Special Measures Action Plan
The Queen Elizabeth Hospital King’s Lynn NHS Foundation
Trust 13th January 2015
KEY
Delivered
On Track to deliver
Some issues – narrative disclosure
Not on track to deliver
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The Queen Elizabeth King’s Lynn NHS Foundation Trust - Our improvement plan & our progress
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What are we doing?
• The Trust entered the special measures programme 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 also 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 has been given a variety of recommendations from the CQC inspection in July 2014, in line with the re-inspection within 12 months of QEH entering Special
Measures. There were 21 ‘Must’ and 7 ‘Should’ under 4 of the 5 Domains of Safe, Effective, Caring, Responsive and Well-led summarised below:
Safe
- storage and documentation of medicines in clinical areas
- medical and nursing access to education and training
- embedding nursing skill mix review
- emergency planning resilience
- review and audit of infection, prevention and control practices
Effective
- review and improve the environment and storage arrangements for A&E and neonatal unit
- strategically plan to move to MEWS
Responsive
- review cancellation rates and discharge processes
- review the mortuary environment
- review the investigations of incidents process
- ensure there are sufficient staff on duty at all times who are trained in restraint
Well Led
- review the medical leadership for elective and emergency surgery
- ensure an Executive Director is appointed as End of Life Care Lead
• The Trust is also responding to the concerns outlined in the CQC press release concerning
Medical Outliers
Elective Surgical patient cancellations
Physical Restraint training for staff
Embedding a robust governance structure.
• The Trust agreed a summary action plan to deal with these 28 recommendations. We have accepted all of the recommendations and are addressing them through current
actions being taken to improve the quality of services. These improvements will be managed through the PMO with Executive Directors as named leads. The Interim Director
of Quality Improvement is due to leave the Trust in November. The lead for the programme of work will be Louise Stevens, Head of Integrated Clinical Governance. The
Trust will set out a longer-term plan to maintain progress and ensure that the actions lead to measurable improvements in the quality and safety of care for patients.
• This document shows our plan for making these improvements and demonstrates our progress against the plan. While we take forward our plans to address the 28
recommendations, the Trust is in ‘special measures’.
• Oversight and improvement arrangements are in place to support changes required through our monthly Performance Review meetings and signed off by Monitor’s
Improvement Director, David Hill.
The Queen Elizabeth King’s Lynn NHS Foundation Trust - Our improvement plan & our progress
Chair / Chief Executive Approval (on behalf of the Board):
Chair Name: Edward Libbey Signature: Date:13th January 2015
Chief Executive Name: Dorothy Hosein
Signature:
Date: 13th January 2015
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Who is responsible?
• Our actions to address the 28 recommendations have been agreed by the Trust Board.
• Our Chief Executive, Dorothy Hosein, is ultimately responsible for implementing actions in this document. Other key staff are Dr Bev Watson, Medical Director and Patient
Safety Lead and Catherine Morgan, Director of Nursing, who will provide the executive leadership for quality, patient safety and patient experience.
• The Improvement Director assigned to Queen Elizabeth NHS Foundation Trust is David Hill, who will be acting on behalf of Monitor and in concert with the relevant Regional
Team of Monitor to ensure delivery of the improvements and oversee the implementation of the action plan overleaf. Should you require any further information on this role
please contact [email protected]
• Ultimately, our success in implementing the recommendations of the Integrated Quality Improvement plan will be assessed by the Chief Inspector of Hospitals, upon re-
inspection of our Trust.
• If you have any questions about how we’re doing, contact Karon Strong, Head of Quality Improvement, [email protected]
How we will communicate our progress to you
• We will update this progress report every month while we are in special measures.
• There will be regular updates on NHS Choices and subsequent longer term actions may be included as part of a continuous process of improvement.
• The Trust is planning to undertake a serious of staff and public meetings through October . Further dates will be announced in updates of this progress report
The Queen Elizabeth King’s Lynn NHS Foundation Trust - Our improvement plan
Summary of Main Concerns Outstanding
Summary of Urgent Actions Required Agreed timescale for implementation
External Support/
Assurance
Progress against original
timescale
Revised deadline (if required)
Outcome 7 – Safeguarding
people who use the services
from abuse
The Trust commenced mandatory training in Mental Capacity Act in November 2013. A
targeted approach has been applied with an overall trajectory set for Trust wide
completion.
