses to sign are available throughout

the Trust pledging to provide the highest standards of care at all times and meet, greet and treat everyone with respect and lead by example.

Clinical Practice

A group has been established to take forward the nationally developed “Nursing High Impact Actions. One which is “keeping nourished, getting better” A multidisciplinary team including nurses, dieticians, and catering staff are working together to take practice forward.

Nurses are able to give supplements immediately using patient group directives which prevents delays in accessing dietetic support

Nurses have been trained to undertake assessment of swallowing to prevent delays in receiving nutrients. Training is on-going to ensure there is always someone on duty that can perform this extended role.

Seeking and acting on Patients Views

Quality and safety reports are presented and discussed at The Trust Board. Patients or relatives were invited to share their experiences supported by the Chief Executive.

In- patient satisfaction surveys are undertaken by the trust. PEAT (Patient Environment action team) findings are utilised by

the Trust The catering teams undertake surveys to gain views on quality

of food.

Complaints

The Trust received 635 complaints in 2010-11 of which 57% related to all aspects of clinical treatment, 6% were concerned with communication and 10% attitude of staff (the remainder were concerned with appointments/admission or discharge arrangements)

Complaints are taken seriously by the Trust and seen as an important way to seek patient views. The CEO or designated executive director in his absence, review them all on receipt and ensure the appropriate level of person is identified to investigate and respond to them. That said, a number of observations suggest

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that there is scope for improving the way complaints are utilised to be able to focus and act on, where areas of poor practice are being identified, specifically: A survey of complainants stated that 43% of patients surveyed

did not feel their complaint had been handled well. Action taken following the complaint is recorded. Many of the

actions are quite specific e.g. “ward refurbished, call bells fixed” but others are quite broad “staff have been made aware” “ward discussions” These statements of actions do not lend themselves well to being able to test the outcomes from the actions or provide adequate assurance that the issue has been effectively resolved

The current system of reporting does not make it easy to monitor trends or track progress, although the Trust is currently enhancing its systems to align to the DATIX system, which should make this easier to do.

Nurse Staffing

A fundamental factor in delivering high quality care is having the correct establishment (number) and skill mix of nurses in post. The Trust has undertaken a range of activities to determine if has the appropriate skill mix and level of staff. It has used RCN guidance, Doctor Foster benchmarking and SHA Workforce Benchmarking. All show that the staffing levels compare at the mid-point of organisations of similar sizes and complexity. The Director of Nursing also reviews each ward every six months with the heads of nursing and matrons to identify any specific challenges or difficulties. An updated workforce dependency and acuity tool was launched by the NHS Institute “The Safer Care tool” which the Trust has begun to use. Staff turnover, sickness and absence also do not vary significantly from their benchmark group.

Monitoring Quality and Safety.

The organisation undertakes large numbers of audits covering a range of clinical and quality topics

PEAT (Patient Environment Action Team) audits are used to benchmark a range of topics including food standards

The Trust uses the Datix system to report clinical incidents and reviews the information to inform action. The system is currently being enhanced to enable better use of information from complains

Controls

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Relevant policies and guidelines were up to date. All had been reviewed and updated where appropriate within the last 12 months.

Following the CQC visit the Trust has introduced a range of actions across the whole Trust to ensure there is a real focus on nutrition and dignity. These have included

Ensuring protected meal times are adhered to Introduction of meal time co-ordinators who

o alert staff that meals are due to ensure they are ready to be able to assist or feed patients,

o Check all patients are ready to eat their meals and ensure patients can clean their hands

o Ensure effective use of the red tray system and that staff are allocated to patients requiring assistance

o Ensure at end of meals all food and drink is recordedo Keep up to date information on patient’s dietary needs in

their “co-ordinators book. Relatives are being encouraged to come in at meal times if they

wished to assist their family member with feeding. Posters have been put up to highlight this. Response from family member overall has been very positive with only a small number stating they did not feel it was appropriate.

Re-energising of the Nutritional Link Nurse programme with schedule of meetings and training commenced in June

Matrons have increased the frequency of audits and unannounced spot checks to ensure good practice is being complied with. Examples include:

o using the CQC standards to audit practice,o Food quality – professional acceptability audito CQuIN Audit that includes nutrition

PEAT scores for the food standards have improved by 31% since January. There has been improvement on all 8 Standards. In January – the range of compliance was 38% - 92%. At the end of May the range was 97% - 100%

Respecting and Involving Service Users

The Trust has a comprehensive policy on privacy and dignity approved Nov 2010 which was widely disseminated.

