KEY
Delivered
On Track to deliver
Some issues – narrative disclosure
Not on track to deliver
1

Medway NHS Foundation Trust - Our improvement plan & our progress
What are we doing?
• The Trust was one of 14 included in the Keogh Review process because of higher than expected mortality rates. This remains an ongoing key focus for the Board with support from ‘buddying’ trusts.
• Following the review the Trust was placed in ’special measures’ and has remained so following Care Quality Commission inspections in December 2013, April 2014, July 2014,
August 2014 and December 2014. The Keogh review made a number of recommendations, the majority of which have been closed. A number of actions have been agreed following each of the CQC visits and have been incorporated with other Trust initiatives into a single 18 month recovery plan.
• The 18 month recovery plan which has been signed off by the Board of Directors, details specific improvements at the Trust, addresses the CQC reports and combines these with the remaining actions from the Keogh review recommendations. Each thematic area in the table is mapped back to the Keogh and CQC actions to which it relates.
The key themes of these recommendations which underpin our 18 month plan are summarised by the headings below:
1.
Data accuracy, monitoring of trends
2.
Standards, risk management and governance from ward to board including escalation policies and incident reporting
3.
Safe and competent staffing levels across wards and departments
4.
Estates and equipment maintenance programmes in place including fire exit accessibility
5.
Patient flow and experience from initial assessment to discharge
6.
Ensure all staff have right skills and training including MCA and DoLs
7.
Ensure staff are trained in and working to updated major incident policy
Since the last report
• Diana Hamilton-Fairley has been appointed to the role of Medical Director and is now in post.
• Karen Rule is transitioning into her new role of Director of Nursing.
• A new organisational structure has been introduced; this includes key leadership roles.
• Clinical leadership appointments have been made and three Directors of Clinical Operations are now in post.
• Through the buddying agreement with Guy’s & St Thomas’s, development of our clinical leaders has taken place through four well attended Clinical Leadership forums.
• During the CQC Inspection in August 2015 (report yet to be received) issues were raised regarding patient safety within the Emergency Department. A system wide escalation to assist Medway NHS Foundation Trust was implemented, under a request for mutual aid. As part of this arrangement, a partial ambulance divert over two x four hour periods was put in place to allow a training programme (addressing the skill gaps identified during the inspection) to be implemented. In addition to this, the Emergency
Department capacity escalation arrangements have also been revised.
• The Board held a preliminary Strategy day to formulate strategic plans post 18 Month recovery plan. Governors joined the Board and undertook stakeholder engagement mapping.
2

Medway NHS Foundation Trust - Our improvement plan & our progress
• Our 18 month recovery plan which has been signed off by the Board of Directors, details specific improvements at the Trust.
• Our Chief Executive Lesley Dwyer is ultimately responsible for implementing actions in this document. Other key staff are Steven Beaumont, Chief Nurse, Trisha Bain, Chief Quality
Officer and Diana Hamilton-Fairley, Medical Director, as they provide the executive leadership for patient experience, quality and patient safety.
• The Improvement Director assigned to Medway NHS Foundation Trust Mark Davies, has resigned with effect from 30 July 2015. Should you require any further information on this role please contact specialmeasures@monitor.gov.uk. The Trust is currently working with Monitor to review requirements going forward.
• Ultimately, our success in implementing the recommendations of the Special Measures Action Plan will be assessed by the Chief Inspector of Hospitals, upon re-inspection of our
Trust.
•
If you have any questions about how we’re doing, contact the Chief Executive by email at Chief.Executive@medway.nhs.uk
How we will communicate our progress to you
• We will update this progress report every month while we are in special measures.
• There will be regular updates on NHS Choices and subsequent longer term actions may be included as part of a continuous process of improvement.
• Updates on our progress will be given at our board meetings, with papers published on our website, and regular members engagement events, which will be held in collaboration with our local health and social care partners.
• Stakeholder and public briefing dates will be provided and will be detailed as part of the communication plan to be approved at the board in January 2015
Chair / Chief Executive Approval (on behalf of the Board):
th
th
3

