Compliance and Improvement Actions following the CQC Inspection of University Hospital, Lewisham; Queen Elizabeth Hospital, Woolwich and Queen Mary Hospital, Sidcup - 26 28 February 2014 A comprehensive action and improvement plan is being developed which will address the changes taking place in the immediate term of 2014/2015, and will also indicate how the Trust intends to embed change and move forward over the next five years. The actions presented here have either already been taken, or are taking in the immediate term. They will all be developed and incorporated into the full Action and Improvement Plan, due to be published July 2014. This document sets out the actions we are taking to: 1. Improve the Accident and Emergency Department at the Queen Elizabeth Hospital 2. Improve our patient journey, from admission and ED, through to the transfer to another service, discharge or to the end of life 3. Improve the numbers and core skills of all of our staff 4. Improve our management of clinical waste 5. Improve our hand hygiene compliance 6. Improve the knowledge we share with our staff about our mistakes and how we handled them 7. Improve the availability of our medical equipment and clinical devices and how we maintain them and check their suitability The framework to monitor progress is owned by the knowledge, governance and communications division, director Joy Ellery. The action plan will be reviewed and any monitored by the CQC operational group and CQC steering group committee. Progress will be fed into the Clinical Effectiveness and the Integrated Governance committees. The whole will then be overseen internally by the Trust Board and externally by the Clinical Quality Review Group comprising CCGs, NHS England and the Trust Development Authority. Page - 1 - of 23
Regulation 9 Care and welfare of service users What the CQC said: 1. Our end of life policy is not consistent across the trust and staff who need to apply it do not always know what to do 2. Our care was not always planned and delivered to meet the needs of the service user 3. QEH waiting times for ambulance patients was too long 4. The planned care on our children s wards did not always reflect individual needs 5. We left infusion alarms and call bells ringing for too long 6. We did not make sure that we had assessed all the risks facing our patients 7. We did not make sure that dangerous chemicals and hazardous waste were always securely locked away 8. Some of our staff are not meeting our high standards and are letting their colleagues down What do we need to do? What we will do When this will be done Who is responsible How we will monitor this Care for patients at the end of their lives Principles of care for the dying With the assistance of the Workforce and Education division, training is in progress and will also feature as part of the Band 5 induction programme Care planning Launch of the Nursing and Midwifery strategy (N&MS) Approved by the trust board March 2014 and implemented across the trust 29 April 2014 Commenced and on-going Completed Jo Peck Head of Nursing Long Term Conditions and Cancer Janet Lynch Director of Workforce and Education End of Life Care steering group will monitor KPIs relating to EOLC, this is part of the Aspiring to Excellence Committee Additional monitoring by CQC Framework The monitoring of the progress of the Page - 2 - of 23
N&MS implementation plan Awaiting approval Review of all band 5 nursing competencies Completed May 2014 Review of all nursing documentation Completed May 2014 Practice Development Nurses will support all clinical areas with implementation of new documentation Risk assessment & documentation training included in new band 5 induction The Trust has introduced the Productive Ward methodology in selected wards, supported by the Nursing Development Teams with the aim of increasing the effectiveness and efficiency of wards processes and procedures, the evaluation of the pilot wards will be shared across the organisation ED waiting times On-going from Feb 2014 Training methodology complete and training on-going December 2014 Janet Lynch Director of Workforce and Education implementation for the Nursing & Midwifery Strategy will be reported to the Senior Nurses & Midwives meeting. The monitoring of the implementation of the new nursing documentation and completion will be measured by monthly auditing of documentation and presentation of reports at the monthly Senior Nurses Meeting This is part of the Trust s pathway redesign programme which is currently underway. The Trust is reviewing the Standard Operating procedures for the Emergency Department with a view to developing clear guidelines for response times for the specialty teams. On-going Professor Gabrielle Kingsley The redesign programme is monitored through the Trust internal committee structures and is reported via external committee structures, Urgent Care Page - 3 - of 23
