New CATEGORY OF PAPER Specific action required: Provides … · 2015. 7. 27. · Page 1 of 38 CATEGORY OF PAPER Specific action required: Provides Assurance: For Information: Board

Page 1 of 38

CATEGORY OF PAPER

Specific action required: Provides Assurance: For Information:

Board of Directors – 30/07/2015

Agenda item: 18

Report title: Francis ‘Hard Truths’ Action Plan Update – July 2015

Purpose of report:

The report has been produced in order to aid the Board’s understanding of the current position with regards to completion of the Francis ’Hard Truths’ action plan against milestones.

Key issues: (key points of the paper, how this supports the achievement of the Trust’s corporate objectives, overview of risk implications, main risk details on page 2)

Following the failings at mid Staffordshire Hospitals and the r e s u l t i n g public enquiry, Sir Robert Francis p u b l i s h e d t h e “ Hard Truths” report in January 2014, which outlines r e c o m m e n d a t i o n s w h i c h a l l NHS Trusts are required to implement i n o r d e r t o ensure wider learning across the whole Health economy.

An action plan has been created internally based upon the recommendations upheld in t h e “ Hard Truths” report, which maps requirements to specific chapters of hard truths which will allow the organisation to fully understand the upheld obligations for NHS trusts. The previous Francis action plan developed by the trust based upon early publications of the Francis Report has been replaced with this refreshed action plan.

This report provides an overview of the Trust’s position in July 2015 in terms of the Trust’s progress against the actions contained within the Francis (Hard Truths) Report Action Plan as follows;

Hard Truth/ Francis Actions

Blue = For Info 18/127 14.2%

Green = Completed 64/127 50.4%

Purple = In progress and on track to deliver

16/127 12.6%

Amber = In progress but at risk of slippage

29/127 22.8%

Red = Delayed/ overdue

0/127 0%

Total 127 100%

The amber rated actions relate to a number of themes including;

Hard Truth/ Francis Actions

Current Position/ Mitigating Actions

Responsibility Of

New policy development and ratification process

Staff have access to policies electronically via the intranet to Q-Pulse. Alerts and reporting require further consideration. A Further policy review against NHSLA standards is continuing when policies are due for review.

Director of Clinical Care and Patient Safety

Governance Review

Action plan is underway dealing with issues raised.

Trust Secretary

New CQC standards

Staff handbook launched, although standards still not fully embedded. Work underway to develop an electronic system for recording and monitoring compliance against standards.


Publication of Learning from Complaints

System for communicating/ providing information to the public is being considered,

Assistant Director of Communications

Page 2 of 38

although following research and consideration of implications, (including the amount of time taken to contact patients for their consent to publish the letters) a decision has been made not to publish each response letter, but instead an extract or summary from ECLIPS reports will be published on the website.

and Engagement

Recruitment and training based on values

There is currently no lead in post for this action.

Director of Strategy, Workforce and Transformation

Fit and Proper Persons Test

The test has been applied to new Directors and the Trust's legal adviser has also checked the professional registration of all applicable Directors. Further work to be conducted to ensure that evidence of compliance with FPP is included on all Directors' files.

Trust Secretary

Issue previously considered by: The paper / key points have not previously been considered by another committee / group.

Recommended actions:

The Board is asked to receive and review the content of the revised plan which sets out the roles, responsibilities and accountabilities in delivering the required actions.

Sponsor / approving director: Director of Clinical Care and Patient Safety

Report author: Monitoring and Compliance Officer

Governance and assurance

Link to trust corporate objectives: (please tick)

1 2 3 4 5 6 7

Link to CQC / KLOE: (please tick)

Caring Responsive Effective Well Led Safe

Any relevant legal / statutory issues? (Such as relevant acts, regulations, national guidelines or constitutional issues to consider)

National recommendations.

Equality analysis completed

If this is not relevant please explain why:

Yes No Not Relevant

Recommendations must be made in line with national guidance.

Key considerations Details

Confirm whether any risks that have been identified have been recognized on a risk register and provide the reference number:

Risks identified are added to the organisational risk register by Directors to their relevant risk registers.

Please specify any Financial Implications

Please explain whether there are any associated efficiency savings or increased productivity opportunities?

Financial implications are considered for each action individually by the action leads.

Page 3 of 38

Are any additional resources required e.g. staff capacity?

N/A

Is there any current or expected impact on patient outcomes/experience/quality?

Services and experiences will improve for patients

Quality issues (in terms of patient safety, clinical effectiveness, patient experience) will be improved upon through implementation of the action plan.

Specify whether appropriate clinical and/or stakeholder engagement has been undertaken:

(stakeholders could include staff, other Trust departments, providers, CCGs, patients, carers or the general public)

Staff across the Trust are involved in implementing and updating the action plan on a regular basis.

Are there any aspects of this paper which need to be communicated to our stakeholders (internal or external)?

(Please tick – if ‘yes’ then please complete all boxes. Please briefly specify the key points for communication and ensure the Comms team are informed via mailto:[email protected])

Yes No Positive Negative

Proactive Reactive Internal External

*The Trust corporate objectives are: 1. To have an effective workforce plan that includes the development of skill mix, clinical enhancement and career progression,

and one that achieves full establishment levels by September 2016. 2. To deliver a programme of cultural change that generates an improvement in staff morale, engagement, evidenced through an

improved FFT score, staff survey results and the cultural barometer by March 2016. 3. Achieve successful CQC accreditation at good or above through the delivery of our Quality Strategy by March 2016, ensuring

we deliver safe, effective care and a positive patient experience 4. To develop a comprehensive evidence base for a single operational model through the Integrated Care and Transport pilot that

would support full roll out of the model from April 2016. 5. To have an effective and responsive Information Technology infrastructure by March 2016 that provides quick access to

business intelligence to drive performance improvement activity. 6. To improve the level of core income to ensure a sustainable future for NEAS with an established funding structure that

incentivises the reduction of hospital conveyances to operate from April 2016. 7. To achieve recurrent cost improvement targets through the transformation strategy, waste reduction and application of lean

methodology to reduce the impact on the 2016/17 target.

mailto:[email protected]

Page 4 of 38

Francis Action Plan RAG Rating

Green Completed

Purple In progress and on track to deliver on time

Amber In progress but risk of slippage

Red Delayed/ Overdue

Blue For Information

Recommendation No

Theme Chapter Number

Recommendation Action Required Corporate Objective

Link Accountable Progress against Action

Expected Completion

Date Risk Rating

Revised Completion Date (where applicable)

Risk Rating Comments Date

Completed

Accountability for implementation of the recommendations

1 Implementing the recommendations

Introduction

It is recommended that: • All commissioning, service provision regulatory and ancillary organisations in healthcare should consider the findings and recommendations of Hard Truths and decide how to apply them to their own work; • Each such organisation should announce at the earliest practicable time its decision on the extent to which it accepts the recommendations and what it intends to do to implement those accepted, and thereafter, on a regular basis but not less than once a year, publish in a report information regarding its progress in relation to its planned actions; • In addition to taking such steps for itself, the Department of Health should collate information about the decisions and actions generally and publish on a regular basis but not less than once a year the progress reported by other organisations; • The House of Commons Select Committee on Health should be invited to consider incorporating into its reviews of the performance of organisations accountable to Parliament a review of the decisions and actions they have taken with regard to the recommendations in this report.

