the francis report - responding effectively as a … francis r… · the breakdown in standards of...

Aneurin Bevan Health Board Wednesday 27 March 2013

Agenda Item:2.4

THE FRANCIS REPORT - RESPONDING EFFECTIVELY AS A

HEALTH BOARD 1. Introduction The publication of Robert Francis’ report of his Inquiry into the Mid-Staffordshire NHS Foundation Trust in February this year was an important moment for all healthcare providers. The description of the breakdown in standards of care at Stafford hospital contains important lessons for the Aneurin Bevan Health Board. Nearly all of the issues which surfaced at Stafford hospital can be seen to some degree to in most busy hospitals, even if the scale of the problems was unusual. It is important that the Health Board makes an effective response to the recommendations Francis has made. Although some of the recommendations require action at governmental or regulatory level, and some apply specifically to the English healthcare system, the Health Board should make an immediate start, building on existing work to improve quality and safety. 2. The Main Issues The Francis report runs to 1781 pages and contains 290 recommendations, so a degree of summation is required to make sense of it. This Robert Francis has usefully done this himself in a presentation given to the King’s Fund ( www.kingsfund.tv/francis-inquiry/Robert_Francis.htm). He identifies a collective failure by the Trust Board, by professionals and by regulators to respond to a number of warning signs (Table 1): Table 1. Warning signs in Stafford Hospital Patient stories identifying problems with: Staffing levels and competency Lack of compassion Problems with training and leadership Systematic failures in patient safety without effective actions Patients felt their complaints would not be listened to Staff with concerns they felt they could not raise, or that were not responded to A negative organisational culture Habituation to poor care Poor morale and disengagement Uncaring behaviour Disconnect between organisational purpose and priorities

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http://www.kingsfund.tv/francis-inquiry/Robert_Francis.htm

http://www.kingsfund.tv/francis-inquiry/Robert_Francis.htm


Agenda Item:2.4 Francis suggests that that his recommendations can be summarised into seven key areas (Table 2): Table 2: Robert Francis’ summary of his recommendations Common values Fundamental standards Openness, transparency and candour Compassionate, caring, committed nursing Strong patient centred healthcare leadership Accurate, useful and relevant information Culture change not dependent on government

To these we might add one further key area of work – the need to make rapid progress on improving services for older people. Francis makes suggestions on the direction healthcare organisations should take when addressing his recommendations. His suggestions for each summary area are given below, together with a brief on the actions the Aneurin Bevan Health Board can take to respond. 3. Common values Francis’ recommendations Organisations should have a clear set of values which put patients first, so that staff do everything they can to protect patients from harm, are always open and most with patients regardless of the consequences for themselves and direct patients to where they can find help. All NHS staff and contractors should commit to these values. Aneurin Bevan Health Board Actions Disconnect between true organisational purpose and organisational priorities were identified as a key root cause of the Mid Staffs issues. There is a good set of existing Health Board values, but it is unclear whether front line staff would currently be able to identify them reliably. We should take the opportunity to consult widely, but swiftly on values; modify them as necessary; and, ensure they are communicated effectively. They should be brief and easy to remember, easily visible throughout the organisation, reinforced through training at every level and modelled by Directors and Senior Managers. The patient experience agenda is being actively developed within the Health Board, and an update is provided in appendix 1.

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Agenda Item:2.4 4. Fundamental standards Francis’ recommendations Standards that the public would see as essential should always be maintained. Examples would be at prescribed medication is always given, food and water and a necessary help is always given, patient and equipment are kept clean, assistance is always provided to use the lavatory and consent for treatment is always obtained. There should be a zero tolerance approach to failure to meet fundamental standards. Aneurin Bevan Health Board Actions Fundamentals of Care provides a good platform, but may require some amendment to include actions expected of doctors and other care professionals, and effective communication to patients. We will also need to set out clearly what happens if basic standards not met. A failure to meet basic standards of care should always be reported, should always be addressed, and patients and their families always told when there has been a failure to deliver a basic standard of care whether they ask or not. Death or serious harm resulting from a failure to meet basic standards should automatically result in a defined process for staff involved, and any service where basic standards are not met consistently should be suspended. 5. Openness, transparency and candour Francis’ recommendations Concerns and complaints should be able to be raised freely and fearlessly, and answered fully and truthfully. Accurate and useful information about performance outcomes should be freely available to staff and public. Patients should always be informed if they have or may have been unavoidably harmed whether or not they ask. Aneurin Bevan Health Board Actions The Health Board has made substantial progress in implementing the Welsh Government’s Putting Things Right measure, and is regarded as an exemplar organisation. Further training is required to improve the skills and confidence of frontline clinicians to respond promptly and effectively to complaints, and to share any failure to deliver care to a proper standard promptly with patients and their families. The Health board should provide increased access to safety and performance data on its internet site, and this process will take an important step forward this month with the open publication of the Risk Adjusted Mortality Index.