A comprehensive scoping process is underway for the pathway for the ED, Acute medicine and elderly care patients. This pathway redesign is underway with workshops being held with all key stakeholders Formalisation of the Rapid Assessment and Triage process to ensure LAS arrivals seen and investigations commenced at the earliest opportunity. July 2014 Commenced and is on-going Medical Director All Divisional Directors Janet Lynch Director of Workforce and Education Network and Clinical Quality Review Meeting with CCGs. Introduction of Board Rounds in ED 3 times a day to support flow of patients. These rounds are multidisciplinary Commenced and are on-going 3 times per day Increase in the number of consultants in ED Vacancies to be advertised in October 2014 to coincide with consultant exams Formal review of nursing skill mix following the redesign scoping process By August 2014 Working with key partners and CCGs to increase the community capacity and plan for increased capacity over winter period July 2014 Children s planned care Children s services are reviewing their use of preprinted care plans and have already implemented engagement and sign off with patients and their families Engagement complete July 2014 Complete review by October 2014 Tony O Sullivan Divisional Director Children s and Young People s Services Page - 4 - of 23
Implementation of revised care plans will include communications and training for all C&YP staff, introduced with the aid of a revised admission and discharge booklet in the patient record Implementation complete by October 2014 Call bells initiative A training initiative has begun to train all bands of nursing staff in the importance of timely response to alarms and call bells A Trust review of the nursing numbers and skill mix has been performed and new nursing establishments have been set across the inpatient wards. Recruitment has been commenced to fill the vacancies for the increased establishments In Children s services, there has already been an increase in the number of nursing staff available on the inpatient wards, which will reduce the problem Completed Completion due July 2014 Completed April 2014 Tony O Sullivan Divisional Director Children s and Young People s Services The monitoring of the response to call bells will be measured by our internal Patient Experience Questionnaires and by the inspections of the Patient Welfare Forum on the UHL site and Patient User Group on the QEH site Admission risk assessment A new Nursing Assessment and Evaluation documentation pack has been developed to ensure nursing risk assessments are well documented The new nursing documentation has all associated risk assessments within the pack June 2014 September 2014 Janet Lynch Director of Workforce and Education The monitoring of the implementation for the new documentation will be managed by the Aspiring to Excellence group and will report each quarter. The New nursing documentation will be implemented across both sites by 1 st September 2014 September 2014 The completion of the documentation will be Page - 5 - of 23
The implementation of the new nursing documentation will be supported by the Nursing Development and Practice Development Facilitators with a full training programme A new monthly audit for the completion of the documentation will be developed and will commence on roll out of the new documentation. Practice Development Nurses within the clinical areas will assist/support with clinically based learning and mentorship. Band 5 competency documents reviewed and updated and care planning training included in new band 5 induction. The Band 6 Leadership Programme reviewed is complete and staff began their training in March 2014. The Band 7 Leadership programmes are currently under review. To support the on-going campaign of documentation completion, the Trust has a year s programme for Dementia Training and Raising Awareness initiatives Over the next year a Review of PDN support to ensure alignment with Trust and local clinical priorities Waste and chemical management September 2014 On-going October 2014 The Trust has established a new working group to address the issues of waste management. This group will also have an operational group for each site Completed May 2014 Janet Lynch Director of Workforce and Education Keith Howard Director of Estates and Facilities measured by a monthly audit which will be developed on the nursing & midwifery audit system and monitored through the Nursing Metrics meetings and the Trust s internal quality governance processes A full audit programme will be developed and will be monitored through the Trust Waste Management Group which will report into the Page - 6 - of 23
Review of the waste management policy New joint operational procedures for QEH & UHL Training for waste handlers Comms strategy to disseminate top tips trust wide Digilocks on storage areas Improved signage and communication Increased frequency of waste collection PPE for waste handlers and compliance monitoring Improved engagement with clinicians Staff to meet all of our high standards Staff appraisals, recruitment and workforce policies used to align the trust behaviours and values Development of a pilot system to deliver training across the clinical and non-clinical areas Trust staff recognition scheme Completed May 2014 On-going Workshops, bespoke events and communications on-going On-going Inaugural ceremony planned for November 2014 Professor Gabrielle Kingsley Medical Director All Divisional Directors Janet Lynch Director of Workforce and Education Trust internal Governance committee structure Behaviours and values are to be monitored through the Senior Nurses and Midwives meeting, the Workforce and Education committees and from there, the integrated governance framework Page - 7 - of 23