An action plan has been put in place with a range of actions to be completed by the end of June.

Two-hourly Care and comfort rounds have been introduced aimed at enhancing the consistency of care. Interactions are recorded on a chart and audited by Matrons to ensure compliance.

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The Trust has introduced of an audit that includes – first impressions, nursing evidence, patient experience, behind the curtains- beneath the sheets.

There has been Improved compliance to eliminating mixed-sex accommodation.

Training for care of dementia patients has commenced.

3.Personal Observation

Unannounced visits to 10 wards across all three sites were undertaken. Different approaches were used in order to attempt to obtain a view of normal day to day activity. This included:

Beginning at the kitchen, observing preparation following the trolley to the ward and following the mealtime process from end to end. At the request from one of the shadow governors a process map of how food progresses from kitchen to ward and back is shown below.

Visiting and observing at different points of protected mealtimes to get a snapshot.

Observing after protected meal times to view documentation. During all visits discussion, questioning and observation was

used. Patients were happy to chat and this also elicited useful

information.

Food heated temperatures checked and

recorded

food arrives on ward, plugged in, served by

catering assitanceNurses/HCA take food to patient

Patient eats food or is assisted to eat

Trays placed in stacker by ward staff

trays cleared and cleaned

tray wastage observed & recorded

tray stacker returned to kitchen

trolley returned to kitchen, food usage

recorded, trolley cleaned

All wards visited had adopted protected meal-times and use of mealtime-coordinators. It was highly evident that staff has re-organised their care to ensure there was a real focus on patients mealtimes. A number of wards have agreed revised times for meals

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to be delivered to ensure they can give out 12mid-day drugs to enable that nurse can also be able to assist with meals. Catering managers on both sites expressed a commitment to be as flexible as possible to assist with this.

The wards overall felt calm and organised as a result of this change. Patients requiring assistance were all receiving support from nurses and care assistants. This and it was being done with care and compassion. The red tray system was operating effectively on all wards.

On two wards at Worcester, it was observed that all at risk patients were being supported, however a small number of patients who were self -caring had not eaten a significant proportion of their food and the reasons why they were not being checked by the nursing staff. This aspect of care needs to be strengthened. It has been immediately dealt with by the head of Nursing.

Many staff spoken to were passionate about the changes, it was evident that this was been taken very seriously and staff felt the changes made it much easier to be able to devote time to ensuring patients received their meals.

All staff raised the challenge, that despite these changes, there are times when more patients need assistance than there are staff on duty and although they were encouraging relatives to come in and assist, there may be an option to ask volunteers to help, but most wards currently only had one volunteer available.

The documentation supporting nutrition was completed to a high standard. I did not observe any omissions of recording weight on any patient record I viewed.

Ward 5 and Ward 11 and, could easily be shown as “exemplars” of the new arrangements. Cookley Ward at Kidderminster was also highly impressive.

The food was of good quality, patients spoken to were enjoying their meals. Feedback from Trust patient surveys also supports this opinion.

PEAT (Patient Environment Action Team) scored all three hospitals’ food as Excellent

Catering services have established a very personalised service to ensure patients are able to receive food of their choice. The team were visible and there appears to be a very good relationship

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between catering staff and the ward teams. Examples of good practice included:

If patients did not like the food choice on offer, they would offer alternative choices available in the staff restaurant to help encourage patients to eat.

A catering assistant visits every patient on high calorie or high protein diets to ascertain their food choices and delivers a personalised diet to increase their nutritional intake.

There was a real commitment from the teams on all sites to provide a flexible and responsive service. All sites interact with patients on a regular basis.

They regularly undertake patient surveys to get feedback on what patients think about the food, its quality and variety.

Catering staff also monitor food wasted – this is divided into trolley waste (food left after serving all meals) and tray waste (food patients leave) This is a useful proxy measure that could be used as part of the overall package of measures to assure patients are eating their meals.

Snacks are available, but the system of obtaining them is different on each site. All staff agreed it was easy to access snacks when the restaurant was open but a small number of staff felt out of hours could be improved, although all acknowledged that toast could be made on wards.

Desert is not currently served in an insulated dish although they are on order.

