SUMMARY REPORT ABM University Health Board
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ABM University Health SUMMARY REPORT Board Quality & Safety Committee Date: 17th August 2017 Agenda Item: 9.1 Subject External Inspections Report Prepared by Huw George, Health Board Risk Advisor, Patient Feedback Team Approved by Hazel Lloyd, Head of Risk & Legal Services Presented by Cathy Dowling, Interim Deputy Director of Nursing & Patient Experience Purpose This report provides the Committee with a summary in respect of activity Decision relating to external inspections and letters from inspectorates for June and Approval July 2017 and an unannounced HIW visit in August. Information X Other Corporate Objectives Healthier Excellent Sustainable Strong A fully Effective Communities Patient & Partnerships engaged Governance Outcomes & Accessible and Skilled Experiences Service Workforce X X Executive Summary The key issues which have arisen since the last report was produced for the Committee meeting are: . The Community Health Council (CHC) has carried out five visits. Two unannounced visits have been carried out by Healthcare Inspectorate Wales (HIW) in Mental Health facilities. Welsh Risk Pool issued a final report regarding Emergency Services in Wales. Correspondence on seven issues has been received from Healthcare Inspectorate Wales. Key Recommendations The Committee is asked to note the attached report. Assurance Framework Monitored through performance meetings between the Unit Directors and Executive Directors. Next Steps Service Delivery Units to ensure that action plans are completed on time and assurance reported to the Executive Directors within the monthly performance meetings. 1 MAIN REPORT ABM University Health Board Quality & Safety Committee Date: 17th August 2017 Agenda Item: 9.1 Subject External Inspections Report Prepared by Huw George, Health Board Risk Advisor, Patient Feedback Team Approved by Hazel Lloyd, Head of Risk & Legal Services Presented by Cathy Dowling, Interim Deputy Director of Nursing & Patient Experience 1. PURPOSE This report provides the Committee with a summary of external inspections and letters received from Inspectorates/Regulators. 2. Abertawe Bro Morgannwg University Health Board Annual Report from Healthcare Inspectorate Wales 2016-17 The Health Inspectorate Wales annual report is attached as Appendix 1. During the year, HIW conducted 39 inspections or visits at Abertawe Bro Morgannwg University Health Board settings. These included: 2 Hospital Inspections 4 General Practice inspections 9 Dental Practice inspections 1 Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) inspection 12 Learning Disability inspections 1 Mental Health Act (MHA) visit 1 Mental Health Unit inspection (follow-up inspection) 9 Death in Custody investigations in the prison services. The inspections conducted within Abertawe Bro Morgannwg University Health Board generally indicate that the care provided to patients is kind, compassionate and is being delivered by committed and enthusiastic staff. There were issues of concern raised during these inspections and investigations. HIW stated that the Health Board generally replied and provided information to HIW in a timely manner. The report also intimates that the ABMU Health Board should reflect on the following:- Issues with maintenance and improvement of clinical environments were identified at a range of settings including hospitals and learning disability residential units. 2 The quality of documentation was cited as requiring improvement in hospital, mental health, dental and learning disability inspections. Evidence indicates that learning from inspections is not effectively shared across the Health Board. The Health Board had issued two local safety notices Health Board wide following the HIW inspections. Nearly a quarter of inspections identified concerns which resulted in the need for HIW to follow its Immediate Assurance process which requires a letter from the Health Board to be received within 7 days providing assurance of actions to be taken. In response to the report a HIW continuous improvement newsletter highlighting the learning and action taken was developed and was issued by the Chief Executive to all staff on 28th July 2017, copy attached as Appendix 2. 