Report for George Eliot Hospital NHS 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
12
5.
Governance and leadership
14
Clinical and operational effectiveness
21
Patient experience
37
Workforce and safety
41
Conclusions and support required
Appendices
47
54
Appendix I:
SHMI and HSMR definitions
55
Appendix II:
Panel composition
57
Appendix III:
Interviews held
58
Appendix IV: Observations undertaken
59
Appendix V:
61
Focus groups held
Appendix VI: Information available to the RRR panel
62
Appendix VII: Unannounced site visit
74
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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 6 February 2013, 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 being reviewed, 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.

Identify:
3
i.
ii.
iii.
Whether existing action by these trusts to improve quality is adequate and whether any additional steps should be taken.
Any additional external support that should be made available to these trusts to help them improve.
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 each trust reviewed is published at http://www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/trust-datapacks/george-elliot-data-packs-PUBLISH.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 departments, and interviewing patients, trainees, staff and Board members. This report sets out the panel’s
findings from this stage to 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 George Eliot Hospital, the single site of George Eliot Hospital NHS Trust (“the Trust”), on Tuesday 21 and Wednesday 22
May 2013. It is noted that the second day of the announced RRR visit took place at a time of high capacity pressures at the Trust with the escalation management system
(EMS) level, used to indicate levels of the pressure experienced by each acute hospital due to the number of patients requiring its services, being a level 3 (out of 4), defined
as ‘severe or prolonged pressure’.
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.
4
The visit included the following methods of investigation:

Listening events
Public listening events give the public an opportunity to share their personal experiences of the Trust, 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 21 May 2013 at the Education Centre on the George Eliot Hospital site. This
was an open event, publicised locally, and attended by approximately 60 members of the public and patients.
The panel would like to thank all those attending the listening event who 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 themes emerging have been included within this report.

Interviews
18 interviews took place with key members of the Executive team, Non Executive Directors and selected members of staff based on the KLOEs during the visits. See
Appendix III for details of the interviews undertaken.

Observations
Observations of clinical areas and meetings 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 place during visiting hours. They allowed the panel to speak with a range of staff and assess any observed handover processes within
wards, to ensure that the staff that were coming on duty were appropriately briefed on patients.
During the RRR announced visit, observations took place in 20 areas of the George Eliot Hospital and a further two observations of meetings took place. See Appendix IV for
details of the observations undertaken.
Further observations were undertaken as part of the unannounced site visit, see below.

Focus Groups
Focus groups provided an opportunity to talk to staff groups individually to ask each area of staff what they feel is good about patient care in the Trust and what needs
improving. They enabled staff to speak up if they feel there is a barrier that is preventing them from providing good quality care to patients and what actions might the Trust
need to consider to improve, including addressing areas with higher than expected mortality indicators.
Focus groups were held during the announced site visit with six staff groups, including a focus group open to all staff. See Appendix V for details of the focus groups held.
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The panel would like to thank all those who attended the focus groups and were open with the sharing of their experiences and balanced in their perceptions of the quality of
care and treatment at the Trust.

Review of documentation
A number of documents were made available to the panellists by the Trust as part of the RRR. Whilst the documents were not all reviewed in detail, they were available to
the panellists to validate findings. See Appendix VI for details of the documents available to the panel.

Unannounced visit
The unannounced site visit took place on the evening of Wednesday 29 May 2013 at George Eliot Hospital. This focused on areas identified at the announced site visit. The
unannounced visit included a meeting with the site manager, observation of a capacity meeting and three handover meetings. It also included panel observation of eight
areas of the George Eliot Hospital and observations of / interviews with three members of staff. See Appendix VII for details of the agenda completed.
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 George Eliot Hospital NHS 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 on 16 July 2013.
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2. Background to the Trust
This section of the report provides background information on the Trust.
Context
The hospital was opened in 1948 and has a total of 318 beds at a single site hospital. The Trust serves a population of just over 125,000 in Nuneaton and Bedworth (ONS
2011 Census data), as well as people in the surrounding areas of North Warwickshire, South West Leicestershire and North Coventry. The Trust has approximately 10,000
members made up from the local, patient/carer and staff communities.
The Trust provides accident and emergency (A&E) services and offers a range of inpatient and outpatient services, including surgical and medical services, services for
women and children, diagnostic and support services, and community services.
From August 2013, the Trust will no longer provide a paediatric overnight service which was determined to be non-viable by commissioners, however a new Paediatric
Assessment Unit will replace it. The Trust provides some community services, such as dental and sexual health to the wider population of Warwickshire. Harmoni, the GP out
of hours service, operates from the Trust’s site.
The Trust is not a Foundation Trust and is not currently in the Foundation Trust assessment process. In the last two years, a decision was made for the Trust not to seek to
achieve Foundation Trust status alone but to seek a partner organisation due to the relatively small size, to secure its operational future. This process is not complete as yet
and is a source of significant concern to the Board and staff.
The Trust’s HSMR has been above the expected level for the last two years (2010/11 and 2011/12) and was therefore selected for this review.
Trust size and focus
The Trust is a small sized trust for both inpatient activity and outpatient activity, relative to the rest of England and is the smallest of all those selected for this review by both
measures of activity. General Medicine and General Surgery are the largest inpatient specialities and Allied Health Professional Episodes and General Surgery are the largest
for outpatients.
The Trust has a 77% market share within a five mile radius. However, the Trust’s market share falls as the radius is increased. Within ten miles, the market share is 17%
whereas within a 20 mile radius, the market share is only 7%. The main competitors in the local area are University Hospitals Coventry and Warwickshire NHS Trust, Heart of
England NHS Foundation Trust, University Hospitals of Leicester NHS Trust and Burton Hospitals NHS Foundation Trust.
George Eliot’s population
Nuneaton is a town in the county of Warwickshire. Warwickshire has less deprivation than the English average. 8.6% of the population belong to non-white ethnic minorities,
particularly Indian. People aged 60 to 80 constitute a slightly larger proportion of the population in Nuneaton compared to the population nationally. Obesity is significantly
more common in the region than in England as a whole, as is teenage pregnancy. Life expectancy for both men and women in Nuneaton is significantly lower than the
national average.
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Key messages from the data analysis
1
The Trust data pack identified a number of key concerns that were used to inform the KLOEs for the RRR, which are outlined below .
Mortality
The Trust has an overall HSMR of 122 for the period December 2011 to November 2012, meaning that the number of actual deaths is higher than the expected level. This is
statistically above the expected range. Further analysis of this demonstrates that non-elective admissions are the primary contributing factor to this figure, with an HSMR of
123, compared with a level of 68 for elective admissions.
Currently, the Trust has a SHMI of 108, which is statistically outside the expected range. Similar to HSMR, non-elective admissions are seen to be contributing primarily to the
overall Trust SHMI with 109, against 95 for elective admissions.
The Trust has had a number of external reviews, including the including the Mott Macdonald “System, Care and Mortality review” commissioned in October 2011 and reported
January 2012 and a Nursing Mortality Review undertaken in February 2012 and the final report issued in August 2012 (draft report issued March 2011).
The key lines of enquiry (KLOEs) for the RRR included a review of the specialities in the Trust with higher mortality indicators and these informed the panel’s
observations and interviews.
Governance and leadership
All Board positions are substantively filled and the Trust Board has been relatively stable over the past two years. There has been a recent review of the Director portfolios,
which resulted in the expansion of director portfolios.
The Trust Board has five subcommittees, including the Quality Assurance Committee, which is chaired by a Non Executive Director and provides assurance to the Board on
quality. The Mortality Group is a subcommittee of the Quality Assurance Committee.
The Trust is compliant with all Care Quality Commission (CQC) standards. However, the Trust has breached the national 62-day cancer target for two of the four quarters in
2012/13 (quarter 2 and quarter 3).
Key risks to quality identified by the Trust in its risk register relate to staffing levels, in particular in maternity and in the neonatal and paediatric services.
Other potential risks identified through review of the Trust’s Board papers show that there have been 87 serious incidents in 2012/13, including 20 related to falls and 32
relating to pressure ulcers. There was also one never event in July 2012.
A high level review of the effectiveness of the Trust’s quality governance arrangements was a standard KLOE for the review.
Clinical and operating effectiveness
The Trust saw 96.2% of A&E patients within four hours over the period January to December 2012 which is above the 95% target level. The Trust’s Integrated Performance
Report Board paper for March 2013 reports that, while the Trust achieved the target in aggregate for 2012/13 (95.7%), it was not achieved in quarter four (92.4%), January to
March 2013. Performance in March 2013 is reported as 89.8% and the first ten days of April as 85.8%. 95.8% of the Trust’s patients start treatment within the 18 week target
time which is just above the target level.
1
For further information and explanations on the data analysis used please see the published data pack at http://www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/trust-data-packs/data-pack-george-eliot.pdf.
8
The Trust’s crude readmission rate is one of the higher readmission rates nationally, at 13.1% which may indicate issues with the appropriateness of treatment offered. The
average length of stay is shorter than that of the national average which may indicate efficiency of treatment. However, it may be a further indicator of issues with clinical and
operating effectiveness when considered alongside the higher readmission rate.
Finally, the Trust had similar or above the expected level of performance on six out of seven of the latest cancer waiting time measures (quarter 3 2012-13). It was however
underperforming on the proportion of patients receiving their first definitive treatment for cancer within two months (62 days) of GP or dentist urgent referral for suspected
cancer breaching the national target of 85% in both quarter 2 and 3 in 2012/13 (quarters 1 and 4 met the national target).
The Patient Reported Outcomes Measures (PROMs) dashboard shows that the Trust was a relatively poor performer in 2009/10 but has improved over the last two years. In
2011/12 only one of the six measures was an outlier - the Hip Replacement Oxford Hip Score measure (tool designed to be completed by the patient to assess function and
pain with patients undergoing hip replacement surgery) which was below the 95.0% control limit and very close to the 99.8% control limit.
A high level review of clinical and operating effectiveness measures was a standard KLOE for the review as was a KLOE to review management of patients to
consider patient flow through the Trust.
Patient experience
Of the nine measures reviewed within Patient Experience and Complaints there are two which were rated ‘red’ for the Trust: the inpatient survey 2012; and results from the
Midlands and East Friends and Family Test.
Particular areas of concern from the inpatient survey were issues around communication to patients, hospital discharge processes and some issues around the environment
including cleanliness and noise from patients.
The quarterly risk profiles compiled by the CQC collate comments from individuals and various sources. Of 26 individual comments from patients and public as part of the
Patient Voice, 16 were negative. These comments highlighted no particular areas for concern. The patient listening event also identified a number of themes for further
investigation, the most consistent area being poor communication by staff to patients.
The Trust is B-rated by the Health Service Ombudsman which indicates that there is an intermediate risk of 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.
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 Trust is ‘red rated’ in five of the safety indicators: reporting of patient safety incidents, “harm” for all four safety thermometer indicators, pressure ulcers, Clostridium
difficile rates and clinical negligence scheme payments.
The Trust has a rate of 4.3 for its patient safety incident reporting per 100 admissions. This is more than three standard deviations below the mean showing the Trust is a low
reporter of incidents and indicating that all incidents may not be being reported. It recorded 263 incidents reported as either moderate, severe or death between April 2011
and March 2012.
9
th
It is 37 highest out of 141 for percentage of patients harmed for the four Safety Thermometer indicators when compared with other non-specialist trusts. Similarly, between
th
2010 and 2012 George Eliot was ranked 9 highest out of 143 trusts for Clostridium difficile infection rates meaning its level of performance is among the poorest nationally.
In recent months, The Trust’s new pressure ulcer prevalence rate has sharply risen above the national rate.
The Trust’s Clinical Negligence payments have exceeded contributions to the ‘risk sharing scheme’ over the last three years, although this is primarily because of a high level
of payouts in 2011/12.
The Trust is ‘red rated’ in 13 of the workforce indicators. It notably has a sickness absence rate above the national mean and employs more agency staff than the median. It
is noted that the Trust states that it made a deliberate decision to use agency staff to reflect the changes to service models, for example paediatrics, and also to respond to
the unprecedented levels of emergency pressures.
It has low levels of staff engagement and has a deanery score (92) below the national average (94) for doctors which are undertaking their training at the Trust. The 2012
National NHS Staff Survey reports the staff engagement score to be an increase since the 2011 survey. However, staff joining rates are higher than the average in the West
Midlands region and employees would recommend it to friends as a place to work.
KLOEs were included in the Trust review focusing on incident reporting within clinical and operating effectiveness, the safety thermometer and workforce
measures, including workforce planning and staff support.
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3. Key Lines of Enquiry
The KLOEs were drafted using the following key inputs:

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 2 for more
details.