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Agenda Item:2.4 6. Compassionate, caring, committed nursing Francis’ recommendations Francis makes a number of recommendations on recruitment, experience, training standards and code of conduct for nurses and healthcare support workers. He also suggests that unnamed nurse (and doctor) responsible for each patient should always be clearly identifiable. Aneurin Bevan Health Board Actions The Welsh Government has set out an agenda to ensure that all wards have safe staffing levels. This work in the first instance is being taken forward via the use agreed nursing staffing principles. A Wales wide approach is being taken to identify an effective acuity and dependency tool as a longer term strategy. A detailed review of Nurse staffing triangulated with professional judgment and benchmarking has been undertaken within the Health Board since 2009 and reviewed on a regular basis In 2012 the Chief Nurse introduced the All Wales Staffing Principles for Nursing in Surgical and Medical Wards. The key principles are:

• Staffing minimum to be 1:1 whole time equivalent per bed. • Staffing should include 60% Registered Nurses. • Day time staffing should be no more than 7 patients per

Registered Nurse. • Night time staffing should be no more than 11 patients per

Registered Nurse. • Sisters/Charge Nurses should be outside the establishment to

lead and develop staff and drive the quality agenda. • The uplift applied to post should be set at 26:9%.

Within the Health Board the nursing workforce within acute and community hospital settings the Health Board has been systematically reviewed. This has been triangulated against professional judgment and an acuity tool (Hurst) and the findings of a Welsh Audit Office Review. Further information on nurse staffing is provided in appendix 2. 7. Strong patient centred healthcare leadership Francis’ recommendations Francis suggests that healthcare managers should be recruited and trained for values, that leaders should model the right values themselves and that there should be a code of conduct for managers prioritising patient safety, well-being and candour.

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Agenda Item:2.4 Aneurin Bevan Health Board Actions The Health Board must ensure that all managers are recruited and trained according to Francis principles. 8. Accurate, useful and relevant information Francis’ recommendations Francis believes that there is an individual and collective responsibility to devise appropriate performance measures, and that these should be transparently visible public in as near real time as possible. Aneurin Bevan Health Board Actions The Health Board has made substantial progress in presenting its performance at open Board meetings, but this information needs to be developed further to ensure it addresses the current priorities for care improvement and made freely available to the public on the Health Board internet site. Patients should be able to see (on the ward board, or on request) basic information such as ward infection rates, procedure outcomes, mortality rates. Improvements in clinical coding performance will be required to meet this requirement. 9. Culture change not dependent on government Francis’ recommendations Francis believes that organisations should set about the necessary culture change to enact his recommendations without waiting for governmental action. Aneurin Bevan Health Board Actions The Health Board should ensure that actions are underway to address the Francis report, recognising that this is a journey that will take some time to complete. Actions should be taken with reference to central direction and processes, but we should not wait for these before acting. The ‘soft side’ of culture change is important. In its response to the Francis Report the Nuffield Trust has pointed out that too form a line on individual accountability will act against the creation of a proper safety culture by discouraging people from reporting incidents. A proper balance must be struck in this area, as in others. Real culture change will result from a clear sense of direction in the Health Board, and effective modelling of values by senior managers ‘walking the walk’. The National 1000 Lives Plus campaign and the local ABCi quality improvement centre will be important vehicles for culture change.

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Agenda Item:2.4 10. Improving services for older people Francis’ recommendations The Francis report makes eight recommendations on care of older people, covering teamwork, communication, hygiene, provision of food, water and medicines and recording of observations. Aneurin Bevan Health Board Actions Good care of older people lies at the heart of preventing the breakdown in care that occurred in Stafford hospital. 5 key areas of strategy have been identified by the Community Division:

• Primary care actions – anticipatory care plans, nursing home liaison

• Geriatric Assessment Units – at RGH, NHH and YYF • Effective hospital flow – MDTs, OPAL teams, proper Unified

Assessment • Frailty teams – effective in-reach by community teams • Improved Social Care Liaison – carer development, prompt

assessments Further consideration of the issues surrounding care for older people is provided in appendix 3, an update on actions to address dementia care is provided in appendix 4, and an update on actions to improve dignity in care is provided in appendix 5. 11. Conclusion This is a far from comprehensive list of responses to all the Francis recommendations, but tries to capture the most important elements of the report as recommended by Robert Francis. A process to embed Francis principles throughout the organisation will be important. Some Divisions have already started to consider the implications of the report. An example of a suite of divisional actions in response to Francis is included in appendix 6. Report prepared and sponsored by: Dr Grant Robinson, Medical Director Miss Denise Llewellyn, Nurse Director

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Agenda Item:2.4 Appendix 1 – Progress on Patient Experience Francis says: “We need a patient centred culture, no tolerance of non compliance with fundamental standards, openness and transparency, candour to patients, strong cultural leadership and caring, compassionate nursing. Culture” 1. National Context Improving the patient's experience of care is a key priority for NHS Wales. A focus on what it is actually like to be a patient in the NHS - the 'patient experience' –is seen as vital in the drive to improve quality in the NHS. 'Patient experience' encapsulates the totality of patients' needs and preferences. It includes both clinical and non-clinical care, and embraces everything from the success of clinical interventions to issues of access, responsiveness, choice, and the state of the physical environment of care. 2. Local Picture A multitude of factors influence patient’s/carers experience of health services including aspects of the care process and the manner in which care is delivered; the physical environment of care and other facilities; and the way in which staff from across the organisation interact with patients and their families. At a strategic level, the Health Board’s commitment to maximising patient experience is articulated through the organisations vision statement and plans. A ‘Patient Experience Framework’ has been developed and ratified by the Board. Multiple work streams are being progressed including:

