The Report of the Morecambe Bay Investigation … · Agenda Item 151 iv) 2015/16 The Report of the...

Agenda Item 151 iv) 2015/16

The Report of the Morecambe Bay Investigation (Kirkup Report)

Monthly Progress and Highlight Report Month Jan 2016 Name of Project Group Education, Learning & Development

Project Lead Lindsey Roome Project Sponsor David Wilkinson

Progress Description: Milestones not achieved in planned timeframe and rationale Following the Kirkup Task and Finish Group on the 11 January 2016, the following has been achieved: Role essential training

CC has signed off the role essential training ready for inputting into TMS. Risks and support identified.

Paediatrics – signed off by Paula Evans

Maternity - although a list has been prepared awaiting sign off, therefore gaps and risks still to be identified.

TMS

Phase 2 TMS priorities have been agreed and an implementation plan has been agreed.

Strategic TMS Group meeting bi monthly. Next meeting 26.1.16.

Updates to be presented to the monthly Kirkup Task and Finish Group

eAppraisal completion date brought forward from the 31 May 2016 back to the 31 March 2015.

LIA

The themes following communications to raise awareness on mandatory training have been collated and will be fed into the re-arranged LIA event on the 1 February 2016.

2.5.3, 2.6.2 role essential training requirements for WAC not signed off on the 11 January 2016 and unable to populate TMS. Gaps and risks not identified for WAC division. Reports cannot be generated from TMS until role essential training has been input. The collation of CPD records (4.2.5, 14.2.3). Revalidation forms part of the TMS development plan (i.e. eAppraisal) and the target date has been brought forward to the 31st March 2016.





Key Actions since last report/ Milestones achieved: Actions to be completed in next reporting month

WAC to sign off the list of role essential training and identify any gaps/risks in delivering and completing training for staff. CC to input role essential onto TMS to identify gaps.

Issues Log:

Description Mitigating Action

Role essential training reporting and compliance. TMS cannot generate reports until the training lists have been entered onto TMS and are dependent on these being signed off and input.

WAC - Role essential training compliance, gaps, risks and support not identified at Kirkup Task and Finish group on the 11 January 2016.

CC role essential training not on TMS to identify gaps.

WAC

A list of WAC role essential training as been drafted and awaiting sign off from the division.

Carl Hunter attending Medical O&G/Paeds fortnightly meeting to support discussions and sign off.

Sascha Wells and Paula Evans to send information by 15 January 2016

Owen Galt to update project lead on progress by 22 January 2016. CC

CC inputting role essential training onto TMS. Gaps to be identified in the next 2 weeks. To update project lead by 22 January 2016.

Regular project updates - Owen Galt and Laure Armistead agreed to be the link and update me on progress.

Input into the Educational Governance Task and Finish group around divisional strategic approach and communication of action plans, risk assessment, mitigating actions and progress reports.

Lack of attendance at the Kirkup Task and Finish group is hindering progress.

To increase attendance - Project Lead requested the group’s availability for alternative dates and times.





The December Practice Educator Group was cancelled due to unforeseen circumstances.

The next one is arranged for February 2015

Limited functionality and resources of Training Management System (TMS) to support the delivery of all areas of the action plan.

Phase 2 priorities agreed and implementation plan agreed and will be progressed through the bi-monthly Strategic TMS Group. The next meeting is due to take place on the 26 January 2016.. All priorities agreed and aim to be completed by 31st March 2016.

Top Project Risks : Actions to be completed in next reporting month


The LiA event on the 9 December 2015 was cancelled due to the venue being flooded. Therefore, the 20 week programme of testing and implementation will not be completed by the project deadline of the 30 April 2016.

LiA re-organised for the 1 February 2016 and staff are booking onto the event.

To date 60 staff are booked onto the event.

Outcomes: Changes to plan

The Trust has an up to date and fully comprehensive mandatory and essential

Training and Skills Needs Analysis for all professional staff.

Staff are fully trained against the TNA and are competent to deliver safe

effective care.

The Trust has robust education governance structures to support becoming a

learning organisation

The milestones regarding collation and review of data (2.5.3,2.6.2,) the list of role essential training to be agreed and input on TMS by February 2016 The collation of CPD records (4.2.5,14.2.3) forms part of the TMS development plan and (i.e. eAppraisal). The group have brought the target date forward to 31st March 2016.

