Action Plan for xxxxx - Ipswich Hospital

Communication Action Plan following CQC Unannounced Inspection (Outcomes 1 & 5)
Green - completed Amber – partially completed/in progress Red – deadline breached
Ref Issue Proposed Action Responsible Lead
1 Communication of findings
to staff on Haughley &
Shotley
Meeting with ward
matron/head matron to
communicate findings
(Shotley and Haughley
ward)
Associate Director of
Nursing (ADoN)
ADoN
Proposed
completion
date
Immediate
Immediate
Actual
Completion
date
23/03/2011
24/03/2011
Comments
Meeting with Haughley ward
WM & HM on 23 rd March 2011
Meeting with SRN & HM
Shotley on 24 th March 2011
Share findings with all
head matrons
Director of Nursing &
Quality (DoN&Q)
Immediate
23/03/2011
Findings communicated to
HM’s on 23 rd march.
2 Communications of findings
to leads for Outcomes 1 & 5
Meet lead for outcome
one
ADoN
31/03/2011
29/03/2011
Meeting held
Meet lead for outcome
five
3 Communications of findings Meeting with GM and
HM for BU 3
4 Trust-wide communication CEO to include in ‘Our
of findings within Trust Week ahead’
5 Communication of findings Share findings with all
WM’s
6 Communication of findings Share findings with all
GM’s
ADoN
07/04/2011
07/04/2011
Meeting held
DoN&Q 31/03/2011 29/03/2011 Meeting held on 29 th March
DoN&Q 04/04/2011 04/04/2011
DoN&Q 25/03/2011 25/03/2011 Discussed at WM meetings
ADoN 01/04/2011 01/04/2011 Feedback provided at HOG.
Action to be distributed to all
1

Ref Issue Proposed Action Responsible Lead
7 Communication of findings Attendance and
presentation of DoN&Q
and TMD at Medical
Staff Committee to
discuss
8 Communication to
complainants raising
complaints as a result of the
publication of the CQC
report
9 Need to manage internal
and external
communication regarding
publication of the formal
report following September
inspection
Development and use of
an appropriate letter
template
Communication plan
required prior to
publication of the
formal report
Proposed
completion
date
Actual
Completion
date
DoN&Q 20/06/2011 20/06/2011
DoN&Q 13/06/2011 13/06/2011
Head of
Communications
26/10/2011
Comments
GMs
Details of revisions
Version 1 25 th March
2011
Version 2 11 th April
2011
Version 3 7 th June
2011
Development of combined compliance plan
Update and creation of specific communication compliance plan
Addition of action point 7
Catherine Morgan
Cath Gorman
Cath Gorman
2

Version 4
Version 5
Version 6
15 th June
2011
22 nd June
2011
19 th October
2011
Addition of action point 8
Update of action point 7
Addition of action point 9
Cath Gorman
Cath Gorman
Cath Gorman
3

Compliance Plan for CQC Unannounced Inspection (Outcome 1 - Privacy & Dignity)
Green - completed Amber – partially completed/in progress Red – deadline breached
Ref Issue Proposed Action Responsible Lead
1 Findings regarding privacy &
dignity – Haughley ward
2 Findings regarding privacy &
dignity on Haughley ward
3 Findings regarding privacy &
dignity on Shotley ward
Immediate action
relating to:
- toileting at the
bedside
- call bells within
reach
- staff attitude
Development of ward
specific compliance plan
Development of ward
specific compliance plan
WM Haughley and
Head Matron
Head Matron – Older
Medicine
Head Matron – Older
Medicine
Proposed
completion
date
Actual
Completion
date
Comments
Immediate 22/03/2011 Meeting with HM & WM to
rectify with immediate effect.
DoN and ADoN visited ward on
day of visit for spot check call
bells and to communicate
immediate action to staff. All
call bells were observed to be
in reach of patients on
inspection.
24/03/2011 24/03/2011 Ward specific compliance plan
developed by HM and
communicated to ward nurses
25/03/2011 25/03/2011 Ward specific compliance plan
developed by HM & WM and
communicated to ward nurses
4 Patients not wearing
appropriate clothing – i.e.
many in hospital nightwear
Increase awareness of
importance of next of
kin/relatives/carers/care
homes providing
clothing for use
Associate Director of
Nursing (ADoN)
31/05/2011 31/05/2011 Discussed at NMB (April
meeting). All care homes to be
written to re addressing need
to provide clothing.
4

Ref Issue Proposed Action Responsible Lead
5 Patients not wearing
appropriate clothing – i.e.
many in hospital nightwear
6 Shared learning of findings
for all ward areas
Increase awareness of
importance of next of
kin/relatives/carers/care
homes providing
clothing for use
Head matrons to
undertake quality
rounds on all areas for
which they are
responsible
Proposed
completion
date
Patient Experience Lead 06/06/2011
Review date
17/06/2011
Review date
30/06/2011
Head matrons 25/03/2011
06/04/2011
Actual
Completion Comments
date
18/08/2011 Leaflet to be trialled on
Haughley and Shotley
encouraging families to bring in
suitable clothing and footwear.
Update 31 st May
Welcome leaflet designed with
clear request for relatives to
ensure that there is sufficient
appropriate clothing provided
for patients to wear whilst the
patient is in hospital and for
discharge from the hospital.
Update 7 th June
Consultation with users
Update 21 st June
Leaflet in production
Update 18 th August
Leaflet completed and in use
25/03/2011 Instruction communicated by
DoN
06/04/2011
Head Matrons Observations
developed for inclusion in QMS
for 2011/12
Update 31 st May 2011
This includes the observation
that patients were
appropriately clothed based
upon clinical condition and
5

