king’s lynn nhs foundation · king’s lynn trust - our improvement plan 5 summary of main...

FT Integrated Action Plan

The Queen Elizabeth Hospital, King’s Lynn NHS Foundation

Trust 14th February 2014

KEY

Implemented, clearly evidenced and externally approved

On Track to deliver

Some issues – narrative disclosure

Not on track to deliver

1

King’s Lynn Trust - Our improvement plan & our progress

What are we doing?

• The Trust was put in Special Measures in October 2013 by Monitor following the publication of two CQC reports in August 2013 and November 2013. The Trust was non-

compliant with twelve of the sixteen CQC outcomes. In addition, the Trust was the subject of a Rapid Responsive Review (RRR) led by NHS Midlands and East with a site

visit in August 2013, making a further 27 recommendations to improve patient care. The Trust was also served with 4 formal warning notice from the CQC.

• The Trust accepted all of the recommendations in the CQC reviews, the RRR and those resulting in the 4 formal warning notices and developed an Integrated

improvement plan to address all these concerns.

• To address all these concerns we needed to ensure that we provide a safe service by listening to our patients, supporting our staff and by providing the right leadership.

We developed the 4 themes listed below to help us communicate our vision for the Trust.

• The improvement plan prioritises our work using a RAG rating system to ensure we prioritise our actions. This programme focuses on staff engagement, empowerment

and responsibility to ensure our actions lead to measurable improvements in the quality and safety of care for patients. These will be assessed by a series of KPIs.

• The Trust has recruited a Quality Improvement Director Ms Wendy Cookson to lead this programmes using a PMO approach and reporting directly to the CEO

• The 4 key themes underpinning our improvement plan, recognising that some of them overlap, are summarised below:

• Listening to patients

• Respecting and involving people who use services

• Operational Delivery

• Meeting nutritional needs

• Safe Care

• Management of medicines

• Records

• Consent to care and treatment

• Safeguarding people who use services from abuse

• Supporting our staff

• Supporting staff

• Nurse staffing levels

• Well led Trust

• Corporate governance

• Compliance management

• Assessing and monitoring quality of services provided

• This document outlines our plans to make the necessary improvements and demonstrates progress against this plan. While we continue to address the 43

recommendations, the Trust will remain in ‘special measures’. 2

King’s Lynn Trust- Our improvement plan & our progress

Who is responsible?

• The Trust Board has approved the actions to address the CQC and Rapid Responsive Review recommendations outlined in this document.

• Our Chief Executive, Mr Manjit Obhrai, is responsible for implementing these actions and is supported by key members of staff including the Deputy Medical Director Dr

Beverley Watson and Catherine Morgan our Director of Nursing. They will provide the executive leadership for quality, patient safety and patient experience.

• David Hill is the Improvement Director appointed by Monitor and is assigned to King’s Lynn Hospitals NHS Foundation Trust. He will work with the Monitor Regional Team to

monitor our delivery plan and oversee the implementation of the action plan. If you should you require any further information on this role please contact

[email protected]

• The Chief Inspector of Hospitals will assess the success of the implementing of the recommendations within the Integrated Quality Improvement Plan. He will arrange to will

re-inspect our Trust within 12 months of QEH entering the Special Measures programme.

• If you have any questions about this integrated action plan please contact; Wendy Cookson, Director of Quality Improvement via email [email protected]. or by

telephone on 01553 613963

How we will communicate our progress to you

• We will update this progress report every month while we are in special measures.

• This report will be available on a regular on NHS Choices.

• The Trust has agreed to communicate this report right across the hospital and with all stakeholders using the 4 themes:

• Listening to patients

• Safe Care

• Supporting our staff

• Well led Trust

• We have developed a communication and engagement strategy and some of the elements of this are:

• Chief Executive Officers blog

• External stakeholder segmentation and engagement programme

• Listening events (staff/patients/public)

• Media including press conferences

• Public meetings including patient experience forum

• Staff and team briefings with targeted quality improvement and awareness campaign to all including: dementia, diabetes, pharmacy, safeguarding and pressure

ulcers

• QEH newsletter

• Assimilation of ‘values and behaviours’ workshops and collating feedback into a follow up action plan

