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["Employee","Hierarchy key"]
["Paul Hancock [E01094]","[HK004699] ISO15189"]
["Alyson Bryant [E01321]"]
["Elaine Boyd [E01649]"]
["Stephen McLaughlin [E01696]"]

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["Reference","Recommendation ","Action Planned/Delivered","Timescales ","Progress ","Responsible ","Monitoring Arrangements","Task & Finish Group"]
["5 (page 24 – Governance & Assurance)","Ensure that the CCN Service is supported in developing effective relationships with pathways of care developed to enable all relevant services to work together successfully","Fully embed the transforming continuing care outcomes ensuring there is an agreed corporate lead.","2022-04-01","Update March 2022 - Awaiting first data group(24/03) meeting to approve                       Update May 2022 - outcome measures approved                                                                            Update July 2022 - Corporate lead confirmed as Director of Nursing","HON/Corporate Team ","Monitor via assurance meetings and feedback from families.","Data Group"]
[null,null,"Support CCN team to develop partnership forum to encourage joint working","2022-03-01","Update February 2022  awaiting confirmation of staff side attendance at future meetings.       Update March 2022 - still awaiting, further email sent to staff side chair                       Update  April 2022 - staff side rep confirmed to attend workforce meeting - action completed","HON ","Record of notes taken and action log.","Workforce Group"]
["34 (page 66- The Views of the CCN Team)\n\n\n\n\n\n\n","Ensure a compassionate leadership model is in place and that the HB demonstrates its recognition of the significance and value of this service","Temporary new leadership now in place – need to continue to work collaboratively with staff and develop a sustainable leadership structure for the future.","2022-04-01","Head of Nursing in post January 8th 2022.                                       Update March 2022 -awaiting decision on business case at BCAG on 31st March               Update May 2022  - Separate finance meeting arranged for 27th June 2022- trying to bring forward further\nUpdate July 2022 - CYP service are reviewing  the current care packages to identify specific staffing requirements link to the funding of each package                                                      Update Oct 2022 - confirmation that part of the business case has been supported         Update January  2023 - key posts out to advert update March 2023 - appointments into key posts made\n","HON/Divisional Manager/NPTSSG","Staff and user feedback and contribution to action plan.","Workforce Group"]
[null,null,"Workforce & Development team to provide a bespoke training/awareness for the Team to include compassionate leadership training for all leaders/managers within the Division in order to embed a compassionate culture. ","June 22 \n"," Update April 2022 - only 2 dates provided for the HCSW's - approx 25% of the staff attended The registered staff have not recieved any training days due to staffing constraints     Update May 2022 - new dates being organised - aim to complete for all staff by Oct 1st 2022    Update July 2022 - 100% registered staff completed OD session. 25 % of HCSW's has completed the OD training day                    Update October 2022 - additional bank staff have been appointed to support packages which will assist in supporting the training.  update Nov 2022 - dates booked for December to progress training                                            Update Jan 2023 - one training session held Jan 2023, 2nd day cancelled due to service pressures - new date tbc                                   update February 23 further dates to be agreed update March 2023 - further 8 staff attended with an additional date being planned       Update April 2023 - current compliance now at 81%                                                                         Update July 2023 - Final date to achieve >85% being planned","HON Divisional Manager/NPTSSG Workforce Team and HB OD Team ","Staff Evaluation Feedback. Monitoring Feedback from users of the service.","Workforce Group"]
[null,null,"Ensure the continuing care services have a reporting and monitoring structure at a division and corporate level and agreed escalation pathway. ","Completed August 2021 for Division. December 2021 for corporate reporting.","Divisional reporting system in place               New guidance includes escalation of concerns Monitoring of progress against the improvement plan is via the HB  Q & S Committee ","Group Nurse Director/Divisional Manager/HON","Reporting to CYP divisional business and updates via NPTSSG Children's Community Improvement Group. (CCIG).","Data Group"]
["23 (page 51 - The Culture of Care) ","Develop robust pathways for communication and service delivery with adult community services as well as acute paediatric services. ","Monthly transition meetings to continue with any potential delays or concerns regarding transition to reported via the Divisional Business Meeting and escalated to the nominated HB lead for CC.","Completed December 2021","Completed December 2021 ","Lead Nurse for Children's Continuing Care ","Number of escalated concerns.","Data Group"]
[null,null,"Identify a link Children's Community Nurse for acute paediatrics to assist with pathways of care. ","Completed August 2021","Community Nurse now avaialable for the inpatient wards  to discuss referrals Completed August 2021","Community Matron","Monitor number of acute paediatric referrals","Workforce Group"]
["1 (Page 12-Purpose and Methodology)","Consider whether additional work is undertaken to seek and capture the views of the families of the cohort of children that transferred to Cwm Taf Morgannwg UHB during 2019","Families under the Continuing Care Service to be contacted by letter with invitation to engage in feedback session.","Completed 17 th November 2021.","Completed 17th November 2021","Head of Patient Experience, Risk and Legal Services ","Copy of letter","Patient/ Parent engagement group"]
["2 (Page 12 - Purpose and Methodology ","Consider whether to make contact with the parents who wished to participate in the review anonymously but were unable to do so for this review.","Families under the Continuing Care Service to be contacted by letter with invitation to engage in feedback session.","Completed 17th November 2021.","Completed 17th November 2021","Head of Patient Experience, Risk and Legal Services ","Copy of letter","Patient/ Parent engagement group"]
["6 (Page 24- Governance and Assurance)","Ensure that the storage of health care records is in accordance with the HB Policy and allows for access to records for children on the active caseload. ","Develop a SOP for the management of community records including storage of historic notes. ","Completed September 2021","Completed September 2021","Head of Nursing (HON)","Record keeping assurance audits"]
[null,null,"Undertake a review of the records stored and add to the Information Governance Asset Register in collaboration with the HB lead.","Completed September 2021","Completed September 2021","HON ","Asset Register "]
