NHS England Site Visit

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Assurance review to Colchester Hospital University NHS Foundation Trust Prepared by NHS England, Midlands and East region, on behalf of Colchester Hospital University NHS Foundation Trust June 2015

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Contents

1. Introduction

2. Purpose of the review

3. Methods of investigation

4. Summary findings

5. Key findings

6. Summary Appendices Appendix 1: Terms of reference for the review Appendix 2: Panel membership Appendix 3: Visit agenda Appendix 4: Focus Groups Appendix 5: Ward visits Appendix 6: Interviews Appendix 7: List of documents reviewed

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1.0 Introduction Colchester Hospital University NHS Foundation Trust was one of 14 NHS hospitals inspected as part of the Sir Bruce Keogh review of the quality of care and treatment in June 2013. As part of that review, a multi-agency risk summit was held to agree an action plan and it was agreed that a follow-up visit would be undertaken to review progress. The Trust was put into special measures by Care Quality Commission (CQC) in November 2013, following concerns with regards to the quality of care for cancer patients. An Improvement Director, Mark Davies, was subsequently appointed by Monitor in December 2013. Since 2013 there had been significant changes to the Executive team, many of whom were recently appointed with an interim Chief Executive and newly appointed Chair Alan Rose on 1st April 2015. The Trust had a number of CQC inspections in late 2014 and remains in special measures. 2.0 Purpose of the review Responsibility for monitoring progress against the agreed action plan rests with Monitor as the regulator of NHS Foundation Trusts. Monitor subsequently requested support from NHS England to undertake the follow up review of the action plan on their behalf in February 2014 and inform preparations for a forthcoming CQC hospital inspection. In 2015, the Trust requested additional follow up support on an agreed set of areas to monitor progress against the previous report and identify areas of further improvement. NHS England’s support has comprised of:

• A desktop review of the documentary evidence supplied by the trust in support of its progress against the agreed Keogh action plan

• A one day announced site visit (28 April 2015), undertaken by a multi-agency panel of experts, to look at whether care and treatment on site at the hospital was in line with the documentary evidence received, and to ascertain to what extent the agreed actions had been implemented and were effective. This included meetings with members of the trust executive and non-executive board, talking to patients, carers and staff, and undertaking ward and departmental visits

• Preliminary feedback has been provided to the Trust at the end of the review, which included representatives from Monitor and the CCG

• Escalation of any concerns whilst on site to the CQC, Monitor, CCG, and trust for action, this was not required • A formal report on the panel’s findings

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The assurance review panel was chaired by Dr David Levy, Regional Medical Director for NHS England (Midlands & East). The panel included a number of the original Keogh Review panellists, including the lay representative, and representatives from North East Essex Clinical Commissioning Group and NHS England’s Midlands and East (East) team. This one day assurance visit was intended solely to review progress against the previous support review and action plan and was not intended to identify any new areas of concern or make recommendations about the removal of special measures in place. 3.0 Methods of investigation A one day desk top review was undertaken by the panel and a one day announced visit followed this at Colchester Hospital University NHS Foundation Trust on Tuesday 28 April 2015. The panel visiting the trust included members of the 2013 Keogh review panel, allowing comparisons to be made over time. As per the Keogh review visit, the panel used a variety of methods including interviews, focus groups, ward observations and a review of documentation. This has enabled the panel to consider evidence from multiple sources in making their judgments. 4.0 Summary findings Following review of evidence from available sources, the panel agreed whether they were ‘assured’, ‘partly assured’ or ‘not assured’ that the trust had implemented the actions agreed following the Keogh quality of care and treatment review in 2013.

Where it was agreed that the trust had fully implemented an action and the outcomes of that action were apparent, an outcome of ‘assured’ was recorded. Where there was evidence of progress with implementation, but implementation was not complete, the outcomes were not yet evident or it was too early to tell if the changes were embedded and sustainable, the panel recorded an outcome of ‘partly assured’. Where there was limited or no evidence that implementation had started, or significant concerns remained, the panel was able to record an outcome of ‘not assured’.

An outcome has been recorded for each group of actions set out in the reports of the Keogh rapid responsive review and risk summit in 2013.

In summary, 30 groups of actions were assessed at this review, it was agreed that the panel would adapt the new CQC ratings to reflect the findings of this visit which could aid the Trust preparations for the next announced CQC inspection, due to be held in September 2015:

Outstanding – the service is preforming exceptionally well

Good – the service is preforming well and meeting expectations

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Requires improvements – the service isn’t preforming as well as it should and we have told the service how it must improve.

Inadequate – the service is preforming badly and not meeting acceptable standards (CQC would class this as requiring an enforcement action notice)

5 rated as Good, 24 rated as requiring improvement, 1 inadequate. The full outcomes are contained later in the report, but the outcomes in summary are listed below:

1. Development of a quality focus – Requires improvement 2. Clinical leadership structure – Requires improvement 3. Committee structure and reporting – Requires improvement 4. Communication between Board and Ward level and escalation of risks and issues – Requires improvement 5. Absence of clear prioritisation and pace of change – Requires improvement 6. Performance reporting – Requires improvement 7. Ward level performance reporting - Good 8. Deteriorating patients – Requires improvement 9. End of Life provision across the health community – Requires improvement 10. Surgical site infections – Good 11. Sepsis – Inadequate 12. Escalation procedures - Good 13. Patient flow and management between A&E and EAU – Requirements improvement 14. Mortality review – Requires improvement 15. Clinical coding - Requires improvement 16. Visibility of Executive team - Requires improvement 17. Effectiveness of Clinical leaders and management at divisional level –Requires improvement 18. Leadership from senior doctors - Requires improvement 19. Complaints process - Requires improvement 20. Patient experience themes – Good 21. Engagement with trust staff - Requires improvement 22. Staffing levels and skill mix – Requires improvement 23. Support for junior doctors – Good 24. Sickness absence and vacancies – Requires improvement 25. Quality of handovers – Requires improvement 26. Reporting of serious incidents - Requires improvement

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27. Dissemination of lessons learned – Requires improvement 28. Clinical supervision – Requires improvement 29. Staff appraisals and development – Requires improvement

30. Compliance with mandatory training – Requires improvement

5.0 Keys findings

5.1 Areas of good practice

There is a new leadership team coming into post with some recent appointments. The current CEO is interim, though there are

plans to recruit a substantive post in the near future. The Executive team appears to work very well together. Many of the senior

clinical and managerial staff is delighted to see stability at last at the Executive team level. However, this “feel good” factor has yet

to filter to all staff.

The team considered that many of the foundations have now been put in place by the Executive team, with the new Chair, to make

progress to deliver significant improvements. The Trust felt a different place with a much more business-like attitude and a can-do

culture.

The team felt much more confident that the Trust had the capabilities and capacity to improve, compared to other visits in the past.