• Implementation of a Behaviours Framework • Completion of actions detailed in the Dignity Action Plan • Embedding ‘Transforming Care’ across all in-patient areas • Improving the environment of care via the Environment

Committee work plan • Development of a ‘Volunteering and Volunteers Policy’ • Introduction of the Nursing Dashboard and measuring

performance through nursing metrics and fundamentals of care audit specifically measuring

Work to evaluate the impact of the Health Boards focus on improving patient experience has been measured through:

• Internal review (using the HIW Dignity and Essential Care Audit tool) of wards in district general and community hospitals

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Agenda Item:2.4 • An audit of performance against the Fundamentals of Care

Standards in all inpatient wards • Internal Audit Department work to test how well Dignity

Action Plan outputs, Healthcare Inspectorate Wales Dignity and Essential care Inspection requirements and Transforming Care expectations are embedded in ward areas.

• Trend analysis of complaints and incidents Obtaining direct feedback from patients/service users is however essential. Some of the mechanisms currently utilised are listed below. Examples of how this information has been used are included as Appendix 1.

• Patient surveys: o 1000 Lives+ surveys o Transforming Care Patient Experience Survey o Fundamentals of Care Patient Experience Survey o Nutrition Reviews

• Observation of Care o HIW reviews and Dignity and Essential Care Inspections

(DECI) o Community Health Council spot checks and inspections o Patient Stories

• Complaints Analysis • Patient/service user participation via service improvement

approaches: o Kings Fund and Health Foundation Patient and Family

Centred Care Programme o Kafka Brigade Reviews.

These methodologies are a key way of listening to what patients and communities think of our services and we have a moral duty to ensure that action is taken when we get things wrong and to spread practice when the experience has been good

Priority areas for action: Considerable work has been undertaken to fulfil the organisations objective to put the patient first and to improve patient experience. Whilst much has been achieved work is ongoing. Priority areas for action include:

• Continued work to realise all of the actions set out in the dignified care action plan

• Continued collation of patient stories and correlation of what we did to change practice.

• Implementation of the carers strategy

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Agenda Item:2.4 • Further development of mechanisms to capture the ‘patient

experience’ of individuals who are particularly vulnerable in the health care system e.g. children and young people, individuals with communication difficulties, individuals with cognitive impairment, learning difficulties or memory loss, individuals who might need a particular approach because of cultural or language related factors

• A key area for development is how the organisation develops the information available for patients and their family carers

• Evaluation of the patient’s experience of the ‘Perfect Ward’ • Further work to embed ‘Transforming Care’ across the Health

Board • Consideration of approaches to optimise the role of

volunteers/volunteering in enhancing patient experience • Development of a patient experience website as a central

resource for patients, the public, and staff so that the organisation can be candid about sharing useful, accurate and understandable information about its services.

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Agenda Item:2.4 Examples of how patient experience information has been used within the organisation include: Data Collection Tool

Method How information has been used

Transforming Care Patient Experience Survey

A standardised Patient Experience Survey was developed (Summer 2012) by the Transforming Care Committee. The survey enables patient experience and opinion to be gathered and measured against the goal of achieving 95% satisfaction

The survey is implemented and analysed within each Division. Results are displayed on the ward’s ‘Knowing How We Are Doing Board’ and ‘You Said We Did Boards’

Service Specific Satisfaction Surveys

Service specific satisfaction surveys have been undertaken in many services including: - Palliative Care - LD - Eating Disorder Service - Huntingdon’s Service - SaLT - Physiotherapy

Results have been published and shared within teams and findings used to inform change

Gwent Association of Voluntary Organisations (GAVO) patient satisfaction review

GAVO were commissioned to undertake an independent review of patient satisfaction in Ysbyty Aneurin Bevan

Results were used as part of a formal evaluation of patient experience at the then newly commissioned hospital

Community Health Council ‘Patient Environment Assessment Regulatory System’ (PEARS) spot checks

The Community Health Council visit patient areas to assess the environment of care, and part of this process seek the views and experiences of patients

Immediate feedback is provided to the ward teams to initiate corrective or improvement actions if required. Findings are also reported to the Corporate Nursing Team

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Agenda Item:2.4 Patient Food Quality Audit

Undertaken monthly, Nutrition Reviews involve food tasting as well as inviting patient views about hospital food

Findings are discussed in the Clinical Nutrition Steering Group who monitor actions taken as a consequence of the audit

Patient Stories “1000 Voices” is the ABHB Patient Stories Mini Collaborative. Story Champions have been identified and trained in each Division. A Story Telling How Too Guide is used.