Production of this action plan to demonstrate commitment to the recommendations and progress on implementation

1


Development of this action plan which is monitored via the Trusts Governance framework and the Board

Oct-14 Green = Completed

Green = Completed

Oct-14

Initial Report was published on the Trust website in December 2013


Plan needs to be updated reviewed at least annually on public website

Dec-14 Green = Completed

Green = Completed

Action plan developed and monitored by the board and executive team. Compliance officer will liaise with communications team annually to upload a progress report

Page 5 of 38

2 20

The NHS and all who work for it must adopt and demonstrate a shared culture in which the patient is the priority in everything done. This requires: i. A common set of shared core values and standards shared throughout the system. ii. Leadership at all levels from ward to the Board, committed to and capable of involving all staff with those values and standards; iii. Freely available, useful, reliable and full information on attainment of the values and standards; iv. A tool or methodology such as a cultural barometer to measure the cultural health of all parts of the system. v. A system which recognises and applies the values of transparency, honesty and candour;

i. Revisit the NEAS core values

Director of Strategy Transformation and Workforce

i. NEAS branding exercise underway to review core values

Oct-14 Red = Delayed

End Sept 2015

Green = Completed

Update 29/12/2014:

The branding scoping exercise has been completed and the next piece of work to do the branding (mission vision and values revisited) will dovetail with strategic planning which has been deferred to Qtr 2 15/16 at earliest to ensure resource and effort is placed on addressing current pressures. Update 06/03/2015 -

Work has commenced to recreate our organisational ‘values’. This is linked to our strategy development work, corporate identity and branding and organisational development programme. The values will have a high visibility embedding them in all documentation; strategic documents, staff handbooks, Intranet, Internet, lanyards, all literature and should be tangible in our approach to Duty of Candour.

Page 6 of 38

ii. Develop a leadership development programme

Head Workforce Development and OD

ii. Organisational Development Strategy agreed and monitored through WEC

Mar-15 Red = Delayed

End Sept 2015

Purple = In progress and on track to deliver on time

Update 29/12/2014:

On appointment of the OD leads the strategy is being refreshed and plan updated. An away was held at end of Dec and revised plan due early January 15. Update 06.03.15 -

Leadership is being strengthened at all levels: • Board development • Management essentials • New Emergency Care Clinical Managers (ECCMs) The organisational development programme will continually be reviewed to ensure its fit with strategy, the wider NHS and innovation, ensuring we have leaders throughout the organisation. 07.07.2015 - NELA

courses to develop leaders. Board development, management essentials but no leadership development course.

iii. Develop metrics to measure attainment of the core values

Trust Secretary iii. Board Development Programme

Jan-15 Red = Delayed

End Sept 2015

Green = Completed

Update 29/12/2014:

This continues to evolve and aspects of the programme have commenced with ET away day and Board session at Dec Trust Board and another planned for 7 January following governance review feedback.

iv. Cultural barometer to be developed to measure baseline of organisational culture


iv. Review how all ‘cultural’ indicators will be recorded, assessed and reported under review, awaiting national guidance on cultural indicators, due in Spring 2014.

Jan-15 Red = Delayed

End August 2015

Green = Completed

Update 29/12/2014:

These will now need to flow from revised strategy and plan. Survey planned January 2015 (tbc) Update 06.03.15 - We

are about to embark on a cultural survey in April 2015, following the release of the staff survey results. This will provide a measure of cultural health and provide a baseline.

Page 7 of 38

v. Ensure there is a robust incident reporting system where staff receive a response in relation to action taken


System in place but has recently undergone full review and go live planned January 15

Jan-15 Green = Completed

Green = Completed

Ulysses is the Trusts electronic incident reporting system. This has recently undergone a full reconfiguration to allow more granular data. Work continues to develop a more open and honest culture and improve reporting

Putting patients first and drive safer care through creating open cultures that take effective action on staff and patient feedback.


v. Incident reporting policies reviewed and new statutory duty of candour included – training on EAT being developed around open and honest care

Nov-14 Green = Completed

Green = Completed

Policies and processes reviewed. Duty of candour training and systems for monitoring compliance in place. Incident reporting and being open now part of EAT

Nov-14

Putting the patient first

3 Clarity of values and principles

21

The NHS Constitution should be the first reference point for all NHS patients and staff and should set out the system’s common values, as well as the respective rights, legitimate expectation and obligations of patients.

Ensure the values in the NHS constitution are included in training and recruitment

Head of Workforce and OD and Head of HR

The Trust's current values were mapped against the NHS Constitution when first brought into place and are appropriately aligned. Whilst our own values are included in recruitment and training, performance review the link to the NHS Constitution has been diluted and will be enhanced through future MET, EAT and performance review in 2015.

Apr-15 Red = Delayed

Mar-16


Update 29/12/2014:

Not started. To prepare for 2015/16 materials. Not due until April 15, changed from Red to Amber. Update 06.03.15 -

The NHS Constitution requires a higher profile in the Trust, throughout documentation, appraisal processes etc. It will feature on MET and EAT in 2015/16. Reference is already made in recruitment documentation. The NHS Code of Conduct for Managers is also to be referenced. 07.07.2015 - Look into

for Management Essentials Training. Last in July and starting again during September possibly.

4 21

The core values expressed in the NHS Constitution should be given priority of place and the overriding value should be that patients are put first, and everything done by the NHS and everyone associated with it should be informed by this ethos.

Ensure the values in the NHS constitution are included in training and recruitment, appraisal and objective setting

Head of Workforce and OD and Head of HR

As above (action 3) Apr-15 Red = Delayed

Mar-16


As above (action 3)

Page 8 of 38

5 21

In reaching out to patients, consideration should be given to including expectations in the NHS Constitution that: • Staff put patients before themselves; • They will do everything in their power to protect patients from avoidable harm; • They will be honest and open with patients regardless of the consequences for themselves; • Where they are unable to provide the assistance a patient needs, they will direct them where possible to those who can do so; • They will apply the NHS values in all their work

Ensure that staff training includes the values and the organisation supports staff to deliver those values by ensuring staff feel supported to report incidents and be open with patients when things go wrong

0 Head of Workforce and OD and Head of HR

As above and there may be more actions arising from the staff survey planned for January 2015 linking with MAPSAF and cultural barometer.


Mar-16


As above (action 3) 07.07.2015 - PTS

counselling for SI and Post traumatic stress. Staff Survey action plan. Duty of Candour training

Page 9 of 38

7 21

All NHS staff should be required to enter into an express commitment to abide by the NHS values and the Constitution, both of which should be incorporated into the contracts of employment

Review all contracts of employment. See 82 for inclusion in contract of Executives and Non-Executives. See 178 for development of checklist of good practice for contracts of employment and 218 re fit and proper persons and reasons for dismissal to be included in contract.

Head of HR

All contracts are currently under review, agency terms, substantive, fixed term and secondments and bank. Executives and Non-Executive contracts to be updated to include Fit and Proper guidance/clauses


Mar-16


Update 29/12/2014:

Due to staffing being number one priority, bank contracts are under review first. An effective bank contract is to be in place mid-January. This review will include a drafting of a standard checklist to benchmark all new contracts of employment and changes needed to be made to existing contracts. The NHS Staff Code of Conduct may cover many of the requirements. Update 16.04.15 - A

Contract review has commenced which will enable the capture of additional information such as the contracts for Executive and Non-Executive Directors will include Fit and Proper persons test and reasons for dismissal, Duty of Candour etc. The process has started with Staff Bank Contracts and will be rolled out to review new starters, student paramedics etc. - all contracts. A checklist of good practice for contracts will be developed (and will have checks in place to ensure there are no ‘gagging clauses’ (similarly this will affect policy)). This work will be undertaken throughout 2015/16 as contracts are reviewed and revised (and potentially in some instances negotiated). 07.07.2015 - Bank

completed and student to go.

Page 10 of 38

8 21

Contractors providing outsourced services should also be required to abide by these requirements and to ensure that staff employed by them for these purposes do so as well. These requirements could be included in the terms on which providers are commissioned to provide services.

Ensure all contracts include the values of the NHS Constitution

Director of Finance and Resources

Reference to be made to the NHS Constitution in all future contracts, and the need for contractors to embrace the principles - copy of constitution to be included with any tender documentation. Emphasis to be made regarding section 4 of the constitution regarding staff and obligations towards them by the employer e.g. health and safety, equality etc. Where contractors are to be engaged with direct contact with patients, they will be reminded of their need to treat patients with respect, consent and confidentiality as if the contractor where an NHS organisation.

This will be ongoing

Green = Completed

Green = Completed

Fundamental standards of behaviour

9 21

Staff abide by the NHS Constitution which includes reference to all the relevant professional and managerial codes by which NHS staff are bound, including the Code of Conduct for NHS Managers.

