cqc improvement action plan

of 86 CQC Improvement Plan (Published 10/8/15)

CQC IMPROVEMENT ACTION PLAN


Contents

FOREWORD FROM THE CHIEF EXECUTIVE ....................................................................................................................................................................... 3

TRFT INSPECTION RATINGS ................................................................................................................................................................................................... 4

AREAS FOR IMPROVEMENT .................................................................................................................................................................................................... 5

ACTION PLAN – MUST do ........................................................................................................................................................................................................ 16

ACTION PLAN – Should do ...................................................................................................................................................................................................... 54


FOREWORD FROM THE CHIEF EXECUTIVE

The Trust Board welcomes the CQC report published in July 2015.

This provided rich feedback and valuable insights about the care that we deliver in acute and community settings and how that care was viewed by our patients, their carers and families. In addition the reports contained the views of colleagues working across the organisation regarding the services they deliver, the challenges they face and highlights good practice in their areas.

The report reinforced what we know as an organisation about the progress we have made and the challenges we face; and reflects our journey of improvement and culture change.

Our journey started in December 2013 when the Trust confirmed its strategic direction to be a stand-alone Trust with collaboration across the wider health and social care economy to achieve improved clinical, financial and operational sustainability. Our strategic objectives set out our focus to move towards a more secure future where we can provide excellence in healthcare, delivered by engaged, accountable colleagues, within sound governance arrangements, based on strong financial foundations and working with partners to deliver sustainable services for the future, together.

However, we are not complacent. We recognise that while we have addressed many of the issues raised following our inspection in February and March 2015, we still have much to do.

The improvement action plan has been developed based on the need to address the Must Do and Should Do actions highlighted in the Trust’s CQC reports. This serves as a document of record to capture the actions that we have taken and sets out clearly our plans for tackling any outstanding issues. It also provides assurance to our board, our colleagues and people in the community of Rotherham, that we are committed to addressing all the issues that the CQC identified. In particular, it sends out a clear message that if we fall short of the high standards we set ourselves we will recognise that honestly, share the lessons we have learned across the organisation and take positive action to improve.

We are an open and transparent organisation and our progress towards meeting the objectives set out in this plan will be reported regularly, in public, at our monthly board meetings.

We also welcome comments and suggestions on this plan from colleagues, patients and the public. If you have any views you would like to share, I would be delighted to hear them. Please email them to me via Lisa Reid at [email protected]

Louise Barnett Chief Executive

mailto:[email protected]


TRFT INSPECTION RATINGS

To get to the heart of patients’ experiences of care, the CQC will always ask the following five questions of every service and

provider they inspect:

Is it safe?

Is it effective?

Is it caring?

Is it responsive to people’s needs?

Is it well led?

Before the inspection the CQC review a range of information including that provided by other agencies such as the Clinical

Commissioning Group, the GMC and NHS England. That information is then triangulated with what patients, visitors and staff

(colleagues) say during the inspection and considered alongside what the CQC observe.

CARE QUALITY COMMISSION – OVERALL RATING FOR THE ROTHERHAM NHS FOUNDATION TRUST

Are services at the Trust Safe? Requires Improvement

Are services at the Trust Effective? Requires Improvement

Are services at the Trust Caring? Good

Are services at the Trust Responsive to needs? Requires Improvement

Are services at the Trust well led? Requires Improvement

Overall assessment Requires Improvement

Community Dental Services Good

Community Health Services for Adults Requires Improvement

Community Health Services for Children, Young People and Families Requires Improvement

Community End of Life Care Requires Improvement

Community Health Inpatient Care Requires Improvement


AREAS FOR IMPROVEMENT – actions the Trust ‘MUST’ take

In presenting the findings of the inspection the CQC have produced a list of actions which the Trust ‘must’ take and a list which the Trust ‘should’ take.

Action Actions the Trust MUST take: Regulated Activity:

M1 The Trust must ensure there are suitable arrangements in place to ensure all relevant staff receive appropriate training. This must include safeguarding adults and children, resuscitation, mental capacity awareness and living with dementia awareness. (Provider report) The Trust must ensure there are suitable arrangements in place to ensure staff working in the medicine, maternity, children's and young people, critical care and accident and emergency services receive appropriate training. This must include safeguarding adults and children, resuscitation and mental capacity act awareness. (RGH report) The Trust must ensure there are suitable arrangements in place to ensure staff working in the community end of life care service receive appropriate training. This must include safeguarding, resuscitation, and mental capacity awareness. (Community End of Life Care report)

Maternity and midwifery services Treatment of disease, disorder or injury

Diagnostic and screening procedures Family planning services Maternity and midwifery services Surgical procedures Treatment of disease, disorder or injury Treatment of disease, disorder or injury

M2 The Trust must ensure there are suitable arrangements in place for establishing and acting in accordance with the best interest of patients without the capacity to give consent and treatment in line with the requirements of the Mental Capacity Act (2005) and its associated Deprivation of Liberty Safeguards. (Provider report)

Diagnostic and screening procedures Surgical procedures Treatment of disease, disorder or injury



The Trust must ensure there are suitable arrangements in place for establishing and acting in accordance with the best interests of patients without the capacity to give consent. this should be in line with the Mental Capacity Act (2005). (RGH report) The Trust must ensure staff are working in accordance with the Mental Capacity Act code of practice (2005). (Community Health Services for Adults report) The Trust must ensure all staff understand their role in relation to the Mental Capacity Act (2005) and its associated code of practice. (Community Health Inpatient Services)

Diagnostic and screening procedures Surgical procedures Treatment of disease, disorder or injury Treatment of disease, disorder or injury Diagnostic and screening procedures Treatment of disease, disorder or injury

M3A & M3B

The Trust must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons deployed to meet the needs of patients. (Provider report) The Trust must ensure there are sufficient numbers of suitably skilled, qualified and experienced staff. (RGH report)

Diagnostic and screening procedures Family planning services Maternity and midwifery services Surgical procedures Treatment of disease, disorder or injury Diagnostic and screening procedures Maternity and midwifery services Surgical procedures



The Trust must ensure there are sufficient numbers of suitably qualified and skilled staff to meet the needs of people who uses the services. (Community Health Services for Adults report) The Trust must ensure that there are sufficient suitably qualified, skilled and experienced staff in the school nursing service to meet the needs of the local population. (Community health services for children, young people and families report) The Trust must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons deployed to meet the needs of patients. (Community Health Inpatient Services report)

Treatment of disease, disorder or injury Treatment of disease, disorder and injury Diagnostic and screening procedures Treatment of disease, disorder or injury

M4 The Trust must ensure all do not attempt cardio-pulmonary resuscitation (DNA CPR) forms are completed in line with the trust’s policy and that patients’ capacity is assessed in line with the requirements of the Mental Capacity Act (2005). (Provider report) The Trust must ensure that all 'do not attempt cardio-pulmonary resuscitation' (DNA CPR) forms are completed appropriately. (Community End of Life Care report) The Trust must ensure all do not attempt cardio-pulmonary resuscitation (DNA CPR) forms are completed in line with the trust’s policy and that patients’ capacity is assessed in line with the requirements of the Mental Capacity Act (2005). (RGH report)

Diagnostic and screening procedures Surgical procedures Treatment of disease, disorder or injury Treatment of disease, disorder or injury Diagnostic and screening procedures Surgical procedures Treatment of disease, disorder or injury



M5 The Trust must ensure patients are not cared for in mixed sex wards / departments apart from those areas which are exempt from meeting the national requirements. (Provider report) The Trust must ensure patients are not cared for in mixed sex wards/departments apart from those areas which are exempt from meeting the national requirements. (RGH report)

Diagnostic and screening procedures Surgical procedures Treatment of disease, disorder or injury Diagnostic and screening procedures Surgical procedures Treatment of disease, disorder or injury

M6 The Trust must ensure the outpatient appointment validation process is completed and actions taken to assess clinical risks to patients of having overdue appointments. (Provider report) The Trust must ensure the outpatient appointment validation process is completed and appropriate actions are taken to assess the clinical risks to patients from having overdue appointments. (RGH report)

Diagnostic and screening procedures Surgical procedures Treatment of disease, disorder or injury Diagnostic and screening procedures Treatment of disease, disorder or injury

M7A & M7B

The Trust must ensure that children are protected from the risks associated with unsafe or unsuitable premises. The children's ward environment must be safe and appropriate for children and young people. (Provider report) The Trust must ensure the environmental risks on the children's ward are assessed and mitigated so that it is safe and secure. (RGH report)

Diagnostic and screening procedures Surgical procedures Treatment of disease, disorder and injury Diagnostic and screening procedures Treatment of disease, disorder or injury



M8 The Trust must ensure all incidents are reported and investigated in a timely manner and that learning is shared with all relevant staff. (Provider report) The Trust must ensure all incidents are reported and investigated in a timely manner and that learning is shared with all relevant staff. (RGH report)

Diagnostic and screening procedures Family planning services Maternity and midwifery services Surgical procedures Treatment of disease, disorder or injury Diagnostic and screening procedures Maternity and midwifery services Surgical procedures Treatment of disease, disorder or injury

M9 The Trust must ensure all directorate and corporate risk registers are reviewed so they reflect the current identified risks, contain appropriate mitigating actions and that the risks are monitored and reviewed at appropriate intervals. (Provider report The Trust must ensure all directorate and corporate risk registers are reviewed so they reflect the current identified risks, contain appropriate mitigating actions and that the risks are monitored and reviewed at appropriate intervals. (RGH report)

Diagnostic and screening procedures Family planning services Maternity and midwifery services Surgical procedures Treatment of disease, disorder or injury Diagnostic and screening procedures Maternity and midwifery services Treatment of disease,



disorder or injury

M10 The Trust must ensure that all community health services for adults’ staff are able to attend mandatory training and other essential training as required by the needs of the service. (Community Health Services for Adults report)

Treatment of disease, disorder or injury

M11 The Trust must ensure that patient records are kept securely (Provider Report)

Diagnostic and screening procedures Treatment of disease, disorder and injury.

M12 The Trust must ensure complaints are dealt with in accordance with the trusts policy, national best practice and guidance and people receive a timely and complete response to their complaint that is sensitive to their situation. (Provider report)

Diagnostic and screening procedures Maternity and midwifery services Surgical procedures Treatment of disease, disorder or injury

M13 The Trust must ensure that children and young people using the short break service, are protected against identifiable risks of acquiring a healthcare associated infection. (Provider report) The Trust must ensure that children and young people using the short break service are protected against identifiable risks of acquiring a health care associated infection. (Community health services for children, young people and families report)

Diagnostic and screening procedures Treatment of disease, disorder or injury Diagnostic and screening procedures Treatment of disease, disorder or injury

M14 The Trust must ensure that children and young people using the short break service are protected against the risks associated with the unsafe use and management of medicines. (Provider report)

Diagnostic and screening procedures Treatment of disease, disorder or injury



The Trust must ensure that children and young people using the short break service are protected against the risks associated with the unsafe use and management of medicines. (Community health services for children, young people and families report)

Treatment of disease, disorder or injury

M15 The Trust must ensure that there is effective liaison between the contraception and sexual health service and the school nursing service about individual young people who may be at risk of abuse. (Provider report) The Trust must ensure that there is effective liaison between the contraception and sexual health service and the school nursing service about individual young people who may be at risk of abuse. (Community health services for children, young people and families report)

Family planning services Family planning services Treatment of disease, disorder or injury


AREAS FOR IMPROVEMENT – actions the Trust ‘Should’ take

Emergency department

Complete a review of staffing levels so appropriate numbers of suitably qualified nurses, emergency department assistants, and healthcare assistants are on duty to manage surges in demand.