5.2 Stroke ward

The stroke ward had a developed a patient record that facilitate the recording of the National Audit data set.

The stroke multidisciplinary team continued to proactively look at ways to improve patient care. Of note the ward had a full

complement of staff on the ward when we visited. It was quiet yet busy

5.3 Dedham ward

We were met on the ward by the ward manager, who helpfully provided an overview about the ward and the care being provided.

She was pleased to report that she had recently recruited to her full establishment; did not need the use of any agency staff; was

passionate about her responsibility to support and develop her staff and explained how she had secured additional cardiology

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courses with the university for her staff to attend. Staff on the ward confirmed they felt much supported on this ward, with a very

good team atmosphere

The wards were calm, clean and clutter free with patient call bells being answered very swiftly. There was up to date information

provided for patients, staff and carers, including the green crosses and quality performance measures. The patient board, used for

the board round was neatly and fully completed, with EDD and other details all completed.

Patients on the ward found the staff very helpful, approachable and informative. Nurses and doctors had explained to them about

their condition and treatment and they were aware of their discharge planning arrangements. Carers also felt informed and included

in care arrangements. Records reviewed were in good order and appropriately completed.

5.4 Nursing Leadership

Huge consensus that nursing leadership had improved since new Director of Nursing arrival and were concerned about when she

leaves! The Director of Nursing listens, spends time to explain and follows up. Ward managers recognised that nurses could be

very influential in improving quality. New structure in place much better and welcomed and felt less challenging.

5.5 Maternity

Staff spoken with felt engaged with the Trust and divisional leadership, and was confident how to escalate concerns, the divisional

leadership was very visible and approachable. Staff feel they can develop at the Trust. The ward had introduced MEWS (Maternity

early warning scores) which staff found very helpful and utilises. The patients spoken with spoke of good care on the ward

however pre admission there had been difficulty gaining a date for elective caseation section which they found frustrating to plan.

In the focus group maternity staff welcomed the peer review assessments being introduced across the hospital, reflecting that they

already undertake a similar process. They would very much want to be involved in peer reviewing across the hospital. This was

echoed by a focus group, that it would be good to be involved in cross-division peer reviews.

Catering staff spoken with highlighted how they meet patient needs with varied diets. Food was made available outside of meal

times for the ladies postnatal that required additional snacks. Food is taken to patient’s bedsides if they need assistance.

5.6 Paediatrics

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The unit was a self-sufficient unit with good 24/7 assessment unit and referral processes, clear links into CAMS services. They

also have a paediatric 24/7 A&E unit.

New staff members have the privilege of having 6 months preceptorship which does seem to help in retention of newly qualified

staff, however the unit has lost a number of experienced staff recently which has left some skills gap.

The new bright spacious unit was calm, with friendly and welcoming staff. Good examples of ‘You said, we did’ displayed, work on

healthy eating and dietary support for children to engage with using CHIMP assessments on every child. School room open to all

children and bedside teaching available if required. Space for the older child is available away from the toddlers and they have

separate play/adolescent rooms. Transition care and services from young people to adult are in place with close links with tertiary

sites such as Great Ormond Street and Addenbrookes to support families of oncology, cardiac, neuro children.

The unit are working closely with GPs and safeguarding teams on trying to reduce the high numbers of DNA and are evaluating the

results. The Trust safeguarding team visit the unit daily, the Saville inquiry recommendations have been consider and reviewed,

and the unit believe they are compliant with ensuring VIP visitors and charity visitors are always chaperoned. Clinical supervision

and clinical psychology is available to staff when required.

5.7 EAD

Staff training tracker in the staff area in A&E is very visual and very useful to encourage staff to take ownership of their mandatory

training. Tash Tuck in EAD was really enthusiastic and informed and seemed to take staff engagement and patient quality very

seriously.

EAD newsletter is attached to staff payslips.

Operating protocols for use by agency and locum staff to enhance knowledge of the CHUFT system and ways of working

5.8 Peer reviews

Staff spoken with really keen on the newly introduced peer reviews extremely helpful.

5.9 Areas that require improvement

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Staffing, skill mix and support on Birch ward needs to be enhanced.

Do Not Attempt Resuscitation processes need to be reviewed in some clinical areas ensuring the most recent status is

visible in any clinical records.

The Trust should prioritise developing a quality strategy as a matter of urgency which will help focus on the priorities going

forward to ensure the highest quality of care is delivered to patients.

The Trust improvement plan (version 6) should have key deliverables and measures with named responsible board

members especially the nominated lead for quality and safety with responsible board member as there was some confusion

who had overall responsibility.

Simple and clear lines of governance and accountability are required that meet the needs of the divisional and ward teams,

so it is evident how the ward to Board communicates as well as from Board to ward.

Patient engagement strategy to be implemented and relocation of the PALS office to ensure is more visible to patients and

families.

Reviews the effectiveness of the red folder in sharing lessons learnt and consider trust wide learning ensuring all staff

benefit, including therapy staff. Some staff see the red folder as just a tick box exercise and not the true value, although

other staff say they are used at team meetings however due to staff shortages not all staff get the opportunity to attend team

meetings.

Information governance - it was noted in the private Board papers that during the busy winter period the notes of some

patients who died had gone missing and thus may not be coded or be available for any mortality review.

The Trust has high numbers of open serious incidents and the backlog is taking time away from staff trying to implement

changes as they are making amendments from action plans from previous incidents and the lessons learnt may be lost in

the process. It would be worth considering commissioning some short term support to review all open Sis, work with the

CCG on developing action plans that link into the improvement plan which the Board will have sight of and can be governed

at Board level, ensuring lessons are learned and sustained improvements implemented.

Ensure staff undertaking SI investigations have the skills and capacities to produce sound credible reports.

Calibre of agency staff was a concern for all ward managers, with some ‘working to rule’ rather than providing the care required. Too many available on the weekend with very few available during the week possibly due to enhanced payments offered at other times. Staff reported the need to have a ‘crib sheet' of competencies on the ward to assess the competency and calibre of agency staff. This was not consistent and developed in isolation. This would benefit from a whole hospital

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review and approach to develop a consistent assessment methodology. An induction pack for agency staff on the ward may not be reviewed to accommodate this need.

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Action/s Assurance: Fully Assured Partly Assured Not Assured

Further evidence required (specify):

Reviewer comments including any outstanding issue(s)

KLOE 1 Can trust staff clearly articulate governance process for escalation of issues and risks and assurance over quality of care?

1. Quality Focus still being developed

1.1 Trust needs to consider how it will develop a clearer focus on quality, based on transparent performance information and a tone from the top. This should include implementation of planned improvements and recommended actions from the Keogh panel report.

1.2 The Trust must increase the pace of planned change to

develop a safe and mature organisation that provides high quality care.