Include in appraisal process


Duplicate. Links to 3, 4, 5 and 7

Red = Delayed


As above (action 3) 07.07.2015 - Jo Emery

to include within appraisal process

10 21

Staff will follow guidance and comply with standards relevant to their work, such as those produced by the National Institute for Health and Clinical Excellence and, where relevant, the Care Quality Commission, subject to any more specific requirements of their employers.

i. Ensure all staff are aware of the CQC fundamental standards and their responsibilities for delivering them

1


The new fundamental standards are being developed into a staff handbook

Feb-15 Red = Delayed

Apr-15 Green = Completed

Staff handbook developed around new CQC Fundamental standards and distributed by managers who have been fully briefed on purpose, the need to gather evidence of delivery personally for staff and organisationally by managers. Knowledge being tested on quality walkarounds

ii. Ensure there is a robust process for monitoring NICE guidance and ensure recommendations are implemented in practice and monitored


New patient safety alert system on Ulysses developed to include electronic cascade and audit trail of actions in place. Organisational link identified for all NICE guidance, audit reports on compliance in development


Green = Completed

Patient Safety Manager responsible for monitoring and cascade

Page 11 of 38

iii. Have robust policies and procedures that reflect best practice and monitor compliance against same


new policy developed for the development and management of procedural governance documents which improves the ratification and monitoring of policies through board level committees. All clinical policies are undergoing review and a new quality management system is being populated with all policies to facilitate staff access, alert system when policies are due for review

Feb-15 Green = Completed

Sep-15

Amber = In Progress but risk of slippage

Staff has access to policies electronically via the intranet to Q-Pulse. Alerts and reporting require further consideration. - policy review against NHSLA standards is continuing when policies are due for review.

11 20

Healthcare professionals should be prepared to contribute to the development of, and comply with, standard procedures in the areas in which they work. Their managers need to ensure that their employees comply with these requirements. Staff members affected by professional disagreements about procedures must be required to take the necessary corrective action, working with their medical or nursing director or line manager within the trust, with external support where necessary.

1 & 3 Chief Operating Officer

All staff are contributing to the development of and are complying with standard procedures in the areas they work. Any employee identified as not working to agreed procedures will be challenged appropriately

immediate Green = Completed

immediate Green = Completed

Ongoing

A common culture made real throughout the system-an integrated hierarchy of standards of service.

13 The nature of standards

21

Standards should be divided into:

i. Quality Strategy developed to ensure minimum safety standards are exceeded and monitored

1


Quality strategy developed and ratified and metrics to be added to IQPR/IPR to ensure CQC fundamental standards are monitored and reported to Quality Committee


Sep-15


Following governance review quality strategy measures monitored through quality governance group and associated subgroups. Quality metrics Reports being developed by Ulysses.

i. Fundamental standards of minimum safety and quality to be abided by– in respect of which non-compliance should not be tolerated.

ii. CQC fundamental standards complied with and monitored


Plan required to ensure all staff are aware of the new CQC fundamental standards and how they contribute to these in their everyday roles



Staff handbook developed and circulated/available on intranet

Jun-15

ii. Failures leading to death or serious harm should remain offences for which prosecutions can be brought against organisations. There should be a defined set of duties to maintain and operate an effective system to ensure compliance;

iii. Trust needs to be fully aware of risks and ensure Duty of Candour is applied


BAF and risk register reveiwed 6 monthly. Training on risk management training part of management essentials training. New system update records duty of candour compliance

Green = Completed

Green = Completed

Duty of candour reporting monitored monthly through ECLIPS

Page 12 of 38

iii. Enhanced quality standards – such standards could set requirements higher than the fundamental standards but be discretionary matters for commissioning and subject to availability of resources to be met;

iv. Ensure enhanced quality standards are delivered and monitored


Enhanced Quality standards identified within the trusts quality report and monitored through Quality Governance Group

Green = Completed

Green = Completed

iv. Developmental standards which set out longer term goals for providers – these would focus on improvements in effectiveness and are more likely to be the focus of commissioners and progressive provider leadership than the regulator. All such standards would require regular review and modification

v. As above Director of Clinical Care and Patient Safety

CQUIN



14 9

In addition to the fundamental standards of service, the regulations should include generic requirements for a governance system designed to ensure compliance with fundamental standards, and the provision and publication of accurate information about compliance with the fundamental and enhanced standards.

Internal reporting systems to measure compliance with Fundamental standards now being developed along the KLOE

1 Director of Clinical Care and Patient Safety

KLOE discussed with performance leads and business managers. Report in progress of development to report to delivering consistently meetings. Compliance officer collates evidence. Develop a station performance framework 'perfect station'


September 15


Full organisational Gap analysis carried out against the CQC fundamental standards and KLOE. Which will inform a programme of work. Compliance against those standards will report through the quality governance framework. IT system being scoped to support this work

15 11

All the required elements of governance should be brought together into one comprehensive standard. This should require not only evidence of a working system but also a demonstration that it is being used to good effect.

Governance structure being reviewed by Deloitte. Recommendations to be implemented once report produced

6 Executive team Draft report received. In discussion with Deloitte to finalise report.


September 15


Action plan now in situ and working to timescales

21

The regulator will have a duty to monitor the accuracy of information disseminated by providers and commissioners on compliance with standards and their compliance with the requirement of honest disclosure. The regulator must be willing to consider individual cases of gross failure as well as systemic causes for concern.

Intelligent monitoring and robust evidence of assurance

Executive team .Data quality/kite mark being developed for internal measures

Apr-15


September 15


IM not yet available for ambulance trusts


See 14 for updates re KLOE evidence

May-15 Green = Completed

May-15


See 14 for updates re KLOE evidence

Page 13 of 38

23

Responsibility for regulating and monitoring compliance

21

The measures formulated by the National Institute for Health and Clinical Excellence should include measures not only of clinical outcomes, but of the suitability and competence of staff, and the culture of organisations. The standard procedures and practice should include evidence-based tools for establishing what each service is likely to require as a minimum in terms of staff numbers and skill mix. This should include nursing staff on wards, as well as clinical staff. These tools should be created after appropriate input from specialties, professional organisations, and patient and public representatives, and consideration of the benefits and value for money of possible staff: patient ratios.

Implement establishment control systems


· Improved establishment control arrangements introduced 1.4.13

2013/14. April 15

Red = Delayed

Mar-16


Update 29/12/2014:

Changed from Green to Amber as further controls need to be developed and embedded. Recruitment controls are established and starting salary policy has been drafted and is in circulation for comment. Other controls for staff movements need to be reviewed and assessed. Update 06.03.15 -

Assessing the suitability and competence of staff is a significant area of work. It links to the employee data project (evidence checks) and the development of ‘fitness to practice’ reporting which will become a standard item of reporting in the Workforce metrics report. Many checks and balances are required to be brought back into HR and it is envisages ESR will facilitate data capture, automated reporting and monitoring. The ESR project is key to being able to assess its capability (and limitations) to determine what other software may be required. A review of OLM (the learning management element of ESR) is also underway about what can/can’t be captured. A competency framework is also in development and will form part of the annual appraisal process (and capability assessment). A review of CPD is also underway due to the disparate nature of capture in the past; this is being pulled together for a review. Similarly, DBS systems are being made singular, so in effect ‘one source of the truth’. 07.07.2015 - Values,

attitudes and behaviours should be assessed at the recruitment stage. This is in place through our approach to values based recruitment however an impact review is

Page 14 of 38

Implement effective workforce planning

Head of Workforce · Improved workforce planning arrangements introduced 1.4.13

2013/14. April 15

Red = Delayed

Oct-15


Update 29/12/2014:

NK Changed from Green to Red as workforce planning has been totally ineffective for the last 12-24 months and working groups need new ToR . Progress is being made for EC, predominantly Paramedics but shortages across all staff groups need to be addressed. 07.07.2015 - On-going

but not embedded.

Implement effective workforce management


· Workforce analysis and recommendations reported to Executive Team – July


Green = Completed

Update 29/12/2014: A

fulsome review of workforce analysis needs to be redone and prepared for ET for review in January. On target for Board report for January. Received workforce plan numbers on 1st January 20145.