At Worcester, a shared food trolley service operates between two wards. The hostess alternates which ward they go to first. The ward teams stated that on occasion this resulted in the meals ordered on the ward receiving their food second, not being available. I have discussed this with the catering manager who is going to look into this and determine how the situation can be improved.

Staff suggestions for further improvement of services

I asked staff what ideas they had to improve services even further and they made the following suggestions:

Be able to offer a cold drink such as squash particularly in summer.

When sandwiches are offered they are served in pack with four quarters. Many elderly patients only want half that amount – so

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offer packs with two quarters which will mean patients do not feel overwhelmed with the portion size. This could also prove more cost effective

Review the vegetarian option to offer a broader choice. Provide snacks on a “top-up basis” rather than as is done at the

Alexandra – offered on the menu only. Review system to ensure there is always adequate supply of

bread and butter on wards to make toast.

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4.Addressing the questions posed.

What may have been the causes of the failure?

1 Culture – Although it is evident that the Trust strives to deliver high quality care and a significant amount of work was being done, the culture of ensuring mealtimes were protected and all staff contributed to patients eating was not embedded prior to the CQC visit. Wards, without doubt are incredibly busy areas with a vast array of constant activity. At mealtimes staff would be giving out drugs, carrying out ward rounds and delivering other aspects of care which inevitably meant that mealtime did not receive the level of focus necessary to ensure all patients received adequate nutrition.

2 Leadership at ward level.

The job description of a ward sister/charge nurse (Band 7) states as a core purpose of the role “to ensure a high standard of nursing care at all times through effective management of staff resources on his or her allocated department.” To undertake this role successfully and effectively, two factors, capability and capacity, can help or hinder delivery. Having spoken to a number of ward sisters, matrons and medical consultants and observed teams on the wards, I believe the following are likely contributors as to why standards were not met on the day of the CQC visit.

2.1 Capability Nationally, there has been a shift over the last few years in the attitude of nurses towards becoming sisters. Where is once something many nurses aspired to, now, staff nurses see the challenges, expectations, complexity and stresses of the job and are choosing not to apply for these roles. This is also the case at Worcester, where in some areas it has been difficult to attract senior nurses to the roles and therefore staff have to be encouraged to apply. As a consequence they are less experienced and less prepared. The trust has a number of very experienced, motivated and highly professional matrons in place to support the ward sister/charge nurses and has recognised that in order to meet the demanding and complex challenges ward leaders face on a daily basis, the ward leaders need a programme of development and support. A development programme has begun, but it will take some time to take staff through this. In the meantime there are ward sisters with a range of experience and skill with some needing more support from the Matrons.

2.2 Capacity: In the normal working week, Ward sisters/charge nurses will be “in the numbers” caring for their own group of patients three days a week. One day a week they carry the bleep to help co-

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ordinate bed management across the Trust and one day a week is classed as an office day which is when they will do tasks such as deal with recruitment, off duty, input audit data. During that time they will have to also deal with several doctors’ rounds, specialist nurses visiting, bed management teams asking about admissions and discharges, speak to relatives and answer phone calls.

As part of their role as leaders they are also responsible for ensuring their staff have the knowledge and skills necessary to practice safely and that they behave in a way in keeping with their professional code of practice. It is genuinely hard to see how they can effectively fulfil their role as leaders when they are unable to be “in-charge” of their ward on a daily basis. Interestingly on the e-rostering system not “being in the numbers” is referred to as non-value added activity The Trust is currently piloting a charge nurse being identified as in-charge in a project called “the Exemplar Ward” The start of this project is delayed however as staff are still being recruited.

3 Individual clinical practice: Nurses operate within a Code of Conduct, performance and ethics agreed by the nursing regulator the Nursing and Midwifery Council. This Code places a personal and professional accountability for individual actions and omissions’ in practice and the expectation that nurses can justify ones decisions. To ensure nurses operate in this way, the Trust has in place a range of development and training programmes and operates an appraisal system for staff. Information from complaints and the findings of the CQC clearly demonstrate that not all practitioners operate to this level consistently. There has been much discussion nationally regarding the quality and approach to pre-registration training and how this impact on the quality of qualified nurses, however it is beyond the scope of this review to explore this. Instead, the review has focussed on what actions the Trust are taking and could take to ensure that the nurses employed operate within their code of practice.

The programmes of training appear to be quite traditional and focus on theory and concepts and do not clearly state expectations of behaviour.