1.3 Trust needs to develop a clear and comprehensive

Quality Strategy and ensure it is consistently applied throughout the organisation. This needs to include areas of priority with defined action plans in place

1.4 The role of the Quality Hub and staffing needs to be

reviewed, including:

Serious Incidents

Complaints

Integrated quality measures including Datix, SI’s and lessons learned

Requires improvement

Quality strategy updated.

With the lack of a robust Trust quality strategy it is

difficult to know how the trust can work towards

focus on improving quality.

The Trust has a substantive improvement plan

(version 6 dated 24 April 2015) but it lacks

measures and accountability in key areas.

The Trust has undergone some significant senior

leadership changes which have impacted on the

pace of change. Now the senior leadership team is

in place there is an expectation that the pace of

improvement will now escalate.

The priority should be to develop a measureable

trust wide quality strategy that has stakeholder

engagement.

The quality hub function and effectiveness should be reviewed to ensure it meets the demands of the trust and divisions within its capacity of staff. A

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significant resource seems to sit within the Hub that could be utilised more effectively.

2. Clinical leadership structure

2.1 The Trust should review the management structure in place to ensure it is robust enough to support consistent leadership and management at divisional level. This should show a single reporting line for both divisional managers reporting into divisional directors. 2.2. The Trust needs to review the organisational structure and consider the benefits of including nursing representation at senior level, to ensure clinical leadership and accountability for patient safety throughout the Trust. 2.3 The Trust should review the reporting lines for clinical and associate directors and consider if current arrangements allow the Executive team to achieve a joined up approach to management. Trust to produce a strategic plan to develop a clinically led and managerially supported strategic organisation to re-visit existing divisional strategy, including consideration of nurse leadership at senior level Trust to appoint a Deputy Divisional Clinical Director for Cancer Trust to clarify reporting lines Trust to undertake a risk assessment of structures and


There is no single document that shows the reporting structures for the newly formed 3 and 2 at the top arrangements. This needs to be resolved quickly. Nursing and Clinical representation is now firmly established at all levels. Good engagement with senior staff. The new arrangements appear to work well from Ward to Board but are new and not yet fully established. As mentioned above the reporting arrangements and expectations and responsibilities of the divisions and ward top teams need clarifying. Senior staff are offered leadership development.

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divisional single point of accountability and staffing Trust to discuss with Leadership Academy the support required for clinical leadership and Board development.

3. Committee structure and reporting

A systematic approach to reporting should be developed, in response to confusion over the Trust’s committee structure and where accountability for patient safety sits:

The Trust should review committee structure to ensure clear lines of reporting and accountability for patient safety.

There still remains confusion about who is the Board lead for safety. Lines of reporting are not clear.

4. Communication between ward and Board level – escalation of issues and risks

Processes for escalation of issues and feedback of outcomes to ward level as articulated by the Board were not consistently understood by ward staff interviewed: 4.1 The Trust should ensure there are robust mechanisms

embedded within the divisional structure that allow front line staff to escalate risks and concerns about the quality of patient care in a consistent manner.

4.2 Trust Board should ensure there is a systematic

approach in place for the collection, reporting and acting upon information on the quality of service. This should include patient and clinician insights and include staff feedback and engagement in learning and service improvement.

4.3 Trust Board and management (wider than the Chief


The 2 at the top (ward sister and consultant at ward level) and 3 at the top - divisional manager and nurse/medical director leads – meetings in place, paper work and staff reports indicate this has started well as an initiative to share information but unclear that it has bedded in yet in some areas –. Trust Board and Quality reports from February 2015 infer systems and processes are in place but not embedded.

The Trust have a timetabled NED and Governors visit set up, however when we spoke with a NED at the last visit the Governors failed to attend so the NED under took the visit on their own, however the Trust are working very closing linking the NEDs and Governors on keys areas, which has had positive feedback. Ward staff say rarely seen anyone except DoN and COO.

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Executive) should consider how to strengthen their visibility, accessibility and listening mechanisms with frontline staff. This could include visiting areas of the hospital including at nights/weekends, to understand concerns and should include feedback to wards on observations.

KLOE 2 How does the Trust use quality and performance information to support good governance?

5. Absence of clear prioritisation and pace of change

5.1 Following the update of the Quality Strategy, the Board should approve a single prioritised action plan for the Trust showing clearly the priorities by time period. This should be clearly communicated to staff and progress against plan monitored.


Current Quality Strategy due for review. The trust has a single improvement plan (version 6) now in place with summary improvement plans received. They have an improvement board on a monthly basis where the actions are monitored. The template used is very comprehensive and will provide detail at divisional level as well as increased progress tracking and executive comments. The key actions required are not reflective of the objective in all instances. Measurements not sufficient for some objectives. Some areas do not have identified responsible names aligned. The improvement plan is currently being refreshed and final iteration will be available in the next 3 weeks. The project management office plan to meet with each action owner to identify SMART outcomes. The executives are sighted on the plan.

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The summary will be helpful to use to communicate with staff as the plan will be too detailed and complicated for this. Divisional governance meetings are where the metrics will be assured. Quality priorities and corporate objectives come together in the trust vision.

6. Performance reporting

The Trust should review the information received by the Board and Executive committees to ensure members receive the correct information at a sufficient level of depth to scrutinise and challenge performance.

requires improvement

Three months’ worth of board papers have been reviewed in advance of the site visit, The new integrated quality and safety report which provides oversight of current position, outlines key quality developments, serious incidents, safety thermometer, claims and complaints. The board receive the improvement plan which does inform Board discussion and decision making and informed the outsourcing decision for dermatology etc. The CEO and Chair provide monthly updates. The Board receive the BAF and HR assurance framework which is RAG rated and includes assurance/evidence.

7. Ward level performance reporting

Ward level information published on notice boards should be displayed in a consistent and standardised way and

Good Ward notice boards display a large amount of standard and consistent data.

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include steps taken to improve where performance is below expectation.

KLOE 3 What governance arrangements does the Trust have to monitor and address clinical and operational performance data?

8. Deteriorating Patients

8.1 The Exec team should engage with clinical leadership and frontline staff to understand the reasons for inconsistent escalation of deteriorating patients. Trust to re-launch sepsis care bundles and escalation policy and seek assurance both are fully embedded at the Trust.

8.2 Immediate action should be taken to address issues

identified relating to deteriorating patients. A clear action plan should be developed and regularly monitored by the Board in order to seek assurance that issues are being addressed.

8.3. The Trust wide roll out of the national early warning

system (NEWS) should be expedited, with a clear training programme for staff, a policy in relation to EWS and escalation, and regular audit of the tool and triggers undertaken.


