Report for Basildon and Thurrock University Hospitals NHS Foundation Trust
Review into the Quality of Care & Treatment provided by
14 Hospital Trusts in England
RAPID RESPONSIVE REVIEW REPORT FOR RISK SUMMIT
July 2013
Contents
1.
Introduction
3
2.
Background to the Trust
7
3.
Key Lines of Enquiry
11
4.
Review findings
13
5.
Governance and leadership
15
Clinical and operational effectiveness
21
Patient experience
30
Workforce and safety
35
Pharmacy support
41
Conclusions and support required
Appendices
42
46
Appendix I:
SHMI and HSMR definitions
47
Appendix II:
Panel composition
49
Appendix III:
Interviews held
50
Appendix IV: Observations undertaken
51
Appendix V:
52
Focus groups held
Appendix VI: Information available to the RRR panel
53
Appendix VII: Unannounced site visit
57
2
1. Introduction
This section of the report provides background to the review process and details of the key stages of the review.
Overview of review process
On 6th February the Prime Minister asked Professor Sir Bruce Keogh, NHS England Medical Director, to review the quality of the care and treatment being provided by those
hospital trusts in England that have been persistent outliers on mortality statistics. The 14 NHS trusts which fall within the scope of this review were selected on the basis that
they have been outliers for the last two consecutive years on either the Summary Hospital level Mortality Indicator (SHMI) or the Hospital Standardised Mortality Ratio
(HSMR). Definitions of SHMI and HSMR are included at Appendix I.
These two measures are intended to be used in the context of this review as a ‘smoke alarm’ for identifying potential problems affecting the quality of patient care and
treatment at the trusts which warrant further review. It was intended that these measures should not be reviewed in isolation and no judgements were made at the start of the
review about the actual quality of care being provided to patients at the trusts.
Key principles of the review
The review process applied to all 14 NHS trusts was designed to embed the following principles:
1) Patient and public participation – these individuals have a key role and worked in partnership with clinicians on the reviewing panel. The panel sought the views of the
patients in each of the hospitals and also considered independent feedback from stakeholders, related to the Trust, which had been received through the Keogh review
website. These themes have been reflected in the reports.
2) Listening to the views of staff – staff were supported to provide frank and honest opinions about the quality of care provided to hospital patients.
3) Openness and transparency – all possible information and intelligence relating to the review and individual investigations will be publicly available.
4) Cooperation between organisations – each review was built around strong cooperation between different organisations that make up the health system, placing the
interest of patients first at all times.
Terms of reference of the review
The review process was designed by a team of clinicians and other key stakeholders identified by NHS England, based on the NHS National Quality Board guidance on rapid
responsive reviews and risk summits. The process was designed to:

Determine whether there are any sustained failings in the quality of care and treatment being provided to patients at these Trusts.
3

Identify:
i.
Whether existing action by these Trusts to improve quality is adequate and whether any additional steps should be taken.
ii.
Any additional external support that should be made available to these Trusts to help them improve.
iii.
Any areas that may require regulatory action in order to protect patients.
The review follows a three stage process:

Stage 1 – Information gathering and analysis
This stage used information and data held across the NHS and other public bodies to prepare analysis in relation to clinical quality and outcomes as well as patient and staff
views and feedback. The indicators for each trust were compared to appropriate benchmarks to identify any outliers for further investigation in the rapid responsive review
stage as Key Lines of Enquiry (KLOEs). The data pack for the trust reviewed is published at http://www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/trust-datapacks/data-pack-basildon-and-thurrock.pdf.

Stage 2 – Rapid Responsive Review (RRR)
A team of experienced clinicians, patients, managers and regulators (see Appendix II for panel composition), following training, visited each of the 14 hospitals and observed
the hospital in action. This involved walking the wards and interviewing patients, trainees, staff and the Senior Executive Team. The report from this stage will be considered
at the risk summit.

Stage 3 – Risk summit
This will bring together a separate group of experts from across health organisations, including the regulatory bodies. They will consider the report from the RRR, alongside
other hard and soft intelligence, in order to make judgements about the quality of care being provided and agree any necessary actions, including offers of support to the
hospitals concerned. A report following each risk summit will be made publically available.
Methods of Investigation
The two day announced RRR visit took place at the Trust’s main site on Tuesday 7 and Wednesday 8 May 2013. A variety of review methods were used to investigate the
KLOEs and enable the panel to consider evidence from multiple sources in making their judgements.
The visit included the following methods of investigation:

Listening events
Public listening events give the public an opportunity to share their personal experiences with the hospital, and to voice their opinion on what they feel works well or needs
improving at the Trust. A listening event for the public and patients was held on the evening of 7 May 2013 at the Education Centre on the Basildon Hospital site. This was
an open event, publicised locally, and attended by approximately 30 members of the public, patients and staff.
4
The panel would like to thank all those who attended the listening event and were open with the sharing of their experiences and balanced in their perceptions of the quality of
care and treatment at the Trust. The panel found the listening event extremely useful as it identified a number of positive themes around patient experiences, along with
highlighting a number of areas for further investigation.
Information obtained about the quality of care and treatment at the Trust from the listening event was used to drive the panel's agenda for the second day of the announced
site visit and for the unannounced site visit. Relevant areas emerging have been included within this report.

Interviews
Twelve interviews took place with key members of the Executive Team, Non Executive Directors and selective members of staff based on the KLOEs during the visits. See
Appendix III for details of the interviews undertaken.

Observations
Ward observations enabled the panel to see the Trust undergo its day to day operations. They allowed the panel to talk to current patients, and their families where
observations took placed during visiting hours. They allowed the panel to speak with a range of staff and enabled the panel to analyse any observed handover processes
within wards, to ensure that the staff that are coming on duty are appropriately briefed on patients.
During the RRR announced visit, observations took place in 17 areas of the Basildon Hospital and an additional observation took place at Orsett Hospital. See Appendix IV
for details of the observations undertaken.

Focus Groups
Focus groups provide an opportunity to talk to staff groups individually and to ask each area of staff what they feel is the contributing factor to the Trust’s high mortality scores.
They enable staff to speak up if they feel there is a barrier that is preventing them from providing quality care to patients.
Focus groups were held with six staff groups, including a focus group open to all staff, during the announced site visit. See Appendix V for details of the focus groups held.
The panel would like to thank all those who attended the focus groups. The groups were open and balanced in sharing their experiences, as well as in their perceptions of the
quality of care and treatment at the Trust.

Review of documentation
A number of documents were provided to the panellists through a copy being available in the panel’s ‘base location’ at the Trust during the site visit. Whilst the documents
were not reviewed in detail, they were available to the panellists to validate findings. See Appendix VI for details of the documents available to the panel.
5