Ref Issue Proposed Action Responsible Lead
Proposed
completion
date
Actual
Completion
date
Comments
patient choice.
7 Nurse staffing skill mix /
numbers below that
required at times on
Haughley
8 Patients observed with food
stained clothing
9 Patients observed with food
stained clothing
Haughley ward staff not
to be depleted to
support other ward
areas
Instruction to ensure
any back fill
requirements are made
in a timely manner
Investigate
commercially available
disposable ‘clothes
protectors’
Commence clinical audit
evaluating the use of
three different brands of
‘clothes protectors’
including patients’
experience of use.
DoN&Q
Head Matron
Ward Matron
25/03/2011 24/03/2011 Instruction from DoN sent to
all HM’s for when they are
responsible for Trust Wide
Staffing
Ward matron informed
ADoN 04/04/2011 04/04/2011 Procurement dept sourcing
products.
Update 11 th April
Three brands of product found.
All three products ordered for
evaluation. See compliance
point 8.
ADoN to identify
nursing lead
13/05/2011
Updated –
06/06/2011
01/06/2011 Compliance point 7 to be
noted. Proposed completion
date may be amended
depending in delivery of items.
Update 6 th May
Awaiting delivery of ‘clothing
protectors’.
Developing an audit tool
Update 31 st May
Audit tool developed. All
products now delivered.
Patient Experience Nurse to
6

Ref Issue Proposed Action Responsible Lead
10 Findings regarding privacy &
dignity
Implement immediate
quality reviews on
Haughley and Shotley
Proposed
completion
date
Actual
Completion
date
Comments
lead the audit to ensure that
the most effective product is
selected. This includes the
views of the patients.
Implementation of pilot on
three wards scheduled to
commence 6 th June.
Update 1 st June
Clothes protectors now on trial
on three wards. Evaluation to
be collated by clinical audit
department
Update 18 th August
Variety of the design of clothes
protectors in use dependant on
patient choice as feedback was
that a number of patients
disliked those that looked like
‘bibs’.
ADoN’s 01/04/2011 01/04/2011 Findings and actions logged
and where applicable issues to
be addressed will be added to
the relevant compliance plans
11 Some patients did not have
call-bells accessible for use.
Develop ‘Matrons
Observations’ audit tool
to include accessibility
of call bells
ADoN 12/04/2011 12/04/2011 Included within QMS and will
be reported within the Trust
Board monthly Quality Report.
Haughley and Shotley ward
matrons and senior staff
7

Ref Issue Proposed Action Responsible Lead
Proposed
completion
date
Actual
Completion
date
Comments
undertaking spot audits 3
times per day.
Update 31 st May
Monthly collection of data and
available to staff through QMS.
Trust wide performance in May
was 414 out of 423 patients
monitored = 97.87%
compliance.
Update 18 th August
Compliance 98% on monitoring
in July.
Update 26 th September
Compliance 99% on monitoring
in August
Update 19 th October
Compliance 98% on monitoring
in September
12 Patients were being toileted
at the bedside
This is not to be
undertaken unless a
clear risk assessment is
made
Head Matrons 23/03/2011 23/03/2011 Patients with cardiovascular
instability or other risks may
need to be toileted at the
bedside however this must be
clearly justified and
documented.
Discussed at Head Matron
meeting for immediate
communication.
Included in ‘Head Matrons
8

Ref Issue Proposed Action Responsible Lead
Proposed
completion
date
Actual
Completion
date
Comments
Observations’.
Update 18 th August
Compliance 97% on monitoring
in July.
Update 26 th September
Compliance 98% on monitoring
in August.
Update 19 th October
Compliance 97% on monitoring
in September
13 Ward Matron Leadership on
Haughley Ward to be
addressed
14 Some patients were being
put to bed at 6pm for the
night
Place an experienced
WM onto Haughley
whilst ward leadership is
addressed
Ensure that any patients
that go to bed early are
done so for clear
reasons that are
documented. These
include pressure area
relief, patient’s choice,
ADoN 03/04/2011 03/04/2011 WM from another Ward
seconded to Haughley for 4
months
Update 26 th September
Substantive Ward Matron
appointed and commences in
post on 12 th October
Update 19 th October
Ward Matron in post and
undergoing induction to post
and Trust
DoN&Q 31/05/2011 31/05/2011 All staff informed through the
Head Matrons that putting
people to be at such early
times in not acceptable and if
done for clinical purposes or
patient choice, this is to be
documented.
9

Ref Issue Proposed Action Responsible Lead
and elevation of limbs.
Proposed
completion
date
Actual
Completion
date
Comments
E-mail sent to all Ward and
Head Matrons.
Spot audits undertaken by
Head Matrons and reported
within ‘Head Matrons
Observations’.
Update 18 th August
Compliance 99% on monitoring
in July.
Update 26 th September
Compliance 99% on monitoring
in August.
Update 19 th October
Compliance 99% on monitoring
in September
15 Some patients state that
their preference of gender
of staff delivering personal
care not considered
Staff must introduce
themselves to patients
and state that they will
be assisting them with
their personal care.
DoN&Q 31/05/2011 31/05/2011 If there is a cultural problem
with the gender of the nurse
caring then this should be
raised with the ward
coordinator to address.
E-mail sent to all Ward and
Head Matrons.
Implementation to be
observed by Head Matrons
whilst on clinical duties.
10