[null,null,"Undertake periodic assurance audits of records to ensure compliance and report to the Division Q&S meeting.","2022-01-01","Delayed until February 2022 due to staff unavailability.                                             Completed  1st march 2022","Deputy Head of Nursing ","Audit findings reported via Division Q&S Group"]
["7 (Page 24- Governance and Assurance) ","Ensure that any future move to online records is managed in line with all legislative, regulatory, national and local policy requirements including consideration of extending the development of the patient portal. ","The Health Board Digital services to develop an app for community records. ","Commenced July 2021\n\n\n","Awaiting final version - end January 2022 the division requested an update - final elements to be agreed and the community team will be meeting again with the digital team.      Update April 2022 - follow up meeting with digital team in March awaiting final nursing assessment programmes to be finalised.      Update October 2022 - programme is being finalised                                                                     Update Jan 2023 - delays due to abscence      update Feb 2023 - team are ready to pilot app  Update April 2023 -  the developer of the app has left the HB this month - this is now on hold whilst a replacement is found.                        Update July 2023 - new appointment by HB is now reviewing the developed app - has already met with the service (delay has been added to risk register)","Digital Services ","Review and evaluation of the system by digital team and users.","Data Group"]
[null,null,"Training on the use of the app to be provided to all community staff when developed.","TBC when system is ready for implementation.","awaiting finalisation of the app ","Digital Services and Practice Development Lead ","Attendance Logs ","Data Group"]
["8 (Page 24 - Governance and Assurance) ","Ensure that the CCN Service continues to report issues/concerns via Datix","The community team to receive governance training to include reporting issues/concerns. ","Completed May 17th 2021","Completed May 17th 2021","WCH Governance Team ","Attendance List and future Datix reports","Workforce Group"]
[null,null,"The Operational Leads to attend weekly multidisciplinary incident review meetings chaired by the HON  or Deputy HON. ","Completed July 2021","Completed July 2021","Deputy HON","Monitoring number of reported incidents and outcomes of reviews","Workforce Group"]
[null,null,"The weekly community huddle to include checking with the HCSW of any issues with any of the continuing care children or their families/carers.","Completed July 2021","Completed July 2021","Deputy/Senior Nurse for Continuing Care/Community Nursing Team","Monitoring of huddle records","Workforce Group"]
[null,null,"All concerns to be logged via the Datix system, reported to the Divisional Core team and investigated in line with PTR regulations ","Completed May 2021","Completed May 2021","HON/All Nursing Staff ","Datix reports","Workforce Group"]
["9 (page 24- Governance and Assurance)","Ensure that concerns and complaints are captured and managed in line with all relevant polices and National Guidance","The Senior Leadership Team to monitor any themes and trends relating to community services","Commenced May 2021","Completed May 2021","HON/WCH Governance Team","Via Quality Safety and Exception reporting","Workforce Group"]
[null,null,"The Division to be involved in review of concerns with the Patient Experience (CRAG Reviews) ","2022-03-01","Update April 2022 - date arranged 6/4/2022 - cancelled until after 19th April.                  Update May 2022 - review completed and feedback provide to the service.","Patient Feedback Team","Outcome report from CRAG review","Patient/ Parent engagement group"]
["14 (Page 41 - The Service Model)","Track the resource provided for the Nurse Assessor posts and ensure it is utilised in line with the requirements of the WG Policy Guidance with the correct expertise, knowledge and skills in place to perform this function","The Leadership team to review the current nursing establishment to ensure there is adequate resources for the Nurse Assessor role. This should include benchmarking with other  HB's","2022-02-01"," Update March 2022 -awaiting decision on business case at BCAG on 30th March 2.       April 22 update - feedback received that business case  delayed until 13th April 22 due to request for further information.                                   Update May 2022 - Separate finance meeting arranged for 27th Jun - trying to bring forward further                                                                               Update July 2022 - CYP service are reviewing  the current care packages to identify specific staffing requirements link to the funding of each package                                                       Update Sept 2022 - confirmation of partial support for the business plan given ( division awaiting final details)                                       Update Nov 2022 - Nurse assessor post supported - going out to advert                    Update Jan 2023 - awaiting recruitment process to be completed                               update February 2023 - interviews planned update March 2023 - appointment made with May 2023 start date","HON ","Report to CYP Divisional Business Meeting","Workforce Group"]
[null,null,"A Specific Nurse Assessor job description to be developed.","2022-02-01","Job Description completed January 2022,  Update March 2022 -awaiting decision on funding                                                                       Update July 2022 - LD Assessor post approved, awaiting approval for general childrens assessor.                                                                Update October 2022 -general nurse assessor JD completed and approved ","Deputy HON","Via Job Evaluation Team","Workforce Group"]
[null,null,"Succession Planning for this specific role to be included in the workforce plans. ","2022-04-01","Update March 2022 - draft workforce plan developed.                                                         Update May 2022 - awaiting final version        Update October 2022 final version completed Update January 2023 - awaiting approval of final draft                                                             update February 2023 - final report to go to divisional business meeting                            Update April 2023 -  awaiting approval - in the meantime key posts have been funded and the majority appointed into.                            Update July 2023 - awaiting final updated version of business plan ","HON","Divisional Workforce Group","Workforce Group"]
["15 (Page 41- The Service Model)","Review the current processes for quality assurance and multiagency decision making to ensure they are managed in line with WG Guidance. ","New guidance to be developed by the service to reflect the multi-agency input and ensure clear governance arrangements incorporating the WG Guidance.","Completed 1st Nov 2021","Completed 1st Nov 2021","Lead Nurse for Continuing Care ","Ratified in CYP Divisional Q&S meeting."]
