George Eliot Hospital NHS Trust Rapid Responsive Review
Review into the Quality of Care & Treatment provided by
14 Hospital Trusts in England
Key Findings and Action Plan following Risk Summit
July 2013
Contents
1.
Overview
3
2.
Summary of Review Findings
6
3.
Risk Summit Action Plan
Appendices
Appendix I:
14
18
Risk Summit Attendees
19
2
1. Overview
A risk summit was held on 21 June 2013 to discuss the findings and actions of the Rapid Responsive Review (RRR) of George Eliot Hospital NHS Trust (“the Trust”). This
report provides a summary of the risk summit including the Trust response to the findings and an action plan for the urgent priority actions from the RRR discussed at risk
summit. The action plan includes any agreed support required from health organisations, including the regulatory bodies.
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 Mortality Indicator (SHMI) or the Hospital Standardised Mortality Ratio
1
(HSMR) .
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 this is reflected in the reports. The Panel also considered independent feedback from stakeholders related to the Trust, 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.
1
Definitions of SHMI and HSMR are included at Appendix I of the full Rapid Responsive Review report published here http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/published-reports.aspx
3
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:
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 followed a three stage process:

Stage 1 – Information gathering and analysis
This stage used information and data held across the NHS and other public bodies to prepare analysis in relation to clinical quality and outcomes as well as patient and staff
views and feedback. The indicators for each trust were compared to appropriate benchmarks to identify any outliers for further investigation in the rapid responsive review
stage as Key Lines of Enquiry (KLOEs). The data pack for the Trust is published at http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/published-reports.aspx

Stage 2 – Rapid Responsive Review (RRR)
A team of experienced clinicians, patients, managers and regulators, following training, visited each of the 14 hospitals and observed the hospital in action. This involved
walking the wards and interviewing patients, trainees, staff and the senior executive team. This report contains a summary of the findings from this stage of the review in
section 2.
The two day announced RRR visit took place at the Trust’s acute hospital site on Tuesday 21 and Wednesday 22 May 2013 and the unannounced visit was held on the
evening of Wednesday 29 May 2013. A variety of methods were used to investigate the Key Lines of Enquiry (KLoEs) and enable the panel to analyse evidence from multiple
sources and follow up any trends identified in the Trust’s data pack. The KLoEs and methods of investigation are documented in the RRR report for the Trust. A full copy of
the report was published on 16 July 2013 and is available online: http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/published-reports.aspx

