RESPONSE TO

RESPONSE TO

RISK & GOVERNANCE REVIEW

MARCH 2005 ~ JANUARY 2006

July 2006

SECTION PAGE NUMBERS

Introduction

The Review

Objectives and Terms of Reference of the Services

Review

Chronology of the Service Review

Validation of the Trust’s initial Risk Assessment on

Anaesthetic and Critical Care Services

Surgery and Accident and Emergency Services

Review

5~6

Inpatient Medical Services Review

6~7

Obstetrics and Gynaecology Services Review

Radiology Services Review

Acute and Community Children’s Services Review

7~9

Risk and Governance Review of Sperrin Lakeland

Trust ~ Final Report

9~11

Corporate Developments in Sperrin Lakeland Trust

11~12

Chronology of key milestones within the Trust

(October 2005 ~ July 2006)

12~13

Action Plan in response to key recommendations

13~14

Performance, Accountability and Monitoring

Arrangements

14~18

Conclusion

18~19

CONTENTS

The Trust has over this past 15 months been subject to considerable detailed review from

a number of external and professional bodies. The review brought to the Trust’s attention

significant deficits in service provision and as a result a set of actions were put in place to

address the deficits. This report details the sequence of events from March 2005, the

specific issues that were brought to the attention of the Trust and the Trust’s response to

these issues.

It is important to realise that this has been an all consuming exercise for Trust staff, its

greatest asset and, without their continued commitment and dedication, the significant

changes that have taken place within the organisation would not have been possible. The

Trust would like to sincerely thank the staff and acknowledge the support and guidance

which has been given by the Clinical Governance Support Team (CGST), the Department

of Health, Social Services and Public Safety (DHSSPS) and the Western Health and

Social Services Board (WHSSB).

During 2004, the Trust undertook an internal risk assessment which identified clinical

governance issues in maintaining anaesthetic and critical care services at Tyrone County

and Erne Hospitals

In early 2005 the Trust commissioned the NHS Clinical Governance Support Team (NHS

CGST) to validate the Trust’s internal risk assessment and perform a comprehensive risk

and governance review of all the acute hospital services within the Trust. The Trust

subsequently requested that community children’s services were included as part of the

review.

The validation exercise, and the report which followed, highlighted deficits in service

provision with associated risk to patient safety. A number of changes took place at senior

management and Trust Board level following the validation of the Trust’s Risk Assessment

by the Clinical Governance Support Team (CGST), along with a set of actions to

implement the recommendations of the review. These changes supported the

development of the core elements of clinical and social care governance with the objective

of placing at the centre of the Trust’s business, patient/client safety high-quality safe care

and the provision of a competent workforce.

A substantial action plan was developed by the Trust to implement the recommendations

of the review and significant progress has been made with the primary aim of ensuring

safe and effective care for patients. To date 79 of just over 200 recommendations have

been fully implemented, with the remainder on the way to completion. The CGST now

recognises that the Trust is a changed and improved organisation with a corporate focus

and increasingly taking control over how it delivers its services.

The Trust has put robust performance management, accountability and monitoring

arrangements in place to ensure the smooth transition of the Trust into the new Western

Area Trust and the continued effective implementation of the action plan to take forward all

of the recommendations of the review. The Trust now considers itself to be in a much

stronger position than prior to the review and places the provision of modern safe services

at the core of its business.

INTRODUCTION

The CGST carried out a Risk and Governance Review in the Trust between March 2005

and January 2006. During the review the team met with 429 people both internal and

external to the Trust. These individuals included professionals, covering a diverse range

of disciplines, and service users.

The review made just over 200 recommendations which required a range of actions by the

Trust, WHSSB and the DHSSPS. The final overview report for all the reviews will be

presented to the Trust in July 2006.

The objectives and terms of reference for the review were as follows:

1) To assess the effectiveness of the Trust’s clinical and social care governance

arrangements including the extent to which the Trust’s clinical and social care

governance strategy has been operationalised across all acute care specialties.

2) To identify and assess service and practice-specific risks and the effectiveness of

current arrangements to manage these risks.

3) To make recommendations and develop a comprehensive action plan.

The Trust developed a comprehensive action plan to take forward the recommendations of

the review.

The review examined the clinical and social care governance arrangements across a wide

range of services provided by the Trust. These included:

Ø Validation of the Trust’s initial risk assessment on

anaesthetics and critical care service.

