Special Measures Action Plan
Hinchingbrooke Hospital
30 March 2015
KEY
Delivered and evidenced
Delivered
On track to deliver
Not on track to deliver
Hinchingbrooke Hospital – Our Improvement Plan & our progress
What we are doing?
The Trust was rated as Inadequate following a CQC inspection visit on 16-18 September 2014 and 2 unannounced
visits on 21 and 28 September 2014. The CQC carried out a comprehensive inspection of the acute core services
provided by the Trust as part of the Care Quality Commission’s new approach to Hospital inspection. An Action Plan
was developed to respond to the 7 Compliance Actions and Must Do and Should do recommendations as below
Compliance Action 1 - Staffing
Compliance Action 2 - Care and Welfare of People
Compliance Action 3 - Assessing and Monitoring
Compliance Action 4 - Safeguarding People
Compliance Action 5 - Infection Control
Compliance Action 6 - Respecting and Involving People
Compliance Action 7 - Records
Must Do and Should Recommendations
19 Must do’s
12 Should do’s
Accountability for actions within each Compliance Area has been assigned to a named Executive Director to support
implementation and change of pace. Each area has named responsible officers to deliver the change.
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The Trust weekly Quality Improvement Steering Group Meetings continue to provide a check and challenge.
Monthly Oversight Meetings are in place led by the TDA core members include the CCG, Health watch, Local
Councillors, NHEE and the Trust Executive Board.
Hinchingbrooke Hospital – Our Improvement Plan & our progress
Who is responsible?
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•
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Our actions to address the recommendations made by the CQC have been agreed by the Trust Board
Our Chief Executive, Hisham Abdel Rahman, is ultimately responsible for implementing actions in this document.
Other key staff are Deirdre Fowler, Director of Nursing, Catherine Hubbard, Medical Director, who will provide the
executive leadership for quality, patient safety and patient experience.
The Improvement Director has not yet been announced, but is expected to be in place by the 1 April 2015. The
improvement Director will be acting on behalf of the TDA to ensure delivery of the improvements and oversee the
implementation of the action plan summarised overleaf.
Helen O’Connor was appointed in 5 January 2015 as the Deputy Director for Infection Prevention and Control and
Quality Improvement.
A second unannounced inspection by the CQC took place 2 January and the Trust is currently awaiting the report to
be completed following factual accuracy.
Ultimately our success in implementing the recommendations of the CQC Composite Action Plan will be assessed by
the Chief Inspector of Hospitals, upon re-inspection of our Trust.
For any initial questions you may have on how and what we are doing, please feel free to contact Anne Senior,
Hinchingbrooke CQC Project Manager by email on annesenior1@nhs.net or calling her on 01480 418744 and she
will take your concerns or queries to the appropriate person or PALS on 01480 428964 / hch-tr.pals@nhs.net
How will we communicate our progress to you?
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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.
Chair/Chief Executive Approval (on behalf of the Board
Chair Name:
Signature
Date
Chief Executive Name : Hisham Abdel Rahman
Signature
Date
CQC Composite Action Plan as at 30 March 2015
CQC Composite Action Plan
% Complete
KEY ISSUE
1
Staffing
70%
2
Care and Welfare of People
39%
3
Assessing and Monitoring
55%
4
Safeguarding people
71%
5
Infection Control
88%
6
Respecting and involving people
40%
7
Records
MD
Must Do
57%
SD
Should Do
76%
CQC CAP - March
Reported in Compliance Action 2
60%
Hinchingbrooke Hospital – Our Improvement Plan
Summary of main
concern
Outstanding
Compliance Action 1
– Staffing
• Nursing Levels
• Paediatric Nurses
• Doctors
• Palliative Care
QELCA - Quality
End of Life Care
for All
Summary of action and progress to date
• A large scale skill mix review undertaken and presented to the
Board.
• Workforce Plan for Nursing Staff and a further document which
includes Medical Staff.