Ref Issue Proposed Action Responsible Lead
16 Some patients state that
they were not referred to
by their chosen name. This
was also not consistently
documented in the
patient’s records.
Reinforce that the
patients name of choice
is written above the bed
and within the patient’s
records.
Proposed
completion
date
Actual
Completion
date
Comments
DoN&Q 31/05/2011 31/05/2011 The legal name of patients will
be written on all
documentation, however in
the section of the patient’s
choice of name, this will be
completed accordingly.
17 Some staff are reported to
have received little training
on dysphasia, rehabilitation,
privacy, dignity & dementia
Undertake a training
needs analysis establish
training programmes
Senior Nurse for
Dementia Care & Adult
Safeguarding
E-mail sent to all Ward and
Head Matrons.
Implementation to be
observed by Head Matrons
whilst on clinical duties.
30/04/2011 30/04/2011 Training needs analysis
completed April 2011. The
Trust is currently actively
recruiting into a Band 6
Dementia Care Trainer.
Interviews scheduled w/c 20 th
June.
Dementia training plan
developed identifying current
position and levels of training
required by staff groups.
Dementia champion The
training programme will be
competency based, these
competencies are based on
the HIEC developed
competencies. The training
11

Ref Issue Proposed Action Responsible Lead
Proposed
completion
date
Actual
Completion
date
Comments
programme commences with 3
day training 12 th & 13 th July &
project presentations on 18
Oct 11(commissioned from the
Alzheimer’s Society).
Update 1 st July 11
A Dementia Care trainer has
been appointed with expected
start date 15 th August 11 on a
1yr fixed term contract.,
The appointment of a
Dementia Care Pathway Lead
to work across Ipswich.WSH &
Community who will also have
responsibility for Dementia
Care trainers across the three
sites.
Dignity study day held on 14 th
June for HCAs that included
Dementia awareness, Falls,
Patient & Carer stories,
Alzheimers Society helpful tips,
Learning Disabilities awareness
and Dignity.
Update 19 th October
Presentations of project work
undertaken by Dementia
Champions presented to Trust
Management , chair of IH User
12

Ref Issue Proposed Action Responsible Lead
Proposed
completion
date
Actual
Completion
date
Comments
Group and Alzheimer’s Society.
Key learning to be identified
and shared within Champion
Forum
18 Patients were being washed
at the bedside
This is not to be
undertaken unless a
clear risk assessment is
made
DoN&Q 31/05/2011 31/05/2011 Patients with cardiovascular
instability or other risks may
need to be washed at the
bedside however this must be
clearly justified and
documented.
E-mail sent to all Ward and
Head Matrons.
Implementation to be
observed by Head Matrons
whilst on clinical duties.
Update 18 th August
Compliance 100% on
monitoring in July.
Update 26 th September
Compliance 98% on monitoring
in August.
Update 19 th October
Compliance 100% on
monitoring in September
13

Ref Issue Proposed Action Responsible Lead
19 Head Matrons not visible
enough to monitor quality
of care and privacy and
dignity on a daily basis
All Head Matrons to
undertake clinical
rounds every day
Proposed
completion
date
Actual
Completion
date
Comments
DoN&Q 31/05/2011 31/05/2011 Communicated by e-mail to all
ward and head matrons.
20 Staff were talking to each
other across patients in
languages other than
English
English is the only
language to be spoken
in clinical areas unless
non-English is being
spoken to patients
requiring interpretation
or as per their choice.
DoN&Q 31/05/2011 31/05/2011 E-mail sent to all Ward and
Head Matrons.
Implementation to be
observed by Head Matrons
whilst on clinical duties.
Update 18 th August
Compliance 100% on
monitoring in July.
Update 26 th September
Compliance 100% on
monitoring in August.
Update 19 th October
Compliance 100% on
monitoring in September
21 Care records of patients do
not include an area to
document individual choice
or preference
Included within new
patient documentation
booklet
Documentation
multidisciplinary group
06/06/2011
Review date
30/06/2011
Review date
20/07/2011
Document remains in
production with training
programme planned
Update 30 th June
Draft finalised and approved.
Now being printed and training
sessions scheduled.
Update 30 June 11
Re-launch of the This is ME for
14

Ref Issue Proposed Action Responsible Lead
22 Music was noted to be
playing in a ward. This was
not necessarily the patient’s
choice.
Patients have a choice
to listen to the free
radio through Patient
Line.
If music is to be played
for therapeutic reasons,
the agreement of all
patients within earshot
must be obtained.
Proposed
completion
date
Actual
Completion
date
Comments
patients with cognitive
impairment
Update 18 th August
Training provided and new
integrated patient record
launched on 1 st August.
DoN&Q 31/05/2011 31/05/2011 E-mail sent to all Ward and
Head Matrons.
Implementation to be
observed by Head Matrons
whilst on clinical duties.
Update 18 th August
Compliance 100% on
monitoring in July.
Update 26 th September
Compliance 100% on
monitoring in August.
Update 19 th October
Compliance 98% on monitoring
in September
23 Confidentiality is
compromised as individual
names are displayed behind
the nurses station on view
to all
Position of
confidentiality to be
clarified with
Information Governance
Manager and Caldicott
Guardian.
ADoN 31/05/2011 31/05/2011 As no patient clinical data is
being displayed this is
considered acceptable.
15