Published May 2005.

Ø Surgery and Accident and Emergency Services Published August 2005

Ø Medical Services Published November 2005

Ø Obstetrics and Gynaecology Services Published July 2006

Ø Radiology Services Published July 2006

Ø Acute and Community Children’s Services Published July 2006

Ø Risk and Governance Review of Acute Services and

Community Children’s Services for Sperrin Lakeland

Health and Social Care Trust: Final Report ~ to be

presented to Trust Board

Published July 2006

OBJECTIVES AND TERMS OF REFERENCE OF THE SERVICE REVIEW

CHRONOLOGY OF THE SERVICE REVIEW

THE REVIEW

Key Findings:

The report on this area identified issues and made recommendations in relation to the

capacity and capability of the Trust to provide the staff with the skills required for intensive

support of patients. Issues pertaining to the standards and suitability of facilities were also

raised. Based on the recommendations of the report the Trust redesigned its delivery of

critical care services.

Trust Response:

· Level 3 critical care services consolidated on the Erne site ~ March 2005

· Support for the provision of critical care formalised with Craigavon Area Hospital via

telemetry ~ June 2006.

· ALERT training and Early Warning System introduced ~ June 2006.

· Approval of the investment of an additional £700,000 to enhance the workforce,

address the required structural changes, improve information and communication,

and to help meet the training and development needs of the critical care team.

· Closer co-operation developed with Altnagelvin Hospital and with the critical care

services network.

Key Findings:

The report on this area drew attention to the need to realign services and to effect

improvements in the surgical and A&E Services. In August 2005 the Royal College of

Surgeons reaffirmed the concerns identified in the CGST review.

In conjunction with the consultation on surgical and A&E services, the Minister also asked

the Trust to establish the maximum level of safe and sustainable emergency and casualty

services and inpatient medical services that can be provided at TCH

On 19 December 2005 the Health Minister, Mr Shaun Woodward, confirmed the Trust’s

proposal to consolidate:

1) Emergency and major elective surgical services within the Trust on the Erne site as

soon as is practicable, leaving routine elective day surgery at TCH.

2) Full A&E services on the Erne site with the minimum of delay, to ensure that they are

safe and sustainable taking full account of the issues identified in the three reports.

The Trust, has implemented the changes to both surgery and A&E services, effective from

31 March 2006.

Trust Response:

- Appointment of two A&E consultants

- Major capital work at Erne Hospital A&E department, commenced in April 2006 with a

completion date of December 2006

- Appointment of eight nurse practitioners across the Urgent Care and Treatment

Centre and A&E departments.

REVIEW AREA: SURGERY AND ACCIDENT AND EMERGENCY (A&E)

REVIEW AREA: VALIDATION OF THE TRUST’S INITIAL RISK

ASSESSMENT ON ANAESTHETIC AND CRITICAL CARE SERVICES

- Appointment of eight middle grade doctors to the Urgent Care and Treatment Centre

and A&E departments

On the 31 March 2006 an Urgent Care and Treatment Centre opened at TCH and

arrangements to continue inpatient medicine were also put in place. In June 2006 a

Clinical Decision Unit with patients managed by the A&E consultant at TCH was opened to

support the model.

Key Findings:

The review team identified a number of areas for improvement in the provision of some

medical specialty services. The team acknowledged that the changes in surgical and A&E

services would have an impact on the existing service model. The Trust also invited the

Royal College of Physicians to offer advice on a model for delivering modern medical

services to the Trust area.

The Royal College stated that the model of inpatient medicine proposed by the Trust did

not fully conform to College recommendations and emphasised the need for ongoing

monitoring. In developing the model the Trust took account of this advice and will continue

to monitor the service to ensure its ongoing safety for patients.

In December the Minister, in referring to future services at TCH, stated:

“The centre will offer resuscitation and stabilisation for patients in an emergency situation

and the administration of vital drugs following heart attacks. These services will be needed

at Tyrone County until more robust and sustainable, community based life-saving services

can be introduced.

