Compliance Plan Update Reporting for March & April 2022 Quality Committee
Trust received approval for transition from SOF 4 to SOF 3, exited Recovery Support Programme. Detailed progress against 2022/23 Compliance Plan, incorporating new actions from CQC report. Oversight meetings canceled, all actions have deadlines. Board approved plan, highlighted at Big Conversation event. Transparency in reporting maintained. Current plan position at Month 1, 17% actions approved for closure. Clinical Review Programme outcome in March 2022 discussed.
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Compliance Plan Update Reporting for March & April 2022 Quality Committee 31 May 2022
Summary The Trust received a letter from Professor Stephen Powis, the National Medical Director for NHSE/I on 14 April 2022, confirming their decision to approve the Trust s transition from System Oversight Framework (SOF 4) (Mandated Intensive Support) to SOF 3 (Mandated Regional Support). This follows the Care Quality Commission s recent inspection and subsequent recommendation for the Trust to be removed from the Recovery Support Programme (formally known as SpecialMeasures ). This report details progress against the 2022/23 Compliance Plan (CP) launched in April 2022. Prior to transitioning to the 2022/23 Compliance Plan, 57 (69%) of actions within the 2021/22 IQIP had been formally reviewed and closed by the Evidence Assurance Group (EAG). The Executive team, attended an extremely positive Recovery Support Programme Exit Meeting with NHSE/I on 25 April 2022 to review the journey of improvement over the last 3 years and discuss key issues addressed and lessons learnt during this time. For complete transparency and to ensure all remaining open actions from the 2021/22 IQIP are fully addressed, the 2022/23 Compliance Plan incorporates these open Must and Should Do actions, in addition to the 13 new Must and Should Do actions from the latest CQC Report, totally 35 actions. The Trust has received formal confirmation from Dr Sean O Kelly, Medical Director NHSE/I that the bi-monthly Oversight & Assurance Group meetings are no longer required and these have been cancelled from stakeholders diaries. All 35 actions within the 2022/23 Compliance Plan have deadlines agreed with the action owners and Executive Leads which have been built into the Forward Plan. The Board of Directors formally approved the Compliance Plan at their Public meeting on 05 April 2022 and receive assurance of progress through the Quality Committee s Chairs Assurance Report in line with the Trusts new governance arrangements for 2022/23. Caroline Shaw and Louise Notley attended a BigConversation event organised by NHSE/I as guest speakers on 11 May 2022 to present and share the Trust s journey of improvement. Feedback has been positive and the Trust has been asked to also speak at a future conference in June 2022. The Compliance Plan follows the same format as the IQIP to ensure the reporting style and transparency of progress is not lost. All actions have been aligned with the relevant Trust Strategic Objectives and include completion dates agreed with action owners. As with the exiting IQIP, any actions linked with the five Trust Quality Improvement Plans will be clearly identifiable within the Compliance Plan to support transparency of monitoring, whilst avoiding duplication. This report details the outcome of the Clinical Review Programme in March 2022 and planned next steps. The Quality Committee is asked to note: The current 2022/23 Compliance Plan position as at Month 1 The removal from SOF04 to SOF 03 and the Recovery Support Programme The next steps for the Clinical Review Programme 6 (17%) of the 2022/23 Compliance Plan actions have been approved for closure as of Month 1 which includes the 4 remaining Section 31 conditions that remain on the Trust s Certificate of Registration.
Overall Plan Position The tables below reflect the actions captured within the 2022/23 Compliance Plan, with 29 open actions covering Must and Should Do actions which are structured accordingly. All 29 open actions are currently RAG rated as OnPlan . Area Clinical Support Services Must Should Corporate Must Medicine Must Should Surgery Should Women & Children Must Should Total On Plan 6 2 4 2 2 18 5 13 2 2 1 1 Total 6 2 4 2 2 18 5 13 2 2 1 1 Status Must Should Section 31 Total Completed & Signed Off Clinical Support Services Corporate Medicine Surgery Women & Children Not Completed Clinical Support Services Corporate Medicine Surgery Women & Children Total 2 1 4 2 6 3 1 1 1 1 2 10 2 2 5 19 4 29 6 2 18 2 1 35 13 2 1 10 21 4 29 29
Overall Plan Status Overall Performance 6 Total Complete Of the 35 total planned actions within the Compliance Plan, 6 actions have been completed 35 Total Planned 17% 100% 0% CQC Conditions & Notices All CQC Conditions and Warning Notices have been closed internally by the Trust Following the removal of the remaining 16 Section 29A conditions in February 2022, the Trust now only has 4 Section 31 Conditions on its Certificate of Registration. Work is ongoing to ensure the Trust has the most up-to-date data within the evidence for submission of the formal application to lift 3 of the 4 Conditions. Sustained operational pressures has delayed the submission of this application. 4 Total Complete 4 Total Planned 100% 0% 100% Must's 10 Must Do actions are incorporated within the 2022/23 Compliance Plan 0 Total Complete 10 Total Planned 0% 0% 100% 21 Should Do actions are incorporated within the 2022/23 Compliance Plan Should's 2 Total Complete 10% 21 Total Planned 0% 100%
