Weston Area Health NHS Trust2014.15 Assurance Framework - June 2014

Weston Area Health NHS Trust2014.15 Assurance Framework - June 2014

Board 1 July 2014

Ref / Risk
Reg
Ref / Principal Risk / Existing Key Controls / Possible Sources of Assurance / Results in Assurances on Controls / Gaps in Controls & Assurances / Last Review Date / Exec Lead / Current Risk Score
LH / Cons / Score
1. / STRATEGIC OBJECTIVE: Ensure that people have a positive experience of care, being treated in a safe environment that protects them from harm.
1.1 / N/A / Risk that nurse staffing will not be at the required numbers or skills to deliver safe and dignified care. / E-rostering system.
Nurse rostering policy.
Bank nurse office and system.
Agreed staffing levels for all wards/ departments.
Daily review of staffing on wards.
Use of agency staffing.
Clinical essential skills training at induction and regular update.
Establishment review 6 monthly. / Internal
Nursing resource council meeting monthly
Six-monthly nursing establishment review
Nurse staffing and care sensitive outcome indicators report to Board
Daily Quality Improvement Team situation report
External
Compliance to NQB nurse staffing guidance
TDA dashboard nurse staffing
Patient survey 2012
Staff survey 2013
CQC monitoring
CCG monitoring via ICQ&PMB / IPR may report shows continued improvements in nursing establishment, nurse vacancies and
agency use.
52/48 registered nurse to nursing assistant ratio
Patient survey 2013 Worse than average for enough nurses on duty improved by 6%
Staff survey 2013 statistically significant positive change in % of staff feeling satisfied with the care they give and in top 20% / Control gaps
None
Assurance gaps
None / June 2014 / Director of Nursing / 1 / 5 / 5
1.2 / Corp 10 Corp 42
HR 007
PCD 64 Emer 31 Corp 46 PCD 72
Corp 46
Corp 47 PCD 73 / Risk that medical staffing will not be at the required numbers or skills to deliver safe and dignified care. / Ongoing programme of international fellowship recruitment
Redesigned medical rota to ensure consistent medical cover across the wards.
Introduction of a generic working for the F1 doctors at night with activity coordinated by a clinical night sister
Continued reliance on NHS and Agency Locums
Active participation in BNSSG wide Urgent Care Groups in relation to demand management and health community wide management of emergency flow.
Hospital OOHs Service / Internal
Locum spend
Recruitment monitoring
Risk management and reporting
Workforce review
Weekly ED assurance report to MD&CEO (and monthly to EMG)
CEO Clinical Sustainability Report to Board, May 2014
External
Deanery/GMC review
NHS TDA dashboard doctor to bed ratio / "Trial" work placements for candidates so that we can carry out "on job assessment" with regard to suitability.
Joint posts with neighbouring Trusts being pursued in a number of specialties within the Trust including surgery and dermatology. Review of how particular services e.g. dermatology are delivered locally.
Working with Planned Care to develop a plan that will mitigate the impact of the Core Surgical Trainees removal in August 2014.
Notice provided to Commissioners in relation to Neurology services, active discussion with NBT and CCG regarding both short term and long term actions to mitigate risk to delays in patient care.
Respiratory and Geriatric Consultants now in post
New GP VTS posts in palliative care and acute paediatrics / Control Gaps
National shortage of doctors, both at Consultant and Middle Grade level in Acute Medicine Community Paediatrics
Difficulty in recruiting to consultant dermatology and haematology
Delay in recruitment to colorectal 2nd Locum
Endoscopy capacity under review
Assurance Gaps
Review of on call service with medical staffing at weekends / June2014 / Medical Director / 4 / 5 / 20
1.3 / Corp 40
Corp 38
Corp 45 / Risk that national and local targets for reduction of healthcare associated infection will not be met and compliance with code of practice for the prevention of healthcare associated infection will not be met / Fully established infection control team
Infection control policies and procedures
Infection Control and Health and Safety committee quarterly meeting
Antimicrobial policies
Infection control policies
Infection control training on induction and update
Infection control programme
Infection control risk assessment on admission
MRSA screening programme
Infection control risk register
Decontamination processes in place.
Systems for segregation, handling, transport and disposal of waste in place.
Systems for the preparation, distribution and handling of food are in place.
Systems to ensure acceptable levels of cleanliness in clinical and non clinical areas are in place.
Revised cleanliness monitoring and escalation process.
Hand hygiene improvement plan
Second permanent microbiologist in post
Staff food hygiene training.