The hospital will continue to meet most of the inpatient medical care needs of the local

population including coronary care. Only very seriously ill medical cases, in particular

those likely to require intensive care services, would not come to Omagh”

Trust Response:

v Secured the agreement of the DHSSPS and WHSSB to proceed with the

implementation of an Urgent Care and Treatment Centre and Clinical Decision Unit

at TCH and to maintain inpatient medicine. These developments are subject to

ongoing monitoring to ensure patient safety and sustainability.

v The Trust has continued to develop protocols to ensure that very seriously ill medical

patients are not brought to TCH.

v Secured support from the Northern Ireland Medical and Dental Training Agency for

the continued placement and employment of junior medical staff.

v Reviewed referral and admission protocols.

v Reviewed and improved out of hours pharmacy.

v Reviewed and improved decontamination arrangements.

v Carried out a specific audit on the small number of patients requiring HDU services at

TCH (3%).

v The Clinical Director is developing/implementing a workforce plan for medicine to

take account of separation from renal medicine and the age profile of the existing

workforce.

v Maintained coronary care services.

REVIEW AREA: INPATIENT MEDICAL SERVICES

v Appointed an architect to enable further re-shape of the physical environment to

commence at TCH.

Key Findings:

The review team found that this service is responsive to the needs of patients. The team

expressed concerns around the modernisation of the service and the sustainability and

maintenance of skills for the workforce.

Trust Response:

The recommendations are currently being addressed by the directorate through the Trust’s

action plan. It is however worth noting that births from 2006/7 are projected to be between

1200 and1300 annually. Planning for a fifth consultant is currently underway for this

service.

Key Findings:

The review team found this service to be modern, responsive, of high quality and did not

identify any significant concerns in relation to clinical and social care governance and the

care provided by the radiology service. The review team made some recommendations to

strengthen governance arrangements which are being addressed through the Trust’s

action plan.

Trust Response:

It is worth noting that a new CT scanner facility, at a cost of over £1million, is now open in

TCH and two substantive consultants were appointed to the department in May 2006

giving it a full consultant establishment.

Key Findings:

To complement this review the CGST liaised with the Social Services Inspectorate (SSI) in

relation to child protection issues and as such the findings of their review are taken into

account in the action plan that has been developed in response to the SSI inspection

which to place in January/February 2006.

The review team, although recognising that there were examples of good practice,

identified some issues which they recommended required urgent action. These included:

Ø The need for improved paediatric leadership and advocacy.

Ø The need for consolidation nursing leadership on the children’s ward.

Ø Effective fluid management protocols and procedures.

Ø Effective arrangements for out of hours care for children at TCH and consultant

supervision for the ambulatory day unit.

REVIEW AREA: OBSTETRICS AND GYNAECOLOGY SERVICES

REVIEW AREA: RADIOLOGY SERVCIES

REVIEW AREA: ACUTE AND COMMUNITY CHILDREN’S SERVICES

Trust Response:

· The appointment of a Clinical Director in paediatrics (January 2006).

· A nominated consultant for child protection (April 2006).

· The appointment of a ward manager for the children’s ward with formal mentoring

arrangements negotiated with the Royal Belfast Hospital for Sick Children (June

2006.

· Addressed improvements in relationships/communication difficulties among staff

(January /February 2006)

· The issue around fluid management has been fully addressed and all newly

appointed staff will receive appropriate training by the Trust.

· Significant multi-disciplinary training and awareness sessions in the management of

fluids has taken place. New departmental guidance issued in April 2006 has been

fully implemented. Solution 18 has been withdrawn from all areas where children are

cared for (October 2005).

· The out of hours care for children at the Urgent Care and Treatment Centre has been

improved with the appointment of additional consultants in accident and emergency

medicine bringing senior expertise to TCH.

· Three consultant paediatricians are trained in Advanced Paediatric Life Support

(APLS). Forty-five nursing staff are trained in European Paediatric Life Support

(EPLS) with plans in place to have all staff trained to this standard.

· Destination protocols have been developed to prevent children presenting at TCH.

Those, who present in need of emergency treatment, have protocols for transfer.

· ENT Services will be provided on a day case basis and no child will be treated

overnight at TCH. This will result in children receive ENT treatment on a day case

basis with designated children lists and appropriately skilled and trained

professionals.

· In the exceptional circumstances of a child requiring an overnight stay, arrangements

will be put in place to transfer them to an appropriate paediatric unit. The new

arrangements will be introduced by August 2006.

· The paediatric directorate is supporting the reshaping of ENT services for children

and the Ambulatory Care Unit at TCH.

· The Ambulatory Care services will be developed to ensure that there is rapid access

to consultant opinions and an effective child centred service is provided for the local

community.