• NHS IQ 7 day Self Assessment submitted
• Medical Engagement Scale work ongoing
• Medical Director post outwith control of Trust
Nursing Levels
• Each ward reviews their nursing levels three times a day and
staffing flexed accordingly to meet patient dependency/acuity.
• Nursing levels reported monthly to the Board via Safer Staffing
returns and Unify.
• Finalised the recruitment of 16 international nurses who are
schedule to start on the wards from Monday 23 March 2015
• Further recruitment campaign in Europe and Philippines is
currently being planned.
Paediatric Nurses
• recruited 2 x Paediatric Nurses to ED with further recruitment
taking place.
• Risk Assessment completed to provide Paediatric cover from
07.30 to 12:00,
• Holly ward covering outside these hours.
• SLA with CCS under review with amendment to contract to
formalise this arrangement and implementation of a
programme of rotation
Palliative Care
• currently provides a 24 hour consultant on call service and a 7
day 9-5 face to face specialist nursing service.
• 24 Hours on call/consultant service is already provided by SLA
with local hospices.
• Qelca training currently being undertaken
• Business Case for improved provision was discussed at
Integrated Board on 27 Feb 2015.
Timescale for
Implementation
Complete
External
Support/
Assurance
% Progress
against
original
timescale
CCS SLA
Complete
Complete
30 June 2015
N/A
31 March 2015
Ongoing
Ongoing
30 June 2015
14 Feb 2016
Complete
70%
Revised
deadline
(if
required)
Hinchingbrooke Hospital – Our Improvement Plan
Summary of
main concern
Outstanding
Compliance
Action 2
Care and Welfare
of People
Summary of action and progress to date
Documentation
Task and Finish Group in place undertaking a review of
Documentation should be finished by June. 2015 This work is led by
Helen O’Connor.
Training
The following Training has been added to the Core Induction
Programme
• Documentation
• Indwelling catheters
• Recording of Water low
• VIP Scores
• Pressure ulcers
DHON’s supporting with all training on wards. Training Needs
Analysis with Training Trajectory will provide progress reports.
Ward Handover
• Revised Ward Handover process in place – Handover moved
from the bedside to enable a more thorough handover in
confidence with effect from March 2015.
• SBAR Training plan in place
SKINN Initiative
• Infection control initiative SKINN launched and continuing across
the Trust for all staff groups.
Communications with Staff
• registered letter of expectation sent to all nursing staff in
January 2015 outlining roles and responsibility in particular on
achieving standards of dignity and respect.
• Catherine Hubbard ,Medical Director send an email to all
Medical Staff in February 2015.
Patient Experience Strategy
• Developed in partnership and adopted by Trust in March 2015
Dementia Strategy
• drafted and evaluated ,though the decision to take this to a
wider stakeholder group to ensure it meets the needs of patients
and organisations supporting dementia outside the Trust has
been taken
Timescale for
Implementation
External
Support/
Assurance
% Progress
against
original
timescale
31 Dec 2015
30 Jun 2016
31 Jul 2015
Complete
Complete
Complete
Complete
Complete with
further actions
39%
Revised
deadline (if
required)
Hinchingbrooke Hospital – Our Improvement Plan
Summary of main
concern
Outstanding
Summary of action and progress to date
Compliance Action 3
Assessing and
Monitoring
Full time Senior Leadership
• Frances Carey - Director of Governance and Risk
appointed to FTC 23 October 2015
Good Governance Review
• GGI undertook a review of governance of the Trust in
December 2014.
• recommendations have been converted into an action
plan,
• Action Plan currently being implemented across the
Trust
• PDCA cycle is scheduled for March 2016
Review and Revise Complaints Process
• Complaints process has not been reviewed due to the
transition of Circle out of the Hinchingbrooke
partnership.
• Complaints policy was written in line with Circle
Operating Systems
• This action has been suspended until the revised
structure and leadership of the Trust has been approved.
Seek Level of Assurance via Internal Audit BDO
• Internal audit by BDO was undertaken in December
2014.
• findings from this review was presented at the Audit
committee on 17 March 2015.