In relation to sepsis 6 being achieved, the panel felt that this was inadequate; the difference in the quarterly independent results and the ward ones is a concern and raises questions about robustness of the ward self-audit process. The timing of sepsis bundle treatments is of course a vital component of the bundle and so even if all elements are given but not within the timescales clinically required, then we would maintain that 0% compliance in the quarterly audit supports the inadequate assured’ judgement. The sepsis documentation from a set of patient notes, on the day, had been removed to allow for audit of sepsis bundle compliance to be undertaken. Nurses reported that timely screening and actions had taken place but this was not present in the notes for other healthcare professionals to see. Two NEWS triggers reviewed during visit did not have clear documentation evidencing referral to medical staff by nursing staff as a result of the trigger. Whilst reviews by medical staff had indeed taken place these were again not documented within the context of the NEWS trigger and so evidencing referral and response times was not clear. A patient who had a DNACPR order and was routinely triggering with a medium risk NEWS score,

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and who was for active treatment, had no documented instruction in relation to what physiological parameters required further medical review. Of concern was that one patient had had their DNACPR order reversed within the notes but still had DNACPR documentation at the front of their medical notes ring-binder (this was escalated at the time of the visit). Several sets of notes were reviewed and calculation of NEWS was consistently good and observation recording appeared to be of a good standard also. Regular NEWS audits are undertaken and there is reporting of audit results to Trust Board. The Trust has successfully introduced MEWS (Maternity Early Warning Scores) and PEWS (Paediatric Early Warning Scores) are also in place.

9. End of Life provision across the health community

9.1 Trust should continue to work with the CCG and community health providers to develop end of life care pathways with partners.

9.2 A strategy should be developed through joint

engagement with the CCG to review wider health system engagement to make better use of hospital beds, including out of hospital care, preventative strategies and community care, to improve end of life provision for patients.


An End of Life (EoL) Care Programme Board is in place overseeing an End of Life Care Project Group which has various work-streams reporting into it. Risk and action logs are in place but timescales were not always clear. Partial assurance only as there are as yet no agreed measurable KPIs to measure success of each work-stream and the delivery of the strategy overall (KPI dashboard poss. available April ‘15). Staff interviews suggest that inappropriate referrals still being made to Palliative Care team with some confusion about who to refer and when. (Note: Pathways for Mid Essex patients who require rapid discharge for end

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of life care from Trust reported as less easy to effect). From the mortality reviewed shared with the panel, a number of notes audited were from EoL patients with clear theme of palliative care decisions made very late on some of the patients, it was unclear how the mortality reviews and themes for EoL have been linked together.

10. Surgical site infections

10.1 The Trust should continue to meet with the consultant body to monitor plans to reduce the rates of surgical site infection.

10.2 The Trust should continue to monitor the use of

surgical safety checklists to ensure they are filled in correctly and consistently by consultants and their teams across all Trust settings where required.

10.3 Trust should review the use of prophylactic antibiotics

by surgical teams.

Good Not able to assess

Requested this but not received as yet (6/5/15)

Good progress has been made. We would recommend that this information is routinely added to the surgical divisional report in the quality section so that there is evidence that it is scrutinised.

11. Sepsis

11.1 The Trust should ensure that the management of sepsis using a care bundle approach is embedded throughout the Trust and is regularly reviewed to make sure it is consistent

inadequate (See section 8)

12. Escalation procedures

12.1 The Trust should consult with front line staff to understand why the policy for escalation is not being used consistently and why, where staff have raised


The escalation of risk as a system looks good however, we saw that there is need for further embedding – the two at the top sheets we

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concerns previously, no action has been taken in response.

12.2 The Trust should review their protocols and plans and

ensure they are followed when there is a need to open additional beds at times of increased activity. These should include forward planning for staffing of wards as well as equipping them.

12.3 The Executive team should clearly understand the

lines of accountability for the quality of care on escalation wards and ensure the governance structure and reporting or risks are appropriately managed. The escalation plan should be audited for compliance with review at Board level.

reviewed showed several problems but very few that were thought to be worthy of escalation. Escalation in terms of capacity – SOP good but has some omissions, for example where does capacity ward get opened when all the beds are full? Birch ward was named as the escalation ward but we found it was staffed with bank staff and clinicians were concerned. The policy lacks some clinical focus, so for example at what stage would extra clinical staff be rostered on? Are the Trust assured that all clinicians would know what to do when the hospital is on black or red alert? How do patients get prioritised if they need to be moved for capacity reasons? (See section 1.4)

13. Patient Flow and management between A&E and EAU

13.1 The Trust should improve bed flows and patient management via:

Reviewing systems to enable best use of beds at all times, minimising movements of inpatients overnight, and ensuring EAU patients are admitted to appropriate ward

Progressing the move to 24/7 working with senior


Critical Care Outreach Team: 7.4 WTE down to 5.2 as a result of secondments. One only on duty 24/7. ‘In the field’ education and support to enhance staff education in early recognition and care of deteriorating patients appears limited and is unchanged from previous visit, despite serious SI reported on sub optimal care of a deteriorating

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doctors available out of hours

Reviewing the use of PAR score documentation and escalation process to provide assurance that Trust policy is consistently applied

Reviewing size and use of the outreach team

Continuing with recruitment plans to increase staffing levels in A&E and EAU

patient in EAU. The one outreach team member holds bleeps for arrests, major haemorrhage protocol, trauma, NEWS > 5; also responsible for follow up of ITU patients and supporting patients with tracheostomies. This one staff member may also be responsible for delivering HCA formal training days while concurrently covering this clinical work. Team expressed concerns that there is a Hospital @ Night group on which they have no representation and they are concerned that a second referral route (to the night duty matron) for deteriorating patients will cause confusion. They additionally expressed concern that NEWS trigger parameters are sometimes ‘re-set’ before consultant review has taken place and at the lack of appropriate monitoring and staffing for patient stepped down to EAU from A&E resus. Their view is that high use of agency staff has resulted in less consistent compliance with the NEWS cascade during the day in surgical wards; that surgical medical attendance to NEWS triggers at night is problematic due to covering theatre and that medical wards still require further support from the team to fully embed timely and appropriate responses to deteriorating patients. New processes in place – changes to wards and divisional structure – re-profiling beds Unclear impact of Operation Fresh Start. Senior doctors not yet in post Nurse staffing establishment increased Nurse staffing (whole hospital) seen to be a 2 year

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plan to reach sustainable levels – international recruitment and local Ward staff report thinking all the management focus is on Urgent care to the detriment of wards.