Insights from the Trust’s lead Clinical Commissioning Group (CCG), North Warwickshire 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 governance processes for assuring the quality of treatment of care? Are the leadership roles
and responsibilities clearly defined for the quality processes? Can staff at all levels of the organisation describe the key
elements of the quality governance processes?
Clinical and operational
effectiveness
2. What governance arrangements does the Trust have to monitor clinical and operational performance data at a senior level?
What processes does the Trust have in place to support monitoring mortality data and clinical effectiveness? Has the Trust
data identified any issues? What actions is the Trust taking to address issues noted?
3. How does the Trust manage medical and surgical patients? Has the Trust identified any issues with the management of
surgical patients? What actions is the Trust taking to address issues noted?
4. How does the Trust manage deteriorating patients? Has the Trust identified any issues with the management of deteriorating
patients? What actions is the Trust taking to address issues noted?
5. What actions are the Trust taking to address safety thermometer issues?
Patient experience
6. How does the Trust review patient experience data and engage with patients to seek views about their experience? What are
the key themes from patients on their experiences? What action is it taking to address the key themes emerging? What do
patients say about the quality of care in the Trust during our observations/interviews?
Workforce and safety
7. How does the Trust approach workforce planning to ensure that patient safety is managed effectively including skill mix? Is
there effective provision for surgical and medical consultant input following admission?
8. How does the Trust support its staff including with adequate training?
The KLOEs were used by the RRR panel to focus the visit and ensure that the key concerns raised by the data review were addressed. However, where concerns were
identified with the areas of focus, the panel ensured that these were also investigated as far as time allowed.
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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 by KLOE.
The panel observed that the Trust has a generally engaged, passionate and loyal staff at a Trust clearly supported by the local public. Staff consistently spoke of the Chief
Executive having a positive impact on the Trust and said that the Executives were visible around the Trust. Further details on good practice identified are included below by
KLOE and in the following section.
Areas identified for urgent action
No issues were identified during the course of the review that were considered by the panel, with the support of the CQC representative on the panel, to need immediate
escalation and resolution.
A high level summary of the areas identified for urgent action are as follows:
Governance and Leadership

Whilst the leadership of the Trust has taken difficult decisions on the long term future of the Trust, it was difficult to identify evidence of proactive, driven leadership that is
focussed on excellent quality of care and treatment, with concerns over leadership of the medical staff.

Governance processes require further development in some areas; a review of a sample Board papers, including the mortality report, found them to be of poor quality,
and to contain limited analysis and evidence of triangulation and scrutiny of the data presented in the paper.

Some Executive Directors were inconsistent or could not clearly articulate their portfolios, when interviewed during the RRR announced visit, particularly in relation to
responsibilities for quality and patient safety, following recent changes in Directors’ portfolios.

The culture at the Trust was acknowledged to have been insular prior to the appointment of the new Executive team two years ago. Whilst the Trust had undertaken
some work to change the culture and provided evidence of working with other trusts, nationally and internationally, the examples provided were fewer than the panel
would have expected and in comparison to other trusts. Further work is needed for a consistent quality focused culture striving for excellence to be fully embedded with
the adoption of best practice from elsewhere.

The divisional structure, in place since December 2011, had been further developed with recent refinements and the introduction of a divisional governance structure in
May 2013, which is still to be tested.
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
There was evidence identified of a gap between ward level and Board level; staff cited that communication stopped at middle management; staff interviewed were not
able to articulate the Board’s quality priorities; the Board did not appear to be receiving ward level information so as to fully understand ward level activity and
performance; and staff interviewed at ward level spoke of informal rather than formal reporting channels, limiting the information that is presented to the Board.
Clinical and operational effectiveness

The Trust stated that the high HSMR reported in 2011 came as a surprise and consequently it commissioned an external review to understand the high index. The
culture at the Trust appeared to place a reliance on external reviews and there appeared to be an absence of detailed analysis internally of mortality (for example
comparing deaths taking place in the day or night).

There were concerns noted about the extent to which there was evidence of a sufficient pace of quality improvements being achieved at the Trust, with many actions not
fully implemented and limited evidence of positive outcomes as a result.

It was not clear that there is sufficient focus on quality and patient safety in the Trust, for example there was limited reference to patient safety when quality of care was
discussed with Trust staff and Board members.

The Quality Strategy did not yet have a detailed plan of how it will be delivered, as this is due to be presented to the Trust Board in June 2013.

Clinical audits were only 60% completed in the past year. Additionally there appeared to be neither accountability nor a culture of learning from or responding to lessons
learned, systematically and in a sustainable manner. Incident reporting levels are low and staff described the reporting system as slow with limited feedback to staff in
response to reported incidents.

There was limited evidence of effective patient flow through the hospital. Wards appeared to contain patients with a wide range of illnesses and whilst consultants were
ward-based, patient moves were not uncommon. As a result there were examples of delays to receiving medical attention from appropriate consultants. Furthermore
issues were noted with the quality and content of medical handovers.

Pressure ulcers are being regularly recorded as “unstageable”, a grading not used by other trusts in the region. Additionally examples of errors were identified in senior
staff’s knowledge of pressure ulcer grading.

Sepsis care bundles were starting to be implemented and resources had been allocated to this. However the ambition set around their implementation (60% compliance)
is far lower than would be expected by the RRR panel, as it was simply the CQUIN target and no greater. There was no evidence of any other care bundle in place and,
although plans were agreed at the time of the visit for Pneumonia and Acute Cardiology Syndrome bundles, no implementation date was given.
Patient experience

The Trust serves an elderly population and we could not identify plans for End of Life care outside hospital.
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Workforce and safety

Concerns were identified with low levels of clinical cover throughout the Trust, particularly out of hours.

The Trust’s Workforce Strategy 2013-16 was still in draft at the time of the panel visit. The action plan was incomplete and also missing both timelines and owners for a
number of listed actions.

7 day working appeared to be in early planning stages, as staff were speaking of business cases rather than implementation.
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
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Governance and leadership
Overview
The KLOE in the governance and leadership area was the standard key line of enquiry for the review.
Examples of good practice were identified in the following areas:

The Trust Board has been relatively stable over the past two years, following the forming of a new Executive team two years ago.

Feedback throughout the Trust was generally that the Chief Executive was effective, his impact on the Trust had been positive and that there was good communication
from him.

Executive team were generally felt by staff to be visible. Staff also spoke of the Executive team being approachable and generally felt that there was an open and
transparent culture at the Trust.

The Non Directors showed commitment to the Trust with strong representation at the Quality Assurance Committee held during the announced visit.
The following areas of outstanding concern were identified:

Whilst the leadership has taken difficult decisions on the long term future of the Trust, it was difficult to identify evidence of proactive, driven leadership that is focussed on
excellent quality of care and treatment with concerns over leadership of the medical staff. Board papers were of poor quality and there were inconsistent responses in
interviews with some of the Executives interviewed over where their responsibilities for quality and safety sat.

Staff noted that there appeared to be a large number of new initiatives and policies, however there was little understanding of a clear overall plan. Panel review of Trust
strategies identified that the strategies tended to be high level and without detail on implementation.

Although the Trust provided some examples of internal stretch targets, panel members saw limited evidence of a culture consistently striving to exceed minimum
standards.

There was an absence of a quality focus in corporate risk management.

There was evidence identified of a gap between ward level and Board level; staff cited that communication stopped at middle management; staff interviewed were not
able to articulate the Board’s quality priorities; the Board did not appear to be receiving ward level information so as to fully understand ward level activity and
performance; and, staff interviewed at ward level spoke of informal rather than formal reporting channels, limiting the information that is presented to the Board.

Evidence identified of a gap between ward level and Board level cited by staff interviewed. The Board did not appear to be receiving information at a ward level to fully
understand ward level activity and performance, and staff interviewed at ward level spoke of informal reporting rather than formal, limiting the information that is presented
to the Board.
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Detailed Findings
Governance and leadership
KLOE 1: Can the Trust clearly articulate its governance processes for assuring the quality of treatment of care? Are the leadership roles and responsibilities clearly defined for
the quality processes? Can staff at all levels of the organisation describe the key elements of the quality governance processes?
Good practice identified
The Trust Executive team welcomed this review to drive improvement and recognised that there is more to do. The Trust presentation at the start of the visit
highlighted the work that had started two years ago. The Trust was had been insular, with a culture that accepted a minimum standard of care (“Good Enough”)
and with governance processes that could be improved. Work had been undertaken to change the culture, to strive for excellence, reduce insularity and
develop new governance structures.
Following a period of change in people and structure, including the forming of a new team, the Trust’s leadership has been relatively stable over the past two
years. The recent review of directors' portfolios has expended all directors’ portfolios. The Director of Governance and Quality (appointed April 2013) is the
lead for governance quality and the Director of Nursing and Quality the lead for clinical quality. Both these Directors support the Medical Director who is lead
director for mortality.
The Trust operates in four divisions which are led by clinical directors for each locality.
The Chief Executive was said to be effective including the following:
 Staff consistently referring to the Chief Executive’s positive impact.
 The all staff focus group agreed that communication had hugely improved within the Trust in the last two years and a number of staff cited the Chief
Executive’s twice weekly blog as an effective means of communication.
 Staff spoke of the Chief Executive being visible, including visiting the hospital operational areas at night.
Staff spoke positively about the Executive team and felt that they were visible. The Executive team were known to staff and undertook regular walkabouts.
Staff also spoke of the Executive team being approachable and generally felt that there was an open and transparent culture at the Trust.
The Non Executive Directors showed commitment to the Trust with strong representation at the Quality Assurance Committee held during the announced visit
with five out of six Non Executive Directors present (noted that the sixth usually attends but was on leave).
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Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
i. Leadership of quality
A Board Development Programme is in
place although this is not externally
The Trust leadership have been in place for less than two
supported and is topic rather than skill /
years and have been operating in a context where the long capability focused.
term future and viability of the Trust has been, and
continues to be, uncertain.
Improve Board capability through
development of constructive critical
challenge skills of the Board, so the Board
effectively scrutinises data, triangulates
and drives effective action throughout the
Trust.
Urgent
Whilst the Trust could be seen to be engaging with
external reviews to understand the mortality issues arising,
the focus of the Trust leadership appeared to be on finding
a strategic partner for the long term future. It was difficult
to identify evidence of proactive and driven leadership,
focussed on excellent quality of care and treatment
throughout the Trust, particularly within the medical
leadership. There was limited evidence of the Trust
leadership driving improvements in quality at the Trust with
sufficient pace – see iii below and KLOE 2(ii) for examples.
Non Executive Directors should gain
assurance through effective review and
constructive challenge of action plans
detailing changes made and evidence of
the effectiveness of the changes.
Urgent
This was evidenced, for example, through the Board
papers primarily showing commentary with limited scrutiny
of data, triangulation and resulting actions. It was also
noted that fewer items were going to the public Board
session than would have been expected by the panel.
Urgent
Ensure clarity over Director portfolios and
development of ownership and
accountability for these portfolios from the
Executive, particularly for quality and
patient safety. In doing so the Board
needs to make sure all Executives have
the necessary skills to perform their role
effectively.
This was also evidenced in our interviews with Executive
members over the responsibility for quality and safety
where the recent changes in Directors portfolios led to
inconsistent responses from some Executives as to where
this responsibility sat and gave limited sense of
responsibility and accountability for these areas.
17
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
ii. Strategy and implementation plans
The Trust has submitted a business case for The Trust should clarify the overall
High
its long term future to the Department of
strategy of the Trust to staff, even in the
The Trust is operating in the context of an uncertain long
Health.
context of an uncertain long term future,
term future with it being clear to the panel that staff and
and ensure that initiatives are launched
patients are worried that the George Eliot Hospital will be
An organisational clinical strategy has been with reference to the strategy and vision so
closed.
ratified by the Board.
that their link is clearly understood.
Urgent
In addition, staff noted there appeared to be a current
The Trust is currently developing a new
Agree a SMART implementation plan
change momentum at the Trust with a large number of new strategy through the Securing a Sustainable including an identified trajectory of
initiatives and new policies without a clear plan. Staff also Future project.
implementation of improvement plans.
spoke of a large number of strategies being initiated in the
Monitor effectively, for example through
few weeks leading up to this review, although the Trust
Further embedding of cultural change.
critical review monthly, seeking evidence
states that is was due to the previously delayed publication
of sustainable implementation and the
of strategies , due to the delayed publication of the Francis
impact of implementation.
report. Furthermore staff mentioned change initiatives
over the past year that had not been embedded or
sustained.
Review of a number of Trust strategies identified that these
tended to be high level plans, lacking detail on how and
when the strategic visions would be delivered.
18
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
iii. Culture at the Trust
The Executive team set out a vision of a
culture of excellence where “good enough is
not good enough” utilising the EXCEL
programme.
Further work is needed to embed a
consistent culture that looks externally for
good practice and employs good practice
and excellence throughout the Trust. This
needs to be led by the Board.
Urgent
The culture at the Trust was acknowledged to have been
insular prior to the appointment of the new Executive team
two years ago. Whilst the Trust had undertaken some
work to change the culture and provided evidence of
working with other trusts, nationally and internationally, the
examples provided were fewer than the panel would have
expected and in comparison to other trusts.
Work is ongoing to attempt to change the
historically insular culture at the Trust and
encourage innovation working in partnership
nationally and internally as required. To
date this has included a variety of projects,
Whilst staff consistently spoke of “EXCEL” (Effective open for example working with two other trusts
communication; eXcellence in all that we do; Challenge but doing research on Quality Nurse
support; Expect respect and dignity; Local healthcare that
Competence – the VITAL programme.
inspires confidence), the Trust’s articulation of its vision,
staff articulation of what “EXCEL” meant was limited.
Although the Trust provided some examples of internal
stretch targets, panel members did not see a consistent
ambition to excel and exceed minimum expectations.
Examples included the sepsis target being set at the
required CQUIN target level rather than higher, action
plans for 7 day working containing no trajectories for
achievement and also no expectation from key leadership
in the Trust to review 100% of death in hospital.
Medical staff interviewed generally could not describe the
safety and quality priorities of the Trust.
19
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
iv. Quality focus in risk management
The Non Executive Directors at the Quality
Assurance Committee on 22 May 2013
challenged content of the risk register.
The Trust Board to review the content and
workings of the risk register and BAF to
ensure that they properly reflect the key
risks for the Trust, that the risks are
addressed and that the Board are clear
and aware of key issues including clinical
risks.
High
Ensure that the divisions link to the
corporate centre and each other by, for
example, creating opportunities for
effective sharing and learning from
divisional meetings, also within divisions
and between divisions, as well as with the
rest of the Trust.
Medium
A number of concerns were noted about the Board
Assurance Framework (BAF) and the corporate risk
register. For example, the highest rated risk showing on
the BAF is breaking even financially despite current issues
with A&E performance, high mortality rates and the Trust is
planning a financial deficit.
v. Gap between Board level and ward level
The Trust has a ‘Board to Ward Accountability framework’
and the divisions have been required to produce their
2013/14 objectives aligned to the Trust’s objectives.
However, the following evidence of a gap between Board
and ward were identified:
 Staff cited a gap in communication, with messages
from the Board stopping at middle management.
 The Chair could not, when interviewed, articulate the
Board to ward processes.
 Knowledge at divisional general manager level was
found to be limited in some individuals, with no
knowledge of the Trust’s Cost Improvement Plan (CIP)
target or current A&E performance.
 Board reports did not report quality by ward.
 Limited interviewed staff were able to articulate the
Board’s quality priorities.
 The Board did not appear to be receiving ward level
information that enabled them to fully understand ward
level activity and performance. Additionally staff
interviewed at ward level spoke of informal rather than
formal reporting which was limiting the information that
is presented to the Board.
The new Director of Clinical Governance
and Quality advised the committee that the
risk register is currently under review to
include additional clinical risks.
The Chief Executive states that the new
divisional structure is designed to enable
clinical leadership by staff.
Specific divisional governance meetings
were due to commence on 22 May 2013.
Non Executive Directors are to attend
divisional boards.
High
Board reports to report by ward either to
the Board or a Board Quality subcommittee.
20
Clinical and operational effectiveness
Overview
The four KLOEs in the clinical and operational effectiveness area focused on governance, management of medical and surgical patients, management of deteriorating
patients and the safety thermometer.
Examples of good practice were identified in the following areas:

Examples of a culture of learning around mortality issues.

The Trust operates a full time nurse-led outreach team that is held in high regard by staff interviewed throughout the Trust.

There were practices within the Trust which demonstrate that safety thermometer issues are being taken seriously.

Examples of access to equipment help safety thermometer issues.
The following areas of outstanding concern were identified:

Absence of detailed analysis of mortality performance, for example analysis between deaths in the day and deaths at night or deaths post-discharge.

There were concerns with the extent to which there was evidence of the Trust achieving sufficient quality improvements and the pace of those changes.

Issues noted with the clinical and quality strategies.

Limited evidence of a focus on patient safety.

The Trust is a low reporter of patient safety incidents and staff described the reporting system as slow with limited feedback to staff in response to reported incidents.

The panel did not identify a culture of systematic organisational learning.

Concerns were identified with the monitoring of performance.

Wards appeared to contain patients with a wide range of illnesses, whilst consultants were ward-based and patient moves were not uncommon.

There was limited evidence of proactive management of patients and examples of many delays for inpatients due to poor planning of medical care.

Issues were identified with the content and quality of medical handovers.

Discharges did not appear to be working effectively.

Concerns were identified with patient admissions.

A number of examples were provided to the panel of IT not supporting patient care.
21

Weaknesses were identified in the process of managing deteriorating patients including a number of staff interviewed did not know of a formal escalation policy and “used
their own judgement” as to when to call doctors / seniors.

Concerns identified with the sepsis care bundle performance target and implementation.

Concerns were noted specific to the recording of pressure ulcers with high numbers of “unstageable” pressure ulcers being recorded, a grading not used by other trusts in
the region, and examples of errors in senior staff’s knowledge of pressure ulcers.

The panel only identified limited monitoring and management of all the safety thermometer elements.
Detailed Findings
Clinical and operational governance
KLOE 2: What governance arrangements does the Trust have to monitor clinical and operational performance data at a senior level? What processes does the Trust have in
place to support monitoring mortality data and clinical effectiveness? Has the Trust data identified any issues? What actions is the Trust taking to address issues noted?
Good practice identified
Examples of a culture of learning around mortality data and clinical effectiveness:
 The Trust response to high mortality rates in November 2011 was to commission a review to understand the reasons behind it. The scope included looking
at the environment external to the Trust. A second review was then commissioned looking at primary and secondary care, particularly around the
appropriateness of admission and discharges.
 A multidisciplinary team looks through the all notes for surgical and orthopaedic mortalities in the Trust on a monthly basis. This team is led by the Associate
Medical Director.
 The mortality team also conducted a review of all trends for a six month period in the lead up to April 2013, which sought to identify trends.
 It was seen on the Elizabeth Ward that a record of all patients who have died was being maintained. Staff interviewed told of the case notes for each being
separately reviewed by the ward sister and doctor to determine any issues.
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
i. Understanding of mortality issues
All surgical and orthopaedic deaths are
fully reviewed however only 20 per
month of medical deaths are reviewed.
Trust led regular analysis of mortality. This
Urgent
should include data analysis, for example
analysis day against night, as well as root
cause analysis of individual deaths. Reviews
should be multidisciplinary, shared throughout
The Trust stated that the high HSMR reported in 2011
came as a surprise and it commissioned an external
review to understand it as a result. The culture at the Trust
Priority – urgent,
high or medium
22
Outstanding concerns based on evidence gathered
Key planned improvements
appeared to be reliant on external reviews and there
appeared to be an absence of detailed analysis of mortality
internally. For example: deaths taking place in the day or
night; weekday against weekend; deaths post discharge;
or an analysis to confirm if the perception of the cause of
the high mortality rates being due to inappropriate
admissions from care homes was accurate.
ii. Pace of change
Recommended actions
Priority – urgent,
high or medium
the Trust and reported to the Board.
The Trust has action plans in place.
The Trust leadership and culture must change Urgent
to instil a pace of sustainable change; action
plans need to be more robust and
implemented effectively, whilst there must
also be a shift from review and planning to
action and outcomes.
The Quality and Safety Strategy has
recently been signed off by the Board
and it will be communicated throughout
the Trust.
Medical Director, Director of Nursing and
Quality and Director of Governance and
Quality must jointly to work on the quality
strategy and improvement plans.
Whilst the Trust was seen to be keen to understand its
issues and develop action plans, there were issues noted
with the extent to which there was evidence of a sufficient
pace of improvements in quality improvements being
achieved at the Trust with many actions not fully
implemented and limited evidence of positive outcomes as
a result.
The panel saw limited evidence of following up action
plans, or monitoring and reviewing the implemented
actions against the predicted issues to review their
effectiveness.
A large number of actions from the Mott MacDonald review
were outstanding and a significant number of actions
reported as due to be reviewed by 31 May 2013 had no
due dates for completion.
iii. Clinical and quality strategies
Issues were noted with clinical and operating strategies:
 In interviews, a number of Board members did not
appear to be aware that the Trust has a Quality
High
23
Outstanding concerns based on evidence gathered



Strategy.
The Quality and Safety Strategy appeared to include
an arbitrary SHMI target of 103. Executive team
interviewees could not clearly articulate a credible
reason for the target or how it could be achieved.
The Quality and Safety Strategy does not contain a
detailed plan on how it will be delivered and there are
no clear delivery trajectories in place or clear
ownership for delivery.
The Clinical Audit Strategy contains no clear targets.
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
The Quality and Safety Strategy sets out
three metrics to be achieved by March
2014:
 Net promoter score of 80.
 SHMI of 103.
 Avoidable harm 98%.
Strategies to be underpinned by clear and
tangible targets with milestones and
responsibility for achievement.
High
The plan of how the Strategy will be
delivered is due to be presented to the
Trust Board in June 2013.
Executive development to understand fully the High
clinical and quality strategies, including the
rationale for targets within them, and to drive
these forward.
iv. Patient safety focus
To continue the process of embedding
A clear connection between patient safety and Urgent
“EXCEL” and validating in line with the
mortality must be made and patient safety
A number of issues were noted around patient safety:
Trust’s vision – to EXCEL at patient care. clearly prioritised. This should be led from the
top of the organisation with defined
 “EXCEL”, the Trust’s articulation of its vision, was not
accountability.
seen by staff interviewed to include patient safety.
Medium
 It was not clear to the RRR panel that the Trust had
The Quality Account should include further
connected mortality and patient safety. This was seen,
detail with regards to what will be done in
for example, through limited reference to patient safety
response to triggers and additional levels of
when quality of care was discussed and staff and
analysis behind causal factors.
Board members being more focussed on health and
safety rather than patient safety.
 The patient safety section of the Quality Account
contains limited information and detail on patient
safety.
 Executive responsibility for patient safety appeared
unclear in interviews
 When interviewed, the Chair did not talk of patient
safety as an area of priority but of key risks being their
financial and market share.
See also v below regarding incident reporting
24
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
v. Incident reporting
None identified
Reform the incident reporting process to make Urgent
it more user friendly and ensure that all
appropriate incidents, including all unexpected
deaths, are reported as serious incidents.
Ensure that staff are encouraged to report
patient safety incidents.
Staff in the all staff focus group agreed that they were
familiar with the Trust’s whistle blowing policy and felt
confident to raise issues by approaching managers rather
than needing to resort to formal systems. These were
evidence of an open culture, also directly cited by staff
interviewed.
Priority – urgent,
high or medium
See also iv above and the need to create a
culture of learning and acting on lessons
learnt quickly and in a sustainable manner.
However the Trust is a relatively low reporter of patient
safety incidents on the National Reporting and Learning
System and scored low at reporting serious incidents (SIs),
with a significant proportion of reported SIs grade 3
pressure ulcers. An example was provided by staff where
an unexpected death was not reported as an SI.
Staff interviewed also spoke of issues with the ability to
report patient incidents on both the Prism web forms and
paper forms as the system was not user friendly, the forms
were too long and feedback was not provided to staff in
response to reported incidents.
vi. Organisational learning
The panel identified pockets of good practice in
organisational learning during the RRR visits. These
included:
 The doctors’ focus group speaking of good practices in
medicine.
 The nurses’ focus group stated that root cause
analysis is discussed at the serious incidents group,
with that learning being fed back at weekly “Back to
None identified
Implementation of systematic organisational
learning processes ensuring that not only are
‘lessons learned’ identified and shared, but
that actions are also implemented as well as
effective and address the issues identified.
These may include:
 Ward to board dashboards to be further
developed to bring together various
sources of data to facilitate identification
of issues.
 Increased multidisciplinary working.
High
25
Outstanding concerns based on evidence gathered

Basics” and divisional meetings.
Learning on an ad hoc basis, through involvement in a
formal audit and through good practice of some
individuals.
However, the panel could not identify a culture of
systematic learning throughout the Trust. For example,
there appeared to be no consistent or formal feedback loop
for clinical staff as a result of serious or adverse incidents,
i.e. no formal structure for the organisation to share
lessons learned from these events, especially between
divisions.
Key planned improvements
Recommended actions