[null,null,"The Transforming Continuing Care work stream to ensure the guidance is fully implemented across the agencies.","2022-03-01","Workshop to be held with the Health Board and local authorities in February 2022                                                                                Update March 2022 - Update and feedback requested.                                                          Update May 2022   -  no progress                          Update July 2022 - Limited progress with fully implementing the guidance across the agencies - this has been escalated                  update Nov 2022 - limited progress - requires senior HB support                                             Update January 2023 - the HB lead for continuing care transformation board has held a workshop to progress collaborative multiagency working                                   Update July 2023 - Following the Vanguard training held in Feb 2023 a multi agency action plan was developed. There is also a strtegic partnership workshop, to progress partnership working.                                 ","Transformation m Leads ","Transformation monitoring process"]
["16 (Page 41 - The Service Model) ","Ensure that the CCN Service is fully compliant with the HBs Lone Worker Policy ","The CYP Division to review Lone Working practices against the HB policy with involvement of th HB Health and Safety Team. ","2021-12-01","Meeting with HB Health & Safety Lead arranged for 16th December 2021.\nUpdate March 2022  - bespoke guidance developed for approval at divisional meeting.  Update April 2022 - awaiting outcome of workforce business case as this includes evening cover to manage out of hours issue.   Update July 2022 - CYP service are reviewing  the current care packages to identify specific staffing requirements link to the funding of each package.                                                    Update September - 2022 Buddy system established                                                         Update Nov 2022 - confirmation that Band 6 nurse will be appointed to cover 5 til 12mn Update April 2023 -  1wt Band 6 recruited in April and further posts shortlisted with interviews planned for end of May 23                Update July 2023 - awaiting final recuritment of band 6's, the proposed plan is to incrementally implement the band 6 cover at night by January 2024.","Deputy HON and Head of Safety.","Report findings through the Divisional  Health and Safety Group.","Workforce Group"]
[null,null,"A review of the current risk assessments used for each family to be undertaken.","Commenced August 2021","Health and Safety lead for Health Board to review the risk assessment process                                                     Update March 2022 - awaiting a date to plan a review with H&S and the community service. Update May 2022 - awaiting final comments back following community visit by H&S lead. Update October 2022- final risk assessment completed - to go to next Q&S for approval  Update January 2023 - new risk assessment piloted during December 22.                       Update March 2023 - risk assessment approved action completed  ","Dep HON","Review as part of the community assurance audits.","Workforce Group"]
["17 (Page 41- The Service Model)","Consider scope to develop wider HB community management for out of hours and lone working services.","To review the current lone working arrangements with the Health & Safety Team and advise on the future arrangements within the organisation.","2022-05-01","Bespoke guidance developed                                                       Update 7 March 2022 - draft SOP completed awaiting approval at divisional level       Update May 2022 - final approval at worforce meeting May 26th.                                           October 2022 - awaiting final details on business plan resources for out of hours support.                                                                Update Jan 2023 - awaiting recruitment process to finish                                                     Update April 2023 -  1wt Band 6 recruited in April and further posts shortlisted with interviews planned for end of May 23         Update July 2023 - awaiting final recuritment of band 6's, the proposed plan is to incrementally implement the band 6 cover at night by January 2024.","Assistant Divisional Manager/H&S Team/Workforce Team","Report to CYP Division H&S Meeting and NPT &SSG (CCIG).","Workforce Group"]
["21 ( Page 51 - The Culture of Care)","Ensure that the leadership style for the CCN Service is participative, and complies with all relevant HB policies and National Guidance.","Temporary new leadership now in place – need to continue to work collaboratively with staff and service users going forward.","Commenced January 2021","New Head of Nursing commenced Jan 8 2022.","HON/Divisional Manager ","Feedback from staff and families ","Workforce Group"]