Timescale for
Implementation
External
Support/
Assurance
% Progress
against
original
timescale
Revised
deadline (if
required)
Complete
Complete
30 Mar 2016
55%
Suspended
Complete
TBA
Hinchingbrooke Hospital – Our Improvement Plan
Summary of main
concern
Outstanding
Compliance Action 4
Safeguarding People
Summary of action and progress to date
Mandatory Training
• Mandatory training on the Mental Capacity Act and
Deprivation of Liberty Safeguards commenced in
October 2014. with a target of 90% by the end of
November 2015.
• As at the end of February there were 26% of staff
trained with a further 3 training courses scheduled for
March 2015.
External Review of Adult Safeguarding Procedures
• In November 2014 the Trust commissioned Nottingham
University Hospital to undertaken a review of Adult
safeguarding procedures at the Trust.
• Report received with recommendations implemented
across the Trust in Feb 2015.
• A further review by NUH has been scheduled for June
2015.
Ongoing programme of Adult Safeguarding Audits
Standing Order Procedure in place to commence a
programme of audits across the Trust led by the Trust Adult
Safeguarding Lead.
Timescale for
Implementation
External
Support/
Assurance
% Progress
against
original
timescale
30 Dec 2015
Complete
NUH
71%
8 June 2015
Complete
(end of first cycle
28 Feb 2015)
Revised
deadline (if
required)
Hinchingbrooke Hospital – Our Improvement Plan
Summary of main
concern
Outstanding
Compliance Action 5
Infection Control
Summary of action and progress to date
Senior Leadership in Infection Control Prevention Team
Deputy Dipc Helen O’Connor appointed into Trust on a
substantive contract in October 2014.
Interim arrangements put in place with support of CCS prior
to start date of substantive post holder.
Substantive Microbiologist
• Locum recruited to post
• Recruitment process undertaken.
• Position offered and subsequently withdrawn
• Recruit with PHE post
Infection Control initiatives
• Hand Washing Programme Secret Shoppers
• Stop the BUG Campaign
• Appreciative enquiry visit – 5 March 2015
• outcomes of which have been developed into an
action plan
• Actions have been implemented across the Trust
Timescale for
Implementation
External
Support/
Assurance
% Progress
against
original
timescale
Complete
Complete
CCS
28 Feb 2015
Ongoing
88%
Unison
Ongoing
Complete
Complete
Revised
deadline (if
required)
Hinchingbrooke Hospital – Our Improvement Plan
Summary of main
concern
Outstanding
Compliance Action 6
Respecting and
Involving People
Summary of action and progress to date
Timely response to Call Bells
• Audit of call bells undertaken on wards which will
continue on a quarterly basis to ensure compliance with
response times.
• standard response time of two minutes set,
• audit checking the feasibility of standard.
Food and Drink Charts and Support Workers
• Nutrition Nurse has led on the work to ensure food and
drink charts are completed effectively
• Volunteer Lead and the Patient Experience Lead trained
workers who can assist patients with additional support
at mealtimes
Mandatory Training
• Trust training programme has been amended to include
nutrition and hydration training as mandatory.
Intentional Rounding
• Intentional rounding document reviewed, revised and
relaunched across the Trust.
• Document reviewed by all nurses including, PU Nurse,
Nutrition Nurse and Adult Safeguarding lead to ensure
document meets requirements of all areas.
Recording of Nutritional Assessment
• Nutrition audit tool being developed led by the Nutrition
Nurse to enable effective assessments to be made of
compliance.
• Quarterly audits agreed.
