North Cumbria University Hospitals NHS Trust :
Our improvement plan & our progress
Message from the Chair – Gina Tiller
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North Cumbria University Hospitals NHS Trust was identified as one of the 14 hospitals across the country because of higher than expected mortality
rates. As a result, the Prime Minister, David Cameron, requested Professor Sir Bruce Keogh, Medical Director of NHS England to fully review each
hospital trust. The purpose of the Keogh Review was to help those trusts identified as having a higher than average mortality ratio on their journey of
improvement.
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In May the review took place at North Cumbria and a risk summit was then held in June, with representatives from all of the health service and
regulators. This was to discuss what the review panel found during their visits and what urgent actions, over and above those actions already taken by
the Trust, needs to be accelerated.
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The Keogh review has provided us with further opportunities to really scrutinise our performance and approaches to patient care and we have
wholeheartedly welcomed the Keogh report and fully support its recommendations. What is clear now is that we are beginning on a long journey of
improvement at North Cumbria and the Keogh Review team clearly recognised this alongside the changes that have already been made, or are in
development, which will positively impact on patient care.
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This summary action plan provides a focus for short-term improvements on immediate issues. We envisage our improvement plan going beyond
Keogh deadline dates to ensure that when the Chief Inspector of Hospitals, Prof Sir Mike Richards inspects, that the Trust is ready. Once the actions
identified here have been completed, 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. (Please note that the Chief Inspector of Hospitals inspection commences North Cumbria
University Hospitals Trust from the 29th April 2014)
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Change will not happen overnight, nor will it be easy. But change must happen and must be, at all times, in the very best interests of patients. The
Trust’s focus as it begins this journey of improvement will be on:
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Putting the patient at the heart of everything
Supporting patients and staff to challenge the status quo
Investing in services for the long term
Developing staff to achieve a culture of continuous improvement.
The weaknesses highlighted by Keogh must be transformed into areas of strength so that North Cumbria can rebuild confidence in local hospital
services and, most crucially, regain the trust of local communities. To do this, the health system in Cumbria is committed to working much better
together. This will ensure that, collectively, there is a long and lasting impact on the way hospital services are provided which will ultimately make a
positive change on the health outcomes for people living in north Cumbria – something they rightly deserve.
We will continue to keep all of our stakeholders fully updated as we progress our safety and quality improvements. There will also be regular updates
on NHS Choices and subsequent longer term actions will be included as part of a continuous process of improvement.
North Cumbria University Hospitals NHS Trust :
Our improvement plan & our progress
What are we doing?
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In July 2013, the Keogh Review made recommendations in eight core areas to help improve the quality and safety of our services for patients in North
Cumbria.
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Specifically, the Keogh Review said that we need to:
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Carry out a full review of the Trust’s corporate risk, business assurance framework and quality governance plans
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Review leadership capability and develop a formal organisational development plan for all staff
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Ensure robust arrangements for serious incident investigations
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Review staffing levels to ensure safe care is delivered
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Ensure mandatory training is supported
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Promotion of a more supportive and open culture
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Review of estates capability and capacity
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Review infection control policies and practices with full organisational ownership
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This ‘plan & progress’ document shows how we already making these improvements and demonstrates how we’re progressing against the plan. This
document builds on the ‘Key findings and action plan following risk summit’ document which we agreed immediately after the review was published on
NHS Choices (click here)
While we take forward our plans to address the Keogh recommendations, the Trust is in ‘special measures’ and continues to work closely with the NHS
Trust Development Authority (TDA), with our acquisition partner Northumbria Healthcare NHS Foundation Trust and with NHS Cumbria Clinical
Commissioning Group (CCG). Oversight and improvement arrangements have been put in place to support changes required
Who is responsible?
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Our actions to address the Keogh recommendations have been agreed by the Trust Board
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Our Chief Executive Ann Farrar is ultimately responsible for implementing actions in this document. Other key staff include Dr Jeremy Rushmer who is
Interim Medical Director.
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Dr Dean Spencer from the NHS Trust Development Authority is supporting us to implement our actions for improvement
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Ultimately, our success in implementing the recommendations of the Keogh plan will be assessed by the Chief Inspector of Hospitals who will re-inspect
our Trust in the coming months.
