Attachment 4. Report to. Board of Directors. Date 28 March Title. Care Quality Commission (CQC) Inspection Improvement Plan. Sponsoring Director

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1 Attachment 4 Report to Board of Directors Date 28 March 2014 Title Sponsoring Director Author Previously considered by Executive Summary Care Quality Commission (CQC) Inspection Improvement Plan Medical Director and Director of Nursing, Quality and Patient Experience Anna Hills, Associate Director of Governance, Safety and Compliance N/A This report provides the Board of Directors with an update on progress towards implementing the improvement plan following the recent CQC inspection. The Board of Directors is asked to approve this report and to confirm that: 1. Suitable controls to prevent the risks to achievement of strategic objectives 1 and 2 materialising are in place or there are gaps in controls; 2. There is assurance that these controls are operating effectively or there are gaps in assurance; 3. Actions to address the gaps in controls and assurance should be identified and monitored by the Safety and Quality Governance Committee; 4. The Board Assurance Framework should be updated from the discussions as above. Related Trust objective 2013/14 Legal implications/ regulatory requirement Report for: 1. CQC standards X 2. Patient experience X 3. Values and behaviours framework 4. Staff performance framework 5. Partnership/community working for joined up services 6. Improved management structure 7. Financial performance Monitor, Care Quality Commission, HSE. Approval CQC improvement plan Anna Hills, Associate Director of Governance, Safety and Compliance March 2014 REP/BOD/AH1803/V1 Page 1 of 2

2 Introduction The Care Quality Commission undertook a routine unannounced inspection of the James Paget Hospital on 27 th and 28 th November In February 2014 the Board received and approved the improvement action plan in response to this inspection. Detailed findings, plan and progress report Regulation 13 HSCA 2008 (Regulated Activities) Regulations (CQC Outcome 9)Management of Medicines Moderate Concern All actions are progressing. A new action has been added, which is to undertake an assessment of improvement on March 31 st using our external review processes. Regulation 20 HSCA 2008 (Regulated Activities) Regulations (CQC Outcome 21) Records- Minor Concern Three of the four actions have been completed. The outstanding action is the completion of the plan to improve the quality and completeness of medical records. This is owned by the Medical Director who has implemented further measures to improve engagement of Consultants with this requirement. The Director of Nursing, Quality and Patient Experience is the lead for the recovery plan and each action is owned by an Executive or Assistant Director. The actionees are staff with responsibility for undertaking each action. Progress is monitored weekly by the Executive Team, with the CQC Monitoring Group, meeting fortnightly, to manage progress. Recommendation The Board of Directors is asked to approve this report and to confirm that: 1. Suitable controls to prevent the risks to achievement of strategic objectives 1 and 2 materialising are in place or there are gaps in controls; 2. There is assurance that these controls are operating effectively or there are gaps in assurance; 3. Actions to address the gaps in controls and assurance should be identified and monitored by the new Safety and Quality Governance Committee; 4. The BAF should be updated from the discussions as above CQC improvement plan Anna Hills, Associate Director of Governance, Safety and Compliance March 2014 REP/BOD/AH1803/V1 2

3 ACTION PLAN FOLLOWING CQC Inspection Dec 2013 Dated: 18/03/2014 Version: 1.0 Aim: The aim of this action plan is to ensure delivery of the improvement actions identified as a result of a CQC Inspection in November Content: This action plan captures all of the actions agreed by management as detailed within the final report and includes responsibilities and timescales for delivery. Responsibility for delivery: The Executive Director and Non-Executive Director leads for Medicine and Nursing are responsible for the delivery of this action plan. Monitoring: Delivery of this action plan will be monitored by the Trust s CQC Monitoring Group. Key for RAGBW rating of Actions: (W)hite = Not yet started (G)reen = Completed (A)mber = In progress (R)ed = Due but not complete (B)lue = Ongoing monitoring to be assured of continued achievement ID Action Required Responsibility Timescale RAG Comments 1 Outcome 9 Medicines Management- Director of Nursing, Quality and Patient Experience 1a 1b 1c 1d Improve compliance to standards of medicines management by providing pharmacy support to wards. Develop and execute a risk based plan Improve the safety and quality of the patient experience by ensuring all clinical staff demonstrate concordance with policies and codes of practice. Staff to be made aware of the report and reminded of the requirement to adhere at all times by letter and meeting Take immediate action to ensure that prescribing and administration practice is in accordance with standards and SOPs by issuing written guidance regarding PRN prescriptions. Review the Board/Ward round processes to confirm that MDTs are proactively progressing discharge plans. Pharmacist Pharmacist/ Deputy Director of Nursing, Safety Director of Nursing/ Medical Director Safety/ Deputy Director of Nursing Action on track. Pharmacist has provided a risk based plan for developing the pharmacy service. Pharmacy work has been rebalanced and wards 1, 2, ACU, EADU, SSMU, ICU, 6, 12, 15 and 17 are receiving a daily service. The available resources are flexed whenever contingencies are required to cover shortfalls Action Completed. Directors of Medicine and Nursing each held clinical summit meetings with their senior staff and reminded them of their respective duties Action Completed. The Pharmacist has initiated regular newsletter called OWL (Organisation Wide Learning) which includes this guidance as the first item Action Completed. Spot check shows the Board Round/Ward Round process is inconsistent. This matter to be resolved by divisions. 18/03/2014 pg. 1