Ref Issue Proposed Action Responsible Lead
24 There is no individual plans
of care in place to reflect if
and how their needs are
being met
25 Staff do not give an
immersion bath or shower
26 No equipment available to
give patients a hair wash in
bed
27 Communication boards
above beds not always
current and relate to the
patient in the bed
MDT Goals based
assessment and
progression within new
documentation booklet.
Patients to be given
choice of bath or
shower and that this will
be provided throughout
the day.
Equipment to be
sourced and ordered.
All staff to be reminded
to ensure that this
board is kept up to date
and wiped clean when
patients discharged to
ensure correct
Documentation
multidisciplinary group
Proposed
completion
date
06/06/2011
Review date
30/06/2011
Review date
20/07/2011
Actual
Completion
date
Comments
Document remains in
production with training
programme planned
Update 30 th June
Draft finalised and approved.
Now being printed and training
sessions scheduled.
Update 18 th August
Training provided and new
integrated patient record
launched on 1 st August.
DoN&Q 31/05/2011 31/05/2011 E-mail sent to all Ward and
Head Matrons.
Implementation to be
observed by Head Matrons
whilst on clinical duties.
ADoN 24/06/2011
Review date
14/07/2011
Update 30 th June
Searches for equipment
currently underway by
Procurement Department
Update 18 th August
Equipment sourced and
ordered for trial of suitability
DoN&Q 31/05/2011 31/05/2011 E-mail sent to all Ward and
Head Matrons.
This information is to be
observed as part of the Ward
Matron’s Observations.
Implementation to be
16

Ref Issue Proposed Action Responsible Lead
information for each
patient
Proposed
completion
date
Actual
Completion
date
Comments
observed by Head Matrons
whilst on clinical duties.
28 Communication boards
above beds not always
current and relate to the
patient in the bed
29 Information leaflets were
not available within the
Stroke Unit for patients and
relatives who have had a
stroke
30 Not all staff receive
feedback from audits and
questionnaires and any
practice changes as a result.
31 Insufficient visitors chairs
available
Redesign Patient Status
At A Glance boards
above bed to identify
individual patient needs
and choices
Leaflets to be provided
within a suitable storage
device
Ensure staff are
provided feedback of
QMS and Meridian
results with associated
compliance plans.
Order additional 250
visitors chairs
ADoN 18/07/2011 18/08/2011 Update 18 th August
Board redesigned and in
Medical Illustration Dept for
design work to be undertaken
Update 26 th September
Currently on draft 3
Update 19 th October
Currently on draft 4 and
learning from dementia
champions projects to be
incorporated
Head Matron, Stroke
Services
Head Matron Older
Medicine & Head
Matron Stroke Services
27/06/2011 27/06/2011
27/05/2011 27/05/2011 Evidenced on Ward staff
update boards.
Discussed at Ward & Head
Matrons Meetings with
DoN&Q on Friday 27 th May
ADoN 31/05/2011 31/05/2011
17

Ref Issue Proposed Action Responsible Lead
32 Visiting hours do not meet
the needs of patients and
visitors
33 Head Matrons reporting
structure currently report
to General management.
34 Inadequate monitoring of
privacy and dignity
standards
35 Improve availability of
dignity training
Extend visiting hours to
3pm – 8pm
Change in managerial
Structure to ensure that
all Head Matrons report
to the ADoNs.
Expand ‘Matrons
Observations’ and ‘Head
Matrons Observations’
audits
Develop and implement
Dignity in Care study
days which is available
to all staff groups
Proposed
completion
date
Actual
Completion
date
DoN&Q 27/05/2011 27/05/2011
Comments
Chief Executive Officer 09/06/2011 09/06/2011 Matron’s report to ADON’s
with a priority focus on quality.
All other workload prioritised
by ADoNs. Immediate
implementation at point of
decision.
Update 26 th September
Head Matrons have reverted to
previous line management but
focus remains on quality
ADoN 30/06/2011 01/07/2011
Clinical Practice
Facilitator team
30 th July 2011 30 th July
2011
Three events to date with 2
further date planned in 2011.
Events currently being
scheduled for 2012.
90 staff have attended first
three events.
Details of revisions
18

