Colchester Hospital University NHS Foundation Trust
Review into Quality of Care and Treatment
PANEL, FINAL AGENDA AND KEY LINES OF
ENQUIRY
May 2013
Page 1
Panel Members
Please find a table below that has all the names of panellists.
Panel Role
Name
Panel Chair
Liz Redfern
Deputy Panel Chair
Chris Gordon
Lay Representative
Neeta Meeta
Lay Representative
Trevor Begg
Lay Representative
Margaret Ogden
Junior Doctor
Shelley Griffiths
Doctor
James Bristol
Doctor
Andrew Phillips
Doctor
Colette Marshall
Student Nurse
Sian Ball
Student Nurse
Amy Burgin
Board Level Nurse
Brigid Stacey
Senior Nurse
Paul Webb
Senior Nurse
Julie Orr
CQC Compliance Manager
Sue Fraser-Betts
Senior Trust Manager
Patricia Miller
Senior Regional Support
Gareth Harry
Senior Regional Support
Lyn McIntyre
Observer – Area Team
Pol Toner
Observer – CCG Nominee
Lisa Llewelyn
Observer, Area Team representative
Christine Macleod
Page 2
Panel Role
Name
Keogh National Advisory Group
Paul Husselbee
Keogh National Advisory Group
Nick Black
Keogh Programme Director
Daniel Burke
Independent Moderator
Sarah Preston
Recorder
Catherine Leith
Recorder
Charlotte Holt
Quality Governance Support
Matt Plummer
PMO
Vanessa Jones
PMO
Cherry Howarth
Page 3
Final KLOEs for the Trust
Area of focus
KLOE
Governance and 1.
2.
leadership
Can Trust staff clearly articulate the governance process for escalation of issues and risks and assurance over quality of care?
How does the Trust use quality and performance information to support good governance?
Clinical and
operational
effectiveness
3.
4.
What governance arrangements does the Trust have to monitor and address clinical and operational performance data?
What does the Trust do to develop and strengthen clinical engagement and leadership?
Patient
experience
5.
How does the Trust engage with patients and ensure it learns from complaints, compliments, survey results and other patient experience intelligence?
Workforce and
safety
6.
7.
8.
How does the Trust engage with its workforce and other stakeholders?
How is the Trust assured that it has the necessary workforce deployed to deliver safe care?
What assurance does the Trust have that the organisation is safe?
9.
How does the Trust support staff development?
Page 4
Draft agenda for the Trust visit
Overview
The Announced RRR Visit Agenda sets out the standard overall process steps to be carried out during announced visits. It is important that each agenda
item is addressed in order to complete the RRR in a consistent and robust manner.
Dates of announced visit
Tuesday 4 June and Wednesday 5 June 2013
Location: Colchester General Hospital, Turner Road, Colchester, Essex, CO4 5JL (Trust contact: Becci Hurst, Assistant Company Secretary)
Base room for the panel: Iceni Centre, Seminar Room 2
Breakout rooms for the panel: Iceni Centre, Seminar Room 1, Post Graduate Medical Centre (PGMC), Rooms 1,2,3, 4 & Lecture Theatre
Parking
There will be parking available at the Postgraduate Centre on the Colchester Hospital Site for up to 10 cars. This is Villa 8 on the left hand side of the
hospital site map on page 88. Those panel members staying at the hotel will need to arrange car sharing.
Attendees
Chair: Liz Redfern
Team 1
Team 2
Team 3
Dr Andrew Phillips, Doctor (Neurosurgery &
Anaesthetist)
Dr Colette Marshall, Doctor (Vascular surgeon)
Dr Chris Gordon, Deputy Chair
Margaret Ogden, Lay Representative
Trevor Begg, Lay Representative
Neeta Meeta, Lay Representative
Mr James Bristol, Surgeon Panel Member – Doctor
(Surgeon: General and Breast)
Paul Webb, Senior Nurse
Shelley Griffith, Junior Doctor
Sian Ball, Student Nurse
Amy Burgin, Student Nurse
Julie Orr, Senior Nurse
Brigid Stacey, Executive Level Nurse
Nick Black , Keogh National Advisory Group
Daniel Burke, Keogh Programme Director
Paul Husselbee , Keogh National Advisory Group
Pol Toner , Observer, Area Team representative
Lisa Llewelyn, Observer, CCG representative
Page 5
Gareth Harry, Senior Regional Support
Lyn Mcintyre, Senior Regional Support/ Christine
Macleod, Observer, Area Team representative
Patricia Miller, Senior Trust Manager
Sue Fraser-Betts – CQC representative
Note: The teams above are indicative as are the panel allocations below and flexibility can be discussed throughout the visit to be balanced with continuity
and visit requirements including the need for each item in the agenda to be attended by a patient representative and clinician.
Panel support:
Sarah Preston (Independent Moderator)
Matt Plummer (Quality Governance Support)
Vanessa Jones (PMO support) – primary point of contact for queries during the site visit
Cherry Hayworth (PMO)
Catherine Leith (recorder)
Charlie Clover (recorder)
Please see joining instructions above for further details on location, travel and accommodation.
In addition, the following have been requested from the Trust:

Passes to enable access

A base room for the panel

Breakout rooms for the panel’s use

A hardcopy of the Trust’s submission and those documents listed in the ‘Document request’ section to be available to the panel throughout the site
visit

Tea, coffee and water throughout the day

Wifi access
For queries during the site visit, please speak to Vanessa Jones in the first instance.
Page 6
Evening Before Monday 3 June
Time
Agenda and Trust attendees
Content
Panel members
Venue/Room
17.30 –18.30 Arrival and check-in at hotel
19.30-20.30 Hospital visit pre-meeting
20.30




At the hotel
Welcome and introductions
Plan for next 2 days and set the scene
Clarify any issues and concerns from the panel on
scope/agenda/KLOEs
Welcome dinner for all panel
members
Day 1: Tuesday 4 June
Note: Due to the size of the teams each team should consider whether the full team is required to attend each session and the time can be used for further
triangulation and documentation of sessions previously held. This should be balanced with the visit requirements including the need for each item in the
agenda to be attended by a patient representative and clinician.
Time
Agenda and Trust attendees
8.00
Meet in hotel reception to drive to
Trust
8.30
Panel arrive at Trust

Panel members arrive at Iceni Centre for site induction and visitor All
pass distribution
Trust attendees: Becci Hurst,
Carmel Cornell, Tammy Diles and
Cara Gosbell

Panel support team arrive to set up and ensure requested logistics
are in place
Pre-meet for review panel

All
Chair’s briefing – Liz Redfern
Recorder – CL/CC
o Welcome and introductions
o Chair’s key message for the visit
Moderator’s briefing - Sarah Preston
o Introduction to the support team
o What to expect
o Your responsibilities over the next few days, including
evidence, documentation, triangulation, the report and check-
9.00-10.30
Content

Panel members
Page 7
Venue/Room
Iceni Centre
Seminar Room 2
Iceni Centre
Seminar Room 2
Time
Agenda and Trust attendees
Content



9.15-9.45
Panel members
Venue/Room
Chair – LR
Support team - SP
Ground Floor
Meeting Room, villa
10
Iceni Centre
Lecture Theatre
out
o Role descriptions
o Escalation procedures (with input from CQC rep)
o Communication procedures, including care of whistle-blowers
Quality Governance Support – Matt Plummer
Re-cap on the KLOEs and run through the plan including areas of
focus
Review of documentation
Media Briefing
Trust attendees: Mark Prentice and
Paul Searle

CEO and Trust senior team to meet the Panel
ALL
Recorder – CC/CL
11.00-11.45 A – Interview:
Gordon Coutts, Chief Executive

Interview with key focus on governance and leadership
Chair – LR
Room 5, PGMC
Lay Representative NR
Recorder – CL
11.00-11.45 B – Interview:
Sean MacDonnell, Medical Director

Interview with key focus on governance and leadership and
clinical and operational effectiveness
Attendees – Team 3
Iceni Centre
Seminar Room 1
11.00-11.45 C – Interview:
Kathy French, Acting Director of
Nursing and Patient Experience

Interview with key focus on governance and leadership and
clinical and operational effectiveness
Attendees – Team 1
Recorder – CC
Lecture Theatre,
Iceni
11.00-12.00 D - Observations – Brightlingsea
Ward - ENT, Vascular, General
Surgery and Mersea Ward - General
Surgery


Undertake observation of clinical areas to observe quality aspects Attendees -Team 2
Informal discussions with patients and staff in clinical areas
Main Block
12.00-13.00 Lunch and triangulation (panel only)

Iceni Centre
Seminar Room 2


Review of evidence identified in the sessions held to date against Attendees – ALL
Lead – LR
the KLOEs
Recorder – CL/CC
Discussion of emerging themes and issues against the KLOEs
Identification of areas of focus for the remaining sessions

Interview with key focus on governance and leadership
10.30-11.00 Trust Presentation
Trust attendees: Gordon Coutts,
Sean MacDonnell, Kathy French
13.00-14.00 A - Meet the Trust Governors
Page 8
Attendees – Team 3
Recorder - CL
PGMC, Room 2
Time
Agenda and Trust attendees
Content
Panel members
Venue/Room
13.00-14.00 B - Interview: Lead Governor

Interview with key focus on governance and leadership
Chair – LR
Iceni Centre,
Lay Representative - Seminar Room 1
MO
Recorder – CL
13.00-14.00 C - Drop in session

