Special Measures Action Plan
Sherwood Forest Hospitals NHS
Foundation Trust
September 2014
KEY
Delivered
On Track to deliver
Some issues – narrative disclosure
Not on track to deliver
1
Sherwood Forest Hospitals - Our improvement plan & our progress
What are we doing?
•
The Trust entered the special measures programme and was selected following the higher than expected mortality rates at the Trust at the time, these are now
within the expected range
•
The Trust has been given a variety of recommendations. The initial Keogh Rapid Response Review identified 23 actions, 13 of which were classed as urgent. All
these actions were deemed either Assured or Partly Assured by the Keogh Assurance review in December 2013. Subsequently the Trust has been re-inspected by
the CQC, April 2014, who recommended to Monitor that the Trust remain in Special Measures for a further 6 months
•
The Trust agreed an initial summary action plan to deal with these. The Trust has developed an action plan to address the issues raised in the CQC report and
combined these with the actions from the Keogh review recommendations. We recognised all of the recommendations and are addressing them through current
actions being taken to improve the quality of services. We envisage that improvements will be implemented and sustained in order for the Trust to be removed from
Special Measure when re-inspected by the Chief Inspector of Hospitals. The Trust will set out a longer-term plan to maintain progress and ensure that the actions
lead to measurable improvements in the quality and safety of care for patients.
•
The key themes of these recommendations are summarised by the headings below:
•
Strengthen assurance processes and outcomes
•
Leadership
•
Accountability
•
Safe
•
Effective
•
Caring
•
Responsive
•
Well - led
•
This document shows our plan for making these improvements and demonstrates our progression against the plan. While we take forward our plans to address the
recommendations, the Trust is in ‘special measures’.
•
Oversight and improvement arrangements have been put in place to support changes required. Weekly Quality Improvement meetings, chaired by the Director of
Nursing monitors the milestone plan and the outputs from task and finish groups. Evidence is submitted to provide assurance the action has been implemented.
Monthly reports to Trust Management Board, Quality committee and Trust Board ensure oversight of the implementation.
•
This document represents the Trusts initial response, detailed actions and progress. The Trust has a process in place to develop these over the coming months to
give a more holistic view of improvements, demonstrating increased consistency and accountability together with reductions in variation.
2
Sherwood Forest Hospitals - Our improvement plan & our progress
Who is responsible?
•
Our actions to address the CQC Report recommendations have been agreed by the Trust Board.
•
Our Chief Executive, Paul O’Connor ultimately responsible for implementing actions in this document. Other key staff are Executive Medical Director and Executive
Director of Nursing, as they provide the executive leadership for quality, patient safety and patient experience.
•
The Improvement Director assigned to Sherwood Forest Hospitals NHS Foundation Trust is Gillian Hooper, who will be acting on behalf of Monitor and in concert with
the relevant Regional Team of Monitor to ensure delivery of the improvements and oversee the implementation of the action plan overleaf. Should you require any further
information on this role please contact specialmeasures@monitor.gov.uk
•
Ultimately, our success in implementing the recommendations of the CQC Trust wide 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 Kerry Rogers, the Trust’s Director of Corporate Service on 01623 622515 Ext 4007, or email kerry.rogers@sfhtr.nhs.uk
How we will communicate our progress to you
•
We will develop and 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.
Chair / Chief Executive Approval (on behalf of the Board):
Chair Name: Sean Lyons
Signature:
Date: 1st September 2014
Chief Executive Name: Paul O’Connor
Signature:
Date: 1st September 2014
3
Sherwood Forest Hospitals - Our improvement plan
Summary of
Main
Concerns
Strengthen
assurance
processes and
outcomes
Leadership
Accountability
Summary of Urgent Actions Required
Maintain Non Executive Director (NED) to Executive 3 monthly
Confirm and Challenge
Recommence NED formal and informal ward / department visits
Agree new Board Assurance Framework (BAF) at September
Trust Board
Re-fresh corporate risk register in line with new BAF
Embed the new process for Management of Serious Incidents
Ensure existing plans to improve clinical productivity, transform
service delivery and ensure quality improve are complimentary,
robust and sustainable
Self- assessment against the new Monitor guidance ‘Well-led
framework for governance reviews’
Review Board effectiveness
Continue planned Board Development programme
Commence Executive Team development supported by East
Midlands Leadership Academy, followed by Executive ‘Team
Coaching.
