Special Measures Action Plan

Medway NHS Foundation Trust

February 2015

KEY

Delivered

On Track to deliver

Some issues – narrative disclosure

Not on track to deliver

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Medway NHS Foundation Trust - Our improvement plan & our progress

What are we doing?

• The Trust was one of 14 included in the Keogh Review process because of higher than expected mortality rates. This remains an ongoing key focus for the Board with support from ‘buddying’ trusts.

• Following the review the Trust was placed in ’special measures’ and has remained so following Care Quality Commission inspection in December 2013, April 2014, May 2014, July 2014 and August 2014. An unannounced visit also took place on 9th December 2014 and the report is awaited.

• The Keogh review made a number of recommendations the majority of which have been closed out, and a number of actions have been agreed following each of the CQC visits these are being incorporated with other Trust initiatives into a single 18 month action plan .

• The action plan addresses the issues raised in the CQC reports and combines these with the remaining actions from the Keogh review recommendations as each thematic area in the table

is mapped back to the Keogh and CQC actions to which it relates.

• CQC ‘Must do’ requirements

1. Urgently address poor data quality issues- Audits of data quality taking place and training for all staff in place. Audit completed by PWC and additional staff now in place to ensure data quality.

2. Urgently review and standardise risk management and governance both at local level and Trust wide to ensure there are robust processes in place from board to ward.

3. Continue to actively monitor its HSMR trends including ensuring that consistent robust minuted mortality and morbidity meetings are being undertaken in all departments.

4. Ensure that the vanguard unit is not used for patients over night- This has now been removed from site.

5. Address its escalation policy within the ED department to avoid the need to stack patients. This should include formal agreements regarding expected professional standards.

6. Ensure that initial assessments for all patients including children are in line with national standards.- system in place to ensure that all patients are assessed within 15 minutes.

7. Address the concerns regards patient flow throughout the hospital, including discharge processes. 8. Update its major incident policy within the A and E department and ensure staff are trained appropriately- now updated and training in place

9. Ensure that there are sufficient numbers of nurse with paediatric experience in the A and E department- Sufficient numbers are now in place.

10. Ensure that all equipment is in date and checked consistently- Checking procedure enhanced

11. Ensure that all fire exits are accessible at all times- All fire risk assessment now complete, a programme of work is in place to address areas of concern. Fire safety specialist employed to check all fires escapes on a regular basis and all staff reminded of their responsibilities regarding fire safety

12. Ensure that mental capacity assessments are undertaken where appropriate and staff are adequately trained in MCA and DOLS- training in place for all relevant staff. Commence robust audit of theatre utilisation to ensure clear allocation of elective and emergency lists-Audit process now in place

13. Improve the quality of cancellation of operations reporting.- more robust data capture in place.

14. Ensure that all wards have the appropriate equipment to meet peoples care needs.- review of requirements taken place and additional equipment purchased.

15. Ensure departments are sufficiently staffed by competent staff with the right skill mix including out of hours

16. Review the current training matrix and improve the recording system so that there is a comprehensive record of compliance with training Trust wide.- In place and reviewed monthly 2

Medway NHS Foundation Trust - Our improvement plan & our progress

What are we doing?

CQC ‘Must do’ requirements cont.

18 Ensure all staff are aware of their roles and responsibilities to report incidents and that they have access to datix. Feed back mechanisms and review processes need to be sufficiently robust to ensure that all staff groups are learning from incidents-Updated guidance now complete. Training session given to staff on all Trusts induction sessions. 1:1 sessions offered to any staff member requiring support

19 Ensure that consultant surgeons are undertaking ward rounds at week ends.- Rotas amended and ward rounds taking place.

20 Review the medical oversight of Medical High Dependency Unit and lack of input form critical care directorate,- Resolved cover now in place.

21 Review the current arrangement for protected consultant presence on the labour ward including the supervision of trainees performing elective caesarean sections.- Reviewed and supervision in place.

Remaining outstanding Keogh actions

1. Need for greater pace and clarity of focus at board level for improving the overall safety and experience for patients.

2. Redesign of unscheduled care and critical care pathways and facilities –

3. Improve methods and frequency .of engaging with the public in order to improve public reputation -

• The 18 month improvement plan will lead to measureable improvements in the quality and safety of care for patients.