Agenda Item 151v) 2015/16


Monthly Progress and Highlight Report Month January 2016 Name of Project Group Estates

Project Lead Andy Waddington Project Sponsor Aaron Cummins

Progress Description: Milestones not achieved in planned timeframe and rationale

Preferred New build option 3 was presented and approved by KRIG members at a meeting on 22.12.15

A paper was submitted to Morecambe Bay Investigation Sub-Committee on 8.1.16. Following extensive discussion the meeting approved option 3 for submission to Trust board for final approval with condition further investigation of theatre location is undertaken

Project has been registered under the P21+ NHS procurement scheme. A high level information pack has been prepared and sent to all 6 P21+ Principle Supply Chain Providers. Expressions of interest were received from 3 PSCP’s and a shortlist agreed. An open day took place on 21.1.16 at FGH commencing at 10.00hrs The 3 P21 PSCP’s attending were

Kier IHP Gallifordtry

Trust representatives were





Lindsay Lewis , Coralie Rogers – WACs Andy Waddington, Paul Coward , Ian Ferguson – Estates Ben Brookes –Trust project manager-, Ryder Hunt

Open day commenced with Andy Waddington welcoming all PSCP’s and then outlining project details and requirements A site inspection took place Contractors were then given opportunity to ask questions. The open day finished with PSCP’s instructed on agenda for final interviews Final interviews will be on 29.1.16 following which contract will be awarded.

Maternity Matters event No2 occurred on 22.1.16 starting at 11.00 in Storey Institute, Meeting House Lane, Lancaster. Estates presented information utilising room elevations and 3D drawings used at previous Barrow Town hall presentation. Other information including Board approved UHMB Estates strategy giving detail of proposed WACS accommodation on RLI site was also on display. The event was well attended and all comments noted

Patient and staff engagement will continue with information disseminated through user group leads






As above Appoint P21 contractor for procurement of preferred option

Trust to set up formal project team including establishing resource requirements

.

Investigate alternative lift location

Issues Log:


WACS departmental operational policies to be developed.

Expansion of current estate at FGH may not be in line with current Government policy

Specific question raised at Subcommittee regarding versatility of new build option to accommodate Midwife lead unit. Whilst modifications were feasible a significant reduction in floor space as a consequence of operational change would result in underutilised floor area .

Ongoing







Clinical requirements change

Capital funding not confirmed

Delay to plan progression

Conflicting requirements identified in other reports

Accommodating those changes

Ensure that Monitor understands the need

Pursue quick turnaround of report recommendations

Assess implications as reports are released

Outcomes: Changes to plan Planned outcome is a completed building scheme that supports all other work within the project and ensures a safe environment for our patients


Monthly Progress and Highlight Report Month January 2016 Name of Project Group Governance

Project Lead Val Wilson Project Sponsor Mary Aubrey

Progress Description: Milestones not achieved in planned timeframe and rationale The Governance Team have progressed actions well during January 2016. The project is largely complete and the focus is now turned to reviewing supporting evidence ahead of the assurance process and ensuring that the improvements are sustained.

15.12 3 Develop a clinical audit module on the Ulysses safeguard system to follow up and monitor the timely implementation of clinical audit and action plans arising - This action remains delayed due to the system requiring further updates from Ulysses and is outside the control of UHMBFT.

15.14 1 Develop standardised divisional Audit reports to reflect the Ulysses Audit Module – This is likely to be delayed to February 2016 due to a delay with Ulysses updating the system.


13. 8 Develop North West Experience Hub - This action is complete. 15.4.12 The Trust will ‘Go-Live’ of new templates, this will include local reporting /escalation meetings and triangulated early warning report

15.4.11 Rapid spread engagement events for WESEE (revised templates/meetings) Feb 16 ‘go live’ - on-going.

15.4.13 Annual review of WESEE template and process has been included in the Annual Governance Business plan

15.57 Consult with divisions to agree the revised WESEE templates (now aligned to 15.4) - This action is complete.

15.55 Review pertinent Terms of References (TORs) to ensure congruency post the completion of the review and scope exercise (15.52. 3 4).

