KEOGH ACTION PLAN - North Cumbria University … · 2.3 Independent ... \Corporate Administration\Meetings\Public Trust Board\March 2014\Enc3-Keogh Action Plan Version 20 20 March

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DOCUMENT CONTROL

VERSION: 20

DATE: 20/03/2014 Post Director Review Meeting 13/02/14

DATE OF LAST TRUST BOARD REVIEW: January 2014

KEOGH ACTION PLAN


KEOGH THEME:

INADEQUATE GOVERNANCE, AND PACE AND FOCUS OF CHANGE TO IMPORVE OVERALL SAFETY AND EXPERIENCE OF PATIENTS

RECOMMENDATIONS ACTION REQUIRED PROGRESS KPMG QG REF

ACCOUNTABLE TIMESCALE RAG

INITIAL RISK

CURRENT RISK

Evidence I.A

1. Urgent review of the Trust’s Corporate Risk Register and Board Assurance Framework

1.1 Independent review of Board Assurance Framework to be undertaken.

BAF re-designed and material content updated. Approved by the Board in July 2013. BAF continues to be updated monthly. BAF continues to be developed & updated as a live document ensuring alignment with the themes and issues within Clinical Business Units and key committees.

1B Ann Farrar July 2013 H L √

1.2 Independent review of Corporate Risk Register to be undertaken

Comparison of NCUH and NHFT corporate risks registers complete in order to form a Trust-wide risk register.

1B Ann Farrar October 2013 H M √

EMT session to get the right content in the BAF and Trust-wide risk register complete 16/10/2013.

October 2013 √

First Assurance Committee Meeting to review Trust wide Risk Register in October in order to assure appropriate mitigation in place.

October 2013 √

As a result of the above, updated BAF and Trust-wide risk register report to be presented to Board in November to be enhanced to a consistent standard.

November 2013 √

Trust wide risk register to be presented to Board in March 2014. Board development session on mitigation plans for top strategic risks.

March 2014


3-5 year strategic plan will address how strategic risks will be mitigated.

June 2014

2. Full independent review of quality governance

2.1 Independent external review of quality governance to be commissioned.

KPMG independent review completed May 2013. Outcome was a score of 9.5 with 18 recommendations. Action plan presented to September Board.

A11

Ann Farrar May 2013 H L √ √

Reduce the quality governance score from 9.5 to 5.0 or less. All 18 KPMG recommendations continue to be implemented. Self Assessment completed in March 2014. Independent re-assessment will be undertaken in June 2014.

March 2014 revised to October 2014

June 2014

M

2.2 External support to lead a board and senior management development session assessment, escalation and management of risk to identify how the Trust evaluates and assures the quality and safety of its services.

Report on escalation completed and presented to Trust Board in July which identified five key areas for development. Listed below:

1B

Ann Farrar July 2013 H √

Management by walkabout – Business Unit dedicated days on each site. New patient safety walkabout programme commenced in November 2013 focussing on learning from serious incidents. Schedule of walkabouts established. Trust continues to build on this to ensure information/intelligence arising from walkabouts are fed into the formal patient safety and quality structures. Early results are encouraging, with findings of walkabouts feeding into formal governance structures i.e.

Ann Farrar October 2013 H

H

√


Quality Panels, Safety and Quality Committee.

Highly effective Clinical

Governance – MD and DoN supporting with development agenda in time out sessions. Business Unit Governance Boards. Medicine and surgery completed. Child health and clinical support to be completed during March. Trust has developed clinical governance to ensure local weekly team meetings feed through to monthly directorate meetings, through to quarterly Safety and Quality Committee via the Clinical Business Units’ quarterly reports. Quality Panels have been established, which will continue to be embedded during 2014/15.

Jeremy Rushmer

October 2013 Revised March 2014

Board to Ward Outcomes – Pilot commenced. Evaluation reported to EMT in January 2014 with plan for full roll out (as outlined in 2.4). Schedule of roll out available. March milestone of 30% achieved in full.

Claire Riley December 2013 √

Formal triggers for escalation – formal triggers for escalation to be confirmed in new risk assessment policy and training – end of November. Policy finalised for sign off at TPG. New training package finalised. Report to Workforce Committee 16 December.

Ramona Duguid

October 2013 √


Trust led Board and senior mgt development session (with KPMG), focused on escalation and mgt of risk. All directors are now clear on the triggers for escalation. New Risk Management Policy and Board Risk and Assurance Framework developed.

Organisational Development – Session on escalation to be part of OD programme with operational teams, facilitated by KPMG.