14. Mortality review

14.1 The Trust should ensure that actions required as a result of the executive mortality review group are systematically communicated to staff 14.2 Trust should consider if staff members from a range of

seniority and departments can attend the mortality review meetings to make this as open a process as possible, and to share learning

14.3 Trust to consider how it can more systematically use

the mortality information it has to improve care pathways and provide assurance to the Board that actions agreed from reviews are being addressed


There was evidence of dissemination of learning to the wider hospital. Additional information was reviewed and exactly the same we were shared in February 2014 review. Although mortality reviews are undertaken, there was no systematic grading of deaths on the NCEPOD or Preventability scale, lack of system wide approach to themes identified, no governance on who monitors or how the actions are followed up as a number of actions were repetitive especially in the palliative care reviews. It is also unclear on patient selection for reviews or discussion can the Trust assure themselves that a true avoidable death get identified using the current methodology? Terms of reference for the mortality reviews would be helpful and outputs to give assurance that work is of high quality and benchmarking against clinical standards. Minutes, that the panel reviewed, of the mortality review meetings still do not appear to have an action log to evidence following up actions. Although the Medical Director referenced improvement in care pathways in her opening talk there was no documentary evidence of improvement in care pathways in the minutes provided from the mortality review group. Previously (on the last visit) there was minuted

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evidence that the Trust was using surveillance data from Dr Foster and HED to proactively monitor mortality across diagnostic groups but on this occasion there was no evidence presented that this is still the case. The trust have advised that they have commissioned a mortality audit for 2014/15 and the findings will be channelled through the mortality group which is chaired by Sean MacDonnell, who is also responsible for reviewing Dr Foster and SHMI. The monitoring at the board is superficial – just a graph of HSMR and a very short narrative about the SHMI, more analysis would be benefit the board to understand the improvements being made and gain assurance..

15. Clinical coding

Trust to continue to develop the clinical coding team and develop relationships with clinical coding staff to reduce the coding error rate.


The trust supplied addition documentation which describes improvements that have been made in the clinical coding department and the results of recent audit which shows a small improvement in some measures since the last audit. One area showed deterioration. There is no benchmarking data provided to be able to make a comparison to other trusts. We would expect an analysis of depth of coding benchmarking to other trusts – particularly to link in with the mortality work.

KLOE 4 What does the Trust do to develop and strengthen clinical engagement and leadership?

16. Visibility of Executive team

The trust should consider the need to formalise ward observations to increase the visibility of the Executive team


As reported above staff report the Director of Nursing and new COO to be very visible.

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with frontline staff and how findings of these observations are reported back at ward level.

17. Effectiveness of Clinical leaders and management at divisional level (links with 2)

17.1 The planned move to a clinically led organisation requires a strategy to achieve this, and should include a comprehensive development programme for those in or aspiring to be clinical leaders. This should apply to clinicians in the wider sense and not just medical staff.

17.2 The Trust should seek feedback from staff at all levels

on how to improve two way communications between front line staff and management.

17.3 Trust should review the assurance process in place for

bullying and harassment. 17.4 The Trust should review any specific reports of

bullying received in order to ensure that the response to this has been appropriate and a proper investigation undertaken.


The development of the three at the top divisional structure and two at the top ward structures re engaging clinical staff. AHPs remain outside this model however. Leadership development is due to be offered shortly. A Comms strategy for managing internal and external messages is required. Staff report multiple newsletters being created at present.

18. Leadership from senior doctors

18.1 The Trust should ensure that there is a clear strategy in place with timescales to implement the clinically led structure.

18.2 The Trust needs to understand from the nursing team

why they perceive that senior consultants are not engaged or support them in a in a more consistent and


Not clear who is the board level Director lead for quality; some staff believe it’s the DoN or DON & MD or just MD. The need for a quality strategy and a clinical strategy is recognised as a priority.

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effective manner (re. ALERT training programme).

18.3 The Trust should seek feedback from nursing staff and

junior doctors on how senior medical staff can engage with and support them in a more effective manner.

18.4 The Trust should be innovative in its engagement with

the senior medical workforce, in order to enable divisional clinical leads and senior doctors to further develop to fulfil their roles, and for their roles and responsibilities to be clarified.

9 never event. Human factors training in areas that had never events. Now to be rolled out. Funding for coaching of 15 people for leadership. Potential risks associated with loss of several hundred staff due to need to get back into financial balance. Shortage of nurses recognised as a major risk. Junior staff would like to be part of the quality improvement agenda, but feel that the medical consultants are in a state of “learned helplessness”. New MD is making in-roads with key clinical leaders, but may need to give more PAs to the MD role.

KLOE 5 How does the Trust engage with patients and ensure it learns from complaints, compliments, survey results and other patient experience intelligence?

19. Complaints process

19.1 The Acting DoN and PALs manager should review the handling of complaints and processes whereby complaints can be systematically feedback and used by staff teams to improve service delivery. This should include:

Improving understanding of visibility of complaints methods with staff and patients The Trust continues to liaise with and meet patients to ensure concerns addressed.

Review size and structure of the complaints team.


Led by the DoN with support from the board good progress has been made in improving the process and assurance structure and changing the culture within the hospital. More evidence of the learning from complaints and concerns cascading through the hospital with the consequent service improvements is required. There were good examples in some divisions but it was variable, closer working engagement with PALS and front staff has started.

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Review the governance arrangements at directorate.

Level to improve ownership of complaints.

Review the process and person responsible for ensuring a complaint is answered in a timely manner.

Develop a mechanism for learning lessons from complaints and communicating these across the organisation to ensure key messages are cascaded. E.g. establishing a lessons learned panel with divisional leadership team membership

19.2 The trust should review the focus, culture and

approach of PALs to be more patient experience focused, impartial and approachable.

The Chair and board are committed to the PAL service and its relocation to the front of the hospital which will deliver significant benefits for patients. The PAL's team are committed and feel well supported. Subject to PALS moving

20. Patient experience themes

20.1 The Trust should undertake real patient communication and engagement through:

Reporting patient stories to the Board in a systematic way (not just numbers and trends)

Communicating actions taken in response to patient feedback back to patients

The Executive team should gain assurance that action plans in response to feedback are implemented.

Actively seeking feedback from patients and relatives which is wider than just from the membership.

The Trust Board should receive a summary of the substance of complaints, trends and themes as a minimum. This should be reviewed and an action plan agreed to respond to key themes. PALS information should be included in this.

Trust should capture more real time patient experience

Good Further evidence required Full assurance will be achieved when the strategy is approved, a work plan agreed and evidence roll out

Patient stories presented to the board. The Trust board has clearly identified patient experience and engagement as a priority and recent progress has been made with greater involvement of the governors with plans to integrate them more closely into the assurance and operational structure. There was some evidence of “you said, we did” at ward level and the cancer user group and work with Health watch are very positive steps. The trust provided a comprehensive draft Patient Experience strategy. A focused work plan with clear outcomes will be required to deliver the strategy. The clear commitment of permanent staff to the hospital will be a big asset in this regard and all staff groups should be fully engaged.

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data and report it in a systematic way from ward to Board and back to ward.

The Trust should develop an action plan to address issues raised in the CQC patient survey.