David Dean, Chairman Signature: Date:13/2/14

Manjit Obhrai, Chief Executive Signature:

Date:13/2/14 3

mailto:[email protected]

mailto:[email protected]

King’s Lynn Trust - Our improvement plan

4

Summary of Main Concerns External

Support/

Assurance

Progress

Status

Rag Rating

Revised deadline (if

required)

CQC Outcome 7

Safeguarding people who use

the services from abuse (end of

November 2013)

Ensure that systems are in place

to provide assurance that people

who use the Trust’s services are

protected from abuse, or the risk

of abuse, and their human rights

are respected and upheld

Identify key gaps in compliance

with safeguarding standards and

policy

Specific work to be undertaken

in relation to the use of

restraints

Address key areas of non-

compliance

Guy’s St

Thomas’ NHS

FT

Eileen Sills

Chief Nurse

Guy’s St

Thomas

13th December 2014

Training undertaken - remains amber until embedded into the organisation key areas of non-

compliance addressed

Specialist external dementia awareness training held and further scheduled early 2014 Completed 4th Nov

2013

Next session

24th Feb 14

Full gap analysis undertaken regarding safeguarding Completed monthly

Interdependent policies being reviewed

All staff trained in use of Mental Capacity Act (MCA) on Necton ward and key staff from

relevant areas

58.5%

Outcomes measured of effectiveness of training through observation and mock CQC

inspection

2 independent mock

CQC -17th Dec 2013

13th January 2014

Targeted dementia training started on Gayton ward Commenced 2nd Jan

2014

57 %

A&E dementia training roll out programme Commenced 15th Jan

2014

44%

Percentage all staff trained in dementia awareness. (January figures available mid Feb) As of 31st Dec 2013 56.6%

Medical and nursing staff mandatory training increased by 1 day Commenced 2nd Jan

2014

Production of guidelines on the application of the Mental Capacity Act and crib sheet in

development

Completed 10th Jan

2014

Review and update of guidelines on the application of the Mental Capacity Act Completed 15th Jan

2014

Procedure for application of deprivation of liberties guidelines created Complete

13th February 2014

Outcomes measured through ward audits, executive ward rounds, and ‘Conversations Board’

for Executive walkabout findings

Trust wide,

independent, mock

CQC visits commenced

31st January

‘Barbara’s’ story, to focus initially on non-clinical staff until April 2013, the staff there after

supported by the continuation of the formal training package.

Commenced 10th Jan

2014

Mandatory training trajectory will be monitored by the newly formed workforce committee,

chaired by a NED

First meeting planned

11th February 2014

Necton ward staff Dementia awareness training 98%

% staff trained in dementia forecasted to achieve 59% by end Jan 2014 56.5%

% staff trained in Mental Capacity Act forecasted to achieve 34% by end Jan 2014 29.6%

% staff trained in Consent forecasted to achieve 35% by end Jan 2014 30.5% 4


5

Summary of Main Concerns External

Support/

Assurance

Progress

Status

Rag Rating

Revised

deadline (if

required)

CQC Outcome 13.

Nursing Levels –Staffing (end

Dec 2013)

Ensure that systems are in

place to guarantee there are

sufficient numbers of staff to

meet patients’ health and

welfare needs in line with

Outcome 13. Actions

undertaken to maintain

prescribed nursing ratios of

1:8 (day) & 1:11 (night)

to agree acuity tool to

support staffing levels

Director of

Nursing

NHS

England

Guy’s St

Thomas’

NHS FT

13th January 2014

‘Supervisory‘ band 7 nurses on each ward. Plan for 60% compliance by 31st March 2014 50%

compliant

13th February 2014

Minimum 1:8 (day) and 1:11 (night) nurse staffing ratio measurement 100%

% Vacancy rate to current establishment : Registered nurse 4.47%

% Vacancy rate to current establishment : Health Care Assistants -9.59%

Turnover rate in month: Registered nurse 0.63%

Turnover rate in month: Health Care Assistants

0.53%

CQC Outcome 14

Supporting Workers (end

Dec 2013)

Ensure that systems are in

place to provide assurance

to the Board of Directors

that staff are properly

supported to provide care

and treatment and are

properly trained, supervised

and appraised.

