Quality Improvement Actions Safe care and treatment Governance – – How the regulation was not being met CQC findings Emergency equipment was not consistently check and serviced in accordance with trust policy. Incidents and near misses were not always reported. Staff did not always receive feedback from incidents they reported. Staff did not meet the Trusts target for completion of appraisals. Undertake harm reviews on adults to identify where lessons can be learned or mortality ratios reduced. Improve compliance with Regulation 28 coroner reports for preventing future deaths. Staff working with patients must have sufficient knowledge and skills to care for patients presenting with mental health condition Staff mandatory training and appraisals did not meet hospitals own targets Ensure that staff are assessed and signed off as competent to deliver patient care How the regulations will be met Mandatory training and appraisals will achieve the target percentage A programme to ensure that staff undertake core skills training Learning from Deaths framework is embedded Incidents are correctly reported Areas for Improvement action Outcome Responsible Deadline Assurance /Evidence Current Improvement person Date status Training and Audit of appraisals and All staff have had their Head of 31/3/17 Audit development mandatory training appraisals Organisational Audit to be CSC performance reports numbers All clinical staff have Development completed Amber undertaken their by 30/9/17 mandatory training Improved SLE reporting SLE reported will be Staff will be competent Associate 31/5/17 Sample audit from Datix correctly graded in grading SLE Director Audit to be Amber correctly and will Governance & completed receive timely updates Quality by 30/9/17 on outcomes Learning from deaths Designing and Embedded learning Medical 31/10/17 Audit of deaths from harm implementing a system from harm reviews Director Amber to undertake learning from deaths
Quality Improvement Actions – Safe care and treatment – Governance How the regulation was not being met CQC findings Emergency equipment was not consistently check and serviced in accordance with trust policy. Incidents and near misses were not always reported. Staff did not always receive feedback from incidents they reported. Staff did not meet the Trusts target for completion of appraisals. Undertake harm reviews on adults to identify where lessons can be learned or mortality ratios reduced. Improve compliance with Regulation 28 coroner reports for preventing future deaths. Staff working with patients must have sufficient knowledge and skills to care for patients presenting with mental health condition Staff mandatory training and appraisals did not meet hospitals own targets Ensure that staff are assessed and signed off as competent to deliver patient care How the regulations will be met Mandatory training and appraisals will achieve the target percentage A programme to ensure that staff undertake core skills training Learning from Deaths framework is embedded Incidents are correctly reported Areas for Improvement Improvement action Outcome Responsible person Deadline Date Assurance /Evidence Current status Training and development Audit of appraisals and mandatory training numbers All staff have had their appraisals All clinical staff have undertaken their mandatory training Head of Organisational Development 31/3/17 Audit to be completed by 30/9/17 Audit CSC performance reports Amber Improved SLE reporting SLE reported will be correctly graded Staff will be competent in grading SLE correctly and will receive timely updates on outcomes Associate Director Governance & Quality 31/5/17 Audit to be completed by 30/9/17 Sample audit from Datix Amber Learning from deaths Designing and implementing a system to undertake learning from deaths Embedded learning from harm reviews Medical Director 31/10/17 Audit of deaths from harm Amber
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