Version 1 25 th Mar 2011 Development of Compliance Plan Catherine Morgan
Version 2 11 th April 2011 Update and creation of specific compliance plan for Outcome 1 Cath Gorman
Version 3 6 th May 2011 Update given for outstanding actions Cath Gorman
Version 4 31 st May 2011 Updates given and new actions added (14 – 32) Cath Gorman
Version 5 1 st June 2011 Updates given for action 9 Cath Gorman
Version 6 7 th June 2011 Updates given for actions 5, 21 & 24 Cath Gorman
Version 7 15 th June 2011 Compliance action 33 added Cath Gorman
Version 8 22 nd June 2011 Update given for action 5 Cath Gorman
Version 9 23 rd June 2011 Compliance action 34 added Cath Gorman
Version 10 30 th June 2011 Updates given for actions 21, 24, 26 & 29 Cath Gorman
Version 11 1 st July 2011 Updates given for action point 17 Julie Sadler
Version 12 18 th Aug 2011 Updates given for action points 5, 9, 11, 12, 13, 14, 18, 20, 21, 22, 24, 26, 28, 34 Cath Gorman
Version 13 26 th Sept 2011 Updates given for action points 11, 12, 13, 14, 18, 20, 22, 28, 33 Cath Gorman
Version 14 19 th Oct 2011 Updates given for action points 11, 12, 13, 14, 17, 18, 20, 22, 28
Addition of action point 35
Cath Gorman
19

Compliance Plan for CQC Unannounced Inspection (Outcome 5 - Nutrition)
Green – completed Amber – partially completed/in progress Red – deadline breached
Ref Issue Proposed Action Responsible Lead
1 Findings regarding nutrition
- Haughley ward
Development of ward
specific compliance plan
Head Matron Haughley
ward
Proposed
completion
date
Actual
Completion
date
Comments
24/03/2011 24/03/2011 Ward specific compliance plan
developed by HM & WM and
communicated to ward nurses
2 Findings regarding nutrition
- Shotley ward
Development of ward
specific compliance plan
Head Matron Shotley
ward
25/03/2011 25/03/2011 Ward specific compliance plan
developed by HM & WM and
communicated to ward nurses
3 Findings of CQC relating to
number of drinks provide to
patients
Audit by all ward
matrons on number of
drink rounds provided
by ISS against SLA
Confirmation of SLA for
provision of drinks
DoN&Q 25/03/2011 24/03/2011 Audit took place on 24 th March
all results sent to DoN.
Update 11 th April
19 wards audited
Drinks provided by ISS ranged
from 4 – 5 per day.
Drinks provided by ward staff
ranged from 0 – 2 per day. On
the ward where nurses didn’t
give hot drinks, these were
replaced by nutritional
supplements.
Confirmation of SLA is
provision of at least 7 hot
drinks per day.
20

Ref Issue Proposed Action Responsible Lead
4 Findings of CQC relating to
number of drinks provide to
patients
5 Insufficient opportunity for
patients to wash their
hands before meals
Address deficit in drinks
provision in identified
wards with ISS
Reinforce the
requirement to offer
patients opportunity to
walk to hand washing
basin or use hand wipes
Proposed
completion
date
Actual
Completion
date
Comments
Contracts manager 14/04/2011 14/04/2011 Contract meeting being held
Update 6 th May
Contract meeting held on 14
April. Details of meeting
regarding drinks for patients
shared with HMs and WMs.
ADoN 11/04/2011 11/04/2011 E-mail sent to all Head Matrons
Update 18 th August
Included within Matron’s
Observations. Compliance 99%
on monitoring in July.
Update 26 th September
Compliance 100% on
monitoring in August.
Update 19 th October
Compliance 98% on monitoring
in September
6 Insufficient hand washing
by staff observed
Reinforce hand washing
requirements and
undertake 50% of all
hand washing audits at
patient mealtimes.
DoN&Q 31/05/2011 31/05/2011 E-mail sent to all Ward and
Head Matrons.
7 Failure to use appropriate
aids for eating and drinking
including plate guards,
mats, adapted cutlery
Housekeepers to ensure
available equipment
Head Matron Older
Medicine
18/04/2011 18/04/2011 Orders placed where deficits
identified.
Update 6 th May
Order placed
21

Ref Issue Proposed Action Responsible Lead
8 Failure to use appropriate
aids for eating and drinking
including plate guards,
mats, adapted cutlery &
cups
9 Ward Matron Leadership on
Haughley Ward to be
addressed
10 Communication boards
above beds not always
current and report patients
nutritional assistance needs
Redesign Patient Status
At A Glance boards
above bed to identify
individual patient needs
Place an experienced
WM onto Haughley
whilst ward leadership is
addressed
All staff to be reminded
to ensure that this
board is kept up to date
to ensure correct
information for each
patient
Proposed
completion
date
Actual
Completion
date
Comments
ADoN 18/07/2011 18/08/2011 Update 18 th August
Board redesigned and in
Medical Illustration Dept for
design work to be undertaken
ADoN 03/04/2011 03/04/2011 WM from another ward
seconded to Haughley for 4
months.
Update 26 th September
Substantive Ward Matron
appointed and commences in
post on 12 th October
Update 19 th October
Ward Matron in post and
undergoing induction to post
and Trust
DoN&Q 31/05/2011 31/05/2011 E-mail sent to all Ward and
Head Matrons.
This information is to be
observed as part of the Ward
Matron’s Observations.
Implementation to be
observed by Head Matrons
whilst on clinical duties.
22