Food hygiene policy / Internal
Infection control quarterly report to Quality and Governance Committee
Annual infection control report to Board
Surgical M&M
Quarterly performance meetings with sterile service and waste disposal contractors
Waste Audits
Decontamination Group
Hazard analysis critical point food system (HACCP) managed by facilities department.
Six monthly kitchen inspection. E&FM weekly and monthly performance meetings
Cleanliness audits
Quality Account key priority 2014.15
External
Public Health England monthly surveillance report
Staff survey
Inpatient survey
CCG monitoring via ICQ&PMB
PEAT scores
EHO inspections / Ontrajectory for MRSA,CDiff & MSSA targetsHand hygiene compliance 99.5%
Training compliance 90%
MRSA screening 90%
Staff survey 2013 in top 20% of Trusts for hand washing materials always available
Patient survey 2012 average for hand wash gels for patients and visitors
EHO inspection February 2013 awarded 5 star for hygiene
PLACE audit / Control gaps
Formally established antimicrobial management team currently being established
Frequency of cleanliness auditing to national standards
Paper based surveillance system
Assurance gaps
Limitedcurrent policies to support best practice in Estates and Facilities Management.
Limited review of waste disposal legislation.
Review current food hygiene standards
Limited review of current and applicable DH bulletins, HTMs, HBNs.
Limited assurance from infection control audit of theatres / June 2014 / Director of Nursing
Director of Finance / 3 / 3 / 9
1.4 / Corp 06
Emer 68 / Risk that medication errors will not reduce in number and in severity / Lead Director
AO for Controlled drugs
Lead Pharmacist
Quarterly incident report to Q&GC
Bespoke QIT monitoring in response to risk
DoN and Team review
Medication policy
Medicines management operational group
Drugs and Therapeutics Committee / Internal
Datix reporting
Quality Improvement Team daily situation report
Quality Hub work
Quality Account key priority 2014.15
External
CCG monitoring via ICQ&PMB / Control gaps
Limited regular reporting of trends, risks etc to Drug and Therapeutics (DT) and hence governance still to be established.
Medicines incident policy to be drafted.
Assurance gaps
Limited medical staff involvement in incident review and medicines management operational group / June 2014 / Medical Director / 3 / 4 / 12
1.5 / Corp 51 Emer 73 / Risk that pressure ulcers will not reduce in number or severity / Pressure ulcer policy
Pressure ulcer risk assessment on admission
Pressure ulcer prevention and management pathway
Tissue viability specialist nurse
Equipment – pressure relieving mattresses, cushions and heel protectors
Post of Vulnerable Adults Nurse to support Tissue Viability Nurse (started 01.04.14) / Internal
Datix reporting
Quality Improvement Team daily situation report
Nursing and Midwifery committee report to Quality and Governance committee
Divisional reports to Quality and Governance Committee
Board IPR
Quality Account key priority 2014.15
External
NHS Safety thermometer results
CCG monitoring via ICQ&PMB / May 2014
18 HA grade 2-4 PUs 1 x grade 3 and 0 x grade 4
Safety thermometer new PU rate0.84 / Control gaps
None
Assurance gaps
None / June
2014 / Director of Nursing / 4 / 3 / 12
1.6 / N/A / Risk that falls will not reduce in number or severity / Falls risk assessment on admission
Use of bed rails risk assessment
Falls prevention strategy
Equipment – hi/lo beds and pressure movement tabs
Nursing and AHP leads now in post / Internal
Datix reporting system
Daily governance situation reports
Divisional reports to Quality and Governance Committee
Board IPR
Quality Account key priority 2014.15
External
NHS Safety Thermometer results
CCG monitoring via ICQ&PMB / May2014
57 falls
Rate 7.06/1,000 bed days.
NHS Safety thermometer falls with harm rate 0.42 / Control gaps
None
Assurance gaps
None / June 2014 / Director of Nursing / 3 / 3 / 9
1.7 / Corp 25
Corp 49
Emer 71 / Risk that vulnerable patients will not be adequately safeguarded (adults and children) / Safeguarding policies and procedures
Safeguarding training for staff on induction and update
Named Nurse and Named Doctor for child protection posts
Adult safeguarding leads nursing and medical
Safeguarding audit programme
Safeguarding supervision
Mental capacity and DOLS training
Policies in place
AWP staff on site
ED staff trained
Junior Drs rota training
CPN liaison service / Internal
Safeguarding Committee minutes
Safeguarding committee reports to Quality and Governance committee
Annual safeguarding report to Board
External
Audit South West internal audit report adult safeguarding Feb 2014
CCG monitoring via ICQ&PMB / Mar 2014 training compliance
Adult safeguarding – 93%
Mental capacity act – 31%
DOLS – 31%
Child protection
Level 1 – 86%
Level 2 – 82%
Level 3 – 79%
Audit South West overall rating amber / Control gaps
PREVENT policy and training programme in development
Difficulty in recruitment to Community Paediatrician posts
Impact on statutory requirements for looked after and adopted children
Millenniumlimitations
Assurance gaps
Limited audit of MCA compliance
MCA/DoLs training attendance below target / June 2014 / Director of Nursing / 3 / 4 / 12
1.8 / HR 011
Corp 37 / Risk that patient experience is not listened to or acted on / Patients Council meeting monthly.