Actions to include:

Review overseas

recruitment process.

Commission additional

mandatory training

Training delivered to ensure

compliance

Induction training

programme revised and

extended to include

dementia

KPMG

NSFT

WNCCG

UHB

13th December 2013

Roll out of the Trust 7 ‘Values and Behaviours’ workshops. Sessions extended till the end of March 2014

to ensure more staff have the opportunity to attend

Commenced 4th Oct

2013 Planned

completion 31st Jan

2014

On-going

until March

2014

Next round of recruitment plans to be in place Jan 2014 End January 2014

To be

discussed at

Workforce

Committee

Reports to Board on mandatory training from November 2013 with additional granular detail Induction

session extended to include consent and dementia training from Jan 2014

Commenced 26th Nov

2013

Ongoing

13th January 2013

‘Value a Month’ commencing with: Value 1- Open and Honest Communication

Value 2 - To be decided mid-January 2014

To commence 1st Feb

2014

To commence 3rd Mar

2014

Externally validated and delivered English lessons to newly appointed Portuguese nurses Revised to include

relevant local idioms


6

Summary of Main Concerns

External Support/ Assurance

Progress

Status

Rag Rating Revised

deadline (if required)

Outcome 14 continued English competency document completed for each member of staff before and after training by Preceptor

3rd programme commenced 11th January

13th February 2014

Current substantive staff appraisal rates to end of December 2013 (January 2014 figures available mid February 2014)

Target = 90% 82%

Mandatory training increased compliance -Trust-wide compliance 84.03% (80.48 clinical, 93.27% non-clinical) N.B. excludes newly added subjects (January 2014 figures available mid February 2014)

Target = 70% 84.03%

Accommodation has been secured June-October 2014 with Freebridge housing association to enable further oversees recruitment to be undertaken

Complete

Practice Development nurses and ward sisters are prioritising assessment in practice for medicines management to support staff to achieve the required competencies

Complete and on-going

Patient story videos presented to senior nursing staff at clinical leadership Fridays Complete and on-going

Recruitment drive held with local press to promote return to practice and nursing as a future career

29th January 2014

Improve retention and recruitment (April 2014)

13th January 2014

In view of the difficulties in recruitment and retention in certain specialities in the locality we are

revising our recruitment and retention strategy

Mark Vaughan Director of HR. Commenced in post 6th Jan 2014

13th February 2014

New workforce committee meeting to formulate Trust strategy on recruitment and retention 11th February 2014

CQC Outcome 16 Assessing and Monitoring the Quality of Service Provision (end Dec 2013) Outcome 17 Complaints Implement the recommendations from the review of clinical governance undertaken by KPMG on behalf of the Board of Directors and Monitor

KPMG NSFT WNCCG UHB

13th December 2013

Weekly review panel including Trust Governor. Commenced 13th Sept 2013 and on-going

Training package being developed for staff that are required to have meetings with patients Included in Portuguese nurse training programme

13th January 2013

Draft Quality Strategy presented to Quality Committee, for wider consultation with nurses and CD’s

For Quality Committee Chair’s action and Executive Board sign-off March 2014

13th February 2014

The Trust commissioned external review of complaints being verified for accuracy, to go to Executives 11th February 2014

Serious Incidents reported to Board of Directors 28th Jan 2014 report to include more granular detail in March Board

March 2014

Changes in staffing of acute medicine with extended consultant and middle grade cover to gain earlier senior review approved by the Executives but currently struggling to recruit

Daily updates on all incidents reviewed by Deputy Director of Patient Safety and are forwarded to Medical Director, Director of Nursing and CEO

On-going

Responding to complaints training Commenced July 2014, on-going


7

Summary of Main Concerns External Support/ Assurance

Progress

Status

Rag Rating Revised


Outcome 16 & 17 continued To include: Revision of monitoring of SIs at the Trust Revised process of monitoring mortality Revised complaints handling

KPMG NSFT WNCCG UHB

NCEPOD grading to be reported 1/4rly to clinical outcomes group April 2014

CEO’s blog updated weekly concentrating on key priorities and updating staff on progress Commenced 13th January 2014