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If you have any questions about how we’re doing, please contact ann.farrar@ncuh.nhs.uk
How our progress is being monitored and supported
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We will update this progress report on the first day of every month while we are in special measure and provide a monthly stakeholder update and
regular briefings as we implement changes. Progress on our improvement will be reported at our Trust Board meetings every month which are open for
the public to attend. (Timescale: From September 2013; Owner: Trust)
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Appointment of a senior representative by the TDA, who will provide expertise to the Trust Board and check that we're meeting our promises to deliver
our improvement plan. (Timescale: By October 2013; Owner: TDA).
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Access support from partnership working as appropriate with the Academic Health Science Network, NHS Improving Quality and the NHS Leadership
Academy. (Timescale: By April 2014; Owner: NHS England).
Signed by the Chair of the Trust
(on behalf of the Board)
Our improvement plan
This table shows the actions we’re taking to address the concerns about the quality of our services which were raised in the Keogh report. It
also shows how we are progressing against our actions.
Summary of Keogh
Concerns
Summary of Urgent Actions Required
Agreed
Timescale
External Support/ Assurance
1. Inadequate
governance, and pace
and focus of change to
improve overall safety
and experience of
patients
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Full review of the Trust’s corporate risk, business assurance framework and quality governance plans,
to include:
a. consolidation of key risks at a corporate level;
b. clinical business unit level .
End July 2013
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CQC to provide independent
review of appropriate CQC
outcomes to verify full
compliance.
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Full review of leadership capability and development of a formal organisational development plan for
all staff, to include:*
March 2014
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TDA to complete the review
of the Executive Leadership.
Development of
Organisational Development
Plan in conjunction with
Northumbria Healthcare
NHS Foundation Trust, NHS
Institute, Health Education
England, Kings Fund and
Monitor.
North Cumbria University Hospitals NHS Trust
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a. review of the leadership structure to ensure that the capability and capacity gaps are filled;
b. Implementation of a formal programme of organisational development and support for
management staff;
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Please note that there are serious issues regarding leadership gaps and capacity in many areas of the
Trust and this requires urgent attention to ensure we have the right people fulfilling the right
leadership roles.
March 2014
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Implementation of appropriate performance management system.
Sept 2013
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Pilot and evaluate 30% of wards.
March 2014
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New leadership team now in
place
New Chair appointed
DoN will take up position in
May 2014
Surgical BUD appointed and
will join the Trust in June
2014.
Northumbria Healthcare
NHS Foundation Trust to
confirm capacity to
implement a system for
Board to Ward performance
management.
Progress
B/G/R/
narrative
Summary of Keogh
Concerns
Summary of Urgent Actions Required
2. Slow and inadequate
responses to serious
incidents and a culture
which does not support
openness, transparency
and learning
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North Cumbria University Hospitals NHS Trust
Ensure robust arrangements for serious incidents investigations, to include:
a. Developing the serious incident investigations process, including a review of all
outstanding investigations.
b. Increase resources in the complaints team to ensure that all complaints are appropriately
responded to within 25 working days.
Agreed
Timescale
External Support/ Assurance
Oct 2013
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3. Staffing shortfalls and
other workforce issues
across both nursing and
medicine which may be
compromising patient
safety
TDA to approve
immediate actions
following never events
and recommend
appropriate support on
broader issues and how to
improve. TDA Quality
Team to provide capacity
support to conclude
outstanding reviews.
TDA to engage best
practice in complaints
handling from an
organisational perspective
and to identify additional
short term capacity to
clear backlog of
complaints.
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Review staffing levels to ensure safe care is delivered, to include:
a. Staffing arrangements in the Trust should be urgently reviewed to ensure they meet
minimum standards. Any review should be concluded rapidly to minimise the impact on staff
morale. The nursing review completed and reported to the ward managers and the Trust
Board in October 2013. A high focus on recruitment has resulted in more nurses working on
the wards but more are still required and we continue to take active steps
b. New Consultants have joined the Trust but we continue to have too many locums in our
medical teams (surgery team posts almost full) and so recruitment continues promoting a
North Cumbria service and more modern models of care which attract potential candidates
Oct 2013
Revised to
March 2014
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TDA to undertake a review
of staffing levels and
provide continuing
support on capacity and
capability issues.
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Ensure mandatory training is supported.
a. Staff should be allowed time to complete mandatory training.
b. Mandatory training programmes should be revisited to include a face-to-face element
where appropriate.
