The Airedale NHS Foundation Trust will submit Document “K” which informs the Committee of the actions the Trust has taken in response to the Care Quality Commission (CQC) Inspection in March 2017 and the plans in place to ensure sustained improvement.

Recommended –

That the report be received and the Committee note that the Trust Board of Directors will approve the Quality Improvement Plan that will achieve improved care for patients and hence greater compliance at their meeting in October prior to submission to the Care Quality Commission.

(Helen Kelly - 01535 294807)

Previous reference: Minute 48 (2016/2017)

The Airedale NHS Foundation Trust submitted Document “K” which informed the Committee of the actions the Trust had taken in response to the Care Quality Commission (CQC) Inspection in March 2017 and the plans in place to ensure sustained improvement.

The Assistant Director of Healthcare Governance at Airedale NHS Foundation Trust gave a presentation which provided a recap of the CQC Comprehensive Inspection undertaken in March 2016, the outcome of the re-inspection in March 2017 and informed the Committee of the key points from the Quality Report (Appendix 1 to Document “K”).  She tabled the Quality Improvement Plan which had been approved by the Trust’s Board of Directors on 25 October 2017 and was due to be submitted to the CQC.  It outlined the actions the Trust were taking following the identified “must dos” within the report along with quality issues to improve patient care and strengthen compliance with CQC regulations.

In response to Members’ questions, it was reported that:

·         Improved staff morale had been identified from staff discussions with CQC inspectors and from walkabouts on the hospital wards undertaken by Executive team members on a regular basis.

·         Staffing levels and bed capacity were monitored regularly throughout the day.

·         Agency staff were employed and the Trust had a ‘staff bank’ which enabled it to provide and manage temporary staffing to ensure safe levels of staffing were maintained.

·         Reference in  the presentation to ‘improve medicine management’ related to the Pharmacist checking all of a patients existing prescribed medicines to ensure there were no adverse affects of any additional ones.

·         With regards to simplifying reporting structures, the Terms of References for all of the Trust’s Committees were being reviewed to ensure the functionality of each was clear and that staff at grass root levels were aware of the reporting processes.

·         Building in cultural changes within the organisation would take time to embed.

·         A number of actions on the Quality Improvement Plan were due to be completed by 31 October 2017; any outstanding actions to be completed by this date were on track to be delivered on time.

A Member raised concerns about the impact on quality levels due to the increased use of agency staffing.  In response, it was stated that the same agency staff were used and placed on the wards they were familiar with to reduce risks.  Members recognised that this workforce issues affected the NHS nationally.

A discussion took place about internal monitoring within the Trust and it was stressed that there was a greater sense of ownership throughout the whole organisation, e.g. more stringent consideration of complaints received, monitoring their trends and tracking their escalation.

A Member praised the Assistant Director of Healthcare Governance for a clear and thorough report and acknowledged that the Trust had progressed well with the improvements it had made so far; he stressed the importance of this continuing.

The Assistant Director of Healthcare Governance informed Members that the Trust received regular visits from CQC Relationship Managers and that unannounced inspections and mystery shopper visits were also taking place.

Resolved –

(1)  That the report (Document “K”) be received and noted.

(2)  That the Committee expresses its concern about the high level of agency nurses being employed and the continued pressure on staffing.

(3)  That the Committee commends the progress made between the two Care Quality Commission inspection reports and requests a further update, through the Chair, on the Trust Board’s Quality Improvement Plan before the end of 2017.

ACTION: Airedale NHS Foundation Trust