Priority – urgent,
high or medium
Cross divisional learning forum.
Learning champions to be introduced
throughout the Trust.
Action plans to include measurable
progress points and responsible
individuals, against which progress to be
reported through the governance
structure.
Implementation of the learning processes
to form part of all staff’s annual objectives
and appraisals.
Some staff identified the root cause of the weaknesses in
organisational learning to be due to the reduced numbers
of registrars at the Trust caused by shortages.
26
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
vii. Monitoring of performance
None identified
True processes and systems to monitor
performance effectively to be implemented
using triangulated data that is critically
assessed.
High
The following issues were identified with monitoring of
performance:
 There appeared to the RRR panel (from interviews
undertaken and review of meeting minutes) to be a
reliance on soft intelligence gained from walking the
wards and talking to people, rather than hard data and
evidence.
 We were informed that only 60% of clinical audits had
been completed.
 The mortality action group meetings in February and
March 2013 were cancelled. It is noted that the Trust
states that the March meeting was cancelled due to
high activity in the organisation and that the Assistant
Medical Director reviewed the mortality data with Dr
Foster in place of the meeting.
 Actions within the mortality action plan do not
consistently have trajectories and a clear end state.
 Mortality reports to the Board were assessed to be
poor with limited commentary.
 The Terms of Reference for divisional governance
committee does not include clinical audit, National
Institute for Health and Care Excellence (NICE)
implementation or outcomes, for example mortality.
 The Quality Report 2012/13 is more focussed on
providing facts rather than commentary.
See also KLOE 1(i) regarding development of
critical challenge skills
High
The governance structure needs to be
reviewed to ensure that it is effective.
27
Management of medical and surgical patients
KLOE 3: How does the Trust manage medical and surgical patients? Has the Trust identified any issues with the management of surgical patients? What actions is the Trust
taking to address issues noted?
Good practice identified
The Trust operate a 24 hour 7 day a week outreach team and have staff rotation from the Intensive Care Unit with one Band 7 covering per shift. The team
links with the medical teams and attends the shift handovers to ensure consistency of care. The team were mentioned in high regard by staff in A&E, ward staff,
junior doctors and senior clinicians.
Infrastructure of the pre assessment surgical service observed to be good.
There is 100% World Health Organisation (WHO) surgical safety checklist compliance.
The Trust has developed an ISOBAR – identify, situation, obs, background, assessment, recommendation – tool in house. The Trust state that this was shared
nationally at the NHS Institute for Innovation and Improvement.
No issues were noted with the nursing handover observed during the RRR unannounced visit.
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
i. Patient locations and movements
The Trust plan to implement a patient
tracker.
Improve bed management through bed
Urgent
managers involving the doctors more to
understand the clinical need of the patient and
minimise patient moves.
Examples of good patient management were identified in
surgery with a weekend plan outlining patient discharges
and any unwell patients. This is shared with the on call
team.
However, discussions with staff and patients on wards
identified issues with patient locations and movements:
 Wards appeared to contain patients with a wide range
of illnesses whilst consultants were ward based.
 Patient moves were not uncommon, including for
vulnerable patients, and appeared to be determined by
In response to the draft RRR report, the
Trust has stated a plan to review paper
based referrals in advance of Lorenzo
implementation (Patient Administration
System replacement), clinically led by
the Assistant Medical Director.
The Trust should consider a change to policy
whereby patients remain with a consultant
specialising in an appropriate area regardless
of location in the hospital rather than ward
based consultants. As a minimum, when a
patient is moved, a medical handover should
occur.
Priority – urgent,
high or medium
High
28
Outstanding concerns based on evidence gathered



the bed managers without consultant involvement or
consultation with the patient in a number of cases.
Two incidents in the last year were noted following bed
moves: one patient was not seen by a consultant for
eight days; and another for ten days.
Ward rounds are not daily. There is limited evidence
of consultants working in teams, other than
gastroenterology, with delays for patients.
7 day working appeared to be in early planning stages
(see also KLOE 7(i)).
Some patients admitted at a weekend may not be seen
after an initial assessment for 48 hours.
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
Referrals should be made more timely with
High
the expectation patients should be seen within
one working day of referral.
See also iv admissions and iii discharges to
improve patient flow.
Patient location is an area that is significant to the Trust
due to the Trust policy of ward based Consultants. If a
patient is on an inappropriate ward or moved, there is a
risk that they will not see the appropriate consultant.
The panel was also told that no medical handovers were in
place if a patient is moved.
Patients moved will be under a new consultant with a risk
of further delays in care and discharge taking place.
Furthermore, as consultant referrals are paper based, staff
informed us that there can be delays of between one to
three days for the right consultant to come and see a
patient resulting in risk of delays in treatment of care and
inappropriate discharge.
29
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
ii. Medical handovers
None identified.
Medical handovers need to be consistently of
sufficient quality to enable quality of care and
treatment, including the following aspects:
 Adequate information provided on patient
treatment to date, outstanding treatment
to be provided and patient location.
 A suitable location for the handover.
 The handover should be led by the
Consultant on call, either by attending or
calling in.
Urgent
End of Life Strategy has been
commissioned.
Improved engagement with the Trust’s lead
commissioner to accurately identify available
capacity outside the Trust and ensure
effective use of community services and End
of Life care outside the hospital.
High
Improved discharge processes, for example
through a discharge lounge or ward.
High
Discharge conversations to commence earlier
in care.
High
Whilst observations of surgical handovers identified these
as an area of good practice, the quality and content of the
evening medical handover observed was of concern to the
panel as it appeared poorly led and unstructured. There
was no evidence of any consultant input.
iii. Discharges
The following issues were noted with discharges:
 Winter pressure wards were still open with no clear
plan for their closure.
 The Trust has a high number of elderly patients and
we could not clearly identify plans for End of Life care
outside the hospital. The lead commissioner for the
Trust informed us that there were available beds in the
community with community services being
underutilised whilst the Trust states that, on the vast
majority of occasions, all available capacity has been
used.
 There is no discharge lounge at the Trust.
 Patients consistently spoke of being unaware of
discharge processes and dates until just before they
were discharged.
 A number of staff interviewed spoke about
encouraging patients to stay in hospital rather than
exploring out of hospital alternatives.
Elizabeth ward are trialling a discharge
nurse post.
30
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
iv. Admissions
Development of ambulatory care
following successful implementation into
a managed and properly located area.
Further development of ambulatory care.
Medium
Engagement with GPs as to point of referral
into the Trust and management of
admissions.
Medium
Accurate identification, reporting and
escalation of all A&E and trolley breaches.
Medium
Enhance Trust policy on use of IT to
encourage the use the electronic, IT
supported processes where possible, rather
than leaving the decision between paper and
system to the individual.
Medium
Whilst there is an out of hours GP on site, the following
issues were identified with admissions:
 GP referrals all come through A&E.
 Ambulatory care area is very small and appeared to
panellists to be chaotic.
 Five patients were observed during the visit to be
waiting in A&E for over 14 hours. (Note that the
second day of the review took place at a time of EMS
Level 3.)
v. Poor IT
A number of examples were provided to us of IT not
supporting patient care including:
 Staff describing paper-based rather than electronic
systems and processes, with the choice between them
being down to the individual.
 Examples of computerised tomography (CT) /
magnetic resonance imaging (MRI) scans having to be
transferred to another hospital by taxi.
 Patient experiences of poor links between the Trust
and GPs and other hospitals.
Implementation of the clinical strategy
with the CCG is under development
covering winter pressures, patient
movements, 7 day working, admission
avoidance, end of life pathways and
stroke.
Arden Cluster is procuring common
PACS (Picture archiving and
communication system)/RIS (radiology
information system) system across
trusts.
Pathology results will be moving as a
cluster to all using “review” portal to
improve access
Rollout of Lorenzo (Patient
Administration System replacement) over
next two to three years as common
portal for 60-70% of clinical information.
31
Management of deteriorating patients
KLOE 4: How does the Trust manage deteriorating patients? Has the Trust identified any issues with the management of deteriorating patients? What actions is the Trust
taking to address issues noted?
Good practice identified
The Trust has some clear escalation processes to manage deteriorating patients and examples were identified to evidence these including:
 Notes reviewed on the Melly wards showed that staff on those wards knew escalation processes. The notes contained evidence of observation charting, the
situation-background- assessment-recommendation (SBAR) tool in operation and also appropriate escalations. SBAR was also observed to be in use at
Felix Holt Ward.
 The modified early warning system (MEWS) is in use. Doctors said that nurses are good at using it and also at keeping them informed of sick patients on
wards.
 The members of the outreach team interviewed felt they were well linked with medical teams and were receiving appropriate escalations (as all registered
staff go on alert training). This team are held in high regard across the hospital and are seen as committed practitioners who link effectively with the end of
life and palliative care teams to support teams and families.
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
i. Management of deteriorating patients
Vitalpak has been piloted (with alerts
connected to monitors).
The Trust needs to enhance Communication
and training for staff on the escalation policyMEWS escalation. This should make clear
the processes to be followed including:
 Policy on what constitutes a peri-arrest
and who to escalate to (i.e. outreach or
arrest team).
 When to manage sicker patients on the
wards rather than escalate their care to
the Outreach team.
 Clear SBAR response times.
High
The Trust should implement training for
medical and nursing teams on failure to
High
The Trust has a high number of elderly patients.
Weaknesses were identified in the process of managing
deteriorating patients evidenced by:
 A number of staff interviewed did not know of a formal
escalation policy and “used their own judgement” as to
when to call doctors / seniors. They were also unclear
on what constitutes peri-arrest and whether to call the
outreach or arrest teams at this stage.
 Staff interviewed expressed concerns that doctors in
A&E are not consistently completing sufficient basic
investigations. This was also evidenced at medical
handover.
The hospital will be rolling out
PatientTrack from the end of May until
October 2013, building on a successful
pilot that has finished.
The Trust has commissioned an End of
Life Care Strategy.
32
Outstanding concerns based on evidence gathered

Key planned improvements
The Trust’s draft quality account for June 2013/14
identifies the quality priorities as achieving Sepsis 6 step
care bundle of 60% by March 2014. It was identified that
the percentage target was a commissioning for quality
innovation (CQUIN) target therefore that was the target
set, rather than a target that would benefit all patients.
Priority – urgent,
high or medium
rescue procedures.
Staff interviewed consistently spoke of the intensive
therapy unit (ITU) and high dependency unit (HDU)
bed numbers being insufficient.
ii. Sepsis care bundle performance and management
Recommended actions
See i above
Surgeons suggested a surgical HDU as a
recommended action. This should be
explored along with an understanding of the
range of possible solutions to the perceived
level of ITU and HDU beds being too low.
High
The sepsis target should be reviewed to
ensure that it is stretching the Trust, as the
RRR panel feel that a higher percentage is
achievable with the correct support and
leadership in place. Additionally
implementation steps should set a pace for
earlier completion dates.
Urgent
It was noted during interviews that the target had not been
effectively communicated with staff, as responses to the
target from Trust staff ranged from 60%, 90% and 100%.
The Trust states that the confusion was due to discussions
with the CCG over the CQUIN target which not been
concluded and communicated at the time of the review.
There was limited evidence that the 60% would be
achieved by the Trust with a phased roll out of care
bundles planned and a lack of evidence of sepsis bundles
on a sample of notes reviewed. Those which were present
were seen either to be not signed or, in many examples,
not completed at all.
33
Safety thermometer issues
KLOE 5: What actions are the Trust taking to address safety thermometer issues?
Good practice identified
Examples of practices within the Trust which demonstrate that safety thermometer issues are being taken seriously:
 There are “nurse sensitive indicators” dashboards which are widely displayed and also discussed in both weekly “Back to Basics meetings” at ward level as
well as between senior sisters and the Director of Nursing.
 Outputs from the audit nurse’s work are discussed with lead nurses and fed back to wards.
 All staff observed were seen to be bare below elbows.
 Staff interviewed in both the A&E and the Emergency Medical Unit (EMU) articulated pressure ulcer grading policy well.
 The falls team told of their visit to South Warwickshire to learn from their best practises and came back with a new care bundle that is now being piloted at
the Trust.
Examples of access to equipment help safety thermometer issues:
 Staff stated that they had good access to mattresses to prevent pressure ulcers (in the Melly ward).
 Staff have access to, and have used, fractured neck of femur mattresses.
 Red, non-slip socks have been piloted and are now on order to reduce falls.
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
i. Pressure ulcers
Review of mattresses across the Trust is
underway.
The grading of pressure damage needs to be Urgent
clarified, as does the teaching to staff around
this issue. Board reports to contain clearer
definitions of pressure ulcers and report
“avoidable” and “unavoidable”, not
“unstageable”. The Trust to focus on reducing
pressure ulcers.
The Trust has had an increase in grade 3 pressure ulcers
since January 2013 and is not achieving the recent
regional ambition of zero avoidable harm.
Issues were noted specific to the recording of pressure
ulcers:
 There is unnecessary duplication of incident forms as
two forms need to be completed.
 A high number of “unstageable” pressure ulcers are
Full root cause analysis undertaken on
all pressure ulcers.
Priority – urgent,
high or medium
34
Outstanding concerns based on evidence gathered


Key planned improvements
Recommended actions
Priority – urgent,
high or medium
The implementation of PatientTrack over
the next three months is expected to help
ensure that patient observations are
collected on time and at appropriate
times.
Develop a patient safety programme to
ensure that all elements of the safety
thermometer are monitored and proactively
managed.
High
being recorded. Many of these pressure ulcers should
be graded a 2. The “unstageable” grading is
acknowledged by the Trust as not being widely used
(including by other trusts in the region).
Examples of errors in senior staff’s knowledge of
pressure ulcer grading were identified.
Nine “unstageable” pressure ulcers were reported to
the Quality Assurance Committee in May 2013 due to
Trust approach of using “unstageable” and as an SI
until the 45 day root cause analysis is complete and
the grading confirmed. Staff interviewed noted that
often “unstageable” are then deemed as a grade 2 and
therefore downgraded and not reported as a SI
following completion of the root cause analysis
meaning reported figures can be inflated during the 45
day root cause analysis period.
ii. Safety thermometer monitoring and management
We identified only limited monitoring and management of
the safety thermometer. When interviewees were
discussing the safety thermometer, they tended to only
focus on pressure ulcers. Venous thromboembolism
(VTE), for example, is not discussed widely with teams, or
used in staff learning.
There are falls improvement and safety
cross initiatives being rolled out.
Increase the number of nurse auditors to
Medium
ensure that lessons learned are shared widely
and that additional areas of concern can be
picked up promptly.
There is only one audit nurse to cover the whole Trust.
iii. Infection control
None identified
The hospital needs to clarify infection control
procedures to staff.
High
The focus group with members of the patient advocacy
forum raised cleanliness and hygiene as a priority for the
hospital to tackle.
35
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
Furthermore recognition of, and clear procedures for,
Clostridium Difficile infections were not evidenced to be
well established. One incident was observed in which a
patient on Bob Jakin Ward was transferred from another
ward overnight into a side room because of a suspected
Clostridium Difficile infection, but at 14.00 the next day the
panel observed that there were still no signs around the
patient indicating any infection risk.
36
Patient experience
Overview
The KLOE in the patient experience area focused on patient experience and engagement.
Examples of good practice were identified in the following areas:

Significant public and patient support for the Trust.