Implement effective resource scheduling systems

Director of Workforce and Organisational Development/ Chief Operating Officer

· Workforce planning strategy and plan reported to Executive Team - Sept. This action is about scheduling systems and needs to be transferred from NK to PLL.

tbc Red = Delayed

tbc


Update 29/12/2014:

NK to agree change in accountable officer with COO/CEO. July 2015 - Project

underway - DEPRO - Joanne Greenup

Apply protected time


· Workforce management system introduced to Contact Centre.

2013/14 Green = Completed

Green = Completed

Fully implemented. Ownership currently sits with COO. Update 29/12/2014: NK to

agree change in accountable officer with COO/CEO.

Workforce planning


· Role and protected time arrangements of Emergency Care Team Leader under review. Workforce analysis and recommendations reported to Executive Team – July

Mar-15 Green = Completed

Green = Completed

Update 29/12/2014:

ECCM role finalised, subject to operational duties apportionment. Recruitment commenced December to be concluded by March 2015/

Paramedic registration/CPD


· Workforce planning strategy and plan reported to Executive Team - Sept.


Green = Completed

Update 29/12/2014:

Need to be satisfied on a continuous basis of all reporting arrangements. Proposed to be reviewed annually via Internal Audit Programme.

Report to Match meeting of BIG, ET and Audit Committee

Develop effective CPD for wider NEAS workforce


Work is now being progressed to review CPD.

Oct-15 Red = Delayed

Oct-15


Update 29/12/2014:

Outstanding. Jan: Picked up within OD and set new date of Oct 15

Page 15 of 38

Apply principle of patient care paramount for all NEAS workforce


· Workforce Development 2014 / 2015

2014/15 Red = Delayed


See 3 for updates Update 08.04.15 from PLL : New Terms of

Reference compiled to amalgamate Workforce Planning Group, Workforce Development Group and Task and Finish Group to ensure that we are keeping pace with the changes in the workforce and maintaining high establishment numbers in each Service Line. Task and Finish Group will continue until new ToR are embedded and will also continue to submit a monthly report to the Trust Board.

24

Compliance with regulatory fundamental standards must be capable so far as possible of being assessed by measures which are understood and accepted by the public and healthcare professionals.

compliance to be reported to the public board in an easy to understand format


Quality Strategy and quality report will monitor some elements of compliance/scoping IT system to support collection of wider trust evidence


September 15


CQC compliance report compiled by compliance officer and reported through Quality governance framework monthly/requires further development

26 9

In policing compliance with standards, direct observation of practice, direct interaction with patients, carers and staff, and audit of records should take priority over monitoring and audit of policies and protocols. The regulatory system should retain the capacity to undertake in-depth investigations where these appear to be required

Care Quality Commission (CQC) inspections to look more closely at records and observe practice


Preliminary assessment undertaken of consultation information.

Mar-15

Green = Completed

Ongoing

Green = Completed


Plan full review of Care Quality Commission expectations of ambulance services recently published

Green = Completed

Green = Completed

- Review CQC expectations and assessment arrangements


Full review of patient facing policies associated with same being undertaken



Policies being assessed against NHSLA standards when due review


Records audit bi annually included in audit programme

Green = Completed

Green = Completed


Processes for safe transfer of paper records being developed to improve IG

Green = Completed

Green = Completed


Mandatory use of ePCR from 1st march 2014 – being monitored

Green = Completed

Green = Completed

Page 16 of 38

28 21

Zero tolerance: A service incapable of meeting fundamental standards should not be permitted to continue. Breach should result in regulatory consequences attributable to an organisation in the case of a system failure and to individual accountability where individual professionals are responsible. Where serious harm or death has resulted to a patient as a result of a breach of the fundamental standards, criminal liability should follow and failure to disclose breaches of these standards to the affected patient (or concerned relative) and a regulator should also attract regulatory consequences. Breaches not resulting in actual harm but which have exposed patients to a continuing risk of harm to which they would not otherwise have been exposed should also be regarded as unacceptable.


Duty of candour included in the current standard contract since April 2013 and is being reported – Family Liaison Officers now trained and available to support families

Nov-14 Green = Completed

Green = Completed

Monitoring has commenced

29

It should be an offence for death or serious injury to be caused to a patient by a breach of these regulatory requirements, or, in any other case of breach, where a warning notice in respect of the breach has been served and the notice has not been complied with. It should be a defence for the provider to prove that all reasonably practicable steps have been taken to prevent a breach, including having in place a prescribed system to prevent such a breach.

Ensure there are systems and processes in place to monitor compliance with regulatory standards


In place Apr-14 Green = Completed

Green = Completed

Ensure all staff abide by these standards and managers regularly monitor compliance

Chief Operating Officer

Any non-compliance is challenged and the necessary action taken to correct

Immediate Green = Completed

Green = Completed

Ongoing

Page 17 of 38

36 Use of information for effective regulations

9

A coordinated collection of accurate information about the performance of NEAS must be available to providers, commissioners, regulators and the public, in as near real time as possible, and should be capable of use by regulators in assessing the risk of non-compliance. It must not only include statistics about outcomes, but must take advantage of all safety related information, including that capable of being derived from incidents, complaints and investigations.

Continued development of the data warehouse and BI solution does indeed help meet this recommendation. CAD is currently reported within 15 minutes but our aim is to get this to 2 minutes live. Now we have access to Ulysses we can report that to the hour and give the breakdown of complaints and investigations. We already have a number of reports that are available to providers, commissioners, regulators and patients. EIS solution will continue to improve this. The term “performance of NEAS” is a broad one and could technically encompass a number of areas including Fleet and Occ Health. However you’ll know we struggle to report non-compliance for parts of the Trust due to poor system use / data held on paper or spreadsheets. I made some recommendations in the paper I sent you around system owners (in particular Geoff, Tom and Bridget) thinking about RPIWs for their areas regarding systems / processes. Not sure how feasible this is at present given winter pressures etc. but hopefully Agile will begin to address this…


EIS programme to develop robust reporting warehouse dashboards and provide reports on key metrics

999 to be complete by Jan 14. 111 and PTS to be in by May 15. Then we will move to support services data but no set completion yet.

Green = Completed

999 to be complete by Jan 14. 111 and PTS to be in by May 15. Then we will move to support services data but no set completion yet.

Green = Completed

Page 18 of 38

37

Use of information about compliance by regulator from: Quality Accounts

11

Trust Boards should provide, through quality accounts, and in a nationally consistent format, full and accurate information about their compliance with each standard which applies to them. To the extent not been achieved. A full account should be given as to the methods used to produce the information. that it is not practical in a written report to set out detail, this should be made available via each trust’s website. Reports should no longer be confined to reports on achievements as opposed to a fair representation of areas where compliance has not been achieved. A full account should be given as to the methods used to produce the information. To make or be party to a wilfully or recklessly false statement as to compliance with safety or essential standards in the required quality account should be made a criminal offence.

To compile the Annual Quality Account in accordance with guidance.

Associate Director of Strategy, Performance and Contracting

The 2014/15 Quality Account is currently being drafted.

tbc Green = Completed

Jun-15 Green = Completed

Update 29/12/2014: There was little change proposed to the Account for 2014/15 in latest consultation, some change expected in relation to the ARM on finance presentation.

Jun-15

38

The Care Quality Commission should ensure as a matter of urgency that it has reliable access to all useful complaints information relevant to assessment of compliance with fundamental standards, and should actively seek this information out, probably via its local relationship managers. Any bureaucratic or legal obstacles to this should be removed.

Develop a system for ensuring any complaints relating to the fundamental standards are readily available to CQC


Set up a system with complaints team to ensure complaints relating to the fundamental standards are reported and tracked.


Sep-15


in progress

39

Ensure reporting allows for this reporting



Sep-15


as above

40

It is important that greater attention is paid to the narrative contained in, for instance, complaints data, as well as to the numbers.

Ensure narrative is contained in complaints data/reporting


monthly board report includes narrative

Jun-14 Green = Completed

Green = Completed

Page 19 of 38

41

The Care Quality Commission should have a clear responsibility to review decisions not to comply with patient safety alerts and to oversee the effectiveness of any action required to implement them. Information-sharing with the Care Quality Commission regarding patient safety alerts should continue following the transfer of the National Patient Safety Agency’s functions in June 2012 to the NHS Commissioning Board.