Ann Farrar October 2013 (revised November

2013)

√

2.3 Independent review of appropriate CQC outcomes to ensure full compliance by July/August.

Report on outcomes from review undertaken by NHCFT presented to Board in July 2013. Action plans to be developed by each of the leads by 31 August 2013.

N/A Birju Rana July 2013 H √ √

Full delivery of compliance against all 16 outcomes forecasted for March 2014. 15 out of 16 achieved. Following review by NHFT. Medical records compliance remains outstanding and detailed plans are in place to deliver full compliance by July/Aug 2014.

N/A Birju Rana March 2014

revised to July/Aug for medical records

compliance

H M

2.4 The TDA Medical Director and Director of Nursing to source ‘best in class’ systems for reporting and monitoring outcomes at service, ward and consultant level. This would include benchmarking with the best. From September, focus on ownership and

Framework in place and being piloted at CIC (Larch AB and Elm A) and WCH (Jenkin and Pillar/Patterdale) for Board to Ward Outcomes based on Unipart way. Full roll out to all wards by September 2014 with milestones set for 30% by March 2014, 50% by May 2014 and 100 % by September 2014. March milestone of 30% achieved

2B Claire Riley September 2014 H M


embed into the surgical services by March 2014.

and confidence is high in remaining roll out milestones.

Clinical audit quarterly report expanded to include ‘everyone counts’. No new major risks highlighted providing a level of assurance that risk management systems are improving. Some low volume items identified.

Jeremy Rushmer

September 2013 √

Quality Panel schedule established from November 2013. Schedule approved at Directors meeting in September. This puts in place a system for service outcomes using benchmarking information. Quality Panel structure continues to gain momentum with attendance by all teams expected to be completed by summer 2014. Trust continues to strive to ensure this forum is made increasingly effective through development of team specific KPIs, increased standardisation of reporting, availability and use of benchmarking data, and the triangulation of themes and issues e.g. B2W, nursing indicators etc.

2A(5)

Jeremy Rushmer and

Ramona Duguid

September 2013 Revised to January

2014

H M √

3. Review the leadership structure to ensure that the capability and capacity

3.1 TDA to support the Trust Board to complete the review of the Executive leadership.

Communication plan confirms changes from August. This was subsequently changed by the TDA in August. Trusts in Special Measures to have an independent Board Capacity Assessment led by

3A Trust Development

Authority

November 2013 H

H √


gaps are filled.

the TDA.

Independent assessment completed in September 2013. Feedback to the Chairman and Chief Executive received in October 2013.

Trust Development

Authority

October 2013 √

New Executive Director team structure to be confirmed November 2013.

Ann Farrar November 2013

April 2014

√

Executive Director appointments completed by April.

√

3.2 Middle management level to be in place by July 14

Middle management level (OSMs and Matrons) re-structure to be concluded by end of October 2013. Two matron posts remain vacant in IPC and paediatrics. Risks continue to be monitored through detailed infection prevention monitoring. Workforce gaps being managed within existing workforce. Current OSM recruitment activity is expected to fill gaps. IPC post appointed externally in November but withdrew December 2013. Re-advertised January 2014. Paediatric matron post not appointed to and therefore plan to appoint internally from 6 January on interim basis. Internal appointment made.

3A Ann Stringer / Corrine Siddall / Chris Platton

October 2013 M √


Capacity has increased in some areas and a recruitment plan is in place with search companies to address remaining gaps. Further work is required on capability of senior management, which will be addressed through delivery of the OD Plan. Trust continues to closely manage this risk through actions including relying on NHFT and search companies to mitigate risk. In addition, re-allocation of people within clinical and corporate teams where priority dictates e.g. emergency care and medicine at CI. Also, fortnightly meeting between the CEO and matrons/managers and 8am weekly meetings on emergency care patient flow attended by the MD, CDs, Matrons and Managers.

Ann Farrar October 2013 Revised to July 2014

H

4. Implementation of a formal OD programme

4.1 NHCFT has strong record of OD. OD programme to be established for CDs, Lead Nurses and OSMs.

Programme in place with specific curriculum for key staff groups. Commenced in September: Board Assurance Programme Coaching interventions Building relationships and

setting direction Senior leadership development

programme Management skills

development programme SUI training programme Managing doctors’ performance

and maintaining high

2B Ann Stringer September M √


professional standards Leading patient safety Consultant recruitment process Consultant 5 day programme Revalidation and appraisal

skills programme Doctor 360 Staff survey results discussion Getting the best from our teams High performing clinical leaders

programme Implementation of care bundle Identifying and managing risk Embed patient-centred culture

and create cross-Trust skills and understanding

Safety and Culture Surveys Patient Safety Survey 9

domains of Mapsaf Medical engagement Score Cultural Team Diagnostics People dimensions of change

Evidence from staff surveys shows broad improvement and an improving trajectory.