Ensure that all staff are able to attend regular staff meetings.

Ensure that there are systems in place that allow for professional sign language interpretation of consultations for profoundly deaf patients who use sign language, either in person or via video link.

Surgery

Improve the 18-week referral-to-treatment targets so that patients have access to timely care and treatment.

Improve access and flow for patients attending fracture clinic appointments.

Minimise the movement of patients from other specialities onto surgical wards, particularly those wards providing elective orthopaedic surgery.

Critical care

Make sure that staff have access to up-to-date, evidence-based guidance.

Review access to the intensive care unit so it is secure at all times.

Ensure that consultant ward rounds take place in accordance with national guidance. Maternity

Review guidance so that the time intervals for recording patient observations are sufficiently frequent to ensure patient safety.

Make sure that suitably trained staff are available to provide postoperative recovery care for women.

Review documentation so that appropriate prompts are available to identify patient safety needs.

Review the process for women with social service involvement, who may require an extended stay on the ward after giving birth.

Review the rates of elective caesarean section and those performed following an induction of labour, with appropriate implementation of identified learning.

Review access and patient flow on the labour and postnatal wards so there is effective use of resources to ensure that mothers and babies are cared for in the most appropriate place.


Children and young people

Review the internal safeguarding processes and implement identified actions.

Review the transition arrangements for children and young people for all pathways.

Review the leadership of the service so there is access to senior children’s nursing advice. Outpatients and diagnostic imaging

Ensure that sharps are managed in a manner which protects staff and patients from the risk of needle-stick injuries. Trust- wide

Ensure that information about how to make a complaint or leave a comment is available in alternative formats and languages.

Ensure that nursing staff have access to clinical supervision.

Ensure that patients who are living with dementia and/or their relatives have the opportunity to give information about their personal circumstances, their preferences and likes and dislikes.

Patients’ records are kept securely at all times. Community Health Services for Adults

Strengthen the engagement with community health services for adults’ staff.

Ensure community staff have access to information relating to people before providing care and treatment.

Ensure staff are accessing interpreter services where appropriate.

The provider should support community and district nursing staff to report patient safety incidents appropriately.

The provider should ensure staff are involved in learning from incidents and good practice is shared across teams and departments.

Community End of Life Care Services

Provide support to staff delivering community end of life and palliative care to report patient safety incidents appropriately and ensure they are able to access training in incident reporting on a regular basis.

Strengthen ways of learning from incidents and sharing good practice across the community end of life and palliative care services.

Ensure that staff visiting patients in their homes to deliver end of life and palliative care are able to access the complete information they need before providing care and treatment.


Ensure that all staff delivering community end of life and palliative care are able to access appropriate one to one supervision on a regular basis.

Strengthen the engagement with staff delivering community end of life and palliative care, and improve communication about service design and strategy.

Community Health Inpatient Services

Review the care being provided in The Oakwood Unit so that patients have the opportunity to engage in social activities as well

as promoting their independence.

Review reasons for staff working in the community in-patient areas feeling isolated and distanced from the senior leaders in the

trust.

Review the delay in discharges caused by lack of access to prompt assessments for receiving social care and continuing

healthcare and lack of availability of specialist packaging for medicines.

Community Children & Young People’s Services

Ensure that systems for reporting and recording safety concerns, incidents and near misses are used effectively and

consistently.

Safeguarding supervision should be reviewed to make sure it is robust and effective for all staff that need this.

The provider should ensure that the substance misuse pathway is effective in providing appropriate intervention for young

people under 16.

The provider should ensure that handovers from midwives to health visitors are taking place in a timely and effective way.

Review the early attachment service to ensure it is not over reliant on one practitioner.

The provider should ensure that discharge criteria for the early attachment service are fully defined.

Review the IT requirements of staff working in the community so that staff are not hindered by old and inefficient IT equipment.

Ensure that all staff working with children, young people and families have received training about the identification and

prevention of child sexual exploitation.

Ensure that young people have access to contraceptive and sexual health clinics during school holidays.


Ensure that waiting time targets are met for physiotherapy non-urgent appointments and child development centre

appointments.

Ensure that letters to parents and carers include how to get the information in languages other than English.

Ensure that information about complaints is captured and shared, including when they are dealt with locally and not recorded on

the reporting system.

The provider should ensure that risks and concerns within the service are dealt with in an appropriate and timely way.

Ensure a consistent approach to obtaining the views of children, young people and families using the service.

Strengthen the engagement with staff delivering community health services for children and young people and improve

communication about service design and strategy.


ACTION PLAN – MUST do

Based on high level feedback at the end of the inspection the Trust was aware of some of the concerns held by the CQC and was

therefore able to take some immediate actions.

All the actions described in this plan have:

An executive lead

An operational lead

A timescale for delivery

An assigned Committee of the Board which will monitor delivery and provide assurance to the Board of Directors

A descriptor of expected outcome

A standard of measurement / evidence

On the basis that some actions have already been started / completed the following key is applied:

Action complete and evidence available

Action complete; evidence being compiled

Action on track; will progress to timescale

Action off track and subject to executive escalation

Not scheduled to have started yet.

This action plan was approved by the Board of Directors at their meeting on 28 July 2015. The Board of Directors will monitor

progress monthly.


Unique Id M1 - Training

Executive Lead Director of Human Resources

Operational Lead Head of Learning, Development and Well Being

Timescale 26/05/15 to 31/03/16

Committee oversight Strategic Workforce Committee

Overall status as at 26 June 2015

CQC requirement:

The Trust must ensure there are suitable arrangements in place to ensure all relevant staff receive appropriate training. This must include safeguarding adults and children, resuscitation, mental capacity awareness and living with dementia awareness. (Provider report)

The Trust must ensure there are suitable arrangements in place to ensure staff working in the medicine, maternity, children's and young people, critical care and accident and emergency services receive appropriate training. This must include safeguarding adults and children, resuscitation and mental capacity act awareness. (RGH report)

The Trust must ensure there are suitable arrangements in place to ensure staff working in the community end of life care service receive appropriate training. This must include safeguarding, resuscitation, and mental capacity awareness. (Community End of Life Care report)

Action already taken since the CQC inspection: The Trust has ensured that staff within the paediatric environment have received training in risk assessment and care planning for the needs of children admitted with mental health problems. Thirty-two staff have been trained by the local mental health provider of CAMHs services The Trust has commissioned Professor Sue Proctor to deliver a presentation on 22 June 2015. This will address the learning from the investigations into the acts of Jimmy Savile and the messages for NHS providers of acute and community services in relation to safeguarding vulnerable adults and children. The Trust has formally signed off the 2015/16 Quality Improvements linked to the Quality Account and this includes further training in the care of patients living with dementia.


TRFT outcome descriptor: The Trust will be able to evidence that the number of staff requiring access to safeguarding adult and children training, resuscitation training and Mental Capacity Act awareness within all services is understood. The Trust will be able to evidence capacity plans consistent with trainers being available to deliver the required levels of training by 31 March 2016. Each division and the corporate teams will be able to evidence how they have prioritised their plans for release of staff to undergo training / awareness. The Trust will be able to evidence a risk assessment of any other gaps in appropriate training.

Actions Source of Evidence Current status

1.1 A training needs analysis of each service in relation to the numbers of staff who require safeguarding, resuscitation, dementia awareness and Mental Capacity Act training / awareness will be carried out.

A service level analysis for all services including corporate teams will be presented to the Corporate Workforce Committee

1.2 Once the level of training during 2015/16 is understood, a capacity analysis of the availability of Trust trainers will be carried out.

A capacity analysis of TRFT Trainers will be presented to the Corporate Workforce Committee

1.3 The Corporate Workforce Committee will advise the Trust Management Committee on whether training needs can be met from additional training needs or not, and if not, solutions will be produced.

Corporate Workforce Committee and Trust Management Committee minutes.

1.4 Each division will lead a piece of work to plan staff release for training consistent with the needs analysis and capacity plans described above.

A written plan from each division and corporate team signed off by the divisional / corporate director. Combined Education Strategy to be jointly written by PGME and Learning & Development dept.


1.5 The Executive Director of HR will lead a risk assessment of any other gaps in training from which a priority training plan for the remainder of 15/16 and 16/17 will be devised.

Evidence of the risk assessment and the priority plan being presented to the Strategic Workforce Committee

1.6 The training plans will be monitored by the Corporate Workforce Committee monthly leading to suitable intervention if the plans de-rail

Minutes of the Corporate Workforce Committee.

1.7 In relation to 3.18 the Trust will develop further training plans for colleagues caring for children and young people with mental illness.

Training Plan


Unique Id M2 - MCA

Executive Lead Chief Nurse

Operational Lead Named Nurse Adult Safeguarding

Timescale 26/05/15 to 01/12/15

Committee Oversight Quality Assurance Committee


CQC requirement:

The Trust must ensure there are suitable arrangements in place for establishing and acting in accordance with the best interest of patients without the capacity to give consent and treatment in line with the requirements of the Mental Capacity Act (2005) and its associated Deprivation of Liberty Safeguards. (Provider report)

The Trust must ensure there are suitable arrangements in place for establishing and acting in accordance with the best interests of patients without the capacity to give consent. This should be in line with the Mental Capacity Act (2005). (RGH report)

The Trust must ensure staff are working in accordance with the Mental Capacity Act code of practice (2005). (Community Health Services for Adults report)

The Trust must ensure all staff understand their role in relation to the Mental Capacity Act (2005) and its associated code of practice. (Community Health Inpatient Services)

Action already taken since the CQC inspection: The Trust has engaged with the Rotherham Metropolitan Borough Council to introduce an e- Deprivation of Liberty Safeguards form, and initiated recruitment of additional resource to the Safeguarding and Vulnerabilities Team. The additional resource will facilitate training and audit.

TRFT outcome descriptor: The requirement for MCA training / awareness and corresponding plans will be evidenced through actions related to M1-Training. The Trust will be able to evidence audit of practice and the development of a second level action plan based on audit findings.



2.1 The Trust will recruit to a Band 4 MCA / Deprivation of Liberty Safeguards administrator by 31 July 2015.

Recruitment file

2.2 The Trust will provide each clinical area / community team with an MCA resource file

Receipts from each clinical area confirming the delivery of a resource file

2.3 The Trust will undertake an MCA audit (involving the SAS doctors in conducting the audit) in October 2015.

Audit undertaken and reported to the Strategic Safeguarding Group in December 2015, with an action plan describing further improvement steps

2.4 The Trust will hold two focus groups in September 2015; one of clinicians assessing capacity to consent and one of families. This will provide an opportunity to hear the voice of families and colleagues, and inform the planned audit.