Develop a robust patient safety alert system and the ability to produce reports on compliance against actions


new system developed, to be rolled out January 15


Green = Completed

42

NECS/Area Teams should, as a matter of routine, share information on serious untoward incidents with the Care Quality Commission.

For information Blue = For Information

Blue = For Information

43

Those charged with oversight and regulatory roles in healthcare should monitor media reports about the organisations for which they have responsibility.

NEAS media office to monitor both positive and negative media and report on same

Assistant Director of Communications and Engagement

Regular media monitoring and analysis is reviewed each quarter at ECLIPs.

Already being done

Green = Completed

Green = Completed

44

Any example of a serious incident or avoidable harm should trigger an examination by the Care Quality Commission of how that was addressed by the provider and a requirement for the trust concerned to demonstrate that the learning to be derived has been successfully implemented.

Ensure that there is a robust process for investigating and applying learning from SI’s and those plans are monitored

1 Director of Clinical Care and Patient Safety

root cause analysis process undergoing full review, incident reporting system undergoing full reconfiguration to record actions taken and learning


Sep-15


RCA process reviewed against new national SI policy published March 2015

45

The Care Quality Commission should be notified directly of upcoming healthcare-related inquests, either by trusts or perhaps more usefully by coroners.

Ensure all inquests are reported to CQC


CQC and coroners society are developing an MOU


Green = Completed

46

The Quality and Risk Profile should not be regarded as a potential substitute for active regulatory oversight by inspectors. It is important that this is explained carefully and clearly as and when the public are given access to the information.

For information Director of Clinical Care and Patient Safety



47

The Care Quality Commission should expand its work with overview and scrutiny committees and foundation trust governors as a valuable information resource. For example, it should further develop its current ‘sounding board events’.

For information Chairman Blue = For Information


Page 20 of 38

48

The Care Quality Commission should send a personal letter, via each registered body, to each foundation trust governor on appointment, inviting them to submit relevant information about any concerns to the Care Quality Commission.

For information Chairman Blue = For Information


59 11

Consideration should be given to the introduction of a category of nominated board members from representatives of the professions, for example, the Academy of Medical Royal Colleges, a representative of nursing and allied healthcare professionals, and patient representative groups.

[Not included in current action-Trust to consider if an action is needed] - Board has a 2 registered nurses and a medical director

Trust Board Green = Completed

Green = Completed

Board has a 2 registered nurses and a medical director

75

The Council of Governors and the board of each foundation trust should together consider how best to enhance the ability of the council to assist in maintaining compliance with its obligations and to represent the public interest. They should produce an agreed published description of the role of the governors and how it is planned that they perform it. Monitor and the Care Quality Commission should review these descriptions and promote what they regard as best practice.

Chairman

Governor role descriptions are included in Governor induction packs and these descriptions are based on Monitor guidance. In addition Governors are involved in external programmes such as GovernWell and a number of annual training events are held throughout the year to ensure that Governors are kept informed of their obligations and new regulatory guidance - for example a training session on the fit and proper persons requirement will be held in April 2015. See recommendation 75 re: current work being undertaken to strengthen the Governors' ability to represent both staff and member interests as part of the Deloitte governance review action plan.

On-going Green = Completed


Update 14/07/15: Fit

& Proper Persons Requirements Task & Finish Group disbanded after its meeting in June 2015. Its work will feed into the Workforce Committee as business as usual (Action Plan will be submitted to Committee for monitoring progress). Presentations by Donna Hunwick to Governors and Board respectively at their April meetings.

Page 21 of 38

76

Arrangements must be made to ensure that governors are accountable not just to the immediate membership but to the public at large – it is important that regular and constructive contact between governors and the public is maintained.

Chairman

Governors are invited to events that NEAS also attend, such as Mela and Pride, and meet the public. They are also invited to observe NEAS officers being scrutinised by public officials so that they may understand the public perspective of NEAS. These meetings are reported to the Governors’ Membership & Engagement Committee and the Trust’s ECLIPs group. A related action has been identified on the Deloitte action plan regarding the need to ensure that Governor relationships with members are further developed

May-15 Red = Delayed

Green = Completed

Amber rating reflects the need to enhance the engagement strategy in line with the Deloitte governance action plan. Update 14/07/15: Staff and

membership engagement will be a recurring agenda item on membership committee meeting agendas. An engagement strategy will be in place with clear, measurable milestones to ensure effective implementation. A Governor workshop to seek their views was held in May 15 to discuss options for engagement. A survey has been issued to all governors to ensure their views are captured. Next steps are identifying the most popular options and developing mechanisms to support governors in engaging with members and the public in this way.

77

Monitor and the NHS Commissioning Board should review the resources and facilities made available for the training and development of governors to enhance their independence and ability to expose and challenge deficiencies in the quality of the foundation trust’s services.

Chairman

A series of training events are held for Governors throughout the year. In 2014/15 this included sessions on health promotion and strategy as well as Governor attendance at national GovernWell events. One Governor has been elected as the ambulance sector representative on NHS Providers' Governor Policy Board.

Ongoing Green = Completed

Ongoing


Need to consider whether we put in place a formal cycle of training to ensure that dedicated time is set aside for skills and knowledge development. Update 14/07/15:

Future training plan to be developed. A session is being held on 27/07/2015 to provide further training on the role of the Governor.

78

The Care Quality Commission and Monitor should consider how best to enable governors to have access to a similar advisory facility in relation to compliance with healthcare standards as will be available for compliance issues in relation to breach of a licence (pursuant to section 39A of the National Health Service Act 2006 as amended), or other ready access to external assistance.



Page 22 of 38

Responsibility for, and effectiveness of, regulating healthcare systems governance-Monitor's healthcare systems regulatory functions

79 Accountability of provider's directors

10

There should be a requirement that all directors of all bodies registered by the Care Quality Commission as well as Monitor for foundation trusts are, and remain, fit and proper persons for the role. Such a test should include a requirement to comply with a prescribed code of conduct for directors

Apply the fit and proper persons test to all Board members

Trust Secretary

Documentation and recruitment processes are being developed, which will first apply to new Non-Executive Director. Process to be establsihed to capture the intelligence of all Board Members by March 2015 for reporting purposes - Annual Report and Quality Report.



Update 29/12/2014:

NK and KD leading Update 15/04/2015:

Papers presented to the January Board outlining the fit and proper person requirements. A task and finish group has been set up to lead on this. The Constitution and Standards of Business Conduct policy will be updated in May 2015 to reflect the new requirements. Update 22/07/2015:

FPP test applied to new Directors and the Trust's legal adviser has also checked the professional registration of all applicable Directors. Further work to be conducted to ensure that evidence of compliance with FPP is included on all Directors' files.

80 11

A finding that a person is not a fit and proper person on the grounds of serious misconduct or incompetence should be a circumstance added to the list of disqualifications in the standard terms of a foundation trust’s constitution.

To update FT constitution.

Trust Secretary

See 80 for general progress made in implementing the fit and proper person test but the Constitution still requires update. A paper will be presented to the April Council of Governors meeting to outline the changes required and the changes must also be approved by the Board.


Green = Completed

The changes to the Constitution were approved by the Board and the Council of Governors in April 2015 and the Constitution now takes the FPP requirements into account. Action completed.

81 11

Consideration should be given to including in the criteria for fitness a minimum level of experience and/or training, while giving appropriate latitude for recognition of equivalence.

See 79. Trust Board Red = Delayed


See 80

82

Provision should be made for regulatory intervention to require the removal or suspension from office after due process of a person whom the regulator is satisfied is not or is no longer a fit and proper person, regardless of whether the trust is in significant breach of its authorisation or licence.

See 79 and 7. Trust Board Red = Delayed


See 79 and 8

Page 23 of 38

84

Where the contract of employment or appointment of an executive or non-executive director is terminated in circumstances in which there are reasonable grounds for believing that he or she is not a fit and proper person to hold such a post, licensed bodies should be obliged by the terms of their licence to report the matter to Monitor, the Care Quality Commission and the NHS Trust Development Authority.

See 7. Trust Board



See 21.

85

Monitor and the Care Quality Commission should produce guidance to NHS and foundation trusts on procedures to be followed in the event of an executive or non-executive director being found to have been guilty of serious failure in the performance of his or her office, and in particular with regard to the need to have regard to the public interest in protection of patients and maintenance of confidence in the NHS and the healthcare system.