4.2 Outcomes from the OD work to be reported to the Trust Board.

Report on ward managers’ development programme. A schedule for other programmes. Content of original programme and prioritise from the Clinical Directorates is being reviewed to ensure we evolve the content and objectives to meet the ongoing needs of the organisation. A key event is scheduled for 06/02/2014 with all the Clinical Directorate Multidisciplinary Teams.

Ann Stringer November 2013

Revised February 2014.

√


4.3 Outcomes from the OD programmes to be reported to Workforce Committee.

Report on high performing teams (CDs, Matrons, Operational Service Managers and Accountants). Report presented to Committee in December 2013. This will be reviewed in relation to 4.2 above.

Ann Stringer January 2014 Revised February

2014

√


KEOGH THEME:

SLOW AND INADEQUATE RESPONSES TO SERIOUS INCIDENTS AND A CULTURE WHICH DOES NOT SUPPORT OPENNESS, TRANSPARENCY AND LEARNING



INITIAL RISK

CURRENT RISK

Evidence

I.A

5. Ensure robust arrangements for serious incident investigations.

5.1 Improved process to be implemented.

New process commenced June 2013. Learning Guide and revised investigation templates implemented. Revised Safety Panel and SI policy in place. Evidence of a significant increase in reported serious incidents (44 in 12/13 and 80 YTD 13/14), actions taken as a result and good quality of reports written with new standardised reports and RCA tools. Better optimisation of Ulysses for reporting and flow of information for SI’s, complaints and investigations is required.. Actions have arisen from the trust’s improved systematic review of incidents and complaints. This has included MDT approach at all levels, including junior doctors.

3B(9) Jeremy Rushmer &

Chris Platton

August 2013 H L √

5.2 TDA Medical Director and Director of Nursing to approve the immediate actions following the never events and recommend appropriate support on the

Report submitted to TDA on actions from Never Events 12/07/2013. Progress on mitigating actions on broader issues reported to the

N/A Jeremy Rushmer &

Chris Platton

July 2013 H L √


broader issues and how to improve.

public Trust Board. All actions have dates for implementation. Report to Trust Board in October 2013 on actions taken on all Never Events. All areas where a never event has occurred have been included in Patient Safety Walkabout Programme. Areas included in audit calendar for specific clinical follow up audits. All Board members to receive Safety Newsletter from January 2014. Themes presented to the Clinical Policy Group in September on serious incidents and complaints. Trust-wide improvements in place to address key themes: Clinical guidelines and

decision making aids Diagnosis and clinical

treatment Patient handover Falls Theatre Communication and

compassion Updates on the themes are included in the Quarterly S&Q report to the Board. Independent assurance actively sought on key serious incidents, for example, two never events relating to a retained guidewire.


As a result of this independent report, the Anaesthetic and ITU CDs attended Trust Board on two further occasions. A recruitment process started, CCP appointed, and a 3

rd on call at WCH

consulted upon and implemented from July CPG.

5.3 TDA to identify resource to address backlog of complaints and incidents.

Serious Incidents: All 2012/13 SI investigations complete and submitted to CCG by 31 August 2013.

Complaints: Additional resource from TDA not required. Trust plan put in place in June 2013 to address backlog. Backlog of complaints significantly reduced. No complaint over 25 days without negotiated date with complainant or external review achieved by September 2013.

N/A Jeremy Rushmer &

Chris Platton

August 2013 H L √

5.4 Trust to identify how they will accelerate learning from SIs. TDA will support the Trust to implement this.

Safety Panels commenced in June 2013 as part of new process, this includes six month follow up on Cat A & B SIs. CPG review of SIs in place. Safety Panels are now well established and meet weekly. Trust intranet has been updated to include this learning.

3B(10) Jeremy Rushmer &

Chris Platton

September 2013

H L √


Trust is implementing a process where all deaths are looked at in the week they occur, with an email on learning going to the whole organisation on a weekly basis. More aspirational plan is to create a clinical website bringing all various aspects of safety and quality together in one place.

Analysis on contributory factors across specialties and sites completed and were reported to the first Safety and Quality Committee in September 2013.

Jeremy Rushmer &

Chris Platton

September 2013

H L √

Trust wide themes from serious incidents and complaints approved by CPG in September: Clinical guidelines and

decision making aids Diagnosis and clinical

treatment Patient handover Falls Theatre Communication and

compassion Accountable clinical leaders confirmed. Progress monitored via public Trust Board each quarter.

