Trust Board Meeting: Wednesday 13 May 2015
TB2015.65
Title
CQC Inspection Action Plan Update
Status
For discussion
History
CQC Compliance Action Plan has been presented to:
•
Trust Management Executive, 12 June and 24 July 2014
•
Quality Committee, 11 June 2014
•
Trust Board, 9 July 2014
The ‘Should Do’ / Advisory Action Plan has been presented to:
•
Trust Management Executive, 24 July 2014
•
Quality Committee, 13 August 2014
•
Trust Board, 10 September 2014
A combined report in relation to progress on both action plans has
been presented to:
Board Lead(s)
Key purpose
•
Trust Management Executive, 28 August, 23 October and 27
November 2014, 12 February and 23 April 2015
•
Trust Board, 12 November 2014
•
Quality Committee, December 2014, February, April 2015
Eileen Walsh, Director of Assurance
Strategy
TB2015.65 Update on CQC Action Plans
Assurance
Policy
Performance
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Oxford University Hospitals
TB2015.65
Executive Summary
1. As previously reported to the Board, the Trust’s action plans in relation to the ‘Must Do’ and
‘Should Do’ recommendations raised in the Care Quality Commission’s (CQC) reports, are
being monitored by the Assurance Team
2. Progress to date with regard to both action plans is summarised in this report.
3. Recommendation:
The Board is asked to:
•
Review and note the progress made to date.
TB2015.65 Update on CQC Action Plans
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Oxford University Hospitals
TB2015.65
CQC Inspection Action Plan Update
1. Introduction
1.1. The Care Quality Commission (CQC) conducted an inspection of the Trust on the 25th
and 26th February 2014 and as a result of the visit action plans were developed and
submitted to CQC. The Assurance Team are monitoring progress against each of the
actions and collating the supporting evidence.
2. ‘Must Do’ Action Plan
2.1. A regular update of the agreed ‘Must Do’ action plan is provided to the Trust Management
Executive in order that progress may be monitored against the plan. As the majority of
actions have now been completed the overall progress to date is provided in the chart
below.
2.2. The information in this report relates to activity up to 5th May 2015.
2.3. The table below provides information on all those actions which have been noted as not
yet completed.
Action
Action description
number
Areas for collaborative action
1.1
with partners
Improved integration of care
pathways
across
hospital,
community, primary care and
social care services to improve the
ability to manage patients in the
clinically appropriate setting.
1.2
Change outpatient’s system from
choose & book to directly
bookable system (DBS).
2.1
Action update
Timeframes linked to the Trust Business
Plan 2014/15-2019/20
This is a long term action which is
monitored via the business plan process
Due for completion by 31 July 2015.
Update on Outpatient Projects paper
(FPC2015.22) presented to F&PC on 15th
April. NB DBS actions are on hold as the
roll out has been suspended to resolve
certain system issues.
Implement the remaining aspects Action delayed from 31st July 2014.
of the Maternity Staffing Business Interviews have taken place and posts
Plan agreed by TME in 2013. This offered. Action will be closed once
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Oxford University Hospitals
TB2015.65
Action
Action description
Action update
number
includes recruitment of four WTE receptionists in post.
ward receptionist posts.
5.3
Recruitment
into
substantive
theatres and sterile services
manager vacancy and deputy
theatre manager vacancy (Clinical
Support Service Division)
Action delayed from 30th September 2014
to Q4 2014/15.
The Theatre & Sterile Services Manager
and two Deputy Manager posts remain
vacant; however there is an Interim Theatre
Manager in post providing a high quality,
effective senior presence into the TASS
Directorate. The substantive Business &
Performance Manager commenced in their
role on 13 April. As a result of the lack of
progress in attracting applicants to a range
of roles the Division has reviewed the
structure and will present this to the
Director of Clinical Services within the next
week. All Band 7 Sister roles are filled
substantively.
Continue to support the four
student Supervisor of Midwives
(SOM’s) to complete the
programme, thereby ensuring from
September the caseload ratio will
be 1:18.
Timeframe extended from 30 September
2014.
The Nursing and Midwifery (NMC) Council
decided on 28 January 2015 to accept the
recommendation from the recent report
‘Midwifery regulation in the United
Kingdom’, that statutory supervision should
no-longer be part of its legal framework. In
the light of this future legislative change, the
Trust is reviewing the actions and revised
actions will be formulated in due course.
To further address this, support
will be given to six OUH midwives
to attend the programme in
2014/15 to improve the ratio to
1:16 (dependent on leave /
turnover).
6.2
3.
Increase the number of urgent Timeframe extended from 31 December
bookable lists from two to four per 2014
week.
There are currently three urgent bookable
lists with a twilight list being worked upon.
‘Should Do’ Action Plan
3.1. The Assurance Team have been monitoring progress to date. To summarise the current
position in relation to the 118 actions: 109 actions have been completed on time; one
action was completed late; six actions are on plan and two actions (SD01) were ‘off plan
beyond completion date’. All actions were discussed at the Trust Management Executive
meeting on 23 April 2015.
3.2. The table below provides information on all those actions noted as not yet completed.
Action
Action description
number
SD01
Action update
Progress the business case initiation proposal Timeframe extended from 31st
for the relocation of Respiratory Services, March 2015 into 2015/16
including outpatients, to the John Radcliffe. capital programme.
(£100k
allocated
in
2014/15
Capital
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Oxford University Hospitals
Action
Action description
number
Programme
Progress the business case initiation proposal
for the relocation of the Clinical Genetics
Department, comprising outpatient and office
accommodation (£500k allocated in 2014/15
Capital Programme)
SD02
and
SD31
SD03
(CH)
SD30
(JR)
SD19
(NOC)
SD 39
TB2015.65
Action update
Business case presented to
TME on 23 April 2015
(TME2015.107) on Respiratory
Relocation of inpatient and
Cystic Fibrosis Services.
Timeframe extended from 31st
March 2015 to into 2015/16
capital programme.
Discussed at TME on 23 April
2015 as part of TME2015.106
Business Case Pipeline paper.
A range of options for
relocation have been critically
reviewed. Feasibility studies
are now in train with respect to
a relocation on the NOC site.
Joint discharge analysis (OUH and Oxford Due
for
completion
by
Health) including the analysis of patient 31/07/2015
feedback regarding their discharge experience
This action links to the Urgent
Care
Improvement
Programme and is being
monitored via the Trust
Management Executive.
Diabetes Business Case Implementation Plan
The implementation plan is
is in place and subject to active monitoring at
due
to
complete
by
the Trust Management Executive.
30/09/2015.
A positive update on Diabetes
Care was provided to the
Quality Committee in April
2015
and
the
Trust
Management Executive on 23
April 2015.
The matron for adult critical care continues to
work with the Lead Nurse of the Patient
Pathway Co-ordinator Team to work through
issues leading to patients being slow to transfer
from critical care.
Action on-going. This action
links to the Urgent Care
Improvement Programme and
is being monitored via the
Trust Management Executive.
4. Next steps
4.1. An update on progress will be provided to the Care Quality Commission at the quarterly
meeting with the Trust in June 2015.
4.2. The Assurance Team will continue to monitor progress and report regularly to TME. The
Committee is requested to note that updated reports are subject to regular review by TME.
5. Recommendations
5.1. The Board is asked to:
•
Review and note the progress made to date.
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Oxford University Hospitals
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Clare Winch
Deputy Director of Assurance
May 2015
Report prepared by:
Lucy Parsons
Accreditation & Regulation Manager
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