For information Trust Board Blue = For Information


86 Requirement of training of directors

10

A requirement should be imposed on foundation trusts to have in place an adequate programme for the training and continued development of directors.

See 2 in relation to Board Development Programme (iii)

Trust Board Red = Delayed


See 3

Responsibility for, and effectiveness of, regulating healthcare systems governance – Health and Safety Executive functions in healthcare settings

87

The Health and Safety Executive is clearly not the right organisation to be focusing on healthcare. Either the Care Quality Commission should be given power to prosecute 1974 Act offences or a new offence containing comparable provisions should be created under which the Care Quality Commission has power to launch a prosecution.



88

The information contained in reports for the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations should be made available to healthcare regulators through the serious untoward incident system in order to provide a check on the consistency of trusts’ practice in reporting fatalities and other serious incidents.


Green = Completed

Green = Completed

Page 24 of 38

89

Reports on serious untoward incidents involving death of or serious injury to patients or employees should be shared with the Health and Safety Executive.

in place Director of Clinical Care and Patient Safety

Green = Completed

Green = Completed

90

In order to determine whether a case is so serious, either in terms of the breach of safety requirements or the consequences for any victims, that the public interest requires individuals or organisations to be brought to account for their failings, the Health and Safety Executive should obtain expert advice, as is done in the field of healthcare litigation and fitness to practise proceedings.



Enhancement of the role of supportive agencies

91

The Department of Health and NHS Commissioning Board should consider what steps are necessary to require all NHS providers, whether or not they remain members of the NHS Litigation Authority scheme, to have and to comply with risk management standards at least as rigorous as those required by the NHS Litigation Authority.

NEAS already aspires to the NHSLA standards and will continue to develop in this regard


Working towards level 2



Policies currently undergoing assessment

92

The financial incentives at levels below level 3 should be adjusted to maximise the motivation to reach level 3.



93

The NHS Litigation Authority should introduce requirements with regard to observance of the guidance to be produced in relation to staffing levels, and require trusts to have regard to evidence-based guidance and benchmarks where these exist and to demonstrate that effective risk assessments take place when changes to the numbers or skills of staff are under consideration. It should also consider how more outcome based standards could be designed to enhance the prospect of exploring deficiencies in risk management, such as occurred at the Trust.




Page 25 of 38

94

As some form of running record of the evidence reviewed must be retained on each claim in order for these reports to be produced, the NHS Litigation Authority should consider development of a relatively simple database containing the same information.




95

As the interests of patient safety should prevail over the narrow litigation interest under which confidentiality or even privilege might be claimed over risk reports, consideration should also be given to allowing the Care Quality Commission access to these reports.




98

Reporting to the National Reporting and Learning System of all significant adverse incidents not amounting to serious untoward incidents but involving harm to patients should be mandatory on the part of trusts.


Green = Completed

Green = Completed

99

The reporting system should be developed to make more information available from this source. Such reports are likely to be more informative than the corporate version where an incident has been properly reported, and invaluable where it has not been.

in progress Director of Clinical Care and Patient Safety



100

Individual reports of serious incidents which have not been otherwise reported should be shared with a regulator for investigation, as the receipt of such a report may be evidence that the mandatory system has not been complied with.

All SI's are reported Director of Clinical Care and Patient Safety

Green = Completed

Green = Completed

104

The Care Quality Commission should be enabled to exploit the potential of the safety information obtained by the National Patient Safety Agency or its successor to assist it in identifying areas for focusing its attention. There needs to be a better dialogue between the two organisations as to how they can assist each other.

Ensure all incidents reported use appropriate language and ……




105

Consideration should be given to whether information from incident reports involving deaths in hospital could enhance consideration of the hospital standardised mortality ratio.

Mortality not currently measured but plans in development to monitor deaths

Medical Director Blue = For Information


Page 26 of 38

107

If the Health Protection Agency or its successor, or the relevant local director of public health or equivalent official, becomes concerned that a provider’s management of healthcare associated infections is or may be inadequate to provide sufficient protection of patients or public safety, they should immediately inform all responsible commissioners, including the relevant regional office of the NHS Commissioning Board, the Care Quality Commission and, where relevant, Monitor, of those concerns. Sharing of such information should not be regarded as an action of last resort. It should review its procedures to ensure clarity of responsibility for taking this action.




Effective complaints handling

Patients raising concerns about their care are entitled to: have the matter dealt with as a complaint unless they do not wish it; identification of their expectations; prompt and thorough processing; sensitive, responsive and accurate communication; effective and implemented learning; and proper and effective communication of the complaint to those responsible for providing the care.

109 3

Methods of registering a comment or complaint must be readily accessible and easily understood. Multiple gateways need to be provided to patients, both during their treatment and after its conclusion, although all such methods should trigger a uniform process, generally led by the provider trust.

Ensure a robust and responsive complaints system


Complaints service planned to undergo review to improve systems and processes.



Mar-14

Complete Complaint process completely reviewed and now all managed via electronic Ulysses system. Monthly reports sent to service lines on compliance with policies around complaints and reported into QC

110

Actual or intended litigation should not be a barrier to the processing or investigation of a complaint at any level. It may be prudent for parties in actual or potential litigation to agree to a stay of proceedings pending the outcome of the complaint, but the duties of the system to respond to complaints should be regarded as entirely separate from the considerations of litigation.




111 3

Provider organisations must constantly promote to the public their desire to receive and learn from comments and complaints; constant encouragement should be given to patients and other service users, individually and collectively, to share their comments and criticisms with the organisation.

- Maximise learning from complaints


Systems in place to maximise learning from complaints

Green = Completed

Green = Completed

- Chief Executive and board to take personal responsibility for complaints

- Boards to see monthly data regarding complaints ‘ the narrative and not just numbers’

Page 27 of 38

Implement strategic engagement plan

112 3

Patient feedback which is not in the form of a complaint but which suggests cause for concern should be the subject of investigation and response of the same quality as a formal complaint, whether or not the informant has indicated a desire to have the matter dealt with as such.

Engage with PALS


Complaints team engaged with PALS and process changes have been made regarding customer feedback and complaint referrals to PALS. Good working relationships established and understanding from both NEAS and PALS regarding patient needs for feedback and complaint handling

Green = Completed

Green = Completed

Engage with patient focus groups

Ensure robust process for recording and reporting concerns

113

The recommendations and standards suggested in the Patients Association’s peer review into complaints at the Mid Staffordshire NHS Foundation Trust (CLYWD) should be reviewed and implemented in the NHS.

Ensure clywd recommendations are incorporated into complaints policies


complete Green = Completed

Green = Completed

114 3

Comments or complaints which describe events amounting to an adverse or serious untoward incident should trigger an investigation.


Existing processes in place to ensure any complaints describing serious untoward incidents trigger an investigation through RCA process

Green = Completed

Green = Completed

Trends and themes from incidents to be reported and lessons learned to prevent re-occurrence

115 Investigations 3

Arms-length independent investigation of a complaint should be initiated by the provider trust where any one of the following apply: · A complaint amounts to an allegation of a serious untoward incident; · Subject matter involving clinically related issues is not capable of resolution without an expert clinical opinion; · A complaint raises substantive issues of professional misconduct or the performance of senior managers; · A complaint involves issues about the nature and extent of the services commissioned. (Recommendation accepted in part in Hard Truths)

NEAS already has systems in place to follow this recommendation


Green = Completed

Green = Completed

116 Support for complainants

3

Where meetings are held between complainants and trust representatives or investigators as part of the complaints process, advocates and advice should be readily available to all complainants who want those forms of support.

Family Liaison officers are trained and in place


In place Green = Completed


Being further developed

Page 28 of 38

117

A facility should be available to Independent Complaints Advocacy Services advocates and their clients for access to expert advice in complicated cases.

For information




118 Learning and information from complaints

3

Subject to anonymisation, a summary of each upheld complaint relating to patient care, in terms agreed with the complainant, and the trust’s response should be published on its website. In any case where the complainant or, if different, the patient, refuses to agree, or for some other reason publication of an upheld, clinically related complaint is not possible, the summary should be shared confidentially with the Commissioner and the Care Quality Commission.

