ENC No 6
Meeting
Quality Oversight Review
Date
13th December 2016
Title of Paper
Patient Care Improvement Plan – Progress and
Exception Report
Rachel Overfield, Director of Nursing
Amir Khan, Medical Director
Zena Young, Deputy Director of Nursing
Lead Directors
Author
PURPOSE OF THE PAPER
To provide an overview of the activity undertaken across the Patient Care
Improvement Plan (PCIP) and associated work streams.
Key issues discussed and addressed
1. Work continues to strengthen the information held within PM3; this in turn will
provide greater programme management discipline and detail supporting
assurance reporting. For example risks, issues and milestone delivery.
2. A deep dive into the majority of areas within the PCIP has now been
conducted.
3. The Executive Confirm & Challenge meetings with the Director of Nursing and
Medical Director in place and providing QA sign-off process.
4. Work is on-going to ensure sustainability in actions completed.
5. MLTC reported in detail to Trust Quality Executive this month and slides are
attached at appendix 1.
6. Both Maternity and Emergency Department taskforces have met in month and
report separately.
7. During October and November all of our inpatient wards, Emergency
Department, Maternity, Paediatrics and medicine safety were reviewed by
WMQRS (reported in Quality & Safety Committee highlight report).
8. Planning is complete with Health Watch regarding patient and public
engagement events
9. Most significant risks associated with the PCIP are:
 Parts of end of life care
 C-section rate reduction
 Gamma Camera installation
 Workforce gaps (please note this is not currently showing as red on
the attached PM3 report but will in the next report)
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Key Successes/Outcomes

Improved assurance on project status.
Wider learning points

The requirement to ensure and evidence all achievements are embedded in
practice.
Key Risks
In brief risks that may be considered at this time include, and are not limited to:






Failure to take timely, effective and efficient actions to address inadequate rating
placing patients and staff at continuing risk- as identified within the CQC report.
Absence/inconsistent/loss of proactive engagement, leadership and delivery of
must and should do actions by the responsible divisional and corporate teams.
Scale of improvement required whilst meeting existing contractual obligations,
operational and financial priorities.
Reputational damage, confidence of local residents and key external
stakeholders, i.e. CCG.
Increase in patient complaints and claims.
Damaged confidence and wellbeing of the Trust workforce; impact on ability to
recruit staff.
Links to CQC and other external reports/standards
CQC registration – all standards.
Strategic Objectives:
Provide safe, high quality services across all our services.
Issues for escalation and action to the Trust Quality Executive
1. NOTE the progress made and risks associated with delivering the Patient Care
Improvement Plan
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1. Background
This report serves to update the Board on progress against the Patient Care
Improvement Plan (PCIP), devised to address the issues and concerns raised as a
result of the CQC planned inspection of our services, September 2015. As a result of
this visit, a Section 29a Warning notice was issued and subsequently the full report
required a significant number of must do and should do actions to be addressed.
Initial transition to PM3 commenced in August, the content of PM3 continues to be
refined. Executive ‘Confirm and Challenge’ meetings with divisions provides
additional quality assurance.
2. Summary Progress
Total
number of
actions
MLTC
Surgery
WCCSS
Estates & Facilities
Corporate
Section 29a
TOTAL
17
8
40
3
29
97
12
109
Number of RED
actions
[significant delay
against project plan]
2 (↑)
1 (↑)
4 (↓)
0 (=)
2 (↓)
9 (=)
0 (=)
Key: ↑ / ↓- increase/decrease in number
Number of BLACK
actions
[confirmed
completed in month]
6 (=)
3 (=)
11 (↓)
0 (=)
0 (=)
20 (↓)
1 (=)
red text = deterioration
An exception report against red actions is provided at appendix 2 and a RAG report
against all must do (highlighted) and should do actions at appendix 3.
3. Deep Dive Reviews
3.1
Estates & Facilities: The CQC report identified three actions, including 2
must do actions.
The division’s actions relate to medical device availability and storage and the
requirement to keep fire exits clear; the majority of actions are complete for these
items and there are no red actions for this division. A medical device committee is to
be re-established in December which will ensure on-going governance and
assurance of equipment-related matters. There is a high degree of confidence in the
ability to demonstrate compliance and a forward plan of audits by H&S
representatives have commenced to ensure sustainability of achievements.
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3.2
Surgery: The CQC report identified 8 ‘should do’ actions and one S29a action
across a variety of areas.
•
Critical Care The actions relating to this area are medication recording (S29a)
and MDTeam working, both have been completed.
•
Theatres The actions relating to this area relate to environment/facilities/hygiene
and have all either been completed or are awaiting final evidence to be uploaded
for completion.