Ref Issue Proposed Action Responsible Lead
11 Insufficient documentation
of ongoing monitoring of
nutritional needs
12 Food charts not always
completed
Update documentation
audit to monitor
ongoing assessment and
actions
Redesign Patient Status
At A Glance boards
above bed to identify
patients requiring
completion of daily food
chart
Proposed
completion
date
Actual
Completion
date
Comments
ADoN 01/04/2011 01/04/2011 Included in QMS
documentation audits
ADoN 18/07/2011 18/08/2011 Update 18 th August
Board redesigned and in
Medical Illustration Dept for
design work to be undertaken
Update 26 th September
Currently on draft 3
Update 19 th October
Currently on draft 4 and
learning from dementia
champions projects to be
incorporated
13 Limited choice of food for
patients with special dietary
requirements
Review of food choice
with ISS contractors
Professional Lead to
Dietetics
24/06/2011 18/08/2011 New food menu choice
designed
Update 26 th September
Extra copies of special diet
menu folders supplied to
wards.
Special diet provision being
reviewed against new standard
menu with some additional
choices where available/
appropriate.
New menu launch with a
23

Ref Issue Proposed Action Responsible Lead
14 Insufficient monitoring of
fluid intake and output
15 The assessors did not
observe red stickers or red
trays in use for patients
requiring observation or
assistance with eating and
drinking
16 There was no finger food
available for patients with
Redesign Patient Status
At A Glance boards
above bed to identify
patients requiring
completion of daily
input/output chart
As patients have
reported to have
difficulty with eating
from red trays, red vinyl
anti-slip mats
introduced
Review of food choice
with ISS contractors
Proposed
completion
date
Actual
Completion
date
Comments
mobile stand/roadshow and
use the opportunity to raise
awareness with staff regarding
the special diets available and
ordering process.
ADoN 18/07/2011 18/08/2011 Update 18 th August
Board redesigned and in
Medical Illustration Dept for
design work to be undertaken
Update 26 th September
Currently on draft 3
Update 19 th October
Currently on draft 4 and
learning from dementia
champions projects to be
incorporated
Patient Experience Lead 14/05/2011 14/05/2011 Update 31 st May
Pilot already in place of red
vinyl anti-slip mats. These
have been reported as
favourable for patients in three
wards. Manufacturer no
longer produces this and
therefore currently sourcing
new supplier. In the interim,
red trays to be re-introduced
Professional Lead to
Dietetics
to remaining wards.
24/06/2011 18/08/2011 Update 30 th June
Contract discussions underway
24

Ref Issue Proposed Action Responsible Lead
dementia
17 Poor assessment and
monitoring of patient’s
weight and needs noted
18 Food trolley observed to be
late and meal serving was
rushed
MUST to be completed
within 24hrs of
admission and at least
weekly (or more
frequently when
condition requires)
Monitor timeliness of
food trolley arrival on
ward.
All Head Matrons or
adult wards / depts
Proposed
completion
date
Review date
05/07/2011
Actual
Completion
date
Comments
Update 18 th August
New food menu choice
designed
Update 19 th October
Finger food pilot commences
Monday 24 th October on
Haughley ward
31/05/2011 31/05/2011 E-mail sent to all Ward and
Head Matrons.
This information is monitored
as part of the Ward Matron’s
Observations.
Implementation to be
observed by Head Matrons
whilst on clinical duties.
DoN&Q 31/05/2011 31/05/2011 All ward and head matrons e-
mailed to ensure that reporting
of late arrival of food trolleys is
undertaken immediately. This
has implications for patients
who may have administered
insulin prior to meals.
Contract monitoring team to
include in schedule of
monitoring
25

Ref Issue Proposed Action Responsible Lead
19 Staff left ward despite
patients still requiring
assistance with feeding
20 Main meals and deserts
served at the same time
resulting in the hot desert
being cold by the time the
patient was able to eat it.
21 Head Matrons reporting
structure currently report
to General management.
No staff to leave ward
until coordinator
assesses that all patients
no longer require
assistance
Discuss with ISS
contractors about timing
of distribution of meals
Change in managerial
Structure to ensure that
all Head Matrons report
to the ADoNs.
Proposed
completion
date
Actual
Completion
date
Comments
DoN&Q 24/05/2011 24/05/2011 Discussed at NMB and agreed
that formal decision to be
communicated to all staff.
Professional Lead to
Dietetics
24/06/2011
Review date
05/07/2011
18/08/2011 Update 30 th June
Contract discussions underway
Update 18 th August
Issue addressed.
Chief Executive Officer 09/06/2011 09/06/2011 Matron’s report to ADON’s
with a priority focus on quality.
All other workload prioritised
by ADoNs. Immediate
implementation at point of
decision.
Update 26 th September
Head Matrons have reverted to
previous line management but
focus remains on quality
22 Insufficient support for
patients at meal times
Occupational Therapy
team have staggered
their breaks to enable
support at meal times
Occupational Therapy
Service Manager
23/06/2011 23/06/2011
26