Patient Experience Strategy
• Strategy in Place
• Launch across the Trust
• Audit Effectiveness of Strategy
Compassionate Practice Strategy ( 6 C’s)
• Compassionate Practice Strategy being developed
Timescale for
Implementation
External
Support/
Assurance
Progress
against
original
timescale
Complete
30 June 2015
Complete
Complete
30 June 2015
Complete
30 June 2015
40%
Revised
deadline (if
required)
Hinchingbrooke Hospital – Our Improvement Plan
Summary of main
concern
Outstanding
Summary of action and progress to date
Compliance Action 7
Records
This compliance action is being actioned, monitored and
reported via compliance action 2
Timescale for
Implementation
External
Support/
Assurance
Progress
against
original
timescale
Revised
deadline (if
required)
Hinchingbrooke Hospital – Our Improvement Plan – Must Do’s
Summary of main
concern
Outstanding
Summary of action and progress to date
Improve and Drive an
open Culture with
the Trust for Safety
of the Patients
Stop the Line Process revised and relaunched
Datix – Member of staff in place to roll out
Trust Whistleblowing Process approved and launched
Trust Governance Structure reviewed
Many initiatives in place in. Joint meetings in place.
Strategic Workforce Plan produced
Improve Medicines
Management
Medicines Security
• All drug fridges locked and temperature checks done
• All drug cupboards locked
• IV fluids stored in tamper proof areas
Medicines Administration
• Expert advice and guidance received from TDA Chief
Pharmacist
Releasing “Time to Care – Medicines “ being developed
across all wards.
Ensure that all
appropriate staff are
adequately
supported through
appraisal, supervision
and training to
deliver care to
patients
Development of Maximising Work force Plan
Development of Workforce and Engagement Strategy
Launch and roll out new Appraisal System
Clinical supervision opportunities
Work in partnership with Staff Side
Training Needs Analysis includes:
• Breaking bad news/difficult discussions
• Caring for people with dementia
Ensure all patients
receive a timely
referral to Palliative
Care Service
Amber Care
Teaching and implementation of Amber Care Programme
for all wards in place. Amber Care training has been part of
mandatory/ Induction training for the last 18 months.
End of life Policy
In place with strong links to Macmillan and local hospice.
Business case developed to strengthen service increasing
consultant on site support.
Timescale for
Implementation
External
Support/
Assurance
Progress
against
original
timescale
Complete
Complete
Complete
Comp Action 3
Ongoing
30 April 2015
Complete – Audit
checks in place
Complete – Audit
checks in place
Monthly incident
reviews – ongoing
31 June 2015
31 Aug 2015
30 April 2015
ongoing
Complete
Complete
Complete
Complete
57%
Revised
deadline (if
required)
Hinchingbrooke Hospital – Our Improvement Plan – Should Do’s
Summary of main
concern
Outstanding
Summary of action and progress to date
Review the checking
o f Resus Equipment
across the Trust
Policy reviewed and relaunched
Process reviewed and refreshed in ED
Work continuing to strengthen the audit cycle
Strengthened nursing leadership in ED
Take action to ensure
that when Pre alert
telephones are
received in ED that
action is taken to
ensure a timely
response
Standing Operating Procedure review – no change
Notification from East of England Ambulance Service no
issues
No further action to be taken
Review the
environment for
having difficult
discussions
Facilities review, report and business case to be presented
to board with proposals for creating rooms to enable
suitable environment for breaking bad news across the
Trust ( including ED)
Review Translation
Services in Trust (
especially ED) to
ensure that patients
receive information
appropriate to their
needs
Translation services reviewed across the Trust and
refreshed information sent out to all departments. HHCT
website amended to include provision for availability of
information in other languages. Monthly usage report
presented at Patient Experience Group
Discontinue practice
of using day rooms as
additional bed spaces
Review complete and change of use to Day room on Apple
Tree established. Review of internal bed escalation policy
undertaken thereby protecting day room space across the
Trust.
Review the Clinical
pathways for TOPS in
the Acute Medical
Ward
Report received though further work required before
presentation to Board.