Patients’ Council membership of Board and all delegated subcommittees.
Associate Director Governance and Patient Experience is Trust Lead.
Friends and Family Test
Exit cards
Patient experience strategy
Customer care training in place corporately.
Patients Council Quality of Interaction Observation visits
Patient Experience Review Group
Local inpatient survey
Exit survey
Analysis of NHS Choices and website
Twitter feeds / Internal
Patients’ Council activity – interaction observation, patient surveying using CQC caring domain, patient story gathering
Patients Council report to Board
Patient Experience Review Group monitoring and report to Quality and Governance Committee
IPR Board report
Annual complaints report to Board
Quality Account key priority 2014.15
External
PLACE inspection annually
NHS Choices feedback
CQC inspection reports
Healthwatch inspection reports
National surveys
Inpatient survey 2013
Cancer patient survey 2013
Emergency Department patient survey
Chemotherapy inpatient survey
CCG monitoring via ICQ&PMB / FFT promoter score May2014
Wards – 59
ED – 92
Inpatient survey 2012
Better than average 4 questions
Average 42 questions
Worse than average 42 questions
Cancer patient survey 2013
Involved in treatment decisions – 74%
Given name of CNS in charge – 90%
Confidence and trust in Doctors – 89%
Post discharge contact information – 94%
Hospital and community staff teamwork – 68%
NHS Choices 3.5 star rating
Healthwatch report 2013 observations generally positive
CQC inspection against outcomes 1 and 4 June 2013 recommend compliance.
Patients Council Open Evening recruited an additional 5 applicants to membership.
Positive 2013/14 Quality Report statements from Healthwatch and Patients Council re Patient Experience Review Group process. / Control gaps
Large numbers of patient information leaflets requiring updates
Assurance gaps
Limited external monitoring in place / June2014 / Director of Nursing / 2 / 3 / 6
1.9 / Corp 44 / Risk that complaints are not processed within set timescales and to the satisfaction of complainants / Complaints management team
Datix system for monitoring of complaints
Complaints policy
Complaints training on induction
HoN Divisional leadership / Internal
Complaints monthly report
Divisional report to Quality and Governance Committee
Complaints report in Board IPR
Annual complaints report
Quality Account key priority 2014.15
Satisfaction survey.
ADG&PE reviews.
External
Ombudsman referrals and outcomes
National Patient Association Complaints review
Inpatient survey 2012
CQC monitoring
CCG monitoring via ICQ&PMB / May2014
Overall compliance to response times – 73%
Planned Care Division has not achieved the 80% target for 8 consecutive months.