Jeremy Rushmer &

Chris Platton

September 2013

H M √

Clinical Audit plan re-aligned to focus on serious incidents. This is formally reported each quarter.

Jeremy Rushmer

September 2013

H L √

New Safety Newsletter commenced from June 2013

Jeremy Rushmer

September 2013

H L √


produced monthly after CPG. Patient Safety Walkabout

Programme being realigned to focus on learning from SIs. Key area of focus for Q4, to ensure all Category A SIs and Never Events have been included in the programme.

Jeremy Rushmer

November 2013

H L √

5.5 External support to be commissioned to undertake dedicated Serious Incident Investigation Training

Training package delivered with DACBeachcroft. 99 staff trained in total to date. Training on risk Management for senior managers commence din Q4. Serious incidents training will be included in the TNA for 14/15.

Jeremy Rushmer

August 2013 H L √

5.6 TDA Medical Director and Director of Nursing to engage best practice in complaints handling from an organisational development perspective by July. Northumbria to support implementation of new standards from July.

Complaints development session held for Trust over 60 staff in June 2013.

Revised complaints policy and guide for staff developed. New policy to be implemented from November (in conjunction with the Hart Clywd Review). This will included revised mandatory complaints training for identified staff. Board development session on national review of complaints held on 25 November. New policy to be agreed with TPG in December 2013 and will be rolled out to all staff with training in January 2014.

Jeremy Rushmer &

Chris Platton

November 2013 Revised

to January 2014

H L √


KEOGH THEME:

LACK OF SUPPORT AND EFFECTIVE, HONEST COMMUNICATION FROM MIDDLE AND SENIOR MANAGEMENT



INITIAL RISK

CURRENT RISK

Evid I.A

6. Promotion of a more supportive and open culture

6.1 Executive Team to implement an enhanced middle management tier, following appropriate consultation, which provides the right capacity and capability to support clinical teams.

See 3.1 above.

New management structure introduced.

Clinical business unit structure – CDs, Deputy Directors. We then confirmed service lines – GMs / OSMs / Matrons – accelerated in March.

Growing the number of matrons managers to replicate NHFT.

Review of safety culture baseline

Introduction of Manchester safety culture measurement tool.

√

6.2 A cultural measurement tool to be launched during June as part of Trust’s OD strategy. This tool, recommended by the NPSA, will be completed by clinical teams who attend our bespoke Patient Safety Days.

MAPSAF culture assessment completed as part of Patient Safety Days (190 members of staff). Confirmed level 2. This fits with due diligence. Complete, results went to Safety & Quality committee, and a board development session.

2B

Jeremy Rushmer

July 2013 H H √

Culture survey will be repeated in the follow up patient safety days in 2014. Scheduled in June 2014.

April 2014 Revised to June 2014

√


Medical engagement survey commenced October 2013. Report received which identifies high risk issues which need to be addressed as part of our improvement and organisational development journey. The first survey is finished. Presented to HPL at castle Inn last month (February). Survey indicated medical engagement was weak, in particular Surgery. Action plan being implemented to address high risk issues. Particular focus has been applied to medical business units, which show improvement as a result.

November 2013

√

Results from Medical Engagement Survey to be presented to Clinical Policy Group in February 2014. Completed and action plan is being implemented. Series of focus groups planned. There will be negotiation around 7 day working and alterations in current T&Cs around annual job planning, better supported appraisal, linked to the trust’s priorities.

February 2014

√


6.3 Evaluation of staff, patient and stakeholder opinions started to be part of our Board assurance model from April. This is part of the Quality Standards agreed with the CCG from April.

Report received in July 2013. 3C

Ann Farrar July 2013

H H √

Staff survey monkey results confirm Safety is the Trust’s top priority. More work on empowerment and influence, workforce and patient flow for staff to feel better. Changed to Staff, Friends and Family test.

Ann Stringer

Reported quarterly since July

2013

√

Patient experience results and FFT positive. Focus on all teams receiving feedback and being empowered to act. Good results received from friends and family test.

Chris Platton Reported quarterly since July

2013

√

Stakeholder views reported to Trust Board in July and to be reported again in November.

Peter Weaving/ Claire Riley

November 2013

√

6.4 Continue to implement the first North Cumbria OD plan, approved by the Trust Board in March. This will be evaluated by Trust Board 4 times a year.

See item 4 above.

M M √

6.5 Trust will commission North East Leadership Academy (NELA) to continue to support senior clinical leaders or similar

Clinical Business Unit Director attending. Trust responded to NELA on 12 July 2013. On-going leadership programme and OD support being

N/A Ann Farrar July 2013 M L √


programme.

considered.