Evidence of patient engagement.

Positive examples of hospital groups working together to improve patient experience.
The following areas of outstanding concern were identified:

Absence of systems to respond to patient feedback.

Communication with patients was an area of concern cited by patients.

Three instances of poor practice were observed in maintaining patient dignity during the ward observations undertaken during the visit.

One ward had a number of bleeps and buzzers going unanswered.

A number of patients interviewed during ward observations said they did not know how to provide feedback.
37
Detailed Findings
Patient experience and engagement
KLOE 6: How does the Trust review patient experience data and engage with patients to seek views about their experience? What are the key themes from patients on their
experiences? What action is it taking to address the key themes emerging? What do patients say about the quality of care in the Trust during our observations/interviews?
Good practice identified
It was clear to the panel that that Trust has significant public and patient support. A number of patients spoke highly of the quality of care and treatment at the Trust.
Evidence of patient engagement was identified including the following:
 The Trust Board papers showed evidence of the Board hearing patient stories.
 The Trust has a Members’ Advocacy Panel (MAP) and Patient Advocacy Forum (PAF).
 The PALS service is well located at main entrance and is clearly signed.
 The members of MAP and PAF who attended the focus group stated that they had meaningful access to the Trust Board.
 Listening events were used to collate 6,000 pieces of staff comments leading up to the implementation of “EXCEL”.
There were positive examples of how hospital groups have worked together to improve patient experience. For example, the Ophthalmology and Outpatient teams had
worked together with an external provider (New Medica) to stagger theatre times and reduce waiting times.
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
i. Response to feedback
The response to the patient survey is
due to go to the June Board meeting.
The response contains an action plan.
Effective and regular review of all patient
feedback identifying trends in terms of both
good practices and concerns. Communication
of the periodic reviews to all staff and the
Trust Board.
High
Complaints policy to be amended to ensure
that the Chief Executive is involved in
responses to complaints.
Medium
It was unclear what action is taken as a result of feedback
or how information is routinely used to improve services.
There was one area that required particular improvement,
which related to complaints procedures within the Trust.
Whilst the Trust stated that the Chief Executive has sight of
all complaints and is involved in individual cases, the
complaints policy states that complaints are signed off by
the Medical Director or nominated deputy, and does not
detail or require the Chief Executive’s involvement.
38
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
ii. Communication with patients
A communication tool for communication
with patients and their families is in place
on Elizabeth Ward and a roll out of this,
starting with Melly Ward, will commence
from the beginning of June.
Ensure patients receive their copy of consent
forms.
High
All staff, particularly medical staff, need to
understand the need to communicate
effectively with patients and relatives.
High
Whilst a number of patients spoken to on the wards spoke
of good communication, the key issue arising from a
number of people attending the public and patient listening
event was that of poor communication including examples
of patients not receiving copies of their consent forms.
For example, on a ward visit, one relative stated the
nursing care was good but the doctors would not tell
anyone, including the patient, what was going on and what
would happen next.
iii. Patient dignity
The patient focus group identified dignity as a priority area,
especially patients with dementia. It is noted that the Trust
states that dementia training is at 93%.
The Trust is considering the use of
Skype and Facetime as means of
communication between patients and
visitors when visiting is restricted due to
infection risks.
None identified
Dignity training to be reviewed and reHigh
launched. Review the effectiveness of
dementia training for all staff groups within the
Trust.
There were three instances of poor practice that were
observed whilst the panel were on wards:
 One patient was seen in their gown in the DTC waiting
room.
 One patient was observed to be using the toilet with
the door open.
 One ward had a number of bleeps and buzzers going
unanswered.
39
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
iv. Patient experience feedback
The Trust Board recognised in their
presentation at the commencement of
the visit that patient engagement is an
area that requires further work and cited
plans in place to improve patient
engagement and involvement going
forward.
The Trust needs to undertake systematic,
proactive collection of meaningful patient
feedback. (Staff should proactively
communicate feedback mechanisms to all
patients.)
Medium
We identified a number of areas of good practice in patient
experience feedback. These included:
 The Trust has patient bedside booklets and welcome
leaflets advising patients of how to provide feedback.
 The panel observed the Trust’s feedback cards and
boxes.
 The Trust’s ‘Smiley Cards’ includes the question “How
likely are you to recommend...” in line with the Friends
and Family Test as well as the opportunity to add free
text.
 In the Bob Jakin ward, it was clear to the panellists
observing the ward that the Trust’s feedback cards had
been proactively handed out to all the patients spoken
to.
 The PAF’s priorities (out of hours staffing, cleanliness
and hygiene and poor IT) had been communicated to
the Trust Board through the Chair.
The response to the patient survey is
due to go to the June Board meeting.
The response contains an action plan
setting out the intention to introduce real
time feedback from patients.
However, a number of patients interviewed during ward
observations said they did not know how to provide
feedback.
In addition to the points above, public and patient feedback obtained through the review identified a number of areas of good practice and concern which have been reported
within the relevant KLOE. For example, concerns over out of hours staffing have been included within KLOE 7 below.
40
Workforce and safety
Overview
The two KLOEs in the workforce and safety area focused on workforce planning and staff support including training.
Examples of good practice were identified in the following areas:

Engaged, passionate and loyal staff at the Trust.

The Trust has invested in nursing and midwifery staff.

Induction and initial training of junior doctors and temporary staff.

Examples of training being taken seriously at the Trust.

Ongoing support for staff including mentors and buddy arrangements are in place.

Staff consistently speaking of the “EXCEL” initiative, the Trust’s acronym to articulate its vision.
The following areas of outstanding concern were identified:

Low levels of clinical cover, particularly out of hours.

The panel did not identify analysis or an understanding of workforce issues at the Trust.

Limited examples of multidisciplinary working detailed by staff interviewed.

Staff not having time for training.

The Trust’s workforce strategy 2013-16 was still in draft. The action plan was incomplete with missing timelines and owners for a number of listed actions.
41
Detailed Findings
Workforce planning
KLOE 7: How does the Trust approach workforce planning to ensure that patient safety is managed effectively including skill mix? Is there effective provision for surgical and
medical consultant input following admission?
Good practice identified
Staff at all grades consistently came across as engaged, passionate and loyal. A reflection of this was in the strong attendance at staff focus groups as detailed in
Appendix V.
The Trust has invested in nursing staff. A nursing workforce paper was received by the Board in January 2011, which agreed investment in staffing within the 2011/12
financial year to achieve 60:40 qualified to unqualified ratio for each ward. The acuity study was undertaken in October 2012 and February 2013. Nurses interviewed
had noted recent investments in staffing numbers and that some relief from winter pressures was beginning to be felt at the Trust.
The Trust has invested in midwifery staff. The November 2011 investment in midwifery staff followed Birthrate plus recommendations and was followed with a further
review in November 2012 leading to further investment in February 2013.
Nurses spoken to stated that they felt under no pressure to stop using bank or agency when they were needed.
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority –
urgent, high or
medium
i.
Nurses interviewed had noted recent
investments in staffing numbers and that
some relief from winter pressures was
beginning to be felt at the Trust.
The Trust needs to understand its current
workforce position in relation to its
performance. A full review of staffing, both
nursing and medical, numbers and skill mix
needs to be undertaken across the Trust.
This review should include an analysis of
current use of agency staff at a granular level.
For example this may include detailed
analysis of the use of agency staff by ward,
speciality and out of hours use to identify high
use of agency staff on particular wards.
Urgent
Low levels of clinical cover particularly out of
hours
A number of issues were identified in relation to the levels
of clinical cover across the Trust as follows:
 Staff and patients cited concerns over the low number
of staff, particularly nursing and medical staff, on duty.
 There is high use of nurse agency staff, particularly at
night. One Board member, interviewed during the visit,
articulated acceptance of the current high levels rather
than an ambition to reduce the current levels of spend.
The May 2013 Trust Board paper
provided a nursing workforce review
update. The Trust state that there will be
a further Board paper outlining further
investment requirements, to provide an
additional qualified nurse to the late shift
42
Outstanding concerns based on evidence gathered
Key planned improvements

on each of the four wards reviewed (Bob
Jakin, Dolly Winthrop, Nason and
Alexandra).
Recommended actions
See KLOE 2 for recommended action to
review of performance at a granular level to
identify areas and periods of concern, for