Staff and public updated on Trusts financial position 28th January 2014

Focus on dementia- staff and public updated on achievements 28th January 2014

Outcome 4 Care and welfare of people who use our service The treatment and care was not always planned and delivered on a way that ensured patients’ safety and welfare and did not always follow relevant research and guidance

13th January 2014

Board round improvement on-going Commenced 18th November 2013

‘Principles of Handover’ document launched W/c 30th December 2013

Visual alert system consistency audit incorporated into ward audit programme EWS audit of scores 3 and above December 2013

31st January 2014 100% compliance of 10 notes

13th February 2014

10 Mock CQC visits undertaken on the 31st January 2014 highlighted large areas of improvement have been made. Further work still required in relation to the management of medicines, records keeping & nutrition. Immediate actions taken, full report to QIDG 12th February with actions into outcomes 5,9 and 21

Outcome 5 Meeting Nutritional Needs People who use the services at QEH are supported to receive adequate nutrition and hydration

13th December 2013

April 2014

Systems, processes and policies are in place

Existing policies and procedures reviewed

Improvement goals identified, reporting of improvements at Board level

13th January 2014

Audit of ‘MUST’ score and fluid balance chart completion Completed 6th December

13th February 2014

December 2013 audit highlighted some areas for improvement in relation to the completion of fluid balance charts and ‘MUST’ assessments

On-going monthly audits with action plans formulated

Trial of new fluid balance chart completed 4th February 2014 due to be presented at patient safety committee.

28th February 2014

Ward managers have been mandated to check the completion of relevant documentation prior to leaving the ward after each shift

15th January 2014

Mock CQC audit 31st January 2014 identified areas of further improvement

Outcome 2 Consent to Care and Treatment

13th December 2013

Reviewed existing systems, processes and policies

Gap analysis undertaken and actions implemented

Mandatory training enhanced to include • dementia awareness,


8

Summary of Main Concerns External Support/ Assurance

Progress

Status

Rag Rating Revised


Outcome 2 (continued) Ensure the Trust has systems in place to gain and review consent from people who use services and act on them. For the purposes of this review the initial focus should be in relation to people who have or may have a diagnosis of dementia or a lack of mental capacity Review existing systems, processes and policies against recommended guidance Measure current position to determine gaps in system, process and/or knowledge

13th January 2014

Darren Handley (Internal Auditor) to undertake independent audit of compliance end January 2014 Delayed till Feb TBC

13th February 2014

Mock CQC visits and ward observations to be fed into scope of internal audit

CQC Outcome 1 Respecting and involving people who use services: Ensure that systems are in place to provide assurance that the Trust respects and involves people who use its services: Appoint a Director of Nursing Ensure the dignity, privacy and independence of service users in A&E

NHSE Regional Director of Nursing

13th December 2013

March 2014

Catherine Morgan appointed as Interim Director of Nursing. Substantive appointment to follow

Completed and started in post 25th Nov 2013

13th December 2013

Ground works have commenced to expand number of spaces in A&E by 9 Commenced 4th Dec 2013

Physical build will be complete by 9th March 2014. On plan

13th January 2014

Ground works to be completed 10th Jan 2014

Link corridor works commenced 6th Jan 2014

Modular build to be delivered 18th Jan 2014

13th February 2014

Ground works/ link corridor complete. Modular build delivered and in place 18th Jan 2014

Handover of refurbished treatment rooms to start next stage of building works 31st Jan 2014

Builders handover to the department Planned 10th Mar 2014

Departmental handover Planned 17th Mar 2014


9



Progress

Status

Rag Rating

Revised deadline (if required)

Outcome 1 (continued) Provide service users with appropriate information and support in relation to their care of treatment. Encourage service users to understand the care of treatment choices available to them In relation to treatment or care

13th January 2014

Speciality co-designed procedure specific consent documents currently available on the Trust intranet A total of 21 complete

Redesign of consent process to ensure all options are discussed before patient and family take decision

13th February 2014

Enhanced consent training now on both mandatory and induction training January 2014

Internal Audit to undertake compliance audit for the 21 procedure specific consent documentation, before more specific consents are devised

Planned February 2014

The Trust has a number of condition and speciality specific guides, with areas of for example; exemplar literature for cancer patients through Macmillan. A full review has still to be undertaken of the standard and source of patient information as part of the Trust wide documentation control

31st May 2014

Patient stories to Board

13th December 2013

Patient experience story has been taken to Board of Directors November 2013 Commenced 26th Nov 2013

13th January 2014

Discussing with other Trusts further possible mediums to present patient experiences to Board of Directors

13th February 2014

Patient stories are presented to the Board of Directors.