6.6 As part of our OD strategy, the Trust to work in partnership with Northumbria on the consistent application of professional standards to address serious concerns raised regarding individual and team relationships, e.g. bullying allegations. Furthermore, the Interim MD is currently engaging specialist support to develop individuals into high performing teams from June, e.g. trauma and orthopaedics.

Report to EMT and Private Trust Board in July. MHPS training completed in June 2013.

3B(11) Ann Stringer July 2013 M M √

Trauma and Orthopaedic process and terms of reference agreed. Company commissioned. First timeout session in September commenced.

N/A 3B(12)

Ann Stringer June 2013

H H √

Final development session in November. Outcomes and actions to be reported to the Trust Board. Action plans being implemented including 3/6 monthly follow up

December 2013

Revised January

2014

√

6.7 Medical staff engagement self-assessment to encourage ownership and leadership.

Peter Spurgeon contacted and funding arranged for survey to be completed by October. (As per 6.2 above).

3C Jeremy Rushmer/ Damian Gallagher

October 2013

H H √


KEOGH THEME: STAFFING SHORTFALLS AND OTHER WORKFORCE ISSUES ACROSS STAFF GROUPS WHICH MAY BE COMPROMOSING PATIENT SAFETY



INITIAL RISK

CURRENT RISK

Evid I.A

7. Review staffing levels to ensure safe care is delivered

TDA Director of Nursing and Medical Director to review by end of July. To include: 7.1 Introduction of

acuity, geographical

location and

professional

judgement model.

Review of ward establishments completed paper to Trust Board October 2013. Band 6 review commenced and under formal consultation process. Safe Care Acuity review of all wards completed. Weekly monitoring and review of nursing vacancies in place. Vacancy rate has reduced from 4.2% October 2012 to 2.9% in October 2013. Since September 2012, 72.94 WTE RN posts appointed. Qualified nurse’s sickness in November is 5.24%.

1A Chris Platton September 2013

Revised to October 2013

H H √

Board approved the following decisions in October 2013:

All wards should move towards a 65:35 skill mix - qualified nurses to healthcare assistants

We will repeat a review of ward acuity in January 2014 and every six months from then on to ensure we have safe staffing levels at all times

There will be peer reviews so that the emergency department, outpatients and theatres will be part of the Trust Board’s determination to improve nurse staffing levels

Ward managers will be spending one day in a supervisory role to develop their leadership and this will be funded via back-fill to ensure staffing levels are maintained

√


We are supporting every ward manager in developing ward sickness monitoring and e-rostering

7.2 Consideration of rostering patterns and their impact on continuity of care and ward leadership 24/7.

Rostering training aims to be completed in November. Effectiveness of training now being audited and first report was given to Trust board in October, which reported good outcomes. This will be audited and reported every quarter.

1A Chris Platton June 2013 H √

7.3 Priority areas to be reviewed first are L shaped wards, critical care areas, including stroke and coronary care, elderly care wards and accident and emergency departments.

Staffing numbers reviewed and increased via ongoing recruitment.

1B Chris Platton June 2013 H √

7.4 Clear escalation

process and

roles of ward

manager,

matron, senior

nurses/midwife

and Nurse

Director to clarify

escalation action

Escalation through daily SITREP. Weekly report to EMT and monthly report to Trust Board.

1B Chris Platton June 2013 √


and reporting.

7.5 Routine audit of

staffing levels

and patterns by

internal audit.

Monthly report on staffing and quality outcomes reported to the Board since June. 91% of posts reported as having the agreed staffing number, October 2013.

1B Chris Platton June 2013 H M √

Additional 5 medical beds opened at CIC on 3/2/14. Remaining 12 beds at CIC and 15 beds at WCH will open as new staff appointed. The Trust Board are committed to the nursing ratio standard of 1:8 (daytime) and 1:10 (night-time) and will not increase capacity which compromises this standard. Every opportunity to recruit nursing staff is being taken. We are looking at an alternative plan.

EMT Risk managed although Trust is cancelling patients.

Not meeting 18 weeks.

Prioritising emergency patients and surgery

1B Chris Platton March 2014 Revised June

2014

7.6 Review of recruitment processes and effectiveness of both clinical and non-clinical staff groups. Identifying areas of success and learning for the organisation.

New recruitment process implemented in May 2013.

1A Ann Stringer May 2013 H L √


7.7 Review medical staff to ensure models are safe and sustainable. To support small clinical teams with a high number of locums.

Clinical Policy Group, in June, considered emergency care and acute medicine and acute surgery at WCH. Agreed the model was safe and appropriate escalation in place. 12 week rotas produced for acute medicine and surgery, and published in clinical areas and intranet. Agreed with Deanery.