March 2014
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On track
Good progress made
Progress
B/G/R/
narrative
Summary of Keogh
Concerns
Summary of Urgent Actions Required
4. Lack of support for
staff and effective,
honest communication
from a middle and
senior management
level
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North Cumbria University Hospitals NHS Trust
Promotion of a more supportive and open culture, to include:
a. An increased emphasis on an open, honest and supportive culture throughout the Trust.
b. Introduction of a development programme for senior and middle management.
c. Implement Organisational Development Plan. The organisational development
programmes are positively received by the staff and developing confidence and skills to
support them deliver better quality. The better outcomes will be monitored and reviewed
by March 2014
Agreed
Timescale
External Support/ Assurance
Revised to
March 2014.
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CCG/AT to agree Quality
Standards.
NE Leadership Academy to
support senior clinical
leaders and develop
individuals into high
performing teams.
Northumbria Healthcare
NHS Foundation Trust to
work in partnership on the
consistent application of
professional standards to
address concerns raised
regarding individual and
team relationships e.g.,
bullying allegations.
5. Failure in governance
to ensure adequate
maintenance of the
estate and equipment
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Review of estates capability and capacity, to include:
a. an urgent review of the estates department to ascertain competence and capability,
including, an assessment of current arrangements relating to water management and
equipment maintenance.
b. an independent assessment of all theatres for compliance with relevant standards.
c. an urgent review of the Trust’s compliance status for the SSD and endoscopy, involving the
DIPC.
d. governance arrangements for decontamination should be reviewed, and form an integral
part of the Infection Control Committee agenda.
e. implement a formal, annual deep clean programme.
End September
2013
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TDA to approve action plans
prepared by the Trust in
response to the issues
raised, including, external
validation of all equipment.
6. Significant
weaknesses in infection
control practices
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Review infection and control policies and practices with full organisational ownership, to include:*
a. A review of infection control practices including the infection control policy,
implementation, governance and audits.
b. Adopt a more multi-disciplinary approach to infection control, including more involvement
from Estates.
c. De-clutter wards to allow better cleaning and an improved patient environment.
d. Urgently secure all drug fridges, and ensure food and drink are stored separately from
drugs. A regular audit programme should be introduced to monitor this.
End October
2013
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TDA infection control team
to provide external support
on best practice and assess
progress.
Northumbria Healthcare
NHS Foundation Trust
supporting the delivery of a
robust real time
performance management
system for the full range of
compliance standards.
*The outcome for this activity will ensure:
• 40% of wards are fully compliant with our infection control core bundle
• Perform at national average for healthcare aquired infection C.Diff
• Reducing levels of surgical site infections
Please note that we expect to be at 50% in December and 75% March
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Progress
B/G/R/
narrative
How we’re checking that our improvement plan is working
This table shows how and when we are checking that the actions we’re taking are making a real difference in our hospitals.
Oversight and improvement action
Timescale
Action owner
Monthly accountability meeting with Monitor/TDA to track delivery of
action plan.
Aug 2013 to July 2014
Trust chief executive
Partnership working with Northumbria Healthcare NHS Foundation
Trust to help embed best practice in North Cumbria and improve the
quality and safety of care
From July 2013
Trust chief executive
Appointment of senior representative from the TDA, who will provide
expertise to the Trust Board and check that we’re meeting our
promises to deliver our improvement plan.
September 2013
TDA
Meetings of the Trust Board – every two months we openly report
progress on the Trust action plan and improvements which are being
made to quality and safety.
Monthly – from July 2013
Trust chair
Regular updates for stakeholders and the public about how the Trust is
improving via briefings to local media and meetings of our shadow
council of governors.
Ongoing / monthly –
from July
Trust chief executive
Agreement and regular reporting of quality measures to demonstrate
that the actions are leading to improved quality of care for patients
Monthly from July
Trust chief executive
An external quality governance review was carried out in July 2013 and
reported to the Trust board with work ongoing to complete
recommendations.
Quarterly
Trust chief executive
Scrutiny of our new ways of working and of the quality of our services is
delivered by a Quality Surveillance Group (QSG) composed of the Trust
CE, NHS England Area Team, CCGs as well as Northumbria Healthcare.
Sept 2013 to July 2014
Trust chief executive /Special
Measures Director/AT/CCGs
Re-inspection
Early July 2014
CQC
Key for progress reports
Blue -delivered
Green – on track to deliver
Narrative – disclose delays/risks/plan to recover
Red – not on track to deliver
Progress