Response and Action:Care Quality Commission

Inspection June 2015

Bill Shields, Chief Executive

CQC Ratings – June 2015Royal Cornwall Hospitals NHS Trust Requires improvement§  Safe Inadequate§  Responsive Requires Improvement   Royal Cornwall Hospital Requires Improvement§  Emergency and urgent care Requires improvement§  Medical care Inadequate§  Surgery Good§  Critical Care Good   West Cornwall Hospital Good§  Medical care Good

Organisational context:• We welcome the report, the focus it provides and are absolutely clear that the

care observed is not good enough;• We are very mindful of those issues carried forward from the 2014 inspection

and know we need to raise our game;• The report addresses many issues we are already actively addressing, some

needing the support of our partners, and resonates with several external reviews we have commissioned;

• We must maintain and build public confidence in our services as we deliver improvements;

• As an organisation with a number of challenges, we recognise this impacts on progress and have, therefore, sought external support where relevant to work with us on our improvement plans;

• We are empowering our clinicians to act to improve safety and responsiveness - our Listening into Action staff engagement campaign is well underway.

Our approach to improvement:• We have an absolute focus on our patients’

safety and the responsiveness of the services we deliver;

• A Task and Finish Group established to ensure robust response and oversight, reporting to the Trust Management Committee and Governance Committee;

• Significantly enhanced staff engagement to drive improvements including Listening into Action programme;

• Acting quickly with a clear focus on immediate actions in response to the CQC Warning Notice;

• Developed a robust quality improvement plan in response to full CQC report.

Examples of good practice and recognised improvements:• Support for dementia patients undergoing surgery;• Patient ambassadors carrying out point of care

observations;• Bite size learning for theatre staff;• Ambulatory Care Unit relieving pressure on Medical

Admissions Unit and the Emergency Department;• Good support and care for patients with learning

disabilities;• Increased provision of critical care outreach; • Introduction of lockable storage cabinets for patient

records;• “Patients on a variety of wards were complimentary

about the care provided.”• We want to thank our staff for the excellent care they

provide every day.

Themes identified for action:• Staffing - Nursing levels and skill mix in Emergency

Department and Wellington Ward subject to a Warning Notice.

• Consistent Clinical Practice – management of sepsis, consistent use of assessment and treatment tools, variable discharge planning, learning from incidents, complaints and risks, uptake of mandatory training.

• Documentation - completeness and timeliness of records, treatment plans.

• Managing Patient Activity and Patient Pathways - flow, escalation and outlying patients, cancellations and discharge planning.

Staffing:Strengthening clinical staffing in response to CQC Warning Notice and inspection report

Improvement actions already taken:• Nurse patient ratios have been adjusted on D Bay on Wellington Ward in response to patients on

NIV requiring level 2 care;• The nursing skill mix on Wellington Ward has been enhanced with the appointment of an additional

3.63 WTE Band 6 nurses to support the Ward Sister; • The registered nurse establishment in ED has been increased from 12 to 14 in the day and from 9 to

11 overnight; • The deployment of paediatric nurses (RN Child) is now explicit within the rota for ED; • The escalation process for staffing concerns has been clarified and reinforced with all wards and

departments;• The role of site operational ‘bed’ meetings in addressing short notice staffing issues has been

strengthened;• All ward staffing rotas have been reviewed with the involvement of Ward Sisters; • Risk assessment of staffing rotas has been strengthened to enable timely remedial action;

Next Steps• An acuity and dependency module is being added to the Trust’s Electronic Rostering System so that

acuity and dependency can be assessed daily on wards from October 2015.

  

Consistent Clinical Practice:Strengthening consistent clinical practice in response to the inspection report

Improvement actions already taken:• ED and Respiratory are part of the Trust’s Clinical Safety and Quality Review process;• Monitoring of quality indicators including pain control and observations such as NEWS

scoring;• Regular board round assessments of patients including ED;  • Strengthening of CARE rounding in ED;• Appointment of a Sepsis Lead Nurse; • Strengthening of the "SAFER" patient care discharge bundle; • Group established to consider management of patients with Medically Unexplained Symptoms• LIA Group established to improve staff training• Trust wide audit of the resuscitation "crash" trolleys, including documentation checks,

undertaken.