1B Jeremy Rushmer

July 2013 H

H

√

Medical Director’s Report to Board commenced in July 2013 to report sustainability and key clinical risks, e.g. temporary transfer of surgery in September.

1B Jeremy Rushmer

July 2013 √

Key teams highlighted as risks due to the number of locums: NC – Elderly care NC – Gastroenterology NC – Respiratory WCH – Obstetrics and Gynaecology WCH – Acute Medicine WCH – Anaesthetics and ITU Medical Directors Report will be expanded to focus on plans to mitigate the risks of locum cover (consultant and middle grade) from November 2013.

1B Jeremy Rushmer

November 2013

√

Planned/unplanned changes in permanent and locum medical workforce has reduced the resilience and stability of acute medicine at WCH. Extensive efforts are being made to recruit to the positions, however different models of care may be required which will be fully considered in conjunction with the CCG, NHS England, Deanery and TDA. Risk increased and has been escalated to NHS

N/A Jeremy Rushmer

April 2014 Revised to July 2014


England.

Discussion with Board by April 2014 which will outline options to manage acute medicine, WCH.

TDA project on root and branch review of existing permanent medical workforce will be undertaken and complete by June 14. This will enable improved quantative analysis or the medical workforce.

Devolvement of day to day clinical mgt and ownership by BU managers and clinicians is currently being implemented. This will allow in a few months’ time the Medical Director to report on a quantitative rather than qualitative on medical workforce shortfalls, to allow a more strategic view on medical recruitment.

Recruitment campaign to be launched 1st

week in April (national and international) to focus on key shortages.

Through enhanced governance a number of risks have emerged resulting in the need for an internal clinical review of Obstetrics and Gynaecology, which was concluded and reported to the Trust Board in January 2014. A Quality Risk Summit was held to confirm mitigating actions were in place and the CEO has requested an independent clinical review which is supported by the CCG and LAT. Follow up risk summit booked in April 2014.

N/A Jeremy Rushmer

May 2014

7.8 the TDA Medical Director and Director of Nursing will

Care bundles approved by Clinical Policy group in May. Printed and available to wards, 2 bundles delayed until September (printing) Prof L Robb attending as part of OD plan to

1A

Jeremy Rushmer

July 2013 Revised to December

2013

H H √


provide advice for the faster implementation of care bundles (pneumonia, sepsis, kidney)

support the Trust produce a Trust-wide systematic framework. Bundle approach re-launched December 2013. D&V and sepsis bundles ‘go live’ 17 December 2013. Acute kidney injury piloted February 2014. Acute COPD and community acquired pneumonia are next pilots to be launched w/c 7/4/14. Quarterly audits on five bundles implemented will commence in Q1 14/15.

7.9 To support the small clinical specialist teams to deliver enhanced national standards, the CCG/LAT will continue to support the implementation of Care Closer to Home and strengthen the links with tertiary centres to ensure long term sustainability of small specialist services, e.g. radiotherapy, vascular.

Meeting held amongst Medical Directors. Letter received confirming programme, to review and report recommendations to the North East Network.

1A Mike Prentice, Medical

Director, Local Area Team

June 2013 H H √

Radiotherapy Initial recommendations from this process for cancer services were received but need more detailed consideration – expected by November. Direction of travel agreed in relation to transfer to a cancer centre and procurement process. However clarity on the timetable and project management arrangements required to ensure delivery and understanding with all stakeholders.

Mike Prentice, Medical


September 2013

Revised to March 2014

(from Jan 14)

H H


Vascular The Medical Director of the LAT confirmed that ongoing oversight by the network is in place and good outcomes continue to be delivered which is supported by National Clinical Audit. Urgent plan required around interventional radiology for vascular and other services. Maybe through Cumbria Learning and Improvement Collaborative (CLIC) about what Cumbria’s Network Vascular service looks like.

Mike Prentice, Medical


January 2014 Revised March

2014

H H

7.10 Safe models of care for 7 day, cross site working, e.g. critical care, anaesthetics, OOH, GI bleeding.

Model for a 7 day high risk surgical pathway presented to Clinical Policy Group, CCG and Trust Board in July. Implemented on temporary safety grounds in September (OOH) and from October for in-hours., with immediate steps and developmental steps up to 2016. High risk T/O has moved and Trust has recruited to a consolidated general surgical rota. Increasing numbers of transfers since 2011 to CIC correlates with a reduction in mortality. Further evidence is required.

1A Jeremy Rushmer

July 2013 H H √

Critical Care & Anaesthetics - 3 tier anaesthetic model for WCH approved by Trust Board October 2013 following a near event and to be implemented by November 2013. Weekend cover live from 28/12, full implementation by March 2014. Rota complete.