• The Trust is putting in place arrangements to maintain progress and ensure that the actions lead to measureable and ongoing improvements in the quality and safety of care for patients. To this end, Key Performance Indicators (KPIs), each with a clear trajectory and timescale for demonstrating sustained improvements, will be agreed and progress against these is monitored by the Executive Team and monthly by the Trust Board and relevant Board sub-committees.

• Assurance and performance management arrangements ensure the early escalation of risks to delivery and ‘on the ground’ testing of these arrangements occurs via a variety of mechanisms including announced and unannounced Director and Management Visits, Chief Nurse and Medical Director walk around and CQC Mock visits and the outcomes are reported to the Executive Team and Trust Board. These testing arrangements will continue as a routine part of the Trust Assurance Framework.

• The Trust is in the process of finalising a ‘buddying’ arrangement with a large teaching hospital this will build on the recommendations received following a review by University Hospital Birmingham which commenced following the May CQC visit . This arrangement will assist with implementing the 18 month sustainability plan.

• Support from our Commissioners has also been sought where actions are outside of the Trusts control.

• The key themes from the reviews can be summarised using the CQC new inspection categories:

1. Well –led - The Trust will support, develop and enhance leadership capability across the organisation, continuing Board and Governor development programmes together with enhancing targeted programmes for development to appropriate staff. Supporting team work and working towards positive performance management

2. Safe - To create a safe and positive experience for all of our patients all of the time, improving clinical documentation and medicines safety. Continuing to identify and mitigate risks. 3. Effective - To create sustainable, efficient and quality core services, establishing clear information flows and reporting, learning and sharing best practice across the organisation and s

strengthening individual responsibility and accountability. 4. Caring - Ensure staff are fully engaged with the Trusts vision and values promoting a shared purpose and positive experience of work. Supporting staff to make continuous improvements . 5. Responsive to peoples needs - Build safe staffing levels with escalation policies to meet unpredicted demand, creating and sustaining optimal patient flow across all services

Oversight and improvement arrangements have been put in place to support the changes required these will be regularly monitored by the Trusts Improvement Director 3

Medway Foundation Trust - Our improvement plan

Summary of Main Concerns

Summary of Urgent Actions Required

Agreed timescale for implementation

External Support/ Assurance

Progress against original timescale

Revised deadline (if required)

Well Led The trust has not had a stable board and executive team. Keogh 1 CQC 1

Appoint a substantive chair Recruit substantive executives including CEO

September 2014 October 2014

• Substantive chair appointed September 2014.

• Unsuccessful CEO recruitment- October 2014 new search to be completed end of February. Medical Director continues to act up as CEO. Acting medical director in place.

• Further interviews for CEO scheduled for 20 February 2015.

• Recruitment of COO, Chief Nurse, CIO on minimum 12 months appointments successfully completed.

• Director of Workforce appointed.

• Director of Corporate Affairs to be appointed by March 2015 (in progress).

March 2015

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Medway Foundation Trust - Our improvement plan

Summary of Main Concerns

Summary of Urgent Actions Required

Agreed timescale for implementation

External Support/ Assurance

Progress against original timescale

Revised deadline (if required)

Well Led Safe Effective The Trust requires a review of its organisational and management structures to ensure effective management, governance and risk management within the organisation CQC action 2 CQC action 5

Carry out review of organisational structure and accountabilities Review and standardise governance structure sand processes throughout the organisation . Review the committees and meetings structure to ensure clear lines of reporting throughout the organisation. Review and implement the new and approved schemes of delegation Improve training on risk management and appropriate escalation Review the policy approval and dissemination framework to ensure that it is line with best practice and understood by the organisation

March 2015 University Hospitals of Birmingham review and recommended organisational structure Governance framework document produced with help of Good Governance Institute and PWC New Buddying Arrangement incorporates additional work on Governance

• New organisational structure reviewed and approved in line with the trusts scheme of delegation (with clear lines of reporting and accountability).

• Consultation on senior management structure started and completed in November 2014.

• Review of structure and roles below divisional Director of operations commenced.

• Divisional Director appointments to be made in February 2015.

• Corporate and Divisional Nursing Structures in consultation. Consultation to end January 2015 – 2 assessment day for new structures in place for February 2015.

• Interviews being held in February. • Post consultation review taking place to agree

final structure. • Governance framework approved by Audit

Committee (December 2014). Approved at Public Board (18th December 2014) Now distributed to corporate and operational areas.

• Training in governance and risk management being reviewed with improved programmes in place by March 2015.

• Policy and procedure policy approved by Board of Directors.