example mortality performance at day against
The Trust is commencing a policy of over mortality performance at night. Workforce
levels during areas or period of concern
recruitment of nurses.
Discussions with staff and patients identified that staffing
should be analysed to identify if workforce is
appears to be more of a concern during out of hours and at
linked to performance issues.
Staff
focus
groups
all
referenced
a
weekends. Junior doctors also noted that staffing levels
proposed move towards 7 day working,
are often low on a Monday due to time off on lieu for onevidencing the plans being developed.
Finalise the workforce strategy for all
call. As a result of the above, staff and patients spoke of
workforce ensuring that it contains specific
variable care experiences.
A staff wellbeing strategy has been put in and measurable progress metrics as well as
timelines and accountabilities. This strategy
Low levels of medical cover appear to be compounded by place.
needs to include an analysis of current
following additional factors:
substantive staff deficiencies and a plan to
 The Trust’s Workforce Strategy 2013-2016 was still in New sickness policy has been launched. address the deficiencies with substantive
draft. The Trust stated that this was awaiting the
appointments.
Francis report to ensure inclusion of relevant
recommendations prior to finalising. The supporting
The Trust need to focus on delivering 7
day/24 hour working. This should be built into
action plan for the strategy includes an action to
a workforce strategy that meets the staffing
implement a systematic workforce planning process.
needs of a 7 day/24 hour service (as outlined
This action had no timeline in the submitted version.
above).
The action plan contains a number of gaps where
timelines and owners should be stated.
Recruitment team to work with the ward staff
 The recruitment team were viewed by ward staff as
to improve the service that is provided through
providing poor service to the wards in terms of working
understanding the effectiveness of current
quickly or transparently.
processes and obtaining feedback on issues
 7 day working appeared to be in early planning stages
currently being experienced. The recruitment
team should aim to work as a support service
with staff speaking of business cases rather than
alongside the wards, not an isolated service.
implementation. It is further noted that the 7 day
working papers submitted to the Board were
Analysis of staff sickness, absence and exits
incomplete (incomplete information on current staffing
to reduce the need for agency staff use.
and blank fields for required whole time equivalents).
Staff informed us that there was only an ad hoc
presence of anaesthetists in pre-assessment units.
Five out of ten medical registrar posts were identified
as unfilled resulting in a reliance on locum doctors.
Priority –
urgent, high or
medium
High
High
Urgent
Medium
Medium
43
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority –
urgent, high or
medium
ii. Understanding of workforce issues
New sickness policy has been launched.
Workforce strategy should include a detailed
approach to understanding workforce issues
including, for instance, implementing formal
exit interviews with a quarterly report of the
findings and analysis of trends within them.
This should be reported to the Board through
the Workforce Committee.
Medium
The Trust needs to focus on increased
systematic multidisciplinary working
throughout it. Staff need to be engaged in this
approach routinely, so that they see it as the
way to work.
Medium
The panel did not identify either analysis or an
understanding of workforce issues at the Trust, despite
high agency staff numbers and low staff engagement
scores.
In addition, the panel noted that the uncertain long term
future of the Trust had impacted on staff, making them
nervous of closure of the George Eliot Hospital. The
nervousness of staff was evident during our visit.
iii. Multidisciplinary working
Some examples identified including
monthly multi-disciplinary teams within
The panel met some outstanding and dedicated individuals one division to review mortality notes.
at the Trust and the nurses’ focus group spoke of feeling
as one team with medics and executive team. The Trust
has also submitted a document containing examples of
multidisciplinary working, however limited evidence of
effective multidisciplinary working was identified during the
visit with minimal or no examples provided by many staff
interviewed.
44
Staff support including training
KLOE 8: How does the Trust support its staff including with adequate training?
Good practice identified
Examples of induction / initial training good practice identified:
 The junior doctors interviewed during the review generally spoke highly of their induction.
 The panel were informed that locums / agency must attend training sessions prior to working at the Trust.
 Health Care Assistants are required to undertake competency based training prior to being allowed to do patient observations.
Examples of training being taken seriously at the Trust:
 Junior doctors and nursing staff spoken to during the review articulated a belief that training is taken seriously at the Trust.
 Junior doctors at the focus group agreed that they had good access to teaching.
 Staff on Elizabeth Ward informed us that pay penalties were in place within nursing if mandatory and statutory training is not completed.
 Acute Illness Management (AIM) training (supporting care of the deteriorating patient) is being introduced for all staff including Health Care Assistants.
 Staff spoken to within A&E and EMU could readily and confidently articulate safeguarding processes.
Ongoing support for staff identified:
 The Elizabeth Ward Sister stated that she has a buddy arrangement with a consultant and meets weekly with them.
 A snap poll of the staff focus group showed a significant majority had received appraisals in last year.
 Junior doctors interviewed described the buddy system (on a three by three matrix) as being effective.
 Overall it was felt that the educational supervision of junior doctors was conducted well by the junior doctors’ focus group.
 The student nurses in the focus group agreed that they felt well supported by mentors and staff throughout the Trust.
“EXCEL”, the Trust’s acronym to articulate its mission, was consistently articulated by a range of staff spoken to and staff spoke consistently spoke positively of
it.
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
i. Time for training
See KLOE 3 and 7
See KLOEs 3 and 7
Whilst the nurses groups generally spoke of no issues with
being released for training, issues were noted from other
Regular dementia training to be provided to
staff.
Priority – urgent,
high or medium
High
45
Outstanding concerns based on evidence gathered
sources with staff having time for training as follows:
 Medical staff struggling to be released for training due
to capacity issues within medical specialties.
 A&E nurses have only been able to attend statutory
and mandatory training since September 2012 due to
service pressure.
 Nurses spoke of funding issues for training.
 Neither of the nursing staff on duty on one ward
containing dementia patients interviewed during the
unannounced visit had received dementia care training
other than dementia awareness training two years
previously.
 A medium-term locum doctor stated he had not time
for essential training and this was negatively impacting
on patient care.
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
The Trust needs to ensure junior doctors and High
Locum doctors have undergone a minimum of
training to deliver effective patient care.
See also KLOE 2(vi) organisational learning
46
5. Conclusions and support required
Conclusions
The Trust was under service pressure, being at EMS level 3 during the second day of the announced RRR visit. It is serving an elderly population with one ward on the visit
noted to have two patients aged over 100.
No issues were identified during the course of the review that were considered by the panel, with the support of the panel’s CQC representative on the panel, to need
immediate escalation and resolution.
Staff spoke positively about the Executive team and felt that they were visible. Staff also spoke of the Executive team being approachable and generally felt that there was an
open and transparent culture at the Trust. Non Executive Directors showed commitment to the Trust with strong representation at the Quality Assurance Committee held
during the announced visit.
The panel were welcomed to the Trust by all staff and patients and met some outstanding and dedicated individuals at a Trust which is clearly supported by its local
population. Staff were generally found to be engaged, passionate and loyal.
The Trust is not a Foundation Trust and is not currently in the Foundation Trust pipeline. In the past two years a decision was made for the Trust not to seek to achieve
Foundation Trust status alone but to seek a partner organisation, due to the relatively small size of the Trust, to secure its operational future. This uncertain long term future
has taken its effect on staff and the public, making them nervous of closure of the George Eliot Hospital. This was evident during our visit. The Trust had not received a
response to the business case on the Trust’s long term future submitted to the Department of Health over a year ago.
The Trust and ward areas were observed to be clean and tidy, with patients generally seen to be well cared for during the visit. There was a good level of patient information
available on walls in poster displays and patient satisfaction surveys were seen to be available.
Examples of good practice were observed in a number of areas including: a full time nurse-led outreach team held in high regard by staff interviewed throughout the Trust;
practices demonstrating that safety thermometer issues were being taken seriously; evidence of patient engagement; investments in nursing and midwifery staff; good
practice around training and inductions; and the staff consistently speaking of the “EXCEL” initiative, the Trust’s acronym to articulate its vision.
The Trust has had two external mortality reviews in the past 18 months (Mott MacDonald and Arden PCT) which have resulted in extensive quality improvement plans with a
high number of actions to be implemented. Whilst the action plans showed a number of completed actions, a significant number remain outstanding and under review without
clarity on the timing for their completion (as completion dates were not always given). Whilst the Quality Assurance Committee and private section of the Trust Board discuss
the action plan, the governance of signing off actions and gaining assurance on the effectiveness of the actions implemented was not clear to the panel. Increased
accountability for actions is also required; the panel suggest that individuals should be held to account for delivery of actions, with the Board providing and effective
governance and oversight of delivery of these actions.
A key concern for the panel is, while the leadership had taken some difficult decisions on the long term future of the Trust, it was difficult to identify consistent evidence of
proactive and driven leadership, focussed on providing excellent quality of care and treatment. There were particular concerns over medical leadership. The culture at the
Trust was acknowledged to have been insular historically. The panel identified remaining evidence of an insular culture , for instance examples of working with other Trusts
were less than the panel would have expected and in comparison to other trusts. At the time of the visit, further work was needed for a consistent culture striving for
47
excellence to be fully embedded with the adoption of national best practices. Staff noted that there appeared to be a high number of initiatives and action plans recently, but
these appeared to be reactive and there was a lack of understanding of a clear overall plan.
The panel had concerns in relation to low levels of clinical cover, particularly out of hours. Additionally wards appeared to contain patients with a range of illnesses and there
is evidence of multiple bed moves being common, which is detrimentally impacting on the patient experience and continuity of their care. With ward-based consultants and
paper-based referral forms, there is a risk that suitable patient care and treatment is delayed whilst the paperwork is processed and the patient is seen by the appropriate
consultant. The panel were concerned about the content and quality of the medical handover observed during the unannounced site visit.
There are a number of good governance and communication structures in place at the Trust, for example the weekly meetings, which, if used more effectively with the right
attendees and right agendas, could increase the pace of improvement at the Trust.
Urgent priority actions for consideration at the risk summit
Problem identified
Recommended action for discussion
Support required by the Trust
1. Leadership of quality (see detailed findings at
pages 19 and 26-27)
Improve Board capability through development of critical
challenge skills of the leadership within the Trust so the
leadership effectively scrutinises data, triangulates it and
then drives effective actions throughout the Trust.
Leadership development support.
Whilst the Trust could be seen to be engaging
external reviews to understand the mortality issues
arising, the overall focus of the Trust leadership
appeared to be that of the long term future and
finding a strategic partner. It was difficult to
identify evidence that the leadership was
focussed, proactively, on leading an agenda for
excellent quality of care and treatment throughout
the Trust, even within the medical leadership.
There was limited evidence of the Trust leadership
driving improvements in quality at the Trust with
sufficient pace either.
Decision on the business case submitted to the
Department of Health on long term future.
A clear connection between patient safety and mortality
must be made, with patient safety clearly prioritised. This
should be led from the top of the organisation.
Ensure clarity over Director portfolios and development of
an ownership and accountability for these portfolios from
the Executive team, particularly for quality and patient
safety. In doing so the Board needs to make sure all
executives have the necessary skills to perform their role
effectively.
Non Executive Directors should gain assurance through
being able to effectively review and challenge action plans,
then detailing changes made as a result of the challenges
and evidence of the effectiveness of the changes.
48
Problem identified
Recommended action for discussion
Support required by the Trust
2. Pace of change (see detailed findings at pages
20 and 26-27)
The Trust leadership and culture must change to instil a
pace of sustainable change. Action plans need to be
robust. Tangible move should be made from review and
planning to action and outcomes.
Leadership development support.
There were issues noted with the extent to which
there was evidence of a sufficient pace of
improvements in quality being achieved at the
Trust. Many actions were not fully implemented
and there was limited evidence of positive
outcomes as a result of actions.
Project/programme management support to drive
change.
Agree a SMART implementation plan including an identified
trajectory of implementation of improvement plans. Monitor
improvement plans effectively by, for example, critical
review monthly, seeking evidence of sustainable
implementation and the impact of that implementation.
A review of a number of Trust strategies identified
that these tended to be high level and lacking
implementation plans detailing how and when the
strategic visions would be delivered.