CQC Outcome 9 Management of medicines (end Oct 2013)

The Chief Operating Officer in partnership with the Trust’s Chief Pharmacist will complete a review of compliance Determine actions to address compliance and recommend implementation plan (by Nov 2013)

13th February 2014

April 2014

Medicines management compliance policy updated 31st January 2014

Self-administration policy ratified and trials commenced in gynaecology 31st January 2014

Full audit of self-administered insulin being undertaken and Insulin policy on self-administration under

review

Planned completion 31st

March 2014

Commissioned internal audit found good compliance in safe storage of medicines

Safe storage of medicines audit undertaken. Actions matrons and ward sisters Immediate action – patient drugs cabinets with enhanced security in MAU

Expected delivery End March 2014

Interviewed and appointed medicines management senior pharmacist To commence 1st May 2014

Review of pharmacy audit process to be able to manage actions through the clinical nurse forum End February 2014


10


External Support/ Assurance Progress

Status

Rag Rating

Revised

deadline (if

required)

Outcome 9 continued Demonstrate compliance to Board of Directors (by Dec 2013)

13th December 2013

April 2014

Progress in achieving compliance will be reported to the Board To commence by 31st Jan 2014

13th January 2013

Bi-Monthly Medicines Management Committee to be chaired by Chief Pharmacist and supported by Medical Director and Drugs and Therapeutics Committee chair

Commencing 15th January 2014.

Missed dose and allergy audits to be presented to MMC and to senior nurses in December and January (resp.) Commenced 7th February

Safe Use of insulin e-learning module mandatory for all new trainees January 2014

Patient Safety Bulletin: learning from medicine-related SIs January 2014

Prescribing errors identified in patient safety office e-mailed directly to responsible trainee and their educational supervisor through the post-grad office

Go-live 31st Jan 2014

New trainee intranet site in development –will provide another route to disseminate learning from safety office 31st January 2014

Trainees induction training to be revised to incorporate prescribing and documentation 2nd January 2014

13th February 2014

Nominated pharmacist in charge of training January 2014

Fortnightly meetings held between Medical Director, Chief Operating Officer and Chief Pharmacist to monitor progress and report to Board

Mock CQC audit 31st January 2014 identified areas of further improvement


11



Progress

Status

Rag Rating Revised


CQC Outcome 21 Records Keeping (end Oct 2013) Determine the actions required to improve the documentation contained with the clinical record – to include a recommendation to the Board of Directors on compliance monitoring. Complete review of existing documentation

Caldictt Guardian and Serious Information Risk Officer

13th January 2014

Redesign of medical documentation to be undertaken with Ambulatory Emergency Care (AEC) unit audit results

Commence Feb 2014

13th February 2014

Audit of 50 AEC notes undertaken with associated actions being developed to feed into the

redesign of general medical documentation Completed 3rd February 2014

Records keeping training now included in Trust mandatory training for doctors Commenced January 2014

Review destroying of blood tests (8th Nov 2013)

13th January 2013

July 2014

From the CQC identified backlog all results have been acted upon 1 report of potential harm. Being validated by GP

Increase administrative support to maintain and monitor the current system to avoid backlog building whilst moving to the electronic system

8 apprentices + 3 admission, discharge and transfer clerks

Introduction of ‘Webice’ in October 2013 ensures an audit trail of clinical review of patient results

Visit to Norfolk and Norwich FTH scheduled; Trudy Taylor and Mr Maheshkumar to review their systems and processes for transition for in patients from paper records system to electronic