· Major refurbishment of the inpatient paediatric unit at the Erne Hospital completed

June 2006.

Since the appointment of the Director of Social Work progress has been made in

implementing the recommendations of this service review and the 185 recommendations

of the SSI inspection of child protection arrangements. Although a separate action plan is

required by DHSSPS for the SSI report it is agreed that this will be incorporated into the

Clinical and Social Care Governance action plan. This is currently being actioned. With

respect to the CGST review, the following specific actions have been taken:

v New Executive Director of Social Work (March 2006)

v Children’s Services Programme established (May 2006)

v Brindley House closed (June 2006)

v Relocation of all children in that facility (June 2006)

v Appointment of Principal Social Worker (May 2006)

SOCIAL SERVICES

v Appointment of Programme Manager (June 2006)

v Development Programme for staff involving

Chief Executive and Chairperson (May 2006)

v Full reporting at Trust Board of all family and child care matters

The implementation of the SSI report ie being taken forward on a western area basis with

formal project planning arrangements now in situ. In relation to the CGST review

initiatives which are inter-related are currently progressing.

The Better Lives for Children project is currently being taken forward, This includes the

promotion and development of integrated working and new management structures for

children’s services, improved communication mechanisms, implementing performance

targets for children’s services and addressing resource requirements for staff, training and

estates. A project, chaired by the Director of Social Work, specifically to promote, across

all directorates, the safeguarding of children is being implemented.

The review team acknowledged how the Trust had, over the past 15, and in particular the

last 9 months, lived through an unprecedented experience of continued scrutiny. The team

recognised that the Trust is now a changed and improved organisation with a corporate

focus and which is increasingly taking control over how it delivers its services.

The Trust now has a stronger involvement of clinicians in decision making, has in place

improved governance arrangements and has made meaningful investment in its staff, its

greatest asset.

While recognising the considerable achievements which the Trust has made, the review

team expressed some concerns in relation to the general medical, emergency and critical

care services at TCH. The review team stated that the service model implemented by the

Trust, and agreed by WHSSB and DHSSPS is not fully consistent with the

recommendations of the CGST and the Royal Colleges of Surgeons and Physicians.

The review team has advised that this model of service delivery should be formally

monitored on an ongoing basis and contingency plans put in place to urgently address any

issues of patient safety identified. The Trust fully accepts this requirement.

The three areas of specific concern highlighted by the review were:

1) Sustainability of the critical care services at TCH in the future.

2) The appropriate care and treatment of patients with life threatening or potentially life

threatening conditions.

3) The out of hours care for children at TCH which included ENT in-patient care.

RISK AND GOVERNANCE REVIEW OF SPERRIN LAKELAND TRUST ~

FINAL REPORT

Trust Response:

Sustainability of the critical care services at TCH in the future.

Ø An Early Warning System introduced in TCH ~ March 2006

Ø ALERT Training is continually ongoing.

Ø Approval of the investment of an additional £700,000 to enhance the workforce,

address the required structural changes, improve information and communication

and to help meet the training and development needs of the critical care team.

Ø Closer co-operation developed with Altnagelvin Hospital and with the critical care

services network.

Ø Carried out a specific audit on the small number of patients requiring HDU services at

TCH (3% of admissions) and will continually monitor the utilisation of the HDU to

assess service sustainability and ensure patient safety.

Ø Telemedicine links in TCH and the Erne hospitals.

Ø Support for the provision of critical care within TCH has been formalised with

Craigavon Area Hospital via telemetry.

Ø Review of anaesthetic/critical care workforce is being carried out with a focus on

cross-site working to ensure skills maintenance.

The appropriate care and treatment of patients with life threatening or potentially life

threatening conditions.

· The Trust has reviewed referral and admission protocols (March 2006).

· The Trust has introduced destination and bypass protocols to ensure surgical

patients are transferred to the appropriate clinical environment (March 2006).

· Protocols developed to ensure the small number of patients who are expected to

require intensive care are not admitted to TCH

· Secured support from the Northern Ireland Medical and Dental Training Agency for

the continued placement and employment of Junior medical staff.

· Clinical Director carrying out a workforce plan for medicine to take account of

separation from renal medicine and the age profile of the existing workforce.

· There is an ongoing audit of coronary care patients.