Summary of
Main
Concerns
The trust has not had a stable board and executive team.
The trust requires a review of its organisational and management structures to ensure effective management, governance and risk management within the organisation
Medway Foundation Trust - Our improvement plan
Summary of
Urgent Actions
Required
Agreed timescale
Revised deadline (if required)
Progress against original timescale
Appoint a substantive
Chair
Recruit substantive executives including CEO
Recruit substantive CEO
Carry out a re view of organisational structure and accountabilities
Review and standardise governance structures and processes throughout the organisation
Review the committee and meetings structure to ensure clear lines of reporting throughout the organisation.
September 2014
April 2015
May 2015
March 2015
August 2015
December 2015
June 2015
March 2015 • Substantive chair appointed September 2014.
Action complete
Successful appointment of :
• Chief Operating Officer
• Chief Nurse (on secondment)
• Interim Director of Corporate Affairs appointed
• Successful appointment CEO Lesley Dwyer May 2015.
Action complete
• New organisational structure reviewed and approved in line with the Trust’s scheme of delegation (with clear lines of reporting and accountability).
• Consultation on senior management structures completed November 2014.
• Corporate and Divisional Nursing Structure consultation complete.
• Post consultation review to agree final structure complete.
• Review of structure and roles below divisional director operations commenced.
• Operational Director interviews took place in July 2015. No appointments were made due to the revised organisational structure . Formal consultation will commence early October 2015 and appointments to newly identified roles will commence November 2015.
• Three Directors of Clinical Operations have now been appointed (October
2015).
• Two new Non-Executive Directors have been appointed and are now in post.
• Governance framework approved by Audit Committee (December 2014).
• Approved at Public Board (18 December 2014).
• Further revision of the Governance Framework was completed in May 2015.
• A revised organisational management structure has been introduced commencing 5th October.
December 2015 • Chief Quality Officers review and amendment of the committee structure is complete and is now being implemented.
• New Quality Assurance Compliance Group is now in place, along with the
Clinical Incident Review Group and the weekly Harm Free Care meetings.
• With the Support of GSTT work has now started on reviewing further groups to rationalise the effectiveness of their role; with specific focus on Clinical
Effectiveness.
• Corporate governance structures are under review by the Company Secretary; this is aligned to clinical governance structures.
• Risk management training commences October 2015.
External Support/
Assurance required)
University Hospitals of
Birmingham review and recommended organisational structure
Governance framework document produced with help of Good
Governance Institute and PWC
New Buddying
Arrangement incorporates additional work on Governance
4

Summary of Main
Concerns
Continued:
Safe and effective staffing of all clinical areas by appropriately trained staff
Summary of
Urgent Actions
Required
Address gaps in clinical leadership
Medway Foundation Trust - Our improvement plan
Agreed timescale
Revised deadline
On-going
August
2015
On-going progress
December
2015
Progress against original timescale
Clinical leadership:
• With support from GSTT, the first clinical leaders forum was successfully launched in June 2015 and was well attended by a group of clinical leaders.
• Four clinical leadership forums have now been conducted and were all well attended. The latest forums held in August and September were “Clinical Governance at MFT” and “An Introduction to
Job Planning”.
• The PATH (partnerships advancing transformation in healthcare) programme is proving successful, with mid-course evaluation of the preparedness to lead questionnaire showing improvements in all areas examined amongst the 6 participants. These include junior doctors, nurses and managers working together on safety improvement projects in the trust. They will be presenting completed projects in a PATH event show casing all the clinical care bundles which have been developed as part of this programme.
• This programme has now been completed . Projects have been presented at various Governance meetings across the Trust.
• Interim structure has been introduced to ensure clinical engagement and clinical leadership development.
• New clinical structures have been consulted on to improve clinical engagement and leadership.
• Structure approval sought by Clinical Council on additional elements to the new organisational
Structure.
• The new clinical structure for the Trust has been introduced; the structure includes an increased number of clinical leadership positions.
• All new staff are trained in safeguarding / MCA and PREVENT as part of the initial induction process. Existing staff gain the same information through normal mandatory training sessions.
• Mandatory training scores are currently 81.83% - we are meeting the minimum standards.
External Support/
Assurance required)
University Hospitals of
Birmingham review of nursing
Homerton review of staffing and processes in ED
GSTT Nursing Support
Health Education
England
ECIST
WELL LED
The Trust requires a review of its organisational and management structures to ensure effective management, governance and risk management within the organisation
Improve understanding of ‘deprivation of liberty standards’ and ‘mental capacity’ assessment
Review and standardise governance structures and processes throughout the organisation .
Improve training on risk management and appropriate escalation
March
2015
June 2015
December
2015
December
2015
• The Board Assurance Framework has been introduced and a post implementation review is now being conducted – completion and subsequent report due by 31 st August 2015. Report now complete. (10.9.15).
• Additional work with the Good Governance Institute is underway to strengthen and sustain work in regard to the Board Assurance Framework.
• Draft report from KPMG has been received and revised trust governance framework is being developed.
• Work started with internal auditors to support the Trust in further refining its risk management arrangements. This work will include the update and review of the Risk Management Strategy.
• A full review is currently taking place .
• By 1 st September 2015 the Trust will have a new guidelines and policy approach. Training for staff is also planned; in addition to process and guidelines this training covers the mitigation of risk, raising risks and producing outcome driven risk registers.
• The Good Governance Institute is now supporting the Company Secretary with risk management.
• Draft report from KPMG now received . New framework guidelines and updated strategy is currently being developed.
University Hospitals of
Birmingham review and recommended organisational structure.
Governance framework document produced with help of
Good Governance
Institute and PWC.
New Buddying
Arrangement incorporates additional work on Governance