A data base of patient stories is maintained to support learning across the organisation. Patient Stories are presented at the Quality and Patient Safety Committee, and at Board to be transparent in terms of patient experience, and to enable identification of trends, themes and organisational learning

Patient Experience Website

A work stream initiated by the Patient Experience Steering Group

Speech and Language Therapy services have developed an interactive website for patients and users. Maternity services have also developed an interactive web site for expectant mothers, which include a virtual tour of the Maternity Service. Progress is reviewed at the Patient Experience Steering Group and feedback will inform future web site developments

Complaints and Concerns

Monthly reports are prepared for the Quality and Patient Safety Committee summarising all ‘concerns’. Once discussed the reports are available on the intranet

Reviewed by Quality and Patient Safety Committee to identify trends themes and organisational learning

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Agenda Item:2.4 Appendix 2 – Nurse Staffing With regards to how ABHB complies with the All Wales staffing principles, a base line assessment of compliance in medical and surgical wards was completed within ABHB and submitted to the Chief Nurse in December 2012. The exercise was repeated across Wales in February 2013 this time measuring the variance from the agreed establishment and the funding gap and the bank and agency usage to deliver the service. The funding gap was 1.8 million and the bank and agency spend = 2.4 million. This implies that whilst the needs of the wards were more than the funded establishment, variable pay was used to address this shortfall by using bank and agency (For ease of reference a table is attached setting out the principles and compliance by Surgical and Medical Ward areas within the Health Board along with financial analysis and variable pay usage and spend.) During 2013/14 ABHB will continue to explore ways of achieving the All Wales staffing principles. The Perfectly Resourced Ward The perfect ward has been piloted at the Royal Gwent on two medical wards introducing Key Performance Indicators covering finance, HR and Quality. One of the objectives for the three month pilot was to achieve better use of resources - by investing in the ward establishment thereby eliminating agency and reducing bank usage. The Perfectly Resourced Ward pilot supports the achievement of a number of priorities within the Annual Quality Framework. These include:

• Improving the quality of patient experience – introducing Transforming care methodology

• Improving patient safety – with 1000 lives programme, NEWS, Sepsis bundle, falls risk assessments

• A detailed evaluation has been undertaken and will be reported to Executives and the Quality and Patient Safety Committee in May 2013.

A key element of this pilot was to ensure that ward sisters and charge nurses should operate in a supervisory capacity 0.6 WTE in order that they could address specific leadership roles during this time and not be part of the nursing provision except in emergency situations. This was also a key recommendation in the Francis report There is still work to be undertaken to address ward establishments numbers on a consistent basis and converting variable pay into bottom line establishments needs to be considered but ensuring both effective and efficient use of this resource. Specifically

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Agenda Item:2.4 additional review is required to ensure safe staffing levels in the Community. ABHB is discussing action to be taken regarding this with the WAO

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Agenda Item:2.4 Appendix 3 – Care for Older People 1. National Context Wales has an aging population. Between 2011 and 2033 the number of people aged over 65 years is projected to increase from 570,600 to 864,800. The projected rise in the number of older people has the potential to impact significantly on the demand health, social care and housing services. The Welsh Government has responded to this through policies and strategies that relate specifically to, or impact on, older people including: NSF for Older People; Strategy for Older People (WG currently consulting on phase 3 of the Strategy); Dignity in Care review (led by Older People Commissioner); Dementia Strategy; End of Life Care policy and strategy; Carers Measure requirements. 2. Local Picture The number of older people resident within the Aneurin Bevan Health Board area is also projected to rise, as illustrated below.

15

20

25

30

35

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020

2021

2022

2023

2024

2025

2026

2027

2028

2029

2030

2031

2032

2033

%

Wales Aneurin Bevan Caerphilly

Blaenau Gwent Torfaen Monmouthshire

Newport

* Y-axis truncated

Population projections, Aneurin Bevan Health Board, local authorities and Wales, % aged 65 and over, 2011-2033*Produced by Public Health Wales Observatory, using StatsWales (WG)

Within the Health Board there are already a range of mechanisms, forums, and associated work plans to address the ‘older person’s agenda’ including:

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Agenda Item:2.4 • NSF for Older People Group (function currently subject to

review); • Dementia Board; • Carers Measure Programme Board; • Patient Experience Strategic Group (including Dignified Care

work programme) The need to develop age appropriate and responsive services for this patient group is essential and important work is well established e.g. Frailty Service development and capacity/demand work across unscheduled care services. 3. Priority areas for action There is opportunity to review and revise current mechanisms and processes across the Health Board and its partner organisations to enable a co-ordinated approach to the planning and delivery of services for older people. The focus should remain on supporting older people to lead as independent and as fulfilling lives as possible. Key areas of focus include:

• End of life care pathways • Dignity in care initiatives • Development of services for people with dementia including

introduction of intelligent targets • Support for carers • Reducing falls and fractures • Evaluation of frailty services • Advocacy and ensuring older people have a voice • Provision of safe, supportive and timely care options in

partnership with local authorities, the independent and third sectors

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Agenda Item:2.4 Appendix 4 - Dementia: Update on Progress 1. Introduction and Context This report has been prepared to provide an updated position on work being undertaken to implement the Aneurin Bevan Health Board Dementia Action Plan. This report has been structured to provide information in respect of:

• The strategic leadership model within Aneurin Bevan Health Board

• Progress to date • Next Steps

2. Strategic leadership model within Aneurin Bevan Health Board Aneurin Bevan Health Board has established a Dementia Board with the overarching aim of ensuring an organisation-wide approach to improving the health care/service experiences of people with dementia. The Board is chaired by the Executive Director of Nursing, and has a multi-disciplinary membership drawn from within the Health Board’s mental health, acute and community services as well as patient, service user and carer representatives invited from the Alzheimer’s society and the Aneurin Bevan Health Board Patient’s Panel. The Dementia Board has an agreed vision and underpinning philosophy founded on equity of access, and quality of care/service, irrespective of which part of Aneurin Bevan Health Board service an individual with dementia or cognitive impairment might access. In addition to identifying a task and finish group to develop a dementia strategy for the Health Board, four separate work streams have been identified in order to focus on primary/community care services as well as acute hospital services:

• Acute care dementia pathway • End of life pathway • Training and development • Patient stories

The Dementia Board will ensure that work plans are cognisant of legislative requirements, (including the Mental Health Measure, Carers Measure, and Mental Capacity Act), along with strategic policy requirements, (including those set out through Intelligent Targets and National Dementia Plan), and have established a process for each group to report progress made.

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Agenda Item:2.4 3. Progress to date Steady progress is being made across the organisation, although there remains much to do. An updated version of the Health Board’s Local Dementia Action Plan has been included as Appendix 1, however it is anticipated that the action plan will be reviewed by the Dementia Board and modified to include the wider development agenda. Progress has also been made through the work streams identified by the Dementia Board: 3.1 Acute care dementia pathway

The Divisional Nurse from the Unscheduled Care Division has been identified to lead the ‘acute care dementia pathway’ work stream. Wards from within five hospital sites (Royal Gwent Hospital, Nevill Hall Hospital, Ysbyty Ystrad Fawr, County Hospital, and St Woolos Hospital) are at varying stages of implementation of the 1000 Lives Plus Dementia Intelligent Targets and the Aneurin Bevan Health Board Cognitive Impairment Pathway including:

• Completion of initial audit to ascertain identification of dementia on admission

• Training of staff in PDSA cycles • Introduction of “This is Me” Life stories using a collaborative

approach between Health Care Assistants, patients and their family members/carers

• Introduction of standard care plans for dementia • Achievement of ‘dementia-friendly’ environmental changes • Introduction of activities boxes • Staff training in dementia care • Exploration of the merits of the ‘butterfly scheme’

3.2 Training and development The Assistant Director of Nursing Safeguarding and Public Protection has been identified to lead the training and development work stream. A small multi disciplinary/multi agency working group has been established with the intention of developing a dementia training strategy for the organisation. To date:

• An audit of dementia training provided within therapy services has been undertaken

• An initial dementia curriculum has been developed. Following consultation the curriculum will be further modified to provide a suite of training options to meet the learning needs of staff from any discipline or role within the Health Board. The group will explore a variety of modes to deliver training including on-line, classroom and ‘on the job’ approaches

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Agenda Item:2.4 • A dementia work book is nearing completion. The work book

will enable health care support workers to undertake self directed and ‘on the job’ training under the supervision of a registered nurse

4. Next Steps Work will continue to address the priorities identified in the Health Board’s Local Dementia Action Plan and through the work streams of the Dementia Board. Specific work will be undertaken to ensure join up with other key objectives of the Health Board (for example, gathering and using patient experience information and implementation of the organisation’s dignified care action plan). Specific work will be undertaken to refine the model of care for people with dementia in acute care settings.

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Agenda Item:2.4 Appendix 5 – Dignity in Care 1. Background In March 2011 the Commissioner for Older People in Wales published the findings of a review of the experiences of older people admitted to general hospitals in Wales. The Commissioner concluded that the review had highlighted that the treatment of some older people in Welsh hospitals was ‘shamefully inadequate’ and made twelve recommendations for the NHS in Wales. 2. Developing the dignity in care work programme Following publication of the review, Aneurin Bevan Health Board established a Dignified Care Task and Finish Group to develop the Health Board response. This Task and Finish Group was Chaired by and Independent Board Member and responsibility for the ‘dignity in care’ agenda was delegated by the Chief Executive Officer to the Executive Director of Nursing. The Task and Finish group, which included representatives from the Community Health Council, local authorities and the third sector, developed the Aneurin Bevan Health Board ‘Dignity Action Plan.’ Although the Commissioner for Older People in Wales’s review was focused specifically on people aged over 60 years of age in general hospital settings, the Aneurin Bevan Health Board Action Plan was intentionally developed to be inclusive of all patient groups accessing all Health Board services. To support this intention, the Action Plan was themed as follows: Leadership and workforce; Dementia care; Continence care; Patient experience; Education and development; Volunteers and carers; Environment of care. To ensure appropriate leadership and executive direction to operational leads, the objectives set out in the Action Plan were cross referenced to other key strategic influences e.g. Standards for Healthcare Services, and an Executive Lead was identified for each theme. The Action Plan was formally agreed in a public Board meeting in May 2010. Since its inception, implementation of the individual objectives detailed in the Action Plan has been facilitated through pre-existing work streams and established fora to secure ‘buy in’ across the organisation, and to maximise the sustainability of the outputs achieved. Overall monitoring of progress continues to be undertaken on behalf of the Board by the Patient Experience Group (which has an Independent Board Member as Chair). Progress made against the Action Plan is also subject to external scrutiny through the Wales Government performance review processes.