Issues Log:


Top Project Risks :

Description Mitigating Action 5. Insufficient resource to implement necessary initiatives and improvements –

no resource to undertake identified 1:1 or face to face RCA training requirement.

RCA training on-going within current Governance Team resource. RAC and Incident reporting also now electronic.

10 Current Trust work-streams may overlap resulting in potential conflict or wasted resources.

Action plan reviewed and overlaps not impacting on Governance workstream.


Monthly Progress and Highlight Report Month January 2016 Name of Project Group Governance

Project Lead Val Wilson Project Sponsor Mary Aubrey

2. Failure to meet the expectations of stakeholders. Engagement event took place in September 2015. Await any feedback and offers of user involvement – update November 2015 – only 1 response received. The Patient Relations team will continue to utilise the customer feedback form sent to every complainant to gather user experience in relation to the complaints process.

Outcomes Changes to plan

15.12 3 Develop a clinical audit module on the Ulysses safeguard system to follow up and

monitor the timely implementation of clinical audit and action plans arising - This action remains delayed due to the system requiring further updates from Ulysses and is outside the control of UHMBFT.

15.14 1 Develop standardised divisional Audit reports to reflect Ulysses audit module –

This is likely to be delayed to February 2016 due to a delay with Ulysses updating the system.

Agenda Item 151 vii) 2015/16


Monthly Progress and Highlight Report Month January 2016 Name of Project Group Communications

Project Lead Louise Jones Project Sponsor Phil Woodford


All major actions that were due to be completed in December were completed on time.

Action 4.12 / Action 5.12: Following discussion at Sub-Committee, this action will be incorporated within the communications plan for the announcement of the new maternity unit at FGH. Action 7.12 - Focused stories on staffing, leadership, clinical guidance across maternity services, and new born screening stories are yet to be drafted. Still awaiting information from the maternity team following initial request from the Deputy Director and Head of Midwifery, due to pressure within the team. New deadline of 29 February 2016 given. Work continues on the other planned focused stories.


Key messages from sub-committee shared (8.1)

Uploaded sub-committee papers to website (8.2)

Produce one page review of single version report (8.3)

Single Version Report uploaded to website(8.4)

Stakeholder update on progress (8.5)

Press update on progress (8.6)

Social media update on progress (8.7 / 8.8)

Staff update on progress (8.9 / 8.10)

Team brief slide for managers and supervisors submitted for February (8.11)

Staff drop in sessions on 28 January (8.12)

Key messages from sub-committee shared

Sub-committee papers uploaded to website

Single Version Report/summary of progress uploaded to website

Staff update on progress

Stakeholder update on progress

Press update on progress

Social media update on progress

Two focused stories on Openness and Transparency. To focus on: what was the problem, what have we done, and what is still to do

Update in the March Team Brief for managers and supervisors

Monthly staff drop in session on 29 February

Agenda Item 151 vii) 2015/16

Issues Log:


N/A N/A



Confusion in messages from each of the maternity projects - MBI, Better Care Together, RCOG, etc.

An overarching strategic statement and set of principles is being developed so that all organisations involved continue to work closely together and not duplicate work.


For staff, stakeholders, service users and the public, to be aware of, and understand:

The Trust’s response and approach to the Morecambe Bay Investigation

Progress on the Reports’ recommendations

The action taken by the Trust

The difference these actions have made to patients and staff These will be measured in a mixture of quantities and qualitative methods, such as:

Questionnaires

Discussions

Briefings and feedback

Focus groups

Action 4.12 / Action 5.12: Request to remove these actions from the project plan as they are now being picked up in the wider communications plan for the new maternity unit at FGH. Action 7.12 - Request to change the date on this action to 29 February 2016 as due to other pressures within the maternity team, they have been unable to provide the information needed to draft these.

Agenda Item 151 vi) 2015/16


Monthly Progress and Highlight Report Month January 2015 Name of Project Group Strategic Partnership

Project Lead Halcyon Edwards Project Sponsor David Walker


The development of Strategic Partnerships project continues to make progress according to plan. Both Central Manchester University Hospitals NHS FT [CMFT] and Lancashire Teaching Hospitals [LTH] have confirmed their agreement to the partnership and the Memorandum of Understanding [MOU] has been produced and approved at the UHMBFT Board Meeting of the 25th November 2015. The Maternity Strategic Partnership Committee has been established, with Draft ToR, and will meet for the first time on the 29th February 2016.

