Agenda item

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 ensued on the presentation with the following issues raised/clarified:-

 

·           The Trust overall faced capacity issues.  There were shortages in certain occupation groups and a particular expertise set to lead the change that was expected

 

·           Additional financial resources were being sought but the Trust was very committed and continually using innovative ways of working

 

·           Volunteers from outside of the organisation were drawn upon for the mock inspections

 

Kathryn Singh, RDaSH, reported that the draft CQC report had been received.  Due to the CQC’s new working practice, the report would become a public document before the Quality Summit was held and an action plan produced. All partners would be briefed in advance.  

 

Resolved:-  (1)  That the CQC Inspection Action Plan for the Rotherham NHS Foundation Trust be noted.

 

(2)  That an update be submitted in 6 months dependent upon the timing of the re-inspection.