Board to seek assurance that where action is taken the impact is triangulated with patient experience themes.

has commenced.

The emerging culture change means there is a good opportunity to impress CQC in this area, for example by initiating the referenced 5 priorities from the CQC survey

KLOE 6 How does the Trust engage with its workforce and other stakeholders?

21. Engagement with Trust staff

21.1 There appears to be an issue with the flow of information between staff and managers at the Trust that is not visible to the Trust Board.

21.2 The Trust should ensure it uses systematic processes

such as Focus Groups to engage with and gather feedback from staff, including ways to gather feedback confidentially.

Requires improvements

The Trust have adopted 2 At the Top - Ward Governance Meetings Chaired by nurse and medical lead on each ward, however they are not all clear how the information they share with divisional leads (3 at the top) goes higher up the organisation and not clear how the message from board to ward is received. Staff Survey – Staff Engagement - The trust's score of 3.50 was in the lowest (worst) 20%, when compared with trusts of a similar type. Percentage of staff reporting good communication between senior management and staff is within the 5 key findings for the trust and lower than the national comparison. Receiving clear feedback from line managers is also lower than the national average. The trust CEO report highlights focus on staff engagement and the ‘at our best’ initiative to be relaunched. Every staff member will receive a letter delivered by hand by their line manager from Lucy regarding the relaunch and stress the Trust can improve without its staff. Staff spoken to highlight they receive newsletters and bulletins from a variety of sources so it may be

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21.3 The Trust should consider how it uses the information

collected to act on concerns raised by staff and how it feeds back actions taken as a result to all staff in a consistent manner.

worth reviewing what information staff are currently receiving to ensure it is most effective.

KLOE 7 How is the Trust assured it has the necessary workforce to deliver safe care?

22. Staffing levels and skill mix

22.1 The Board should urgently review staffing levels on the following wards to assure themselves that staffing levels are safe, especially out of hours:

22.2 staffing reviews have taken place and additional

nursing and medical staff recruited, however the panel felt that they did not see a comprehensive strategy for assessing and addressing staffing issues at the Trust. The Trust should develop a clear credible plan for staffing levels which sets out how it will ensure staffing levels and mix are safe.

22.3 The Board should assure itself that investment in additional medical and nursing staff is impacting in high risk areas. Information should be reported to the Board that clearly triangulates staffing levels qualified to unqualified nurse ratios, incident rates, (e.g. falls), so that the Board can measure the impact of additional investment in staffing levels and ensure staffing levels are consistently safe.

Requires improvements

Turnover reported at 17.6% Vacancies at 12.2% Sickness at 4.2% Spend on temporary staff is high – agency use in and off framework. Staff report some shifts some wards running on one or 2 members of trust staff – the rest agency. Staff report wards with good retention having to regularly send staff to other wards. Clear evidence of board reporting and use of tools to understand required skill mix of ward staff, however board reports regarding nurse staffing discuss numbers – no evidence of triangulation with safety metrics being reported formally. Unclear whether nursing recruitment and retention strategy is signed off by board, this is a concern. Local and international recruitment of nurses initiatives – Nursing strategy to be published May 12 2015 – aiming to bring pride back into nursing Limited evidence of focus on AHPs Locums, there is a local induction systems in place. Recent change from daily planning /reactive to planning shifts 8 weeks in advance – feels less

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chaotic - and offers more assurance to staff.

23. Support for junior doctors

The Trust should review the staffing levels and support for junior doctors, addressing concerns about bleeps, inappropriate delegation and escalation processes.

Good The actions following the previous Health Education EoE visit have provided this assurance.

24. Sickness absence and vacancies

24.1 The Trust should review reporting for medical sickness. If sickness levels are inaccurate the Trust should investigate the reasons for this and develop clear actions to address the issues.


Staff sickness absence is reported but is not broken down by division/department, although reference is made in the February Performance Report to HR Advisors undertaking an audit of all sickness information within divisions/departments to verify reasons for absence and ensure accurate reporting and identification of key themes. However, sickness absence is collated by department/division and is discussed at the Monthly Divisional Board meetings. The report has been refined to allow close scrutiny of each episode enabling identification of patterns/themes of absence. This report provides the foundation for HR Advisors and Line Managers to review and monitor each individual staff member’s absence history, provide commentary, note key dates and effectively manage and reduce sickness absence

A reduction in sickness absence has been achieved in Medicine reducing to 4.6% from the previous

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month. Sickness Absence is a key workforce metric which is a standing agenda item for discussion at Divisional Board Meetings. Staff nurse from Occupational health – discussed staff burnout and staff suffering mental health issues HR director – clear that new systems and process have been introduced to focus on staff retention and wellbeing.

KLOE 8 What assurance does the Trust have that the organisation is safe?

25. Quality of handovers

25.1 The Trust should ensure that all members of the handover team (medical) understand and follow standard operating procedures in place.

The observed handover could have been improved by:

More emphasis on physiology by patients with the highest PAR scores.

Acutely sick patients being prioritised and highlighted during handover

Clear allocation of tasks

Greater detail in the description of patients, for example via the use of SBAR framework

25.2 Surgical and other speciality handover arrangements

should be formalised and attended by senior nursing staff


Junior doctors consider nursing handovers to be better than the handovers to junior medical staff. Juniors would like to be kept informed of service developments e.g. CDU and MDU opening. The outreach team would like some board ward rounds with the teams twice a day but this is not in place as yet. Junior doctors would like to see more medicine and less management in the messages in the CEO weekly blog. Perceived problem of internal communications by fax, with no record of receipt. GPs still faxing referrals for non-cancer patients. Sometimes front sheet with patients name is missing.

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Concerns over re-opening of Birch ward, with mainly agency staff. Concerns that agency nurses may was a lesser range of therapeutic skills to assist the doctors. Shortage of respiratory medicine consultants, MAU consultants and 3 registrars down. Some very long stays of medical patients in cardiology.

26. Reporting of Serious incidents

26.1 The Trust should clarify the process for escalation of SI’s and communicate this to all staff.

26.2 The Trust should ensure that the learning from incident

reporting happens at all levels throughout the Trust. The Trust must assure itself that lessons learned from events, themes and cases are visibly used in Trust-wide events in a systematic manner to alert the relevant staff to the issue.

26.3 The Trust should make it easier for front line staff to

escalate quality issues such as a trigger form (other


The trust have a daily SI and complaints multi-

disciplinary panel meeting which discusses all SIs,

management, escalation and accountability, it is

predominantly lead and attended by nursing. The

process is good but for sustainability the time spent

at the meeting daily and formal written minutes

should be reviewed as to the value long term. All

staff were aware of the process.