Signing in sheet and high level notes of the focus groups

2.5 The Trust will publish the improvement journey in the 2015/16 annual safeguarding report

Publication of the report with relevant content

2.6 The Trust will develop a second level action plan based on audit findings.

Audit and action plan reported to the Strategic Safeguarding Group in December 2015


Unique Id M3A – Nurse Staffing

Executive Lead Director of Human Resources (HR specific elements) Chief Nurse (Professional Nursing Leadership)

Operational Lead Heads of Nursing, Midwifery & Clinical Professions & Deputy Director of Human Resources

Timescale 26/05/15 to 31/03/16

Committee Oversight Strategic Workforce Committee


CQC requirement:

The Trust must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons deployed to meet the needs of patients. (Provider report)

The Trust must ensure there are sufficient numbers of suitably skilled, qualified and experienced staff. (RGH report)

The Trust must ensure there are sufficient numbers of suitably qualified and skilled staff to meet the needs of people who uses the services. (Community Health Services for Adults report)

The Trust must ensure that there are sufficient suitably qualified, skilled and experienced staff in the school nursing service to meet the needs of the local population. (Community health services for children, young people and families report)

The Trust must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons deployed to meet the needs of patients. (Community Health Inpatient Services report)

Action already taken: The Trust has already taken action to reduce bed numbers in paediatrics, initiate an external review of paediatric nursing services (in-patients), devise a nurse staffing matrix for use on the paediatric ward, benchmark paediatric nurse staffing with other units across the Yorkshire and the Humber region, speak with the strategic clinical network lead and procure PANDA to review the paediatric nurse staffing levels.


Secondly, the Trust plans to visit Croatia during June as part of the existing recruitment plans. To date 40 registered nurses have joined the Trust from Spain, Italy and Romania. Thirdly, the Trust has liaised with the Rotherham, Doncaster and South Humber Mental Health Trust in relation to the provision of Child and Adolescent Mental Health services within the Trust; this includes the provision of one-to-one staffing levels for children admitted to the children’s ward. Fourth, the Trust has reviewed the structure of nursing and midwifery leadership within the Division of Family Health and will be recruiting to a Deputy Head of Nursing / Midwifery with a children’s qualification. Similarly, the Trust has reviewed the structure of nursing and midwifery leadership within the Division of Medicine and will be recruiting to a Deputy Head of Nursing with community leadership experience. The Trust has rolled out the use of the Safer Nursing Care Tool and will next report as full nursing establishment review, to the Board of Directors in July 2015.

TRFT outcome descriptor: Each clinical service, team, department, ward will have an agreed staffing establishment and there will be one ‘version of the truth’, i.e. the establishment will be recognised by the operations team, HR and finance and published at the entrance to each department. The Trust will have an agreed set of workforce indicators that are reported in the integrated performance report to Board. These will enable the Trust to determine whether it has sufficient numbers of suitably skilled, qualified and experienced staff. The ‘staffing’ risk on the risk register will be reduced.


3A.1 A joint operations, HR and finance team will systematically work through coming to one version of the truth on staffing establishments for all clinical areas. For areas employing nurses / midwives, appropriate tools will be used and the establishments will be signed off by the Chief Nurse and reported to the Board.

The payroll system, ESR and finance ledger all agree on the establishment. Nursing establishments are presented to the Board by the Chief Nurse at least every 6 months

3A.2 Vacancies against establishment will be prioritised for recruitment based on a risk assessment and a recruitment plan will be generated. The risk assessment will be formally reviewed at the Trust Management Committee alternate months.

Risk assessment. Trust Management Committee notes


3A.3 Changes in skill mix influenced by whether the Trust is able to recruit experienced staff, or not, will be formally risk assessed and influence the recruitment plan.

Risk assessment

3A.4 The Trust will appoint vendors for nursing agency staff and agree key performance measures which will be managed via regular business meetings.

Vendor appointments Minutes of business meetings at least quarterly.

3A.5 The Trust will procure an e-roster system which will enable real time analysis of staffing and provide a valuable tool to achieve staffing management

Procurement and implementation of e-roster

3A.6 The executive team will agree a set of HR / Workforce KPIs Monthly report to Board with decisions captured in the minutes

3A.7 The Trust will hold a Band 7 – sister / charge nurse two day event in September and use the event to provide training on budget management, staffing establishment reviews, the use of flexible staffing, risk assessment techniques, good people management etc. This will assist in addressing exit interview feedback about some people management practices.

Training programme and signing in sheet showing minimum of 70% of eligible band 7 attendances.

3A.8 All staffing establishments will be published at the entrance to wards / departments. These will be clearly dated and refreshed as a minimum, every 6 months.

Assurance visits

3A.9 The Trust will offer every person resigning from position the opportunity of an exit interview with a member of the Trust Management Committee (TMC)

Exit interview analysis

3A.10 The Trust will establish minimum and optimal staffing levels for all in-patient ward areas

Agreed levels

3A.11 The Trust will review School Nursing and Community Nursing caseloads using recommended tools and / or benchmarks

Caseloads published in the nurse staffing report to Board

3A.12 The Trust will agree maximum caseload sizes for community practitioners,

Agreed caseloads


3A.13 The Trust will continue to publish nursing and midwifery staffing data in accordance with ‘hard truths’ on the website monthly

Monthly uploads on the Trust website

3A.14 The Trust will strengthen the analysis of planned versus actual nurse / midwife staffing levels and continue to report to Board monthly

Monthly reports to Board

3A.15 The Trust will continue to pursue a reduction in sickness / absence levels, achieving best in sector performance during 2016/17, and a rate no greater than 4% by March 2016.

Integrated performance report

3A.16 The Trust will evaluate the success of the overseas recruitment and make a decision by mid-July on the frequency with which an overseas programme might be repeated and the opportunity to partner with an overseas education establishment to become a UK provider of choice for registrants.

Paper to the Strategic Workforce Committee

3A.17 The Trust will initiate a dedicated School Nursing recruitment campaign

Campaign materials

3.18 Whilst not singularly a result of staffing levels the Trust will work with the Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH) to review all aspects of the Child and Adolescent Mental Health Service provision here in the Rotherham NHS Foundation Trust. The Trust will seek a service which achieves timely specialist CAMHS assessment, a CAMHS care plan and risk assessment and follow up response relevant to the needs of each individual child.

A quarterly audit of the records of each child admitted to the Children’s Ward subject to shared care.


Unique Id M3B - Staffing

Executive Lead Director of Human Resources (HR specific elements) Medical Director (Professional Medical Leadership)

Operational Lead General Managers & HR Manager – Medical Staffing and Recruitment

Timescale 26/05/15 to 31/03/16



CQC requirement:

The Trust must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons deployed to meet the needs of patients. (Provider report)

The Trust must ensure there are sufficient numbers of suitably skilled, qualified and experienced staff. (RGH report)

The Trust must ensure there are sufficient numbers of suitably qualified and skilled staff to meet the needs of people who uses the services. (Community Health Services for Adults report)

The Trust must ensure that there are sufficient suitably qualified, skilled and experienced staff in the school nursing service to meet the needs of the local population. (Community health services for children, young people and families report)

The Trust must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons deployed to meet the needs of patients. (Community Health Inpatient Services report)

Action already taken: The Trust has commissioned ATOS to undertake a capacity and job plan review. This is being used by the Divisional Directors, supported by the Medical Director, to review job planning. The Quality Assurance Committee has been receiving medical staffing reports on alternate months for the past 6 – 8 months. Recent discussions have led to a request for the data to be enriched and for the reports to provide a similar level of depth and analysis to that which is available in the nurse staffing reports.


TRFT outcome descriptor: Each clinical service will have an agreed medical staffing establishment and there will be one ‘version of the truth’. The Trust will have an agreed set of workforce indicators that are reported in the integrated performance report to Board. These will enable the Trust to determine whether it has sufficient numbers of suitably skilled, qualified and experienced staff. The ‘staffing’ risk on the risk register will be reduced.


3B.1 A joint Division, HR and finance team will systematically work through medical staffing data coming to one version of the truth on medical vacancies.

The payroll system, ESR and finance ledger all agree on the establishment.

3B.2 The medical staffing report will be strengthened in line with the discussion at QAC in June 2015 and continue to be submitted to QAC every other month.

Medical Staffing report to QAC

3B.3 The Trust will appoint vendors for medical agency staff and agree key performance measures which will be managed via regular business meetings.

Vendor appointments Minutes of business meetings at least quarterly.

3B.4 The Divisional Directors and Medical Staffing Manager will influence the forward-looking workforce plan to identify opportunities for the development of Advanced Nurse Practitioner roles and Physician Assistants to replace traditional medical roles not least in those hard to fill vacancies.

Workforce plan

3B.5 The Medical Director will ensure that all Consultant and Specialist / Associate Grade Doctors’ job plans are completed by August 2015 and agree the timescale for completing the 2016/17 job plan review.

Report to Board of Directors September 2015

3B.6 The Divisional Directors will work together to define ‘medical red flags’ and ensure that all medical staff report against them.

Included in the medical staffing report to QAC by October 2015.


3B.7 The executive team will agree a set of HR / Workforce KPIs Monthly report to Board with decisions captured in the minutes

3B.8 The Trust will offer every person resigning from position the opportunity of an exit interview with a member of the Trust Management Committee (TMC) to all Trust-employed staff.

Exit interview analysis

3B.9 The Trust will publish medical staffing data alongside nursing and midwifery staffing data exceeding the ‘hard truths’ recommendations on the website on alternate months

Monthly uploads on the Trust website

3B.10 The Trust is considering how we input medical vacancy data into the existing quality metrics.

Alternate month report to QAC

3B.11 The Trust will continue to pursue a reduction in sickness / absence levels, achieving best in sector performance during 2016/17, and a rate no greater than 4% by March 2016.

Integrated performance report

3B.12 The Trust will initiate a medical staffing campaign linked to the development of the Emergency Centre.

Campaign materials


Unique Id M4 - DNACPR

Executive Lead Medical Director

Operational Lead Associate Medical Director, Standards of Medical Care

Timescale 26/05/15 to 01/01/16


Overall status as at 29 May 2015.

CQC requirement:

The Trust must ensure all do not attempt cardio-pulmonary resuscitation (DNA CPR) forms are completed in line with the trust’s policy and that patients’ capacity is assessed in line with the requirements of the Mental Capacity Act (2005). (Provider report)

The Trust must ensure that all 'do not attempt cardio-pulmonary resuscitation' (DNA CPR) forms are completed appropriately. (Community End of Life Care report)

The Trust must ensure all do not attempt cardio-pulmonary resuscitation (DNA CPR) forms are completed in line with the trust’s policy and that patients’ capacity is assessed in line with the requirements of the Mental Capacity Act (2005). (RGH report)

Action already taken since the CQC inspection: The Trust has completed a Patient at Risk (PAR) audit and a review of all deaths during December 2014. This audit and mortality review included consideration of the DNA CPR status of the patient. The results of the audit have been shared with clinical teams and the mortality review has been presented at the consultants conference held on 21 May and subsequently at the Board of Directors on 26 May. The Medical Director and Chief Nurse have committed to writing to all consultants, ward and community leaders outlining expectations in regard to participation in mortality reviews as part of annual appraisal and revalidation.