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Agenda Item:2.4 3. Raising awareness about dignity and respect across the Health Board The Aneurin Bevan Health Board Nursing Conference 2011 was used as an initial platform to launch the Dignified Care Campaign in the organisation. The campaign was underpinned by a poster campaign and a short film, which was played at the conference. The film is introduced by the Executive Director of Nursing and features a cross section of Aneurin Bevan Health Board staff reciting the poem ‘Crabbit Old Woman.’ Nurses attending the conference commented on its powerful message and the film has subsequently been shown to staff of all disciplines across the organisation through meetings and committees and with a wider audience at national conferences. Throughout 2012 the Health Board has continued to keep awareness of the dignity agenda high. Aneurin Bevan Health Board Dignified Care intranet pages have been developed. The ‘Crabbit Old Woman’ film, dignified care posters and other resources are available for staff to access at any time via the Aneurin Bevan Health Board Dignified Care intranet pages. A further short film, targeted at support workers of all disciplines in the Health Board, was developed and presented at the Health Care Support Workers Conference in November 2012; the key message being that all staff including those who are not directly involved in delivering ‘hands on care’ have a role to play in ensuring the services provided by the Health Board are delivered in a dignified and respectful way. This film is being modified to provide a stand alone learning and reflection tool that can be accessed by staff at any time via the Aneurin Bevan Health Board Dignified Care intranet pages. This is expected to be concluded early in 2013. Work is also in progress to develop a corporate Dignity in Care poster. The work, supported by Pfizer, is further developing the Health Board’s ‘Dignity Sunflower Logo’ and will provide the Health Board with professionally developed art work to reproduce posters for display in patient and staff areas. The Health Board is also developing a scheme to recognise the good practice on hospital wards who achieve specific and ambitious quality standards for delivering dignified continence care. Awareness about the award scheme was raised in the 2012 Aneurin Bevan Health Board Nursing Conference, and will be formally launched in 2013. 4. Work underway in respect of the twelve recommendations made following the review The Health Board recognised from the outset that its action plan was ambitious, however implementation has progressed well. Most actions have been completed but some require further and longer term work before the objective is fully realised.

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Agenda Item:2.4 5. Evaluating the impact of change and measuring whether the experiences of older people in hospital has improved The impact of the Health Boards focus on the provision of Dignified Care on patient experience has been measured through:

o A review (using the HIW Dignity and Essential Care Audit tool) of wards in general hospitals

o A review (using the HIW Dignity and Essential Care Audit tool) of wards in community hospitals

o An audit of performance against the Fundamentals of Care Standards in all inpatient wards

o An internal audit to test how well Dignity Action Plan outputs, Healthcare Inspectorate Wales Dignity and Essential care Inspection requirements and Transforming Care is embedded in ward areas

o Trend analysis of ‘dignity’ related complaints 5.1 Internal Review (using the HIW Dignity and Essential Care Audit tool) of wards in general hospitals settings Objectives and Scope The Dignity and Essential Care Inspections undertaken in the Health Board follow the Health Inspectorate Wales auditing framework for reviewing key elements of care provided to patients in hospital. The audit focused on the following aspects of care provision:

• Patient environment • Staff attitude/ behaviour/ ability to carryout dignified care • Fluid and nutrition • Personal care and hygiene • Toilet needs • Buzzers • Care planning and provision • Pressure Sores • Communication • Medicine management and pain management • Records management • Management of patients with confusion • Discharge planning

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Agenda Item:2.4 Method: The auditors adopted an unannounced, peer review based approach. Senior Nurses conducted audit visits to wards outside their operational sphere of management. Predefined audit tools were used to ensure consistency, and information was gathered through observation, speaking to patients, carers and relatives and reviewing documentation. The audit commenced in January 2012 and concluded in September 2012. During this period 16 wards across three general hospital sites were audited. Each wards received verbal feedback immediately after the audit, and this was followed up with a detailed report and recommendations for improvement. The Action Plans generated will be reviewed as part of the second stage of the audit, which will be undertaken over a six month period concluding in March 2013. Key Findings: Results indicated that for the most part the quality of care provided was of a good standard and feedback from patients was generally complimentary. The audit identified that further work is required to improve the quality of nursing documentation, and that some wards still require refurbishment. 5.2 Internal Review (using the HIW Dignity and Essential Care Audit tool) of wards in community hospitals Objectives and Scope The Dignity and Essential Care reviews undertaken followed the Health Inspectorate Wales auditing framework for reviewing key elements of care provided to patients in hospital. The audit focused on the following aspects of care provision:

• Patient environment • Staff attitude/ behaviour/ ability to carryout dignified care • Fluid and nutrition • Personal care and hygiene • Toilet needs • Buzzers • Care planning and provision • Pressure Sores • Communication • Medicine management and pain management • Records management • Management of patients with confusion • Discharge planning