3. EXTERNAL INSPECTIONS June and July 2017 Several inspections have been carried out by external bodies within the Health Board since the last report was submitted to the Committee. These are summarised as follows: 3.1 Community Health Council (CHC) Inspections The CHC held five visits in ABMU premises during June 2017. Details of the visits are as follows. Type of Visit Date Area Inspected Monitoring & Patient 16/06/2017 Gynaecology Out Patients Department Experience visit at Princess of Wales Hospital Monitoring & Patient 23.06.2017 Gynaecology Out Patients Department Experience visit at Neath Port Talbot Hospital Monitoring & Patient 16/06/2017 Gynaecology Out Patients Department Experience visit at Singleton Hospital GP monitoring visit 05/06/2017 Manselton Surgery Monitoring & Patient 27/06/2017 Singleton Hospital Assessment Unit Experience visit The feedback available is that the GP monitoring visit was generally well received but that work on the appointment system is required. Detail of other visits has been requested from the Service Delivery Units. 3.2 Healthcare Inspectorate Wales (HIW) Inspections No Inspections were carried out in June. Unnanounced inspection – Taith Newydd and Angelton Wards An unannounced inspection was carried out in July in Taith Newydd and Angelton Wards in Glanrhyd Hospital. Verbal feedback was provided by the HIW Inspections Manager who explained that the visits had taken place as part of their planned 3 programme of work to review mental health services and Mental Health Act monitoring and not as a result of any complaints or concerns raised. The HIW Team confirmed that there were no immediate concerns identified and the visit was described as very positive. A summary of the feedback is set out below: Domain Feedback Mental MHA Team are highly experienced and effective. Health Act Good documentation and IT systems. Monitoring Manual files are in “excellent” order and condition. Clinical staff benefit from the quality of paperwork and support from the team. The Health Board is in “safe hands” due to the work of the team. HIW asked that this feedback be shared with the MHA Team. Quality & General Observations: Patient Positive interactions observed between staff and Experience patients/relatives in all areas Patients & relatives in both Units indicated that they are very happy with care received and approach of staff Environmentally the units are very nice, well maintained and pleasant. Areas for Improvement: Ward 3 had less information for patients/relatives than other areas but it was acknowledged that there was a lot of information available in the concourse of Angleton Long term problem with leaking roof on Angleton. Being appropriately managed by staff today but could be a slipping hazard and needs to be resolved Some of the garden areas need more attention – query raised if there is a scheduled maintenance programme for the gardens Suggestion that the current policy restricting drinks containing caffeine for patients on Cedar & Rowan should be reviewed. Staff explained that this was based on research paper and the link between good sleep hygiene and stimulants. Timing of evening meal at 4.30pm in Taith Newydd may be too early although acknowledged that snacks are available in the evening. Good Practice: HIW acknowledged that they had observed lots of good practice Staff teams in both Units friendly, professional and patient focussed Facilities are modern with single bed rooms, en-suite bathrooms and communal areas 4 In Rowan & Cedar there was a strong focus on activities, planning for discharge. Advocacy arrangements in place. Good access to health care teams to meet physical health care needs in Rowan & Cedar. Good MDT input was evident. Safe & General observations: Effective Both areas have robust arrangements for ensuring safe Care & effective care Committed staff teams Areas for improvement: Patient documentation is comprehensive and of high quality. Treatment plans clear but documentation high in volume as we are using both the MH Measure documentation and Fundamentals of Care documentation – is there an opportunity to streamline. The Vice Chair asked if there were any examples of good practice we could look at but HIW stated that our documentation was amongst the best they had seen. On Rowan & Cedar the ward based treatment plans were detailed and recovery focussed with Community Plans more broad. SALT service provision on Angelton should ideally be increased- currently only 0.5 days per week although advice available by phone and e-mail OT assessments happen in a timely manner but OT input into ongoing care would offer a more rounded patient experience, acknowledged good work of activity co-ordinators. Some long term estates issues on Rowan & Cedar – in particular water damage to bedrooms. Broken locks on kitchen cupboards in Rowan & Cedar meaning that the kitchen itself is locked and thus access restricted. Ward Manager explained that this approach had been agreed at weekly patient meeting. Good Practice Good medication management systems in both units. Clean environments Management General Observations: & Length of stay for some patients too long but Leadership acknowledged that the HB has been pro-active in this area Need to maintain focus on communication with staff on new service models Management structure