Use of the CQUIN payment framework

A proportion of Wye Valley NHS Trusts income in 2013/14 was conditional on achieving quality improvement and innovation goals agreed between Wye Valley NHS Trust and any person or body they entered into a contract, agreement or arrangement with for the provision of NHS services, through the Commissioning for Quality and Innovation payment framework. Further details of the agreed goals for 2013/14 are included in Section 2.3.3 and the

following 12-month period is available electronically on the Trust website.

3.5 Statements from the CQC

The Trust is required to register with the Care Quality Commission and its current status is registered without conditions.

The Care Quality Commission has taken enforcement action against the Trust during 2013/14.

The Trust has made the following progress by 31 March 2014 in taking such action;

 All staff have been reminded of the importance of providing patients with information about how to prevent pressure damage to their skin.

 The availability of patient information has been checked within all wards across the Trust.

 Spot checks have been initiated during Patient Experience Walk Rounds to check patients receive and understand the information they have received.

 Ward Sisters conduct periodic reviews of all documentation to ensure the provision of patient information is being documented.

 A Trust wide audit of the use of the SSKIN bundle will be undertaken in July 2014.  Training for staff will include the need to provide patient information booklets for

patients

 A project group has been set up to formulate a plan of additional long term works required to maximise privacy and dignity within the DSU.

 Female surgical patients have been rerouted to ensure they do not pass through a male occupied area following surgery.

 Temporary privacy screens were put in place immediately following the inspection visit to eliminate the line of site between male and female bays.

 Permanent medical privacy screens have been purchased to eliminate direct line of site between male and female bays.

 Mixed sex breaches are monitored on a daily basis and reported to NHS Herefordshire Clinical Commissioning Group (CCG) weekly.

 All incidents in relation to mixed sex breaches are reported and investigated via the Trust’s incident reporting processes.

 Small storage lockers used for DSU patients made available to inpatients for their belongings.

 DSU department is looking to purchase slim mobile units as a more permanent solution to storage issues.

 Clinical Assessment Unit opened in October 2013 to reduce the need to use outlier areas for inpatients. This was extended in size and scope from January 2014.  The use of DSU is on the risk register and reviewed monthly by the Service Unit and

Trust Executive Committee to ensure privacy and dignity is optimised.  All inpatient admissions are recorded on Datix. A daily report is provided to

 From 10 January 2014 surgical cases only may be located in the Day Surgery Unit.  The Trust’s plan (assuming full use of the CAU) is to cease to use the Day Surgery

Unit for inpatients during February 2014.

 All staff have been reminded of the importance of completing the SSKIN bundle and following the SSKIN bundle guidance.

 Ward Sisters conduct periodic reviews of all documentation to ensure this is been completed accurately.

 The Trust’s Training plan for the prevention and management of pressure area care is being reviewed to ensure staff receive robust and regular training.

 A full route cause analysis was undertaken in relation to the patient identified during the inspection visit whose NEWS chart was not followed.

 The DSU SOP provides clear guidance to staff about the use of the DSU for inpatient beds. Within this it is made clear that one of the exclusions for admission to the DSU are patients with a single NEWS score of 3 or combined score of 5.

 NEWS audit was conducted during December 2013. The results will be reported to the Quality Committee in February 2014.

 Unexpected admissions to ITU /HDU and suboptimal care of the deteriorating patient are now reported as separate fields within DATIX.

 A NEWS campaign was conducted across the Trust to raise awareness.

 Additional training in relation to the use of NEWS has been conducted across the Trust by the Practice Development Team.

 A revised training programme for 2014 has been developed by the Practice Development Team (PDT) and Tissue Viability Nurses.

 The Link Nurse training programme is being re-established across the Trust.  The Tissue Viability Action Plan has been updated and monitored by the Director of

Nursing & Quality.

 A revised TNA has been developed for implementation across the Trust.

 An action plan has been developed to ensure training is delivered in accordance with the TNA.

 Alternative training is routinely offered if training is cancelled due to operational pressures.

 A revised Induction Programme has been developed by the PDT.

 ESR is being updated to allow for training data to be provided in a more user-friendly format for reporting and monitoring both locally and by the Trust.

 Learning lessons from incidents, complaints, claims and audit are included within Trust Talk and Team brief

 The Director of Nursing & Quality holds meetings monthly with the Heads of Nursing and Ward Sisters upon which learning lessons is a standing agenda item.

 Formalised documentation of learning for incidents, complaints and claims is taken to Service Unit meetings by the Quality and Safety team on a monthly basis.

 A six monthly report will be provided to the Quality Committee on “learning from incidents, complaints and claims”

 Nursing metrics including Friends and Family (FFT), complaints, compliments, pressure ulcers, patient falls, medication errors and ‘You said… We did…’ are provided monthly to wards. This ensures staff and patients have access to relevant ward/department information on a monthly basis

 Weekly FFT data is sent to ward managers.

 Staff knowledge regarding never events and other issues that have occurred within their area are included within the Patient Experience Walk rounds.

 Generic PowerPoint presentation slides are included within each Trust training session. These will highlight learning across the organisation from incidents, complaints, claims and audits

 Staff listening events were undertaken during November 2013 and reported to the Trust Executive Meeting in February 2014.

 A rolling programme of on-going listening events is planned for 2014 to enhance the dialogue between senior management and the workforce.

 The Trust has commenced an annual programme to capture staff feedback through the Safety Culture Survey.

 A global email was sent by CEO to all staff emphasising the importance of reporting incidents and taking positive steps to maintain quality care for patients Each Service Unit reviews its risk register (in accordance with the Risk Management Strategy) at their monthly Service Unit Governance Group. The risks are discussed, prioritised and any risks requiring escalation are identified.

 The Service Unit Directors (SUDs) or representative attend the Trust wide Service Unit Performance Committee at which they are expected to raise issues pertaining to the risk register. The Service Unit Directors are also invited and encouraged to attend the Quality Committee where clinical commitments allow. If the Service Unit Director is unable to attend a representative from the Service Unit is expected to attend in their place.

 The risk register and any significant Service Unit risks are discussed at both the Trust wide Service Unit Performance Committee, Trust Executive Committee and any significant issues are escalated to the Trust Board (via the Trust Executive Committee) so that appropriate actions can be taken.

 Quality and safety issues are reported to the Quality Committee where additional actions are discussed, recommended and agreed. In addition, all minutes of the Trust Executive Committee are sent to the Non Executive Directors.

 The Quality Committee also examines the Board Assurance Framework (which contains both strategic and operational risks) on a monthly basis.

 The effectiveness of the governance arrangements within the Trust will be audited annually.

 The Trust has initiated systems and processes to ensure mixed sex breaches are being reported in accordance with national definitions.

 These arrangements include SOPs for the use of the DSU. This provides clear guidance to staff regarding what constitutes a breach and what actions should be taken if this occurs.

 The SOP also identifies exclusion criteria for patients who are not suitable for admission to the DSU

 The Trust monitors this process throughout the day at its bed meetings and also provides assurance updates to NHS Herefordshire Clinical Commissioning Group on a weekly basis.

 The DSU has been reviewed jointly with NHS Herefordshire Clinical Commissioning Group on two separate occasions, since the RRR visit, to ensure no breaches are occurring.

 Any deficiencies are reported via the incident reporting process and are included in the monthly Quality and Safety Overview Report to Quality Committee. This includes an explanation of action taken and the appropriate investigations that are being undertaken should a breach occur.

3.6 Statement on relevance of Data Quality and your actions to