Drop in session for patients and staff
Attendees -Team 2
Recorder - CC
13.00-14.00 D -Observations: Birch Ward and
Peldon Ward – Elderly Care Wards


Undertake observation of clinical areas to observe quality aspects Attendees – Team 1
Informal discussions with patients and staff in clinical areas
Gainsborough Wing
A – Emergency Assessment Unit


Undertake observation of clinical areas to observe quality aspects Attendees -Team 2
Informal discussions with patients and staff in clinical areas
EAU
B – A&E


Undertake observation of clinical areas to observe quality aspects Attendees -Team 2
Informal discussions with patients and staff in clinical areas
A&E
C – Wivenhoe ward – general
surgery and West Bergholt Ward –
trauma and orthopaedic


Undertake observation of clinical areas to observe quality aspects Attendees -Team 1
Recorder - CL
Informal discussions with patients and staff in clinical areas
Main Block
D – Lexden Ward – Obs and gynae,
special care baby unit – paediatrics,
Stanway Ward - gynaecology

Undertake observation of clinical areas to observe quality aspects Attendees -Team 3
Recorder - CC
Informal discussions with patients and staff in clinical areas
Constable Wing
15.00-15.30 Tea and Coffee – panel triangulation
(panel only)

Review of evidence identified in the sessions held to date against Attendees – ALL
Lead – LR
the KLOEs
Recorder – CL/CC
Discussion of emerging themes and issues against the KLOEs
Identification of areas of focus for the remaining sessions
Iceni Centre, Room
2
Lecture Theatre,
PGMC
14.00-15.00 Observations:


15.30-16.30 Breakout Sessions – focus groups
A – Focus group: Student Nurses


B – Focus group: Health Care
Assistants


C – Focus group: Non-clinical staff
and AHP

Explore the groups understanding of key processes for ensuring
quality of care and treatment in the Trust
Identify any concerns and collate feedback from the group
Attendees - Team
1(split team)
Recorder – CL
PGMC Room 2
Explore the groups understanding of key processes for ensuring
quality of care and treatment in the Trust
Identify any concerns and collate feedback from the group
Attendees – Team
1(split team)
Iceni Centre,
Lecture Theatre,
Explore the groups experience of quality of care and treatment in Attendees - Team 2
Recorder – CC
the Trust
Page 9
PGMC Room 3
Time
Agenda and Trust attendees
D – Focus group: Registered Nurses
16.30-17.30 Triangulation (panel only)
17.00-17.15 Feedback to Trust on Day 1 and
plan for Day 2
Content
Panel members
Venue/Room
Attendees – Team 3
PGMC Lecture
Theatre

Identify any concerns and collate feedback from the group



Explore the groups understanding of key processes for ensuring
quality of care and treatment in the Trust
Identify any concerns and collate feedback from the group



Review of evidence identified in the sessions held to date against Attendees – ALL
Lead – LR
the KLOEs
Recorder – CL/CC
Discussion of emerging themes and issues against the KLOEs
Identification of areas of focus for the remaining sessions


Thanks for day 1
Escalation of any significant immediate issues

Explore the groups experience of quality of care and treatment in Attendees – Team 1
Recorder – CL
the Trust
Identify any concerns and collate feedback from the group
PGMC, Room 3
Attendees – LR, SP
Lead – LR
Recorder – SP
Iceni Centre,
Seminar Room 2
Iceni Centre,
Seminar Room 1
Trust attendees: Gordon Coutts,
Sean MacDonnell, Kathy French
17.30-18.30 A – Focus group: Consultants and
registrars

17.30-18.30 B - Travel time

A significant portion of the Trust’s patients live within the Tendring Attendees – Team 3
Peninsula. This area has a large elderly population for which travel Recorder – CC
may be difficult. The Trust has proposed a second patient/public
listening surgery is held in this area. The travel time from
Colchester is approximately 30 minutes. The Trust will arrange
appropriate transport for members of the panel.
Transport arranged
by Trust
18.30-20.00 A - Patient/Public drop in session
(“listening event”)

Explore the groups experience of quality of care and treatment in Attendees – Team 1
Recorder – CL
the Trust
Identify any concerns and collate feedback from the group
Lecture Theatre ,
Postgraduate
Medical Centre,
Colchester General
Hospital, Turner
Road, Colchester
CO4 5JL

Explore the groups experience of quality of care and treatment in Attendees –Team 3
Recorder – CC
the Trust
Identify any concerns and collate feedback from the group
Princes Theatre,
Station Road,
Clacton CO15 1SE


Review the documentation provided by the Trust
Identify any areas of focus for day 2

18.30-20.30 B - Patient/Public drop in session
(“listening event”)
18.30-20.00 C -Document review (panel only) or
Unannounced visits
21.00