Stage 3 – Risk summit.
This stage brought together a separate group of experts from across health organisations, including the regulatory bodies (Please see Appendix I for a list of attendees). The
risk summit considered 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.
The Risk Summit was held on 21 June 2013. The meeting was Chaired by Paul Watson, NHS England Regional Director (Midlands and East), and focussed on supporting
the Trust in addressing the urgent actions identified to improve the quality of care and treatment. The opening remarks of the Risk Summit Chair and presentation of the RRR
key findings were recorded and are available online: http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/published-reports.aspx
4
Conclusions and priority actions
The panel observed that the Trust has generally engaged, passionate and loyal staff and is 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.
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.
The review identified a number of areas of outstanding concern across all eight KLOEs. A key concern for the Board to address is, while the leadership had taken difficult
decisions on the long term future of the Trust, it was difficult to identify evidence of proactive leadership that is focussed on of excellent quality of care and treatment. There
were particular concerns over medical leadership.
The panel also had concerns in relation to low levels of clinical cover, particularly out of hours. It was also identified that a number of wards appeared to contain patients with
a range of illnesses in them and multiple bed moves were common during a patient stay. These issues may be detrimentally impacting on patient experience and continuity of
care.
The Trust found the RRR process challenging, thorough but fair. It accepted the recommendations and stated that it found that many recommendations built on work already
in place and, at the time of the risk summit, was already acting on new recommendations.
Ten areas were identified for discussion at the risk summit. These are summarised in the following sections and are detailed within the RRR report. An action plan was
agreed at the risk summit addressing the first seven of the urgent priority actions discussed. Due to time constraints, the action plan could not be agreed for the remaining
three areas identified for discussion at the risk summit. The Trust and the risk summit chair committed to agreeing an action plan for the remaining three areas within two
weeks of the risk summit, being Friday 5 July along with the required external support for the action plan.
Next steps
As the risk summit had focused on urgent priority actions, the Trust also agreed at the risk summit to provide a detailed action plan to all outstanding concerns and
recommended actions included in the RRR report to the risk summit chair within four weeks of the risk summit, being Friday 18 July 2013.
Follow up of the RRR and risk summit action plan will be undertaken by other organisations within the system, including CQC and GMC visits. A formal follow up will consist
of a desktop review and a targeted one day site visit to the Trust in October 2013 reviewing key areas to understand the improvements that have taken place. A report of the
follow up findings will be issued to the risk summit attendees and will consider, if there are significant remaining concerns, if there is a need to convene a further risk summit.
5
2. Summary of Review Findings
Introduction
The following section provides a summary of the RRR panel’s findings and the Trust’s response presented at the risk summit. The detailed findings are contained in the
Trust’s RRR Report. The Trust response was presented by Kevin McGee, Chief Executive, supported by Andrew Arnold, Medical Director, and Dawn Wardell, Director of
Nursing and Quality. The agreed action plan in response to the urgent priorities is included in the following section.
Background
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.
The Trust is not a Foundation Trust and is not currently in the Monitor pipeline. In the past two years, a decision was made for the Trust not to seek to achieve Foundation
Trust status alone due to the relatively small size of the Trust, but to seek a partner organisation to secure its operational future. It was evident during the visit that this
uncertain long term future has affected staff and the public, making them nervous of closure of the George Eliot Hospital, which was evident during our visit. The Trust has
not received a response to the business case on the long term future submitted to the Department of Health over a year ago.
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 Trust 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’.
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. The panel found that further work was required to fully implement these plans.
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 RRR Panel were welcomed to the Trust by all staff and patients and met some outstanding and dedicated individuals at the Trust which is clearly supported by its local
population. Staff were generally found to be engaged, passionate and loyal.
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.
Overview of Trust response
The Trust found the RRR process challenging and thorough but fair. It accepted the recommendations and stated that it found that many recommendations built on work
already in place and, at the time of the risk summit, was already acting on new recommendations.
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Summary of RRR findings and Trust response
1. Leadership of quality
Whilst the Trust could be seen to be engaging external reviews to understand the mortality issues arising, the focus of the leadership appeared to be that of the long
term future and finding a strategic partner. It was difficult to identify evidence of a proactive and driven leadership of excellent quality of care and treatment throughout
the Trust, particularly medical leadership. There was limited evidence of the Trust leadership driving improvements in quality in the organisation with sufficient pace.
Recommendations

Improve Board capability through development of critical challenge skills so the leadership effectively scrutinises data, triangulates and drives effective actions
throughout the Trust.

A clearer connection between patient safety and mortality must be made and patient safety clearly prioritised. This should be led from the top of the organisation.

Ensure clarity over Director portfolios and development of 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 Executive Directors have the necessary skills to perform their role effectively.

Non Executive Directors should gain assurance through effective review and challenge of action plans detailing changes made and evidence of the effectiveness of
the changes.
Trust response
The Trust has agreed to take the following actions:

Undertake a diagnostic leading to a rolling Board development programme and a clinical leadership development programme with support from NHS Improving
Quality (NHS IQ).

Implement a dispersed model of clinical leadership to reinforce the role of Clinical Directors and Matrons.

Comprehensive leadership development programme to be offered to band 6 upwards with support from NHS Elect and the NHS Leadership Academy.
The risk summit chair requested further actions to make the Board more effective with pace. The TDA offered a role to support this and the risk summit attendees
emphasised that this support must be tailored to the Trust. The RRR panel stressed that the Board development must be both at an individual member level and for the
Board as a whole.
7
2. Pace of change
The panel did not see evidence of a sufficient pace in quality improvement at the Trust. Many actions identified by the Trust were not fully implemented and there was
limited evidence of positive outcomes as a result of its current plans.
A review of a number of Trust strategies identified that these tended to be high level without implementation plans detailing how and when the strategic visions would be
delivered.
Recommendations