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Agenda Item:2.4 Method: The auditors adopted an unannounced, peer review based approach. Predefined audit tools were used to ensure consistency, and information was gathered through observation, speaking to patients, carers and relatives and reviewing documentation. The audits were undertaken in Torfaen community hospitals in May 2012, in Blaenau Gwent community hospital in October 2012, and in Monmouthshire community hospitals in November 2012. Verbal feedback was provided immediately after the audit, and action plans were generated in response to recommendations made. Key Findings: It is difficult to generalise the key findings from each review however, generally feedback from patients was complimentary. The reviews in each area identified areas for further work including to improve the quality of nursing documentation, the environment of care, and discharge planning arrangements, particularly in respect of individuals with limited capacity for decision making. 5.3 Audit of performance against the Fundamentals of Care Standards in all inpatient wards Objectives and Scope ‘Fundamentals of Care’ (2003) is a Welsh Government programme which aims to improve the quality of care for adults. It contains 12 standards all relating to essential elements of care. The NHS Wales Delivery Framework (2011/12) identified the ‘Fundamentals of Care’ audit as the vehicle to assess organisational performance against the tier 1 priority dignity and quality in care. The audit is recognised as providing a measure of the quality of care provided. Method: The audit was undertaken in two parts:

• A patient satisfaction survey to capture patient experience of care provided

• An audit of operational processes including policy and procedural conformity and documentation standards

The Community Health Council assisted with completion of the patient satisfaction survey elements to enable a degree of independence. Operational processes were audited through a peer review process consequently Ward Sisters, Charge Nurses and Senior Nurses did not audit their own areas. 82 wards across Aneurin Bevan Health Board were subject to the audit.

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Agenda Item:2.4 Key Findings: In respect of ‘User Experience’, there were generally good levels of satisfaction reported across all Divisions (the user experience score being 90% or above). The results reflect feedback from the Community Health Council in the annual HPE audit whereby patient experience has been reported as good and staff were described as professional and courteous in their interactions with patients and families. Some patient comments however highlighted areas where more work needs to be done to improve their experience of the service. In respect of ‘Operational processes’ there was a downward trend across all divisions when compared to the 2011 audit results. Detailed analysis indicated that reduced performance against the documentation standards has impacted significantly on the overall performance score. This is recognised across Wales as an emerging problem, and is attributed in part to the extra documentation demands associated with implementation of improvement approaches including the 1000 Lives+ approach and the requirement for bundles and audit. An ABHB Nursing Documentation Group, led by an Assistant Director of Nursing, has been established to review existing documentation requirements, reduce duplication and enhance user-friendliness. 5.4 Audit to test how well Dignity Action Plan outputs Dignity Action Plan outputs, Healthcare Inspectorate Wales Dignity and Essential care Inspection requirements and Transforming Care is embedded in ward areas Objectives and Scope The audit sought to provide reasonable assurance in respect of the identified standards:

• ‘There is evidence at ward level of action taken to address the recommendations raised in the review by the Older People’s Commissioner of Wales entitled “Dignified Care? The experiences of older people in hospitals in Wales” issued on 14 March 2011’

• ‘Wards are able to demonstrate an awareness of the 3 HIW audit tools (Advanced Operational, General Observational and Records of Care) to be used upon inspection’

• ‘Wards are utilising the WG/NLIAH tools to review, evaluate and implement 'Transforming Care’

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Agenda Item:2.4 Specifically, the audit assessed progress in terms of:

• Stronger ward leadership; • Better knowledge of the needs of older people; • Timely response to continence needs; • Sharing of personal information in the hearing of others; • Appropriate use of volunteers; • Staffing levels reflect the needs of older people; • Capturing the experience of older people, their families and

carers; • Identifying, evaluating and learning from good practice; • Appropriate levels of knowledge and skills for those working

with older people; and • Whistle blowing arrangements. • Dehydration; • Nutritional risk; • Pressure sores; • Toileting needs/concerns; • Mobility issues; • Mental health conditions such as confusion or dementia; • Sensory impairments (hearing, visual or speech); • End of life care; • Patient Environment; • Staff attitude and behaviour; • Personal Care and hygiene; and • Buzzers.

That a system was in place to ensure robust records management in terms of:

• Care planning and provision; • Pain management; • Medicines management; • Record keeping; • Personal care; • Communication with the patient; and • Discharge planning/discharge in timely manner.

Whether wards were utilising the WG/NLIAH tools to review, evaluate and implement 'Transforming Care’. Method: The internal audit work was carried out through a series of unannounced visits to 22 wards across six hospital sites. The Auditors used a standardised programme to facilitate observation of each ward, discussion with ward staff, and the review of documents as necessary to confirm the effectiveness of the controls in place.

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Agenda Item:2.4

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The majority of visits were made during office hours, however two visits were made on weekday evenings, and a further two visits were made on weekends to enable observation of the wards at different times, including times when the Sister/Charge Nurse would not be present. Announced re-visits were made where necessary to meet Ward Sisters. Key Findings: The audit focused on ward-level compliance with the activities and requirements (detailed above) which are relevant to the provision of dignified and respectful care. The audit determined that most of the wards visited were implementing Transforming Care, and that there was clear evidence of the impact of this initiative on some of the wards visited. Compliance with the principle of ‘intentional rounding’ was high; this means that in most cases patients were being attended to by the nursing team at least every two hours. Most wards reported that registered nurses participated in medical ward rounds to ensure that the patient’s right to confidentiality and privacy is observed. Overall the internal audit provided an overall classification of assurance as:

• ‘There is evidence at ward level of action taken to address the recommendations raised in the review by the Older People’s Commissioner of Wales entitled “Dignified Care? The experiences of older people in hospitals in Wales” issued on 14 March 2011’ - Adequate

• ‘Wards are able to demonstrate an awareness of the 3 HIW audit tools (Advanced Operational, General Observational and Records of Care) to be used upon inspection - Limited.