Urgent address poor data quality issues
Summary of Main
Concerns
Summary of Urgent
Actions Required
Review the policy approval and dissemination framework to ensure that it is in line with best practice and understood by the organisation
Review of patient notes and the establishment of a template for formalised on-going monitoring and review of outcomes
Development of a coherent clinical strategy
Thorough review of all data quality issues with corrective action plan to address historic deficiencies and ensure future accuracy
Review PAS project to ensure delivery on time.
Medway Foundation Trust - Our improvement plan
Agreed timescale
March 2015
Revised deadline
(if required)
December
2015
March 2015
Progress against original timescale
• The Trust implemented a procedure for managing and developing policies. There is a current Policy Review Group however; with the revisions in governance framework, we are currently looking at a revised approach for policy sign off.
• Arrangements have been revised to improve visibility and ownership of policies at
Executive and Board level. Work is currently underway to streamline all policies with the aim of reducing the total number and making usability easier.
• Initial comprehensive notes review completed in August 2014 and acted upon by
Management. Additional notes review carried out by an external high performing
Trust- report received- action plan being compiled.
External Support/
Assurance required)
University Hospitals of
Birmingham case note review and review of PAS
Q3 2015-
2016
February
2015
On-going
August 2015
March 2015
• There is no overarching clinical services strategy document; the essence of such a strategy is captured through elements of the Trusts 18 month recovery plan and
CQC action plan.
• A strategic program office is being established to commence the development of the strategy in September 2015. This will now be set up in October due to delays relating to the CQC inspection .
• Strategy workshops took place on 5th October with key Trust members. Over the next 2 months we will be holding key stakeholder meetings to agree the strategic direction of the Trust.
PwC undertook a data quality review . Recommendations taken to address identified issues. All actions complete in relation to systems and processes in relation to RTT and
ED. Further reviews undertaken in relation to the i mplementation of the findings in review of cancer targets. Since the PWC review the Trust has developed a robust action plan in collaboration with the CCG’s. This plan is currently in the process of being implemented. Outcomes to date are; the Trust has set up a Cancer Board, improved pathways to prevent breaches and implemented new processes to improve validation of cancer data.
Action complete
• Review of mandated KPIs and data information system to commence June 2015.
Report to be completed July 2015. Additional request to review the first draft the week beginning 20.7.15.
• PWC have completed the work and will produce a draft report. This will be finalised and signed off by 31 st August 2015.
• The report has been signed off and a Business Intelligence Strategy is being developed that includes a Data Quality improvement plan. This will be reported to the Board in October 2015.
PAS ‘Go Live ‘,9 February 2015. PAS /OASIS go live date went ahead as planned .
OASIS system now live and in use within the hospital.
Action complete
PWC review of data quality
Deloitte review of PAS pre implementation status confirmed - agreed no key concerns or risks.
6