TRFT outcome descriptor: The Trust will be able to evidence point prevalence audit of completion and compliance with Trust policy, including the assessment of patients’ capacity in line with the MCA (2005). The Trust will agree a baseline position from which improvement will be reported. The Trust will be able to evidence improved levels of completion. The Trust will be able to evidence 2016/17 improvement and audit plans



4.1 The Trust will establish the opportunity for a point prevalence audit on one set date each month

Arrangements minuted in the Resuscitation Group records

4.2 Feedback will be given to the clinical teams on the day of the audit

Signed feedback forms

4.3 The DNACPR policy will be reviewed to ensure it is in line with best practice

Policy review minuted in the Resuscitation Group records

4.4 The basic life support resuscitation training package will be reviewed to incorporate DNA CPR

Copy of training package

4.5 Divisional performance will be discussed in the performance meetings

Performance meeting action logs

4.6 The Medical Director will write to all consultants outlining the plans

Letter to consultants

4.7 The Chief Nurse will write to all ward and community team leaders / sisters / charge nurses outlining the plans

Letter to all relevant nurse leaders


Unique Id M5 - EMSA

Executive Lead Chief Operating Officer

Operational Lead Deputy Director of Operations

Timescale 26/05/15 to 01/09/15



CQC requirement:

The Trust must ensure patients are not cared for in mixed sex wards / departments apart from those areas which are exempt from meeting the national requirements. (Provider report)

The Trust must ensure patients are not cared for in mixed sex wards/departments apart from those areas which are exempt from meeting the national requirements. (RGH report)

Action already taken since the CQC inspection: The Trust has already established a zero tolerance for mixed gender sleeping accommodation and only had two occurrences of a breach of this standard since 01 April 2015 (1 on SAU and 1 on HDU both for less than 1 hour).

TRFT outcome descriptor: The Trust will develop plans for improving ‘pass-by’ breaches The Trust will establish a trajectory for achieving compliance with the ITU/HDU 8 hour rule, i.e. transfer out of the unit within 8 hours of the clinical decision being made (to be operated between the hours of 10:00 and 20:00 hours only) The Trust will be able to evidence improved ‘patient reported experience’ in the 2015 in-patient survey on related questions.


5.1 The Trust will continue to reinforce the requirement to escalate to the director on call before any anticipated breach of the mixed gender sleeping standard thereby affording the director the opportunity to prevent the breach

Site manager records

5.2 The Trust will continue to report to Board monthly Integrated Performance Report


5.3 The Trust will devise a standard operating procedure for the avoidance and management of ‘pass-by’ breaches and ensure that compliance is managed and audited by the Matrons

SOP and weekly reports from all in-patient matrons

5.4 An audit of compliance with the national requirements will be undertaken across the main hospital site, RCHC, breathing space, the Flying Scotsman and the community unit

Audit report to TMC

5.5 The Trust will agree and manage a trajectory for achieving compliance with the ITU/HDU 8 hour rule by 01 September 2015 and then develop a plan for achieving compliance with a 4 hour rule by 31 March 2016.

Agreed trajectory and weekly reports from critical care


Unique Id M6 - Out-patients


Operational Lead General Manager, Clinical Support Services

Timescale 26/05/15 to 01/09/15

Committee Oversight Divisional Performance Meetings


CQC requirement:

The Trust must ensure the outpatient appointment validation process is completed and actions taken to assess clinical risks to patients of having overdue appointments. (Provider report)

The Trust must ensure the outpatient appointment validation process is completed and appropriate actions are taken to assess the clinical risks to patients from having overdue appointments. (RGH report)

Action already taken since the CQC inspection: The Trust has reviewed 13,500 patient pathways, and confirmed that 10 patients breached the 52 week rule. The details of the review have been shared with commissioners, Monitor and the Board of Directors (26 May 2015). There has been no direct patient harm as a result of the delays. As a result of the deep dives undertaken, further pathway reviews have been conducted and 4 additional patient delays have been identified. This brings the total as at 29 May 2015 to 14 patients. All patients have been contacted and individual pathways management agreed.

TRFT outcome descriptor: The Trust will be able to evidence that the pathway review / validation is complete and that the clinical risks have been assessed for all patients affected.


6.1 The Trust will scope out the full patient backlog delays across all specialities.

Backlog Update Report


6.2 The Medicine Division review showed specific problem in Gastroenterology. Weekly review meetings have been set up with the Chief Operating Officer, Divisional Management Team and Clinical Leads to implement a recovery plan.

Recovery trajectory against plan

6.3 Establish a training programme for the management of appointments between specialties and the contact centre.

Training plan and training pack.

6.4 Undertake a demand and capacity analysis across Gastroenterology with the support of the NHS Intensive Support Team which will be replicated in other specialities should it be required.

Demand and Capacity analysis report and if needed a business case for additional capacity.


Unique Id M7A - Children’s ward


Operational Lead General Manager, Family Health

Timescale 26/05/15 to 11/06/15



CQC requirement:

The Trust must ensure that children are protected from the risks associated with unsafe or unsuitable premises.

The children's ward environment must be safe and appropriate for children and young people. (Provider report)

The Trust must ensure the environmental risks on the children's ward are assessed and mitigated so that it is safe and secure. (RGH report)

Action already taken since the CQC inspection: Concerns were identified during the inspection and these were immediately rectified. Firstly, one of the fire escape doors was not secure. This concern was addressed within a matter of hours. Secondly there was concern that children with a mental health problem could harm themselves if they managed to get through the aforementioned exit. In addition to the appropriate levels of physical security on the door a Perspex screen was erected to distract from the possible opportunities of a stairwell. Thirdly, concerns were expressed regarding ligature points and an immediate risk assessment was undertaken in conjunction with the Trust Health and Safety Advisor. A programme of environmental upgrades is being commissioned. The fourth matter raised related to the sounding of the nurse call system throughout the children’s ward and in response the Trust completed work during April to fit additional call points and an additional fire escape buzzer at the second nurse station. Finally, an assessment of window restrictors along the corridors leading to the Children’s ward was carried out by the Director of Estates following concerns raised by one of the inspectors. The Director of Estates confirmed that all restrictors were secure and compliant with legislative requirements. In addition to the specifics above the Trust has provided one-to-one care of all children assessed as being at risk of self-harm whilst in hospital. The Board of Directors has discussed safety on the children’s ward and been advised by both clinical executives that in their opinion the ward is a safe environment for the provision of effective paediatric care.


TRFT outcome descriptor: The Trust will be able to evidence that environmental risks have been assessed and mitigated and that these are captured on the Family Health Risk Register. The Board will continue to be assured that the paediatric ward provides a safe environment in which to provide care to children and young people.


7A.1 The Family Health Division will undertake a further environmental risk assessment on the Children’s ward. This will be undertaken by a clinician in conjunction with the Trusts Health and Safety Advisor, and formally reported to the executive team on 10 June 2015.

A written risk assessment

7A.2 The outcome of the assessment will lead to plans being devised for safe mitigation in order to be assured that the environment is safe for children

A written mitigation plan with timescales for improvement


Unique Id M7B - Children’s environment


Operational Lead General Manager, Family Health

Timescale 26/05/15 to 01/07/15



CQC requirement:

The Trust must ensure that children are protected from the risks associated with unsafe or unsuitable premises.

The children's ward environment must be safe and appropriate for children and young people. (Provider report)

The Trust must ensure the environmental risks on the children's ward are assessed and mitigated so that it is safe and secure. (RGH report)

Action already taken since the CQC inspection: The Trust undertook an assessment of the risks associated with the use of an interview room in the emergency department.

TRFT outcome descriptor: The Trust will be able to evidence that it has assured itself that an environmental risk assessment has been carried out in all locations regularly caring for children, e.g. out-patients, the day care unit, the emergency department and the short break facility (Kimberworth Place), and that mitigation of all identified risks is in place.


7B.1 The Family Health Division will undertake an environmental risk assessment on the aforementioned areas and any others that they identify as locations providing regular care to children. This will be undertaken by a clinician in conjunction with the Trusts Health and Safety Advisor, and formally reported to the executive team by 24 June 2015.

A written risk assessment and mitigation plan.

7B.2 The Family Health Division will manage the findings of the risk assessment, and oversight of the mitigating actions, in conjunction with the other relevant divisions and the director of estates, reporting through the Performance meetings.

Notes of the performance meetings


Unique Id M8 - Incidents


Operational Lead Assistant Director of Patient Safety & Risk

Timescale 26/05/15 to 01/10/15



CQC requirement:

The Trust must ensure all incidents are reported and investigated in a timely manner and that learning is shared with all relevant staff. (Provider report)

The Trust must ensure all incidents are reported and investigated in a timely manner and that learning is shared with all relevant staff. (RGH report)

Action already taken since the CQC inspection: The Trust has agreed a set of KPIs which will be reported through the Chief Nurse Performance Meeting monthly. These are:

the number of incidents reported on Datix within 2 days of the incident occurring – target 95%

Number of Datix incident investigations completed within 30 days – target 90%

Number of Datix incident investigations completed within 60 days – target 100% Secondly the Chief Nurse has included examples of learning in her monthly Chief Nurse newsletter, the example being the results of the PAR audit following examples of patient deterioration. Thirdly the Medical Director and senior clinicians have presented learning following the mortality reviews at the Clinicians conference and the Board of Directors, and finally the Chief Nurse led a ‘day to celebrate’ on 08 May during which three nursing / midwifery teams presented their failures of care and the improvements they have made. This event will now be repeated in September and three times per annum thereafter.

TRFT outcome descriptor: The Trust will establish a baseline performance position (timely investigation) and agree a trajectory for improvement. The Trust will see an improvement in the relevant staff survey questions during 2016 (it is unlikely that improvements will be seen in the 2015 survey due to timing); (Questions 13 and 180 The Trust will be able to evidence and assure itself that learning is being shared.



8.1 A baseline performance position will be reported to the Chief Nurse performance meeting in June 2015.

Performance meeting notes

8.2 An improvement trajectory will be agreed with the Operational Quality, Safety and Experience Group (OQSEG) in July taking account of at least 6 months of actual performance data and resource prioritisation consistent with the other actions in this plan

OQSEG notes

8.3 The Chief Nurse, through the OQSEG will hold the patient safety team and the divisions accountable for delivering the improvement trajectory escalating any concerns to the Trust Management Committee

OQSEG notes

8.4 The Patient Safety Team together with the Patient Safety Group and the Patient Experience Group will agree a learning lessons publication scheme which will be presented to the OQSEG in August 2015. The scheme will build on, but not be confined by, the Trust Governance structures.

