Agenda item

10:15

As requested by the Committee at the previous meeting, the final approved action plans developed by the Oxford University Hospitals (OUH) NHS Trust are attached at JHO6. These are in response to the Care Quality Commission (CQC) Chief Inspector of Hospitals Report which was published on 14 May 2014.

Andrew Stevens, Director of Planning & Information, OUH, will attend the meeting to discuss the detailed action plan and to give an update on progress since the inspection.

As requested at the previous meeting, the Committee had before them the final approved action plans which had been developed by the Oxford University Hospitals NHS Trust (OUH)(JHO6). These were in response to the Care Quality Commission (CQC) Chief Inspector of Hospitals Report which had been published on 14 May 2014.

Andrew Stevens, Director of Planning & Information (OUH) attended the meeting to discuss the detailed action plan and to give an update on progress since the inspection. He was accompanied by Claire Winch, Deputy Director of Assurance (OUH).

Mr Stevens gave a brief overview of his report requesting the Committee to note the two action plans, which had been formally approved by the CQC on 14 August. He also undertook to provide an update on the implementation of the action plans to a future meeting.

In response to a query about the monitoring procedure, Mr Stevens informed the meeting that the intention was not to undertake it as a separate exercise. The action plans would be monitored by the Clinical Governance Committee on a monthly basis. An escalation process was in place so that corrective action could be undertaken, if it is found necessary. To date the Trust was on track with the exception of two which related to recruitment issues.

A committee member asked if staff training would be conducted on an ongoing basis as part of a rolling programme. Mr Stevens responded that a competency training needs analysis had been completed on services across the board and the resulting set competencies had then to be kept up to date. He added that all had their own training menu and these were monitored via performance management processes.

In response to a query about how staff vacancies were advertised and also how much was spent on agency staff, Mr Stevens stated that recruitment and retention was a key issue in the organisation at the moment and staff across the Trusts were trying to be as imaginative as possible in their efforts to re-invigorate the recruitment and retention field.  Initiatives in recruitment packages such as flexible working, career mapping for staff, and overseas recruitment (as a short term measure only) were being established. The key message being given to managers was the importance of retention as well as recruitment.  Expenditure on agency staff was a major cost pressure and the Trust was seeking to prioritise this issue, at the same time ensuring that the quality of care given by agency staff was of a good standard. Mr Stevens stated that, in short, the Trust had to get smarter in relation to how it organised its services and how it developed a workforce to tie in a new pattern of service delivery that was both clinically safe and financially sustainable.

A member asked whether the revisions to the Dementia Strategy would be achievable in light of all the financial pressures the Trust was dealing with. Mr Stevens responded that the Physical medical service now incorporated mental health of which dementia and delirium were key parts. He added that the Trust was party to the multi-agency approach and had been successful in gaining financial support for the Physical ward. The ward had not yet been vacated in order to carry out the upgrade. The Trust was in the process of strengthening its Dementia Strategy which would include a psychological service to ensure all staff picked up possible signs of dementia in patients and a fast tracking service from Accident & Emergency for patients to a more appropriate service. He undertook to send members details of the Trust’s AGM which was focusing on the revised Dementia Strategy.

Mr Stevens was asked if there had been any escalation on the ‘should do’s’ and how was the work on staff inclusion measured. Mr Stevens responded that as the report had only just been signed off, tracking measures had not yet been developed. He added that the key was to listen actively when undertaking staff engagement in order that they could feel empowered to raise problems and hence influence solutions to issues which would ultimately lead to meaningful improvement. A major performance measure was the annual staff survey and there were regular ‘pulse checks’ on a smaller scale to tie in with clinical performance.

A member asked how the Plans would be programme managed. Mr Stevens responded that they were to be built into the existing performance management structures for clinical and general management, in order that the Board could see the overall picture across the organisation and action being taken. He added that quite a few of the completion dates had already been accomplished and it was hoped that all would be achieved by November 2014.

In response to a question, Mr Stevens confirmed that computer records were being monitored more closely and quality processes were in place.

Mr Stevens and Ms Cinch were thanked for their attendance and the Committee

 AGREED to:

(a)  congratulate the Trust on their ‘good’ outcome from the CQC;

(b)  note the action plan developed to address the compliance actions (‘must do actions’);

(c)  note the action plan developed to address the advisory actions (‘should do’ actions);

(d)  note that both action plans were formally approved by the CQC on 14 August 2014; and

(e)  request the Trust to submit an update on the implementation of the action plans in February 2015.