Medway Foundation Trust - Our improvement plan
Summary of
Main
Concerns
Summary of Urgent
Actions Required
Agreed timescale
Safe and effective staffing of all clinical areas by appropriately trained staff
Agree nursing establishments across the organisation and work with nursing leadership to staff consistently to these levels
April 2015
March 2015
Review consultant workforce in
Medicine to ensure appropriate medical input at all times, particularly in relation to ED and consultant cover over weekends
February 2015
July 2015
Address shortages in Junior
Doctor rotas
March 2015
Revised deadline (if required)
Progress against original timescale
External Support/
Assurance required)
• Signed off nursing establishments at Board in August 2014. Weekly monitoring of vacancies, fill rates, temp staffing usage and skill mix and other absences. Further nursing establishment report presented at board in May 2015.
• Strategy for recruitment and retention forms part of the 18 month improvement plan.
• Site safety reviews are taking place twice a day (9.30 and 19.30) to review staffing levels and skill mix .
• A buddying agreement with Guy’s and St Thomas’ Hospital has benefited close collaboration between the Trusts in regard to nursing and medical establishments.
Action complete
• Roll out of implementation of eRostering ensuring effective use of nursing workforce – is now rolled out to all wards. Proposed new establishment presented to the Trust Board June 2015. 90 wte added to the establishment.
University Hospitals of
Birmingham review of nursing
Homerton review of staffing and processes in
ED
GSTT Nursing Support
Health Education
England
ECIST
• Consultant job plans amended to ensure weekend cover and appropriate input into ED
• Consultant led ward rounds taking place seven days a week.
Action complete
• Consultant interviews in Medicine have taken place and appointments made.
• Discussions initiated with Health Education England to develop enhanced supervision programme for Junior Doctors, actions and enhanced opportunities for supervision and training to be agreed and in place March 2015
• Discussions have taken place with Health Education England, funding in place to take forward.
7

Summary of
Main Concerns
Summary of Urgent
Actions Required
Monitoring of HSMR at board to be strengthened
Medway Foundation Trust - Our improvement plan
Agreed timescale
Immediately improve oversight and understanding of HSMR at board
Ongoing
Ongoing
March 2015
August 2015
Revised deadline (if required)
Progress against original timescale
Mortality
• All maternal deaths are reported automatically as an SI and investigated accordingly. All Intra-Uterine Deaths are formally reviewed by the Bereavement Midwife, using a very comprehensive standardised methodology. Each fetal loss over 24/40 will also have a review carried out.
• Children services - mortality reviews monthly. Data on all infant deaths is entered into the MBRRACE-UK database which collates national data on both stillbirths and infant deaths and provides reports on statistics to each Trust. All deaths are then presented for discussion at Medway Child Death Overview Panel..
• Monthly Mortality information is reviewed and discussed by the
Board.
• A buddying agreement with Guy’s and St Thomas‘ Hospital is assisting with the development of clinical quality within the Trust.
• A Mortality Learning Coordinator was appointed on 7 th September.
The post holder will be responsible for the organisation, facilitation and dissemination of learning from the divisional mortality and morbidity meetings throughout the trust. The post holder will support the Quality, Governance and Improvement Lead in identifying policy changes and specific interventions; which will seek to improve the trust’s position within the published mortality indicators, by utilising evidence and learning from the divisional meetings.
• First Mortality group meeting has now taken place and the terms of reference were agreed. The mortality standardised template was discussed and a decision made that all specialities will now trial the template with the exception of neonates (as they have a robust process in place). This meeting will be an arena for shared learning across specialities from mortality reviews.
• Further analysis being undertaken by Methods Consulting to identify any further activities; in addition to those included in the Mortality
Action Plan which is reviewed at QI&CG monthly.
• Mortality Coordinators role approved and out to advert. Once the post is appointed to this will be recorded as complete.
• Successful appointment of Mortality Coordinators . Action complete staff in post.
External Support/
Assurance required)
New Buddying
Arrangement incorporates specific focus on mortality and patient safety
8