Compliance end of October 73.07% against target of 70%
Compliance end of November 77.05% against target of 70%
Compliance end of December 78.28% against target of 70%
Outcome 13 – Nursing levels - staffing
A large-scale skill mix review was undertaken in April. The Board subsequently approved £3m investment in nurse recruitment. All budgets were updated accordingly in April 2014. Nurse staffing is reviewed 3 times each day and staffing is flexed to meet patient dependency/acuity. Turnover rate in month 31st December: 12.7% against target of <10%. Vacancy rate to current establishment 31st December: 9.3% Registered nurse against target of <6% .
Outcome 14 – Supporting Workers
71% of staff have attended the Trust Values and Behaviours’ workshops and are now
part of the Trust induction training and are being used in recruitment. Mandatory
training -Trust-wide compliance to end of September 2014 86.07% against target of 85%
N.B. excludes newly added subjects.
Outcome 4 – Care and welfare of the people who use the service
Board rounds are embedded on all wards. Focus on Social Services attendance. Current
compliance as of December shows 68% compliance. Weekly random spot checks of 2
wards per week to reinforce compliance.
Outcome 5 – Meeting Nutritional Needs MUST accuracy 89% for November 2014 against a target of 90%
New fluid balance chart introduced in March with many wards now achieving 100%
compliance. Current Trust wide compliance for December 2014 - 91% against target of
90%.
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The Queen Elizabeth King’s Lynn NHS Foundation Trust - Our improvement plan
Summary of Main Concerns
Summary of Urgent Actions Required Agreed timescale for implementation
External Support/
Assurance
Progress against original
timescale
Revised deadline (if required)
Outcome 9 – Management of medicines
Automatic, centralised drug fridge temperature monitoring system:- Installation
commenced 6th October 2014
Installation complete
By 31st October 2014
System calibration and validation date: 15/16 December. 15/16 December 2014
Handover of temperature monitoring to Tutela and inform staff of the change over January 2015
Outcome 9 – Management of medicines
Medicine reconciliation audit completed. 54% compliance. Internal productivity review in
progress to release current pharmacy capacity. CCG and Trust discussed funding to
increase resource to improve compliance . A new Medicines Management technician
has been recruited to help increase compliance.
Monthly compliance audits being undertaken. To be placed on the Medicines
Management action plan.
To be incorporated
into the medicines
management action
plan.
Outcome 21 – Record Keeping
Positive feedback has been received from the new medical documentation. This has
been substantiated by recent audit results. Work has now commenced to modify the
emergency surgical pathway into the same format.
Revised date for completion 1st December 2014
Outcome 21 – Record Keeping
Proposed switch-off of paper system only for in-patient areas. Work commenced with
Project Management office and Business Intelligence and IM&T.
Revised date for completion April 2015
Operational Delivery November 2014 A&E performance 85.58%
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The Queen Elizabeth King’s Lynn NHS Foundation Trust - Our improvement plan
Summary of Main Concerns
Summary of Urgent Actions Required Agreed timescale for implementation
External Support/
Assurance
Progress against original
timescale
Revised deadline (if required)
Safe Urgent efforts are made to comply with the warning notice issued last year in regard to safeguarding people who use services from abuse, restraint of patients, staffing levels and staff training.
• From 1st July 2013, two Security Guards trained in restraint are available during the day and one during the night.
• From 3rd July 2014, two Security Guards trained in physical restraint on duty 24/7
• Substantive Training Officer (violence and Aggression) in post 22nd September
• 3 day training in physical restraint techniques and relevant laws will commence 17th November 2014 Prioritised clinical staff group to be trained:
- Site management team (7) • 3 members of the site team still to be trained in March 2015 however
training has been rolled out to other teams – 11 trained to date.
By 31st December 2014
Datix reports for each physical restraint incident from 30th January 2014 Mandatory training rates by staff group by month.
Safe Concerns around the management of medical outliers are addressed. The trust was not effectively tracking outliers, and therefore appropriate monitoring and follow-up care was not always being provided
• Medical outlying patients reviewed every morning by dedicated Medical
Consultant Monday – Friday from 1st July 2013.
• Reduction in total number of outlying medical patients as a result of
Emergency Flow Programme.
• 3 times daily monitoring through operations centre at bed meetings.
