Quality Improvement Actions – Privacy, Dignity and respect How the regulation was not being met CQC findings Patients should not be transferred from ambulance trolleys in the corridor outside pit stop. Staff should move the patient to a more discreet area before attempting transfer, unless urgent transfer is required due to the patient’s clinical condition The hospital must declare mixed sex accommodation breaches as they occur in line with Department of Health guidance Conversations between the navigator nurses should be held in a private area to preserve the patient’s dignity and respect How the regulations will be met Zero mixed sex accommodation breaches occur in line with DH guidance Staff to consistently maintain patient privacy and dignity Areas for Improvement Improvement action Outcome Responsible person Deadline Date Assurance /Evidence Current status Ensure that staff adhere to DH guidance to avoid any mixed sex accommodation (MSA) breaches Review areas highlighted e.g. Cardiac Day Unit, Renal and escalation areas Risk assessment will be carried out and where potential appropriate, screens should be used in line with DH guidance Head of Nursing for Critical HSDU, Anaesthetics and Theatres 31/07/17 Safety Learning Events (SLE) raised for non clinically justified breaches Clinically Justified breaches included in report to Board Screens observed in use Daily reporting of compliance with MSA requirement Amber Ensure that staff maintain patients privacy and dignity along the emergency pathway Embedding of staff responsibilities regarding meeting patient privacy, dignity and respect Patients are moved to a discreet area in a timely manner. Patient privacy and dignity is maintained Head of Nursing for each Clinical Service Centre (CSC) 31/8/17 Feedback from : Quality Care reviews Sit and see programme Peer reviews CCG visits Amber
Quality Improvement Actions – Safe care and treatment – Governance How the regulation was not being met CQC findings Emergency equipment was not consistently check and serviced in accordance with trust policy. Incidents and near misses were not always reported. Staff did not always receive feedback from incidents they reported. Staff did not meet the Trusts target for completion of appraisals. Undertake harm reviews on adults to identify where lessons can be learned or mortality ratios reduced. Improve compliance with Regulation 28 coroner reports for preventing future deaths. Staff working with patients must have sufficient knowledge and skills to care for patients presenting with mental health condition Staff mandatory training and appraisals did not meet hospitals own targets Ensure that staff are assessed and signed off as competent to deliver patient care How the regulations will be met Mandatory training and appraisals will achieve the target percentage A programme to ensure that staff undertake core skills training Learning from Deaths framework is embedded Incidents are correctly reported Areas for Improvement Improvement action Outcome Responsible person Deadline Date Assurance /Evidence Current status Training and development Audit of appraisals and mandatory training numbers All staff have had their appraisals All clinical staff have undertaken their mandatory training Head of Organisational Development 31/3/17 Audit to be completed by 30/9/17 Audit CSC performance reports Amber Improved SLE reporting SLE reported will be correctly graded Staff will be competent in grading SLE correctly and will receive timely updates on outcomes Associate Director Governance & Quality 31/5/17 Audit to be completed by 30/9/17 Sample audit from Datix Amber Learning from deaths Designing and implementing a system to undertake learning from deaths Embedded learning from harm reviews Medical Director 31/10/17 Audit of deaths from harm Amber
Quality Improvement Actions – Safe care and treatment – Patient Care How the regulation was not being met CQC findings There was no medical staff allocated to the pink area of AMU or the winter pressures ward. Patients did not routinely have robust, individualised care plans to enable staff to plan and deliver their care and treatment appropriately and mitigate any identified risks. Patients in the emergency department who had been referred to the medical team were not routinely reviewed in a timely way (Medical Model). Staff working within the emergency pathway did not recognise that patients with mental health needs present with increased risk and did not take practicable steps to mitigate risks (Mental Health plan). How the regulation will be met Patients on the emergency pathway will be referred and seen by the medical team in a timely manner Areas for Improvement Improvement action Outcome Responsible person Deadline Date Assurance /Evidence Current status Recruitment of staff Proactive recruitment strategy Compliant rota Director of Unscheduled Care 31/5/17 Timeliness of medical review Green Not all patients have a plan of care Review use of existing flags within the Bedview system to identify vulnerable patients and how this information can be used in a more intelligent manner. Patients will have an individualised plan of care Chief of Service Emergency Department (ED) 30/6/17 Audit of Bedview Documentation audit Green