The impact of failings of three of the standards was judged to have a moderate impact on people using the Trust's services, however Outcome 16 – Staff – was judged to have a high impact on people using the Trust's services and the Trust has been served with a warning notice against this standard. Given the main focus on Outcome 13 Staffing and the time frame to deliver the required improvements, a detailed update of activity to date is included in the report (Annex 2). After receiving the outcome of the inspection and the warning notice, the Trust developed and provided the KQC (and key parties) with copies of the corporate action plans (Attachment 1) by the required deadline of 30 December 2013 and prior to the publication of report findings on January 8, 2014.
There remains a high focus on staff communication to ensure that the Trust's workforce understands both the positive aspects of the report and the focus and action that the Trust is and continues to take in delivering the improvements required. Some of the issues identified and reported by the CQC were in the process of being identified and addressed by the Trust, however the publication of the report has ensured that corporate action plans are now in place which are supported by a range of work streams defined by the local service. In addition to staffing changes (outcome 13), undertake a review of the flow of patients through the Trust to be involved.
Work relating to the Trust's core values and the '6Cs' will focus on this. A focus on compassion in practice has begun, a workshop has previously been held and the work plan for the coming year will include the implementation of the national strategy. The recent planned review of nurse staffing through the deployment of the Safer Nursing Care Tool (SNCT) was completed in late October (November for pediatric nurse staffing data). Professional assessments and challenges against some positions are currently being conducted through the heads of nursing departments, with expected results available for discussion with executive directors and for presentation to the board of directors at the earliest opportunity.
Redefine role specification to accommodate this, including appropriate professional standards and responsibilities – Depending on the outcome of the redefined operational structure, role descriptions will then be confirmed.
Toconsistently deliver safe and suitable senior (Consultant & senior doctor) medical support in line with agreed staffing standards across the 24 hour period
Date actions will be completed
Processes to support improve management of patient flow
Helen Barker - Chief Operating Officer How will you ensure that improvements have been implemented and are sustainable. Helen Barker - Chief Operating Officer What resources (if any) are required to implement the change(s) and are these resources available? Date by which actions will be completed: Plan developed for Q4 2013/14 How will non-compliance with these regulations be mitigated until this date.
Please clearly describe the action you will take to comply with the regulation and what you intend to achieve.
Address all concerns regarding patient mealtimes including hand hygiene, choice, protected mealtimes and staff focus
Appropriate deployment of the ADT screen to ensure patient confidentiality is maintained
Effective communication with patients for whom the first English is not their first language
Addressing insufficient toilet facilities for patients in SAU
Nursing staff acting more compassionately in their interactions with patients
Report on actions Bradford Teaching Hospitals NHS Foundation Trust plans to take to meet CQC essential standards. Care and treatment were not planned and delivered in a way that would ensure people's safety and welfare. The Foundation Trust proposes to take three key actions to address the issues identified in the inspection report.
Deliver and ensure consistent standards and documentation of nursing care and interventionswith appropriate personalisation
Consistent approach to the Trust’s policy of Intentional Rounding
Inappropriate patients were transferred to be cared for on trollies in MAU
The Foundation Trust proposes four key actions to address the issues identified in the inspection report.
To address the failure to consistently deliver agreed nurse staffing levels or skill mix
Addressing the issue of insufficient access to senior medical staff & consultants
To addressnurses undertaking ward clerk activity
Ensure sufficient portering capacity
The provider did not have an effective system to regularly assess and monitor the quality of the service that people receive. The Foundation Trust proposes to take two key actions to address the issues identified in the inspection report.
Role clarity of operational and clinical management
To implement a Board Assurance Framework
The supervision and management of the medical workforce is being overseen by the Chief Operating Officer with professional input from the Medical Director, Director of Education and Divisional Clinical Directors. The AED Consultant and Associate Consultant Rotation Agreement is enhanced by ensuring that the number of Consultants and their placement is consistent with patient needs; this has been externally validated by ECIST. A comprehensive rotation for the second senior decision maker in the AED from 12 midnight to 8 am has been developed by the Clinical Lead; validated by HR and moving to business affairs.
