Issue - meetings

Tracey McErlain-Burns and Lisa Reid, Rotherham Foundation Trust to present

Board Members may wish to view the action plan in advance of the meeting: http://www.therotherhamft.nhs.uk/About_us/CQC_Accreditation/

Tracey McErlain-Burns, Chief Nurse, gave a powerpoint presentation on the CQC Improvement Plan as follows:-

Inspection Ratings

-          Overall rating – requirements improvement

-          Safe – requires improvement

-          Effective – requires improvement

-          Caring – good

-          Responsive – requires improvement

-          Well-led – requires improvement

-          Overview of ratings:-

26Good

33 Requires improvement

5 Inadequate

Detailing ratings: Core Service Level

-          Community Care Services

Community Health Services for Adults – overall requires improvement

Community Health Services for Children, Young People and Families – overall requires improvement

Community End of Life Care – Overall requires improvement

Community Dental Services – overall good

Community Health Inpatient Services – overall requires improvement

-          Acute Core Services

Urgent and Emergency Services – overall requirements improvement

Medical Care – overall requires improvement

Surgery – overall requires improvement

Critical Care – overall requirement

Maternity and Gynaecology – overall requires improvement

Services for Children and Young People – overall inadequate

End of Life Care – overall good

Outpatients and Diagnostic Imaging – overall good

Improvement Action Plan

-     Approved at Board of Directors in July 2015

-     ‘Must Do’ actions from Requirement Notices

-     ‘Should Do’ actions as advised by the CQC

-     17 ‘Must Do’ sections with 101 actions

-     12 ‘Should Do’ actions with 126 actions

-     Each section has an Executive Lead and an Operational Lead responsible for delivering all actions in that section

-     A Corporate Committee has oversight of all sections of the action plan

JSNA and CQC actions

-          Starting Well

M7: Children’s Environments

M13: Infection Control in short break service

M14: medicines Management in short break service

-          Developing Well

M15: Liaison between Contraception and Sexual Health Service and School Nursing Service

-          Living and Working Well

M5: Elimination of Mixed Sex Accommodation

-          Ageing Well

M2: Mental Capacity Act and Deprivation of Liberty Safeguards

M4:  Do not attempt cardio-pulmonary resuscitation

Reporting Arrangements

-          Monthly monitoring of all actions

-          Updates against actions and evidence of completion of actions required from all Operational Leads monthly

-          Board of Directors receives a monthly exception report of progress

-          Corporate Committees monitor the progress against the sections for which they have oversight, escalating when required

-          Progress is also tracked at the monthly Divisional Performance Meetings

-          Weekly steering group meetings attended by all Operational Leads designed to assure the evidence of completion of actions and test that the outcome descriptors have been achieved

-          Monthly progress updates on internet and intranet

Preparing for Re-inspection

-          Mock inspections: 1 completed in November, another shortly

-          2 page staff briefings: pre-inspection briefings evaluated well so have been reintroduced highlighting the progress made since February 2015

-          Challenging available evidence: via mock inspections, dip samples and the weekly steering group meetings

-          Ensuring that completed actions deliver the outcomes required by CQC: via 1-2-1 meetings with Chief Nurse, mock inspections and dip samples

-          Raising awareness: targeted communications campaign ensuring staff are mindful that CQC could re-inspect at any time

Discussion  ...  view the full minutes text for item 38