Forward plan for the completion of actions This table details a breakdown of all 35 actions within the Compliance Plan which are included within the forward plan. Completed & Signed Off 3 Area May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 Apr-23 Total Clinical Support Services Must Should Section 31 Corporate Must Medicine Must Should Section 31 Surgery Should Women & Children Must Should Section 31 Total 1 2 2 2 1 9 2 5 2 2 2 1 2 1 2 1 2 2 1 1 1 2 2 2 10 2 8 3 19 5 13 1 2 2 3 1 1 1 35 2 3 1 2 2 2 1 1 1 1 6 1 2 2 6 1 4 10 3
Actions Approved at the EAG in March 2022 ID Ref Service Category Action Description Owner End Date RAG Status 011 Women & Children Should The service should continue to work on the culture within the department. DLT Women & Children 30/04/2022 G 011 Clinical Support Services Should The trust should continue to improve staff engagement. DLT Clinical Support Services 30/04/2022 G
Clinical Review Programme : Assurance Actions Sustained and Embedded Clinical Review 17th March 2022 Due to operation pressures, the Director of Patient Safety took the decision to run a scaled down Clinical Review in March. A team of three non-clinical staff and four clinical staff were involved in this review, consisting of the Assistant Director Clinical Quality NHSE/I, Support Manger, Woman and Children, Staff Nurse on Tilney, Ward Manager Surgical Assessment Unit, Matron, Patient Safety Team, Head of Clinical Effectiveness and Patient Safety,Safer Invasive Procedures Lead, QEH, as well as one Trust Governor. Areas of Good Practice: Overall positive visits to the areas 2 areas were welcoming and accommodating upon arrival, the third was welcoming once staff made aware that the team were in the department. Staff were engaged and enthusiastic when speaking to the team Across all areas the review teams observed positive interactions between staff and patients Staff introduced themselves Areas were all very busy, staff appeared calm and in control Patient care was good, caring and compassionate Staff on all areas expressed feeling confident when speaking up and were able to articulate the method for raising concerns The review was limited to 3 areas: Windsor Ward (Red) Emergency Department Theatres Areas of Improvement: Adherence with Information Governance Standards appeared to be an issue on the Windsor ward, with the lack of notes trollies, The team were informed that two trolleys are being sourced and the issue already escalated appropriately. Out of date information on the Emergency Department information board. The Nurse in Charge made aware. Evidence of missed Resuscitation trolley checks within Theatre, escalated to ODP in charge. The Quality Improvement Board has requested Divisional assurance that equipment safety checks being consistently carried out Training gaps noted for equipment, currently no plan in place On the day of the review, all areas faced challenges with staffing levels (due to sickness) In view of the significant pressures on staff as a result of COVID-19 the KLOE focused on Patient and staff experience, Resuscitation trolley checks and documentation whilst drawing on broader findings through the use of the 15 Steps methodology.
Clinical Review Programme : Assurance Actions Sustained and Embedded Overall the review teams felt they had positive visits to all wards. They observed good multidisciplinary working, which was caring and compassionate, and staff were engaged and enthusiastic to speak to the review teams. Whilst good practice was noted, the review teams did identify the specific areas for improvement for each area. Windsor Emergency Department Main Theatre Good Practice: Good adherence to Infection Control Standards were observed Patients expressed feeling well-cared for and happy on the ward Focus on documentation through the visit, this showed good compliance Good compliance with medication management It was apparent that staff knew their roles and responsibilities The ward felt well-ventilated, de-cluttered and clean It Discharge planning was good with discharge plans in place Good Practice: The review team witnessed dignified care being given to patient's. Staff across the department were friendly and welcoming New call bell system in working order action from previous review Paediatric area Child friendly , very positive feedback, Nurse in the area was very kind and informative. Nurse in charge spoke passionate about staff welfare and her role in pastoral care. Student board very useful and good use of resource Good Practice: All equipment checks in date Compassionate and caring interaction between staff and patient Organised and well structured It was apparent that staff knew their roles and responsibilities Areas of Improvement: Call-bells and telephone calls were not answered promptly During the review the team identified a lack of notes trollies. This was feedback to the Nurse in Charge The review team noted staff morale was low This was feedback to the Matron and Heads of Nursing. Additional support already in place to support the staff. Coordination of the ward and the team could be improved as part of the day to day running of the ward. This has already been identified by Matron of Windsor and support is in place. Areas of Improvement: Zone 3 and 4 area checks not completed - Highlighted to Nurse in Charge Information board out of date Resuscitation checks not consistently completed Bereavement room cluttered and used as a store room. Areas of Improvement: Storage an issue Gaps in training of equipment Staff not aware of any plans in place to commence training. Gaps in resuscitation trolley and equipment checks.