0 complaints referred to Ombudsman
Inpatient survey 2012 average for seeing or receiving information on how to complain
Action plan from redesign session 19.06.14 / Control gaps
HoN difficulty in ensuring responsiveness of key staff
Lack of central records overseen by Complaints Manager
Central guidance and templates and monitoring of the quality of investigations by Complaints Manager newly developed. Satisfaction survey indicating limited confidence in sincerity of response
Assurance gaps
None / June 2014 / Director of Nursing / 4 / 4 / 16
1.10 / Infro 50 / Risk that patients and staff will experience violence and aggression from other patients and the public / Datix reporting
Security policies and procedures
Security contract
Training on induction and update
Policy on enhanced observation of patients / Internal
Health and Safety Committee minutes
Board IPR report staff incidents
External
Staff survey results
Inpatient survey results
NHS Protect Audit and RAG rated work plan overseen by EMG & H&S Committee / 18 staff incidents involving abuse reported in Mar 14
Staff survey 2013 worse than average for staff experiencing violence from patients, relatives or the public
Patient survey 2013 average for patients reporting they felt threatened during their stay by other patients or visitors / Control gaps
Specific training for challenging behaviour patients
Updated acceptable behaviour policies
Assurance gaps
None / June 2014 / Exec Lead for Health and Safety / 4 / 4 / 16
1.11 / Corp 38 / Risk that the Trust will fail to manage the health, safety and environmental risks. Minimise risk by having systems in place to meet the requirements of the Ionising Radiation (medical Exposure) Regulations 2000 / Health and Safety Committee
Health and Safety representatives
Health and safety policy
Fire safety policies and procedures
Health and safety and fire training at induction and update / Internal
Health and Safety training compliance (induction and mandatory)
Health and Safety Committee review
Risk management Committee Review
Staff incident reports in Board IPR
Fire safety audits
Health & safety Reps
External
NHS Staff survey
NHS Protect Audit / Staff survey 2013 in best 20% for staff receiving health and safety training in last 12 months
Trust historically attained CNST level 1 / Control gaps
Formal programme of audit not as yet completed (currently behind schedule with 1/3 complete)
Health and Safety risk assessments for capital projects not as yet embedded
Limited Estates policies for contractor management
Assurance gaps
None / June 2014 / Exec Lead for Health and Safety / 3 / 3 / 9
1.12 / N/A / Risk that learning from incidents and never events will not be identified or acted on / Datix system
Daily situation monitoring
Divisional Governance meetings
Weekly SIRI report to CEO/MD /Chair & DoN
Quarterly Safety Bulletin to all staff
Quality Improvement Team risk scoring of all incidents in place from Q3.
Divisional and Team Governance Meetings
Trust wide safety alert
Grade 3 & 4 pu investigators now presenting reports to DoN & Safeguarding Lead / Internal
Weekly review meetings for falls, pressure ulcers led by DoN
Datix reports
Daily sitrep reports
IPR to Board
Quarterly incident reports to QGC
Divisional Governance Reports to Q&GC
PAF reports
External
STEIS database
NRLS reports
CCG monitoring via ICQ&PMB / Staff survey 2013 reported limited communication of changes made / Control gaps
Limited capacity to quality assure investigation and learning from all incidents
Assurance gaps
None / June2014 / Director of Nursing / 3 / 3 / 9
1.13 / Corp 33 / Risk that appropriate systems will not be in place for gathering and evaluating information about the quality and safety of services / Trust Lead AD G&PE
Incident management inc incidents from stakeholders
Risk management
Complaints and PALs management
Clinical audit and improvement
Policy compliance management and report to QGC
CAS alert management and reporting
Executive Walk rounds
Medicines Management
Mortality monitoring
Internal CQC compliance monitoring
Patient Experience Monitoring / Internal
Quality and Governance Committee
Risk Management Committee
Audit and Assurance Committee
Divisional Governance management
Incident reports
Risk register reporting
Complaints reports
PALs reports
Clinical Audit reports
Patient Experience Review Group monitoring
Patients Council monitoring
IPR report to each Board
GTT mortality reviews
Quality Account
External
Audit Southwest review
CQC monitoring
TDA monitoring
DH monitoring via STEIS
CAS alerts monitoring
GP incidents monitoring
Stakeholders incident monitoring
NHS Choices

Mortality data
Complaints Ombudsman
Audit South West
CCG monitoring via ICQ&PMB
NHS Protect Audit / Audit Southwest review of Governance and Risk Management – Green Feb 2014
NPA peer review of complaints – Feb 2014 satisfactory
National Inpatient Survey response rate above National average at 48%
CQC Intelligent Monitoring Report March 2014 Trust in Band 5
GTT currently at 50%
VTE compliance monitoring process revised
90% participation in National Clinical Audits 2013.14
National Cancer Peer Review - positive / Control gaps
Lack of Datix web for risk management
Lack of adherence to annual work plan for QGC
Divisional governance under development
Limited audit of coding of HES data
Assurance gaps
Lack of audit of Mental Health Act compliance
Lack of reporting from Health & Safety programme of Audits
Limited identification of gaps in controls and assurances at Divisional level
Reporting from Quality Hub re National Audit and NICE Quality Standards remains underdeveloped / June2014 / Director of Nursing
Medical Director / 3 / 4 / 12
1.14 / NA / Risk that cost improvement programmes will impact on quality of care / Quality impact assessments protocol
Monthly Executive programme risk review
Programme management through Director of Strategic Development
Monthly business plan review chaired by CEO begun / Internal
Executive Management Group minutes
Quality Account 2014.15
KPIs developed for each CIP
Quality dashboard developed and reviewed by monthly CIP meeting.
External