There should be improvement in Trust leadership and culture to instil a pace of sustainable change. Agree a SMART implementation plan including an identified
trajectory of improvement plans. Monitor these plans effectively, for example through critical review monthly, seeking evidence of sustainable implementation and
the impact of changes.
Trust response
The Trust has agreed to take the following action:

Consolidation of findings from mortality reviews, the RRR, Francis reviews and the Trust’s Quality Strategy into an overall quality improvement plan with SMART
objectives. This will be monitored monthly with the Clinical Commissioning Group and internally at the Quality Assurance Committee and Board. The SMART
objectives will link to divisional and individual objectives and personal development plans.
The Trust action plan was accepted by the risk summit provided that the organisation and individuals were held accountable for delivery of the objectives.
8
3. Patient locations and moves
Discussions with staff and patients identified issues with patient locations and movements:
 Wards appeared to contain patients with a wide range of illnesses being treated in 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.
Recommendation

Improve bed management through bed managers involving the doctors more to understand the clinical need of the patient and minimise patient moves.
Trust response
The Trust has agreed to take the following actions:

Review acute bed configuration to reduce patient moves and implementation of a ‘Do not move me’ initiative. The Trust will also put additional investment in ward
clerks to support keeping PAS (patient administration system) updated.

The electronic PatientTrack system is being implemented, including an alert and assessment base.

Review model of ward-based consultants and ensure consistent ward rounds are completed by 9am each day.

Improve discharge processes, review the discharge lounge and support community provision of nursing support to nursing homes.
The RRR panel asked the Trust to strongly consider ward based teams overseeing patient care to avoid consultants doing safari rounds. The risk summit reinforced the
need for daily ward rounds to be led by a senior decision maker and be audited. The Trust was encouraged to look at other trusts using the ward based team model.
The Trust was also reminded that moves included moves from the emergency department into the hospital and the need to admit patients into the right location at the
point of admission.
9
4. 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. Discussions with staff and patients identified that staffing appears to be
more of a concern for out of hours and at weekends.
Seven day working appeared to be in early planning stages with staff speaking of business cases rather than implementation.
Recommendations

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,
to be undertaken by the Trust. To 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.

The Trust needs to focus on delivering 7 day/24 hour working. This should be built into a workforce strategy.
Trust response
The Trust has agreed to take the following actions:

To undertake workforce reconfiguration including reduction of agency staff and robust planning for the winter.

To move the Trust to seven day working through the nursing acuity review and consultant appointments.
The RRR panel clarified that the issue identified covered both medical and nursing staff. The risk summit chair requested that new actions be agreed as a result of the
workforce review in addition to the work already underway at the Trust. Actions were agreed for immediate implementation and a more sustainable action.
10
5. Medical handovers
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.
Recommendations

Medical handovers to consistently be of sufficient quality to enable quality of care and treatment, including:
o Adequate information provided on patient treatment to date, outstanding treatment to be provided and patient location.
o Suitable location for the handover.
o Lead by the Consultant on call.
Trust response
The Trust accepted the recommendation.
6. Sepsis care bundle performance and management
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% would be achieved by the Trust because a phased roll out of care bundles is planned and there was a lack of evidence of
sepsis bundles being used 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.
Recommendations

The sepsis target should be reviewed to ensure that it is stretching. A higher percentage was considered to be achievable by the RRR panel with the correct
support and leadership in place and implementation should be with pace with an earlier date.
Trust response
The Trust has agreed to take the following actions:

The Trust had agreed with the CCG to increase the target from 60% to 90% by the final quarter of 2013/14.
The risk summit chair requested that the Trust target a quicker implementation and increase in percentage and that actions be included not only for sepsis but for other
care bundles, specifically pneumonia and Congestive Cardiac Failure (CCF). The Trust requested support with capacity and capability in order to be able to achieve
90% within three months.
11
7. Culture at the Trust
Although the Trust provided some examples of internal stretch targets, panel members did not see a consistent ambition to excel and exceed minimum expectations on
quality.
Recommendations

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.
Trust response
The Trust has agreed to take the following actions:
 Amend EXCEL, the Trust’s acronym to articulate its vision, to be explicit about patient safety and drive and embed EXCEL from Board to divisions to ward to
individuals.
 Extensive Board development programme focussed on patient safety and experience.
 Implementation of overarching quality improvement methodology.
The risk summit attendees agreed that this action is the sum of all the other urgent priority actions and that no specific actions were required in this area.
8. Understanding of mortality issues
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 of placing a reliance on external reviews and there appeared to be an absence of detailed analysis of mortality.
Recommendations