There is limited focus on assuring competence, which is necessary to “close the loop” and ensure theory is consistently applied in practice.

The process of appraisal is in place within the organisation. That said, in discussion with staff, it seemed like the process was viewed as bureaucratic and something that “had to be done” rather than seeing it as a crucial and integral part of assuring staff were clear about their objectives and development needs were identified and met.

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4 Documentation – All staff commented on the huge amount of paperwork, how consuming it was and how much repetition there was. The need for comprehensive assessment, planning, evaluating and recording the care of each patient is important both clinically and legally. Over the years the range of assessment tools and documentation had grown hugely. Assessment tools developed nationally and locally have invariably been developed in isolation of one another, despite this creating significant duplication. Worcestershire NHS Trust is not alone in attempting to cope with this challenge.

Although incomplete documentation cannot be condoned, it is unsurprising given the time it takes to complete this documentation and the amount of duplication that exists, that there were omissions. For example current documentation requires a patient label to be put on each patient nursing records 26 times.

5 Action Plans – There are a number of action plans for a range of programmes of work (there are now additional plans following the CQC visit). The existing plans, whilst comprehensive in content, are not sufficiently outcome focussed, or as effectively project managed to ensure implementation with pace and grip. This problem is not unique to this Trust and highlights a gap in the skills of effective project management.

Why were the Board not alerted to the problems prior to the CQC visit?

Until April the Board met quarterly and relied on committees below to provide assurance to the Board. The Board received a range of quality reports in the main from the Nurse Director. Minutes show these were discussed and noted for information. These included information on Essence of Care, Nursing High Impact Actions, Same sex accommodation, fall, and safeguarding.

The reports did include data and information generally at a point in time e.g. how many MRSA cases or falls there had been and where relevant how the figures compared to the previous year. Having reviewed the reports, minutes and actions from the Board and the sub-committees, whilst there was indeed a plethora of information available and discussed, it was not organised into a robust performance framework that would have been able to alert the Board to a problem easily.

Although there is a strategic intent to provide safe, high quality services, and the Trust does collect a huge amount of data in its desire to achieve its goal, fundamentally it is not underpinned by an

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infrastructure to capture the evidence it needs to monitor and track trends and progress at Trust, hospital and ward levels in an organised and structures way.

Whilst there are a number of individual quality measures reported to the board and the team have begun to consider the key performance and quality measures, essential to assure the Board or flag the key risks, the work is in an early stage.

One reason as to why this may not have occurred is the lack of the basic hard and software necessary to support effective use of data and intelligence... Although the procurement of a system has been discussed for some time, its failure to materialise has without doubt hampered the organisations ability to establish an effective assurance process. Existing systems and processes are not “joined-up” meaning a disproportionate amount of effort is required to provide the current level of assurance.

Culturally – staff feel overwhelmed by the amount of audit they have to undertake and whilst they recognise its importance, there is a sense of it being a bureaucratic task. There is significant duplication in the audits particularly nurses are undertaking and many of them are being recorded in a “word” format, the rest are manually entered onto a spread sheet – which is hugely time-consuming.

Staff in the main, also lack some of the knowledge, skills and support necessary to present the data in a format that would enable them to track and monitor progress, highlight good practice or alert them to a problem.

There currently are a range of committees and sub-committees in place in order to support clinical and corporate governance. It has been recognised that the current terms of reference and ways of working do not effectively support robust governance and assurance, therefore a new Quality Assurance and Scrutiny has been established and will report to the Board. Its terms of reference and key responsibilities should enhance the current approach.

Actions taken on the two wards and sustainability of these actions.

Formal letters outlining expectations were set to the ward sisters and matron by the Director of Nursing outlining findings and expectations. The wards have been closely monitored and supported by the senior

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team. Regular audits and spot checks have been undertaken. There has been a change in leadership on Ward 5.

The actions taken on both wards have resulted in significant improvements, these include

Ensuring protected meal times are adhered to Introduction of meal time co-ordinators who Relatives are being encouraged to come in at meal Identification of a Nutritional Link Nurse Guidelines updated and made available and discussed with staff

The teams are totally committed to regaining the confidence of both patients and the public by demonstrating high standards of care.