• ‘Wards are utilising the WG/NLIAH tools to review, evaluate and implement 'Transforming Care’ - Adequate

The audit identified six areas for improvement in respect of Nurses’ cleaning schedule, Designated Management and Leadership Time, Completion of Competency Based Workbooks, Use of Dignity Pegs, Call Bell Response Times, Dignity and Respect Training, and Patient Information and Feedback

Appendix 6 - Francis report – Impact Assessment for Unscheduled Care Division

Ref. Recommendations Specific Recommendations Action Required

3;4;9;10;12;191

Fundamentals of behaviour

Behaviours framework Codes of Conduct

Uptake of Customer care training All staff to be reminded of Behaviours Framework All registered staff to be reminded of codes of conduct

13; 14; 15; 37; 41; 67; 124; 126; 139;140;141;142;143;144; 190; 247

Standards of care / Quality Metrics

Completion of internal and external audits Compliance with fundamentals of care Performance management

Need to demonstrate compliance with Fundamentals of care, Nursing Metrics, HIW inspections, D&ECI audits, WRP, Nursing Strategy, Standards for Health Services, Nursing Metrics, NICE compliance, mandatory and statutory training, NPSA alerts PADRs and pressure Ulcer information Action plans to improve compliance need to be regularly reviewed by Division Risks need to be escalated via exception reporting

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13; 14; 15; 20; 49

Self assessment to be replaced by routine and risk related monitoring

Quality & Risk profile Quality accounts New/ existing peer review schemes Themed inspections

Need to demonstrate compliance with self assessments process Need to bring out learning from D&ECI (internal inspections) and feedback/ actions from external inspections

97; 98

NPSA Role and function to be protected

NRLS reporting on all incidents Need to improve compliance with sign off and upload of incidents Need improved awareness of themes and monitoring of actions to address issues

45; 282

Inquests/ Rule 43s Learning from Rule 43s published by Coroner

Know what cases are going to Inquests and concerns Regular checking of Lord Chancellor’s web site for new Rule 43s

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38; 39; 40; 62; 109; 111; 112; 114; 116; 118

Complaints

Easier access for making a compliant All concerns to have same response as formal complaint Compliance with standards Access to complaints information Patterns/ themes and learning from complaints Encouragement and learning from patient and public feedback Support for complainants Summary of each complaint which has been upheld

Demonstrate improved compliance against 20 day target Potential for increase in numbers of complaints Poor compliance in developing and monitoring action plans following complaints Need to demonstrate learning from concerns and public and patient feedback

239 Discharges

No discharges to be in the middle of the night No discharges without assurance of ongoing care in place Discharge areas staffed and able to provide continued care

Deliver safe and timely discharge

242 Medication

Checks whether medication given as prescribed – by NIC or deputy

Medication task and finish group – (USC represented) Pharmacy liaison – no formal process to identify medication issues with ward sisters Demonstrate learning from previous pharmacy audit

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12; 46; 253;

Risk Register

Risk assessments, scores and how risk has been mitigated Public access to quality and risk profile

risk assessments required from Directorates Needs to be live document New risks and overview of old to DMT (captured on Dash board)

279 Death certificate Cause of death to be completed by consultant or senior

Some issues with regards to death certificates stem from juniors completing (eg POVA raised by Coroner)

185; 197

Leadership

Leadership training to be included at every level Leadership reinforces values and standards of compassionate care

Band 7 development packs to be completed To increase compliance with PADRs

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174; 175; 177; 178; 179; 180; 238

Communication with patients and relatives

Pts/ relatives should be informed when a serious incident has occurred and the surrounding circumstances. Full and truthful answers must be given to any question reasonably asked with regards to treatment Being Open Policy Nursing to feed into regular ward rounds Review of information contained on discharge letters Named nurse each shift

Circulate the Putting Things Right Tool kit Circulate Being Open Policy Ensure nursing input on the ward round/ compliance with RCP recommendations Improve E Discharge compliance

181 Statutory duty of candour

Need to escalate serious incidents

Promote a reporting culture Training/awareness of what this means in practice may be required

194 Training

Documented evidence regarding training to demonstrate commitment, compassion and evidenced by feedback from patients and families

Demonstrate improved compliance with PADRs Demonstrate improved compliance with mandatory and statutory training.

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195 Staffing

Ward nursing managers to have supervisory capacity – not to be office bound or expected to double up as part of nursing provision except in emergencies

Impact on variable pay/ establishment review May aid compliance with standards and PADR’s, mandatory, statutory compliance and nursing on ward rounds

262 Mortality rates RAMI information to feed into DMT and Q&PS meetings Need to ensure we can access regularly

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