· There is Trust participation in the Regional Review of Rural Medicine which will

produce standards for inpatient medical units in rural areas. The standards will be

implemented across N. Ireland and will be adopted by the Trust

The out of hours care for children at TCH which included ENT inpatient care.

v Out of hours care for children at the Urgent Care and Treatment Centre has been

improved with the appointment of two additional consultants in Accident and

Emergency medicine who are skilled in handling emergencies

v Three consultant paediatricians are trained in Advanced Paediatric Life Support

(APLS). Forty-five nursing staff are trained in European Paediatric Life Support

(EPLS) with plans in place to have all staff trained to this standard.

v ENT Services will be provided on a day case basis and no child will be treated

overnight at TCH.

v In the exceptional circumstances of a child requiring an overnight stay, arrangements

will be put in place to transfer them to an appropriate paediatric unit. The new

arrangements will be in place August 2006.

v The directorate is supporting the reshaping of ENT services for children and the

Ambulatory Care Unit at TCH.

v The Ambulatory Care services will be developed to ensure that there is rapid access

to consultant opinions and an effective child centred service is provided for the local

community. This will result in children receive ENT treatment on a day case basis

with designated children lists and appropriately skilled and trained professionals.

v A review of Anaesthetic workforce to ensure there are designated anaesthetists for

paediatric lists.

v Preoperative assessment of all children requiring elective surgery.

The final report made a further 11 recommendations to the Trust which have been

incorporated into the overall Trust action plan and will be monitored through the robust

performance and accountability arrangements which have been put in place between the

Trust, WHSSB and DHSSPS.

These have taken place to respond to the overarching management, governance and

organisational matters raised by the CGST.

Controls Assurance

- Controls assurance standards for ‘Risk Management’ and ‘Governance’ for 04/05

have been revisited and rescored

- Actions plans have been developed to address shortcomings identified and evidence

portfolios established for each Controls Assurance standard

- Quarterly progress reports on those actions are completed by the appropriate

functional manager and signed off by the lead director

Risk Management

- The Risk Register for each directorate as well as the corporate Risk Register has

been ’cleaned’ and we have established a departmental directorate and a corporate

risk register

Incident Reporting

- The back-log of incidents reported in May 2005 was cleared by July 2005 and there

has been no recurrence

- A target of 24 hours was set to record all reported incidents since July 2005 and this

has been achieved since that time

- Additional support staff have been deployed to support incident recording

- An on-line version of DATIX has been purchased and a roll out plan is well underway

- Accountable staff can now record on-line actions taken as a result of reported

incident, lessons learned and close the incident

- A monthly incident report is produced and widely circulated. It provides information at

directorate and corporate level

- Incident reporting and response is one of the performance indicators set out in the

balanced score card report, presented monthly to Trust Board

CORPORATE DEVELOPMENTS IN SPERRIN LAKELAND TRUST

Complaints Management

- New internal targets have been set for complaint investigation – 10 working days

- A target of 75% response within 20 working days has been agreed

- Directorate performance is reported monthly on the balanced scorecard

October 2005

- Chief Executive and Chairperson appointed.

- Senior Nurse Development programme for senior nurse managers.

December 2005

- Appointment of Director of Nursing

January 2006

- Appointment of Non-Executive Directors

February/March 2006

- Business Case for Acute Hospital approved at Trust Board

- Appointment of Director of Human Resources.

- BAMM training for senior professional leaders.

- LEO Leadership programme for ward manager and team leaders.

- Reconfiguration of surgical and A&E services

- Successful international recruitment for A&E/UCTC middle grade doctors.

- Regained financial control £1.8 million to working break-even.

- Director of Nursing assumes executive responsibility for governance.

April 2006

- Appointment of Director of Social Services

- Trust Corporate Plan launched.

- ICT DBS OBC 1 Services in the Trust approved

May 2006

- Appointment of Head of Clinical and Social Care Governance.

- Trust Board approval of new Clinical and Social Care Governance Directorate and

structure.

- First meeting of the newly established Clinical and Social Care Governance

Committee.

- Appointment of Principal Social Worker (Quality Assurance).

- Introduction of new appraisal system for doctors.

- New performance management and accountability arrangements introduced.

- Establishment of Project Board to take forward the recommendations of the CGST

and SSI reviews.

CHRONOLOGY OF KEY MILESTONES WITHIN THE TRUST ~

OCTOBER 2005 – JULY 2006

- Review of incident reporting and investigation processes.