Attendees – Team 2
Attendees – All
Evening meal for Panel
Page 10
Iceni Centre,
Seminar Room 2
The panel may decide it is appropriate to undertake unannounced visits out of hours on the evening on Tuesday 4 June. Should these take place, the
attached unannounced visits procedures should be followed.
Day 2: Wednesday 5 June
Time
Agenda and Trust attendees
08.3009.15
Panel gathering – Plan day
09.15 11.30
A -Flexible observations throughout
the Trust to be confirmed in the
planning meeting
Content
Panel members
Venue/Room
Attendees – All
Lead – LR
Recorder – CL/CC
Iceni Centre
Seminar Room 2


Undertake observation of clinical areas to observe quality aspects
Informal discussions with patients and staff in clinical areas
Attendees – Team 2
and 3
Various
Locations to consider: Critical Care
Unit, Elective day surgery, Elective
orthopaedics, Elmstead day unit,
Stroke Unit
09.1510.15
B -Interviews:

Acting Director of HR

Deputy Medical
Director/Training, Education
and Appraisal

Interview with key focus on workforce and safety
Attendees –Team 1
Recorder - CL
Iceni Centre,
Seminar Room 1
10.1511.15
C -Interviews:

Associate Medical Director
Audit and Effectiveness

Associate Director – Service
Improvement

Interview with key focus on clinical and operational effectiveness
and patient experience.
Attendees –Team 1
Recorder -CC
Iceni Centre,
Seminar Room 1
11.3012.30
A -Interview: Chair of Quality and
Patient Safety Board Assurance
Committee

Interview with key focus on governance and leadership and
clinical and operational effectiveness
Attendees –Team 1
Iceni Centre
Seminar Room 1
11.3012.30
B -Interview
Non –executive Directors

Interview with key focus on governance and leadership and
clinical and operational effectiveness
Attendees –Team 2
Recorder - CC
PGMC, Room 3
Page 11
Time
Agenda and Trust attendees
Content
Panel members
Venue/Room
11.3012.30
C -Interview
Chair, Dr Sally Irvine

Interview with key focus on governance and leadership and
clinical and operational effectiveness
Chair – LR
Lay Representative NR
Recorder – CL
PGMC, Room 5
11.3012.30
Flexible Time for
observations/document
review/evidence review

TBC
Attendees –Team 3
Iceni Centre,
Seminar Room 2
12.3013.30
A -Focus Group: Junior Doctors

Attendees -Team 3
PGMC, Lecture
Theatre

Explore the groups experience of quality of care and treatment in
the Trust
Identify any concerns and collate feedback from the group
12.3013.30
B -Focus group: Essex County
Hospital

Transport arranged by Trust for Panel members
Attendees -Team 2
Recorder - CC
Training Room 8,
Old Nurses Home,
Essex County
Hospital
12.3013.30
C -Drop in session

Drop in session for staff and patients
Attendees -Team 1
Recorder - CL
PGMC, Room 3
13.3014.30
Triangulation (panel only) with lunch

Review of evidence identified in the sessions held to date against
the KLOEs
Discussion of emerging themes and issues against the KLOEs
Identification of areas of focus for the remaining sessions
Attendees – ALL
Lead – LR
Recorder – CL/CC
Iceni Centre,
Seminar Room 2
Main Block


14.3015.30
A -Observations – Dedham Ward cardiac

Observations focused on outstanding areas / emerging themes
and issues
Attendees – Team 1
14.3015.30
B – Interview – Divisional Clinical
Directors

Interviews focused on outstanding areas / emerging themes and
issues
Chair – LR
Iceni Centre,
Lay representative – Seminar Room 1
MO
Deputy Chair – CG
Executive Level Nurse
- BS
Recorder - CL
14.3015.30
C -Interviews – TBC

Interviews focused on outstanding areas / emerging themes and
issues
Attendees -Team 2
and 3
Recorders – CL/CC
Suggested interviews:

Director of Operations
(overseeing operational
Page 12
PGMC, Room 5
Time
Agenda and Trust attendees



15.3017.00
Content
Panel members
Venue/Room
Attendees – ALL
Lead – LR
Recorder – CL/CC
Iceni Centre
Seminar Room 2


Review of evidence identified in the sessions held to date against
the KLOEs
Discussion of emerging themes and issues against the KLOEs
Identification of areas of focus for the remaining sessions



Thanks
Escalation of any significant immediate issues
Next steps
Attendees – LR, SP
Lead – LR
Recorder – SP
Iceni Centre,
Seminar Room 1
performance and services)
Director of Finance (finance,
capital investment,
commissioning, IT,
information and
performance).
Complaints and Litigation
Services Manager/Nurse
responsible for complaints
Head of clinical coding
Final triangulation (panel only)
16.0016.45
Meeting with Trust Chief Executive,
and Chair
17.00
Leave Trust

Page 13
Page 14