Regulation 10 Assessing and monitoring the quality of service provision What the CQC said: 1. Our capacity in ED, in the hospitals themselves and our ability to escalate these problems, is creating delays for our patients 2. Our medical pathways are not always effective and our pathway to treat patients with a gastrointestinal bleed could be better 3. Our response from radiology should be more timely 4. When we make mistakes, we investigate and learn from the mistake so that we avoid repeating the error, but we need to be better at sharing the learning with all of our staff 5. Our outpatient department is too busy and our patients wait too long 6. We need to make sure access to ED is secure to protect our most vulnerable patients 7. We need to make sure that there are appropriate clinical pathways for all of our patients What do we need to do? What we will do When this will be done Who is responsible How we will monitor this ED capacity Please refer to pathway re-design plan on page 3 and 4 Completion due July 2014 The Trust has developed a Silver Command process of escalation which ensures that mobilisation of a full escalation plan takes place when capacity is cause of delays The Trust is working with the Urgent Care Network and NHSE to ensure that a full plan is developed and implemented for winter period Medical pathways Completed On-going This will be monitored through the Trust s pathway redesign programme, Trust performance and Governance committees, the Urgent Care Network and the Clinical Quality Review meetings with CCGs. The Trust has commenced a programme of work to scope Review during July 2014 Professor Gabrielle Through the Page - 8 - of 23
and review the Acute Clinical Model on both sites. This review will scope all existing models and models used elsewhere with a view to developing a defined acute clinical model for each site for the management of acute patients. The management of patients with gastrointestinal bleeding will be incorporated into this review. Kingsley Medical Director Transformation Project Board and then the Trust s internal quality governance processes The Trust is also reviewing the pathways for frail older people (and scoping the feasibility of implementing the Leicester Comprehensive Geriatric Model CGA) Radiology response times As part of the Trust s Transformation programme a review of radiology services has been undertaken for the UHL site and is on-going on the QEH site. The Trust has developed a proposal to increase the radiology service to seven day working and a consultation proposal is being worked up. This will enable key diagnostics to be available seven days a week. September 2014 Dr Julia Jacomb-Hood Clinical Director, Imaging Katy Wells Head of Transformation The monitoring of the Transformation programme will be managed by the Transformation Team and will be reported through the Trust Management Executive The Trust has also recently obtained a new PACs supplier Learning from mistakes The Trust has developed a new model for the dissemination of learning across and throughout the organisation. All learning identified through the Trust Outcomes With Learning Group, Aspiring 2 Excellence, Divisional Governance and Action After Review committees will be summarised and will be written up into a monthly Trust-wide newsletter which will be circulated and printed for all staff The Trust will make better use of the intranet site by publishing learning from key incidents and patient stories Quarterly payslip messages will be introduced August 2014 Liz Aitken Deputy Medical Director, Quality & Safety Janet Lynch Director of Workforce This will be monitored and reported through the Patient Safety Committee, Divisional Governance Committees and Departmental meetings Page - 9 - of 23
Identification of patient stories as a key tool Divisions will be asked to develop Patient Safety Improvement Plans and will be asked to present and report on these through the Trust Patient Safety Committee Publication of themes arising Serious Incident and Complaints resolution training now included in band 5 preceptorship and Junior Doctors Induction and Training Outpatient delays The Trust has developed an Outpatient Improvement Plan which is currently being implemented Completed April 2014 Communication to patients to ensure that outpatient appointments are attended or rescheduled if required. All letters have been revised at QEH as part of i-care Completed February 2014 implementation plan. Process to be repeated at UHL for i- Care go live November/December 2014 As part of the Improvement Plan a review of staffing in outpatient areas has been commenced As part of the plan, a Trial for Kiosk booking will be commenced in June 2014, with the aim to speed up the process of booking in for appointments and will improve and assist the communication of waiting times Completion due September 2014 June 2014 and Education Joy Ellery Director of Knowledge, Governance and Communications Jo Peck Head of Nursing Long Term Conditions and Cancer All Divisional General Managers The monitoring of progress for these actions will be reported through the Divisional Management Performance Review and through the Trust Internal Governance committees A review of the start times for all clinics is underway to ensure all clinics commence on time August 2014 Security in the ED at QEH The Key pad access has been ordered for the Ambulance bay access to QEH Emergency Department June 2014 John Ferguson Service manager QEH ED Health and Safety Committee Page - 10 - of 23