Report learning on Trust website


Reporting on Trust website under development

Aug-14 Red = Delayed

End Sept 2015


10.04.15 Process under review. AW met with complaints team to start webpage build and training for website uploads. July 2015 - Meeting

with AG, AW and GS to discuss - over 700 complaints letters per year - the amount of time taken to contact patients etc. for their consent to publish the letters is too onerous. Additional summary to be shared with Monitor and Commissioners. Research into other NHS Trusts looking at this recommendation and no other Trusts are doing this. Posting from ECLIPS reports, learning from complaints. Web page developed by Comms team - awaiting confirmation of exactly what should be published.

119 3

Overview and scrutiny committees and Local Healthwatch should have access to detailed information about complaints, although respect needs to be paid in this instance to the requirement of patient confidentiality


Bi-annual presentation on performance, quality and complaints is made to the North East regional Health scrutiny committee. Newcastle OSC, as the “home” OSC for NEAS, also receives regular complaints information and feedback.

Already being implemented.

Green = Completed

Already being implemented.

Green = Completed

121

The Care Quality Commission should have a means of ready access to information about the most serious complaints. Their local inspectors should be charged with informing themselves of such complaints and the detail underlying them.




Openness, transparency and candour

Openness – enabling concerns and complaints to be raised freely without fear and questions asked to be answered.

Transparency – allowing information about the truth about performance and outcomes to be shared with staff, patients, the public and regulators.

Candour – any patient harmed by the provision of a healthcare service is informed of the fact and an appropriate remedy offered, regardless of whether a complaint has been made or a question asked about it.

Page 29 of 38

173

Principles of openness, transparency and candour

22

Every healthcare organisation and everyone working for them must be honest, open and truthful in all their dealings with patients and the public, and organisational and personal interests must never be allowed to outweigh the duty to be honest, open and truthful

Further develop and foster a culture of being open


Duty of candour included in the current standard contract since April 2013 and is being reported – Family Liaison Officers now trained and available to support families

Green = Completed

Green = Completed

New recommendations for duty of candour – paper produced for QC and WEC – awaiting government response

174 Candour about harm

22

Where death or serious harm has been or may have been caused to a patient by an act or omission of the organisation or its staff, the patient (or any lawfully entitled personal representative or other authorised person) should be informed of the incident, given full disclosure of the surrounding circumstances and be offered an should be informed of the incident, given full disclosure of the surrounding circumstances and be offered an appropriate level of support, whether or not the patient or representative has asked for this information.

The new duty of candour regulations have been implemented


Ulysses System has been upgraded to record all duty of candour and being open cases

Green = Completed

Green = Completed

175 22

Full and truthful answers must be given to any question reasonably asked about his or her past or intended treatment by a patient (or, if deceased, to any lawfully entitled personal representative)

Green = Completed

Green = Completed

176 Openness with regulators

22

Any statement made to a regulator or a commissioner in the course of its statutory duties must be completely truthful and not misleading by omission

Green = Completed

Green = Completed

177 Openness in public statements

22

Any public statement made by a healthcare organisation about its performance must be truthful and not misleading by omission

Chief Executive On-going



All public statements are open and transparent. For example our governance rating trigger event was disclosed within our Annual Report.

178

Implementation of the duty. Ensuring consistency of obligations under the duty of openness, transparency and candour.

22

all organisations should review their contracts of employment, policies and guidance to ensure that, where relevant, they expressly include and are consistent with open and honest principles and abide by the duty of candour and these recommendations.

See 7 re contract reviews. To review new policy /guidance to ensure obligations are included.


Not started Jan-15 Red = Delayed


See 7.

Page 30 of 38

179 Restrictive contractual clauses

22

“Gagging clauses” or non-disparagement clauses should be prohibited in the policies and contracts of all healthcare organisations, regulators and commissioners; insofar as they seek, or appear, to limit bona fide disclosure in relation to public interest issues of patient safety and care.

As above Director of Strategy, Workforce and Transformation

Red = Delayed


See 178

180 Candour about incidents

22

Guidance and policies should be reviewed to ensure that they will lead to compliance with Being Open, the guidance published by the National Patient Safety Agency.


in place Green = Completed

Green = Completed

Nursing

185 Focus on culture of caring

23

There should be an increased focus in paramedic training, education and professional development on the practical

External review of training to commence in January 2015. Reporting timescales tbc


Scope of review in draft. Update 06.03.15 - Training

standards should be in place with emphasis being placed on a ‘caring culture’. • A review of training is in the process of being undertaken by Teesside University and we may be asked to contribute to an OFSTED inspections of HENE. • An independent review was also due to commence in January, however this has been delayed due to reliance of external reviewer. • It is anticipated this will start in March 2015. Work is underway to review the revalidation requirements for nursing staff which replaces the post-registration education and practices standards from 31 December 2015. • Preparations are also underway to roll out the care certificate for Bands 1-4 from April 2015. 07.07.2015 - Care

certificate - Ofsted by appointed member of staff - in receipt of draft report. M . Gordon leading on Nurse requirements


Mar-16


requirements of delivering compassionate care in addition to the theory. A system which ensures the delivery of

proper standards of requires:

· Selection of recruits to the profession who evidence the:

−− Possession of the appropriate values, attitudes and behaviours;

−− Ability and motivation to enable them to put the welfare of others above their own interests;

−− Drive to maintain, develop and improve their own standards and abilities;

−− Intellectual achievements to enable them to acquire through training the necessary technical skills;

· Training and experience in delivery of compassionate care;

· Leadership which constantly reinforces values and standards of compassionate care;

· Involvement in, and responsibility for, the planning and delivery of compassionate care;

· Constant support and incentivisation which values paramedics and the work they do through:

Page 31 of 38

−− Recognition of achievement;

−− Regular, comprehensive feedback on performance and concerns;

−− Encouraging them to report concerns and to give priority to patient well-being.

191 Recruitment for values and commitment

23

Healthcare employers recruiting clinical staff, whether qualified or unqualified, should assess candidates’ values, attitudes and behaviours towards the well-being of patients and their basic care needs, and care providers should be required to do so by commissioning and regulatory requirements

To assess impact of Values Based Recruitment processes.


Update requested from KS on 29/12/2014.


Mar-16


OD- Impact lead in post now to lead on this action. 07.07.2015 - Lead no

longer at the Trust and this has not yet been appointed

204 23

All healthcare providers and commissioning organisations should be required to have at least one executive director who is a registered nurse, and should be encouraged to consider recruiting nurses as non-executive directors.

The Director of Clinical Care and Patient Safety is a registered nurse and there is one Non-Executive Director with a nursing background.

Chairman No further action required Green = Completed

Green = Completed

Page 32 of 38

205 23

Commissioning arrangements should require the boards of provider organisations to seek and record the advice of its nursing director on the impact on the quality of care and patient safety of any proposed major change to clinical staffing arrangements or provision facilities, and to record whether they accepted or rejected the advice, in the latter case recording its reasons for doing so.

Develop systems to report safe staffing to board and publicly Ensure that robust processes are in place to ensure that planned changes to staffing do not have an impact on quality - i.e. Undertake robust quality impact assessments for service changes.

Trust Board

Hours reports is made available. Further detail is in development. A QIA process requiring the sign-off of the Director of Clinical Care and Patient Safety is in place for all cost improvement programmes / service changes.


Mar-16


Update 29/12/2014: A

'safe' staffing report is in development, a progress report was shared with Trust Board by NK in November 2014. Update 01/03/2015:

Report to March meeting of BIG, ET and Audit Committee Update 15/04/2015: In

recent months the Board and its committees have received a greater volume of workforce reports reporting both retrospective performance and future plans. Note that in line with NQB guidance there is a need to ensure that data on staffing capacity and capability is published publicly at least every six months - most papers are currently presented at the private Board meetings.

The reporting mechanisms from the QIA process are currently being revised as part of the response to the Deloitte governance review (recommendation 9). Amber rating assigned to reflect that this action is ongoing. 07.07.2015- report to

QC in July for further guidance re. assurance expectations

211 Training standards for healthcare support workers

23

There should be a common set of national standards for the education and training of healthcare support workers

To be incorporated in external training review - assessment and potential recommendations for improvement. See 185.