[null,null,"The service needs support to strengthen the leadership structure for the future.","2022-03-01","Update March 2022 -awaiting decision on business case at BCAG.                                        Update April 22 -  BCAG on 13th April 22  Interim posts need to be put in place at risk until case is approved.                                   Update July 2022 CYP service are reviewing  the current care packages to identify specific staffing requirements link to the funding of each package                                                     October 2022 - awaiting final details on business plan resources                                      Update January 2023 - Deputy Head of Nursing (DOH) post to be advertised                                           Update April 2023 - DOH appointed awaiting start date","NPTSSG Workforce Team and HB OD Team ","Staff and user feedback.","Workforce Group"]
["24 (Page 51- The Culture of Care)","Ensure that safeguarding is managed and overseen in line with the Wales Safeguarding Procedures","Maintain and monitor safeguarding training compliance within the team.","March 31st 2022","2021/2022 compliance:                       Safeguarding child level 1 - 95.92%\nSafeguarding child level 2 - 83.67%\n","Clinical Nurse Specialist for Safeguarding Children and Young People","Training compliance data.","Workforce Group"]
[null,null,"Ensure all staff are able to respond to safeguarding concerns by discussing at weekly huddles.","Commenced September 2021","Safeguarding concerns now documented and part of the weekly huddles with the team.  ","Deputy HON  ","Record of \"huddles\""]
[null,null,"Ensure there is individual and group safeguarding supervision available and attendance is recorded","Commenced November 2020","Safeguarding supervision plan in place and available.","Lead Nurse for Safeguarding","Attendance records ","Workforce Group"]
["26 (Page 51- The Culture of Care)","Ensure appropriate audit processes for Children and Young People Continuing Care are in place that measure compliance with WG Guidance ","Develop an audit plan to report compliance against the standards in the WG guidance through the existing quality assurance framework.","2022-01-01","February 2020 draft in progress for ratification at divisional Q&S group March 7 2022.                               Update April - assurance audit document for approval at Divisional meeting                      Update May 2022 - assurance audits approved in divisional meeting - now to be included on divisional audit plan","Lead Nurse for Continuing Care ","Audit plan progress to be reported to the CYP Division Q&S Group"]
[null,null,"Report compliance via the monthly reporting template to the Divisional Core management team meetings. ","Commenced August 2021","Commenced August 2021","Lead Nurse for Continuing Care ","Divisional Business Minutes ","Data Group"]
[null,null,"Report compliance via the multi-agency transformation programme.","2022-03-01","No progress yet due to limited progress in the transformation programme                                    Update July 2022 - no progress and it has been escalated                                                               Update Nov - limited progress needs senior HB support                                                           Update Dec 2023 - plans for a workshop to be held early in 2023                                             Update Feb 2023 - the HB lead for continuing care transformation board has held a workshop to progress collaborative multiagency working                                      Update July 2023   Following the Vanguard training held in Feb 2023 a multi agency action plan was developed. There is also a strtegic partnership workshop, to progress partnership working             ","HON","Transformation meeting minutes"]
["27 (Page 51- The Culture of Care) ","Ensure concerns and complaints processes:\n- are managed in accordance with HB and National Policy requirements;\n-responses are appropriate and proportionate with nay sanctions only applied with the agreement of senior HB mangers","Training on governance requirements and concerns and Redress to be provided to the nursing team.","Completed May 2021","Completed May 2021","Service Governance Team","Attendance at session ","Workforce Group"]
[null,null,"All responses to be approved at Head of Nursing/Divisional Manager and Service Group Director Level.","Commenced May 2020","Awaiting a CRAG review date  Planned for April 2022                                                             Update May 2022 - review completed","Service Governance Team","CRAG review outcome report"]
[null,null,"Any disputes between families and the service must be escalated and managed by the Divisional Senior Team.","Commenced August 2021","Completed Reporting via datix and to the CYP senior team ","HON","Divisional Business minutes"]
[null,null,"Escalation of unresolved disputes to be reported to the Service Group Directors.","Commenced August 2021","Completed and now included in the monitoring reports and datix incident reporting system","HON/Divisional Manager ","Communication to the Senior CYP Management Team and recorded via Datix system."]