Unannounced visit
The unannounced site visit took place on the evening of Sunday 12 May 2013. This focused observations in identified areas from the announced site visit, see Appendix VII.
Next steps
This report has been produced by Dr David Levy, Panel Chair, with the full support and input of panel members. The RRR findings contained in this report have been agreed
with the Trust for factual accuracy. This report was issued to attendees at the risk summit, which focussed on supporting Basildon and Thurrock University Hospitals NHS
Foundation Trust (“the Trust”) in addressing the actions identified to improve the quality of care and treatment.
Following the risk summit the agreed action plan will be published alongside this report on the Keogh review website. A report summarising the findings and actions arising
from the 14 investigations will also be published 16 July 2013.
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2. Background to the Trust
This section of the report provides background information on the Trust.
Introduction
The Trust became one of the first ten Foundation Trusts in the country in 2004 and has a total of 667 beds. Prior to this, in 2002, the Trust had gained University Hospital
status. The Trust services a population of approximately 400,000 and has more than 10,000 public members as well as 3,700 staff.
1
The Trust’s SHMI has been above the expected level for the last two years (112 ) and was therefore selected for this review. The Trust’s HSMR is within the expected range
(106).
Trust size and focus
The Trust is a medium sized Trust, relative to the rest of England, for both inpatient and outpatient activity. The Trust provides an extensive range of acute medical services
with overnight beds. Regulated services provided by the Trust are: diagnostic and screening procedures; management of supply of blood and blood derived products;
maternity and midwifery services; surgical procedures; termination of pregnancies; and treatment of disease, disorder or injury. Nephrology and Gynaecology are the largest
inpatient specialties while Trauma & Orthopaedics and Dermatology are the largest specialties for Outpatients.
The Trust has 66% market share of inpatient activity within a 5 mile radius of the Trust sites. However, the Trust’s market share falls to 31% within a radius of 10 miles and
8% within a radius of 20 miles. The main competitors in the local area are Southend University Hospitals NHS Trust, Mid Essex Hospital Service NHS Trust, Barking,
Havering and Redbridge University Hospitals NHS Trust and Colchester Hospital University NHS Foundation Trust.
The Trust has two hospital sites – Basildon Hospital and Orsett Hospital – with the Essex Cardiothoracic Centre (CTC) also located within the grounds of Basildon Hospital.
The CTC opened in 2007 and is one of the most modern centres of its kind in the country. Heart attack victims from across the county are brought directly to the CTC to have
stents fitted to repair constricted coronary arteries. It also has 24 haemodialysis stations; this is the largest renal unit in Essex. The unit currently has over 150 patients
receiving haemodialysis daily, six days a week.
Basildon and Thurrock’s population
Basildon and Thurrock is not a particularly deprived region of England. Over 65s constitute a lower proportion of the population in this region, compared to their proportion of
the English population as a whole. However, obesity is a particular health concern in this region, just as postnatal care is below the national average on some measures. The
ethnic composition of the population varies significantly between the two unitary authorities that comprise the region, with Thurrock being home to a higher percentage of
Black African, Indian and other ethnic minorities than Basildon. 7% of Basildon’s population belong to non-White ethnic minorities.
Childhood obesity is significantly more common, whilst breastfeeding is significantly less common than in the rest of England. Basildon and Thurrock’s health profile outlines
that there are a number of aspects for which children’s and young people’s and adult’s health is significantly lower than the national average. It also shows that in Basildon
and Thurrock male life expectancy is slightly lower than the national average.
1
Source: Healthcare Evaluation Data (HED)
7
Key messages from the data analysis
2
The Trust data pack identified a number of key concerns that were used to inform the KLOEs, which are outlined below .
Mortality
The Trust has an overall SHMI of 112 for the last twelve months, meaning that the number of actual deaths is higher than the expected level.
Deeper analysis of this demonstrates that non-elective admissions are the primary contributing area to this figure, with a SHMI of 112 compared to a level of 92 for elective
admissions. Specialty-level analysis of SHMI results highlighted some key diagnostic groups for further review: cancer of colon; general surgery; general medicine; palliative
medicine and geriatric medicine.
The Trust has an overall HSMR of 106 for the period 1 January 2012 to 31 December 2012 and which, though above 100, is still within the expected range.
As with SHMI non-elective admissions are seen to be contributing primarily to the overall Trust HSMR with 107, against 84 for elective admissions. In addition, the Trust is an
outlier for weekend mortality based on HED mortality; this shows mortality is not flat across weekdays and weekends. The data shows changes by small increments but the
trend is consistent and weekend mortality a statistical outlier. It is noted that the Trust’s analysis of the data suggests that its death rate is flat across the full week and the
weekend mortality is made to look higher due to the rate of discharge fluctuating between weekday and weekend. It is agreed that a reduction in discharge rates could
potentially affect the HSMR.
Specialty-level analysis highlighted areas for further review in non-elective admissions: Coronary atherosclerosis (blocked arteries) and other heart disease and senility and
organic mental disorders. Review of diagnostic groups revealed further areas for analysis including cancer of bronchus, lung; cancer of colon and chronic obstructive
pulmonary disease and bronchiectasis.
The KLOEs for the RRR informed the panel’s observations and interviews to include a review of the specialities in the Trust with higher mortality indicators.
Governance and leadership
The Trust was deemed to be in significant breach by Monitor in 2009 as a result of concerns raised by the Care Quality Commission (CQC). These concerns included high
mortality indicators, poor infection control and concerns regarding clinical leadership. Since this period the Trust continues to have a 'red' governance rating.
There have been a number of changes to the Board over the last 18 months including the appointment of a new Chief Executive in September 2012 and a new Medical
Director in February 2013. All executive roles are permanent, except for the current Director of Estates (interim) and the current Finance Director (acting up). The Trust
established a new Clinical Director role on 1 April 2013, as part of the new clinically-led operational management structure which has five clinical divisions, instead of the
previous three.
The Trust has established a Hospital Mortality Review Group (HMRG) which meets fortnightly and is chaired by the Medical Director. It also has a Quality & Patient Safety
subcommittee, which provides the Board with assurance on quality and has a non-executive chair. The Board governance structure is currently being revised following a
review by the Good Governance Institute.
A high level review of the effectiveness of the Trust’s quality governance arrangements was a standard key line of enquiry for the review.
2
For further information and explanations on the data analysis used please see the published data packs please at http://www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/trust-data-packs/data-pack-basildonand-thurrock.pdf.
8
Clinical and operating effectiveness
The Trust saw 92.3% of patients attending accident and emergency (A&E) within 4 hours in 2012. This is below the 95% target level and performance has been dropping in
recent years. In the year to February 2013, 89% of patients referred to the Trust were seen and treated within the 18 week target time (RTT) which is lower than the target
level.
3
The Trust’s readmission rates are lower than average and it has a shorter than national mean average length of stay for the period January 2012 to December 2012 , which is
generally considered to be an indicator of efficiency. It is noted that the Trust benchmarked analysis has identified their length of stay to be above average.
Patient Reported Outcome Measures (PROMs) assess the quality of care delivered to NHS patients from the patient perspective, currently covering four clinical procedures
(hip replacements, knee replacements, hernia and varicose veins). PROMs calculate the health gains after surgical treatment using pre and post-operative surveys. The
Trust is in line with the average outcomes across the procedures covered but the average health gain from hip replacement declined in each of the last two years, and is now
close to the lower control limit (outcomes less good than average).
High level reviews of clinical and operating effectiveness measures were standard KLOEs.
Patient experience
Of the nine measures reviewed within Patient Experience and Complaints there are three which are rated ‘red’: ‘Cancer Survey’, ‘Patient Voice Comments’ and ‘Complaints
about Clinical Aspects’.
Particular areas of concern from the ‘Cancer Survey’ were diagnostic tests, deciding best treatment and hospital doctors.
The Care Quality Commission’s Patient Voice helpline received 144 individual comments from patients and public for the Trust in the two years to 31 January 2013. 66 of
these comments were negative (46%) and 62% of complaints related to clinical treatment (the average is 47%).
The Trust is A-rated by the Ombudsman for satisfactory remedies which indicates a low risk for non-compliance with its recommendations. The Ombudsman investigates
complaints escalated to it by complainants who are not satisfied with the Trust's response. It rates Trusts on whether they have implemented the recommendations made at
the end of an investigation in a satisfactorily and timely manner, helping to ensure that Trusts learn from mistakes. The Ombudsman rates each Trust’s compliance with
recommendations and focuses on monitoring organisations whose compliance history indicates that they present a risk of non-compliance.
The patient voice comments received directly to the Keogh review website (at the time of writing this report) identified the following themes from 29 emails and letters:
Positive
Negative
Good care in intensive care unit
Lack of communication
Excellent after-care and treatment received after surgery
Lack of basic patient care
No follow up or change of medication
3
Source: HED. Data source listed as Hospital Episode Statistics.
9
Positive
Negative
Lack of respect for family members
Neglect to inform family of illness prior to death
The patient listening event also identified a number of themes for further investigation, including:

Frequent bed moves for inpatients

Inappropriate discharge arrangements

Examples of a lack of compassion from some staff

PALS appearing to serve the hospital rather than the patient.
KLOEs were included in the review focusing on what patients say about the quality of care and treatment and what the Trust was doing in response to this
feedback.
Workforce and safety
The NHS Safety Thermometer monitors trust incidents and measures rates of harm. The Trust is ‘red rated’ in four of the safety indicators: rate of “serious harm”, “harm” for
all four safety thermometer indicators, pressure ulcers and clinical negligence scheme payments. The Trust is higher than average terms of the percentage of patients that
develop new pressure ulcers once admitted.
The Trust’s Clinical Negligence scheme payments have exceeded contributions to the ‘risk’ sharing scheme’ in each of the last 3 years. A review of the Coroners rule 43
reports flagged two items:


Review of risk assessment
Record keeping
A review of the workforce data flagged eight ‘red rated’ indicators. Most notably the Trust’s response rate to the staff survey rate has fallen since 2011 and is below national
average rate for both years on almost all indicators. The Trust’s staff engagement is below average when compared with trusts of a similar type in the 2012 National Staff
Survey Results. The Trust is below the national average on all but one - care of patients/service users in my organisation’s top priority - of the organisational questions.
KLOEs were included in the review focusing on pressure ulcers, workforce measures and what staff say about the quality of care and treatment.
10
3. Key Lines of Enquiry
The Key Lines of Enquiry (KLOEs) were drafted using the following key inputs:

The KLOEs which were included expected areas of focus for all 14 trusts building on the RRR guidance and design work.

The Trust data pack produced at Stage 1 and made publicly available to tailor the KLOEs to address any areas the Trust was an outlier in (see section 3 for more details).

Insights from the Trust’s lead Clinical Commissioning Group (CCG), Basildon and Brentwood CCG.

Review of the patient voice feedback received via the Keogh review website specific to the Trust prior to the site visit.
These were agreed by the panellists at the panel briefing session prior to the RRR visit.
The KLOEs identified for the Trust were as follows:
Theme
Key Line of Enquiry
Governance and leadership
1. Can the Trust clearly articulate its new governance processes for assuring the quality of treatment of care? Can
staff at all levels of the organisation describe the key elements of the quality governance processes?
Clinical and operational effectiveness
2. What actions are the Trust taking to improve mortality performance, particularly having had an ongoing issue with
mortality over a number of years and a significant difference between weekday and weekend mortality? How does
the Trust manage deteriorating patients?
3. What actions are the Trust taking to reduce pressure ulcers and falls?
4. What processes does the Trust have to manage bed occupancy? How does the Trust manage beds? How does
the Trust manage patient moves during their time in hospital including between the main hospital and the
Cardiothoracic Centre?
Patient experience
5. How does the Trust seek views from patients about their experience? What are the key themes from patients on
their experiences? What action is the Trust taking to address the key themes emerging? In particular, what actions
have been taken to improve cancer care?
6. How does the Trust ensure adequate quality of care to patients with learning disabilities?
Workforce and safety
7. What do staff groups interviewed (including trainee groups) say are the main barriers in the Trust to delivering high
quality treatment and care for patients?
11
Theme
Key Line of Enquiry
8. How does the Trust approach workforce planning to ensure that patient safety is managed effectively including skill
mix? How is clinical cover managed out of hours particularly at weekends for patients on the emergency pathway?
9. How does the Trust support its staff with adequate training, including safeguarding training?
Trust specific – pharmacy support
10. How does the Trust ensure that there is adequate pharmacy support to the wards, including out of hours?
12
4. Review findings
Introduction
The following section provides a detailed analysis of the panel’s findings, including good practice noted, outstanding concerns and prioritisation of actions required. A high
level summary of the areas identified for urgent action are as follows:
Leadership and governance:

Prioritisation of improvement plans – the panel noted a significant numbers of plans for improving quality of care and services currently in place at the Trust, in
response to the many reviews undertaken in recent years. The Trust needs to develop a single, prioritised action plan to focus on the key improvement areas noted
in this report

Developing quality focus - the Trust needs to evidence a clearer focus on quality through its improvement and delivery plans

Clarity of governance – the Trust needs to ensure that its new governance structure is embedded and well communicated to its staff
Clinical and operational effectiveness:

Bed management – the systems for bed management and patient flows need to be urgently reviewed and improved

Infection control – the Trust needs to ensure its infection control procedures are consistently applied in the organisation and undertake audits to gain assurance on
this area
Patient experience:

Action on patient experience themes – the Board needs to urgently review and understand what their patients’ views are and address key complaints themes.
Workforce and safety:

Staffing and skill mix – the Trust needs to review its current staffing levels for nursing and medical staff and action any changes required for improving quality and
safety of care.
13
The following definitions are used for the rating of recommendations in this review:
Rating
Definition
Urgent
The Trust should take immediate action to respond to these recommendations and
ensure improvement in the quality of care
High
The Trust should develop a response and action plan for these recommendations to
ensure improvement in the quality of care
Medium
The Trust should implement these recommendations to ensure ongoing improvement
in the quality of care
14
Governance and leadership
Overview
The review into governance and leadership focused on the articulation and understanding of the new governance processes for assuring the quality of treatment of care.
The following good practice was identified:

The Trust has recognised that the previous governance processes were not fit for purpose and has reorganised its structure.