3. Patient locations and moves (see detailed
finding at pages 31-32)
Discussions with staff and patients identified
issues with patient locations and movements:
 Wards appeared to contain patients with a
wide range of illnesses on them.
 Patient moves were not uncommon, including
for vulnerable patients, and appeared to be
determined by the bed managers without
consultant involvement or consultation with
the patient in a number of cases.
Improve bed management through getting bed managers to Patient tracking and bed management support.
involve doctors more; this will increase understanding of the
clinical need of the patient and minimise the number of their Clinical leadership support.
moves.
49
Problem identified
Recommended action for discussion
4. Low levels of clinical cover particularly out
of hours (see detailed finding at pages 45-47)
The Trust needs to understand its current workforce
Workforce review and planning support.
position in relation to its performance. A full review of
staffing numbers and skill mix, both nursing and medical,
should be undertaken by the Trust. This review should
include an analysis of current use of agency staff by ward,
specialty and out of hours use to identify high use of agency
staff on particular wards.
A number of issues were identified with in relation
to the levels of clinical cover across the Trust.
Discussions with staff and patients identified that
staffing appears to be more of a concern of out of
hours and at weekends.
7 day working appeared to be in early planning
stages with staff speaking of business cases
rather than implementation.
5. Medical handovers (see detailed finding at
page 33)
Whilst observations of surgical handovers
identified these as an area of good practice, the
quality and content of the medical handover was
of concern to the panel.
Support required by the Trust
The Trust needs to focus on delivering 7 day/24 hour
working. This should be built into a workforce strategy.
Medical handovers need to be consistently of sufficient
quality to enable quality of care and treatment and should
include the following elements:
 Adequate information on patient treatment to date,
outstanding treatment to be provided and the patient
location.
 Be in a suitable location for the handover.
 Be led by the Consultant on call.
Handover support.
50
Problem identified
Recommended action for discussion
Support required by the Trust
6. Sepsis care bundle performance and
management (see detailed finding at page 36)
The sepsis target should be reviewed to ensure that it is
stretching the Trust, as a higher percentage is felt to be
achievable by the RRR panel with the correct support and
leadership in place. Implementation of this higher target
should keep pace with an earlier date.
Utilise any national work and teams for support e.g.
Sepsis UK.
The Trust’s draft quality account for June 2013/14
identifies the quality priorities as achieving Sepsis
6 step care bundle of 60% by March 2014. It was
identified that the percentage target was a
commissioning for quality innovation (CQUIN)
target therefore that was the target set, rather than
a target that would benefit all patients.
There was limited evidence that the 60% target
would be achieved by the Trust with the current
planned phased roll out of care bundles. There
was also a lack of evidence of sepsis bundles on a
sample of notes reviewed; those which were
present were either not signed or, in many
examples, not completed at all.
7. Culture at the Trust (see detailed finding at
page 21)
Although the Trust provided some examples of
internal stretch targets, panel members did not
see a consistent ambition to excel and exceed
minimum expectations.
Further work is needed to embed a consistent culture that
Leadership development support.
looks externally for good practice and employs good
practice and excellence throughout the Trust. This needs to
be led by the Board.
51
Problem identified
Recommended action for discussion
8. Understanding or mortality issues (see
detailed finding at page 26)
Trust led regular analysis of mortality. This should include
Data analysis support
data analysis, for example analysis day against night, as
well as root cause analysis of individual deaths. Reviews
should be multidisciplinary, shared throughout the Trust and
reported to the Board.
The Trust stated that the high HSMR reported in
2011 came as a surprise and it has commissioned
an external review to understand it as a result.
The culture at the Trust appeared to be one
placing a reliance on external reviews and there
appeared to be an absence of detailed analysis of
mortality. (For example, deaths taking place in the
day or night or an analysis to confirm if the
perception of the cause of the high mortality rates
being due to inappropriate admissions from care
homes was accurate.)
9. Incident reporting (see detailed finding at page
28)
The Trust is a relatively low reporter of patient
safety incidents on the National Reporting and
Learning System and low at reporting serious
incidents (SIs) with a significant proportion of
reported SIs grade 3 pressure ulcers.
Reform the incident reporting process to make it more user
friendly and ensure that all appropriate incidents, including
all unexpected deaths, are reported as serious incidents.
Ensure that staff are encouraged to report patient safety
incidents.
Support required by the Trust
Incident reporting support.
Staff interviewed also spoke of issues with the
ability to report patient incidents on the Prism web
forms as the system was not user friendly, whilst
paper forms were too long and additionally
feedback was not provided to staff in response to
reported incidents.
52
Problem identified
Recommended action for discussion
Support required by the Trust
10. Pressure ulcers (see detailed finding at
pages 37-38)
The grading of pressure damage needs to be clarified, as
does the teaching to staff around this issue. Board reports
to contain clearer definitions of pressure ulcers and report
“avoidable” and “unavoidable”, not “unstageable”. The
Trust to focus on reducing pressure ulcers.
Pressure ulcer training and avoidance support.
The Trust has had an increase in grade 3 pressure
ulcers since January 2013 and is not achieving the
recent regional ambition of zero avoidable harm.
Issues were noted specific to the recording of
pressure ulcers including the high number of
“unstageable” pressure ulcers being recorded.
53
Appendices
54
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.
55
3) The Indicator will utilise five 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
HSMR
SHMI
Are all hospital deaths included?
No, around 80% of in hospital deaths are included, which Yes, all deaths are included.
varies significantly dependent upon the services provided
by each hospital.
When a patient dies, how many times is this counted?
If a patient is transferred between hospitals within two
days, the death is counted multiple times.
One death is counted once, and if the patient is
transferred, the death is attached to the last
acute/secondary provider.
Does the use of the palliative care code reduce the
relative impact of a death on the indicator?
Yes.
No.
Does the indicator consider where deaths occur?
Only considers hospital deaths.
Considers in hospital deaths, but also those up to 30
days post discharge anywhere too.
Is this applied to all health care providers?
Yes.
No, does not apply to specialist hospitals.
56
Appendix II: Panel composition
Panel role
Panel Chair
Name
David Levy
Lay representative (Patient/public representative)
Anthony Glover
Lay representative (Patient/public representative)
Asa’ah Nkohkwo
Lay representative (Patient/public representative)
Tim Thorp
Junior Doctor
Krishna Chinthapalli
Doctor
Peter Davis
Doctor
Jane McCue
Student Nurse
Board Level Nurse
Senior Nurse
CQC representative
Senior Trust Manager
Madalina Veturia Fabian
Em Wilkinson-Brice
Bridget O’Hagan
Andy Brand
Deborah Needham
Senior Regional Support
Graeme Jones
Senior Regional Support
Finola Munir
Senior Regional Support
Gareth Jones
Observer, CCG
Jacqueline Barnes
57
Appendix III: Interviews held
Interviewee
Kevin McGee, Chief Executive
Stuart Annan, Chair
Date held
21 and 22 May
21 May
Andrew Arnold, Medical Director
21 and 22 May
Dawn Wardell, Director of Nursing & Quality
21 and 22 May
Claire Campbell, Director of Governance & Quality
21 and 22 May
Gordon Wood, Associate Medical Director
21 May
Chris Bradshaw, Director of Finance and Performance
22 May
Christine O’Brien, Clinical Director, Raj Reddy, Clinical Director, Mike Watzman, Clinical Director
22 May
Adam Race, Head of Human Resources – Operations
Note: The Director of HR was on annual leave during the review so could not be interviewed
22 May
Kay Cathcart, Head of Nursing Medicine
22 May
Chris Belcher, Head of Organisational Development
22 May
Ethel Yates, Deputy TV nurse specialist and Dilly Wilkinson
Note: The TV nurse specialist was absent from work on the 22 May due to sickness so could not be interviewed
22 May
Members of the Outreach team
22 May
Malcolm Dade, NED
22 May
John Cornall, Associate Director of IT
22 May
Kay Farmer, General Manager for Medicine
22 May
Jason Ryan, Trigger and Track Project Manager
22 May
Kath Kelly, Director of Operations
24 May
58
Appendix IV: Observations undertaken
Observations were undertaken in the following areas of the George Eliot Hospital:
Observation area
A&E
Emergency Assessment Unit
Date of observation
21 and 22 May
21 May
Melly Ward
21 and 22 May
Dolly Winthrop Ward (oncology)
21 and 22 May
Adam Bede Ward (winter pressure)
21 May
Bob Jakin Ward (acute general medicine)
21 May
Maternity
22 May
Caterina Ward (paediatrics)
22 May
PALs
22 May
Day Procedures Unit
22 May
Outpatient D
22 May
Elizabeth Ward
22 May
Felix Holt Ward (stroke)
22 May
Palliative Care
22 May
Pharmacy
22 May
Special Care Baby Unit
22 May
Drayton Ward
22 May
Pre assessment surgical services
22 May
59
Observation area
Date of observation
Theatres
22 May
Radiology
22 May
Observations were also undertaken of the following meetings:
Observation area
Bed capacity daily briefing
Quality Assurance Committee
Note: observation of the first half of the meeting only
Date of observation
Midday, 22 May
22 May
Further observations were undertaken as part of the unannounced site visit, see Appendix VII.
60
Appendix V: Focus groups held
Focus group invitees
Focus group attendees
Date held
Doctors
20 doctors including two locums.
21 May
Nurses
45 nurses from various wards.
21 May
All staff
49 members of staff from a range of departments including clinical and administrative roles.
21 May
Junior doctors
20 junior doctors (medical and surgical).
22 May
Trainee nurses
17 student nurses from various wards.
22 May
MAP / PAF
Mixed group of 11 ex-healthcare professionals, patients and patient families – as well as interested outsiders.
22 May
61
Appendix VI: Information available to the RRR panel
The following documents were provided to the panellists through a copy being available in the panel’s ‘base location’ at the Trust during the announced site visit. Whilst the
documents were not reviewed in detail, they were available to the panellists to validate findings.
Trust Visions and Values
Risk Management Strategy
Royal College of Surgeons Colorectal Surgical
Review February 2012
GEH Values & Pledges
Terms of Reference Quality Assurance
Committee
Arden Cluster Nursing Review
Quality & Safety Strategy
Terms of Reference Patient Safety &
Experience Group
Action Plan for Nursing Mortality Visit 2012
Assurance Framework
Terms of Reference Mortality Group
MM Quality Work Stream Report
Trust Risk Register
Board – Minutes Received Front Sheet
MM Information & Coding
Anaesthetic Department Clinical Audit Programme
2013/14
Private Board Minutes February 2013
MM External Factors
Division C Clinical Audit Programme 2013/14
Public Board Minutes February 2013
MM HSMR Analysis and Modelling
General Medicine Clinical Audit Programme 2013/14
Private Board Minutes March 2013
MM Key Findings and Recommendations
General Surgery Clinical Audit Programme 2013/14
Public Board Minutes March 2013
NHSLA Maternity Clinical Risk Management
Standards 2012-13
Medicines Management Clinical Audit Programme
2013/14
Quality Assurance Committee Papers &
Minutes February 2013
NHSLA Risk Management Standards for NHS
Trusts providing Acute and
Community Services 2012-13
Obstetrics & Gynaecology Clinical Audit Programme
2013/14
Quality Assurance Committee Papers &
Minutes March 2013
Results of the Patient Environmental Action
Team(PEAT) September 2012
62
Paediatric Clinical Audit Programme 2013/14
Palliative Care Coding Audit
Patient Survey Report
Radiology Clinical Audit Programme 2013/14
Mortality Action Plan
Patient Advocacy Forum (PAF) – Hand Gel
Machines
Theatres Clinical Audit Programme 2013/14
Completed actions
Private Board of Directors Agenda – January 2012
Trauma & Orthopaedics Clinical Audit Programme
2013/14
Evidence Log
Friends & Family Survey A&E February 2013
Clinical Audit Annual Report 2011/12
Mortality Review Process
Friends & Family Survey Acute February 2013
Draft Audit Annual Report 2012/13
CQC Review of Mortality Alerts
GEH Staff Survey Results 2012
Cost Improvement Programme 2012/13
Review of alert/s and potential alert/s via Dr
Foster Data Analysis Tools
Public Health Annual Report
Cost Improvement Summary 2012/13
Dr Foster Alert ‘Senility and organic mental
disorders’ December 2012
Census
Cost Improvement Summary 2013/14
Agenda Mortality Group January 2013
Arden Cluster Systems Plan 2012/13 – 2014/15
Internal Audit Report August 2012
Minutes Mortality Group January 2013
Board Paper - Paediatric Re-Design
Internal Audit Report November 2012
National Quality Board Draft Report to Mortality
Group April 2013
Winter Plan
Internal Audit Report January 2013
Monthly Mortality Report Dr Foster
Mott MacDonald – GEH & North Warwickshire
Burdett Checklist
Agenda Mortality Group April 2013
Community - Patient Audit
Quality Assurance Report January 2013
Minutes Mortality Group April 2013
Emergency Steering Group TOR
Quality Assurance Report November 2012
HOB Divisional Report
Lorenzo – Investment Plan
Organisational Structure
Quality Account 2011/2012
Elective Care Steering Group TOR
63
Chief Executive CV
Quality Account 2012/13
NHS Warwickshire North Clinical Commissioning
Intentions – 2013/14
Medical Director CV
Integrated Performance Report February
2012/13
Internal Incident – Capacity Pressures 15.03.2013
Director Of Finance CV
Integrated Performance Report March 2012/13
IT Strategy Presentation
Director of Governance & Quality CV
Quality Report to Quality & Assurance
Committee February 2013
Clinical Services Strategy
Director of Nursing CV
Quality Report to Quality & Assurance
Committee March 2013
Clinical Services Strategy Implementation plan and
Pathway Facilitation Report July
2012
Directors Portfolios Director of Human Resources
CQUIN 5a Mortality
Trust analysis of mortality including any detailed
analysis
Associate Medical Director CV
CQUIN 5b Care Bundles
Complaints and incidents policy and latest report
Associate Medical Director Women’s & Children’s
CQUIN 5c Record Keeping
Escalation policies
Director of Community Services CV
CQUIN 7b Conversion to Outpatient
Procedures
Operational policies for surgery
Director of Operations CV
CQUIN 7c Improving Theatre Efficiency
Patient feedback surveys
Associate Medical Director Paediatrics and Child Health
CV
CQUIN 8 Hospital Palliative Care Team (Acute
Hospital)
Audit of their use of the World Health Organisation
(WHO) Safety Checklist
Clinical Director of Division A CV
Trust Business Plan + 4 Appendices
Template referral form
Clinical Director of Division B CV
Review Process for CQC Mortality Alerts – Flow
Chart
Template handover form
Communications Lead CV
CQC Termination of Pregnancies
Quality Impact Assessment process and reporting
for Cost Improvement Plans
64
Board Paper – Committee Review May 2012