[null,null,"Monthly Concerns, Redress and Assurance Group meetings with HON/Deputy HON/Divisional Manager ","Commenced May 2020","Awaiting confirmed CRAG -  April 2022            Update May 2022 - review completed","Head of Patient Experience, Risk and Legal Services/Patient Feedback Manager ","CRAG review outcome report","Patient/ Parent engagement group"]
["31 (Page 61 - The Experience of the Children and Families)","Ensure staff are fully aware of the HB Polices and any relevant professional regulatory requirements regarding the use of various social media apps to communicate with each other","Updating to be provided to all staff which includes how to access relevant corporate policies","Commenced June 2021","Completed - August 2021","Practice Development Lead ","Training compliance data","Workforce Group"]
[null,null,"Ensure all staff are compliant with Information Governance training.","2022-01-01","Compliance for IG training February 88%.    Update April 2022 - compliance for 2021/22 - 83.67%","Assistant Divisional Manager ","Training compliance data","Workforce Group"]
["Service Development "]
["10 (Page 41 - The Service Model)","Identify a dataset of key management information related to the CCN Service","The Division to review all community activity including acute and chronic care and develop data collection methods to report and demonstrate the level of community based activity provided.","2022-03-01","Data monitoring task & Finish Group to be established by February 2022 to manage ongoing data                                                       Update May 2022 - until an electronic solution can be agreed the community team will collate activity manually which will be reported via the CYP Divisional Business Meeting.                                                                      Update July 2022 - PIMS + is now being developed                                                                 Update Nov 2022 - data for acute activity to be validated and plans to commence chronic and Cont care activity underway                         Update Jan 2023 - awaiting task & finish group in January to progress this action further        Update Feb 2023 - meeting with data team to plan next steps of data collection                 Update April 2023 - Data collection validation has been undertaken - with further validation for another month planned                          Update July 2023 - further validation of the data collected via pims planned, meeting arranged with ccN's","Assistant Directorate Manager/ Informatics support","Reporting as part of CYP Divisional Performance monitoring","Data Group"]
[null,null,"To review the current datasets used in Primary and Community or Mental Health and LD services to identify agreed reporting levels.","March 31st 2022","Data monitoring task & Finish Group to be established by February 2022 to manage ongoing data                                                         Update July 2022   - division has developed children community specific datasets which will be reportable via PIMS + once finalised ","Assistant Directorate Manager (ADM)","Include as part of the CYP Divisional Performance reporting","Data Group"]
[null,null,"Benchmark with other Childrens Community Nursing teams across Wales to establish reporting systems and compare activity.","March 31st 2022","Data monitoring task & Finish Group to be established by Febuary 2022 to manage ongoing data                                                          Update May 2022 - action delayed                     Update October 2022 - CYP services in SBUHB have shared the learning  with Continuing care services across Wales.SBUHB  Baseline assessment tool shared and it was agreed that learning  and benchmarking exercises can be undertaken via the All wales Group. SBUHB will contribute to the benchmarking. ","Deputy HON","Include as part of the CYP Divisional Performance reporting","Data Group"]
[null,null,"Consider options such as Patient Involvement Group, in line with families wishes following disclosure of CCN report.","2021-01-01","Patient/Parent Engagement Task & Finish group - booked for 23 March letters sent to families with update and request for involvement.                                                        Update May 2022 - development of group underway with support from Corporate engagement Team                                             Update October 2022 - plan to await the   follow up review to re- ask families how they wish to engage with the service                      Update Jan 2023 -      letters to the families being sent by the external reviewers requesting they provide an update on their experience of the team.                                update Feb 2023 - reviewers have started to re meet with families                                           update April 2023 - the final report from the follow up review is expected by June 23.      Update July 2023 - report recieved - need to consider how to further involve parents.","HON/Head of Patient Experience, Risk and Legal Services","Report feedback from families once sessions have taken place","Patient/ Parent engagement group"]
["11 (Page 41- The Service Model) ","Consider whether the current skill mix and staffing establishment is sufficient to meet the demands placed upon all elements of the service including stepping down service including if a child is no longer deemed eligible for Continuing Care ","Undertake a review of the current activity across the community nursing service and assess the staffing requirements to manage the caseloads.","2022-02-01","Data monitoring task & Finish Group to be established by February  2022 to manage ongoing data - first meeting March 24 2022.    Update July 2022 - PIMS + under development to cpature community activity                             Update Nov 2022 - data for acute activity to be validated and plans to commence chronic and Cont care activity underway                           Update Jan 2023 - awaiting task & finish group in January to progress this action further     Update Feb 2023 - meeting with data team to plan next steps of data collection                Update July 2023 - further validation of the data collected via pims planned, meeting arranged with ccN's","Deputy HON","Report back to CYP Divisional Business Meeting","Data Group"]
[null,null,"Consider recruitment plans for the nursing team including opportunities for rotational posts into the secondary setting ","2022-05-01","To be managed via the Workforce Task & Finish Group in February 2022 meeting. Update March 2022 - draft workforce plan developed.                                                              Update July 2022 - workforce plan completed and awaiting final approval.                              Update Nov 2022 - rotational posts in place - new appointments commenced into the Team. Workforce plan complete and finalised.","HON","HON/Matron Minutes","Workforce Group"]
[null,null,"Liaise with adult services to consider the option for some staff to transfer to adult services when the young person transitions if appropriate.","2022-01-01","To be managed via the Workforce Task & Finish Group in February 2022 meeting. Update March 2022 - workforce group agreed this would not be progressed due to ongoing staff constraints within the team and unlikely to happen routinely due to the majority of staff likely to want to remain in Childrens Services therefore action closed nfollowing discussion at divisional meeting.","HON","Report to Divisional Business meeting and NPTSSG (CCIG).","Workforce Group"]