OQSEG notes

8.5 A number of SAS doctors will audit distribution of publications and knowledge of the lessons shared in January 2016 reporting to the OQSEG

OQSEG notes


Unique Id M9 - Risk Registers

Executive Lead Chief Executive

Operational Lead Chief Nurse

Timescale 26/06/15 to 01/12/15



CQC requirement:

The Trust must ensure all directorate and corporate risk registers are reviewed so they reflect the current identified risks, contain appropriate mitigating actions and that the risks are monitored and reviewed at appropriate intervals. (Provider report

The Trust must ensure all directorate and corporate risk registers are reviewed so they reflect the current identified risks, contain appropriate mitigating actions and that the risks are monitored and reviewed at appropriate intervals. (RGH report)

Action already taken since the CQC inspection: The Board of Directors held a seminar session on the Board Assurance Framework and the Risk Register, and considered a draft Risk Management Strategy. The Quality Assurance Committee and the Trust Management Committee have received a revised corporate risk register. The decision has been taken that risks scoring 16 or above cannot be closed without a recommendation to the Trust Management Committee based on assurance that the risk has been mitigated. The management decision to close such risks will be taken by the Trust Management Committee.

TRFT outcome descriptor: The Trust will publish a revised Risk Management Strategy in July 2015 and be assured that all directorate and corporate risk registers have been reviewed by this time. The revised strategy will describe the arrangements for monitoring and reviewing risks at appropriate intervals.


9.1 All directorates (now divisions) and corporate teams will prioritise a review of risk registers during July 2015 and provide a statement of assurance to the Trust Management Committee (TMC) in September 2015.

TMC notes


9.2 The Chief Nurse will produce a revised risk management strategy for the Board of Directors to approve in July 2015.

Board of Director papers

9.3 The Trust Management Committee will review the corporate risk register in August and provide assurance to the Quality Assurance Committee that this reflects the current identified risks and contains appropriate mitigating actions.

TMC and Quality Assurance Committee notes


Unique Id M10 - MAST


Operational Lead Divisional Director, Integrated Medicine

Timescale 26/05/15 to 31/03/16



CQC requirement: The Trust must ensure that all community health services for adults’ staff are able to attend mandatory training and other essential training as required by the needs of the service. (Community Health Services for Adults report)

Action already taken since the CQC inspection: The Trust has been engaging with community health services for adults staff (colleagues) to understand the pressures they face and support the management of sickness absence which has been impacting on the capacity and community nursing caseloads.

TRFT outcome descriptor: The Trust will have confidence that it understands the mandatory, statutory and essential training needs of the community nursing teams, has risk assessed the position and agreed an in-year plan with the locality leaders.


10.1 The Divisional Director of Medicine and the Head of Nursing for Medicine will commission the Matrons and locality leads to engage with community health services for adults staff to validate their mandatory, statutory and essential training records and define the level of need; presenting a paper to the Division of Medicine Governance meeting no later than September 2015.

Division of Medicine notes

Community Governance meeting Team meetings

Preparation of report


10.2 The Divisional Director of Medicine and Head of Nursing will risk assess the position presented and then agree an in-year plan (based on the risk assessment) from the Matron and locality leads no later than October 2015 (Nb. The Matron must take account of the actions in M1-training.)

In-year plan signed off by the Divisional Director and the Head of Nursing.

Submission of Risk Assessment on the Trust Datix electronic reporting


system and appropriate escalation and monitoring

Divisional Governance agenda/ minutes

10.3 Delivery of the plan will be monitored and reported at the Medicine Performance meeting

Performance meeting notes / action log

10.4 By January 2016, the locality leads will present a plan for 2016/17 to the Head of Nursing for sign off.

2016/17 plan signed off by the Head of Nursing and recorded in the Division of Medicine notes



Unique Id M11- Records

Executive Lead Director of Corporate Affairs / Company Secretary

Operational Lead Head of Clinical Professions

Timescale 26/05/15 to 01/01/16

Committee Oversight Corporate Informatics Committee


CQC requirement:

The Trust must ensure that patient records are kept securely (Provider Report)

Action already taken since the CQC inspection: Through Listening into Action a review of Nursing records and documentation has commenced.

TRFT outcome descriptor: The Trust will have assurance that records are not left unattended. The Trust will have assurance that loose forms have patient identifier labels on them. The Discharge Lounge will have secure note storage.


11.1 The Discharge lounge will be provided with secure record storage by 12 June 2015.

Delivery of a records trolley

11.2 The Trust will communicate reminders and statements of accountability regarding the need to attach patient identifiers to loose forms, and not leaving records unattended during June, July and August.

Copies of the communications

11.3 The SAS doctors will undertake point prevalence audit in August, September and October and report the results to the Operational Quality, Safety and Experience Group (OQSEG)

OQSEG notes


11.4 The Trust will communicate the results of the point prevalence audits using ‘league tables’

Copies of the communications

11.5 Confirming the securing of records on each and every quality / safety visit will be built into the visit proforma.

Copy of the visit reports


Unique Id M12 - Complaints


Operational Lead Deputy Chief Nurse

Timescale 26/05/15 to 01/12/15



CQC requirement:

The Trust must ensure complaints are dealt with in accordance with the trusts policy, national best practice and guidance and people receive a timely and complete response to their complaint that is sensitive to their situation. (Provider report)

Action already taken since the CQC inspection: A number of actions have taken place. Firstly additional complaints training plans have been devised. The Trust has commenced recruitment to a substantive Complaints / Patient Experience Manager A further audit of complaints by one of the Non-Executive Directors has been conducted. This found that 5 of the 6 responses met the timescales and all 6 responses had an appropriate balance of detail and sensitivity to needs.

TRFT outcome descriptor: The Trust will be meeting the standards described in its policy


12.1 The Trust will recruit a long-term, substantive Manager for the Patient Experience team

Manager recruited and in place more than 12 months

12.2 The current training programme will be extended, with training opportunities provided through the year. Training to include recognition of a complaint, immediate responses, recording of complaints, management of formal complaints and informal concerns, how to manage an investigation, how to prepare a response, how to lead a complaints meeting, how to write an action plan, use of audit and other assurance methodologies, the role of the Patient Experience Group etc.

Plan in place and approved by the Patient Experience Group by July 2015. Training commenced June 2015 Training records Improved overall performance


12.3 Quarterly newsheets to be produced which include the lessons learnt from complaint investigations and reminders of the dates of future training.

First newssheet to be produced in July and quarterly there after

12.4 The new Patient Experience Manager should be provided with access to supervision and management time one day per month to visit other NHS and Non NHS providers to benchmark and develop practice

Statement of assurance from the new PET manager once in post, expected August 2015


Unique Id M13 – Infection prevention

Executive Lead Director of Finance

Operational Lead Service Manager, Children and Young People’s Services

Timescale 26/05/15 to 01/10/15



CQC requirement:

The Trust must ensure that children and young people using the short break service, are protected against identifiable risks of acquiring a healthcare associated infection. (Provider report)

The Trust must ensure that children and young people using the short break service are protected against identifiable risks of acquiring a health care associated infection. (Community health services for children, young people and families report)

Action already taken since the CQC inspection: The Trust has ensured that the short-break service has access to a washing machine

TRFT outcome descriptor: All Children and young people teams will submit their quarterly infection prevention audits Staff will be able to describe the results of the audits evidencing that feedback has been provided Written guidance will be available to ensure the effective cleaning of toys and equipment.


13.1 PRIORITY – the Assistant DIPC / Lead Nurse will visit the short-break service to undertake an immediate risk assessment, and provide guidance and direction. This will be completed by 11 June 2015.

Written statement

13.2 The service manager will put arrangements in place for the regular audits to be undertaken and reported.

Audits submitted to the infection prevention team


13.3 Written guidance will be produced by 10.07.15

Written guidance

13.4 Audit of compliance with the guidance will take place by 01.09.15 and again by 01.10.15

Audit reports


Unique Id M14 - Medicines

Executive Lead Director of Finance

Operational Lead Service Manager, Children and Young People’s Services

Timescale 26/05/15 to 01/08/15



CQC requirement:

The Trust must ensure that children and young people using the short break service are protected against the risks associated with the unsafe use and management of medicines. (Provider report)

The Trust must ensure that children and young people using the short break service are protected against the risks associated with the unsafe use and management of medicines. (Community health services for children, young people and families report)

Action already taken since the CQC inspection: Risk assessments have been carried out and immediate action taken.

TRFT outcome descriptor: The Chief Pharmacist will provide a statement of assurance that the concerns have been addressed and children using the short break service are protected against risks associated with the unsafe use and management of medicines.


14.1 PRIORITY – the Chief Pharmacist will facilitate a detailed risk assessment by a suitably competent person no later than 11 June 2015.

Written Risk Assessment

14.2 An action plan will be devised based on the risk assessment. The action plan will cover the specifics of the findings at the time of assessment and those concerns raised by the CQC:

Written guidance or policy on safe storage of medicines

Access to medicines

Action plan


Written guidance on the recording of administration of medicines

The provision of training to staff in accordance with the guidance / policies to be produced

14.3 With immediate effect the key for the medicines cabinet should be carried by a registered practitioner and not left next to the cabinet containing medicines.

Letter from the service lead to staff outlining this requirement

14.4 Once the risk assessment has been undertaken a suitable medicine cabinet will be provided and this will be securely mounted to a wall

Statement of completion

14.5 Assuming the pharmacist assesses the need, a medicines fridge will be purchased and instruction will be provided on its use, including secure access

Copy of purchase order and instructions on usage.

14.6 A point prevalence audit will be undertaken within 4 weeks of the action plan being completed.

Copy of the audit


Unique Id M15 – Sexual Health


Operational Lead Clinical Service Manager Sexual Health & Clinical Services Manager C&YPS

Timescale 26/05/15 to 01/09/15



CQC requirement:

The Trust must ensure that there is effective liaison between the contraception and sexual health service and the school nursing service about individual young people who may be at risk of abuse. (Provider report)

The Trust must ensure that there is effective liaison between the contraception and sexual health service and the school nursing service about individual young people who may be at risk of abuse. (Community health services for children, young people and families report)

Action already taken since the CQC inspection: System will be in place by end July 2015 to ensure CASH and GUM services communicate with School Nursing Service

TRFT outcome descriptor: The Trust has documented pathways to ensure effective liaison between the contraception and sexual health service and the school nursing service about individual young people who may be at risk of abuse


15.1 A risk assessment will be undertaken on the position as at 01 June 2015.

Copy of the Risk Assessment

15.2 The service leads will liaise with other providers to ascertain evidence of best practice

Statement of assurance detailing the contacts made

15.3 The service leads will develop pathways Pathways evidenced and approved via the Family Health Division Governance meeting


15.4 The service leads will visit the front line contraception, sexual health and school nursing teams to describe the pathways and facilitate understanding of their use in practice

Attendance sheets

15.5 The service leads will undertake audit 2 months after implementation

Audit report

15.6 The pathway will be built into the October refresh of the School Nursing Specification

School Nurse specification


ACTION PLAN – Should do

In addition to the MUST do actions outlined in previous pages, the CQC reports contain 35 other actions which the Trust should do

in order to demonstrate that it has taken timely, responsive action to the requires improvement rating.

The details of these plans will be worked up by the relevant divisions and presented to the Quality Assurance Committee in July

2015.