CQC Inspection Report Urgent Care November
2012
Patient experience and engagement strategy
Board Committee Structure May 2012
CQC Inspection Report November 2012
Safeguarding policies (adults and children)
Standard Template for Terms of Reference
WMQRS Letter
Whistle blowing Policy
Annual Cycle of Board Business 13/14
WMQRS Report
Phased implementation plan for 7 day working
Nursing Mortality Review report February 2012
Emergency Intensive Support Team Review –
report
Detailed action plan for 62 day cancer target
Medicine Directorate scorecard
BOD Paper – Safeguarding Adults
CCG Commissioning Intentions
Falls and Bone Health Strategy
Business Case – Frail and Elderly
JD – Care of the Elderly Consultant
Nurse Quality Indicator Dashboard
Business Case – Capacity 7 Day Working
IMPACT
Vulnerable Adults Study Day Poster
Dr Foster Latest Weekend Relative Risk Data
JD – Physicians Assistant
Anonymised Safeguarding Incident
HOB paper – 7 Day Working
Medical Staff Review
Business Case – Physicians Assistant
VITAL Phase 1 Completion Percentage
GEH Discharge Targets & Achievements
Business Case – Radiology 7 Day Working
VITAL Phase 1 Presentation
Zip File containing 8 Documents Referring to
Nursing Increases
Management of Change – Proposal for Pharmacy
Department
VITAL Phase 1 Statistics
Midwifery Staffing Expansion Paper
Training for Community Nurse Prescribers
VITAL – Signs Monitoring Agenda
CQUIN Position
Quality Account 2011/12
VITAL – Signs Monitoring Workbook
HOB paper – Winter Plan 2012/13
Quality Account 2012/13
Ward Round Report 2
ISOBAR handover tool- Nursing
CQRG Documents January 2013
Ward Round Report
Ward Round Checklist
Medical Directors CV
Associate MD Medicine CV
CD Paediatrics CV
65
Director of Finance CV
Associate MD Women & Children’s
CD Surgery CV
Director of Governance CV
Director of Community Services CV
Director Lead Roles – Portfolios
CD Medical Division CV
Director of Operations CV
Division A Objectives
Director of Nursing CV
Chief Executive CV
Division B Objectives
Director of HR CV
Director of Communications CV
Division C Objectives
GEH Organisational Charts
TOR – Division A
Division A Minutes – February 2013
JD – Heads of Nursing
TOR – Division B
Theatre Dashboard
Structure – Board Committees
TOR – Division C
Division B Minutes – February 2013
Structure – Senior Medical Staff
Division C Minutes – March 2013
TOR – Hospital Operational Board
Structure – Governance
Division B Report to HOB – March 2013
Introduction of VITAL – Learning knowledge base for
nursing staff
Structure Operational Division
Division C Report to HOB – March 2013
Zip File containing 9 Documents relating to review of
six months complaints against Francis Report and
CQC standards/mortality
Structure – Operational Management
Division A Report to HOB – March 2013
Quality Risk Committee (QAC) Agenda May 2012
QAC – Annual Review of Governance Reports
September 2012
Grievance Policy
TOR’s for combined Patient safety/ Patient
experience group
QAC – Final Reporting Matrix
Safer Surgery – Theatre Visits Schedule
Report of review of current numbers of staff trained
in ALERT
QAC – Key Governance Reports – Delivering Good
Governance
Whistle blowing Policy
Revised Fluid balance charts
QAC – Mid Staffs Inquiry Report – February 2013
WHO Surgical Checklist
Patient Safety Nursing Times Award example
BOD– Theatre Review
BOD report – Never Events
Sepsis Pathway
Dignity At Work Policy
Assurance Framework
Sepsis campaign /Staffing
Quality Accounts 2011/12
Deteriorating patient poster
Nursing Senate TORs
66
Quality Accounts 2012/13
IPPAC Minutes January 2013
WMQRS Visit report- long term Conditions
Quality Strategy
SIG Minutes January 2013
Workforce Assessment Toolkit
CQC Report
Nursing Homes training programme
Defending Dignity presentation
Critical Care Delivery Group Agenda
Zip file containing 7 files for Norovirus outbreak
evidence
Delirium ppt.
Critical Care delivery Group Meeting Minutes
QAC- Quality Report – March 2013
Dementia ppt
Making a difference – Falls prevention ppt.
Mortality Review Process
TOR Mortality Group
Mental Capacity Act ppt.
Mott MacDonald Key Findings and
Recommendations
Mortality Meeting Agenda – February 2013
Person centred care ppt
BOD – Mortality Review Paper November 2012
Mortality Meeting Minutes January 2013
Safeguarding adult Level 2 – Study Day
Mortality Coding Form
Email – Invite to Mott MacDonald Mortality Review
Study Day Poster
Mortality Quarterly Review – April – June 2012
Dr Foster Report January 2013
Final combined draft Dr Foster alert senility and organic
mental disorders report
Clinical Service Strategy
Coding Planning Sheet
Medical Advisory Minutes October 2012
Clinical Service Implementation Plan
Coding – Proposed foundation course for coders
TOR Mortality Group
Work stream 1: GEH System Care and
Mortality Review
Coding Audit Findings
Hinckley & Bosworth’s GP Meeting August 2013
Work stream 2: GEH System Care and
Mortality Review
Mott MacDonald Coding Review
Hinckley & Bosworth’s GP Meeting July 2013
Work stream 3: GEH System Care and
Mortality Review
Nursing Mortality Action Plan
Hinckley & Bosworth’s GP Meeting Update July 2013
Work stream 4: GEH System Care and
Mortality Review
Nursing Mortality Review July 2012
Colorectal Annual Report
Project Board Minutes – Sustainable Future
January 2013
NHS Staff Survey
Colorectal Minutes of Operational Policy Review May
Project Board Minutes – Sustainable Future –
BOD paper – Appraisal Compliance February 2013
67
2012
Actions Agreed
New Colorectal Proforma
Securing a Sustainable Future Risk Log
Appraisal Training
Colorectal Work Programme 2012
Project Board Agenda – Sustainable Future
February 2013
Appraisal Training
Royal College of Surgeons Review Report February
2012
Evidence Log Mortality Review
Appraiser Top Up Training
JEST August 2011
GEH CQUIN Position Quarter 1
Consultant Appraisals March 2013
PHEEM August 2011
GEH Organisational Chart
GEH Visions & Values
F1 – F2 August – December 2012
Structure – Senior Medical Staff
Value Pledges
PHEEM August 2012
Structure – Research Department
Board Etiquette
Dignity At Work Programme
Helpful Interview Tips
Staff Consultation Document
Grievance Policy
Value Based Interview Questions
Management of Change – Admin Workforce
Revised Strategic Objectives
Preceptorship Information Pack
Bleep Issue 16
TOR – Workforce Wellbeing Committee
Preceptorship Policy
Francis Report – Staff Letter
Well being terms of reference approved
Preceptorship Programme
GP News April 2012
Whistle blowing Policy
Employee Relations Report September 2012
GP News December 2012
Behavioural Interview Questions
Employee Relations Report October 2012
GP News issue 3
Dignity At Work Programme
Employee Relations Report November 2012
GP News Issue 4
GP News January 2013
Risk Reminder Pharmacy / Governance
January 2013
CEO BLOG 19th April 2013
GP News November 2012
Departmental Newsletter Apprenticeships
CEO BLOG 22nd March 2013
GP News PDF
Risk Reminder Pharmacy / Governance
February 2013
CEO BLOG 19th March 2013
GP News October 2012
HSMR Letter Staff
CEO BLOG 12th April 2013
68
Team Brief Key Messages
Sir Bruce Keogh Letter Staff
CEO BLOG 5th April 2013
Team Brief March 2013
Sire Bruce Keogh Review Staff
CEO BLOG 2nd April 2013
Team Brief Mortality Messages
Twitter
CEO BLOG 26th March 2013
Bleep Issue 14
CEO BLOG 22nd April 2013
CEO BLOG 9th April 2013
Staff Bulletin 13th March 2013
Staff Bulletin 25th February 2013
CEO BLOG 5th April 2013
Staff Bulletin 12th March 2013
Staff Bulletin 25th March 2013
Turnaround Document – Our Journey So Far.
Staff Bulletin 11th February 2013
Staff Bulletin 4th February 2013
Clinical Coding Structure
Staff Bulletin 16th April 2013
Staff Bulletin 6th March 2012
Coding – Doctors Presentation (induction)
Staff Bulletin 19th February 2013
Staff Bulletin 8th April 2013
Coding – Proposed Foundation Course
Staff Bulletin 19th March 2013
Stakeholder Matrix
ACC examination date
Staff Bulletin 2nd April 2013
Communications Calendar
Amalgamated into section 1.2g
Staff Bulletin 22nd April 2013
Communications and Engagement Strategy
Coding Audit
KMR1 form presentation
Digitisation options Under Consideration Paper
Zip file containing 7 documents re: Lorenzo
Coding – Junior Doctors Presentation
Health Records EDMS and Clinical Coding
Update March 2013
JD – Patient Track Project Manager
KMR1 forms - Presentation
Retention and Destruction of Medical Records
Policy
Patient Track implementation Risk Register March
2013
Medical Records – Guidelines for Clinicians
CHKS report
Patient Track implementation Risk Register April
2013
On Line Doctors - Presentation
PBR 2011-12 Inpatients at GEH
Patient Track implementation Status Report January
2013
Health Records Structure
PBR 2011-12 Follow ups at GEH
Patient Track implementation Status Report 8th
March 2013
JD – Health Records Manager
PBR 2011-12 Coding Audit
Patient Track implementation Status Report 12th
April 2013
69
GEH – Lorenzo Investment Plan
IT Strategy Presentation
Patient Track implementation Status Report 22nd
March 2013
JD – Ward Clerk
Ripple Presentation ppt.
TOR Emergency Care Steering Group
End of Life Strategy Group Minutes February 2013
Use of Liverpool Care Pathway at GEH Report
August 2012
Internal Incident – Capacity Pressures March 2013
Business Case – End of Life – Route to Success
Use of Liverpool Care Pathway at GEH Report
November 2012
Transformational programme sub groups
LCP audit – External -February 2012
Well Being Terms of reference
Ambulatory – Abdominal Pain Pathway
LCP audit – Internal – February 2012
Mott MacDonald GEH and North Warwickshire
Community PAPF
Ambulatory Care Operational Policy
WMAS – Protocols Ambulance - Diverts
Draft Interim Well Being Strategy
Ambulatory - Community Acquired Pneumonia &
Lower Respiratory Tract Infection Pathway
WMAS – Protocol Ambulance –Handover delays
BOD paper – Making every contact count –
April 2012
Ambulatory – Pleural Effusion Pathway
The following documents were requested by the panellists at the announced site visit and made available to those panellists attending the unannounced site visit. Whilst the
documents were not reviewed in detail, they were available to the panellists to validate findings:
1.1a.4 frail elderly Business Case_V5
Acuity review May 2013
CaseMixSummary
CIP Summary 201314
CLC (Modified Early Warning Score Calling
Criteria for Adults)
DataAppendix
DIRECTORS LEAD ROLES Final version after exexs
End of Life Care Document
End of Life Strategy Update
Guide to your Case Mix Programme Version 3.0
electronic Data Analysis Report
Quarterly mortality review April – December
2012
TVS Consensus PU Reporting
70
The following documents were provided to the panel chair following the site visits. Whilst they were not reviewed in detail, they were available to the panel chair to validate
findings and support the drafting of the report:
Board Development Schedule May 12-13
Current Sepsis pathway
Deteriorating Patient Policy – revision
Observations incident form
SBAR usage Dilly
CQUIN 8 – Minimising Bed Moves (undated)
The following documents were provided to the panel chair is response to the draft RRR report issued to the Trust for a factual accuracy check. Whilst they were not reviewed
in detail, they were available to the panel chair to validate the Trust’s response and support further drafting of the report:
Re-admissions update Paper to QAC – April 2013
Unconfirmed minutes of the Public Board of
Directors Meeting 24 April 2013
Financial information for HR dashboard – agency
use by directorate
2012 National NHS staff survey – Brief summary of
results from George Eliot Hospital NHS Trust
Trust Board (private) Listening to staff 2012 –
27 February 2013
Board of Directors Meeting – Public: Integrated
Performance Report – 24 April 2013
2012 National NHS staff survey – Results from George
Eliot Hospital NHS Trust
Board of Directors – Nursing Workforce Update
– 26 January 2011
Board of Directors unconfirmed minutes of a private
meeting 28 November 2012
Board of Directors unconfirmed minutes of public meeting
26 January 2011
Report to Board of Directors – Implementation
of 60/40 nursing workforce – 27 April 2011
Board of Directors unconfirmed minutes of public
meeting 27 April 2011
Board of Directors unconfirmed minutes of private
meeting 27 April 2011
Report to Board of Directors – Implementation
of 60/40 nursing workforce – 25 May 2011
Board of Directors unconfirmed minutes of public
meeting 25 May 2011
Report to Board of Directors – Nursing workforce update
(60/40) – 26 October 2011
Board of Directors unconfirmed minutes of
public meeting 26 October 2011
Trust Board meeting – Matrons report surgery
division – 25 January 2012
Three year business plan 2012/13 to 2014/15
External review action plan v7 – 14 March 2012
Mortality review completed actions v3 – 14 March
2012
Board of Directors – private – mortality action plan – 28
March 2012
Board seminar notes of meeting – 9 May 2012
Board of Directors – public – Review of winter plan
2011/12 – 27 June 2012
71
Nursing Times award 2012 Finalist Care of older people
certificate
Nursing Times Award 2012 papers (undated)
Tissue Viability Society Achieving Consensus in
Pressure Ulcer Reporting
CQUIN 8 – minimising bed moves paper (undated)
Division B Objectives and Priorities 2012/13
Divisional accountability ‘making us fit for purpose’ –
March 2012
Examples of working with other Trusts/national and
international work
CQUIN care bundles paper (undated)
Healthcare operational board – Winter 2012/13
Responding to mortality review and best practice
emergency care transformation programme – 1
November 2012
Workforce strategy 2013-16 (draft) – January 2013 v11
Workforce strategy implementation plan
2013/16 (undated)
Examples of doctors job plans 2011
Directors lead roles final version – 12 April 2013
Theatre review action plan template
Board of Directors – private – Theatre review update
– 26 September 2012
Assurance framework 2013-14 – April 2013
Improving Quality of Care – Our journey so far
(undated)
Modified early warning score calling – criteria for
adults
Mortality review completed actions v14 – 19 April 2013
Terms of reference – Serious incident group
(undated)
Simply safer ward dashboard 2012/13
CIP summary 2013/14 (undated)
PMO CIP progress report – 2013/14 for finance
committee meeting 28 May 2013
QIA review of CIPs 2013/14 – meeting notes 19
March 2013
ISOBAR handover form
ISOBAR Nursing Times submission
ISOBAR poster: Standardising nursing handover
Smiley Face card
Board of Directors – public – Ongoing reviews
of quality – 30 January 2013
Terms of Reference – Divisional governance
committee (undated)
Welcome to George Eliot leaflet
Examples of multidisciplinary working
Draft business plan 2013/14 – 2015/16 v1.4 First
submission to NHS TDA – 25 January 2013
Executive team briefing – Nursing workforce review
update – 28 May 2013
Board of Directors – private – Midwifery
expansion project – 27 February 2013
Strategic workforce plans 2012 – 2017 – Narrative
planning template – June 2012
72
Workforce plans 2012 – 2017 return – June 2012
LocumPod implementation plan – 7 January
2013
73
Appendix VII: Unannounced site visit
Agenda item
Panel pre-meet.
Entry into George Eliot Hospital A&E and announced arrival to site manager.
Meeting held with site manager to understand current staffing and patient levels and observation of 21.00 capacity meeting.
Observations undertaken of the following areas of the hospital:
 A&E – minors, majors and paediatrics.
 CDU.
 EMU.
 Adam Bede Ward.
 Mary Garth Ward.
 Nason Ward.
 Bob Jakin Ward.
 Dolly Ward.
Observation undertaken of the following handovers:
 20.00 surgical handover in Alexandra Ward.
 21.00 medical handover.
 21.00 nurse handover.
Observations / interviews undertaken of the following staff:
 Surgical junior doctor on call following handover at 17.00 prior to night shift.
 Medical junior doctor on call following handover at 17.00 prior to night shift.
 Critical Outreach Team member.
Panel left Trust and announced exit.
74