The ED Service Manager, together with security have completed a review of security within the department and have identified vulnerable areas, specialist locks have been ordered and will be fitted immediately on arrival August 2014 All clinical pathways As part of the Trust s two year strategy, transformation programme, and plans for compliance with the London Quality Standards, the Clinical pathways for the following areas are already subject to key work streams which have commenced work reviewing the pathways: The Acute Clinical Model Elective Care Maternity Services Radiology Pathology April 2016 Professor Gabrielle Kingsley Medical Director All Divisional Directors The progress of the implementation of the Trust s Strategy and outputs from the Transformation Programme will be monitored through the Trust s internal performance and governance committees, together with CCG and TDA monitoring structures Page - 11 - of 23
Regulation 12 Cleanliness and control of infection What the CQC said: 1. Staff don t always wash their hands before and after patient contact 2. Some staff wear clothing and jewellery despite our bare below the elbows policy 3. We do not always make sure that dangerous chemicals and hazardous waste are securely locked away 4. Sometimes, we allow public access to our contaminated waste and used sharps 5. Some of our hand rub dispensers were empty or were not at the ward entrances 6. We did not always provide complete hand washing facilities for all of our staff 7. Our yellow bins were not collected often enough 8. We did not provide all of our staff with personal protective equipment 9. Staff did not always adhere to our cleanliness and medicines policies 10. Some of our areas might not have protected patients from the illnesses of other patients What do we need to do? What we will do When this will be done Who is responsible How we will monitor this Hand washing and Bare Below the Elbow and provision of hand rub Information campaign in all areas with visible posters and leaflets for patients. Training and updates included in mandatory training, including band 5 induction, junior doctor induction and nonclinical staff induction Policy review, to include clear escalation for non-compliant staff, monthly audit and publication of results for all areas to be included in Divisional Performance Review meetings with CEO July 2014 and then ongoing On-going Approval given at Infection Prevention and Control Committee Jul 2014, Director of Infection Prevention and Control All Divisional Directors All Clinical Directors Keith Howard Director of Estates and Facilities Monthly hand hygiene audits Monitoring through the Infection Control Committee, Trust Internal governance committees and Divisional Performance Review meetings Page - 12 - of 23
Divisional purchase of light boxes and training gel to audit effectiveness of hand hygiene Policy review and update to include clear escalation process for non-compliant staff Completed Hand rub to be provided at point of care and by staff use of toggles Ensuring chemicals and hazardous waste, including sharps are safe Policy review and formation of joint operational policy for QEH & UHL Training for waste handlers and domestic staff Storage site review and digilocks fitted to control access Swipecards for external holds Increased collections for waste Review complete and due for approval On-going Completed Completed Completed Heads of Nursing and Midwifery for all Clinical Divisions and DIPC Keith Howard - Director of Estates and Facilities Full audit programme will be developed and monitored through the newly established Waste Management Group and Internal Trust governance committees Provision of lockable trolleys for cleaning staff Completed Provision of PPE for staff handling waste Completed Grey Chairs Area in QEH Emergency Department The Trust is working through a capital plan to redesign the ED at QEH. A project manager has been appointed to assist the Trust in the design and development of a capital business case September 2014 The monitoring of the Transformation programme will be managed by the Divisional Management Team, Transformation Page - 13 - of 23
There is a scoping project to review ED capacity and escalation for the long term improvement of the department, which will be supported by a business case for capital development. The CCGs have agreed to support the plans Scoping project for A & E will also take in concerns for patients with potentially contagions being initially triaged to the grey chairs area August 2014 for scoping exercise All Divisional Directors Team and will be reported through the Trust Management Executive, Divisional Management Meetings and Urgent Care Network Page - 14 - of 23