Unique Id S1- Emergency Department

Divisional / Corporate Lead Divisional Director, Emergency Care

Operational Lead Emergency Department Matron, Service Manager, Emergency Care & General Manager, Emergency Care

Timescale 26/6/15 – 30/9/15

Committee Oversight Strategic Workforce Committee & Medical Division Performance Meetings


CQC requirement: A. Complete a review of staffing levels so appropriate numbers of suitably qualified nurses, emergency department assistants, and

healthcare assistants are on duty to manage surges in demand. B. Ensure that all staff are able to attend regular staff meetings. C. Ensure that there are systems in place that allow for professional sign language interpretation of consultations for profoundly deaf

patients who use sign language, either in person or via video link.

Action already taken since the CQC inspection: None

TRFT outcome descriptor:

Completed review of staffing levels and evidence to show that the appropriate numbers of suitability qualified nurses, emergency department assistants and healthcare assistants are on duty to effectively manage surges in demand.

Evidence of improved staff attendance at regular team meetings.

Clarity as to the systems in place currently (and when the new Emergency Centre is in operation) to address the needs of profoundly deaf patients during consultations.

Action Named Action Lead

Timescale Status

A - i To undertake a review of the staffing levels within the ED utilising the NICE guidelines and RCN guidance to ensure appropriate numbers of suitably qualified nurses, emergency department assistants and health care assistants are in duty to manage surges in demand

Matron 30 September 2015


A - ii Utilise the Best tool to undertake the skill mix review Matron 30 September 2015

A - iii A skill mix review to be undertaken in line with the development of the Emergency Care centre to ensure future proof of the new services

Matron / Service manager

30 September 2015

B - i A re-launch of the key operational Meetings within the Division of Emergency Care has been undertaken, to include CQRMG and POG.

General Manager 31 July 2015

B- ii To ensure colleagues are supported to attend these key meetings agreement has been provided to backfill the clinical team rota. A rotation of non-clinical colleagues has been introduced to facilitate representation of all key stakeholders, including reception team members, porters and volunteers

General Manager July 2015

B- iii A review of the meeting times, day and schedule to ensure the most suitable options are utilised


B- iv Improved administrative support to ensure that agendas and minutes are circulated in a timely manner to allow colleagues who are unable to attend an opportunity to have their opinions represented


C - i Review processes of booking in at reception to ensure that if anyone is in need of support an appropriate trigger is identified on the symphony system, this will alert staff to take appropriate interventional actions to support the patient

Service manager 30 September 2015

C -ii Reception staff/ YAS to escalate requirement for assistance earlier in the patients journey to avoid unnecessary waiting and anxieties on the patients behalf – this may include access to a signer, utilisation of communication book, cards by reception, referral to the ORBIT translation system utilised by the Trust

Service manager 30 September 2015

C - iii Ensure relevant signage is appropriately displayed throughout the department


C - iv Ensure that all actions taken are in line with the Trust wide approach Matron 30 September 2015


Unique Id S2 - Surgery

Divisional / Corporate Lead Divisional Director, Surgery

Operational Lead General Manager, Surgery

Timescale 26/6/15 – 30/9/15

Committee Oversight Quality Assurance Committee & Surgical Division Performance Meetings


CQC requirement:

Improve the 18-week referral-to-treatment targets so that patients have access to timely care and treatment.

Improve access and flow for patients attending fracture clinic appointments.

Minimise the movement of patients from other specialities onto surgical wards, particularly those wards providing elective orthopaedic surgery.

Action already taken since the CQC inspection: Identification of issues in line with access and patient flow has been a focus for the Divisional management team. The process for ‘outlier escalation’ has been made more robust with additional actions identified on a daily basis. Scoping of where issues are and the depth of culture and process have been carried out with agreed way forward through CSU management teams.

TRFT outcome descriptor: Evidence to demonstrate compliance of sustainable delivery against RTT across Division. Evidence of reduction in complaints and delays beyond appropriate waiting times. Developed Standard Operating Procedures for each ward.

Action Named Action Lead Timescale Status

Management of inpatient beds Standard operating procedures to be developed for each ward to ensure a push and pull for patient, ensuring both high quality patient care and experience as well as, appropriate use of commissioned beds

Head of Nursing With support from Matron from each area

31 July 2015

Work with EIST to ensure all pathways are in place and education is available for all staff in relation to 18ww

General Manager 30 September 2015


Working with all consultants to ensure flow of patients through OPD to conversion is appropriate in line with RTT. Have a plan in place for all services to ensure stability of 18week position.

General Manager 30 September 2015


Unique Id S3 – Critical Care

Divisional / Corporate Lead Divisional Director, Surgery

Operational Lead General Manager, Surgery

Timescale 26/6/15 – 31/7/15

Committee Oversight Quality Assurance Committee & Surgical Division Performance Meetings


CQC requirement:

Make sure that staff have access to up-to-date, evidence-based guidance.

Review access to the intensive care unit so it is secure at all times.

Ensure that consultant ward rounds take place in accordance with national guidance.

Action already taken since the CQC inspection: Through team meetings and PDR processes all staff have been made aware of responsibility of ensuring patient flow is appropriate and in line with clinical expectations. Consultant ward rounds take place daily with clear actions being identified for clinicians and support services.

TRFT outcome descriptor: Clarity of understanding from staff and evidence from meetings regarding inclusion of evidence based guidance discussions Lockable doors or equivalent security system in place Daily reviews in place for each patient – evidenced through notes


Consultant ward rounds instigated and carried out on a 7 day plan

Clinical Lead, Critical Care 1 June 2015

Team meetings and governance meetings to ensure all evidence – based guidelines are highlighted to staff on a monthly basis

Matron for Critical Care 31 July 2015


Estates to be notified of issue and plan in place for security

Service Manager – Anaesthetics, Theatres & Critical Care

31 July 2015


Unique Id S4 - Maternity

Divisional / Corporate Lead Divisional Director, Family Health

Operational Lead Clinical Lead for Obstetrics

Timescale 26/6/15 - 31/03/16

Committee Oversight Quality Assurance Committee & Family Health Division Performance Meetings


CQC requirement:




Review the process for women with social service involvement, who may require an extended stay on the ward after giving birth.

Review the rates of elective caesarean section and those performed following an induction of labour, with appropriate implementation of identified learning.


Action already taken since the CQC inspection: The Trust has engaged with the Rotherham Metropolitan Borough Council (RMBC) to escalate concern regarding the delays to care proceedings affecting extended lengths of stays for both women and babies. Several meetings have taken place and a pre-birth protocol is being devised. Weekly escalation reports are being provided to the Chief Nurse who in turn is then working with her director counterpart in RMBC and briefing the TRFT Chief Executive.




Review guideline for early recognition of severely ill pregnant women with a view to amending the frequency of observations in line with National guidance. National guidance requested from CQC

Consultant Anaesthetist

August 2015





Risk assessment completed 28/01/2015 with mitigation Escalated to Family Health Governance and CSU. Plan to compile a business plan including options appraisal and send to CSU

Consultant Anaesthetist / Clinical Lead for Obstetrics

December 2015




Review guideline for early recognition of severely ill pregnant women with a view to include an assessment of vaginal blood loss and/or condition of the maternal uterus

Consultant Anaesthetist / Labour Ward Manager / Matron Inpatient Womens Services

December 2015

Review immediate care of the newborn guideline with a view to incorporate an early warning system for babies and include a trigger chart if applicable

Governance Lead C&YPS / Consultant Paediatrician

December 2015



Review the process for women with social service involvement, who may require an extended stay on the ward after giving birth


During pre-delivery multi agency forum meetings, ensure safeguarding is discussed and appropriate plans are in place in a timely manner

Matron Inpatient Womens Services / Ward Manager, Wharncliffe ward / Head of Midwifery

March 2016


Review the rates of elective caesarean section and those performed following an induction of labour, with appropriate implementation of identified learning


Audit of induction of labour currently being undertaken and audit of sweeps undertaken in the community setting completed. Both due to be presented at Clinical Effectiveness in August 2015. Review the outcomes with a view to address the increase in trend in practise.

Clinical Lead for Obstetrics / Consultant Obstetrician / Matron Inpatient Womens Services / Labour Ward Manager

March 2016





Consider the feasibility of an outpatient induction of labour service following the outcome of the induction audit.

Consultant Obstetrician / Labour Ward Manager

December 2015

Relocation of triage area to outside the Labour ward completed. Monitor the effectiveness of this area

Matron Inpatient Womens Services / Triage Midwife

September 2015

Streamlining of elective section list through a dedicated area outside of labour ward

Labour Ward Manager / Clinical Lead for Obstetrics / Matron Inpatient Womens Services

September 2015

Enhanced recovery being considered for elective caesarean section

Consultant Obstetrician / Consultant Anaesthetist

March 2016


Unique Id S5 – Children and Young People


Operational Lead Head of Midwifery / General Manager, Family Health

Timescale 26/6/15 – 31/01/16



CQC requirement:

Review the internal safeguarding processes and implement identified actions.

Review the transition arrangements for children and young people for all pathways.

Review the leadership of the service so there is access to senior children’s nursing advice.

Action already taken since the CQC inspection: The Trust commissioned a review of paediatric nursing. In addition the roles of the matrons have been reviewed and the division has discussed establishing the position of Deputy Head of Nursing with the Chief Nurse. This post holder will be a Registered Sick Children’s Nurse / Child Branch and therefore able to meet the needs of provision of access to a senior children’s nurse for advice.


Improved internal safeguarding processes

A review of the transition arrangements and development of an improvement plan

Access to senior children’s nursing advice


Timescale Status

Review safeguarding processes

Review risk assessment process and recording for cases of concern

Review investigation criteria

Review flow chart for suspected safeguarding concerns

Review out of hours care pathways and contact numbers and internal contacts

Head of Midwifery / Assistant Chief Nurse, Vulnerabilities

June – August 2015


Implement changes to the above 4 bullet points

Review flow of information from safeguarding committee to Children CSU/governance

September - December 2015 June - August 2015

Review transition arrangements in the context of Royal College recommendations (where they exist, e.g. Asthma, Diabetes and Epilepsy)

Meet with other Divisional Directors to agree an improvement plan

Consultant with special interest in each area

Divisional Director for Family Health

July - September 2015 October - December 2015

Senior nurse leadership

Transitional arrangement with secondment of governance lead to matron post

Agree job description for the matron and Head of Nursing in children’s services

Recruit to posts

Head of Midwifery / Divisional Director for Family Health / General Manager, Family Health

June - November 2015 May 2015 July - November 2015


Unique Id S6 – Diagnostics and Out - Patients

Divisional / Corporate Lead Divisional Director, Clinical Support

Operational Lead Nursing Services Manager for Patient Access

Timescale 26/6/15 – 30/10/15

Committee Oversight Quality Assurance Committee & Clinical Support Division Performance Meetings


CQC requirement:

Ensure that sharps are managed in a manner which protects staff and patients from the risk of needle-stick injuries

Action already taken since the CQC inspection:

Reviewed practice and interpretation of the safe use of the sharp safe bins. Previously the interpretation had meant that each bin was ‘opened’ at the beginning of the day and ‘closed’ at the end of the clinical session. Now practice has been changed to mean that the bins are ‘closed’ after every single use.