Sustainability – can be described as “when new ways of working and improved outcomes become the norm” and for the NHS this includes not only changing the process and outcome, but also behaviours and attitudes. Evidence would suggest that it is too early to assess whether these changes will sustain, however the NHS Institute has developed evidence based tool to help organisations predict the likelihood of an improvement sustaining.

Having reviewed this, I would outline a number of the features that will require action if the Trust is to be confident that the improvement will be sustained, not only on the two wards, but across the Trust.

Benefits beyond helping patients including improving efficiency, reducing duplication.

Effectiveness of the systems to monitor progress Having effective feedback systems to reinforce progress and

initiate action Effective communication of results to patients staff, the

organisations and beyond

Given these features have already been mentioned as potential contributors to the problems that occurred; unless they are addressed it would not be possible to assure the Board that the changes made will be sustainable.

Review of Outcomes from actions taken

There has been real and tangible change in the way nutrition is being dealt with. It is receiving the focus and attention it rightly deserves. Audits have shown improvement in compliance. The quality of completion documentation is high. The actions outlined in this report

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show real progress in a short time. The follow- up visit by the CQC indicated (verbal feedback) that the Trust is now compliant.

Clarity of roles and responsibilities

There have been a number of organisational changes over the recent years, with the latest reorganisation occurring at the start of the year. Discussion with staff revealed that there was varying clarity about roles responsibilities for which they attributed the most recent changes had not yet had chance to “bed-in.” The new structure is based on having Hospital Management Teams one for Worcester and Kidderminster and the other for the Alexandra site. The management teams are clear they are the ones that should be accountable for ensuring delivery of high quality and efficient, effective services and care.

That said, there is a lack of clarity about how this new structure aligns with the current nursing structure. This structure was described by many as “running alongside” the new arrangements rather than being “aligned to.” This appears to have created a situation where staff feel “pulled in different directions”

For example, matrons are accountable to the general managers within the Hospital Management Team but have professional accountability to the Head of Nursing. They are asked to undertake work by the General Manager and the Head of Nursing who is responding to the request of the Director of Nursing.

Effective communications between the Director of Nursing ( and her team) and the Hospital Management team has not yet been fully established to ensure that each parties strategic goals can become aligned and that there is absolute clarity concerning who is responsible for what.

Bed management appears to occupy the time of many staff and especially matrons and ward sisters. This occurs, despite the organisation having a range of roles dedicated to capacity and bed management. It is beyond the remit of this review to determine the reasons for this, however the Trust may wish to take the opportunity to review roles and responsibilities and ensure they are following good practice for demand capacity and patient flow to determine if there is a way to both improve processes, but also utilise the ward managers and matrons more effectively in this work.

Administration – Ward sisters and matrons are responsible for the majority of administrative tasks concerned with recruitment including organising venues and sending out letters to candidates. This may be

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an area that could be reviewed if seeking ways to free up time to enable them to take responsibility for quality.

Recommendations

The following recommendations are made based on the findings of the review, the authors’ experience of working with 40 NHS organisations and known good practice across the NHS. The findings of the review do show that the Trust has a range of activities and good practice in place but these need to be built on, strengthened and enhanced.

In accepting the recommendations, the Trust should actively seek out known good practice, tools and techniques already available in the NHS and avoid “reinventing the wheel.”

The recommendations are weighted on the basis of “early wins,” to increase the likelihood of achieving sustainable change and the recognition that some actions are complex and will take longer to plan and implement.

In the next four weeks,

1. Agree the set of nursing and quality indicators and review the range of nursing audits undertaken. Make sure they are aligned to the Trusts nursing strategy and agreed indicators. This is not just about reducing the number but reducing duplication. Whilst waiting to procure a new electronic system – access some information/ IT expertise and ensure any audits undertaken use excel instead of word to enable the production of graphs and charts to track progress.

Suggested goal – One audit that can be undertaken to capture all necessary information, that can be done in one day. implemented within two months.

2. Review the process of audit feedback and action and agree approach to ensure “the loop is closed” and action follows promptly. This is applicable to all professional clinical audits.

3. The recommendations from the review should not generate an additional action plan, instead review and simplify your current action plans to incorporate additional actions. Be clear about the actions

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required at corporate level and those at hospital level to help clarify roles and responsibilities

Suggested goals. Clear understanding of corporate and divisional responsibility, outcome focused plans and that they are implemented with focus, pace and grip.

4. Identify Trusts that have already implemented new streamlined and simplified nursing documentation and acquire copies. Review with a view to minimal adjustment (if any) and develop an adoption and implementation plan for Trust.

