CQC Update
Month: May 2015
Progress/successes in the last month
Quality – Deirdre Fowler, Frances Carey, Catherine Hubbard
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Survey of Patient Experience at Night completed - 90% satisfaction in Cleanliness, Food, hydration, and Communication. Areas for
improvement were in noise and Named Nurse. Included in Inpatient Action Plan and monitored through the Patient Experience Group.
IPC Programme - Secret Shoppers (focus on hand hygiene including bare below the elbow) initial visits undertaken last week, which will be
repeated on the last week of each month. Feed back will be provided to ward Matrons; provided at the Divisional Heads of Nursing’s
meetings ; monthly IPC Committee; and to the Trust IPC Committee
Dementia Strategy consultation to be concluded 30 June 2015. Anticipated date of Strategy completion 31 July.
Responding to Feedback Policy ratified, adopted and implemented. Process in place for reporting to Patient Safety Committee. New metrics
for complaints in place and RAP for CCG completed. Metrics to be included in Integrated Performance Report going forward. Interim Lead
in place ensuring compliance with new process
MCA DoLS Compliance 48%– April 2015 (867 with 413 achieved)
Performance – Cara Charles Barks
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£581,936
Acute Physician 7 day working now in place. Greater focus on£312,152
Ambulatory Care
and expansion of services offered. Improvement in ALSO for
non-elective by 0.5 day YTD since January 2015. Average free beds at 0800 has increased from 5 in November 2014 to 21 in April and March
2015
Day rooms and Quiet rooms - see update within Key Milestones
Moving patients at night procedure - Procedure and SOP in place. Improvement from 25 avoidable moves from first week of April to 1
avoidable move week beginning 11th May and week beginning 18th May. Current performance is outperforming trajectory agreed as per
CQINN scheme
Workforce – Patricia Williamson
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Paediatric Nurses recruitment continuing – Full complement for 24/7 provision expected from September 2015.
Nursing Recruitment drive in Europe commenced.
Since February 2015 recruited 18 RN’s, 3 x Band 6’s and 1 x Ward matron
Appraisals – currently 84.34% against a target of 90% (31 March 2016)
Training Needs Analysis – Statutory, Mandatory, CQC essentials is complete. All competences have been mapped and we are now just at
the review stage to ensure all competences against an individual are correct.
Mandatory Training – compliance is 91.91% against a target of 90%
Substantive Microbiologist recruitment successful due to commence imminently date TBA
CQC Update
Month: May 2015
Issues/Challenges
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Paediatric CCS SLA agreed, but not yet signed off by CCS
Staff Engagement officer leaving Trust in June
DATIX
DTOC
Key Milestones /Decisions for May
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Adult Safeguarding Review – revisit by NUH on 8 June 2015
70% of transactional milestones in CQC Action Plan complete
Survey of Patient Experience at Night report to be presented at DHON’s and Senior Ward Matrons Meeting and Patient
£312,152
£581,936
Experience Group.
Dementia Awareness Week 18 to 24 May with activities which included a Dementia Strategy Awareness Conference on
20 May 2015. This campaign included Guest Speakers and requested feedback on the HHCT Dementia Strategy to be
fed into the consultation process.
Review of Quiet Rooms and Breaking Bad News rooms conducted recommending the creation of a Day Room on
Cherry Tree Ward refurbishment commenced. The Trust has agreed that the Day Rooms are multi functional and can
be used as Breaking Bad News Rooms. ED Breaking Bad News Room which is deemed to be too small by the CQC
are included in the ED renovation plans. Sufficient resource is available across the Trust
Safety Culture Communications Plan currently being drawn up; will include focus on Whistleblowing, Stop the Line and
Responding to Feedback
22 staff over the last 6 weeks have been recruited to the Trust through a local recruitment campaign and local
engagement.