Recognition by the Trust that it needs to improve quality of care and treatment.

The visibility and positive impact of the new Chief Executive (CEO).

A good working relationship between the Director of Nursing and new Medical Director.
The following areas of concern were identified:

An absence of organisational stability and frequent external reviews have led to a lack of clear prioritisation on improvement plans.

There is a lack of clarity of governance.

A focus on quality is still being developed.

There is a gap between ward level and Board level in terms of understanding of quality governance arrangements.
For all the above areas of concern the panel identified a number of improvements already underway at the Trust or planned improvements demonstrating the Trust’s
continued progress and improvement. Many of these are in the process of implementation and are not yet embedded.
15
Detailed Findings
Understanding of the new governance processes for assuring the quality of treatment of care
KLOE 1: Can the Trust clearly articulate its new governance processes for assuring the quality of treatment of care? Can staff at all levels of the organisation describe the
key elements of the quality governance processes?
Good practice identified
During interviews, the Trust Chief Executive noted that the previous governance processes were not fit for purpose and that changes were required. At the time of the
visit she had started to implement these changes including introduction of a Director of Transformation, appointment of a new Medical Director and a restructuring of the
clinical divisions from three to five. The changes to the Board of Directors, since the appointment of the new CEO, have been communicated to staff by the CEO through
a number of ways including the CEO blog.
During interviews, the Trust Executive Team acknowledged that there were issues with the quality of care and treatment at the Trust. For example, the Chief Executive
recognised that prior to her appointment the Trust had achieved its financial targets but quality and safety were not considered such a high priority. The Trust had not
prioritised care of its emergency patients and sickest patients. Furthermore, the Executives interviewed recognised the significant levels of work needing to be done at
the Trust to change the culture and focus on quality and patient experience. The CEO had appointed a Director of Transformation to ensure a focus on the
transformational work, to prioritise actions and clearly focused on long term sustainable solutions.
Throughout the visit during focus groups, one to one interviews and ward observations the staff throughout the Trust noted the visibility and positive impact of the new
CEO, citing the CEO blog as one such example.
We observed a good working relationship between the Director of Nursing and new Medical Director, further demonstrated by the joint chairing role of the Clinical Quality
Board.
Patients, staff and the Trust Board interviewed consistently spoke of a changing culture at the Trust, albeit slowly, to one of improvement and forward planning. The Trust
recognises the significant amount of work still to be done.
16
Outstanding concerns based on evidence
gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
i. Absence of stability and clear prioritisation
The Trust is now demonstrating a
desire to review current practices,
understand issues and design
solutions in a more proactive way so
as to sustain the required
improvements.
The Trust should put in place a single clinical
strategy for the Trust.
High
The Board should approve a single, prioritised
action plan for the Trust showing clearly the
priorities by time period, e.g. for the next six
months, six months to a year and so on. This
should be clearly communicated to staff.
Urgent
The Trust has been under scrutiny for an ongoing
period and has undergone a number of reviews;
including a number commissioned by the new Chief
Executive to gain an in-depth understanding of the
issues at the Trust. Historically the Trust has
generally been viewed as a reactive organisation
rather than a proactive one when dealing with issues
and concerns.
A number of staff members talked of the number of
reviews that the Trust has undergone in recent years
and the tendency of the Trust Executive to react with
significant change in response to the reviews. Staff
members referred to “knee jerk reactions” and spoke
of not being able to see initiatives through and
evaluate their impact, moving onto the next thing
before completing the last. Staff expressed concern
that they did not know whether initiatives had been
completed, for example ‘right patient, right place’,
which some thought had been abandoned.
In January 2013, the Trust appointed
the Director of Finance as Deputy
Chief Executive and gave him the
responsibility of leading the Trust’s
transformation programme.
Interviews with the Chief Executive
identified that this role will include
prioritisation of actions for the Trust.
The Chief Executive and Chair have
stated that they will ensure that they
will regularly review, through the
board development programme, that
the Trust has the necessary skills,
background and experience to lead
the organisation on an ongoing basis.
Whilst the Executives interviewed referred us to a
number of action plans in place, we observed an
absence of prioritisation of the actions. Staff, including
some of the Executive Team, were unable to clearly
articulate the key priorities for the Trust.
17
Outstanding concerns based on evidence
gathered
ii. Lack of clarity of governance arrangements
Key planned improvements
The restructuring of clinical
governance is underway and the
Whilst Board members interviewed could articulate
members of the Executive interviewed
the governance restructuring, this was still in the
stated the implementation date as 1
implementation stage. A number of actions will not be June 2013.
in place until 1 June 2013 so it was not possible for
the panel to understand the new arrangements fully.
An improvement plan in place is using
the Hub, the Trust’s intranet
The majority of staff members interviewed had a
communication tool, as a mechanism
limited understanding of the new structure and lines of of communication.
accountability going forward.
Recommended actions
Priority – urgent,
high or medium
Communication of the revised structure to all staff,
clearly detailing the new structure, and the policies
and processes to be used, so there is clarity of
how the new system works.
Urgent
Middle management should be engaged to ensure
that communication is effective throughout the
Trust.
Medium
18
Outstanding concerns based on evidence
gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
iii. Quality focus still being developed
The Chief Executive stated that a
NED with a clinical background will be
sought as part of the next rotation of
NEDs.
The Trust will need to consider how it develops a
clearer focus on quality, based on transparent
information and a tone from the top. This should
include implementation of the planned
improvements and recommended actions in this
report.
Urgent
The Trust has a Quality and Patient Safety
Committee, which is a subcommittee of the Board. It
was clear from our interviews with the Chief
Executive, Medical Director and Director of Nursing
that they recognised the need for a quality and safety
focus to be developed at the Trust. The Trust
governors attending the focus group stated that they
had appointed Non Executive Directors (NEDs) with
the background and skills to address the issues faced
by the Trust.
We noted the following issues:
 The Trust does not have a NED with a clinical
background.
 The Board agenda has not had a Nursing Report
presented for over a year.
 The Board does not hear patient stories (see also
KLOE 5).
 The Board only receives details of numbers of
complaints and response times, not the detail of
the complaints (see also KLOE 5).
 The panel could not clearly see quality risks
recorded on the Board Assurance Framework.
 The Governors did not appear to take a fully
active role on quality, receiving information rather
than actively requesting it and using it to
challenge the Trust.
We were informed that a Nursing
Report was to be received by the May
2013 Board meeting.
Governors should be more active in their role of
holding the Board to account on all aspects of
We were informed that a patient story quality. The Trust has 50 governors and should
would be heard by the May 2013
consider a reduction in numbers of governors and
Quality and Patient Safety
offer them further development so they can
Committee.
undertake their role more effectively.
High
The recent appointment of a new
Medical Director in January 2013
along with the new Chief Executive
alongside the Director of Nursing was
cited by a number of staff spoken to
as increasing the quality focus at the
Trust.
Governors commented they now
considered the Trust engages with
them and responses to their
concerns.
19
Outstanding concerns based on evidence
gathered
Key planned improvements
Recommended actions
iv. Gap between ward level and Board level
A number of staff interviewed
provided positive feedback on actions
underway by the Chief Executive in
particular, including reference to
increased visibility and the CEO blog.
The Trust Board should consider how it can
High
strengthen their visibility, accessibility and listening
mechanisms with staff (also with patients and the
public, see KLOE 5). This could include visiting
areas of the hospital, including at night and during
weekends, to understand the current position and
any concerns.
The panel considered that processes and actions
articulated by the Board members interviewed were
not consistently understood by ward level staff
interviewed.
Whilst staff interviewed spoke positively of the Board,
the majority of comments were specific to the Chief
Executive rather than the Board as a whole and very
limited reference was made to the NEDs.
A number of staff interviewed spoke of the Executive
Team open door policy in a positive manner, although
comments were made that this was seen as an open
door to more senior staff rather than all staff. It was
also noted that the open door policy was unrealistic in
practice, as the management offices were separately
located at a distance from operations. Comments
were made that the Board only visited the staff to
perform checks and audits.
Continued executive open door
policy.
Priority – urgent,
high or medium
These visits should be clearly distinguished from
audits and checks performed by the Board
throughout the Trust. These should involve all
Board members and the Trust should consider
including NED only events.
High
Board to review the BAF and ensure that it
captures significant risks to the quality of care and
treatment, including workforce issues, considering
patient and staff feedback and concerns.
High
It was clear that the changes being implemented were
closing the gap and the panel observed a positive
movement in this area.
Staffing issues are not included within the Board
Assurance Framework, (BAF) despite there being
poor morale amongst some staff and concern about
staffing levels.
20
Clinical and operational effectiveness
Overview
The three KLOEs in the clinical and operational effectiveness area focused on the following:

Actions to improve mortality performance, particularly having had an ongoing issue with mortality over a number of years and weekend mortality being a statistical outlier
based on HED mortality.