Ref Issue Proposed Action Responsible Lead
23 Inadequate care of patients
at meal times
Development of a multidisciplinary
‘Meal Times
Audit’ tool
Proposed
completion
date
Actual
Completion
date
Comments
ADoN 30/06/2011 30/06/2011 Completed and in place for
commencement on 1 st July
24 Inadequate care of patients
at meal times
Admin staff given
training for feeding of
patients to ensure that
when wards have large
numbers of patients
requiring assistance,
staff can be called upon
to assist
Head of Dementia 31/08/2011 31/08/2011 Completed and in place for
commencement on 1st July
Details of revisions
Version 1 25 th March 2011 Development of Compliance Plan Catherine Morgan
Version 2 11 th April 2011 Update and creation of specific compliance plan for Outcome 5 Cath Gorman
Version 3 6 th May 2011 Update given for outstanding actions Cath Gorman
Version 4 31 st May 2011 Updates given and new actions added (10 – 20) Cath Gorman
Version 5 15 th June 2011 Compliance action 21 added Cath Gorman
Version 6 23 rd June 2011 Compliance action 22 & 23 added Cath Gorman
Version 7 30 th June 2011 Updates given for action points 16, 20 & 23 Cath Gorman
Version 8 18 th August 2011 Updates given for action points 5, 8, 9, 12, 13, 16, 20 Cath Gorman
Version 9 26 th Sept 2011 Updates given for action points 5, 9, 12, 13, 14, 21. Action point 24 added Cath Gorman
Version
10
19 th Oct 2011 Updates given for action points 5, 9, 12, 14 & 16 Cath Gorman
27

Action Plan for Student Education following CQC unannounced inspection of Outcomes 1 & 5
Green - completed Amber – partially completed/in progress Red – deadline breached
Ref Issue Proposed Action Responsible Lead
1 NMC have concerns about
Student Nurses remaining
on placements on Shotley
and Haughley wards in
response to the CQC Report
from March 2011.
Meeting with ward
matrons to discuss
recent events and to
establish feedback
about student
placements and capacity
within Shotley &
Haughley wards
Clinical Practice
Facilitator (CPF) Team
Proposed
completion
date
Actual
Completion
date
Comments
02/06/2011 02/06/2011 Meeting with Haughley ward
WM students on the 01/06/11
Meeting with UCS
02/06/11
2 Concerns have been raised
about the suitability of
student placement on
Haughley & Shotley to meet
educational needs and
provide support for the
students (particularly third
year final placement
students).
Hold meeting with
students currently in
practice on Haughley
and Shotley Ward to
establish feedback on
placement and learning
experience.
CPF Team 01/06/2011 01/06/2011 Students state that they wish
to remain in practice on both
wards and feel that they are
gaining valuable experiences,
with supportive ward staff.
Update 19 th October
Students removed from
Haughley ward on 15 th July
following a meeting with UCS
where students raised further
concerns. Haughley closed as a
placement area until NMC
review in February 2012.
28

Ref Issue Proposed Action Responsible Lead
Place experienced ward
Matron on Haughley
ward.
Associate Director of
Nursing (ADoN)
Proposed
completion
date
31/03/2011
Actual
Completion
date
31/03/2011
Comments
An experienced ward matron
has been asked to transfer to
Haughley ward for six months
to replace the acting ward
matron.
WM is actively updating
Triennial reviews, ensuring
attendance of RNs for Mentor
Updates in line with NMC
requirements.
Update 19 th October
Permanent Ward Matron
commenced on Haughley
ward. Keen to re-open
Haughley as a placement area.
Holds Mentor and Sign-off
Mentor qualifications.
3 Assurance required by
University Campus Suffolk
(UCS)on suitability of
Investment by the Trust
in an increased
Substantive Head
Matron structure within
Older Medicine & Stroke
Services expanding from
1.2 WTE to 1.6 WTE.
Weekly Education Link
Tutor visits to be
implemented in
Director of Nursing &
Quality
CPF Team / UCS
Professional Lead
Feb 2011
Feb 2011
13/06/2011 13/06/2011 Programme of visits
implemented and direct access
to ADoN as required
29

Ref Issue Proposed Action Responsible Lead
educational placements
4 Assurance required by
University Campus Suffolk
(UCS)on suitability of
educational placements
5 Assurance required by
University Campus Suffolk
(UCS)on suitability of
educational placements
6 Assurance required by
University Campus Suffolk
(UCS) on suitability of
educational placements and
meeting educational
standards.
conjunction with CPF
team.
Programme of a
minimum of weekly
visits to Haughley and
Shotley wards from CPF
team implemented.
Ongoing discussion and
support from ADoNs
Further Education
Audits scheduled for
July, September and
December 2011
Proposed
completion
date
Actual
Completion
date
Comments
CPF Team 02/06/2011 02/06/2011 CPF team to visit weekly and
meet with Students /Mentor
and Ward Matrons. All
concerns to be immediately
escalated to ADoN
ADONs 02/06/2011 02/06/2011
CPF Team / UCS
Professional Lead.
July 2011
September
2011
December
2011.
July 2011
September
2011
Educational Audits in both
wards have been achieved and
demonstrate no educational
issues in line with UCS
requirements. Audits carried
out in March and May 2011.
Further audits will take place
to ensure standards are being
met.
Shotley July 2011 by UCS staff
Shotley September 2011 joint
review
Update 19 th October
Haughley not re-audited as
closed to students. Plan to reaudit
prior to the NMC visit in
February 2012
30

Ref Issue Proposed Action Responsible Lead
7 Assurance required by NMC
on suitability of educational
placements and meeting
educational standards.
Joint attendance to
NMC by IHNHST & UCS
Proposed
completion
date
Actual
Completion
date
Comments
ADoN 5 th July 2011 5 th July 2011 Meeting with NMC.
Information requested for
submission to them
Mentor database
Mentor Development Day
Trust Governance Issues
Support from SHA/CWG
Triggers for pulling
students from placements
Feedback loop/audit trail
for Education Audit
Document
Update 18 th August
Meeting with UCS and IHT –
joint decision made to remove
students from Haughley
following combination of
positive and negative
feedback.
Update 26 th September
UCS and IHT have yet to
receive report from the NMC
following review of evidence
and meeting held 5 th July
Update 19 th October
Report received from NMC
31