Regulation 15 Safety and suitability of premises What the CQC said: 1. The ED grey chairs area compromised privacy and dignity 2. The layout in the children s ward in QEH made it difficult to see the children at all times What do we need to do? What we will do When this will be done Who is responsible How we will monitor this Grey Chairs area in QEH Emergency Department The Trust is working through a capital plan to redesign the ED at QEH. A project manager has been appointed to assist the Trust in the design and development of a capital business case. There is a scoping project to review ED capacity and escalation for the long term improvement of the department, which will be supported by a business case for capital development. The CCGs have agreed to support the plans Scoping project for A & E will also take in concerns for patients with potentially contagions being initially triaged to the grey chairs area Children s Ward QEH September 2014 August 2014 for scoping exercise Keith Howard, Director of Estates and Facilities All Divisional Directors The monitoring of the Transformation programme will be managed by the Divisional Management Team, Transformation Team and will be reported through the Trust Management Executive, Divisional Management Meetings and Urgent Care Network Immediate increase in the number of staff available on the children s inpatient wards at QEH Completed April 2014 The ratio is now 1:4. Tony O Sullivan Divisional Director Part of the C&YP 5 year clinical strategy, Page - 15 - of 23
Review the working practices of the nurse teams to maximise patient contact. Full review to be completed October 2014 Children and Young People s Services monitored via the Trust Management Executive and Trust Board Review of all C&YP areas with the Estates and Facilities department Full Review to be completed by October 2014 Department to ensure that plans to change the ward structure improve nurses ability to see patients. Explore communication technology to enhance nurse response to patient needs Review to be complete March 2015 March 2015 Safer Staffing review Completed March 2014 Elisa Steele, Director of IM & T, Through the Workforce and Education Committee and Trust Board Page - 16 - of 23
Regulation 16 Safety, availability and suitability of equipment What the CQC said: 1. We do not have suitable equipment in all the areas of the hospital 2. We must make sure that all of our equipment is checked and maintained regularly What do we need to do? What we will do When this will be done Who is responsible How we will monitor this Suitable equipment for all areas of the hospital Completed May 2014 The Trust has established a Trust Wide Medical Devices Group which has two site-based Medical Devices Operational Groups which will monitor the action plan for Medical Devices We have commissioned a review of all of the equipment being used in the hospital. We have integrated the policies being used across the Trust. We have provided adequate staffing to ensure implementation of the devices policy. Identification of gaps in service provision has been identified for C&YP - purchase orders have been made to fill gaps Preparation of capital equipment bids for C&YP equipment costing over 5000 to feed into the Trust capital bids process Completed May 2014 Analysis completed May 2014 Immediate purchases made by June 2015 All agreed purchases in place by March 2015 Keith Howard Director of Estates and Facilities General Manager as part of normal process General Managers as part of normal process Keith Howard Director of Estates and Facilities The monitoring of these actions will be the role of the Trust Medical Devices Group which will report into the Trust internal Governance Committees Finance and Investment Committee and Trust Board Page - 17 - of 23
Ensure that all our equipment is checked and maintained The Trust will develop a robust system of managing medical devices at ward/departmental level - Clinical Divisions take lead role in identifying designated Medical Device controllers with the Practice Development Nurses taking the lead in training and education Robust ledger of devices, planned maintenance and staff competencies - System E-Quip has been established as suitable. Purchase to be approved by Director of Estates and Facilities. Implementation plan being formulated September 2014 September 2014 Keith Howard Director of Estates and Facilities Divisional Directors of all clinical services The monitoring of these actions will be the role of the Trust wide Medical Devices Group which will report through to the Trust Internal Governance Committees Page - 18 - of 23
Regulation 20 Records What the CQC said: 1. Clinical staff did not always have up to date test results and full medical history about patients because the permanent paper records were difficult to track down 2. Too many of our patients had temporary records at QEH What do we need to do? What we will do When this will be done Who is responsible How we will monitor this Provision of permanent medical records The need for temporary notes has been exacerbated at QEH because of the historic processes at South London Healthcare NHS Trust making it more difficult to locate notes. The Trust has established a recent Change of practice - temporary notes now formed only as last resort when all other steps have been followed. If temporary notes are required, then additional information is included: contents of complete medical records; last inpatient episode; last tracked location of the permanent notes & if the last letter cannot be located, a record of why not Medium term improvement move to electronic patient records Action completed April 2014 Action completed April 2014 Go-Live date for EPR at QEH is 7 th July 2014 Barbara Tringham Head of Information, Clinical Coding and Medical Records Elisa Steele Director of Information Management and Technology Monitored by spot checks by the medical records management team and quarterly medical records audit, reported to Records Management group and through the CQC Framework Page - 19 - of 23