Suggested goal. Documentation no duplication, used by Trust, that combines assessment tools, reduces significantly the time it takes to complete

Within 3 months

5. Review goals of Exemplar Ward project (being used to test value of the sister charge nurse not being “in the numbers”) to help determine implications of new ways of working and resources necessary to progress .

6. Progress the review and implementation of a more robust governance and assurance process and ensure staff fully understand the relationship between controls (policies and procedures), risk management, performance monitoring, performance reporting and provision of high level assurance information.

7. Progress the acquisition of an electronic system to enable all information to be pulled together into one area, follow this with comprehensive implementation plan.

8. Review and strengthen the Sisters/Charge Nurse and Matrons development programmes. Articulate the leadership and management behaviours and competences sought. Include a method to assess individuals against these and ensure the programme of development is tailored to meet individual needs.

Within 3-6months

9. Review current training programmes and methods of delivery to ensure they include a process of clarifying and testing the competences required (skills and behaviour) N.B this is relevant to all professional training programmes

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10. Review and identify the preferred (and simple) process for appraisal and set clear measurable expectations of performance, behaviour, care delivery and competence required. Build into this a process of assurance to be confident staff meet expected standards.

11. Build on work done to improve the handling and learning from complaints. Ensure the system in development will enable Trust to easily monitor numbers, types and trends. Ensure learning is shared across Trust and that actions taken are outcome focused and are monitored to ensure completed.

12. Consider undertaking volunteer recruitment programme to help at mealtimes, in areas where significant numbers of patients require assistance.

13. Review process for patients obtaining snacks to: meet patient needs, achieve consistent approach across Trust, and utilise expert advice from dietician.

14 .Undertake a full sustainability assessment using the NHS Institute tool. This will help you focus effort in the areas of higher risk of hindering sustainability.

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ANNEX I

WORCESTERSHIRE ACUTE HOSPITALS NHS TRUST

CQC UNANNOUNCED INDEPENDENT REVIEW WORKING GROUP

TERMS OF REFERENCE

Purpose and Objective

The overall objective of the Independent Review is to ensure that the wards are now compliant with CQC standards and that it is sustainable. In addition, the review will provide learning which can be utilised across the Trust.

Terms of Reference

Specifically the review needs to address the following:

1. Root causes of the failure.2. Why the Board was not alerted to the problems prior to the

CQC visit – systems, process, reporting etc.3. Review of actions taken in the 2 wards and sustainability of the

actions.4. Review of outcomes from those actions against the CQC

standards providing assurance it should not happen again.5. Clarity of individual and team accountability and responsibility

in delivering quality care.6. As a result of the review provide learning for the Trust as a

whole in relation to:o quality process and systemso measuremento accountability

Importantly where possible the results should be measurable not anecdotal. This takes cognisance of the fact that quality indicators are not well developed in the NHS and are primarily qualitative not quantitative but what is not measured cannot be managed.

InputsTo include:

Action plans Internal Audits – trend basis Patients & Public Forum & LINKs visits Feedback from unannounced visits Policies

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Standards

Reporting Structure

A written report of the review will be presented to the:-1) Working Group - 27 June 20112) Shadow Council of Governors– 29 June 20113) Public Trust Board – 30 June 2011

MembershipThe Working Group will comprise:

Chair – Lynne Todd Non Exec Director and Chair Quality Assurance & Scrutiny Committee (QASC)

Non Exec Director – John Burbeck Shadow Council of Governors:

o David Allison – Public Wychavon Constituencyo David Farmer – Appointed – Practice Based

Commissioners o Tony Hadfield – Appointed – NHS Worcestershireo Bill Tucker – Appointed – Medical Staff Committee

Authority and Attendance

The Working Group is authorised by the Board to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any employee and all employees are directed to co-operate with any request made by the Group. The Group is authorised by the Board to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary.

Record of Business

Minutes of the Group meetings shall be produced and circulated to the members of the Group no later than five working days following each meeting.

Agendas and associated papers will be sent out no later than 2 working days before the next meeting.

Group Secretary

The Trust Secretary will be the Group Secretary.

Frequency

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As required.