Next steps:• Implementation of e-observations across the Trust in 2015;• Roll out of refreshed education and training Trust wide on the SEPSIS 6 bundle.

 

Documentation:Strengthening clinical documentation in response to the inspection report:

Improvement actions already taken:• Review of documentation audit results, spot checks conducted and feedback given to

staff;• Increase in senior nurse spot checks of bedside documentation. Next steps:• Roll out across the Trust of a revised documentation audit tool, including peer review (as

currently used in Cardiology and Respiratory and noted in CQC inspection report);• Implementation of documentation ‘tool box’ training.

Managing Patient Activity and

Patient Pathways

Emergency Department/Patient FlowImprovement actions already taken- Revised nurse leadership structure in ED;- Implementing rapid assessment &

treatment, pit stop and see/treat;- Board rounds;- Interim lead appointments in ED and for

site team;- Multi-agency clinical group looking at

admission pathway.

Next steps- Embed changes in ED;- Agree action plan for site management

and implement;- Agree/implement ‘front door’ pathway;- Steering Group to be established by MD to

review critical care provision.

Key issue- Delays on acute discharge pathways.

Note: September Performance to 15/09 only

1300

1400

1500

1600

1700

1800

1900

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Attendances per week

Cancelled Operations

020406080

100120140160180200

Cancellations and rebooking breaches

On day hospitalcancellations

28 day breaches

0

20

40

60

80

100

120

140

Aug 2

014

Sep 2

014

Oct 2

014

Nov 2

014

Dec 2

014

Jan 20

15Fe

b 201

5Ma

r 201

5Ap

r 201

5Ma

y 201

5Jun

2015

Jul 20

15Au

g 201

5

All-reason Galaxy cancelled operations

Beds unavailable

Patient-related reasons (DNA,patient unfit for surgery)

Hospital reasons (insufficientlist time, staff unavailable etc)

Improvement actions already taken- Strengthened bed management

arrangements, eg, outliers reviewed by clinical site team to expedite flow;

- Focus on ‘urgent’ and ‘cancer’ to enable lists to start promptly;

- ‘Protection’ of cardiology beds avoiding high volume list cancellations;

- Instigation of formal process to review rebooking;

- Intensive support team visit scheduled.

Next steps- Embed process change;- Focus on scheduling and other hospital

reasons through the Elective Surgery Productivity Programme Board;

- Respond to feedback from IMAS visit.

Stroke

Improvement actions already taken- Intensive training programme within

ED and MAU for swallow assessment by specialist nurse and speech and language therapist, with ongoing monitoring for each patient;

- Protected beds in place since August;

- Consultant commitment to discharge/flow management.

Next steps- Health economy, externally

facilitated, workshop (October) to review pathway and develop ‘top 3’ highest impact changes for implementation.

0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%

100.00%

Axi

s Ti

tle

Stroke Metrics

90% on Stroke Ward

To Stroke Unit in 4hrs

Swallow Screen in 4 hrs

Note: September Performance to 15/09 only

Cardiology

0

50

100

150

200

250

Incomplete pathways >18weeks

Actual 8% RTT PTL

Improvement actions already taken- Action plan developed by Cardiology

interim project manager;- Appointed clinical lead;- Agreed escalation process with

tertiary centre for in-patients;- ‘Protected beds’ within CIU for

planned care, coupled with continued use of independent sector;

- Appointment to key support posts.

Next steps- Continue to deliver plan:

demand/capacity, process redesign, efficiency/productivity, seven day services and out-patients.

Delivering sustainable change:• The CQC inspection report requires a serious and significant response from the

Trust and our partners;• We have acted immediately on all of the areas we must improve and are

progressing at pace all other improvement actions; • We are clear about the action required and are taking a rigorous approach to

deliver rapid improvement;• We are strengthening staff involvement and clinical leadership to support change

and build ownership;• While the majority of actions are the responsibility of RCHT, we also need partner

support - particularly to address patient flow;• The CQC will conduct a full inspection of the Trust in January 2016. At that time we

will demonstrate our improvement and commitment to be ‘Outstanding’.