- Business Case for Local Hospital in Omagh approved at Trust Board.

- First tranche of new corporate nursing policies approved at Trust Board.

June 2006

- New renal physician takes up post.

- Appointment of two substantive consultant radiologists.

- A&E consultant rota introduced.

- Permanent appointment of lead nurses.

- Appointment of social services programme manager.

- Appointment of ward manager ~ Children’s Ward.

- Critical Care Business Case approved.

- Clinical Decision Unit at TCH opened.

- First quarter of financial year break-even position.

July 2006

- The placing of the European Journal advert for the acute hospital has enabled the

commencement of the procurement process.

- Commencement of a Trust Coaching Programme for senior professionals in the Trust

provided through the N. Ireland CSGT.

- Publication of the Risk and Governance Progress Report.

- Multi-disciplinary workshops regarding SSI report recommendations.

An Action Plan was developed by the Trust to implement the recommendations of the

review of anaesthetics and critical care services. Recommendations in subsequent CGST

reports have been incorporated into the action plan. The purpose of the action plan is to

manage, monitor and report on the implementation of all of the recommendations from the

review.

In this regard the plan articulates the:

a) Improvements already made to the effectiveness of governance arrangements within

the Trust both at specialty-specific and corporate levels

b) Process by which the Trust will address and manage key risks in the short and

medium term.

c) How the Trust will ensure the delivery of high quality and safe services to the

population of Fermanagh and Tyrone in the longer term.

The recommendations from all of the service reviews have been collated into the action

plan with the responsibility for implementation being assigned using a model which has

identified five key areas/main groups.

Key Areas/Main Groups:

1) Surgery

2) Medicine

ACTION PLAN IN RESPONSE TO KEY RECOMMENDATIONS

3) Children’s

4) Support Services

5) Senior Management Team

To date 79 recommendations have been fully implemented by the Trust with progress

being made on the remainder. Where progress has already been made against

recommendations, this has clearly been detailed in the plan. Where work still needs to be

progressed, the deliverables have been identified for each recommendation.

The Trust has, over the past number of months, committed to developing a new system to

ensure effective internal performance management and accountability arrangements. The

new system is used to ensure that regional targets and objectives for health and social

care delivery are transferred into meaningful local objectives for the Trust. This

methodology has proved extremely helpful in the implementation of the Trust’s action plan

for the recommendations of the CGST and the SSI reviews.

Throughout this period the Trust has reported to the Strategic Change Management

Group, a group comprising of Trust representatives, DHSSPS, WHSSB, CSGT, N. Ireland

Ambulance Services and Western Health and Social Services Council.

The Trust has put in place a formal monitoring process with active participation from

DHSSPS and WHSSB. This process will ensure that the recommendations of the review

will continue to be delivered during the period of transition to the Western Area Trust.

The Chief Executive has instigated a process of formal performance management and

accountability to ensure the effective delive ry of safe services for patients. This process

includes:

Ø Monthly performance and accountability meetings with each director and the

designated clinical lead ~ governance is a standing item on the agenda.

Ø The respective person with lead responsibility updates the Chief Executive on

progress on the action plan and each Directorate provides a summary of progress to

the Clinical and Social Care Governance Committee, which in turn is reported at

Trust Board.

Ø The Head of Clinical and Social Care Governance has overall responsibility in

conjunction with the respective clinical or Senior Management Team director for

ensuring timely progress is made against implementation timescales for the

recommendations of the action plan.

Ø The Trust has established a group chaired by the Head of Clinical and Social Care

Governance to oversee the implementation of the action plan.

Where there are issues that militate against progress, these are also highlighted at the

performance and accountability meetings, Clinical and Social Care Governance

Committee and Trust Board. Through this the Trust Board has assurance of robust

arrangements for effective performance management of which governance is integral, with

clear lines of accountability.

PERFORMANCE, ACCOUNTABILITY AND MONITORING

ARRANGEMENTS

These processes and systems will enable the Trust to provide assurances of progress

against the action plan to the Western Board as its commissioner and to the DHSSPS. In

addition:

The Trust will provide a copy of the update report developed for Trust Board, on a

monthly basis, to the DHSSPS and WHSSB.

v The Trust will communicate on a quarterly meeting with the DHSSPS and WHSSB,

both to facilitate the monitoring of progress made against the action plan and to

inform them of any services developments needed to ensure the continued focus on

patient safety.

v The Trust, through the continued monitoring arrangements, in conjunction with

relevant stakeholders will ensure that steps are taken to ensure patient safety at all

times.