On going
• Frailty Ward model planned for Pentney w/c 6th October. We expect this
will reduce the length of stay for Care of Elderly patients by 1 day and will
also contribute to reducing the conversion rate in A&E by 30%
• Patients moves are tracked and electronically recorded out of hours by
the Hospital at Night Team and during the day by the Site Practitioner
team. MAU to have 24 hour ward clerk cover to ensure a robust system
for tracking going forward.
31st March 2015
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The Queen Elizabeth King’s Lynn NHS Foundation Trust - Our improvement plan
Summary of Main Concerns
Summary of Urgent Actions Required Agreed timescale for implementation
External Support/
Assurance
Progress against original
timescale
Revised deadline (if required)
Responsive Improvements are made within the trust’s surgery service. Several elective surgeries were cancelled due to capacity and low availability of beds
• As a result of the Emergency Flow Programme commenced 31st July, cancelled
operations did continue to reduce (July = 52; Sept = 16; Oct = 25; Nov = 46 Dec = 14).
However due to severe bed pressures and an early outbreak of Noro Virus this
number significantly increased in November.
• Monitoring is through Divisional Managers who attend Trust bed management
meetings 3 times daily to assess outlying patients and capacity for elective admissions
• The Board receives a monthly Integrated Report with aggregated numbers of
cancelled operations
On going Governance Structure
Effective Progress is made towards embedding a robust governance structure. The trust’s governance system must work more effectively to provide assurance to the board that the services being provided are safe and effective. This included ensuring that the trusts policies are up to date as during the inspection CQC inspectors found almost 200 polices were out of date.
• All Substantive Executive Directors including CEO and Non-Executive Director’s
appointments will be made by 8th October. The Medical director, Director of Nursing,
Chair and NEDs are in post, Chief Operating Officer from 1st November and Human
Resource and Organisational Development Director from 1st December.
By 31st December 2014
KPMG
• The head of Integrated Governance has been in post since 6th June 2014. 2 of 3
Divisional Governance and Risk Managers are in place from 1st October.
Interview for the 3rd post 15th October 2014.
• A policy management system (Hadron) is planned to be in place by 31st March 2014.
• All RCA investigation outcomes and action plans to be uploaded to the Patient Safety
intranet site to enable shared learning
• Revised Committee Structure agreed at Audit Committee 8th April 2014
• Terms of References of every committee reviewed.
• Chairs changed where requested and Clinical Chair numbers increased to 17
• Work has commenced to review and implement a new Quality Strategy.
By 31st December 2014
• KPMG commenced a second Monitor GQF review of November 2013 on 30th
September 2014.
• KPMG’s second GQF results published – Action Plan currently being compiled.
30th June 2015
The Queen Elizabeth King’s Lynn NHS Foundation Trust - Our improvement plan
Summary of Main Concerns Summary of Urgent Actions Required Agreed timescale for implementation
External Support/ Assurance
Progress against original timescale
Revised deadline (if required)
Musts SM1 –Ensure that resuscitation support, equipment and training is consistent throughout the trust, and compliance with Resuscitation Council guidance is achieved. We found several examples of different equipment on resuscitation trolleys, lack of training and audit especially in A&E and outpatients.
The equipment on all trolleys is now standard across the trust and complies with current guidelines. Delivery of 2 new defibs still awaited to ensure trolleys are situated in all inpatient areas.
31st December 2014
Compliance audits are currently undertaken 3 monthly which will increase to monthly when the Resus administrator commences post on 3rd November 2014
31st December 2014
Training is currently at 86.07% which is above the trust target of 85%. A second Resus officer was appointed on 6th October2014 and will commence in post 2nd February 2015, with specific role for monthly audits.
2nd February 2015
SM2 – Ensure that the management of medicines, including storage and recording of temperatures, is done in accordance with national guidelines.
A weekly compliance tool has given to ward Sisters 13th October 2014 with a communication from the Director of Nursing to launch the tool.
13th October 2014
The importance of daily fridge temperature checks to be reiterated by Chief nurse in newsletter. Centralised monitoring system to be fully functional by end January 2015.
31st January 2015
SM3 – Ensure that patients are protected from the risks associated with the unsafe use and management of medicines, by means of ensuring that appropriate arrangements for the recording and use of medicines are in place.
The Trust is to be involved in a pilot of the regional drug chart. Pilot to commence on West Raynham Ward 5th January 2015. The Trust will also adopt the medicines safety thermometer.
On going
SM4 – Review and improve medical staffing levels, education and training to ensure patient safety.