4 ID Action Required Responsibility Timescale RAG Comments 1e 1f 1g 1h 1i 1j Reduce discharge delays attributable to provision of TTO medicines. Audit the ward and pharmacy processes, act on findings. Improve the patient experience by providing timely information about medicines during admission and at discharge. Improve the patient experience by providing staff with information about the referral process. Improve medicines security by making sure all combination locks which protect medicines are changed on a six monthly basis Improve the safety of PRN prescriptions by issuing guidance to prescribers. Establish forward audit plan of Standards for Medicines Management. 1k New Action Divisions to communicate a clear message through Lead Nurses and Matrons/ Ward Managers that nurses and members of the MDT must ensure that the process of providing patients with TTO s must be prioritised within their daily work plan. Pharmacist/ Director of Quality and Safety Pharmacist/ Director of Quality and Safety Pharmacist/ Director of Quality and Safety Pharmacist Audit method agreed Audit to take place during March. Revised deadline April 11 th Decision made to introduce a credit card style information measure which will be given to every patient. New implementation date Action on track. Posters to advertise the service have been designed for staff and a poster for patients is to be produced for general display Action complete. Plan in place to change every six months. Medical Director Action complete Pharmacist has issued the guidance within a Medicines OWL. Pharmacist 2 Outcome 21 Records- Director of Nursing, Quality and Patient Experience 2a 2b 2c Improve the completeness and quality of medical record keeping by reinforcing the framework for Formative Ward Rounds. Improve the completeness of nursing and MDT records by reinforcing the share your care process. Improve the completeness of the healthcare record by ensuring that wound photographs are filed in the patient documentation so that they are accessible to all members of Divisional Managers Deputy Director of Nursing Deputy Director of Nursing Action on track Pharmacist has developed 3 audit tools and training for pharmacists has started Revised deadline agreed at meeting on for all Consultants except Obs and Gynae who will complete to a different timescale Action complete. Implementation of SYC has been reinforced at meetings and 1:1 s with Matrons and Ward Managers Action complete. 18/03/2014 pg. 2

5 ID Action Required Responsibility Timescale RAG Comments 2d the healthcare team. Review how we present audit results to make it more impactful and easier for staff to identify areas needing improvement. Compliance Manager Action complete. Reports are sent with a reminder to the recipient that the detail must be shared with the team. 3 Outcome 2 Consent- Director of Nursing, Quality and Patient Experience- the provider may wish to note 3a 3b Improve the completeness of the consent process by ensuring that patients are provided with information with which to give their informed consent. Letter has been sent to all Consultant Surgeons to remind them of the requirement to provide information as part of the consent process. Improve the adequacy of the consent process by ensuring that staff taking consent act in accordance with best practice guidance with regards to mental capacity. Review training and address any gaps The CQC Monitoring Group agreed further actions as follows: Re-audit to be conducted to test effectiveness of this action. i Review the Consent Policy DD Elective Compliance Manager has agreed to support the DD Elective by undertaking a stakeholder consultation and reviewing the underpinning legislation in case it has changed since the policy was last published. ii Urgently review and implement Form 4. DDN Copping DDM/Elective iii Send controlled stationary communication to surgeons re information leaflets MD The review of Form 4 is complete. Now need to move to implementation stage. iv v Review the Mandatory Training uptake for Consent for medical staff Plan and deliver a training session which will address gaps in iv To be identified once scale of task is confirmed. This action cannot be started until we know the scope of the issue at iv. 18/03/2014 pg. 3

6 ID Action Required Responsibility Timescale RAG Comments V1 3c Design and implement a Competency Questionnaire to demonstrate learning. Improve the completeness of DNAR forms so that there is clear evidence of patient/carer involvement as appropriate to the mental capacity of the patient. Will complement action iv This action cannot be started until we know the scope of the issue at iv A flow chart has been designed to guide staff in the decision making process. Nursing and medical staff have been made aware that their practice must improve and the impact of this needs some further discussion. DQS leading on this matter. 3d New action Update Resuscitation Policy to reflect changes in DNAR decision making policies and guidance. Senior Resuscitation Officer st version to be completed by 21/03/14 and final version to be presented to Resuscitation committee on Outcome 16 Assess and monitor the quality of services 4a Check that the actions in this plan have had the required impact and that our services are compliant to the required standards. Director of Nursing, Quality and Patient Experience The next external review/corporate audits will focus specifically on these outcomes and will provide us with an evidence base of impact. This is due to take place March 31 st /03/2014 pg. 4

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