Completed 14th Jan 2014

Clinical appraisal of ordering pathology tests via order comms Completed January 2014

Implementation timeline agreed July 2014

13th February 2014

Proposed switch off of paper system only for in-patient areas July 2014

Administrative support has been agreed to enable ‘Webice’ to be more clinician friendly

Recommend improvement plan and compliance monitoring proposal to Board of Directors (end Nov 2013)

13th January 2014

Jan 2014

Results of first audit of medical notes received, letter from CEO/MD to all medical staff to reiterate expectations

Completed 8th January 2014

Agreement to intensify programme of nursing notes audit Using coding staff to increase patient note numbers

Commenced 13th January 2014

Outcome of existing audits disseminated for action to Medical Director and Director of Nursing Completed 8th January 2014

13th February 2014

Clinical appraisal of order comms complete and action plan being formulated

Daily senior nurse ‘check and challenge’ of documentation being rolled out From 30th January 2014

Integrated quality report including documentation to be presented to the Quality Committee

Next Quality Committee due 18th February 2014


12



Progress

Status

Rag Rating Revised


CQC Outcome 6 Cooperating with other providers (end Dec 2013) Engage Board to Board with local partners

WNCCG 13th January 2014

March 2014

Delayed discharges escalated daily to all partner organisations through daily silver calls Commenced 14th Oct 2013 and on-going

Weekend social worker based at QEH to assist discharges Commenced 21st Dec 2013

Patient Transport Services attending week day bed meetings to agree discharge times Commenced Nov 2013

Continue with care home workshops linking with Norfolk, Cambridgeshire and Lincolnshire Care Homes both Residential and Nursing to standardise admission and discharge documentation and improve communication channels

Commenced Feb 2013 next workshop scheduled for 23rd April 2014

13th February 2014

Report received on discharge process, action plan being formulated 10th February 2014

Operational Delivery (end Nov 2013) To ensure the Trust addresses operational areas of concern as identified in the Key Lines of Enquiry following visits from the CQC and RRR. This specifically relates to A&E The roll-out of winter monies allocated to the Trust

WN Urgent

Care Board

Norfolk and Suffolk Local Area Team

13th January 2014

March 2014

Dr Laurence Potter part time Psychiatrist appointed for older persons and A&E liaison In post 17th Jan 2014

Approved Mental Health Practitioner appointed In post 7th Jan 2014

2 Mental health liaison staff appointed To be in post end Jan 2014 1WTE in post, 2nd post to be recruitment by end March

December A&E performance 94.52 %

Acute Physician model introduced Commenced 3rd February 2014

13th February 2014

January 2014 A&E performance 95.53%

Claire Gowland appointed as senior service manager for emergency services 6th January 2014

Kate Turner appointed as senior services manager for medicine 20th January 2014

2 month project on simple discharge task and finish group to ensure 30% of simple discharge is achieved by 11AM

3rd February 2014

Voluntary transport system to assist in timely discharge 3rd February 2014

Additional weekend GP’s seeing primary care patients January 2014

7 day, 10 hours a day A&E consultant cover 23rd January 2014

Emergency Care Intensive Support Team to undertaking external review To be completed end February 2014

MTOPS Paediatric supervision (end Nov 2013)

13th December 2013

Discharge lounge relocated to improve privacy for MTOPS Completed 27th Sept 2013

An A&E nurse will directly supervise children when in the department. Commenced 13th Dec 2013


13



Progress

Status

Rag Rating Revised


Corporate Governance Implement the 25 KPMG recommendations Review of Trusts Corporate Governance (by end Dec 2013

13th January 2014

Full implementation March 2014

2a:Rec. 6 – Catherine Morgan appointed as Interim Director of Nursing and Patient Experience Commenced in post 25th

November 2013

3b: Rec. 14 – Wendy Cookson appointed as Interim Director of Quality Improvement Commenced in post 30th

December 2013

2a: Rec. 8 Leadership and Management review of substantive and interim Board members

• Revised Executive portfolios to address governance issues • Review of structure and ToRs to align committees with new management

structure

Completed 31st

Dec 2013.

Communicated to Trust 17th

January 2014 Date in 2014 TBC

Revised clinical and corporate governance structure

First draft 30th

January 2014.