•
Ward areas The action relating to medical device training for ward staff requires
additional consideration of actions for medical staff and temporary workers to
ensure full compliance.
There is one red action for this division relating to food hygiene training for ward
staff which has since been progressed and closure is expected in Q4.
3.3
MLTC: The CQC report identified 17 ‘should do’ actions. (see attached slides
for detail)
•
Emergency Department - There was significant commentary regarding ED,
including environment, triage, pain assessment and care of children and
significant progress has been made: A Paediatric Working Group has been
established; the department now has sufficient nurses to ensure 24/7 cover and is
employing more; a separate child friendly triage room has been created; a
Paediatric Early Warning Score (PEWS) system is in place; and a specific transfer
sheet has been developed to ensure safe transfer of children. There is robust
evidence that the concerns relating to triage and streaming in priority order and
pain assessments / treatment have been fully addressed; staff local induction and
engagement have all been addressed. Progress with these actions is monitored
at the ED Taskforce meetings.
•
For Ward areas, acute illness training; ensuring an appropriate physio
environment; sufficiency of equipment availability and fluid balance monitoring all
required improving and work is underway on all of these areas but is yet to
complete and/or provide evidence for closure. We expect this to happen in
quarter 4.
Two red actions for this division are reported this month, both have since reduced in
risk; the above food handling action as described for Surgery which should close in
Q4; and secondly the ordering of physio equipment to ensure compliance with
Infection Control regulations – the equipment is pending delivery.
3.4
WCCSS: Overall, the CQC report identified 39 ‘should do’ actions for the
division, one ‘must do’ action and three main S29a actions, along with significant
narrative relating to culture within maternity services which is addressed separately
under OD reports.
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•
Maternity A S29a action pertains to low midwifery staffing levels and the quality
and patient experience effects of this. A significant action has been to cap births
and this is working well for both WHC and partner organisations. Midwifery
staffing ratios have improved with additional midwives appointed since the CQC
inspection. The current midwife/birth ratio is 1:31.6 and active recruitment
continues. The ratio will be further improved with the 17 WTE midwives on
maternity leave returning to work on the New Year. A second S29a action relates
to patient confidentiality with personal information publically on display – this has
been resolved.
There is substantial work underway and completed against a number of should do
actions and progress is steady with evidence in place to support this. However
due to the volume of improvements required and management changes this has
not progressed at the expected pace for all actions. We expect all but the
reduction of C-section rates to be substantially delivered in quarter 4.
A significant amount of audit needs to occur in order to provide on-going
assurance of actions embedded and plans for this are underway. An outstanding
action remains around the funding of wireless CTG equipment at a cost in excess
£85k – this is subject to a charitable funds request.
There are four red actions reported this month; these are:
•
•
•
•
Baby resuscitaire checking, there has been significant improvement but we need
to see this sustained before agreeing compliance.
Induction of Labour & C-section rates, which remain higher than expected.
Policies/guidelines reflect NICE best practice, a scoping exercise has identified 60
documents that require updating; work has commenced to resolve this over the
next few months.
Action plans to respond to national quality audits, since reduced in risk as a
process for addressing these has now been agreed and will report into the newly
formed Clinical Effectiveness Committee as it needs addressing for the whole
Trust.
For the latter two actions, the forthcoming appointment of an audit team member and
a band 7 Governance Midwife will greatly assist progress.
There is risk that 2 amber actions (normality agenda and involve women in labour
care decisions) will turn red if there continues to be insufficient progress over the next
reporting period. Attempts to achieve improved clinical engagement are underway.
•
Paediatrics Of the above number of actions for WCCSS, there are six ‘should do’
actions and the one ‘must do’ action for the division of ensuring the security of the
treatment room – this has been addressed. Capacity issues relating to NNU are
being progressed by way of a business case for capital development, with
processes in place to manage capacity surges across NNU and paediatrics as a
whole. This requires close monitoring. Review of staffing arrangements shows
that staffing (medical and nursing) is sufficient for 15 cots and once recruitment
complete for 18 cots.
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A should do action relates to a Transitional Care service for newborns and this is
at an advanced stage of planning, ready to implement in Q4. The remaining
‘should do actions’ are progressing to closure.
•
Support services There is one S29a ‘must do’ action relating to the gamma
camera; ‘The trust is failing to take decisive action to either replace the camera or
explore options sooner and there is an increased risk that patient’s diagnosis will
be delayed.’