[null,null,"Benchmark with other Childrens Community Nursing services in wales on staffing levels.","2022-02-01","Update March 2022 - feedback requested from other HB's across Wales - limited information back to date.                                                              Update October 2022 - CYP services in SBUHB have shared the learning  with Continuing care services across Wales. SBUHB  Baseline assessment tool shared and it was agreed that learning  and benchmarking exercises can be undertaken via the All wales Group. SBUHB will contribute to the benchmarking. ","Deputy HON","Report to CYP Divisional meetings","Workforce Group"]
["18 (Page 41- The Service Model) ","Explore alternative options to deliver more flexible and timely care including a review of the bank and agency processes","Work with Bank Services to look at the expected activity and demands on the service and explore the prospective of using agency staff when there are staff shortages or new packages requiring commencement.","2022-04-01","To be managed via the Workforce Task & Finish Group in February 2022 meeting. Update March 2022 - due to significant staffing pressures this needs urgent support from Bank.                                                                      Update May 2022 - the future plan to support the service from bank & agency to be included in workforce paper as there are signifciant limitations with this option to support care packages.                                                              Update October 2022 - facebook recruitment for the bank has successfully identified a number of staff who are currently recieving training and will be avaialble to support the service by Nov 2022.","HON/Bank Manager ","Report to the Divisional Business Meeting and NPT & SSG (CCIG)","Workforce Group"]
["19 (Page 41 - The Service Model)","Explore a multiagency approach to develop local pathways agreed and jointly owned by the HB and its partners","Fully embed the transforming continuing care pathways and monitor via the Quality Assurance meetings.","2022-04-01","Update July 2023 - Following the Vanguard training held in Feb 2023 a multi agency action plan was developed. There is also a strtegic partnership workshop, to progress partnership working.","HON","Transformation Monitoring meeting records"]
["25 (Page 51 - The Culture of Care)","Ensure the skill mix model of 24-hour service delivery is reviewed with benchmarking models across other HB's in Wales ","Review the current staffing rosters and establishments - with particularly attention to registered nurse availability out of hours.","2022-04-01","Update March 2022 - draft workforce plan developed. Awaiting outcome at BCAG for staffing resource business case on March 31st. Update May 2022 - a separate finance meeting is planned for July 2022                                       Update July 2022 CYP service are reviewing  the current care packages to identify specific staffing requirements link to the funding of each package                                                    October 2022 - awaiting final details on business plan resources for out of hours support - band 6 nurse post supported     Update Jan 2023 - awaiting recruitment process to finish                                               Update Feb 2023 first of the Band 6's appointed                                                            Update April 2023 -  1wt Band 6 recruited in April and further posts shortlisted with interviews planned for end of May 23            Update July 2023 - awaiting final recuritment of band 6's, the proposed plan is to incrementally implement the band 6 cover at night by January 2024.","HON/Service Group Director ","Report to CYP Divisional Business Meeting and NPT & SSG","Workforce Group"]
[null,null,"Benchmark existing community nursing staffing models in other HB's across Wales.","2022-04-01","no progress due to limited responses from other HB's in May 2022 the lessons from SBUHB external review were presented at the All Wales CCN forum                                                Update October 2022 - CYP services in SBUHB have shared the learning  with Continuing care services across Wales. SBUHB  Baseline assessment tool shared and it was agreed that learning  and benchmarking exercises can be undertaken via the All wales Group. SBUHB will contribute to the benchmarking. ","Support from Workforce Business Partner/Rostering Team","Divisional Business Meeting and NPT &SSG","Workforce Group"]
["30 (Page 61 - The Experience of the Children and Families)","Ensure the leadership of the CCN Service is one which is participative and continues to engage with families","Establish formal and informal mechanisms for user engagement and actively  encourage participation.\n- Involve users and their families in any service development.\n- Actively seek involvement in any guidance or parent information development.\n- Invite users and families to be involved in appointments of staff into the team.\n- Provide opportunities for regular formal and informal feedback on the services their children receive.","Commenced January 2022","January 26th meeting held with a Patient Engagement Specialist to advise on developing an engagement strategy.\n\nPatient/Parent Engagement Task & Finish Group established March 2022.                        Update May 2022 - CYP Division have met with Corporate engagement team to look at the developing an engagement plan for CYP and in particularly bespoke work with the cont care families.                                                                  Update July 2022 - draft engagement plan presented at task and finish group - proposed date to write to parent/families to inivite them to be involved is October 2022            Update August 2022 - the Exec Director of Nursing & Head of quality & Safety have confirmed with the external reviewers that the planned follow up review of the services will take place in October 2022. This means that the engagement events will wait until after the reviewers have spoken to the families and staff. Draft proposal for the 'follow up review' has been prepared for the HB to finalise and approve.                           Update Feb 2023 - reviewers have stated to re meet with families                                            update April 2023 - the final report from the follow up review is expected by June 23.        Update July 2023 - report recieved - need to consider how to further involve parents.","HON/Patient Experience Manager ","Report to CYP Divisional Business Meeting and NPT & SSG Children's Community Improvement Group ","Patient/ Parent engagement group"]
["32 (Page 66 - The View of the CCN Team)","Ensure a more streamlined process in place to link the CCN's with their team of HCSWs to ensure appropriate delegation, competence and assurance mechanisms are in place","Ensure each HCSW has a registered nurse identified as their line manager to support development and manage performance.","2022-01-01","Completed ","HON","Copy of communication sent to each HCSW confirming line manager.","Workforce Group"]