• Policy Review Group re-established first meeting to take place 17.2.15.

• Governance Framework agreed and approved by the Trust Board in December 2014. In process of implementing the new structure which incorporates the Clinical and Care Quality Group and the Compliance and Risk Group.

• In the process of updating the Strategic Objectives. A new version of the Board Assurance Framework is being presented to the Trust Board February 2015.

• The Risk Management Strategy will be updated by the end of March 2015.

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Medway Foundation Trust - Our improvement plan

Summary of Main Concerns

Summary of Urgent Actions Required

Agreed timescale for implementation

External Support/ Assurance

Progress against original timescale

Revised deadline (if required)

Well Led Safe Effective A failure to plan and effectively manage a sustained programme of improvement CQC action 1 CQC action 2 CQC action 3 CQC action 5 CQC action 7 CQC action 16 CQC action 18 Keogh Action 1 Keogh action 2 Keogh action 3

Development of a single, coherent action plan, effectively communicated, managed by the executive and overseen by the Board Implementation sustained over period of time with accurate KPIs Establishment of a Programme Team Office (“PTO”) to support COO in delivery of comprehensive and disciplined transformation plan

3 month action plan by October 2014 18 month plan by end of January 2015 PTO in place by March 2015

University Hospitals of Birmingham Homerton review of staffing and processes in ED ECIST review and recommendations GSTT Nursing Support

• Three month action plan taken to Board in October 2014 and now sits within the 18 month recovery programme.

• Monthly update to Board by exception against the 3 month plan. Superseded by the 18 month recovery programme.

• Establishment of Trust Recovery Group to review evidence of delivery – Monthly meetings Commenced

• Recruitment to Programme Team Office commenced with a programme manager appointment

• Two service improvement managers appointed

• Project manager for specific CQC , governance and risk related issues.

• Appointment of Estates and Facilities Project Manager to complete review of estates and facilities

• 18 month plan to be taken to Board in January 2015 with communication and member and public engagement strategy -agreed by the Trust Board January 2015.

• Weekly stakeholder call held with key external stakeholders with transparency over progress on all key issues

• Updating of 18 month recovery plan commenced (4 February 2015) with all internal stakeholders.

• Two public events held in January 2015 regard to the organisations Quality Accounts.

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Medway Foundation Trust - Our improvement plan

Summary of Main Concerns

Summary of Urgent Actions Required

Agreed timescale for implementation

External Support/ Assurance

Progress against original timescale

Revised deadline (if required)

Safe Effective Mortality and patient safety. In particular the monitoring of HSMR trends and putting in place actions to address concerns. CQC action 1 CQC action 7 Keogh action 1 Keogh action 2

Review of patient notes and the establishment of a template for formalised ongoing monitoring and review of outcomes Development of a coherent clinical strategy Thorough review of all data quality issues with corrective action plan to address historic deficiencies and ensure future accuracy Review PAS project to ensure delivery on time. Monitoring of HSMR at board to be strengthened

Patient Note Review by March 2015 Clinical Strategy by Q3 2015-2016 (December 2015) New PAS in place by March 2015 Immediately improve oversight and understanding of HSMR at board

University Hospitals of Birmingham case note review and review of PAS PWC review of data quality Deloitte review of PAS implementation status New Buddying Arrangement incorporates specific focus on mortality and patient safety

• Initial comprehensive notes review completed in August 2014 and acted upon by Management.

• Additional Notes review carried out by an external high performing Trust- report received- action plan being compiled.

• Buddying Trust been asked to assist with monitoring and reviewing HSMR including assistance with board reporting.

• PWC data quality review ongoing. Initial recommendations taken to fix identified issues (with significant investment by Trust in data validation).

• PAS project now progressing at pace • New Director of informatics appointed • Programme management structure in in

place. • PAS ‘Go Live ‘,9 February 2015. Mortality • All maternal deaths are reported

automatically as an SI and investigated accordingly. All Intra-Uterine Deaths s are formally reviewed by the Bereavement Midwife, using a very comprehensive standardised methodology. Each fetal loss over 24/40 will also have a review carried out.

• Children services - mortality reviews monthly. Data on all infant deaths is entered into the MBRRACE-UK database which collates national data on both stillbirths and infant deaths and provides reports on statistics to each Trust. All deaths are then presented for discussion at Medway Child Death Overview Panel.

• Mortality meetings taking place within the specialities of the Surgical & Anaesthetic division and the Adult Medicine division. Soon to be appointed ‘Buddy Trust’ will assist in embedding this within the two Divisions.