Completed risk assessments for both methods of use of the sharp safe bins.

Analysis of Datix system to understand which method of use is the safest for both patients and staff.

Advice from the manufacturers of the sharp safe bins as to which is the safest method of use.


Undertake risk assessments for both methods

Nursing Services Manager for Patient Access

30 June 2015

Issue raised at Infection Prevention and Control Committee on 2/7/15. Agreed action is to review the Sharp Safety policy.

Lead Nurse / Assistant Director for Infection Prevention and Control

30 August 2015

Undertake pilots of each method over a period of 1 month (if allowed by both risk assessments)


30 August 2015


Analysis of results of each pilot and creation of outcome report


30 September 2015

Analysis of Datix reported incidents re: sharps in Main Outpatients Department over the last month.

Waste Management & Environmental Services Officer and Nursing Services Manager for Patient Access

11 July 2015

Assess practice across the Trust in use of safe sharp bins

Waste Management & Environmental Services Officer

11 July 2015

Seek advice from manufacturers re: both method for use of sharp safe bins

Waste Management & Environmental Services Officer

11 July 2015

Presentation of findings to Divisional Governance Meeting and to OQSEG in October 2015 for definitive decision as to which practice is safest.

Head of Clinical Professions 30 October 2015


Unique Id S7 – Trust wide

Divisional / Corporate Lead Chief Nurse

Operational Lead Deputy Chief Nurse

Timescale 26/6/15 – 31/12/15



CQC requirement:

Ensure that information about how to make a complaint or leave a comment is available in alternative formats and languages.

Ensure that nursing staff have access to clinical supervision.

Ensure that patients who are living with dementia and/or their relatives have the opportunity to give information about their personal circumstances, their preferences and likes and dislikes.

Patients’ records are kept securely at all times.

Action already taken since the CQC inspection:


Information in alternative formats and languages regarding how to make a complaint or leave a comment.

All nursing staff have access to regular clinical supervision

Evidence is available that patients living with dementia and their relatives report that they are given the opportunity to give information about their personal circumstances, their preferences and their likes and dislikes.

Secure storage of medical records across the Trust can be evidenced.


Revise current complaint leaflet and ensure that there is facility to translate to other languages.

Deputy Chief Nurse September 2015

Approve clinical supervision policy and launch across the organisation

Assistant Chief Nurse, Vulnerabilities

August 2015


Develop a list of existing clinical supervisors across the Trust

Deputy Chief Nurse August 2015

Implement existing carers survey more widely

Lead Nurse Dementia Care October 2015

Undertake weekly carers surveys across Trust

Lead Nurse Dementia Care July 2015

Review notes storage across the Trust. Undertake an audit of practice in all clinical areas and develop recommendations for improvement

Heads of Nursing/ Midwifery September 2015 - audit complete December 2015 - agreed standard implemented across the Trust


Unique Id S8 – Community Adult

Divisional / Corporate Lead Divisional Director, Integrated Medicine

Operational Lead Head of Nursing and Matrons

Timescale 26/6/15 – 31/03/16

Committee Oversight Quality Assurance Committee & Medical Division Performance Meetings

Overall status as at 26 June 2015.

CQC requirement: A. Strengthen the engagement with community health services for adults’ staff. B. The provider should ensure community staff have access to information relating to people before providing care and treatment. C. Ensure staff are accessing interpreter services where appropriate. D. Support community and district nursing staff to report patient safety incidents appropriately. E. The provider should ensure staff are involved in learning from incidents and good practice is shared across teams and

departments.



Evidence of improved engagement from and communication with community health services for adults staff.

Assurance that community staff have access to information prior to providing care and treatment to patients.

Evidence of appropriate access by staff to interpreter facilities.

Evidence that community and district nursing staff are appropriately reporting of patient safety incidents.

Evidence of staff involvement in learning from incidents and good practice across all teams and departments.


Timescale Status

A i Underutilising the use of social media within the organisation, as evidenced by the #hellomynameis…campaign. The Division of Medicine would like to commence #transformationinrotherham as a vehicle for communication across the Division, but in particular to engage and make available to our community colleagues.

Divisional Director, Integrated Medicine

30 September 2015


A ii Laptops have been provided which deliver the building blocks to support alternative communication method such as social media, issues of connectivity need to be addressed by the Trust IT team

Head of IT 30 September 2015

A - iii Locality MDT will commence with the deployment of locality physicians, the first of which will commence in July 2015

Divisional Director, Integrated Medicine / Locality Leads

30 September 2015

A - iv Locality Leads are invited to the Band 7 meeting, chaired by the Matrons within the Division of Medicine to promote proactive communication and engagement between teams

Matrons June 2015

A - v Head of Nursing meets with Locality leads on a weekly basis to discuss staffing and general concerns

Head of Nursing, Integrated Medicine

June 2015

A - vi A ‘Welcome to the Division’ event is planned for August 2015 for all colleagues to attend across the Division, supported by colleagues from the Acute and Community settings

Matrons August 2015

A - vii Head of Nursing/ Matrons have agreed to hold quarterly meetings with band 5 and band 3 colleagues for across the Division to facilitate effective communication, support and engagement

Matrons 30 September 2015

B - i There is a generic issue of multiple patients record systems for which a collaboration between the CCG and TRFT IT Department is ongoing

Head of IT 31 March 2016

B- ii Despite provision of portable IT equipment to staff there remains an ongoing issue of connectivity – this will be addressed as part of the transformation program work stream 4


31 March 2016

B - iii An increased emphasis on handover and evidence of process will be implemented and co-ordinated by the Locality Leads and monitored by the Matron and Head of Nursing



B- iv A review of the documentation used within the Trust has been considered as a project of the LIA group and should consider a record which can be utilised across the Trust

Deputy Head of Nursing for Community

31 March 2016

C - i Ensure staff are aware of the telephone and interpreter services which are available through the Trust in the form of the ORBIT facility – and how staff can access these


C - ii Ensure there is a system in place to ensure that there is an emphasis on identification of patients who cannot understand English prior to the visit. Locality Leads should reinforce this at their team and handover meetings


C - iii Matron to monitor the uptake of use of interpreter services and findings at Community Governance Meeting


D - i Matron will support the actions which form part of the M8 – incidents Trust action plan

Matron 01 October 2015

D - ii Locality Leads will review with their teams as the perceived barriers to reporting patient safety incidents and escalate concerns to Matron and Governance Matron, Governance Matron to support individuals/ teams with processes. This information will be discussed at the Community Governance meeting

Locality Leads 31 July 2015

D - iii Incident reporting will be monitored and reviewed at the Community Governance meeting

Matron 31 July 2015

E - i The Division of Medicine PLT will recommence in September 2015 and provides an opportunity for learning from incidents and sharing good practice across teams Division.


30 September 2015

E - ii Locality Leads to provide information on learning from incidents to the Governance Matron be included in the Division of Medicine monthly Governance Newsletter


E - iii Feedback of incidents and complaints to be shared with individuals and teams at governance meeting, locality team meetings to ensure learning opportunities are not missed



Unique Id S9 – Community End of Life


Operational Lead Matron and Locality Leads

Timescale 26/6/15 – 31/03/16



CQC requirement: A. Provide support to staff delivering community end of life and palliative care to report patient safety incidents appropriately and

ensure they are able to access training in incident reporting on a regular basis. B. Strengthen ways of learning from incidents and sharing good practice across the community end of life and palliative care

services. C. Ensure that staff visiting patients in their homes to deliver end of life and palliative care are able to access the complete

information they need before providing care and treatment. D. Ensure that all staff delivering community end of life and palliative care are able to access appropriate one to one supervision on a

regular basis. E. Strengthen the engagement with staff delivering community end of life and palliative care, and improve communication about

service design and strategy.



Evidence that community end of life care staff are appropriately reporting of patient safety incidents and training records which show that all staff are up to date with incident reporting training.

Evidence of staff involvement in learning from incidents and good practice across community end of life care and palliative care staff.

Assurance that community staff have access to information prior to providing care and treatment to patients.

Evidence that shows regular one to one supervision arrangements are in place for all staff delivering community end of life and palliative care.

Evidence of improved engagement from and communication with staff delivering community end of life and palliative care in relation to service design and strategy.



Timescale Status

A - i Matron will support the actions which form part of the M8 – incidents Trust action plan


A - ii Locality Leads will review with their teams as the perceived barriers to reporting patient safety incidents and escalate concerns to Matron and Governance Matron, Governance Matron to support individuals/ teams with processes. This information will be discussed at the Community Governance meeting


A - iii Incident reporting will be monitored and reviewed at the Community Governance meeting

Matron 31 July 2015

A – iv One of the locality Physicians will lead on palliative care and will support the patient safety agenda in palliative care


30 September 2015

B - i The Division of Medicine PLT will recommence in September 2015 and provides an opportunity for learning from incidents and sharing good practice across teams Division. The focus on the event will be centred around palliative care. And communication at end of life


30 September 2015

B - ii Locality Leads to provide information on learning from incidents to the Governance Matron be included in the Division of Medicine monthly Governance Newsletter


B - iii Feedback of incidents and complaints to be shared with individuals and teams at governance meeting, locality team meetings to ensure learning opportunities are not missed


C - i There is a generic issue of multiple patients record systems for which a collaboration between the CCG and TRFT IT Department is ongoing

Head of IT 31 March 2016

C - ii Despite provision of portable IT equipment to staff there remains an ongoing issue of connectivity – this will be addressed as part of the transformation program work stream 4


31 March 2016


C - iii An increased emphasis on handover and evidence of process will be implemented and co-ordinated by the Locality Leads and monitored by the Matron and Head of Nursing


C - iv A review of the documentation used within the Trust has been considered as a project of the LIA group and should consider a record which can be utilised across the Trust

Deputy Head of nursing for Community

31 March 2016

D - i A robust 1:1 appraisal process should be in place for all colleagues delivering End of Life Care. Line managers should be aware of how to access appropriate support if deemed necessary i.e. form the hospice, health and well being

Locality leads 31 August 2015

E- i Underutilising the use of social media within the organisation, as evidenced by the #hellomynameis…campaign. The Division of Medicine would like to commence #transformationinrotherham as a vehicle for communication across the Division, but in particular to engage and make available to our community colleagues.


30 September 2015

E - ii Laptops have been provided which deliver the building blocks to support alternative communication method such as social media, issues of connectivity need to be addressed by the Trust IT team

Head of IT 30 September 2015

E - iii Locality MDT will commence with the deployment of locality physicians, the first of which will commence in July 2015

Divisional Director, Integrated Medicine / Locality Leads

30 September 2015

E - iv Locality Leads are invited to the Band 7 meeting, chaired by the Matrons within the Division of Medicine to promote proactive communication and engagement between teams

Matrons June 2015

E - v Head of Nursing meets with Locality leads on a weekly basis to discuss staffing and general concerns

Head of Nursing, Integrated Medicine

June 2015


E - vi Head of Nursing/ Matrons have agreed to hold quarterly meetings with band 5 and Band 3 colleagues for across the Division to facilitate effective communication, support and engagement


E - vii The results of the specific clinical service review for Palliative care to be shared at the adult community governance group


30 September 2015


Unique Id S10 – Community Health Inpatient Services


Operational Lead Matron and Head of Nursing

Timescale 26/6/15 – 31/12/15



CQC requirement: A. Review the care being provided in The Oakwood Unit so that patients have the opportunity to engage in social activities as well

as promoting their independence. B. Review reasons for staff working in the community in-patient areas feeling isolated and distanced from the senior leaders in the

trust. C. Review the delay in discharges caused by lack of access to prompt assessments for receiving social care and continuing

healthcare and lack of availability of specialist packaging for medicines.