Actions to reduce pressure ulcers and falls.

Management of beds.
The following good practice was identified:

The Patient at Risk Support (PARS) escalation process and team.

Development of a real time measure of SHMI (crude) for ongoing monitoring, as well as detailed mortality reviews.

Examples of good levels of cleanliness.

The use of sepsis care bundles.

Good assessment practices and incident reporting for both pressure ulcers and falls.

Regular bed management meetings to manage capacity challenges.
The following areas of concern were identified:

Understanding of mortality issues throughout the Trust.

Dissemination of lessons learned throughout the Trust.

Out of hours staff cover.

Examples of areas where the panel observed that infection control management still needed to be improved.

An effective ambulatory care operating model was not clearly in place.

Quality impact assessing of cost improvement plans (CIPs).

The need for wider and consistent use of care bundles.
21

Inconsistent use of Trust policy for pressure ulcer grading.

Bed flows and management.
For the majority of the areas of concern, above, we identified a number of improvements planned or already underway at the Trust evidencing continued progress.
Detailed Findings
Improvement of mortality performance
KLOE 2: What actions are the Trust taking to improve mortality performance, particularly having had an ongoing issue with mortality over a number of years and a significant
difference between weekday and weekend mortality? How does the Trust manage deteriorating patients?
Good practice identified
Staff interviewed were consistently very supportive of the PARS team for management of deteriorating patients and their support and visibility on the wards. Escalation
of concerns was evidenced through review of a sample of patient notes and speaking with members of the PARS team who confirmed that sicker patients were referred
to them throughout the Trust.
The Trust has developed a real-time crude SHMI to monitor mortality performance on an ongoing basis.
One key consultant was found to be undertaking 100% death reviews and findings were being discussed with peers at mortality review meetings, evidencing a sharing
of lessons learned. In addition 20% of mortality reviews are independently assessed.
The Trust is participating in the national cardiac arrest audit.
During the visit, examples of good practice were observed and staff and patients provided further examples, including:
 Bulphan ward – good practice and good level of care observed.
 Caring assistance provided to elderly people with eating.
 Lionel Cosins ward – observers impressed with the level of care given to elderly patients.
 Kingswood ward – good levels of care observed.
 Orsett ward – able to demonstrate evidence through the nearest set of patient notes to the observation team indicating a consistent approach to care.
 Pre-assessment service for surgical elective patients.
 In-patient risk and assessment documentation.
 Fracture of the femur service including excellent multi professional orthopaedic team and theatre capacity.
During the visit, examples of good levels of cleanliness observed, including:
 Patient observations that A&E is cleaner than previously.
 Examples of clean wards observed throughout the Trust.
22
Good practice identified

Elsdon ward out of hours observation found the ward to be clean and tidy and infection control was considered by the observers to be very good.
The discharge lounge and refurbished clinical decision unit were observed to be well designed clinical areas, including being in close proximity to A&E.
The Trust’s use of sepsis care bundles.
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
i. Understanding of mortality issues throughout the
Trust
The governance restructure
includes the Quality and Patient
Safety Committee responsible for
the review of the Trust developed
crude SHMI.
The Trust should consider ways to increase
understanding and ownership of mortality
performance throughout the organisation. This
should include mortality reviews undertaken through
multidisciplinary speciality groups so that these
groups take ownership of mortality performance.
High
Mortality performance is an agenda item at Board
meetings. This agenda item is led by the Medical
Director and Director of Nursing with support from a
NED.
When interviewed, a number of staff and governors
within the organisation stated that the Trust’s mortality
performance was due to sicker patients being admitted
(which is to some extent already taken into account in
calculating mortality rates). The Trust Executive Team
and staff did not demonstrate that they had reviewed
mortality data in detail to understand the root causes
and identify improvement actions that could be taken.
ii. Dissemination of lessons learnt
There was limited evidence of systematic mortality and
other clinical reviews being undertaken, lessons being
learnt and dissemination of these themes across the
whole Trust.
The Trust has a mortality reduction
programme that has three strands –
improving information, focus on
outlier pathways and mortality
review.
The Board has an explicit prioritised
objective to reduce crude mortality
to less than 2%.
The panel obtained evidence of
good practices throughout the Trust
and reviews were being undertaken
to learn lessons from them. For
instance cross-ward senior nurse
meetings were being held
See the single prioritised action plan recommended High
in KLOE 1(i) – to contain reference to improvement
of mortality performance and actions that the Trust
own to manage performance. This should be clearly
communicated to all staff.
The Trust should evaluate the performance of the
new Quality and Patient Safety Committee by the
Board in six months to assess its effectiveness in
monitoring and managing mortality performance.
Medium
The Trust should consider further investment in
High
learning from reviews and ensure that lessons learnt
and key themes are clearly disseminated throughout
the organisation.
Medical staff job planning should be reviewed to
High
23
Outstanding concerns based on evidence gathered
From discussion with medical staff, it appeared that
they have very little protected time to undertake clinical
audit. The panel observed that many board clinical
audit reports were incomplete.
iii. Out of hours staff cover
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
periodically, enabling good practice
to be shared and nurses to learn
from each other.
ensure all medical staff have protected time that is
appropriately used to undertake clinical audit and
attend clinical audit meetings.
See KLOE 8(ii) for details.
See KLOE 8(ii) for details.
The Director of Nursing states that
the Trust has an infection control
action plan.
Immediate improved infection control using policies
consistently across the Trust through ownership at
divisional and ward level.
Urgent
Use of processes that incentivise the staff to comply
with infection control policies, for example
publication of infection data by ward.
High
Board to review infection control plan and to seek
assurance that leadership is in place at all levels to
deliver the action plan.
High
Ambulatory care should be further reviewed and
developed at the Trust, working with the CCG to
agree protocols for common ambulatory conditions.
High
We identified issues with staff cover, including junior
doctor workload, particularly out of hours and at
weekends. This will impact performance and
effectiveness. See KLOE 8(ii) for details.
iv. Examples of infection control concerns
Whilst the panel observed examples of good practice in
infection control during the site visit, issues were also
noted in some areas:
 A member of staff entering an isolation area without
using universal precautions.
 Observation of the Surgical Referral Unit, out of
hours, found a number of infection control concerns
on the ward including empty drip bags, IV lines with
no covering on the end and no evidence of IV line
labelling.
 Concerns raised by staff about the building work in
the Cardiothoracic theatres proceeding without
infection control input.
v. Ambulatory care model not evidenced
The panel did not obtain evidence that the ambulatory
care model was sufficiently well defined at the Trust.
None identified
24
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
The Trust was only using ambulatory care for one
clinical indication and examples were noted of
unnecessary admissions.
vi. Quality impact assessment of CIPs
The Trust has a £15 million CIP target for 2013/14.
Whilst interviews with Executives evidenced some
clinical sign off of CIPs, the panel did not identify a
clearly articulated and consistent response as to how
CIPs are Quality Impact Assessed (QIA) before
approval, or monitored once implemented. Whilst some
interviewees stated that the Medical and Nursing
Directors are involved in all CIP sign off, the Medical
and Nursing Director themselves said they were
involved only where there was a patient impact.
The Medical Director and Director of The Medical Director and Director of Nursing’s
Nursing are involved in some CIP
involvement in all CIP sign-off should be understood
sign off.
and clearly and consistently articulated by all
Executives with Board sign-off of the full CIP
programme for each year.
The QIAs should be regularly reviewed and
monitored. Where a concern over quality is
identified, this risk should be properly mitigated
before the plan is allowed to go ahead / continue.
In future years, the full CIP programme with QIA
should be completed and signed off by the Trust
Board before the start of the financial year.
High
High
There was a wide variation in the value of CIPs
considered to be signed off and approved by different
members of the Executive Team ranging from £6m to
almost all of the full £15m.
Executives were unable to give strong examples of
where the Board had stopped a proposed plan being
implemented or subsequently paused or changed due
to quality concerns. The Trust state that this is due to
2012/13 CIPs largely consisting of additional income
due for extra activity from the PCTs rather than being
quality related.
There appeared to be no quality monitoring process for
CIPs. Executives were unable to clearly articulate
triggers that would be used by the Board to identify if
25
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
The Trust states that it is actively
reviewing care against care bundles
and leads have dedicated time
allotted for pneumonia, sepsis,
COPD, AMI (acute myocardial
infarction) and senility.
Regular planned audits of the use of all care bundles High
should take place and the results shared with clinical
teams and at Board level.
delivery of a CIP is leading to a quality issue and the
need to consider pausing, stopping or changing a CIP.
The Trust state that the root cause of this issue is not a
weakness in process but one of articulation in part
caused by the timing of the review falling at the start of
the financial year and an issue articulating the
differences between 2012/13 and 2013/14.
vii. Use of care bundles
Care bundles for the management of patients with
some common conditions such as pneumonia and
sepsis were available in the Trust. However, the panel
noted that these were not always used by clinical staff
on wards observed.
Pressure ulcers and falls
KLOE 3: What actions are the Trust taking to reduce pressure ulcers and falls?
Good practice identified
The panel observed good assessment practices in place for both pressure ulcers and falls, with the Trust tools for these areas seen to be being used by staff. Good use of
systems was evidenced for both skin assessment and the falls process, with appropriate access to equipment.
The panel observed actions taken by staff to reduce pressure ulcers including observing good use of slide sheets and air mattresses.
The panel’s review of the Hub and discussion with staff concluded that it was a straightforward process to order equipment to reduce pressure ulcers such as mattresses.
Review of a sample of patient notes provided evidence of comfort rounds taking place.
Review of incidents reported provided evidence of good reporting of both falls and pressure ulcers as incidents.
26
Good practice identified
Staffing structures were seen to include pressure ulcers and falls nurses in post.
Outstanding concerns based on
evidence gathered
Key planned improvements
Recommended actions
Priority – urgent, high or
medium
i. Inconsistent use of Trust policy
Verita, an external consultancy, has
reviewed all serious incidents including falls
and pressure ulcers for any learning.
Ensure that the latest pressure ulcer policy is
communicated to all staff and that staff
understand and apply it across the
organisation.
High
Whilst the Trust provided evidence of a
pressure ulcer grading policy, we did
not see evidence of an embedded,
owned policy or guidance at the Trust.
Discussions with staff on Orsett ward
identified that staff had developed their
own policy. Staff interviewed explained
this was due to the Trust policy being
too complex.
The Trust changed its policy in line with all of
the East of England trusts last year as part of Learning from Verita work to be shared with
the ‘Stop the Pressure’ campaign.
staff
Medium
Bed management
KLOE 4: What processes does the Trust have to manage bed occupancy? How does the Trust manage beds? How does the Trust manage patient moves during their time in
hospital including between the main hospital and the Cardiothoracic Centre?
Good practice identified
The Trust staff detailed in interviews the regular bed management meetings held at the start of the day, midday, mid afternoon and an optional fourth meeting
depending on the need for it.
The staffing structure was seen to include a discharge doctor at weekends to support bed management.
The Trust has an elderly care strategy including the use of medi-home.
The Chief Executive stated that she had implemented increased consultant presence during week days and weekends. Staff interviewed spoke positively of
27
Good practice identified
this for leadership decisions and support.
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority –
urgent, high or
medium
i. Bed flows and management
A single patient tracking system
is being implemented and was
observed by the panel on
Katherine Monk ward.
Full implementation of real time patient tracking to
manage flow rather than record issues post event.
Urgent
The Trust has high activity levels as evidenced by performance
data and the panel’s observations. Also staff and patients
interviewed consistently spoke of how busy the hospital was.
Whilst the Trust Board members interviewed recognised the
issue, we did not obtain evidence of a clear and prioritised plan
to address the issues with bed management.
Throughout our visit we identified evidence of poor bed
management and flows including the following:
 Use of escalation areas over extended periods, including
the use of the Surgical Referral Unit and Cardiac Suite to
bed patients down.
 A high number of outliers which did not appear to be
managed.
 A high number of patient moves during in-patient stays.
 Observation of ambulances stacked outside A&E.
The panel also reviewed:
 A&E waiting times through the system and by speaking to
patients and staff. This process identified patients regularly
breaching the four hour target.
 Acute Medical Unit (AMU) stays through discussion with a
number of patients. Patients stated that their stay exceeded
the 48 hours for which the AMU was designed and some
patients stated that they had been in the unit up to 14 days.
Improved bed flows and management through:
Urgent
 Review of systems to enable best use of beds at
all times including ensuring staff have access to,
and are making effective use of, patient flow IT
systems.
 A move to seven day working, with Senior
doctors reviewing in-patients every day on all
wards.
 Improved end of life care planning and
application, discharge planning.
 To review use of the PARS team and ward
rounds to provide assurances that the policies
are being consistently applied.
 Better use of the discharge lounge
 To systematically review discharge planning at
all stages of a patient’s journey to enable safe
and effective discharge.
High
Bed flow and management should be underpinned
by quality of care and treatment and making
effective use of the service. Additional beds should
be considered as a last resort and only in agreement
with commissioners.
28
Outstanding concerns based on evidence gathered
Other issues noted included:
 A number of patients interviewed stated that they had been
inappropriately discharged and required readmission (this
could not be investigated by the panel further).
 Whilst patients with dementia were confirmed to be
transferred to wards on ground level to reduce the risk of
harm, the panel identified a number of dementia patients
not being cared for on appropriate wards.
 Temporary areas being used for patients were observed to
not be consistently fit for purpose. For example there were
no showers for inpatients in AMU where patients were
staying for period for up to 14 days.
 Observation of the discharge lounge identified poor use of a
good facility with one patient and four staff.
 Staff interviewed, particularly junior doctors, spoke of the
pressure to discharge patients due to the shortage of
available beds.
 Some staff spoke of an overuse of the PARS team and we
observed the use of the PARS team on a palliative care
ward. A number of staff also noted the reluctance of some
medical staff to discuss end of life care and discuss the
application of Do Not Resuscitate agreements.
 Observation of the operations room identified that staff did
not have access to the relevant patient flow IT systems
without IT support.
 Absence of real time patient tracking and multiple systems
in place to monitor patient location – A&E list, AMU list
(manual), PAS (reliant on a ward clerk to update) and the
doctor list.
Key planned improvements
Recommended actions
Further staff training on dementia including
appropriate wards for dementia patients to be
transferred to for care.
Priority –
urgent, high or
medium
High
A strategy should be developed through joint
engagement with the CCG to make increased use of High
other facilities. This could include reviewing use of
the minor injuries unit at Orsett Hospital. Also this
should include wider health system engagement to
make better use of hospital beds including using out
of hospital care, preventative strategies and
community care.
29
Patient experience
Overview
The two KLOEs in the patient experience area focused on how the Trust understands and responds to patient feedback and adequate quality of care to patients with learning
disabilities.
The following good practice was identified:

Examples of good levels of patient care and treatment and good experiences from the patients.

Feedback leaflets within wards and electronic feedback points around the Trust.

A learning disabilities nurse was identified as being in post. Interviews with staff confirmed that staff were aware of how to contact her if necessary.
The following areas of concern were identified for patient experience:

Systematic Board understanding of patient experience.

Clarity over actions taken in response to concerns and complaints.

Patient communication and engagement.
For the majority of the areas of concern above, we identified a number of improvements planned or already underway at the Trust evidencing continued progress.
30
Detailed Findings
Patient involvement and experience
KLOE 5: How does the Trust seek views from patients about their experience? What are the key themes from patients on their experiences? What action is the Trust taking
to address the key themes emerging? In particular, what actions have been taken to improve cancer care?
Good practice identified
During the visit examples of good practice were observed and staff and patients provided further examples, including:
 Bulphan ward – good practice and good standard of care observed.
 Caring feeding of the elderly observed.
 Lionel Cosins ward – observers were impressed with the level of care given to elderly patients.
 Pre-assessment service for surgical elective patients was noted by the panel to be good practice.
 Evidence of in-patient risk and assessment documentation.
 Existence of fracture of the femur service, including excellent multi-professional orthopaedic team and theatre capacity.
Examples of good experiences of care and treatment at the Trust provided to a number of patients spoken with.
Leaflets observed within wards detailing how to provide feedback to the Trust as well as electronic feedback points had been installed at the Trust.
There were protocols in place for Individual Care Plans.
Outstanding concerns based on evidence gathered
Key planned improvements
i. Systematic Board understanding of patient experience
We were informed that a patient story Patient stories to be regularly heard by Urgent
would be heard by the 2013 May
the Board with lessons learned from the
Quality and Patient Safety Committee story and any action required as a
result.
Whilst Board members interviewed spoke of knowing about patient
experiences, issues were noted with the lack of processes in place
to ensure they monitor it regularly, including:
 The Board does not hear patient stories.
 Whilst the Trust states that is has a monthly Patient
Experience data report, providing analysis of all areas of
patient experience feedback including complaints received, the
Board only receives details of numbers of complaints and
Recommended actions
Priority – urgent,
high or medium
The Board should receive a summary
Urgent
of the substance of complaints, trends
and themes as a minimum. This should
be reviewed and an action plan agreed
to respond to key themes.
31
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
The complaints process needs to be
quickly reviewed to ensure there is
clarity of the role of PALS.
High
response times, not the detail of the complaints.
The panel did not see evidence of action being taken in response
to these complaints.
ii. Clarity over concerns and complaints
The Trust states that considerable
work is underway in the management
The Trust has policies for incidents and complaints and these are
of complaints including:
under review.
 Introduction of a Senior Nurse to
provide specialist support to
Interviews with staff identified a lack of clarity, from the majority
patients and their carers /
interviewed, as to what constituted a Patient Advice Liaison
relatives.
Service (PALS) concern and how this was differentiated from a
 Development of focused KPIs
complaint. Staff also struggled to articulate the complaints process
(key performance indicators)
and definition of “serious” consistently.
regarding the quality of service
provision and data indicating
Some comments were received from patients that the perception
themes and trends within quality
was that the PALS service was there to serve the Trust and not
measures.
patients.
 Patient information is being
developed with new leaflets
Some staff interviewed indicated they did not feel they could raise
regarding PALS and complaints.
concerns and that action will be taken.
 Planned move of the Patient
Experience Team alongside
PALS to strengthen routes of
referrals between the teams.
 Links are being developed
between chaplaincy and
bereavement teams, which will
also include counselling services.
 Creation of a new post of Patient
Experience Lead commencing 1
July 2013.
Definitions of and policies for concerns, High
complaints and serious incidents should
be reviewed and clarified, so that the
terminology and processes are
understood by all staff.
Executive Team should take action to:
- Remind staff of their responsibility to
raise concerns as per the whistle
blowing policy,
- Promote a positive culture towards
complaints, including consideration of a
complaints forum for patients and
relatives, supported by the Governors.
High
32
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
iii. Patient communication and engagement
The Trust has installed electronic
feedback points around Basildon
Hospital.
Real patient communication and
High
engagement through:
 Report patient stories at Board.
 Actions taken in response to patient
feedback communicated to
patients.
 A culture of openness to issues to
be further developed.
 Consideration to be given to
moving PALS from the CTC to front
of house to make finding it easier.
 Increased communication of
accurate expected discharge dates
consistently to all patients.
 Involvement of patients and carers
in their care plans.
 Actively seeking feedback from
patients and relatives.
Whilst we observed leaflets within wards on how to provide
treatment and the electronic feedback points, interviews with
patients identified that the majority had not noticed either of them
and were unaware of how to provide feedback to the Trust.
Further issues were noted with patients including:
 The majority of patients interviewed out of hours in A&E cited
communication as the one area that the Trust could improve
in. Examples provided included the provision of better
signposting towards the assessment nurse on arrival, as well
as better communication of the A&E waiting times and
process.
 Significant numbers of in patients interviewed were unaware of
their expected discharge date (EDD). There were examples of
the EDDs showing on ward boards in a number of wards being
inaccurate.
 More than one patient stated that they would not provide
feedback to the Trust or make a complaint either due to an
assumption that nothing would be done, or due to fear that
they would not receive good treatment if they complained.
 The panel found the location of PALS difficult to find.
Furthermore when panel members spoke to PALS they were
not able to provide evidence that the team were working for
patients rather than the Trust (as per concerns raised above).
 The panel identified only limited evidence of patient and family
involvement in the design or application of care plans and
treatment.
PALS is located in the hospital.
Leaflets on the complaints procedure
were observed within wards.
The recent appointment of a new
Medical Director in January 2013,
along with the new Chief Executive
and the Director of Nursing, was cited
by a number of staff spoken to as
increasing the patient focus at the
Trust.
Better signage is planned for PALS.
Priority – urgent,
high or medium
See also ii above
33
Patients with learning disabilities
KLOE 6: How does the Trust ensure adequate quality of care to patients with learning disabilities?
Good practice identified
A learning disabilities nurse was identified as in post and interviews with staff confirmed that staff were aware of how to contact her if necessary.
Outstanding concerns based on
evidence gathered
Key planned improvements
Recommended actions
Priority – urgent, high or
medium
No significant outstanding concerns.
34
Workforce and safety
Overview
The three KLOEs in the workforce and safety area focused on staff views of the main barriers in the Trust to delivering high quality treatment and care for patients, workforce
planning and staff training.
The following good practice was identified:

Workforce is generally committed, loyal, passionate, caring and motivated.

Orthopaedics was cited by a range of staff as a general exemplar of effective rotas and ward systems.

The surgical handover room was observed as well set up.
The following areas of concern were identified within workforce and safety:

Staffing levels and skill mix need urgent further review.

Implementation of NHS Professionals (NHSP) did not appear to have been well managed.

Consistency and comprehensiveness of training, including adult safeguarding training.
For the majority of the above areas of concern, we identified a number of improvements planned or already underway at the Trust evidencing continued progress.
35
Detailed Findings
Staff issues
KLOE 7: What do staff groups interviewed (including trainee groups) say are the main barriers in the Trust to delivering high quality treatment and care for patients?
Good practice identified
From interviews with the staff, the panel found the workforce to be committed and loyal to the Trust. The vast majority of student nurses interviewed stated that they
would like a job at the Trust. The panel observed passionate and caring staff including a number of staff attending the listening event as they wanted an awareness of the
patient feedback. A large number of staff observed appeared to genuinely care and want the best for their patients despite the high level of negative press and local
criticism of the Trust.
Good care was observed within the Trust. Nursing teams and junior doctors were noted as being particularly motivated and driven; despite a high workload they were
found to be putting in the energy and effort to meet demand.
Friendly, receptive and open staff, welcomed the review panel. Some staff said that they felt they were able to be open about concerns and could provide examples of
the Trust Board acting upon feedback.
Outstanding concerns based on
evidence gathered
Key planned improvements
A number of issues raised by staff have See KLOE 8
been included in the relevant KLOE.
For instance staff observed were
clearly under a high work load and
pressure due to staffing levels and skill
mix - see KLOE 8
Recommended actions
Priority – urgent, high or
medium
See KLOE 8
36
Workforce planning
KLOE 8: How does the Trust approach workforce planning to ensure that patient safety is managed effectively including skill mix? How is clinical cover managed out of hours
particularly at weekends for patients on the emergency pathway?
Good practice identified
Orthopaedics was cited by a range of staff as a good example of an effective staff rota and ward systems.
Observation of the surgical handover identified good practice with six PCs and a proper PACS (picture archiving communication system) screen supporting a handover
process. The process included the detail of the patient condition, what had been done and what needed to be done.
Staff commented on improvements made by recent increases in senior medical presence in some parts of the Trust into extended hours
Outstanding concerns based on evidence gathered
Key planned
improvements
Recommended actions
Priority – urgent, high
or medium
i. Staffing levels and skill mix
An additional overnight
registrar has been in place
over the last three months.
Noted this post is being
filled on a temporary basis
through locum support.
Full staffing levels and staff mix reviews
to be completed across nursing and
medical staff.
Urgent
Relieving clinicians care time through
initiatives such as:
 Advanced nursing roles.
A review of numbers of
 Cannula and phlebotomy support.
nursing has been
 Nursing sister triaging calls.
completed and a paper is
 Greater use of administration staff.
due to go to the May 2013  Electronic booking system.
Trust Board.
 Real time patient tracking.
 Additional overnight registrar post to
A similar review of medical
be made permanent.
numbers is planned.
Urgent
The Trust activity levels are high and Basildon Hospital is very busy as
observed by the panel and cited consistently by staff and patients.
A number of issues were noted by the panel with staffing levels and skill
mix:
 Junior doctor workload, particularly overnight, was pressured. A
recent junior doctor audit had identified the work required for a 12
hour shift was an average of 19 hours. Panellists particularly noted
concerns around obstetrics and gynaecology cover and the majority
of staff, from throughout the Trust, highlighted concerns over junior
doctor workload and welfare.
 Due to the use of escalation wards and high number of outliers, we
identified a number of areas where the ward skill mix was not
appropriate to the patients on the ward at that time.
 The staffing levels were observed to not be consistently sufficient, for
example we observed a nurse in charge responsible for caring for 10
Review of recruitment processes to
ensure that there is interaction with the
ward managers for staff who are being
High
37
Outstanding concerns based on evidence gathered



Key planned
improvements
patients during an overnight shift. We also observed long wait times
in A&E, paediatric A&E and the fracture clinic.
Discussion with staff during interviews identified a number of
vacancies on all shifts dependent on agency and bank staff. A
number of staff further commented on the recruitment process as
being disengaged with operations and for having issues with
communications, for example staff arriving to commence work
without this being communicated to the ward.
A number of staff interviewed felt that there was an increase in
paperwork that took away from hands on care.
Health Care Assistants (HCAs) stated that they felt they were doing
more observations and bed baths that expected.
ii. Implementation of NHS Professional (NHSP)
At the time of our visit, the Trust had recently implemented NHSP and a
Steering Group had been in place to govern its implementation.
Discussions with a number of staff identified issues with the
implementation including operational deployment, management and
payment of temporary staff. This was observed to be a significant risk to
quality of care for patients during the visit and escalated to the Trust.
Recommended actions
Priority – urgent, high
or medium
recruited.
None identified
The Trust should demonstrate
implementation issues have been
addressed.
Urgent
The Steering Group should continue to
meet post implementation to closely
monitor and manage NHSP.
Urgent
It was also identified that the Trust did not plan for the Steering Group to
meet following implementation.
This issue was escalated to the Director of Nursing on 8 May 2013 when
it was identified by the panel as it was felt it could be a significant risk to
the quality of care and treatment.
38
Staff support and training
KLOE 9: How does the Trust support its staff with adequate training, including safeguarding training?
Good practice identified
The feedback provided by the junior doctors who attended the focus group was that training and support was generally good. This was consistent with interviews with
junior doctors during observations.
Interviews with staff in paediatrics concluded that staff in paediatrics had a strong understanding of safeguarding processes. During the observation of the paediatric A&E
out of hours, the sister in charge was able to clearly articulate the safeguarding process to a level of detail that impressed the panel members interviewing her.
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
i. Consistency and comprehensiveness of training
The Trust has rolled out increased
e-learning to address mandatory
training completion issues.
Student nurses to be consistently
provided with appropriate training
including ward training.
High
The Trust has rolled out increased e-learning replacing face-to-face
training. Staff interviewed were mixed in their response to this, with
a significant number responding negatively due to the decreased
networking opportunities and opportunities to share lessons learned
as well as the reliance on computer literacy and confidence.
To review the use of e-learning based High
on staff feedback. Staff to be
provided with opportunities to network
and share ideas.
From interviews with nurses and the Executive, the panel identified
that the nursing development strategy was not clear.
Strategy for advanced nursing roles
and nursing development.
Medium
Student nurses interviewed stated that they were provided training
through the university but were not involved in ward training.
See also KLOE 4(i) regarding
dementia training.
Furthermore it was identified that the Qualification and Credit
Framework (replacing NVQ) for students has been stopped and the
panel observed inconsistent practices by student nurses.
See also KLOE 4(i) regarding dementia training
ii. Consistency of safeguarding training, particularly for adults
The Trust is currently recruiting to
The safeguarding training provided to
Medium
39
Outstanding concerns based on evidence gathered
While staff members in paediatrics interviewed were able to clearly
articulate paediatric safeguarding processes, this was not consistent
for all staff interviewed. Panel members were provided with vague
details on the escalation route for adult safeguarding issues.
Key planned improvements
Recommended actions
the post of an adult safeguarding
lead.
be sufficient so that staff can clearly
articulate the safeguarding processes,
particularly for adults.
Priority – urgent,
high or medium
The panel noted that the post of Nurse Advisor for safeguarding and
disabilities is vacant and that this role is being covered by the
Deputy Director of Nursing.
40
Pharmacy support
Overview
Due to the issues identified in the data pack related to use of out of date drugs, a specific KLOE for pharmacy support to the wards was included.
The following good practice was identified:

Daily ward visits by pharmacy technicians who review all drug charts and drug trolleys.
The following area of concern was identified:

Risk of incorrect drugs being prescribed due to inadequate labelling.
Detailed Findings
KLOE 10: How does the Trust ensure that there is adequate pharmacy support to the wards, including out of hours?
Good practice identified
Staff informed the panel that wards have daily visits by pharmacy technicians who review all drug charts and drug trolleys.
Outstanding concerns based on evidence gathered
i. Risk of incorrect drugs being prescribed
Key planned
improvements
The Trust states that a
review of this process is
During interviews with staff the panel identified that, for efficiency, the list of drugs already underway and is a
for discharge uses coding for drugs of alphabetic lettering (i.e. A, B, C rather than key element of the newly
either specific codes for specific drugs or the full name of the drugs along with the developed Strategy for
dose).
Pharmacy Services and
Medicines Management.
Whilst the panel recognise the efficiency from the process, there is a risk of
incorrect drugs being issued. Interviews with staff identified that incorrect
prescriptions were not uncommon. Members of the public also spoke of
concerns with this issue.
Recommended actions
Priority – urgent,
high or medium
Consideration to be given to the
full details to be seen by the
pharmacy to enable a check to
be made.
High
41
5. Conclusions and support required
Conclusions
The Executive Team and staff recognise that the historical culture of the Trust was focused on financial targets and that finances were prioritised over quality. This is now a
Trust undergoing significant transformation with a new Chief Executive, Medical Director and Chair. The Chief Executive and Chair have stated that they will regularly review
the board to ensure, through its development programme, that the Trust has the necessary skills, background and experience to lead the organisation on an ongoing basis.
The Executive Team interviewed recognised both the issues at the Trust and the need for change. The Chief Executive and Chair are clear that the tone at the top should be
one of long term sustainability and not short term solutions. As a result a transformation programme is underway. There is a lot to do within that and many priorities, for
which there needs to be an explicit plan (with timelines) to ensure all staff are aware of what is important and the pace of change.
Although the Trust is on a transformation journey members of the Board need to ensure that they close the gap between ward level and Board level, communicating and
engaging with the staff throughout. This should include being clear as a Board on the quality priorities and in communications with staff on transformation plans. The Trust
also needs to ensure that the effectiveness of the transformation is regularly evaluated, ensuring that patients remain at the heart of this improvement journey.
The Trust is currently delivering financial targets but under extreme service pressure with high activity levels evidenced throughout our visit. It is noted that the 2012/13
surplus was delivered due to the commissioners funding the increased activity and that the Trust is yet to fully identify the £15m CIP target for 2013/14 despite being two
months into the financial year. During interviews the Executive Team were unable to clearly articulate the process for quality impact assessing cost improvement plans and
the Trust must ensure that costs are managed without compromising patient care and treatment.
The Trust has been under scrutiny for some time and has undergone a number of reviews, including a number commissioned by the new Chief Executive, to gain an in-depth
understanding of the issues at the Trust. Historically the Trust has generally been viewed as a reactive organisation rather than proactive one when dealing with issues and
concerns. The Trust leadership now want to review current practices, understand issues and design solutions in a more proactive way so as to sustain the required
improvements. They are on an improvement journey and the next stage is, perhaps, the most challenging, requiring implementation and embedding changes in practice - a
period of stability is required to enable the Trust to deliver this challenging programme of transformation. Until this implementation and embedding is complete, the effect
of the changes cannot be assessed as appropriate.
Our review identified a number of areas of good practice, although these generally related to specific areas, wards or specialities. Therefore there is more for the Trust to do
in ensuring good practices are in evidence across the organisation, all of the time.
Our review also identified a number of areas of outstanding concerns across all ten KLOEs. For the majority of areas we identified a number of improvements either already
underway at the Trust or planned actions. However we have included further recommended actions for each area including a number of areas of concern outstanding from
the July 2012 Silverman report. These include, for example, the presence of medical outliers and examples of infection control issues.
42
Urgent priority actions for consideration at the risk summit
Problem identified
Recommended action for discussion
Support required by the Trust
1. Stability and prioritisation (see detailed finding at
A single, prioritised action plan for the Trust showing clearly
the priorities for the Trust by time period, e.g. for the next
six months, six months to a year and so on. This should be
clearly communicated to staff.
Support from external stakeholders for a period of
stability for the Trust.
A clear focus on quality based on transparent information
and a tone from the top.
Quality governance support.
Communication of the revised structure to staff, clearly
detailing the new structure. The policies and processes to
be used also need to be shared at the same time.
Communication and supporting policies and processes.
Improved infection control practises need to be applied
consistently across the Trust, all of the time.
Infection control support.
page 16)
Absence of stability in governance and clear
prioritisation of actions.
2. Quality focus (see detailed finding at page 18)
Quality focus of the Trust is still being developed.
3. Governance structures (see detailed finding at
page17)
Lack of clarity of governance structures.
4. Infection control (see detailed finding at page 23)
Whilst the panel observed examples of good
practice in infection control during the site visit, the
panel also observed examples of infection control
issues.
43
Problem identified
Recommended action for discussion
Support required by the Trust
5. Bed management and flows (see detailed finding
Full implementation of real time patient tracking, either
through a single system or automated links between those
systems used to track patients.
Support for implementation of a real time patient
tracking system.
at pages 27 to 29)
Throughout our visit we identified evidence of poor
bed management and flows.
6. Systematic Board understanding of patient
experience (see detailed finding at page 30)
There is no systematic Board understanding of
patient experiences and evidence of action being
taken to respond to issues raised in them.
7. Staffing (see detailed finding at pages 23 and 37 to 38)
A number of issues were noted by the panel with
staffing levels and skill mix.
8. Implementation of NHSP (see detailed finding at
page 37)
Improved bed flows and management through:
 Review of systems to enable best use of beds at all
times including ensuring staff have access to, and are
making effective use of, patient flow IT systems.
 A move to seven day working, with senior doctors
reviewing in-patients every day on all wards.
 Improved end of life care planning and application,
discharge planning.
 To review use of the PARS team and ward rounds to
provide assurances that the policies are being
consistently applied.
 Better use of the discharge lounge
 To systematically review discharge planning at all
stages of a patient’s journey to enable safe and
effective discharge.
Patient stories should be regularly heard by the Board with
lessons learned from those discussed and any action
required as a result agreed upon.
Recommended action provided to enable the Trust to
address the problem identified.
The Board to receive a summary of the substance of
complaints, trends and themes and debate the actions
required to address these.
Full staffing levels and staff mix reviews to be completed
across nursing and medical staff.
Staff review support.
Relieving clinicians care time through initiatives.
Support for implementation of appropriate initiatives.
Action plan to address implementation issues to be
presented.
Recommended action provided to enable the Trust to
address the problem identified.
44
Problem identified
Recommended action for discussion
Discussions with a number of staff identified a
number of issues with the implementation of
NHSP affecting the management of temporary
staffing.
Steering Group to continue to meet post-implementation to
closely monitor and manage NHSP.
Support required by the Trust
45
Appendices
46
Appendix I: SHMI and HSMR definitions
HSMR definition
What is the Hospital Standardised Mortality Ratio?
The Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare quality that measures whether the mortality rate at a hospital is higher or lower than you would
expect. Like all statistical indicators, HSMR is not perfect. If a hospital has a high HSMR, it cannot be said for certain that this reflects failings in the care provided by the
hospital. However, it can be a warning sign that things are going wrong.
How does HSMR work?
The HSMR is a ratio of the observed number of in-hospital deaths at the end of a continuous inpatient spell to the expected number of in-hospital deaths (multiplied by 100)
for 56 specific groups (CCS groups); in a specified patient group. The expected deaths are calculated from logistic regression models taking into account and adjusting for a
case-mix of: age band, sex, deprivation, interaction between age band and co-morbidities, month of admission, admission method, source of admission, the presence of
palliative care, number of previous emergency admissions and financial year of discharge.
How should HSMR be interpreted?
Care is needed in interpreting these results. Although a score of 100 indicates that the observed number of deaths matched the expected number; in order to identify if
variation from this is significant confidence intervals are calculated. A Poisson distribution model is used to calculate 95% and 99.9% confidence intervals and only when
these have been crossed is performance classed as higher or lower than expected.
SHMI definition
What is the Summary Hospital-level Mortality Indicator?
The Summary level Hospital Mortality Indicator (SHMI) is a high level hospital mortality indicator that is published by the Department of Health on a quarterly basis. The SHMI