The Trust has a monthly quality improvement

bulletin which discusses incident themes and

improvements, the Chair of the quality and safety

committee was only recently made aware of this

resource which he welcomed

With regards to providing responses and feedback, the trust has recently introduced red folders to every

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than Datix for incident reporting) that requires a response back.

ward area with divisional with recent SI relating to that area and a copy of the integrated quality and patient safety report. From speaking with staff, an evaluation of the effectiveness of the red folders may be warranted as support staff was unaware and some ward staff see it as just a tick box exercise as they have to sign that they have seen the book. I think the Trust would benefit for specifically theme reviews such as sepsis or deteriorating patients undertaking an aggregated review with clear outcomes and learning and link these into the trust wide improvement plans so the board have full sight of these. Some wards do say they find the folder useful and

use these at ward and team meetings, however due

to the staff shortages often staff are unable to

attend team meetings so do not get the benefit of

team de briefing from incidents and discussions.

27. Dissemination of lessons learned

27.1 The Trust should consider further investment in learning from reviews and ensure lessons learned and key themes are disseminated throughout the organisation and progress against action plans monitored.

27.2 Trust should introduce regular Trust-wide risk newsletters highlighting lessons learned and improved outcomes for patients


The Trust has a significant backlog of SIs which may need to consider commissioning some short term additional resources to undertake a review and action plan all linking into the Trust wide improvement plans. Currently the Trust are under pressure from the back log which is prohibiting moving forward to implement the changes needed and allow time to evaluate for sustained quality and safety improvement.

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27.3 The Board should assure itself that staff trained in root

cause analysis have responsibility for monitoring action plans and embedding lessons learned throughout the organisation supported by, risk managers and reporting to the clinical effectiveness group.

On the day we were advised that the RCA programme is under review with the quality hub staff identified to deliver the training.to all staff identified as requiring it. The panel have since been advised that the training programme was revised and re launched in March 2015, but the panel have not seen evidence of this. The panel would recommend that for a RCA investigation to be undertaken correctly first time they should seek agreement with the CCG on the SI terms of references prior to starting any investigations, this should in turn reduce the Sis reports and action plans been returned for further amendments. Staff undertaking RCA must also have the capacity to undertake the training and have time allocated to undertake any review.

KLOE 9 How does the Trust support staff development?

28. Clinical Supervision

The Trust needs to ensure that there is sufficient clinical supervision for student nurses and newly qualified nurses.


Staff reported that student nurses and newly qualified nurses are provided with clinical supervision and that this was challenging at times due to the staffing establishment. No assurance was provided to confirm compliance and there was no opportunity to check this within a focus group arena. This is being addressed by the employment of clinical skills nurses

29. Staff appraisals and development

29.1 The Trust needs to ensure that all consultants complete the appraisal process in a timely manner.

Assurance paperwork states that medical appraisal is up to date. NHS England undertook a revalidation review on the 29th April and found

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29.2 The Trust needs to review the appraisal process for

staff to ensure that appropriate development needs are identified and progress against development plans monitored.

effective process in place however the governance and links to complaints required additional work. Very early days for nurse revalidation. Appraisal non-medical staff – February 2015 completion rate =76.78%. ‘Quality survey to be sent to all staff that have had an appraisal recorded within the past 6 months via survey monkey.

30. Compliance with mandatory training requirements

The Trust must assure itself that there are adequate staffing levels to allow protected time for the completion of mandatory training. The Trust may need to use innovative solutions to address this issue.


HR Performance and assurance report states that “overall core training is very gradually improving since last year and was at 85.2% at March 2015. Staff reported that core training was delivered during team days and a number of areas reported they had not had organised team days to access core training since 2014 due to prioritising service needs. Compliance is low due to the staffing being below establishment and the need to cancel education sessions”. The Trust advised that additional sessions on some mandatory training were made available including evenings and weekends to accommodate service needs. With regards to safeguarding training the Trust state that 2014/15 the average % compliance has been 97% for adult safeguarding and 93% in child safeguarding, this gets reported and monitored at the monthly safeguarding committee.

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The Trust have acknowledged that during 2014/15, due to prioritising service needs some team days were cancelled, the Trust have appointed a new clinical skills nurse for emergency who is focused on mandatory training compliance including the provisional team days, we saw evidence of the mandatory training board on our visit.

6.0 Summary

The assurance review panel would like to thank the Trust for their cooperation and help throughout the assurance review process. There was a positive feeling throughout the Trust with the new leadership team and a genuine feeling that things were improving from the staff point of view. Although the panel had just a ‘snap shot’ on the day, The review team report that a number of improvements are now beginning to appear, although these need time to become further embedded. Patients and visitors spoken to were very complementary about the care and treatment they have received and there is a real community feeling of support for the Trust. We observed progress against most actions during the visit, however the focus on quality of care must remain a priority of the Trust. There are some quick wins to:

Improve clarity of the trust structures and how it works to all staff, with the “two at the top” and “three at the top”.

To rewrite the Quality Strategy

Agree the Nursing strategy and subsequently a wider workforce strategy

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Move the PALs office to the front of the hospital

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Appendix 1: Terms of Reference for the site visit to Colchester Hospital

Colchester Hospital University NHS Foundation Trust was one of 14 NHS hospitals inspected as part of Sir Bruce Keogh’s review of the quality

of care and treatment in June 2013. The Trust was put into ‘special measures’ on 14th November 2013. Following several Care Quality

Commissioner visits in 2014 remains in ‘special measures’. NHS England under took a desktop review and multi-site visit on the 6 and 7

February 2014 on behalf of Monitor.

Colchester Hospitals and Monitor has requested support again from NHS England to review the Trust’s progress to date against the agreed

action plan.

NHS England will undertake a one day desk top review of the evidence provided by the Trust against the agreed action plan/s.

Following the desk top review a one day announced site visit will be held to triangulate the evidence received against progress made.

This will comprise of meeting with the Trust Board, patients/carers and staff, and ward and department visits

The one day visit will solely be to review the progress made against the action plan/s and not to identify any new areas. Any new areas

identified will be escalated by the panel Chair to Monitor, CCG and East Team for action

The team will be chaired by Dr David Levy and will include a patient representative and representation from North East Essex CCG and

East Medical Team

The visit and feedback will be shared with Monitor and CQC

NHS England will not be in a position to remove the ‘special measure’ - this responsibility remains with CQC

The announced visit is scheduled for Tuesday 28 April 2015.

