Compliance Plan Update Reporting for May and June 2022
This report highlights the progress made against the Compliance Plan actions for May and June 2022. It includes details on the alignment with Trust Strategic Objectives, integration of CQC actions, and status updates on completion. The report also outlines actions moved to AtRisk and provides an overview of the overall plan position and status.
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Compliance Plan Update Reporting for May and June 2022 Quality Committee 26 July 2022
Summary Following the launch of the 2022/23 Compliance Plan in April 2022 this report details the progress against the actions during May and June 2022. The Compliance Plan follows the same format as the Integrated Quality Improvement Plan (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 are clearly identifiable within the Compliance Plan to support transparency of monitoring, whilst avoiding duplication. The Compliance Plan incorporates the remaining open Must and Should Do actions from the 2021/22 IQIP with the 13 new Must and Should Do actions from the latest CQC Report and became live in April 2022. In turn, CQC actions are linked, where relevant, to the Radiology, Ophthalmology, Maternity, Urgent and Emergency Care and Elective Recovery Improvement Plans. The Quality Committee is asked to note: The 2022/23 Compliance Plan position as of Month 03 3 Actions moving to AtRisk All 35 actions within the 2022/23 Compliance Plan have deadlines built into the Forward Plan and include a RAG status and narrative update by exception. There were no actions due to be submitted to the Evidence Assurance Group in May. In June, 1 action from Clinical Support Services was presented to the Evidence Assurance Group, in line with the Forward Planner. This action was approved increasing the total number of actions closed to 7 (20%). As of June 2022, 3 actions were moved to AtRisk which relate to the Emergency Department (ED) 4hr standard and staffing levels within Radiology. See slide 7 for further details. There are no actions Behind Plan.
Overall Plan Position The tables below reflect the actions captured within the 2022/23 Compliance Plan, with 28 open actions covering Must and Should Do actions which are structured accordingly. Status Must Should Section 31 Total Area At Risk On Plan Total Completed & Signed Off Clinical Support Services Corporate Medicine Surgery Women & Children Not Completed Clinical Support Services Corporate Medicine Surgery Women & Children Total 3 2 4 2 7 4 Clinical Support Services Must Should Corporate Must Medicine Must Should Surgery Should Women & Children Must Total 2 2 3 5 2 3 2 2 3 2 2 1 1 1 1 2 1 1 17 4 13 2 2 1 1 25 18 5 13 2 2 1 1 28 10 2 2 5 18 3 28 5 2 18 2 1 35 13 2 1 10 21 4 3
Overall Plan Status Overall Performance 7 Total Complete Of the 35 total planned actions within the Compliance Plan, 7 actions have been closed including the 4 Section 31 conditions which remain on the Trust s Certificate of Registration 3 actions are currently RAG rated AtRisk and no actions are behind plan at Month 04 35 Total Planned 20% 100% 0% All CQC Conditions and Warning Notices have been closed internally by the Trust The Trust has 4 Section 31 Conditions on its Certificate of Registration A more detailed review of the Section 31 Condition evidence for significant findings is being carried out which will inform the timing of the Trust's application to the CQC to formally request the lifting of the 2 remaining Radiology Section 31 Conditions in addition to the Maternity Condition CQC Conditions & Notices 4 Total Complete 4 Total Planned 100% 0% 100% Must's 10 Must Do actions are incorporated within the 2022/23 Compliance Plan and all remain open 3 Must Do actions are currently RAG rated AtRisk 0 Total Complete 10 Total Planned 0% 0% 100% 21 Should Do actions are incorporated within the 2022/23 Compliance Plan 3 Should Do actions have been closed to date, including 1 Should Do action from Clinical Support Services which was approved at the Evidence Assurance Group in June Should's 3 Total Complete 21 Total Planned 14% 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 4 Area 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 2 2 2 1 9 2 5 2 2 2 2 2 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 7 2 2 6 1 4 10 3
At Risk Actions ID Ref Category Action Description Owner End Date RAG Status The trust must ensure that staffing levels are adequate to provide safe care and treatment to patients in a timely way. (Diagnostic Imaging) The trust must be assured that the out of hours staffing arrangement is sustainable and robust to provide safe care and treatment to patients. (Diagnostic Imaging) The trust must improve its performance times in relation to ambulance turnaround delays, four-hour target, patients waiting more than four hours from the decision to admit until being admitted and monthly median total time in A&E. (Urgent & Emergency Care) General Manager CSS General Manager CSS 102 Must 31/07/2022 A 103 Must 31/07/2022 A 109 Must Deputy Medical Director 31/03/2023 A 102 & 103 Staffing Due to a number of vacancies within the current establishment and a national shortage of Radiographers the service is heavily reliant on agency and bank staffing which at times puts staffing levels at risk to provide safe care and treatment. This is not a robust and sustainable arrangement at present. The service is currently undergoing a skill mix review and supporting the recruitment of apprentices and Assistant Practitioners. A consultation is planned to review the out of hours staffing provision in due course. 109 4 Hour ED Standard Due to the increasing demand within the Emergency Department; there is a risk that this action is not being sustained with the 15 minute national target. The mitigating actions are that a trial is commencing that the GP stream service will work alongside the triage nurse to assess the patients within the target time however due to current recruiting concerns this target is not being met. There is a plan for a triage nurse to be placed within minor injuries to take all minor patients through the pathway.
Actions Approved at EAG in June 2022 ID Ref Category Action Description Owner End Date RAG Status General Manager CSS 105 Should The trust should continue to embed the governance and risk management processes. (Diagnostic Imaging) 30/06/2022 B No actions were due for closure in May 2022 in line with the forward planner
Actions to be submitted to the EAG in July 2022 ID Ref Category Action Description Owner End Date RAG Status The trust must ensure that staffing levels are adequate to provide safe care and treatment to patients in a timely way. (Diagnostic Imaging) The trust must be assured that the out of hours staffing arrangement is sustainable and robust to provide safe care and treatment to patients. (Diagnostic Imaging) General Manager CSS General Manager CSS 102 Must 31/07/2022 A 103 Must 31/07/2022 A