Red = Delayed


See 185.

Page 33 of 38

212 23

The code of conduct, education and training standards and requirements for registration for healthcare support workers should be prepared and maintained by the Nursing and Midwifery Council after due consultation with all relevant stakeholders, including the Department of Health, other regulators, professional representative organisations and the public.

As above. Director of Strategy, Workforce and Transformation

Red = Delayed


See 185.

Leadership

214 Shared training 24

A leadership staff college or training system, whether centralised or regional, should be created to: provide common professional training in management and leadership to potential senior staff; promote healthcare leadership and management as a profession; administer an accreditation scheme to enhance eligibility for consideration for such roles; promote and research best leadership practice in healthcare.

To assess the impact of the introduction of MET and new EAT and leadership.


Links to 191. Red = Delayed


See 191.

215 Shared code of ethics

24

A common code of ethics, standards and conduct for senior board-level healthcare leaders and managers should be produced and steps taken to oblige all such staff to comply with the code and their employers to enforce it.

To review NHS Code of Conduct for Managers to determine if separate 'code of ethics' is required.


Not started Apr-15


Mar-16


To start work in Qtr 4. Update 06.04.15 - It is

recommended a common code of ethics, standards and conduct for senior board-level healthcare leaders and managers should be produced and steps taken to oblige all staff to complete with the code and their employers to enforce it. This will be considered as we review our ‘values’ and also review the NHS code of conduct as part of contract review and link this work to rejuvenate our service improvement activity (lean) and development of a ‘compact’. 07.07.2015 - Values work to finish in September and then work on this will commence

Page 34 of 38

218 Enforcement of standards and accountability

24

Serious non-compliance with the code, and in particular, non-compliance leading to actual or potential harm to patients, should render board-level leaders and managers liable to be found not to be fit and proper persons to hold such positions by a fair and proportionate procedure, with the effect of disqualifying them from holding such positions in future.

As above and linked to contracts and fit and proper person guidance.


To include in contract review.


Apr-15


See 7.

Information

244

Common information practices, shared data and electronic records

26

There is a need for all to accept common information practices, and to feed performance information into shared databases for monitoring purposes. The following principles should be applied in considering the introduction of electronic patient information systems:


Record keeping policies had full review and now live on Q-pulse -


Jul-16


Record keeping policy under review. New eprf system being developed. National standards for ambulance records published 2014 are being incorporated into spec.

· Patients need to be granted user friendly, real time and retrospective access to read their records, and a facility to enter comments. They should be enabled to have a copy of records in a form useable by them, if they wish to have one. If possible, the summary care record should be made accessible in this way.

· Systems should be designed to include prompts and defaults where these will contribute to safe and effective care, and to accurate recording of information on first entry.

· Systems should include a facility to alert supervisors where actions which might be expected have no to have occurred, or where likely inaccuracies have been entered.

· Systems should, where practicable and proportionate, be capable of collecting performance management and audit information automatically, appropriately anonymised direct from entries, to avoid unnecessary duplication of input.

Page 35 of 38

· Systems must be designed by healthcare professionals in partnership with patient groups to secure maximum professional and patient engagement in ensuring accuracy, utility and relevance, both to the needs of the individual patients and collective professional, managerial and regulatory requirements. Systems must be capable of reflecting changing needs and local requirements over and above nationally required minimum standards.

245 Board accountability

26

Each provider organisation should have a board level member with responsibility for information




From 2011/12

247 Accountability for quality accounts

26

Healthcare providers should be required to lodge their quality accounts with all organisations commissioning services from them, Local Healthwatch, and all systems regulators

This is already an embedded part of the process.




No further action required.

248 26

Healthcare providers should be required to have their quality accounts independently audited. Auditors should be given a wider remit enabling them to use their professional judgement in examining the reliability of all statements in the accounts.

As above





249 26

Each quality account should be accompanied by a declaration signed by all directors in office at the date of the account certifying that they believe the contents of the account to be true, or alternatively a statement of explanation as to the reason any such director is unable or has refused to sign such a declaration.

As above





252 26

It is important that the appropriate steps are taken to enable properly anonymised data to be used for managerial and regulatory purposes.

IG controls are in place.

Executive team In place Green = Completed


255 Using patient feedback

26

Results and analysis of patient feedback including qualitative information need to be made available to all stakeholders in as near “real time” as possible, even if later adjustments have to be made.


Patient experience reports are available on Trust website and presented to stakeholder groups such as OSC and HealthWatch and QRG on demand.

Green = Completed

Green = Completed

Page 36 of 38

260 Information standards

26

The standards applied to statistical information about serious untoward incidents should be the same as for any other healthcare information and in particular the principles around transparency and accessibility. It would, therefore, be desirable for the data to be supplied to, and processed by, the Information Centre and, through them, made publicly available in the same way as other quality related information.

Report Serious Incidents and learning to Clinical Commissioning Groups and Quality Review Group




In place

262

Enhancing the use, analysis and dissemination of healthcare information

26

All healthcare provider organisations, in conjunction with their healthcare professionals, should develop and

Chief Operating Officer

Higher level information available. Informatics need to develop dashboards to be disseminated down to stations and staff

Mar-15 Red = Delayed

Green = Completed

Update 08.04.15 from PLL : Progress on this

is hindered by the development of relevant dashboards and information to be able to manage at individual staff member level. Director of Finance & Resources to identify date of completion.

maintain systems which give them:

· Effective real-time information on the performance of each of their services against patient safety and

minimum quality standards;

· Effective real-time information of the performance of each of their consultants and specialist teams in relation to mortality, morbidity, outcome and patient satisfaction.

In doing so, they should have regard, in relation to each service, to best practice for information management of

that service as evidenced by recommendations of the Information Centre, and recommendations of specialist

organisations such as the medical Royal Colleges.

The information derived from such systems should, to the extent practicable, be published and in any event made

available in full to commissioners and regulators, on request, and with appropriate explanation, and to the extent

that is relevant to individual patients, to assist in choice of treatment

Page 37 of 38

268 Resources 26

Resources must be allocated to and by provider organisations to enable the relevant data to be collected and forwarded to the relevant central registry.

Associate Director of Strategy, Performance and Contracting - If this

is in relation to central returns/STEIS then the accountability needs to transfer to RDF. Director of Finance and Resources

This refers to allocation of resources to ensure good quality data is collected locally and made available to central repositories such as the Health and Social Care Information Centre. The Trust has invested significant resources both to Informatics and users of local systems and fulfils its requirements in terms of reporting.



269 Improving and assuring accuracy

26

The only practical way of ensuring reasonable accuracy is vigilant auditing at local level of the data put into the system. This is important work, which must be continued and where possible improved.

vigilant auditing at local level of the data put into the system

Director of Finance and Resources to

assess all Directors to ensure Data Quality input into Information systems This section refers to the Quality of data specifically in relation to local audit of clinical records therefore arguably should be allocated to the Director of Clinical Quality and Patient Safety.

Each major Information system has a system owner (Information Asset Owner) responsible for the Quality of Data input to their systems via the Data Quality Group Ownership is at best patchy as is attendance at the Group

On going


On going


This section refers to the Quality of data specifically in relation to local audit of clinical records therefore arguably should be allocated to the Director of Clinical Quality and Patient Safety. Notwithstanding that the Trust has invested heavily in clinical audit over recent years to the extent that the trust audits 3 times as many clinical records as strictly necessary under legislation.

On going

273 Information to Coroners

14

The terms of authorisation, licensing and registration and any relevant guidance should oblige healthcare providers to provide all relevant information to enable the coroner to perform his function, unless a director is personally satisfied that withholding the information is justified in the public interest.


Green = Completed

Green = Completed

Green 64 Green 64

Purple 1 Purple 16

Amber 9 Amber 29

Red 35 Red 0

Blue 18 Blue 18

Total 127 Total 127

Page 38 of 38

Documents

New CATEGORY OF PAPER Specific action required: Provides … · 2015. 7. 27. · Page 1 of 38 CATEGORY OF PAPER Specific action required: Provides Assurance: For Information: Board