Special Measures Action Plan

Sherwood Forest Hospitals NHS Foundation Trust

September 2014KEY

Delivered

On Track to deliver

Some issues – narrative disclosure

Not on track to deliver

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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.

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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@sfh-tr.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

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Sherwood Forest Hospitals - Our improvement plan

Summary of Main Concerns

Summary of Urgent Actions RequiredAgreed timescale for implementation

External Support/ Assurance

Progress against original timescale

Revised deadline (if required)

Strengthen assurance processes and outcomes

Maintain Non Executive Director (NED) to Executive 3 monthly Confirm and ChallengeRecommence NED formal and informal ward / department visitsAgree new Board Assurance Framework (BAF) at September Trust BoardRe-fresh corporate risk register in line with new BAFEmbed 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

Oct 14 – Mar 15Sept 14 – Mar 15

May – Sept 14Sept – Nov 14July – Dec 14

Oct 14

On track to deliver

Leadership 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

Dec 14Sept – Dec 14Sept 14 – Mar 15

Sept 14 – Mar 15Feb 14 – Mar 15

On track to deliver

Accountability Executive accountability matrix agreed Nursing & Midwifery:All ward areas have Care & Comfort Boards in placeAccountability DVD producedStandardised accountability handover record keeping introducedStandard operating procedure for accountability handover agreedResource pack developed and 8 Practice Development Matrons recruited supporting all ward areas with implementation

Completed

July – Sept 14July – Sept 14July – Sept 14July – Sept 14

July – Sept 14

On track to deliver

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Sherwood Forest Hospitals - Our improvement plan

Summary of Main Concerns

Summary of Urgent Actions RequiredAgreed timescale for implementation

External Support/ Assurance

Progress against original timescale

Revised deadline (if required)

SafeImprove sharing and learning across the organisation

Ensure accurate record keeping, particularly in relation to observations hydration and drug administration

Improve the storage of medicines within ED and Medicine and ensure the Trust has a secure system for storing medicines.

Reduce medicine omissions ensuring patients receive critical medicines according to the prescribed times and prescriptions

Improve the recognition of the deteriorating patient reducing the risk of failure to rescue, whilst improving safety and outcomes for patients

Improve the Mandatory Training compliance rate

To embed the WHO checklist, particularly the briefing before and after surgery

Ensure safe and sustainable staffing across the Trust

Aug – Dec 2014

Aug - Dec 2014

Aug – Sept 2014

Aug – Dec 2014

Nov 2014

Oct – Dec 2014

July 2014

Sept – Nov 2014Final implementation March 2016

On track to deliver

Effective Standardise Care Pathways – protocols for transfer, escalation policies for ED and clinical.

Undertake comprehensive pathway review through elective pathway transformation programme

Training in practice – identify appropriate metrics of how staff use their knowledge from training to improve the quality of patient care

Review appraisal documentation and data collection

Implement End of Life Care Guidelines and plans

Sept - Oct 2014

June – Dec 2014

Oct 2014

Oct – Nov 2014

Aug - Dec 2014

On track to deliver

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Sherwood Forest Hospitals - Our improvement plan

Summary of Main Concerns

Summary of Urgent Actions RequiredAgreed timescale for implementation

External Support/ Assurance

Progress against original timescale

Revised deadline (if required)

Caring Improve the response rates for Family and Friends June – Sept 2014On track to deliver

Responsive Improve the complaint response times

To be more responsive by reducing the delays in discharge

Achieving consistently and sustaining all Referral to Treatment Times

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

To address concerns raised in relation to the provision of clinical administrative support

Oct 2014

Sept 2014 – Jan 2015

Aug – Dec 2014

Oct 14 – Mar 2015

June – Sept 2014

On track to deliver

Well-led Improve communication between staff and management through the implementation of robust communication and feedback networks Undertake a trust wide cultural assessment

Enshrine Quality for All behaviours in all that we do - cascade values and behaviours into the trust

Effective Board Working and Engagement - implementing Board and governor training and development programmes

Implement trust wide Leadership development strategy

Sept – Dec 2014

Jul - Nov 2014

Oct – Dec 2014

Aug - Dec 2014

Sept – Dec 2014

On track to deliver

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Sherwood Forest Hospitals - How our progress is being monitored and supported

Oversight and improvement action Agreed Timescale for Implementation Action owner Progress

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

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