Medway Foundation Trust - Our improvement plan

Summary of Main Concerns

Summary of Urgent Actions Required

Agreed timescale for implementation

External Support/ Assurance

Progress against original timescale

Revised deadline (if required)

Well Led Safe Effective Caring Safe and effective staffing of all clinical areas by appropriately trained staff CQC action 9 CQC action 16 CQC action 17

Produce a manpower plan Agree nursing establishments across the organisation and work with nursing leadership to staff consistently to these levels Review consultant workforce in Medicine to ensure appropriate medical input at all times, particularly in relation to ED and consultant cover over weekends Address shortages in Junior Doctor rotas Address gaps in clinical leadership Ensure a multidisciplinary training programmes are in place to improve multidisciplinary working Improve understanding of ‘deprivation of liberty’ assessments and ‘mental capacity’ assessment

Ongoing (with KPIs monitored on regular basis)

University Hospitals of Birmingham review of nursing Homerton review of staffing and processes in ED GSTT Nursing Support Health Education England ECIST

• Manpower planning commenced. • Signed off nursing establishments at Board in August

2014. Weekly monitoring of vacancies, fill rates, temp staffing usage and skill mix and other absences

• Roll out of implementation of eRostering ensuring effective use of nursing workforce – In the process of rolling out to all wards.

• GSTT led review of recruitment and retention in nursing workforce with support to implement. Strategy for recruitment and retention will form part of the 18 month improvement plan

• Consultant job plans amended to ensure weekend cover and appropriate input into ED

• Discussions initiated with Health Education England to develop enhanced supervision programme for Junior Doctors, actions and enhanced opportunities for supervision and training to be agreed and in place March 2015

• Discussions initiated with Health Education England and large teaching trust to create comprehensive clinical leadership development programme to be in place summer 2015

• New divisional structures in place to improve clinical engagement and leadership

• All new staff are trained in safeguarding / MCA and PREVENT as part of their initial induction process. Existing staff gain the same information through normal mandatory training sessions.

• Site safety reviews are taking place twice a day (9.30 and 19.30) to review staffing levels and skill mix .

Ongoing (with KPIs)

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Medway Foundation Trust - Our improvement plan

Summary of Main Concerns

Summary of Urgent Actions Required

Agreed timescale for implementation

External Support/ Assurance

Progress against original timescale

Revised deadline (if required)

Well Led Safe Effective Caring Responsive The safety and experience of patients attending ED and Acute Medical and Surgical Assessment Unit Temporary unit on site (vanguard unit) being used fro assessment but patients being kept their overnight Patients not being reviewed in the emergency department within 15 minutes of arrival CQC action 4 CQC action 6 CQC action 7 Keogh action 2

Review of entire emergency care pathway (from admission to discharge and including care outside hospital) Review impact on elective and non elective surgical patients Review of the physical environment within ED and escalation areas in which patient care is being delivered Vanguard unit to be removed 15 minute assessment to be undertaken on all patients.

October 2014 January 2014

University Hospitals of Birmingham review Homerton review of staffing and processes in ED ECIST Royal College of Emergency Medicine Commissioners

• Original timescales met:

• Dr Laurence Gant appointed for one year to implement improvement programme within the emergency patient pathway.

• Review of emergency care pathway provided to October Board. 100 point action plan approved. Ongoing Board oversight (via single Action Plan)

• Implementation of new care models starting 8th December 2014.

• Major progress made on physical environment (e.g. Pre operative assessment unit, closure of temporary unit, Medoc 24-7, ward upgrades , paeds ED opening 22 December 2014).

• Paediatric emergency department completed on time and opened.

• Estates and property strategy to be developed once clinical strategy agreed.

• Equipment being checked on regular and appropriate intervals with regular auditing of compliance.

• Business case completed for Emergency Village (Phase 1) – reconfiguration of emergency department – now approved.

• Vanguard unit removed. • Over 95% of patient being reviewed within 15

minutes. If a patient waits longer than this timescale a review is undertaken of the patients condition. No patients who have waited longer than 15 mins have been adversely affected.