Medway Foundation Trust - Our improvement plan – Emergency Care Pathway Only
Summary of Main
Concerns
The safety and experience of patients attending ED and Acute
Medical and Surgical
Assessment Unit
The safety and experience of patients attending ED and Acute
Medical and Surgical
Assessment Unit
Summary of
Urgent Actions
Required
Review of entire emergency care pathway (from admission to discharge and including care outside hospital)
Review of entire emergency care pathway (from admission to discharge and including care outside hospital)
Agreed timescale
January 2015
Ongoing
March 2015
Ongoing from
11th September
2015
On-going
March 2015
May 2015
Ongoing
Revised deadline
(if required)
Progress against original timescale
• Dr Laurence Gant appointed for one year to implement improvement programme within the emergency patient pathway.
Action complete
• Review of emergency care pathway provided to October 2014 Board. 100 point action plan approved. Ongoing Board oversight (via 18 month Recovery
Plan Action Plan).
• Revised ED command and control and roles and responsibilities structures have been designed and rotas realigned to support increased clinical and nursing leadership.
• A revised Clinical work wear policy within ED supports the new structure to ensure clarity on shift roles..
• Realignment of the ED Consultant rota has provided increased depth of cover at required periods.
Action complete
• During the CQC Inspection in August 2015 (report yet to be received) issues were raised regarding patient safety within the Emergency Department. A system wide escalation to assist Medway NHS Foundation Trust was implemented, under a request for mutual aid. As part of this arrangement, a partial ambulance divert over two x four hour periods was put in place to allow a training programme (addressing the skill gaps identified during the inspection) to be implemented. In addition to this, the Emergency Department capacity escalation arrangements have also been revised.
• The MCAP (Managed Care Appropriateness Program) STREAM project has now concluded.
• Information from the project has provided the evidence to design new initiatives within Primary Care and Rapid Access Specialty follow-up.
Action complete
• New roles created within the Ambulance Handover process to assist with managing Ambulance handovers and patients in Majors.
Action complete
• A specific senior Administration role has been created to manage staffing rota’s across Nursing, Medical and A&C staff within the Emergency
Department
Action complete
• Recruitment process ongoing 24/7 Paediatric ED service.
External Support/
Assurance required)
University Hospitals of
Birmingham review
Homerton review of staffing and processes in
ED
ECIST
Royal College of
Emergency Medicine
Commissioners
9

Summary of
Main Concerns
Medway Foundation Trust - Our improvement plan – Emergency Care Pathway Only
Summary of Urgent
Actions Required
Agreed timescale
The safety and experience of patients attending ED and Acute Medical and Surgical
Assessment Unit
Review impact on elective and non elective surgical patients
Vanguard unit to be removed
Review of entire emergency care pathway (from admission to discharge and including care outside hospital)
On-going
August 2014
On-going
Ongoing to April
2016
October 2014
Address concerns regarding patient flow throughout the
Hospital.
May 2015
Revised deadline (if required)
Progress against original timescale
95% A&E target
October 2015
• GSTT assisting the Trust in reviewing the elective and non elective surgical pathways as part of the buddying arrangement
• Vanguard unit removed.
Action completed
• All agreed actions relating to Equipment Management within the 100 point plan have now been implemented and are under review.
• 50% of all actions on the ED Action Plan have been completed and the audit and review process for completed actions has now commenced.
• Quarter 1 performance against the Clinical Quality Indicator of 95% of patients seen within 4 hours was >92.5%
• The present position has deteriorated compared to Q1 and this is now the focus of new remedial actions.
• Aim to have a sustained position of 95% on the four hour target by
April 2016.
• Ambulance handover system in place to release ambulance crews rapidly, resulting in more than 70% reduction in handovers >30 minutes since January 2015.
• Since the beginning of April 2015, more than 95% of patients arriving by Ambulance were handed over in <30mins.
• Improved working relationship with SECAmb to improve the patient experience and clinical continuity during Ambulance Handover.
• Frailty project across health care sector has been launched. This has commenced with the Acute Trust providing a Specialist Geriatrician at the Front Door service for all admitted patients 80 years and over, from March 2015.
• The service is operational 5 days/week with clinician ,Specialist nursing and AHP support. Median length of stay is currently 8 days which represents a reduction of over a week against previous baseline length of stay
• 6 weekly review cycles are now in operation and the 7 day service pilot concluded in August is currently being evaluated
Action completed
• Discharge to assess pilot is beginning; initially for frail patient in mid-
September 2015 and will be overseen by community based health and social care services.
External Support/
Assurance required)
University Hospitals of
Birmingham review
Homerton review of staffing and processes in
ED
ECIST
Royal College of
Emergency Medicine
Commissioners
Medway and Swale CCG’s,
Local Community Health providers, Adult Social
Care – Medway & Kent
(Swale)
ECIST
10