None


MATERNITY STRATEGIC PARTNERSHIP COMMITTEE [MSPC]

Melanie Weeks, non-executive director of MBHT, has been appointed to Chair the MSCP.

The membership of the Committee includes senior obstetricians and midwives from all three organisations [Central Manchester University Hospitals NHS FT, Lancashire Teaching Hospitals NHS FT, and MBHT]; Medical Director [MBHT], Director of Governance [MBHT], workforce/communications and DGM representation [MBHT.

Dates have been set for the four quarterly meetings as follows: o 29th February 2016 o 13th June 2016 o 12th September 2016 o 15th December 2016

1. Papers for the first MSPC to be sent out to all Committee members w/c 15th February 2016.

2. Discussions will be held with CMFT and LTH about the type of training and development opportunities suitable for midwifery staff [identified through discussions with the HOM at MBHT].

3. Meetings with CMFT and LTH re the first placement of a member of the consultant medical staff.

4. Work to identify further detail of the existing collaborative work undertaken across MBHT O&G departments, and maternity units [how often, who has taken part, etc]

5. Meeting with TMS lead to further the MSP data capture module of TMS.





Diary invitations have been sent to all members for all four meetings.

The meeting with CMFT scheduled for the 12th January 2016 had to be cancelled due to the Junior Doctors’ strike. It has been rearranged for the 29th January 2016

Six members of staff from MBHT attended the Audit and Clinical Effectiveness Day at CMFT on the 19th January 2016. They included three O&G consultants, a senior audit midwife, the Head of Clinical Audit and the lead for Clinical Effectiveness.

o The day was very productive and reports from clinicians and the Audit Department were enthusiastic. Good links were made with clinical and audit colleagues, the presentations were interesting and informative, and discussions were wide ranging.

o The presentation of a ‘never event’ with an educational film showing good and bad practice has led one UHMB member of staff to check our PPH policy to see if it needs improvement.

o ‘it was a good educational day’ o ‘It was interesting and impressive to see the way they went about

this’ – development of a new guideline

Since the 19th January the following information has been received from CMFT

o A list of specialist obstetric clinics provided by St Mary’s [by day of the week] with names of the lead obstetricians and physicians supporting them.

o A list of regular MDTs – with times + days of the week o A list of internal department meetings





With an open invitation for UHMBFT staff to attend. Details of the processes to be followed for placements will be worked out with our Partner organisations and the clinical leads at RLI and FGH.

MBHT Midwifery establishment figures have been obtained.

Discussions have been held about the type of training and development opportunities that would be most appropriate for midwifery staff.

Issues Log:

Description

A proposed Addendum to the MOU has been put forward by LTH. It covers areas such as Intellectual Property, Clinical Indemnity, information governance, and FOI requests.

Mitigating Action

This has been shared with Capsticks who will be providing legal advice on the same. The addendum will be shared with CMFT once this legal advice is received.

None None



The costs associated with the Maternity Strategic Partnership have not yet been identified. This work will be undertaken in the forthcoming months.

Once costs have been identified to UHMBFT by CMFT and LTH discussions will be held within the Trust [WACS/Finance] to determine how these will be funded.

Outcomes: Changes to plan Memorandum of understanding reached with one or more Trusts. Establishment of partnership project programme.

None


Monthly Progress and Highlight Report Month January 2015 Name of Project Group Kirkup Programme

Project Lead Tina Turner Project Sponsor David Walker


The Morecambe Bay Investigation Programme (Kirkup) continues to make progress according to plan. The focus of the programme remains on delivery and monitoring of projects and to ensure good communication processes are maintained to projects group and Sub-committee.