TRFT outcome descriptor: A. Evidence that all patients are aware of their ability to engage in social activities. B. A clear understanding as to the reasons why staff working in community in-patient areas feel isolated and distanced from senior

leaders in the Trust. C. Clear assessment of the extent to which a lack of prompt access to assessments for social acre and continuing healthcare as

well as availability of specialist packaging of medicines are resulting in delayed discharges as part of the relevant transformation project work stream.


Timescale Status

A - i The Oakwood Unit is in a state of transition. Matron to monitor activities within the unit and discuss with the team to promote a culture which actively promotes independence and social activities for patients within the unit. The appointment of a clinical nurse consultant lead will continue to develop the cultural changes required.



A - ii Interaction with Neuro-rehabilitation team will further promote rehabilitation culture and shared learning


B- i Underutilising the use of social media within the organisation, as evidenced by the #hellomynameis…campaign. The Division of Medicine would like to commence #transformationinrotherham as a vehicle for communication across the Division, but in particular to engage and make available to our community colleagues.


30 September 2015

B - i Head of Nursing/ Matrons have agreed to hold quarterly meetings with band 5 and band 3 colleagues for across the Division to facilitate effective communication, support and engagement


B - iii Matron to promote team meetings and ensure 1:1appraisal process is in place for team members

Matron 30 July 2015

C - i Progress has been made relating to delay in discharges caused by lack of access to prompt assessments for receiving social care, leading to a reduction in delays in transfer of care. This forms a work stream in the transformation project.

Divisional Director, Integrated Medicine / Head of Nursing, Integrated Medicine / General Manager, Integrated Medicine

31 November 2015


Unique Id S11 – Community Health Services for Children


Operational Lead Service Manager – Children and Young People’s Community Services

Timescale 26/6/15 – March 2016



CQC requirement: A. Ensure systems for reporting and recording safety concerns, incidents and near misses are used effectively and consistently. B. Safeguarding supervision should be reviewed to make sure it is robust and effective for all staff that need this. C. The provider should ensure that the substance misuse pathway is effective in providing appropriate intervention for young people

under 16. D. The provider should ensure that handovers from midwives to health visitors are taking place in a timely and effective way. E. Review the early attachment service to ensure it is not over reliant on one practitioner. F. The provider should ensure that discharge criteria for the early attachment service are fully defined. G. Review the IT requirements of staff working in the community so that staff are not hindered by old and inefficient IT equipment. H. Ensure that all staff working with children, young people and families have received training about the identification and prevention

of child sexual exploitation.

Action already taken since the CQC inspection: Issued a triggers list to all Children and Young People Service staff (acute & community) Temporary safeguarding supervisor in place to fill gap Standard item added to team meeting agendas entitled ‘Incidents & Learning Identified’ and ‘New risks added to the risk register’ Replacement of some IT equipment already in progress: £70k investment from TRFT capital programme, equipment has arrived and is currently being installed. Survey in development to identify remaining problems following roll out of replacement IT.


Evidence that community C&YP staff are appropriately reporting patient safety incidents and training records which show that all staff are up to date with incident reporting training. Reviewed at Governance meetings.

Monthly report on supervision accessed by community CY&YP staff – reported through C&YP Governance meeting

Revised pathway with evidence of usage through the number of referrals made to substance misuse service

Evidence of improved communication between midwives and health visitors in the form of: a communication template for use by


midwives and health visitors, a written communication pathway from midwifery to health visitor, an audit tool and audit report.

Establishment for service based on more than one Health Visitor

Early attachment service discharge criteria agreed and disseminated.

Gap analysis illustrates that IT equipment used by the service is fit for purpose.

Training records show that all relevant community C&YP staff have had training in identification and prevention of child sexual exploitation.


A - i The service will support the actions which form part of the M8 – incidents Trust action plan

Complex needs – Service Manager – Children and Young People’s Services

Health Visitors & School Nurses – Area Managers

AHPs - Clinical Team Lead - Community Paediatric Physio & Clinical Lead / Specialist Speech & Language Therapist

October 2015

A – ii Develop training programme for Datix system Children’s Services Lead / Governance Lead

31 August 2015

A – iii Roll out training in reporting incidents via the Datix system to all community C&YPS staff

Children’s Services Lead / Governance Lead

31 December 2015

B – i Strategic Safeguarding Committee has prioritised 4 groups of staff for access to safeguarding supervision, these are: family nurse partnership, complex care team, midwifery and Emergency Department.

Assistant Chief Nurse - Vulnerabilities

30 September 2015

B - ii The Trust has brought in some interim additional supervision resource and this commenced on 1 July 2015


Complete

B - iii A full review of the Trust supervision policy is to be undertaken


31 August 2015


C - i Undertake a review of the substance misuse pathway and the current outcomes for young people under 16 (A&E / school nursing)

Area Manager 31 October 2015

C - ii Benchmark current substance misuse pathway, its interventions and its outcomes with other providers to establish whether improvements are required (A&E / school nursing)

Area Manager 30 November 2015

C - iii If improvements are required, create and agree improvement action plan (A&E / school nursing)

Area Manager December 2015

D - i Review of the antenatal midwifery pathway to ensure the inclusion of the consistent recording and sharing of information on SystmOne. Review GP Practice EMIS IT users pathway to ensure the inclusion of the consistent recording and sharing of information

Deputy Service Manager

July 2015

D - ii To review the written communication pathway from midwifery to health visitor, ensuring that it is still fit for purpose.


July 2015

D - iii Audit the information sharing between midwifery to HV service


December 2015

E - i Review the skill mix within the Early Attachment Service to ensure that the staff currently being trained will provide sufficient numbers of suitability qualified and experienced staff within the service to meet the needs of its users.

Senior Nurse C&YPS 30 September 2015

E - ii If the review in E - i reveals that the skill mix is not appropriate, a business case for investment / change should be submitted for approval using the Trust’s business planning process.

Senior Nurse C&YPS & Service Manager – Children and Young People’s Community Services

October 2015

F -i Discharge criteria for the early attachment service to be agreed with all key stakeholders

Senior Nurse C&YPS 31 October 2015


F – ii Implement criteria across the service Senior Nurse C&YPS 30 November 2015

G - i Following implementation of £70k worth of new IT equipment, a further replacement analysis to be undertaken to ascertain exactly which pieces of equipment require replacement next and a prioritised replacement programme to be created based upon risk assessment.

Service Manager – Children and Young People’s Community Services

31 October 2015

G – ii Survey to be undertaken of IT needs. Questionnaire developed and awaiting feedback from IT department.


31 October 2015

G - iii Procurement of additional IT equipment and implementation within the service


31 March 2016

H A gap analysis will be undertaken, and a plan will be put together for the remainder of 2015/16. In the interim period we will ensure all staff working in the service receive written materials.

Service Manager – Children and Young People’s Community Services in conjunction Assistant Chief Nurse - Vulnerabilities

31 August 2015


Unique Id S12 – Community Health Services for Children


Operational Lead Service Manager, C&YPS & Area Manager

Timescale 26/6/15 – 31/03/16



CQC requirement: A. Ensure that young people have access to contraceptive and sexual health clinics during school holidays. B. Ensure that waiting time targets are met for physiotherapy non-urgent appointments and child development centre

appointments. C. Ensure that letters to parents and carers include how to get the information in languages other than English. D. Ensure that information about complaints is captured and shared, including when they are dealt with locally and not recorded on

the reporting system. E. The provider should ensure that risks and concerns within the service are dealt with in an appropriate and timely way. F. Ensure a consistent approach to obtaining the views of children, young people and families using the service. G. Strengthen the engagement with staff delivering community health services for children and young people and improve

communication about service design and strategy.

Action already taken since the CQC inspection: A. Action plan in place to develop contraceptive and sexual health clinics during the school holidays B. Review of paediatric therapy services underway C. Communications team contacted to request the text for inclusion into a letter template to request in other languages and

disseminated to all for inclusion in letter templates by the end of July 2015. D. Complaints are a standing agenda item on standardised agenda for all CYPS team meetings. E. Risks and Concerns are a standing agenda item on standardised agenda for all CYPS team meetings. F. Friends and family test started in CYPS community services G. Core meetings held weekly with Senior Managers and Service Managers with wider leads invited as necessary. Service leads

should attend monthly Governance, Clinical Support Unit and Clinical Managers meetings. Service leads hold regular team meetings to disseminate information from above meetings. Leads required to attend Team Brief which is disseminated through team meetings. Monthly newsletter sent out to all CYPS staff.


TRFT outcome descriptor: A. CASH clinics for young people held in school holidays (measured by number of clinics) B. Waiting times met (performance monitoring) C. All letters to parents to contain details of how to get information in languages other than English (template rolled out to all areas) D. Both formal and informal complaints logged within services and themes shared at monthly CYPS governance meetings (audited

through check of logs at governance meetings) E. Risk log monitored and updated through monthly CYPS governance meetings F. FFT responses regularly gathered from all CYPS services (review of number submitted through FFT group, action plans

developed for any negative comments G. Improved staff engagement scores from community staff


A Complete and implement action plan to hold CASH clinics for young people in the school holidays

Service Manager, Gynaecology, Integrated Sexual Health

Sept 2015

B – i Complete review of therapy services with options appraisal

Service Manager - Children's & Young Peoples Community Services

August 2015

B – ii Implementation plan from therapy service review Service Manager - Children's & Young Peoples Community Services

August 2016

C Develop template for all letters to parents including how to get information in languages other than English


August 2015

D – i Devise and roll out standard agenda for all team meetings including FFT and governance (encompassing complaints, risks, learning identified and anything to escalate to CYPS Governance meetings)

Governance Lead Complete

D – ii Share lessons learned from incidents and concerns/complaints through CYPS Governance meetings


D – iii Implement the logging of informal concerns at service level, to be discussed at CYPS Governance meetings

Governance Lead September 2015


D – iv Complaints training for all CYPS community leads and managers


March 2016

E – i Risk assessment training for all CYPS community leads and managers


March 2016

E – ii Risks reviewed and updated through CYPS governance meetings


F – i Friends and family test rolled out across all CYPS community services


F – ii Friends and family test uptake and results reviewed through TRFT Friends and family test Group and locally at CYPS governance meetings


G - i Service Managers and Leads invited to Core group to develop processes for disseminating appropriate information regarding service redesign and strategy to wider staff teams


August 2015

G – ii Review of regular none attenders at CSU, Governance, Clinical Managers meetings to be undertaken over 6 months and feedback to managers


February 2016

G – iii Services Leads to develop processes for disseminating information from above meetings to their teams


August 2015

cqc improvement action plan

Documents