Trust led regular analysis of mortality. This 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 and reported to the Board.
Trust response
The Trust recognised the need for more intelligent use of the data and that this would be part of the Board development actions.
The risk summit attendees highlighted that the Trust needs to ensure that it is focused on the areas that the data leads to. Detailed actions would be agreed by two
weeks from the date of the risk summit.
12
9. Incident reporting
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.
Staff interviewed also spoke of issues with their ability to report patient incidents on the Prism web forms and paper forms as the system was not user friendly. The
forms are too long and feedback was not provided to staff in response to reported incidents.
Recommendations

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.
Trust response
The Trust has agreed to take the following actions:
 The incident reporting system is to be reviewed and good practices currently applied to higher risk alerts (red and amber) alerts to be applied to all incidents.
The risk summit confirmed that the action required needs to encourage reporting and feedback. This was accepted by the Trust and detailed actions would be agreed
by two weeks from the date of the risk summit.
10. Pressure ulcers
The Trust has had an increase in grade 3 pressure ulcers since January 2013 and is not achieving the recent NHS England regional ambition of zero avoidable harm.
Issues were also noted specific to the recording of pressure ulcers, including the high number of “unstageable” pressure ulcers being recorded.
Recommendations

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 should focus on reducing pressure ulcers.
Trust response
The Trust has agreed to take the following actions:
 Cease using “unstageable” from 1 July 2013 supported by a change in training, policies and a communication to staff.
The risk summit attendees requested further actions around the care bundle for skin. Detailed actions would be agreed by two weeks from the date of the risk summit.
13
3. Risk Summit Action Plan
Introduction
The risk summit development of an outline plan focused on the urgent priority actions from the RRR report. No information in addition to the RRR report was presented at the
risk summit.
The following section provides an overview of the issues discussed at the risk summit with the developed action plan containing the agreed actions, owners, timescales and
external support. This is followed by details of the agreed next steps following the risk summit.
Issues and action plan
Key issues
1. Leadership of quality
Whilst the Trust could be seen to be engaging external reviews to
understand the mortality issues arising, the focus of the leadership
appeared to be that of the long term future and finding a strategic partner.
It was difficult to identify evidence of a proactive and driven leadership of
excellent quality of care and treatment throughout the Trust, particularly
medical leadership. There was limited evidence of the leadership driving
improvements in quality at the Trust with sufficient pace.
2. Pace of change
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
with many actions not fully implemented and limited evidence of positive
outcomes as a result.
Agreed actions and support required
Board Development plan to be produced taking account
of the quality concerns raised.
Owners
Timescales
Trust
By 1 July 2013
Demonstration of clarity of Directors’ portfolios through a
report setting out their key responsibilities.
Trust
By end of June
2013
Create single consolidated quality of care improvement
program which incorporates all improvement plans
including the TDA plan from the Board review.
Trust
By end of July
2013
Support to be provided by the TDA.
This will be created alongside a refresh of the Operating
Plan to be submitted to the TDA for sign off.
A review of a number of Trust strategies identified that these tended to be
high level without implementation plans detailing how and when the
strategic visions would be delivered.
14
Key issues
3. Patient locations and moves
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.
Agreed actions and support required
Owners
Timescales
Review of acute bed configuration plan including
implementation plans and timescales.
Trust
By 5 July 2013
Implement a policy for consultants to authorise all bed
moves.
Trust
Completed
Review ward based consultants with considerations of
Trust
moving to a daily ward round by a senior decision maker
undertaking the ward round in teams. Detailed plan to be
produced.
By 1 September
2013
Implement PatientTrack including alerts and assessment
base.
Trust
By October 2013
Review every out of hours shift for planned versus actual
staff attendance and intervene if issues are identified.
Trust
Immediate
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 for out of hours and at
weekends.
Develop a clear escalation procedure for any failure to fill
a staffing post, including actions to be taken to mitigate
the risk.
Trust
By end of June
2013
7 day working appeared to be in early planning stages with staff speaking
of business cases rather than implementation.
Plan for an audit programme out of hours staffing to
provide assurance over staffing levels.
CCG / TDA
By end of June
2013
Undertake a full strategic review of workforce – both
medical and nursing – needs and plan for resolution of
issues identified.
Trust
To complete
review and agree
further actions by
end of July 2013
Create a written handover process/policy addressing
content and location including guidelines for the
involvement of consultants on evening handovers. This
work should be focused on the evening medical
Trust
By end of July
2013
4. Low levels of clinical cover particularly out of hours
5. Medical handovers
Whilst observations of surgical handovers identified these as an area of
good practice, the quality and content of the medical handover was of
15
Key issues
Agreed actions and support required
concern to the panel.
handover.
6. Sepsis care bundle performance and management
Target 90% for sepsis care bundle.
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.
CCG to monitor.
Owners
Timescales
Trust
By end of
September 2013
Trust
Completed
Trust
By 1 August 2013
No additional actions agreed as this was included in the
approach to all other actions
n/a
n/a
8. Understanding or mortality issues
Create a mortality review policy setting out the following:
Trust
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 of placing a reliance on
external reviews and there appeared to be an absence of detailed
analysis of mortality. For example, reviewing 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.