Lynne ToddNon-Executive Director1 June 2011

Annex II

1) CQC Dignity and nutrition for older people – review of compliance

2) CQC inspection – Report to the Trust Board 2 June 2011 3) Board Actions in response to CQC Inspection4) Keeping Nourished & Hydrated Implementation plan(CQC)5) Nutrition and Hydration link nurses programme6) Strategy for nurses and nursing 2010 - 20137) Job description Ward sister/charge nurse8) Job description Matron9) Nursing and Quality Workforce report July 201010) Nursing and Quality Workforce report 28 Oct 201011) Nursing and Quality Workforce report Jan 201112) Nursing and Quality Workforce report May 201113) Current Trust Board Committee Structure14) Organisational structure Worcester and Kidderminster15) Organisational structure at the Alexandra site16) Director of Nursing & Midwifery Structure17) Clinical Governance and Risk Management structure18) PEAT food standards audit results Jan – May 201119) PEAT Trust results 201120) Care and Comfort Round Documentation21) CQuIN Audit Tool22) Patients food and quality audit23) First Impressions, Nursing evidence Patient experience audit24) Respecting Others & Involving People who use service audit25) Example of Catering Survey for the Alexandra and

Kidderminster sites26) Example of audit of food and plate waste27) Mealtime observation 8 June Ward 528) Band 7 (ward Sisters) Development programme29) Matron Development Programme30) Preceptorship Programme31) Guidelines for Good Practice at Mealtimes32) Percutaneous endoscopic gastrostomy (PEG) guideline33) Guideline for the nutritional risk assessment & mgt. of

malnutrition34) Parenteral Nutrition guideline35) Respecting and Involving Service Users Implementation Plan

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(CQC)36) Privacy and dignity policy37) CQC In-patient survey results for Worcester hospital 201038) Inpatient patient satisfaction survey Worcester &

Kidderminster39) Key performance Indicators Band 7 (Sisters)40) Template for Matrons Quality Report41) Terms of reference for Quality Assurance and Scrutiny

Committee42) Nursing & midwifery council code of conduct, performance &

ethics43) CQC Essential standards – provider compliance assessment

tool.44) Food 4 Thought Group Action Plan45) Minutes of Public Trust Board 28 October 201046) Minutes of Public Trust Board 27 January 201147) Minutes of Public Trust Board 5 May 201148) Nursing Admission documentation plus assessments

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Annex III

Glossary

Clinical Audit Comparison of measured performance against agreed standards in order to identify where improvements in patient care can or have been made and how they can be achieved

Clinical Governance

Clinical governance is the system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care, by creating an environment in which clinical excellence will flourish

CQuINN Commissioning for Quality and Innovation Payment framework)

This enables commissioners to reward excellence, by linking a proportion of English healthcare providers' income to the achievement of local quality improvement goals. Since the first year of the CQUIN framework (2009/10), many CQUIN schemes have been developed and agreed.

DATIX system

The Datix Common Classification System for Incidents in Healthcare (CCS) enables Trusts to identify shortcomings in the healthcare system from the evidence of incidents accumulating their database

Essence of Care

Was developed in partnership with people1 and carers2 and as such reflects the views of their health and social care needs and preferences. Essence of Care 2010 is a veryVersatile tool that can be used in a number of ways and at different levels. it can be used as:

a quality assurance or benchmarking tool a reference document or checklist – Essence of

Care 2010 includes what people, carers and staff3 agree is best practice and care and this can, therefore, be referred to in order to understand people’s and carers’ ‘[perspectives

an audit tool – as a foundation and focus for audit data collection tools used to assess practice and care (linked to above)

a tool to provide evidence of compliance with registration criteria for the Care Quality Commission

High Impact Actions

The High Impact Actions for Nursing and Midwifery were developed following a ‘call for action’ which asked frontline staff to submit examples of high quality and cost effective care that, if adopted widely across the NHS, would make a transformational difference. Nurses and midwives responded by

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submitting more than 600 examples in less than three weeks. The Essential Collection developed by the NHS Institute highlights just some of the stories behind those submissions by providing details not only of what was done, but also ‘how they did it’.

Safer Nursing Care Tool

The Safer Nursing Care Tool (SNCT) is a robust valid evidence-based easy to use tool which uses acuity and dependency to help plan for future workforce requirement. It is a natural extension to the original Association of United Kingdom University Hospitals (AUKUH) Patient Care Portfolio project.

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worcestershire acute hospitals nhs trust: independent web viewprofessor janice stevenscbe ma rgnjune...

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