Timescale for
Implementation
External
Support/
Assurance
Progress
against
original
timescale
Revised
deadline (if
required)
Complete
Complete
TBA
Complete
Complete
March 2015
76%
Complete
01 April 2015
28 Feb 2015
30 April
2015
Hinchingbrooke Hospital – How our progress is being monitored and supported
Quality Improvement Steering Group
Ensure that Letter to all staff is included in orientation pack for
agency staff. Copy to be sent to ID Medical
HR to formally write to ID Medical to advise that any agency
nurse who is unwilling to distribute medicines will be reported
through the incident reporting system
Discuss Catheter Care Bundles with Wendy Durham and Helen
O’Connor
Revisit back boards of bed to make accessible
Contact Sue Jarrett to request date for availability of financial
information
When will training trajectory be available for oversight meetings
Timescale for
implementation
Action Owner
Progress
HR Director
OUTSTANDING –
Escalated to
Associate Director of
Nursing, Midwifery
and Quality
5 Feb 2015
HR Director
OUTSTANDING –
Escalated to
Associate Director of
Nursing, Midwifery
and Quality
5 Feb 2015
Followed up 17 March 2015
Revised deadline 13 April 2015
CQC Project Manager
In progress
16 Feb 2015
Followed up 17 March 2015
Revised Deadline 13 April 2015
Associate Director of
Nursing, Midwifery
and Quality and
Facilities Manager
Report received –
further work
required – In
progress
16 Feb 2015
Followed up 17 March 2015
Revised deadline 13 April 2015
CQC Project Manager
Report received –
further work
required – In
progress
13 April 2015
Associate Director of
HR - OD
In progress
5 Feb 2015
Hinchingbrooke Hospital – How our progress is being monitored and supported
Integrated Board Actions
( Relevant to CQC Action Plan)
The board voted for the Trusts QGAF self assessment to be
amended to score 1.0 for patient experience.
Meeting to be held to discuss options for recruiting a
microbiologist with CH, HAR, EB and DF.
CCB to meet with CH to discuss proposals for 7 day working and
SDIPS for the 2015/16 contract.
Staffing paper to be reviewed to ensure appropriate trajectory and
assumptions around turnover etc. EB to validate position.
DF to circulate Key Lines of Enquiry for Clinical Observation Visit
taking place during April to Board for information.
Agreed Timescale for
implementation
Action Owner
Progress
22 April 2015
Director of Risk and
Governance
In progress
22 April 2015
Chief Executive
In progress
22 April 2015
Chief Operating Officer
In progress
22 April 2015
HR Director
In progress
15 April 2015
Director of Nursing,
Midwifery and Quality
/ Facilities Manager
In progress
Hinchingbrooke Hospital – How our progress is being monitored and supported
Oversight Meeting Action Log
Target Date
Action Owner
Progress
Full QGAF Self Assessment to be completed
30 April 2015
HHCT - Director of Risk and
Governance
In progress
Liaise with Quality Team and share summary of reinvestment
for CQUINS group
29 April 2015
HHCT – Chief Operating
Officer
In Progress
6 March 2015
Completed: 19 March
2015
HHCT – HR Director/Director
of Risk and Governance
Final staffing risk assessment paper was to be distributed to
group 19 Feb 2015. Review by TDA has required a re-draft. To
be circulated with papers for next meeting
Headlines/Enforcement from subsequent visit in January to be
distributed to group once received
29 April 2015
Details of group(s) requiring patient contribution to be sent to SS
31 March 2015
Updated Complaints SOP to be presented at next Oversight
Meeting
Face to face meeting to be arranged with JD, AS, JH, RT, AB and a
Trust IT lead to fine tune the CAP document in time for the next
meeting.
Discussion to be held with SH, AB & DF regarding the risk
assessment analysis and presentation.
JH to provide the CCG’s report to AB. All visit reports to be tabled
at the next meeting to allow participants time to consider the
contents more fully.
HHCT - Director of Nursing,
Midwifery and Quality and
Facilities Manager
HHCT - Director of Nursing,
Midwifery and Quality and
Facilities Manager
Complete
In progress
29 April 2015
HHCT - Director of Risk and
Governance
29 April 2015
HHCT - Director of Nursing,
Midwifery and Quality and
Facilities Manager
In progress
29 April 2015
TDA - Head of Delivery and
Development/Deputy Clinical
Quality Director – Midlands &
East
In Progress
19 March 2015
CCG – Director (Quality, Safety
and Patient Experience
Completed