Acute medicine Consultant and junior establishment and inpatient consultant staffing establishment and job planning is being reviewed as part of the Emergency Flow Improvement Plan. Educational supervisors and clinical supervisors have undertaken a training day 1st October2014, to improve the support for trainees accessing study leave. Simulation Suite – space has been identified, funding agreed , funding agreed, faculty established and programme for courses being developed.
31st December 2014
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Summary of Main Concerns
Summary of Urgent Actions Required Agreed timescale for implementation
External Support/ Assurance
Progress against original timescale
Revised deadline (if required)
SM5 – Embed skill mix assessments for nursing staff and review nursing establishments and adjust as required to ensure patient safety.
Establishment will be reviewed every 6 months after initial baseline in April 2014. Tracking of staff turnover is undertaken monthly. HR support has been increased to support recruitment and retention.
On going
SM6 – Review nursing staffing levels in both the neonatal and paediatric units to ensure patient safety.
The skill mix review is to be presented to Board 28th October 2014. Increased funding has been agreed for 2.75 WTE nurses in both areas. Posts have been offered to 5 nurses, HR currently processing.
28th February 2014
SM8 – Improve access to training both mandatory and required to undertake the role to ensure that the staff have the knowledge to care for patients for example those at the end of their life
September compliance of mandatory training, 87.59% against target of 85%. “Hot spot” wards identified for additional support.
On Going
All enhanced skills training information available on the Practice Development intranet site. All Ward sisters are aware of dates.
On going
Template sent to band 7’s
All Ward Sisters to undertake a training needs analysis. 31st January 2015
EM3 – Improve the environment in the emergency department, including paediatric A&E, and outpatients; the mortuary also required improvement.
Estates have reviewed the footprint of the plans have been approved. See implementation plan below.
Plan agreed to incorporate new waiting areas for under 16’s, High Acuity area and outside play space
31st March 2015
Mortuary refurbishment design completed , construction work to commence 20th April 2015
3rd July 2015
An outpatient work stream programme has been created by the PMO, to ensure that the right patient is seen in the correct place to meet best practice guidelines and enhance the patient journey. Timescales for delivery to be scoped Wednesday 15th October . Phase one to be completed by 31st March 2015
31st March 2015.
RM3 - Review the elective surgery cancellation rates, and review the elective surgery service demand
As a result of the Emergency Flow Programme commenced 31st July. Cancelled operations continue to reduce (July = 52; Sept = 16, Oct = 25, Nov = 46, Dec = 14).
On going
RM4 – Ensure that patients are discharged in a timely manner across all wards and, in particular, at the end of their life.
Monitoring discharges before midday continues weekly. October Trust-wide compliance 17% against target of 30% (with a variance between wards between 3.1% and 30%). Focus on poor performing wards by project team.
On going
The Queen Elizabeth King’s Lynn NHS Foundation Trust - Our improvement plan
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The Queen Elizabeth King’s Lynn NHS Foundation Trust - Our improvement plan
Summary of Main Concerns Summary of Urgent Actions Required Agreed timescale for implementation
External Support/ Assurance
Progress against original timescale
Revised deadline (if required)
RM5 – Review and improve cancellation rates within outpatients
RM1 - Ensure that outpatient clinics are not overbooked, and cancellations are minimalized
An outpatient work stream programme has been created by the PMO to ensure the right patient is seen in the correct place to meet best practice guidelines and enhance the patient journey. Phase 1 to be initiated 19th January 2015 and is due to be delivered by 12th June 2015.
12th June 2015
RM 6 – Ensure there are sufficient staff on duty at all times who are trained to restrain patients.
Substantive Violence and Aggression Training Officer in post 22nd September. 3 day training in physical restraint techniques and relevant laws will commence mid October. Staff group to be trained:- Site management team (7) 3 members of staff still to be trained and are booked for March 2015. Training of other groups has commenced, 11 people currently trained.
March 2015
WLM1 – Review medical leadership for elective and emergency surgery.
Clinical Director structure discussed at EDs 11th November.
31st December 2014
WLM2 – Ensure an Executive Director is appointed to champion End of Life Care as directed by Norman Lamb in his letter to NHS chief executives.
Dr Watson, Medical Director appointed to role. End of Life Care Strategy task and finish group has been developed. Strategy has been written and will be presented to Board 27th January 2015
31 October 2014
Shoulds ES1 – Ensure that equipment storage, within A&E resuscitation areas, is improved.