Clinical Review Programme: Positive Themes Q4 Multidisciplinary team working Good interactions were observed between Medical, Nursing and Support Staff with interactions between staff being kind, clear and concise. Staff worked together to provide the best possible care for the patients focused on meeting the patients' needs. Patient Care Compassionate Positive interactions between staff and patients were observed, with staff treating patients with compassion and kindness, respected their privacy and dignity and patients treated as individuals. Staff were observed closing curtains around bed spaces when delivering care to protect privacy and dignity. Patient Feedback Patients said staff treated them well and with kindness with many positive comments about the hospital and staff. This was consistent across all clinical reviews. Patients used words such as staff were wonderful, caring and thoughtful , taking time to explain what is happening. Patients were given enough to eat and drink and food and fluid charts completed in most cases. Patients and relatives reported being well informed about their care and the plans for when they are being discharged. Both staff and patients talked positively about the Family Liaison Officer and the difference they are making. Staff Feedback Nurse in charge shared her compassion for staff welfare and her role in pastoral care. Evidence of staff interaction with employee of the month and celebrating staff success. Information for students available with a dedicated education team to provide support and reassurance. Awareness and Learning from Complaints and Incidents Real improvement noted in this area. Staff know how to raise concerns on DATIX and feel confident in doing so. They know about recent incidents and complaints within their areas. They said that feedback is given after an investigation that they had raised individually. Complaints are discussed in the team. Staff knew how they have learnt from recent incidents and complaints. Learning is discussed at safety huddles, team meetings and Newsletters. They are aware of the Safety Alerts shared. Infection Prevention & Control Good IPC and PPE were observed across the Trust. Good compliance hands, space and ventilation was observed. Staff knew how to manage closed bays and showed good hand hygiene before, during and after interaction with patients, equipment and tasks. We observed staff wearing masks, aprons, and gloves for all patient interactions.
Clinical Review Programme: Areas for Improvement Themes Q4 Call Bells / Telephone Calls It was noted that call bells and telephones were not always answered in a timely way during the Clinical Reviews. The Clinical Review team would give challenge to the ward staff (of any discipline) at the time this was observed to action. This reiterated that responding to call bells is everybody's responsibility, and during times of high demand, by simply acknowledging the call bell, patients can be put at ease. A message was included within the Trustwide communications In the Know reiterating the importance of answering ward telephones. The introduction of the Family Liaison Officers (FLOs) ensures relatives/carers are kept informed and supports the answering of telephone calls during visits to the inpatient wards, and relatives now call the helpline directly rather than contacting the ward. Storage It was noted a lack of storage with equipment being stored in inappropriate rooms. Plan to share the Room for Improvement scheme with hope to support staff in creating adequate storage space. Ward Managers have been offered support to complete the application process and gain further knowledge that there is financial support available. Resuscitation Colleagues attending the Clinical Review were asked to check the resuscitation trolleys and the frequency of missed checks. Compliance was poor in some areas and checks were found to have been missed. In support of this and the CQC MustDo action, the following support and measures are in place: My Kit Check continues to be used to allow for rapid, streamlined checking of equipment and also for reporting. Missed check emails are sent to nominated individuals for each clinical area for follow up . Weekly checks remain as a standard on a Tuesday Monthly daily and weekly check compliance reports are compiled by the Resuscitation Service and sent to all Ward Sisters, Managers and Matrons Information Governance It was noted that patient notes were not always stored appropriately. The evaluation of Health Record Storage has been added to the monthly Tenable (Previously Perfect Ward) Audits to ensure compliance going forwards, and in March 2022 the Trust was 91% compliant with record keeping standards. The lock screen time-out on all Trust computers has also been shortened to 5 minutes to reduce the possibility of patient identifiable information being on display, furthermore privacy screens are fitted on many reception computers to stop information being viewed from side angles. All staff are trained to always lock computer screens when leaving their desks and to exit patient records.
Clinical Review Programme Next Steps Due to operation pressures, the Director of Patient Safety took the decision to cancel the Clinical Review planned for April 2022. The Clinical Review Programme has been an established mechanism to provide further assurance that improvements are sustained and embedded. It is now important that these evolve and it has been agreed with the Chief Nurse to move the programme under the Chief Nurse Team from July 2022 with support from the Compliance Team. The timetable below has been agreed to allow for the smooth transition of this programme from the Compliance Team to the Chief Nurse Team. The Patient Safety & Improvement Team will participate in all future Clinical Review visits. Month Lead Comments May 2022 Compliance Team No Change June 2022 Compliance Team Shadowed by Chief Nurse Team July 2022 Chief Nurse Team Supported by Compliance Team August 2022 Chief Nurse Team Compliance Team available to support if required