Regulation 22 Staffing What the CQC said: 1. We don t have enough people to provide care for all of our patients 2. We need to check the numbers and skills of our staff and make sure we have enough 3. We especially need to review the numbers and skill mix in ED 4. Our medical wards don t have sufficient staff numbers on them 5. Our surgical wards don t have sufficient staff numbers on them 6. We don t have enough children s nurses What do we need to do? What we will do When this will be done Who is responsible How we will monitor this Staffing Numbers As part of the Clinical Strategy for the next two years and as a result of actions taken from the Francis Report, a full Workforce Strategy and plan will be developed to support the Lewisham and Greenwich clinical strategy. This will include improved use of e-rostering to ensure the right nursing staff are in the right place, an increased emphasis of supervision, managing sickness, mandatory training and appraisals, including individual performance reviews and targets. Reward packages for health care assistants and their reasons for leaving to be monitored October 2014 On-going Janet Lynch Director of Workforce and Education Progress against these actions will be monitored by the Trust Board, Workforce and Education Committee, Trust Management Executive Meeting, Senior Nurses and Midwives Meeting A comprehensive review of nursing establishments and skill mix has been undertaken and the Trust has developed a staffing model which is currently being implemented. Completed April 2014 Page - 20 - of 23
A Trust wide recruitment initiative is underway and the Trust has already recruited up to 45 overseas new recruits T he Trust has also re-introduced a Return to Practice Programme to maximise the ability to recruit experienced nursing staff On-going - Safer Staffing review paper agreed at April Trust Board with support for investment in the ward based nursing workforce. Project completion expected March 2015 The Trust is also developing a programme for safer staffing reviews for all nursing and midwifery areas in line with NICE guidance and will provide the Trust Board with 6 monthly workforce reports aligned to the National Quality Board recommendations On-going - the Safer Nursing tool is being introduced in all inpatient general clinical areas supported by training Further reviews of clinical specialty skill mix and numbers will be incorporated as part of the pathway re-design and transformation programme for the specialties On-going Immediate increase in the number of staff available on the children s inpatient wards at QEH Completed - ratio is now 1:4 Nurse Staffing Escalation policy drafted subject to final agreement, ratification and implementation to ensure robust management of staffing levels across the organisation June 2014 Review of consultant cover for outpatients, creation of business case Skill Mix and Competencies Revised preceptorship programme now in place Review completed Business case presentation Aug 2014 Completed May 2014 Janet Lynch Director of Workforce and Education Through the Workforce Page - 21 - of 23
All Band 5 competencies have been reviewed Completed May 2014 All other competency documents band specific/task specific are under review To be completed by October 2014 and Education Committee and the Workforce and Education Directorate Leadership Development programme review underway as part of the Organisational Development strategy and will include group and individual development in clinical and non-clinical areas Training has been reviewed and is now available in all areas of high harm, either classroom setting or as e- learning includes: Pressure ulcers, Aseptic Non Touch Technique, Falls, Dementia Nursing documentation pack has been reviewed to ensure nursing risk assessments are well documented The Trust has appointed a Nursing Development Team led by two Nursing Development Managers who will facilitate and support the Nursing Teams implement the Nursing and Midwifery Strategy. The Practice Development Nurses and Facilitators will provide clinical support, learning and mentorship to nursing and midwifery staff Clinical staff have full access to a wide range of clinical development via the HESL funding, full commissioning for October 2014 Revised programme implemented in May 2014 All clinical divisions have completed their commissioning plans fully utilising HEI indirect funding, these are being refined and will be submitted end of May 2014 Support reviewed at quarterly contract key account meetings with HEIs and as part of annual placement area audit. Page - 22 - of 23
14/15 is underway due to be completed end of May 2014 Clinical link lecturer support to registered staff available in wards and department supporting pre-registration students The Trust Nursing and Midwifery strategy has been launched. This highlights all key areas within the 6Cs and the Trust Values. An implementation plan has been drafted which is awaiting approval and agreement Recruitment and Retention Through the Trust Recruitment and Retention committee, a recruitment and retention plan is being developed. Dedicated recruitment days for newly qualified nursing and midwifery staff On-going agenda item and discussion at R&R committee, full action plan to be developed Janet Lynch Director of Workforce and Education Through the Workforce and Education Committee Page - 23 - of 23