[null,null,"Ensure the record keeping audits include monitoring the documented care against the individual care plans.","2022-01-01","Audits completed by community registered nursing team.","HON","Audit Reports"]
[null,null,"Identify a process for registered staff to undertake regular reviews of the care provided by the HCSW including observational visits at night.","2022-02-01","Workforce paper awaiting approval includes a Band 6 post to support this action.           Update April 22  - business case going BCAG 13th April. Interim posts need to be put in place at risk until case is approved.                                   Update May 2022 - seperate finance meeting planned for July 22                                               Update July 2022 CYP service are reviewing  the current care packages to identify specific staffing requirements link to the funding of each package                                                      Update October 2022 - awaiting final details on business plan resources for out of hours support - Nov 2022 confirmation Band 6 post to be support for out of hours. Recruitment to commence however Band 4 supernumary post to support Band 3 HCSW's out of hours is currently not agreed                                        Update Jan 2023 - awaiting recruitment process to finish                                                       Update Feb 2023 first of the Band 6's appointed - back out to advert for others       Update April 2023 - Closing date for additional band 6's ended, interviews planned for end of May.                                                                         Update July 2023 - awaiting final recuritment of band 6's, the proposed plan is to incrementally implement the band 6 cover at night by January 2024.","HON","Observational record sheets","Workforce Group"]
["33 (Page 66 - The Views of the CCN Team)","Review the roles undertaken by the various band of staff and ensure that staff skills and abilities are utilised to their full potential ","Undertaken a review of the roles and responsibilities of the Band 3 and Band 4 staff to ensure staff are working at their banding.","2022-04-01","To be managed via the Workforce Task & Finish Group in February 2022 meeting. Update March 2022 - new Band 4 JD developed which reflects the role differences between the Band 3's.                                    Update July 2022 - Band 4 JD approved - competency framework and training programme being developed                      Update September 2022 - JD's, role descriptors & competency programmes hve been finalised and the first cohort of trainee Band 4's have been appoitmented. Training is linked with swansea University.","HON/Group Nurse Director/Workforce Business Partner ","Report to CYP Divisional Business meeting","Workforce Group"]
[null,null,"Benchmark with other HB's to establish the role descriptors for each of the Band's.","2022-02-01","To be managed via the Workforce Task & Finish Group in February 2022 meeting.        Update May 2022 -   outstanding due to limited information from other HB's            Update October 2022 - the HB has progressed with the role descriptors and training programmes with HCSW training leads and Swansea University and therefore this action has been closed.","HON","Report to CYP Divisional Business meeting","Workforce Group"]
["Partnership and Engagement "]
["12 (Page 41- The Service Model)","Ensure that working in partnership with parents becomes a fundamental principle applied by the CCN Service","Continue to embed this into the culture by establishing ways to gain the views of the families","2022-01-01","January 26th meeting held with a Patient Engagement Specialist to advise on developing an engagement strategy.            Update May 2022 - Corporate Engagement Team supporting the CYP Division to develop an engagement plan for Cont care families    Update July 2022 - QR code specifically for cont Care families shared with families.     Update October 2022 - Families have options to feedback with CCN's asking key feedback questions at the reviews, use of the QR code and HCSW's providing any feedback from families                                                                   Completed & monitored \n","HON & Patient Experience Manager ","Division patient experience reports","Patient/ Parent engagement group"]
[null,null,"Ensure any views and issues which the HCSW's feedback are acted upon by the named CCN via the weekly huddles ","2021-12-01","Completed and monitored ","HON","Monitoring the huddle record sheets","Patient/ Parent engagement group"]
[null,null,"Plan future assurance monitoring process to incorporate peer review (which could be external to the division) ","2022-01-01","Delayed until an all Wales agreement can be planned.  Update March 2022 - All Wales Peer review is being piloted                                      Update May 2022 - All Wales Forum supporting  peer review of Cont Care assessments                                                            Update Nov 2022 - programme of cases to peer review to be proposed at next All wales meeting. Completed ","HON","Report to NPT & SSG (CCIG)"]
["13 (Page 41 - The Service Model)","Develop a comprehensive \"Parental Agreement\" that sets out the role and expectations of both the HB and the parents working in partnership","New parental agreement to be developed seeking views from families.","Completed first draft Nov 21\nNEXT STEP - parental involvement ","Letters being sent to families by March2022. Awaiting feedback from the families before re- issuing a new parental agreement.              Update May 2022 - due to nil responses from families new agreement to be piloted with each family with a 6 month review process which was agreed in Divisional meeting in May 2022                                                                Completed & monitored","Lead Nurse for Continuing Care ","Monitor feedback from families","Patient/ Parent engagement group"]
["22 (Page 51 - The Culture of Care )","Support the CCN Service in moving to a partnership approach ensuring the \"what matters to me\" requirement is embedded in all processes ","Ensure there is a service wide approach to gaining views and encouraging engagement which needs to be promoted to all staff.","2022-01-01","OD planned sessions for January for the registered and non-registered workforce   Update - April 2022 limited progress made  due to staff shortages and demands on service Update - July 2022 - staff feedback seesions implemented in May which also includes the 'whats the Noise' app for feedback              Update October 2022 - there are systems in place for all staff to provide feedback and engage with service improvements - apps, weekly catch ups, staff huddles and lunch & learn sessions","HON & Patient Experience Manager ","Reporting to CYP Q&S Group and NPT & SSG (CCIG)","Patient/ Parent engagement group"]