1A Jeremy Rushmer

November 2013 Revised March 2014

Out of hours GI Bleeding needs to transfer to CIC site once GI medical workforce is stable. Emergency plan for endoscopy and GI bleeding rota required, including a plan to address the short and medium term recruitment and retention risks. A report was

1A Jeremy Rushmer

March 2014


presented to Trust Board in February 2014 in relation to this risk and the proposed way forward.

Out of Hours – Investment to nurse practitioners in preparation for reduction in junior doctors in August 2014. As posts transfer to CIC to support Hospital at Night on CIC and reflect reduction in surgical training opportunities at WCH. Employed, trained at WCH. Using NHFT training.

1A Jeremy Rushmer &

Chris Platton

August 2014

8. Ensure mandatory training is supported.

8.1 Prioritise mandatory training to ensure staff have appropriate time within the rostering.

100 % of ward managers trained by June 2013.

3B(13)

Chris Platton March 2014 H M √

Revision of TNA completed to align with Northumbria.

December 2013

√

8.2 Mandatory training compliance is part of Board assurance, however, evaluation of training to be part of Board assurance model.

Training % to increase month by month to achieve 80%. February achievement is 76% at Trust level. Trust is confident of achievement in March.

3B(13)

Ann Stringer March 2014

H

8.3 Additional face to face training to be delivered by the appointment of a Fire Officer and Resuscitation Officer. (TDA to identify suitable additional training capacity.

Fire Officer commences 24 July. Three Resuscitation Officers in post and further part-time post to commence in September. Full training being delivered currently Fire training action plans have delivered full compliance ahead of target (83% vs. 80% target)

3B(13)

Steven Bannister/Ann

Stringer

July 2013 H

√


KEOGH THEME:

FAILURE IN GOVERNANCE TO ENSURE ADEQUATE MAINTENANCE OF THE ESTATE AND EQUIPMENT



INITIAL RISK

CURRENT RISK

Evid I.A

9. Review of Estates capability and capacity.

9.1 Interim Director and Deputy of Estates & Facilities appointed in the short term for the purpose of the Keogh review. This took effect on 21 May. Objectives agreed that fit this improvement plan and an appropriate range for the post of Director.

Secondment in place and objectives agreed. Interim Director appointed from NHFT.

N/A Ann Farrar May 2012 H L √

9.2 Independent external validation of governance was commissioned March 2013 for the 9 key HTMs. The reports were received in May. Independent

Reports on target to be delivered by end of September. Initial reports lodged with Governance Committee and EMT. Subsequent reports now lodged with both Safety & Quality Committee and Trust Board, with specific reports to IPCC.

1A & 1B

Steven Bannister

September 2013

H

√


external validation on procedural matters, e.g. operating theatre ventilation. Reports expected by the beginning of August, operating theatre report already received and being implemented now and expected to be complete by end of August. Systems are currently safe to use.

Highest risks addressed. A programme of known risks is included in the Estates and Facilities risk register and programme of works is prioritised. Risk levels have been reduced incrementally and continue to be so.

N/A

Steven Bannister

September 2013

√

Interim Director of E&F reported a new issue to the Trust Board regarding the CIC site. A report will be presented to the Board in November 2013 on the legal advice of the limitations of the PFI contract specifications and the requirement to meet the NHS Standards. Report on serious breaches delivered to full Trust Board. Response and action plans from PFI company to be lodged at December Trust Board.

November 2013

√

Independent review of contractor’s activity has now commenced. This will be reported to Trust Board when concluded. Contract report due April 2014.

April 2014

9.3 Trust in the process of commissioning an external company to assess the competence and capability of the estates and facilities

Commissioned report received and recommends a series of actions which are being taken forward by the Interim Director.

2A Steven Bannister

September 2013

M √


team. The report is expected to be complete by end of September.

Action plan to be presented to the Trust Board in November. This will determine the timescale to complete. Action plan discussed with CEO. Rollout of proposals currently being implemented in accordance with the Human Resource policies and procedures.

November 2013

√

9.4 The same company as above is being commissioned to assess full compliance of the appropriate CQC outcomes and their report is expected by the end of September.

EMT agreed to cease the commissioned work and focus on producing evidence by the internal workforce in order to demonstrate compliance Work sat down due to efficacy of evidence being dubious. Trust Board informed of decision.

1A Steven Bannister


H H

9.5 An independent investigation to provide assurance that safe systems for medical device equipment maintenance are in place started. This is expected to be complete within two weeks.