To agree
implementation
actions for future
roll out by 5 July
2013
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
Implement the pneumonia care bundle on the wards.
CCG to monitor.
Implement CCF care bundle on the wards
CCG to monitor.
Although the Trust provided some examples of internal stretch targets,
panel members did not see a consistent ambition to excel and exceed
minimum expectations.
When mortality will be reviewed.
How reviews will align to the data.
Inclusion of triangulation.
Reporting lines.
Action to focus on learning from within the organisation
and internal data analysis.
16
Key issues
9. Incident reporting
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.
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.
10. 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 including
the high number of “unstageable” pressure ulcers being recorded.
Agreed actions and support required
Owners
Timescales
Develop SI and incident reporting policy including:
reviewing the reporting system; outlining how the policy
will be implemented; and, governance and reporting,
including feedback on issues reported and escalation.
Trust
To agree detailed
implementation
plan and actions
by 5 July 2013
Develop a culture of reporting. [Specific action TBC]
Trust
To agree detailed
implementation
plan and actions
by 5 July 2013
Revise reporting technology to support a culture of
reporting and to make it user friendly.
Trust
To agree detailed
implementation
plan and actions
by 5 July 2013
Cease using “unstageable” grading supported by training, Trust
policies and communication to staff.
By 1 July 2013
Action to reduce pressure ulcers including the use of the
care bundle for skin to be agreed.
To agree detailed
actions by 5 July
2013
Trust / NHS
England
17
Appendices
18
Appendix I: Risk Summit Attendees
Risk summit role
Risk summit chair
NHS England Regional Director (Midlands and East)
RRR panel chair
NHS England Regional Medical Director (Midlands and East)
Name
Paul Watson
Dr David Levy
RRR panel representative – Doctor
Peter Davis
RRR panel representative – Nurse
Bridget O’Hagan
RRR panel representative – lay representative (public / patient
representative)
Antony Glover
RRR panel representative – senior regional support
Finola Munir
RRR panel representative – senior regional support
Gareth Jones
Trust Chief Executive
Kevin McGee
Trust Director of Nursing
Dawn Wardell
Trust Medical Director
Andrew Arnold
NHS England, Regional Dir Ops and Delivery
NHS England, Regional Chief Nurse
NHS England, Regional Deputy Medical Director
Sarah Pinto-Duschinsky
Ruth May
Alistair Lipp
NHS England, Regional Deputy Director of Nursing
Sylvia Knight
NHS England, Regional Deputy Director of Nursing
Lyn Mcintyre
Area Team Director
Lesley Murphy
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Risk summit role
Area Team Medical Director
CCG Accountable Officer
CCG representative
CQC Regional Director
Name
Martin Lee
Andrea Green
Jacqueline Barnes
Andrea Gordon
CQC Representative
Jackie Howe
Health Education East of England representative
Russell Smith
Health and Wellbeing Board
General Medical Council representative
Cllr Alan Farnell
Jill Williams
Independent moderator
Rachel Vokes
Recorder
Alkay Masuwa
20