Revised draft 6th

February 2014

Self-assessment to be completed once permanent Directors in post with individuals subject to performance measures if not fulfilling role

TBC mid/end 2014

2a: Rec. 7 and 8 Review of current Board members who have undertaken development as per Board Development Programme to ascertain effectiveness before redesign of plan to address gaps.

Commenced 29th

January

Further self-assessment once permanent Directors in role Date TBC 2014

The Trust will monitor risks to compliance on a monthly basis and report to the BoD on a quarterly basis.

13th December 2013

January 2014

1a: Rec.1,2 and 3 CQC mock inspections being revised

13th January 2014

External mock CQC inspections of two wards, Necton and Stanhoe Completed 17th Dec 2013 Outcomes in ward specific action plans.

13th February 2014

Programme of Trust wide, independent, MDT mock CQC inspections commenced 31st January 2014.

Completed 31st January Findings to be presented at QUIDG 12th February

First draft of the new Trust Quality Strategy reviewed at Quality Committee December 2013 For wider clinical consultation and metrics to be aligned to Improvement Programme

Implementation plan to be outlined with paper to Board Trust Board in March

1b: Rec. 4 and 5 Risk register reviewed at January Board. Action for Trust Secretary and Directors to update or remove risks.


14



Progress

Status

Rag Rating Revised


The Trust will monitor risks to compliance on a monthly basis and report to the BoD on a quarterly basis. (continued)

13th February 2014 cont

February 2014

TOR agreed including risk escalation, line management and governance:

Draft reports 10th February 2014

Management response 24th February 2014

Final report 28th February 2014

Internal review of risk register and BAF in January with 2 additional external risks added as a result On-going

Training package for ‘Chairs’ of meetings

4a: Rec. 21 13th December 2013

January 2014

ToRs approved

13th February

Scope of development session held 30th January 2014, an External development is being planned with chairs being identified. Internal training for committee clerks being planned in line with chairs development

TBC

Poor line of sight from Board to Ward

2b: Rec. 9 and 10 13th December 2013

More frequent Executive walk round Commenced December 2013

13th January 2014

Continued roll out of ‘Values and Behaviours’ workshops Commenced 1 February 2014.

2b: Rec. 11, 15 , 16 and 18 13th February 2014

A clear ‘Lessons Learnt’ structure has commenced with revised SI process and patient mortality process using NCEPOD

Commenced in January 2014

Patient’s stories commenced at each Trust Board and nursing ‘Clinical Friday’ meetings Commenced 28th January 2014

Triangulated outcomes evident in KPI integrated dashboard

Commenced 28th January 2014. Further development w/c 20th January 2014

2b: Rec 17 Nursing levels have been maintained at 100% compliance to minimum general ward ratios of 1:8 (day) and 1:11 (night)

On-going

Draft acuity nursing levels paper to Board 28th January 2014

Revised paper to newly formed Workforce Committee

11th February 2014

2b:Rec.18 The Trust commissioned external review of complaints being verified for accuracy.


15



Progress

Status

Rag Rating Revised


Improved communication channels (November 2013

13th December 2013

January 2014

March 2014

The Trust is developing a communication and engagement strategy with our new 4 themes and will be in place by mid-late January 2014

13th January 2014

3c: Rec. 19 and 20 Patient stories are embedded in Board meetings and Clinical Fridays

4a: Rec 22 Regular consultation with ACNs and CDs on appropriateness of quality information

4b: Rec 23 CANS exception report presented quarterly to Board

4c:Rec. 24 and 25 Narrative on Quality reports to be included

Part of integrated quality dashboard work (2b)

Committee papers circulated in advance in a disciplined manner

13th February 2014

Clinical Engagement Strategy review forms part of Communications Strategy

Improved process for circulation of papers; January Board papers received before circulation deadline with no follow up papers

CEO is devising a revised timetable for report preparation to include Executive review stage

CEO has instructed that no tabled papers or verbal presentations are permitted

CEO and Executives to undertake a series of listening events with the public March 2014

king’s lynn nhs foundation · king’s lynn trust - our improvement plan 5 summary of main...

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