Started and report finalised. Safe systems in place. Report lodged with EMT. Report on the annual position on priority 1,2 and 3 pieces of equipment currently being validated, this will be reported to Safety and Quality Committee in February 2014. Reporting to S&Q committee completed. Independent investigation complete. Assurance provided.

1B Steven Bannister

July 2013 M √ √

February 2014

9.6 Trust approved an additional post in late 2012 and an

We have changed the way we report, and the first set of real data will go to board in December, the approach

N/A Steven Bannister


H


employee commenced March 2013 to undertake planned preventative maintenance for high risk equipment.

being consistent with Northumbria’s methodology. The reports will be quarterly in arrears. First reports lodged in full at Safety & Quality Committee December 2013. Additional posts approved in January – started in March.

9.7 Additional manpower is required to maintain the non-high risk equipment on a planned preventative basis. Currently the equipment is maintained ‘on request’; this does not compromise patient safety. Funding for these posts is planned to be made available once the Trust achieves a recurring balance.

We have changed the way we report, and the first set of real data will go to board in December, the approach being consistent with Northumbria’s methodology. Additional resource has been approved by the EMT. An additional 1 WTE to be appointed. Further resource being available (1 WTE) following cessation of CPFT contract w.e.f. 30/11/13. NHFT providing ‘flying squads’ to offer support. Planned Preventative Maintenance Trust Performance as at Q3: Priority 1 Equipment: 90% Priority 2 Equipment: 34% Priority 3 Equipment: 33%



H

9.8 A replacement equipment programme for North Cumbria is included in the long term financial model; new equipment for West

As the Trust is in Special Measures, the requirement now is to produce a business case for £10m for a reasonable medical equipment replacement programme. Application to be made to the Trust


March 2014

H H


Cumberland Hospital is part of the hospital redevelopment plan. The new hospital is scheduled to open 2014. The Trust Board will be assured by quarterly reports on key performance, e.g. % of equipment maintained.

Development Authority by January 2014. At the Trust Board in October, the DoF confirmed the submission date has been changed to December 2013. £5m finance secured. Risk assessment on impact of securing 50% of required funds to be undertaken with Capital Resource Group.

May 2014


KEOGH THEME: SIGNIFICANT WEAKNESSES IN INFECTION CONTROL PRACTICES



INITIAL RISK

CURRENT RISK

Evid I.A

10. Review infection and control policies and practices with full organisational ownership

10.1 TDA infection control team to continue to provide external support on best practice and assess progress.

Ongoing with visits 3-4 weekly intervals.

1A Clive Graham

April 2013 H √

10.2 A revised and comprehensive service development plan was approved by the Trust Board in April following a visit to a best practice site arranged by the TDA

Completed. Regular Public Trust Board item of business

1A Ann Farrar

April 2013 H √

10.3 Interim CEO started to Chair the new Infection Prevention Control Committee from May to emphasise the organisation’s commitment to this national minimum standard and confirm the delivery is everybody’s responsibility.

Completed. N/A Ann Farrar

April 2013 M √


10.4 DIPC leadership changed to the CBUD on 1 April 2013 and there is a plan for one DIPC on the date of acquisition.

This will be reviewed in light of Special Measures announcement in August. The DIPC role will continue as at 1 April 2013 and will change from 1 April 2014, as part of the proposed ‘buddy’ arrangements.

N/A Clive Graham

April 2014 M √

10.5 From June, Northumbria is supporting the delivery of robust real-time performance for the full range of compliance standards. First report expected July and will be reported to the Infection Prevention Control Committee and Trust Board from July.

First ward outcome report on prevention and outcome measures reported to wards and Trust Board in July.

1A Clive Graham

July 2013 H √

10.6 95% of staff to receive mandatory training on infection control by March 2014.

Infection Prevention as at end of February 2014 is 80%. Trajectory needed to identify risks towards delivery of 95% in each area and appropriate escalation.

3B(13)

Clive Graham March 2014

April 2014

H


10.7 From May, urgent implementation of best practice, that is, deep cleaning, HPV, cleaning products, antibiotic compliance and root cause analysis by the consultant and ward manager.

Antibiotic compliance standards commenced in March. Consultants and ward managers complete RCA and present to CEO from May. Standardised cleaning products commenced in April. Deep cleaning programme commenced 24 June 2013.

1B Clive Graham

July 2013

H

H

√

Best Practice Standards 25% of wards operate to best practice standards

September 2013

M

√

50% of wards December 2013

√

100% of wards

March 2014

NOTE: References to the KPMG quality governance actions have been added to this plan to show the connectivity and cross references between the key actions to improve quality which are being implemented.

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