Medway Foundation Trust - Our improvement plan – Emergency Care Pathway Only
Summary of Main
Concerns
The safety and experience of patients attending ED and
Acute Medical and Surgical
Assessment Unit
Summary of
Urgent Actions
Required
Agreed timescale
Review of the physical environment within ED and escalation areas in which patient care is being delivered
December 2014
March 2015
March 2015
March 2015
April 2015
May 2015
December 2015
August 2015
August 2015
Revised deadline (if required)
95% A&E target
Progress against original timescale
• Paediatric emergency department completed on time and opened.
Action completed
• Phase 1 Emergency Village (Accident and Emergency) rebuild work underway , marking the start of the reconfiguration of the
Department. Minors refurbishment commenced on schedule in
March 2015. Phase 1 due to be completed within a 9 month improvement programme and the project remains on schedule,
• Ambulatory care service has been relocated to be co-terminus with the Acute Medical Unit (AMU).
Action completed
• Real-time ED performance information now available on a large screen within the Majors area.
Action completed
• Clinical Decision Unit (CDU) operational in the Emergency Care
Pathway with strict admission criteria and senior Medical and
Nursing input to oversee clinical care.
Action completed
• Remodelling of ED environment to improve queuing and safety compliance.
• Reconfiguration of clinical and administrations areas within Majors to provide improved accessibility to shift leaders for shop-floor staff
Action completed
• As part of the 18 month recovery plan a project has been designed to review and improve discharge processes within the Trust; this includes working closely with partner organisations to develop pathways for discharge as appropriate.
• We are currently working to develop the implementation plan.
• Major progress has been made on physical environment (e.g. Pre operative assessment unit, closure of temporary unit, Medoc 24-7, ward upgrades)
• Unscheduled care – Revised Surgical Admission Unit (SAU) policy in place, increased leadership on SAU, reviewed Fractured Neck of
Femur pathway.
External Support/
Assurance required)
University Hospitals of
Birmingham review
Homerton review of staffing and processes in
ED
ECIST
Royal College of
Emergency Medicine
Commissioners
11

Medway Foundation Trust - Our improvement plan – Emergency Care Pathway Only
Summary of Main
Concerns
The safety and experience of patients attending ED and
Acute Medical and Surgical
Assessment Unit
Patients not being reviewed in the emergency department within 15 minutes of arrival
Summary of Urgent
Actions Required
15 minute assessment to be undertaken on all patients.
Agreed timescale
Revised deadline (if required)
September
2014
Ensure all equipment is in date and checked consistently
Ensure department is sufficiently staffed
March 2015
April 2015
September
2015
Progress against original timescale
• Over 95% of patients being reviewed within 15 minutes is now embedded and performance for this month has been maintained across all “arrival by” groups in Adults and Children’s ED.
• All initial assessments are recorded in real time and made available to shop floor and shift management staff.
• The FIAT breach code recording is operational recording reason for delay and impact on the patient . Non compliance with recording is a management issues. The FIAT breach recording is monitored daily by the Matron.
Action completed
• Equipment being checked on regular and appropriate intervals with regular auditing of compliance. Supported by the introduction of bespoke checklists, Matron of the Day rota and quarterly re-audit programme within ED -
Action completed
• Four band 8a Matrons are now in post with Matron of the Day active.
• The Band 7 Nursing establishment has been stabilised from the 2
March 2015 as a result of internal promotions.
• Improved multi-disciplinary structured handovers with 3 x daily board rounds within ED now embedded.
Action completed
• Senior staffing in ED has been revised and refined resulting in the introduction of a Band 8b Matron and a Practice Development
Nurse. The Band 8b Matron has been appointed and will commence in autumn 2015. The consultation process for the
Senior ED Nursing structure has now concluded other appointments will be advised in due course
Action completed
External Support/
Assurance required)
University Hospitals of
Birmingham review
Homerton review of staffing and processes in
ED
ECIST
Royal College of
Emergency Medicine
Commissioners
12

Medway NHS Foundation Trust - How our progress is being monitored and supported
Oversight and improvement action
Agreed Timescale for
Implementation
Action owner
Progress
13