Evaluate buddying arrangement s c/o Newcastle
Executive accountability matrix agreed
Nursing & Midwifery:
All ward areas have Care & Comfort Boards in place
Accountability DVD produced
Standardised accountability handover record keeping introduced
Standard operating procedure for accountability handover agreed
Resource pack developed and 8 Practice Development Matrons
recruited supporting all ward areas with implementation
Agreed
timescale for
implementation
External
Support/
Assurance
Progress against
original timescale
Revised
deadline (if
required)
On track to deliver
Oct 14 – Mar 15
Sept 14 – Mar 15
May – Sept 14
Sept – Nov 14
July – Dec 14
Oct 14
On track to deliver
Dec 14
Sept – Dec 14
Sept 14 – Mar 15
Sept 14 – Mar 15
Feb 14 – Mar 15
Completed
On track to deliver
July – Sept 14
July – Sept 14
July – Sept 14
July – Sept 14
July – Sept 14
4
Sherwood Forest Hospitals - Our improvement plan
Summary of
Main
Concerns
Summary of Urgent Actions Required
Agreed
timescale for
implementation
Improve sharing and learning across the organisation
Aug – Dec 2014
Ensure accurate record keeping, particularly in relation to
observations hydration and drug administration
Aug - Dec 2014
Improve the storage of medicines within ED and Medicine and
ensure the Trust has a secure system for storing medicines.
Aug – Sept 2014
Reduce medicine omissions ensuring patients receive critical
medicines according to the prescribed times and prescriptions
Aug – Dec 2014
Improve the recognition of the deteriorating patient reducing the
risk of failure to rescue, whilst improving safety and outcomes for
patients
Nov 2014
Improve the Mandatory Training compliance rate
Oct – Dec 2014
To embed the WHO checklist, particularly the briefing before and
after surgery
July 2014
External
Support/
Assurance
Progress against
original timescale
Revised
deadline (if
required)
Safe
Ensure safe and sustainable staffing across the Trust
Effective
On track to deliver
Sept – Nov 2014
Final
implementation
March 2016
Standardise Care Pathways – protocols for transfer, escalation
policies for ED and clinical.
Sept - Oct 2014
Undertake comprehensive pathway review through elective pathway
transformation programme
June – Dec 2014
On track to deliver
Training in practice – identify appropriate metrics of how staff use
their knowledge from training to improve the quality of patient care
Oct 2014
Review appraisal documentation and data collection
Oct – Nov 2014
Implement End of Life Care Guidelines and plans
Aug - Dec 2014
5
Sherwood Forest Hospitals - Our improvement plan
Summary of
Main
Concerns
Summary of Urgent Actions Required
Agreed timescale
for
implementation
Caring
Improve the response rates for Family and Friends
June – Sept 2014
Responsive
Improve the complaint response times
Oct 2014
To be more responsive by reducing the delays in discharge
Sept 2014 – Jan
2015
External
Support/
Assurance
Progress against
original timescale
Revised
deadline (if
required)
On track to deliver
On track to deliver
Well-led
Achieving consistently and sustaining all Referral to Treatment
Times
Aug – Dec 2014
To improve patient experience within outpatients, addressing in
particular communications from the Trust, minimising cancellations
and ensuring the availability of all patient information for
appointments
Oct 14 – Mar 2015
To address concerns raised in relation to the provision of clinical
administrative support
June – Sept 2014
Improve communication between staff and management through
the implementation of robust communication and feedback networks
Sept – Dec 2014
Undertake a trust wide cultural assessment
Jul - Nov 2014
Enshrine Quality for All behaviours in all that we do - cascade
values and behaviours into the trust
Oct – Dec 2014
Effective Board Working and Engagement - implementing Board
and governor training and development programmes
Aug - Dec 2014
Implement trust wide Leadership development strategy
Sept – Dec 2014
On track to deliver
6
Sherwood Forest Hospitals - How our progress is being monitored and supported
Oversight and improvement action
Agreed Timescale for
Implementation
Action owner
Replacement Improvement Director appointed
August 2014
Monitor
Delivered
Ensure existing plans to improve clinical productivity, transform service delivery
and ensure quality improve are complimentary, robust and sustainable
Oct 2014
T C Exec
On track to deliver
Progress
7