95% A&E target (March 2015)

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Medway Foundation Trust - Our improvement plan

Summary of Main Concerns

Summary of Urgent Actions Required

Agreed timescale for implementation

External Support/ Assurance

Progress against original timescale

Revised deadline (if required)

Well Led Safe Effective Caring Responsive The safety and experience of patients attending ED and Acute Medical and Surgical Assessment Unit Temporary unit on site (vanguard unit) being used fro assessment but patients being kept their overnight Patients not being reviewed in the emergency department within 15 minutes of arrival CQC action 4 CQC action 6 CQC action 7 Keogh action 2

Continued from previous page: Review of entire emergency care pathway (from admission to discharge and including care outside hospital) Review impact on elective and non elective surgical patients Review of the physical environment within ED and escalation areas in which patient care is being delivered Vanguard unit to be removed 15 minute assessment to be undertaken on all patients.

October 2014 January 2014

University Hospitals of Birmingham review Homerton review of staffing and processes in ED ECIST Royal College of Emergency Medicine Commissioners

Progress continued:

• Ambulance handover, system in place to release ambulance crews rapidly – 44% reduction in >30 minute breaches.

• Remodelling of ED front desk and waiting room to improve queuing and safety compliance.

• Four band 8a Matrons are now in post with Matron of the Day active.

• Identified Senior Nursing lead to develop advanced nursing and resus practitioner roles.

• Improved multi-disciplinary structured handovers. • Frailty project across health care sector has been

launched. • Started recruitment process for 24/7 Paediatric ED

service. • ED handbook developed and published bringing

together clinical and procedural information for staff. • As part of the 18 month recovery there is a now a

project in place to review and improve discharge processes within the Trust which includes working closely with partner organisations to develop pathways for discharge as appropriate.

• Unscheduled care – Revised Surgical Admission Unit (SAU) policy in place, increased leadership on SAU, reviewed Fractured Neck of Femur pathway,

• Dedicated leads for Trauma and CEPOD, morning board rounds to identify first patient on list. Process of identifying a ‘Golden patient ‘ now introduced (patient identified previous night as the most appropriate to be listed as the first surgical case on the trauma list for the following day). This ensures all necessary assessments and diagnostics tests are available and that the theatre lists start on time.

95% A&E target (March 2015)

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Medway NHS Foundation Trust - How our progress is being monitored and supported

Oversight and improvement action Agreed Timescale for Implementation

Action owner Progress

Monthly meetings with Monitor to track performance ongoing Trust CEO and Monitor

A new improvement director Mark Davies has been appointed by Monitor

August 2014 Monitor

Weekly stakeholder calls to update on performance On going Trust Chief Executive/Monitor

Trust recovery group formed to review and challenge the development and implementation of the 18 month recovery plan. The membership with be the senior leadership team and the non executive directors, plus subject matter specialist as required.

Terms of reference approved at Trust board December 2014 Reviews to take p[lace at 3 and 6 months to ensure effectiveness of the group.

Chair On track

Buddying arrangements- University Hospital Birmingham conducted a review with recommendations.

To be agreed at trust Board and incorporated into 18 month plan

CEO On track

Re inspection TBC CQC Blank-white

Communication and public engagement strategy to be presented at the January and effectiveness of the strategy monitored by the trust recovery group

ongoing Chair On track

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Medway NHS Foundation Trust - Our improvement plan & our progress

Who is responsible?

• Our short term action plan which builds on previous plans has been agreed and the 18 month plan will be presented in detail at the January board of directors meeting

• Our Acting Chief Executive, Phillip Barnes is ultimately responsible for implementing actions in this document. Other key staff are Morag Jackson Chief Operating Officer, Steve Beaumount, Chief Nurse and Paul Ryan, Acting Medical Director as they provide the executive leadership for quality, patient safety and patient experience.

• The Improvement Director assigned to Medway NHS Foundation Trust is Mark Davies, who will be acting on behalf of Monitor and undertake regulatory responsibilities. Should you require any further information on this role please contact specialmeasures@monitor.gov.uk

• Ultimately, our success in implementing the recommendations of the Special Measures 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 the Medical Director by email at Medical.Director@medway.nhs.uk

How we will communicate our progress to you

• 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.

• Updates on our progress will be given at our board meetings, with papers published on our website, and regular members engagement events, which will be held in collaboration with our local health and social care partners.

• Stakeholder and public briefing dates will be provided and will be detailed as part of the communication plan to be approved at the board in January 2015

Chair / Chief Executive Approval (on behalf of the Board):

Chair Name: Mrs Shena Winning Signature: Date: 9/2/2015

Chief Executive Name: Dr Phillip Barnes

Signature:

Date: 9/2/2015

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