Ref Issue Proposed Action Responsible Lead
8 Assurance required by NMC
that mentor pool capacity
supports commissioned
student numbers.
Mentor data shared
with allocations team at
UCS to enable a capacity
review.
Link lecturers have
supported with
additional mentor
update sessions to
increase mentor pool by
10%
CPF Team/UCS
Placements Manager &
Allocation team
CPF Team/UCS
Placements Manager &
Allocation team
Proposed
completion
date
July 2011
November
2011
November
2011
Actual
Completion
date
July 2011
October
2011
Comments
with further information
requested.
Update August 2011
Placement meeting held in
August 2011 following removal
of students from Haughley and
opportunity for raising of any
concerns regarding Shotley.
Update 18 th October
71 additional mentors trained
as a result of these sessions
Immediate contact with
Allocations team where
mentor numbers do not meet
NMC standards. This has
resulted in an increase of 15%
of active mentors
Quarterly reviews held
with allocations team to
ensure student support
is available.
CPF Team
August 2011
August 2011
UCS Education audit
documents demonstrate
Whole Time Equivalent of
mentors to reflect true mentor
availability.
Quarterly mentor data
send to County
Workforce Group.
CPF Team
3rd November
2011
18 th October
Routine process which
commenced in September
2010
32

Ref Issue Proposed Action Responsible Lead
9 Assurance required by NMC
of improved Mentor
compliance with Standards
to Support Learning and
Assessment in Practice.
In particular relating to:
inactive mentors on
database
non-compliance with
triennial review
requirements
Ward Matrons
instructed to submit
plan for attendance at
‘Preparation for
Mentorship Module’
during Quarterly
placement reviews
Mentor database
changed to reflect
dormant and live
Mentors .
Ward Matrons
CPF Team
Proposed
completion
date
November
2011
July 2011
Actual
Completion
date
July 2011
Comments
Staff who hold a mentorship
qualification but do not mentor
due to job role or no students
now in dormant section of
database. Data reflects live
mentors compliance with NMC
standards; inactive includes
maternity leave, long term
sickness, awaiting update or
triennial review. Data logged
within 1 week of collection.
Individual Ward Matron
and Head Matrons sent
data outlining
compliance in July 2011
of the mentors within
their areas. Information
reiterated on how to
access mentor updates
and Triennial review
CPF Team/Ward &
Head Matrons
July 2011
July 2011
Additional Mentor update
sessions given on 10th August.
Delivered by CPF team and UCS
lecturer.
CPF team provided
individualised sessions for
areas with large teams.
33

Ref Issue Proposed Action Responsible Lead
documents.
Proposed
completion
date
Actual
Completion
date
Comments
Increased uptake of UCS
Mentor
E-update completion.
CWG Practice Education
Facilitators run Mentor
Support days which includes
Triennial Review completion –
widely advertised in Trust.
Annual update
attendance and
completion of Triennial
Review added to
Business Unit
Mandatory Training
Workbooks for
monitoring of
compliance.
Head & Ward Matrons
August 2011
August 2011
Monthly Compliance report to
be run and sent to Nurse
Education Lead, necessary
action taken and where
appropriate, escalated to
ADoN
Increase availability of
face-to-face mentorship
updates as part of
mandatory training
process.
CPF Team
January 2012
Additional sessions scheduled
into annual manadatory
training programme from
January 2012
34

Ref Issue Proposed Action Responsible Lead
Proposed
completion
date
Actual
Completion
date
Comments
10 Requirement to raise
students awareness of how
to raise concerns and report
incidents and risks
Hold a student
workshop facilitated by
CPF and Trust Risk
Management
Coordinator (RMC) to
discuss risk
management and the
role of students.
CPF & RMC
September
2011
September
2011
Event held on 23 rd September
with 35 students in attendance
11 Widening opportunities for
students to training on
dignity and care
12 Widening opportunities for
students to training on
dignity and care
RMC to undertake work
with UCS in
development of
teaching material for
risk management
Hold a student
workshop facilitated by
CPF team on ‘Dignity &
Care’.
Induction events more
focused to dignity and
the role of students in
ensuring maintenance
of dignity and raising
concerns
UCS / Trust RMC
January 2012
CPF November2011 Event planned for 10 th
November utilising same
format and agenda as the
regular Trust Dignity & Care
training events.
CPF November2011 Event planned for 10th
November utilising same
format and agenda as the
regular Trust Dignity & Care
training events.
35

Details of revisions
Version 1 15 th June
2011
Version 2 30 th June
2011
Version 3 18 th August
2011
Version 4 26 th Sept
2011
Version5 19 th October
2011
Development of Educational action plan
Addition of action point 6
Update of action point 6
Update of action point 6
Update of action points 2, 6 & 7
Addition of action points 8, 9, 10, 11 & 12
CPF
Cath Gorman ADON
Cath Gorman
Cath Gorman
Cath Gorman
Kate Vine & Cath Gorman
36