A task and finish group has been set up to review and streamline resus. First meeting planned 13th October. Initial work has already been undertaken to move some equipment and stores to a more appropriate area.
31st December 2014
Compliance with daily equipment checks is being monitored weekly. Oct – Non compliant Nov – Non compliant Dec – Non compliant
On going
Paediatric resuscitation equipment to be checked daily
Resuscitation officer to standardise resuscitation folders
ES2 –Ensure that the environment and storage of equipment in the neonatal unit is more organised.
Ward stock has been reduced and a housekeeper has commenced in post to manage stock levels and storage.
31st October 2014
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The Queen Elizabeth King’s Lynn NHS Foundation Trust - Our improvement plan
Summary of Main Concerns Summary of Urgent Actions Required Agreed timescale for implementation
External Support/ Assurance
Progress against original timescale
Revised deadline (if required)
ES4 – Review the equipment used to transport the deceased from the wards to the mortuary to ensure it respects people’s privacy and dignity.
Company to supply trial unit 12th November. Plan to purchase 2 new concealment trollies. Part funding secured from MacMillan
31st December 2014
Trolleys not suitable – to source alternative
Alternative trialled - order to be placed
SS1 – Ensure that there are sufficient numbers of staff who are CBRN trained. (CBRN refers to chemical, biological, radiological and nuclear equipment and policies.)
52 staff have been trained as of end of October 2014. Training will continue every month going forward by the three trained trainers in A&E. This equates to 60% of staff in the department trained against a 60% trajectory for 31st December 2014.
31st March 2015
ES3 – Ensure that plans to strategically move over to NEWS are agreed and implemented. (The NEWS system relates to the management of deteriorating patients)
The Trust will review the move to NEWS in April 2015. April 2015
SS2 – Review the availability of hydration on Pentney, Oxborough and Necton Wards.
The senior nurse in charge on all wards is responsible for coordinating nutrition and hydration. 3 new patient comfort and support workers are currently in post with another 3 commencing in post February 2015. Housekeeper hours have been increased on all wards to support nutrition and hydration.
On going
RS1 – Ensure that all serious incident investigations are undertaken by trained investigators
Funding has been identified for external training of key divisional teams on investigation training. Training dates agreed 4th and 5th March 2015 with 22 people booked to attend. There will be further training sessions rolled out throughout the year.
December 2014 Date slipped to March 2015
All RCA investigation outcomes and action plans to be uploaded to the Patient Safety intranet site to enable shared learning
January 2015
WLS3 - Ensure that all Board members have received training in emergency planning, business continuity and local security specialists
All substantive EDs have undertaken training. New EDs training booked 30th January 2015
January 2015
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The Queen Elizabeth King’s Lynn NHS Foundation Trust - Our improvement plan
Summary of Main Concerns Summary of Urgent Actions Required Agreed timescale for implementation
External Support/ Assurance
Progress against original timescale
Revised deadline (if required)
ES4 - Ensure that all staff work together effectively to enhance the experience of the patients, ensuring effective communication at all levels.
Substantive board will continue to drive forward the Trust Values and Behaviours
On going
WLS1- Ensure that its governance systems, including committee structures, divisional structures, shared learning and incident investigation, are improved and embedded.
KPMG QGF review November 2013 resulting 25 actions, managed through the NHS Choices reporting process.
November 2013
KPMG QGF review November 2014 November 2014
Divisional Structure consultation commenced on 12th September with 3 appointments made.
September 2014
WLS2 - Ensure that there are clear reporting processes and risk monitoring in place for the emergency planning and local security work, including the testing of resilience plans.
Head of Emergency Planning monitors risk locally, regionally and nationally
On going
Table –top and live emergency preparedness exercises carried out as planned throughout the year including: Viral Haemorrhagic Fever; Child Abduction; Loss of IT and Loss of electric supply.
On going
The Queen Elizabeth King’s Lynn NHS Foundation Trust - How our progress is being monitored and supported
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Oversight and improvement action Agreed Timescale for Implementation
Action owner Progress
Monitor appointed Improvement Director, David Hill Appointed 6th January 2014 Monitor Completed
Guys and St Thomas NHS Foundation Trust appointed as ‘Buddy’ Trust Commenced December 2013. QEHKL
A review of our support from a number of different Trusts as appropriate is currently under review to enable support going forward.
End February 2015 QEHKL