follows a similar principle to the general standardised mortality ratio; a measure based upon a nationally expected value. SHMI can be used as a potential smoke alarm for
potential deviations away from regular practice.
How does SHMI work?
1) Deaths up to 30 days post acute trust discharge are considered in the mortality indicator, utilising ONS data.
2) The SHMI is the ratio of the Observed number of deaths in a Trust vs. Expected number of deaths over a period of time.
47
3) The Indicator will utilise 5 factors to adjust mortality rates by:
a. The primary admitting diagnosis
b. The type of admission
c.
A calculation of co-morbid complexity (Charlson Index of co-morbidities)
d. Age
e. Sex.
4) All inpatient mortalities that occur within a Hospital are considered in the indicator.
How should SHMI be interpreted?
Due to the complexities of hospital care and the high variation in the statistical models all deviations from the expected are highlighted using a Random Effects funnel plot.
Some key differences between SHMI and HSMR
Indicator
Are all hospital deaths included?
When a patient dies how many times is this counted?
HSMR
No, around 80% of in hospital deaths are included,
which varies significantly dependent upon the
services provided by each hospital.
If a patient is transferred between hospitals within 2
days the death is counted multiple times.
Does the use of the palliative care code reduce the
relative impact of a death on the indicator?
Does the indicator consider where deaths occur?
Yes
Is this applied to all health care providers?
Yes
Only considers in-hospital deaths
SHMI
Yes all deaths are included.
1 death is counted once, and if the patient is
transferred the death is attached to the last
acute/secondary care provider.
No
Considers in-hospital deaths but also those up to 30
days post discharge anywhere too.
No, does not apply to specialist hospitals
48
Appendix II: Panel composition
Panel role
Name
Panel Chair
David Levy
Lay representative (Patient/public representative)
Fiona Loud
Lay representative (Patient/public representative)
Asa’ah Nkohkwo
Lay representative (Patient/public representative)
Jenny Robinson
Junior Doctor
Lola Loewenthal
Doctor
Gillian Derrick
Doctor
Jane McCue
Student Nurse
Board Level Nurse
Senior Nurse
CQC representative
Elizabeth McKerrow
Fay Baillie
Clare Beattie
Margaret McGlynn
Senior Trust Manager
Rebecca Brown
Senior Regional Support
Graeme Jones
Senior Regional Support
Finola Muir
49
Appendix III: Interviews held
Interviewee
Date held
Claire Panniker, Chief Executive
7 May
Celia Skinner, Medical Director, and Diane Sarker, Director of Nursing
7 May
Celia Skinner and Diane Sarker, joint chairs of Quality and Patient Safety Committee
7 May
David Hulbert (Non Executive Director), Chair of Clinical Quality Board
7 May
Diane Sarkar, Director of Nursing
8 May
Andy Ray, Acting Director of Finance, and Adam Sewell-Jones, previous Director of Finance
8 May
Hannah Coffey, Chief Operating Officer
8 May
Nigel Taylor, Director of Personnel & Organisational Development
8 May
Michael Catling, General Manager, Medicine
8 May
Dr Tayyab Haider, Divisional Clinical Director for Medicine, Stuart Harris, Divisional Clinical Director for CTC, and Celia Skinner, Medical Director
8 May
Liz Seale, Associate Director of Clinical Governance & Risk (Head of Quality)
8 May
Julie Hickman, Deputy Director of Nursing (Safeguarding lead)
8 May
50
Appendix IV: Observations undertaken
Observation area
Date of observation
Care of the elderly wards
7 May
Accident and emergency (A&E)
7 May
Paediatrics ward
7 May
William Harvey ward
7 May
Acute Medical Unit (AMU)
7 May
Cedar ward
8 May
Maternity
8 May
Cardiothoracic Centre (CTC)
8 May
Elizabeth Fry ward, Renal
8 May
Orsett ward, palliative care
8 May
Katherine Monk ward, endocrine and general medicine
8 May
PALS
8 May
Discharge lounge
8 May
Florence Nightingale, respiratory
8 May
Operations room
8 May
Lionel Cosins ward, care of the elderly
8 May
Pasteur ward
8 May
Orsett Hospital
8 May
Further observations were undertaken as part of the unannounced site visit, see Appendix VII.
51
Appendix V: Focus groups held
Focus group invitees
Focus group attendees
Date held
Doctors
12 registered attendees; attendees included consultants, clinical leads, a CSU lead and radiologist.
7 May
Patients and public
15 registered attendees; attendees included patients, relatives of patients, visitors and ex-patients.
7 May
All staff
18 registered attendees; attendees were primarily nurses and health care assistants; also staff from radiology,
health and safety, administration and a porter.
7 May
Governors
8 registered attendees; attendees included staff and public governors.
8 May
Junior doctors
11 registered attendees; attendees included junior doctors from acute medicine, surgery, orthopaedics, renal,
and CTC; attendees included FY1, FY2, CT1, CT2, CT3 and SPRs.
8 May
Trainee nurses
14 registered attendees; all attendees were student nurses.
8 May
Nurses
12 registered attendees; attendees included sisters, lead nurses and HCAs.
8 May
52
Appendix VI: Information available to the RRR panel
Quality Strategy
Quality Strategy Overview
Patient Safety Steering Group and combined TOR
v4 June 2012
BAF 2012/13 updated 16.04.2013
Revised significant risk report April 2013
Corporate Clinical Audit report and Plan for April
2013 QPSC
Clinical Audit and Effectiveness Q4 2012-13 Acute
Medicine
Clinical Audit and Effectiveness Q4 2012-13
Critical Care
Clinical Audit and Effectiveness Q4 2012-13
Cardiology
Clinical Audit and Effectiveness Q4 2012-13 CTC
Surgery & Anesthetics
Clinical Audit and Effectiveness Q4 2012-13
DMOP & Stroke
Clinical Audit and Effectiveness Q4 2012-13 General
Medicine
Clinical Audit and Effectiveness Q4 2012-13 General
Surgery & Urology
Clinical Audit and Effectiveness Q4 2012-13
Head & Neck
Clinical Audit and Effectiveness Q4 2012-13 Imaging
Clinical Audit and Effectiveness Q4 2012-13 Obs &
Gynae
Clinical Audit and Effectiveness Q4 2012-13
Paediatrics
Clinical Audit and Effectiveness Q4 2012-13
Pathology
Clinical Audit and Effectiveness Q4 2012-13 Pharmacy
Clinical Audit and Effectiveness Q4 2012-13
Specialist Medicine
Clinical Audit and Effectiveness Q4 2012-13 T&O
Clinical Audit and Effectiveness Q4 2012-13 Therapies
2012/13 CIPs
CIP process document (Quality Impact Document)
March 2012
2013/14 CIPs
GGI Basildon RapidReviewReport 290113
GGI BTUH Gov Review Maturity Matrix Jan2013
Final
Executive Team CVs (collated from applications)
Operational Management Structure
Committee Structure August 2012
(in process of being updated for 2013-2014)
ToR - Audit and Risk Committee
ToR Quality and Patient Safety Committee
ToR Finance Committee
ToR Investment Committee
ToR Health and Safety Committee
Trust committee Structure 2013 including reporting
53
committees
Public BoD 27.02.2013
Private BoD 25.02.2013
Public BoD 27.03.2013
QPSC 11.03.2013
QPSC 08.04.2013
Quality Contract Meeting Minutes 7.03.2013
(DRAFT - for approval at the April meeting)
Quality Contract Meeting action log 7.03.2013
Quality Contract Meeting Minutes 11.02.2013
Quality Contract Meeting action log 11.02.2013
Quality Contract Meeting Minutes 03.01.2013
Quality Contract Meeting action log 03.01.2013
Risk Steering Group minutes 14.03.2013
Risk Steering Group minutes 13.02.2013
Health and Safety Committee minutes March
2013
Health and Safety Committee minutes Feb 2013
HMRG - 18.03.2013
HMRG - 08.04.2013
HMRG ToR v3 July 2012
Performance Report for BoD 2012/13
Performance Report appendix
Annual Plan 2012-13 with guidance removed
DRAFT Annual Plan 2013 - 2014 (Draft annual plan to
be submitted to Board of Directors 24.04.2013)
Mortality Alert AMI March 2011
AMI Medical Directors report July 11
CQC AMI mortality Report – update
AMI - Mr Chris Sherlaw letter May 2012
AMI - Mr Chris Sherlaw letter August 2011
AMI - Mr Chris Sherlaw letter September 2011
AMI - Mr Chris Sherlaw letter October 2011
AMI outlier closure
Email re outlier - 25.05.2012
Email re AMI - 31 May 2012
Email re mortality figures - 31.05.2013
Email re AMI and continued actions - 14.01.2013
Closure letter AMI - 8.12.2013
20120503 BTUH alert letter for pneumonia
Letter to Mr Chris Sherlaw - response to alert 01.06.2012
Pneumonia review Mortality - audit tool
Paediatric Service Review BTUH CQC final report
180113
Pharmacy Basildon peer review final report 11.12.2012
GGI risk management system at BTUH FT
03012013
West Midlands SHA review in to mortality 09072012
(Stan Silverman)
54
Legionella Hydrop Review July 2012
IST cancer summary visit March 2012
IST pressure ulcer South Essex Review Letter
CQC Jan 2013
NMC Review December 2012
IST Emergency Care Review November 2012
Report of PCT visit to BTUH on Wednesday 16th
January 2013
PCT visit to Paediatric Unit 16.01.2013
PCT visit 8.01.2013
Radiology Review 19.03.2012
Infection control review (Steve Barratt)
OHI results & OHI Board Report
Elderly care strategy development - 11th April v4
Elderly Care Steering Group outline pack
Elderly Care Strategy - Week 2 update
Elderly Care Strategy - Week 3 update
Elderly Care Strategy - Week 4 update
Elderly Care Strategy - Week 5 update
130315 Elderly Care Strategy workstreams
130403 Elderly Care Strategy Progress Report
20130311 elderly care steering group charts 5
20130312 Elderly Care Strategy data summery V4
Complex discharge pathway (MDT
assessment)
Draft SLA pharmacy 040412
Social Care Timelines in regards to the community care
act 2003
NMC Strategy
Risk Strategy
Quality Account (2011/12)
Generic CQC Action Plan Feb 2013
CQC action plan - outcome 4 & 8 March 2013
Real-time feedback
Quality and Patient Safety Committee agenda
Monthly Serious Incidents report
Analysis of mortality by day of the week
Cardiac arrest national data
Parent survey – Acute Children’s Services
A&E Patient feedback survey
WHO (World Health Organisation) Checklist
Tissue Viability Referral Form
Adult in-patient risk and assessment documentation
CIP (Cost Improvement Schemes) listing,
detailed summary and key instructions for
reporting
CLIP (Complaints, Litigation, Incidents and PALS)
report
HSMR colorectal data
Complaints policy
Patient experience and engagement strategy
55
Increased nursing supervision trigger
Letters of
responses
complaints
from
patients
and
Community Acquired Pneumonia Care Bundle
Leaflet provided by hospital summarising complaints /
compliments policy
Hospital newsletter
CPR booklet
Medical on call rota
CQC/OFSTED Action Plan
Safeguarding policies (adults and children)
Operational Policy for the Surgical Referrals Unit
56
Appendix VII: Unannounced site visit
Agenda item
Panel pre-meet
Entry into Basildon Hospital and announced arrival to site manager
Observations undertaken of the following:
 Accident and emergency
 Paediatric accident and emergency
 Katherine Monk ward
 Kingswood ward
 Elsdon ward
 Surgical Referral Unit
 Doctors on call - surgical and general medical teams.
Meeting held with site manager to understand current staffing and patient levels
Panel left Trust and announced exit
57