None


KRIG and project leads meeting occurred Action plans for all projects monitored, maintained and updated Highlight reports received centrally Single Version Report produced Communicated progress to the MBI Subcommittee and Trust Board Review of project risk register Evidence continues to be uploaded to central electronic repository from projects PMO continues to complete stage 2 assurance checks in progress Data collection and sustainability process identified Outline ‘End of Project’ plan completed MIAA have started stage 3 assurance process with PMO Risk Register reviewed at KRIG and reported to subcommittee Produce report for MBI December deadlines

Closure report for clinical Quality Detailed End of project plan Ongoing Monthly Actions Direct, coordinate and administrate fortnightly KRIG and project leads meeting Direct, coordinate and administrate monthly MBI subcommittee meeting Monitor, maintain and updated all projects action plan Co-ordinate central management of Highlight reports received Produce monthly Single Version Report Monthly review and revision of project risk register Ensure good communication between project leads, Subcommittee, Board of directors etc. Continue

Issues Log: Description:

Mitigating Action:

None None

Top Project Risks: Description

Mitigating Action

Failure to meet the expectations of families

Family who have been involved in the investigation have been invited onto the Morecambe Bay Investigation Sub Committee. Cath Broderick appointed as engagement officer to work with families involved and wider service user groups. Engagement event occurred at Furness and Lancaster. Risk Increased again as representative not attended sub committee and escalated to project lead and sponsor of communication and engagement for further

Agenda Item 151a i) 2015/16


Monthly Progress and Highlight Report Month January 2015 Name of Project Group Kirkup Programme

Project Lead Tina Turner Project Sponsor David Walker

consideration. Chair to discuss with communication and cath brodeick re family expectations. (update 29/1/15) New service user sub committee member identified and currently role being discussed. Risk remains at 9, until service user attends


A structured programme management and project approach is to be used to: 1) Facilitate a consistent approach to planning and delivery across the Kirkup project 2) Provide accurate and timely communication of project progress 3) Enhance individual visibility, transparency and focus 4) Assist with scoping and development of project plans 5) Strengthen accountability by challenging progress on individual projects

None

Agenda Item 151a i) 2015/16

Agenda Item 151 ii) 2015/16


Monthly Progress and Highlight Report Month January 2016 Name of Project Group Workforce

Project Lead Rupert Wainwright

Project Sponsor Foluke Ajayi


1. Recruitment and retention Strategy approved by Workforce Committee. 2. Leadership structure for WACS reviewed. 3. Review of leadership role descriptions underway. 4. Action plan reviewed and updated with completed actions described against

each recommendations since 2012. 5. Evidence against completed actions collated. 6. Complete role description review. 7. Divisional plans for implementation of R&R Strategy – process established and

monitored through WAC. 8. Self assessment survey results passed to divisions for action 9. Leadership review completed. Job descriptions and roles for senior leaders

complete and amended roles advertised

All project in line with Dr Kirkup recommendation dates. Some slippage with some of the internally set dates/ milestones.


14.1.7, 9.2.6 – Leadership review completed. Job descriptions for senior leaders complete and amended roles advertised.

Review of job descriptions and roles where necessary for less senior managers and clinicians

Issues Log:







None reported N/A



Inability to meet some internal milestones within timescales specified Escalated concern to Implementation Group. Requests made and accepted to timescales and appropriate actions taken to meet them

Duplication across work streams and wider organisation Work closely with other work streams

External factors (BCT, RCOG etc) Ensure awareness in all discussions of impact of external factors

Regulatory intervention with the Trust and other partner organisations Maintain awareness

Re-validation of Nursing and Midwifery staff Maintain awareness

Lack of clarity over responsibility for completing middle level job description and role reviews

Meeting with HR partner and PMO support to create plan of action


Clinical leaders have current job descriptions with clear roles and responsibilities. Regular appraisals with staff and clinical director. Regular proactive team meetings with clear decision making and action planning in line with divisional objectives. Regularly appraised team member with clear aims and objectives. Team members working closely together and working closely across specialities to deliver safe excellent patient care. Improved recruitment and retention of staff ensuring staffing levels are in line with national guidance and acuity levels. UHMB is a preferred place of employment. Consistent high quality care provided across the Trust.

Updates and clarification of KPIs Post-Kirkup internal plans to be agreed for review of less senior manager and clinical leader job descriptions and roles. The less senior management positions are being reviewed within divisions to set up triumverates at each level of lead doctor, nurse (or AHP), and manager. This exercise has started and is part of post-Kirkup leadership improvement






Staff able to work on any Trust site where short term needs necessitate. All middle managers, senior managers and non-executives have a clear understanding of their roles and responsibilities in relation to quality.

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