Acute Medicine continues to be a difficult specialty to recruit for nationally, the Trust has recently appointed a 3rd consultant to commence in April 2014 and a review is ongoing with the Medical Director, Chief Operating Officer and the Department of Medicine for to look at alternative models for secure recruitment. A tracker has been implemented to ensure visibility to the director of vacancies and progress in recruitment; this includes evidence of mitigation measures where gaps are identified. Consultant, SPR etc across the fund has been established with a process being developed to allow this to be tracked weekly to ensure visibility of gaps and corrective action.
A meeting was held with all surgical and anesthesia medical trainees in response to Dean's feedback. This meeting was attended by the Director of Education, the Departmental Leadership Team, the Managing Director from the Office of the Medical Director, the Chief Operating Officer, and the Dean's Office. Feedback from interns and the deanery was very positive, with a representative from the deanery praising the trust's proactive approach and level of engagement.
The Division was asked to develop an action plan from the meeting and will have several trainees work with them on this development. An overview of the Trust's actions to address staffing shortages during compliance at the Trust's institutions during 2013/14, both before the CQC report and after the CQC report, including comments on the challenges and the actions that were successful has been implemented;. We have a few individuals who have used this over AED & MU which has worked well.
National staffing changes and pressures – RN post 18/12 suffered unemployment issues after qualifying with BTHFT supporting unemployed newly qualified nurses to join the Trust's own local internal nursing bank and supporting these new staff nurses with mentorship during their transition. Often have a waiting list of student nurses wanting a post in the Trust RN issue in September with a normal waiting list. The beds were therefore closed and at the time of the CQC inspection these beds remained closed and throughout the period data collection for the SNCT was on site in October. still waiting for the information from Sharon).
As planned, in October 2013 he undertook a planned 4-week review of staffing levels in the department with SNCT - ongoing when the CQC review was carried out.
Use of the Safe Nursing Care Tool – SNCT - in 2012/13 against the agreed project plan (document provided) – results reported to the Board of Directors April 2013 Time Out – with investment made against the recommendations of the Chief Nurse. As inspectors identified and raised staffing concerns with the Chief Nurse, these were immediately validated and acted upon - moving staffing resources to support areas under operational pressure. The Head Nurse informed the Matron/Head of Nursing, Ward Manager and Operations Service Manager of the observations and requested the immediate development of a ward action plan before day 4 of CQC.
The head nurse immediately reviewed the datix reporting of events &. appeals – section 29 &. Rely on broad incident reporting of personnel concerns raised from April 2012 to the present to identify any specific changes in trends. The Deputy Head Nurse carried out an unannounced inspection of ward 29 following the development of an action plan and prior to the CQC Day 4 inspection with a particular focus on recruitment - leading to the Head Nurse's expert recommendation to reduce activity on the ward/close 10 beds.
Chief Operating Officer, Medical Director and Chief Nurse discussed the impact and risks at ward and organizational level of closing 10 beds - ultimately 10 beds on ward 29 were closed as of 27.10.13. The HR Director began with a detailed review of current vacancies – progress and areas for system improvement. Development of a department-based nursing quality dashboard that includes expected &. available nurses and HCA staff – planned Council quality scorecard.
Development and adoption of a local stress action plan covering a number of areas – specifically the Elderly Department's areas – in response to the Trust Stress Focus Group. Nurse Recruitment Task and Finish Group created. Led by head nurse. Successful effect is felt in both RN & HCA out turns. No changes to current nurse staffing arrangements or skill mix without discussing and obtaining the support and approval of the Chief Nurse (process included) – The impact is to ensure we maintain current agreed nurse staffing and skill mix levels.
While numbers are constantly changing with turnover, we currently have 64 people at various offer/pre-employment stages with 52 open vacancies. This compares to position 31 in the process with 97 vacancies at the time of the CQC visit. The results of this will be presented by the Chief Nurse as a document supported by the Executive Team to the Public Board at least every 4-6 months for informed discussion and debate.