There are mitigating actions in place to ensure patient safety using the existing
camera for limited procedures and an order for the new camera has been placed,
with delivery expected at the beginning of April 2017. In advance of this, certain
enabling works are required to house the new machine. Negotiations are
underway to address the cost and timeline of this, and it is expected that a
completion date of February for these works will be agreed.
3.5
Corporate
Overall there are 31 actions listed within Corporate areas of management, including
two S29a corporate actions. A process of quality assurance of confirmation of
actions against the CQC report, as well as progress and achievements against each
action is underway. Therefore the number of actions may change as a result of this
work. From work to date, it is expected that a small number of actions will progress
to confirmed complete status during the next reporting period, including: 18 week
RTT reporting; access to translation services; health records; and infection control.
•
Governance: 9 actions, includes one S29a (review of risk registers and risk
management – green) and 5 must do’s relating to ensuring confidentiality,
incident reporting, duty of candour and training for RCA’s etc. Work against these
actions is progressing well and on-going auditing to ensure embedded behaviours
has been agreed.
•
Nursing: 3 actions, 2 of these are ‘must do’ actions. Consistent achievement at
around 90% of MCA/DoLS assessments and recording in association with Do Not
Resuscitate Orders has been sustained. The remaining gap relates to patients
transferred from the community or in GP led beds. We are working to resolve this.
Achievement of safe staffing levels across the trust remains the main action of
concern (amber). There has been a significant amount of work undertaken to
firstly ensure staffing management controls are fully utilised and secondly to
recruit to RN’s. This has had mixed results, reflecting the shortage of RN’s
nationally, hence the proposal for international nursing campaign. Safe levels are
maintained but at premium cost. This will be turned ‘red’ for the next report as the
gap, despite efforts, remains a concern.
•
End of Life Care: 8 actions, includes one S29a (policy - green). The majority of
actions are amber and detailed QA will take place during next reporting period.
Achieving full compliance is dependent upon clinical areas adopting the new care
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pathways (Amber bundle). We feel that this remains a risk for full compliance.
There is one red action relating to identifying and achieving preferred place of
care at end of life and this risk has since reduced.
•
Pharmacy: 5 actions, one of these is a ‘must do’ relating to medicines storage
(amber). The Director of Pharmacy has undertaken a detailed QA of all
pharmacy actions. Achieving full compliance is dependent upon clinical areas
adhering to policies for prescribing and storage of pharmacy items. Monthly audits
are in place and feedback is provided to individual wards/departments and the
importance continues to be stressed with teams. There has been significant
improvement around some aspects e.g. fridge temperatures, but there needs to
be more focus around other areas e.g. storage. There is one red action relating to
the administration of IV saline flush and this is being addressed by way of a
prescribing change in practice.
•
Medicine: One ‘should do’ action relating to mortality reviews. This is subject to a
relaunch in association with RCP guidance to achieve 100% mortality review. It is
not expected to fully achieve before end Q4, however substantial progress has
been made (20% to 75% in September).
•
Infection Control: 1 ‘should do’ action awaiting QA to close in terms of audit
results against the action, but we are mindful of Infection Control performance, so
will continue to closely monitor.
•
Operations: 4 actions, one of these is a ‘must do’ (PAS data accuracy – amber).
The remaining actions of patient flow in critical care and Major Incident training
are progressing. (These are all subject to separate reports seen regularly by Trust
committees).
4 Summary & Conclusions
Of the 9 ‘red’ actions at the time of report extraction, 5 have moved to improved
assurance and reduced risk.
Substantial work is underway and progressing to address all of the required actions
as identified in the CQC report and it is expected that the large majority will be fully or
substantially completed by end Q4.
A recurrent theme is the need to ensure changes are consistently reinforced and
embedded as usual practice. Coupled with the existing divisional and care group
management responsibilities, the forward audit plans within each division as well as
the corporate assurance visits will provide a mechanism of checking.
Work has now commenced on preparing for CQC re-visit expected in Q4. A weekly
CQC preparation group has been established, chaired by the Director of Nursing. A
forward plan of staff briefings, Q & A sessions, visits and board walks is under
development. Resources are being identified for evidence collection and logistics for
the visits will form part of this group’s remit. Work continues to ensure our ‘good’
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services have continued to progress using similar confirm and challenge sessions
and visits to clinical areas.
5 Actions
A summary of actions for the next reporting period:
 Quality Assurance process continues.
 Corporate CQC assurance visits and new Board walk process commenced in
October.
 Completed WMQRS reviews and action plans in response to recommendations
progressing.
 Agreed process with Health Watch for public engagement/feedback events
starting in December.
 Commenced preparation for ‘re-inspection’ – developing a communication plan;
series of roadshows; specific staff group meetings.
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