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Appendix 2: Panel membership

Panel role Name and job title

Panel Chair Dr David Levy Regional Medical Director, NHS England (Midlands and East)

Senior Management Support

Finola Devaney Regional Quality Assurance Manager, NHS England (Midlands and East)

Senior Support Tracey Cogan Regional Head of Performance Improvement, NHS England (Midlands and East)

East Team Medical representative

Christine MacLeod Medical Director, NHS England (East)

Lay representative Trevor Begg

Doctor Colette Marshall Consultant Surgeon and Medical Director, Bedford Hospital

Senior Nurse Liz Hogbin Head of Compliance Governance, Norfolk and Norwich FT

CCG Lisa Llewelyn Director of Nursing and Quality, North East Essex CCG

Regional Senior Nursing representation

Fiona McMillan-Shields Deputy Director of Nursing Midlands and East (Patient Experience)

Regional nursing support representative

Shelley Bewsher Quality Assurance Programme Manager, Nursing

PMO support Neil Rolfe Performance Support Manager, NHS England (Midlands and East)

PMO support Sarah Jane Bailey Team Administrator & PA to Dr Alistair Lipp NHS England (Midlands and East)

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Appendix 3: Visit agenda 08.30-09:00 Panel arrival at the Trust 09.00-10:00 Trust presentation then 30 minutes Q&A/clarification

10.00-10:45 Interviews with Executives:

Chief Executive

Medical Director

Director of Nursing & Patient Experience

Chief Operating Officer 10.45 – 11:45 Interview with Executives:

Trust Chair

Chair of Patient Safety Committee

Director of HR

10:00 - 12:15 Ward visits

Refer to appendix 5

13:30-14:15 Focus Groups:

Junior Doctors

Staff Nurses

Consultants

Ward sisters

All staff

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14:15-15:00 Interviews with key staff:

Director of Clinical Governance

Outreach Team

A&E/Urgent Care Lead

Clinical Directors/Matrons

13.30 -15.00 Further ward visits and talk with families

Refer to appendix 5 17.00-17.15 Feedback to Trust Chief Executive

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Appendix 4: Focus Groups

Junior doctors

Staff nurses

Consultants

Ward sisters

All staff Appendix 5: Ward visits

Brightlingsea ward (ENT, Vascular, General Surgery)

Children’s day unit

Children’s ward

Dedham ward (Cardiac)

Emergency assessment unit (EAU)

Langham ward (General Medicine)

Mersea ward (General Surgery)

Nayland ward ( General Medicine)

West Bergholt ward

Lexden ward (Obstetrics & Gynaecology)

Birch ward (Care of the Elderly)

Layer Marney Ward (Medicine)

Stroke unit (Specialist Medicine)

Tiptree ward (Care of the Elderly)

EAU/MAU/A&E/FMU/CAU Appendix 6: Interviews

Chief Executive – Dr Lucy Moore

Chief Operating Officer – Dr Shane Gordon

Medical Director – Dr Angela Tillett

Director of Nursing & Patient Experience – Dr Barbara Stuttle

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Trust Chair – Alan Rose

Chair of Patient Safety Committee – Tom Fleetwood

HR Director – Lynn Lane

Director of Clinical Governance – Selina Sibanda

Outreach team

Clinical Director/Matrons

A&E/Urgent Care Lead – (Did not attend)

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Appendix 7: Documents reviewed by the panel (Please note that this does not include all evidence as supplied by the Trust to the panel but summarises the main documents reviewed)

2 at the top – Ward Governance meetings, December 2014 – February 2015

A&E seniors meetings – January 2014 – February 2015

Audit reports – Trust audits 2014/15

Bed management plans – Standard operating procedure (SOP) – 6th March 2015

Board performance reports – February – December 2014

Business continuity and contingency plan – Trust business continuity plan

Cancer pathways – Cancer improvement action plan 2015 – Version 18, Clinical protocol – Breast, Colorectal, Gynae

CHUFT improvement plan 2015 – Improvement plan 26th March 2015

Decontamination action plan – Update January 2015

Divisional Bulletins – Surgery August 2014, October 2014 – January 2015. Women and children’s – December 2014 – February 2015

Divisional complaints reports – February report for medicine, surgery, urgent care, women’s and children, CSS & C

Divisional dashboards – Medicine, Surgery, Women & Children, Urgent Care

Divisional Governance – Meeting papers for October 2014 – March 2015

Divisional Governance SI and incident reports – Medicine divisional report Feb-15, Medicine dashboard March 2015

Divisional performance reports – Medicine, Surgery and Urgent Care February 2015

Draft quality account – Quality report 2014/15

End of life – Care of the patient after death procedure – version 11, Guidelines for care of the dying

E-roster UNIFY staffing level reports – UNIFY report December 2014 – February 2015

Feedback from Universities – CHUFT annual survey 2014/15, Bi-monthly student placement feedback October 2014 – January 2015

GMC/LMC reports – Health education East of England quality and performance review action plan

HSE action plan – Action plan February 2015

ICOOH documents – Recognition of the deteriorating patient procedure

Improvement Board papers and action plan – Board papers – September – October 2014, December 2014, February 2015

Integrated QPS reports – Quality and Safety report – November 2014, January – March 2015

Job planning – Weekly job planning reports

Maternity improvement action plan – Integrated action log maternity services – May 2014

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MHRA action plan – Response to MHRA inspection V8.4

Mortality – Mortality meeting notes on lessons from mortality – February – March 2015

Nurse recruitment tracker – Nurse recruitment and assurance report – 25th March 2015

Operation fresh start – Evaluation briefing February 2015

Organisational structure – Board of Governors and Executives structure, Divisional structure, Governance structure (including Board

Committees)

Patient flow documentation – Protocols for sepsis, asthma, back pain and cellulitis

Peer service review tools – Outpatients, Adult In-Patient, Maternity, Paediatric

POD Board committee – Papers November 2014, January 2015, March 2015

Private Board – Board papers from January – March 2015

Public Board - Board papers from January – March 2015

QPS Board committee papers – November 2014, January – March 2015

Quality improvement bulletins – Papers from December 2014 – March 2015

Quality reports and dashboards - Quality scorecard – December 2014 – Feb 2015

Quality strategy – Trust quality strategy 2013 – 2015

Risk management strategy – Strategy version 10, BAF risk dashboard 2015

Safeguarding action plans – Adult and children audit action plan March 2015

Service user involvement – Cancer services – Minutes – January – February 2015

Serious Incidents – SI reports from December 2014 – March 2015

Serious Incidents panel meeting – Minutes from November 2014 – March 2015

Training compliance reports – Core training reports December 2014 – February 2015

Transformation – Five year sustainability plan 2014 - 2019

Urgent care improvement plan and RAP – Version 5.1 2015

Whistleblowing guidance – Whistleblowing policy – Version 5, November 2014, January – February 2015

Workforce staffing and skill mix - People and Organisational Development Committee (POD) meeting papers for November 2014,

January 2014 and March 2015

Workforce staffing and skill mix - Urgent Care Division – Nursing workforce plan for Accident and Emergency and Emergency

Assessment – Meeting date 21st January 2015 notes

Workforce staffing and skill mix – 2 at the top minutes showing discussion of staffing establishment.

NHS England Site Visit

Documents

Transcript of NHS England Site Visit