The Trust will not shirk from its obligation to continue to make recommendations, decisions

and take action as appropriate to ensure patient safety is at the core of its business.

The monitoring processes will be particularly important under the Review of Public

Administration as the three Trusts in the Western Board area merge to form the new

Western Area Trust. The N. Ireland Clinical Governance Support Team has provided

support and guidance during the period of review across a number of fronts. This

arrangement will continue and the relationship will be developed in the future to assist with

the further implementation of the action plan and the development of staff leadership

capacity within the organisation.

The key elements of the Trust’s performance management and accountability

system are made up of the following

1. The setting of clear, Trust wide, realistic but challenging targets and objectives within

our Corporate Plan, covering the eight key areas of our work including services

delivered in hospital and community settings, sound governance arrangements,

financial management, improved performance, ensuring a skilled workforce, effective

leadership and management and the maintenance and development of facilities and

equipment (Figure 1).

The Trusts monitoring arrangements look at ’perspectives’ on organisational performance

outcomes and select a range of indicators that can be used to show progress from a:

¨ Financial Perspective

¨ Governance Perspective

¨ Service User Perspective

¨ Staff Perspective

¨ Activity and Targets Perspective

Figure 1

Performance Framework and examples of the types of indicators used to measure

progress

2. Translating those objectives and targets into operational plans for each of our four

service delivery Directorates or Divisions and the Senior Management Team which

are monitored on a monthly basis at the Chief Executive’s accountability reviews.

3. Allocated those activities and sub -tasks to Accountable Officers to be achieved within

given timescales.

4. Setting out the commitment of Support Services Directorates and special projects to

enabling agreements, again assigned to Accountable Officers that will aid the

achievement of service delivery objectives (Figure 2).

Trust Directorates and Relationships (Figure 2)

Finance

Directorate

Planning/Business

Support

Directorate

Human Resources

Directorate

Support

Services/Facilities

Management

Directorate

Developing Better

Services &

Special Projects

ISD, ICATS…

Acute Services

Directorate

Children’s

Directorate

Adult MH and

Disability

Directorate

Elderly and

Primary Care

Services

Directorate

Corporate Objectives and

Targets

CORPORATE PLAN

Enabling Agreements

Operational Plans

Governance

& Professional Accountability

5. The presentation of measurable progress on achievement using the Balanced

Scorecard tool to show how one area of work links with or impacts upon another

(Figure 3).

Corporate Plan 2006/07 – Key Themes (Figure 3)

6. Ensuring the progress and achievements of Accountable Officers, and the Trust

collectively, is subject to appraisal and review.

These processes and systems set out the basis for the Trust Performance and

Accountability Framework which is designed to ensure the effective and efficient delivery,

and sustainability, of services and provide an open and transparent performance reporting

system.

The Trust services have, over the past 15 months, been subject to considerable detailed

review from a number of external and professional bodies. The extent of the scrutiny has

been without precedent in Northern Ireland.

The review brought to the Trust’s attention significant deficits in its service provision. The

Trust has accepted these conclusions and has embarked on a programme of change to

address the matters raised.

It is important to acknowledge that this has been an all consuming exercise for staff and

the organisation alike. Nevertheless, there has been significant progress made in relation

CONCLUSION

to implementing the recommendations of the review, promoting and embedding new

arrangements for Clinical and Social Care Governance, ensuring safe and effective patient

centred care and maintaining public confidence. These improvements will help the Trust to

sustain the momentum for making its services safe and sustainable and support the

proactive management of the transition.

The organisation has taken ownership of the entire process and has demonstrated its

continual commitment to proactively managing the extensive health and social care

agenda along with the quality improvement agenda.

There has been a drive to ensure robust leadership throughout the organisation with the

re-establishment of a Trust Board and an effective Senior Management Team. The Trust

has also facilitated leadership development across all levels of the organisation and is

continuing to invest in further development opportunities for staff. This is paramount in

order to ensure that services, now and in the future, are safe, sustainable and of high

quality and places the Trust in a strong position as it becomes part of the new Western

Area organisation.

The Trust considers it is now in a stronger position than prior to the review and has the

ambition to embrace the continual change necessary to provide modern, safe services to

its population.