[null,null,"Training to be provided to all staff on engagement and the benefits of feedback.","2022-01-01","Awaiting confirmation from the patient feedback team.                                                     Update May 2022 - training video developed to go to CYP Q & S meeting in May 2022 for ratificaton                                                               Update July 2022 - training video shared with training team, advised further work required to include voice overs from children & young people - support requested from the Bay youth                                                                     Update Jan 2023 - training presentation completed and for final viewing at next task and finish group on 19th January 2023.        Update March 2023 - presentation being modified by Childrens Rights Director - will be ready for launching May 2023                             Update april 2023 - trainging to commence May 23.                                                                   Update July 2023 - 3 training session already held ","Patient Experience Manager ","Staff training attendance. Monitoring of parent feedback levels following training.","Patient/ Parent engagement group"]
["IG28 (Page 51 - The Culture of Care) ","When addressing concerns and complaints from a family perspective, ensure:\n-the needs of the child continue to be safely met;\n-that all feedback is timely and appropriate;\n- compassionate care forms the basis of interactions with families regarding concerns and complaints.","Concerns and Redress training to enable the community nursing service to ensure all concerns are responded to in line with the Health Board values and in line with the Concerns and Redress Regulations. Monitoring of compliance to these standards to be reported vi the CRAG reviews. ","2022-03-01","Awaiting a date for a CRAG review to be undertaken.                                                              Update April 2022 - CRAG review completed","Redress Teams and Concerns Assurance Manager ","CRAG review outcome reports","Patient/ Parent engagement group"]
[null,null,"Patient Experience Team and C&YP Service Directors to develop relevant and appropriate feedback questions to monitor and improve services provided. ","2021-12-01","Meeting with Patient Feedback team in December in order to share with parents and staff for their views before commencement of surveys in February 2022.                                 Update May 2022 - QR code with specific feedback questions for parents launched      Update July 2022 - all parents have been given the QR code - to date only one has provided any feedback.","HON/Patient feedback manager ","Sample questions to HON/Deputy HON 8/11","Patient/ Parent engagement group"]
["29 (Page 61- The Experience of the Children & Families)","Consider undertaking engagement events, which includes senior HB representation","The Division to work in partnership with the corporate team to develop an engagement plan.","2022-02-01","  May 2022  Engagement plan developed    Update August 2022 - the Exec Director of Nursing & Head of quality & Safety have confirmed with the external reviewers that the planned follow up review of the services will take place in October 2022. This mean that the engagement events will wait until after the reviewers have spoken to the families and staff. Draft proposal for the 'follow up review' has been prepared for the HB to finalise and approve.                                                               Update Nov 2022 - letters & TOR sent out to all parents in reciept of cont care for their child      Update Jan 2023 -   letters to the families being sent by the external reviewers requesting they provide an update on their experience of the team.                               Update Feb 2023 - reviewers have started to re meet with families                                      Update April 2023 -  review report expected by June 23                                                            Update July 2023 - report recieved - need to consider how to further involve parents.             ","HON/Patient Feedback manager ","Reporting plan at NPT&SSG (CCIG)","Patient/ Parent engagement group"]
["Strategic Planning "]
["3 (Page 24 - Governance & Assurance) ","Consider the most appropriate position for the CCN Service within the HB structure","The Division to work in partnership with the corporate team to agree the future structure of the CCN Service.","2022-01-01","The action to be delayed until wider discussions and consultation has been planned.                                                                    Update May 2022 - no further progress to date October 2022 - HON and Service Directors have a date to meet with the Director of Nursing    Update October 2022 - meeting with Exc Nurse Drector re future structures of Childrens Services across the HB.                                        Update April 2023 -  no further update ","Service Group Director/Service Nurse Director/Executive Director of Nursing/Chief Operating Officer","Provide recommendations to the CYP Divisional Business meeting & NPT&SSG (CCIG)"]
["4 (Page 24 Governance & Assurance)","Develop clear and effective governance arrangements for the CCN Service that includes adequate resource allocation from the governance team","Review the current governance arrangements to ensure there is adequate resources and develop a business case of need if required.","2022-02-01","Division has developed a Clinical Governance Nurse for CYP to support the Quality & Safety agenda - require 0.4 wte additional Band 7 to have a 1.0wte post - part of the business case.  Update May 2022 - 0.6wte clinical governance post to be advertised.                                    Update October 2022 - JD has been job matched and post will be advertised at 0.5wte.                                                                     Update Jan 2023 - awaiting recruitment process                                                                     Update April 2023 - Division has recruited a Band 5 wte governance lead. They will work closely with the division, the WCH Governance team and the service group team","Service Group Director/Service Nurse Director  ","Report findings of review to service Group Directors."]
[null,null,"Communicate reporting arrangements to ensure staff notify the governance team of any governance matters relating to the Children's Community Service","2021-12-01","Meeting with Women and Children Governance Lead - May 2021. Email to remind staff sent on 15th December 2021.","W&CH Governance Team","Evidence of communication and Datix reports."]
["20 (Page 41- The Service Model)","Continue to build upon regional work including multi-agency service planning to address consistent and recruiting gaps in universal and specialist services. To support this the HB should consider sharing the recommendations with LA Partners. ","Undertake a review of the service provision across the region and benchmark with other Health Boards in how they support families.","2022-03-01","Limited progress to date due to lack key appointments into the Community Matron or Deputy Head Head of Nursing post (this post is part of the workforce business case)            .          Update Nov 2022 - CYP services in SBUHB have shared the learning  with Continuing care services across Wales. SBUHB  Baseline assessment tool shared and it was agreed that learning  and benchmarking exercises can be undertaken via the All wales Group. SBUHB will contribute to the benchmarking. ","HON","Report to CYP Divisional Business Meeting.","Data Group"]
[null,null,"The HB to share the recommendations and Executive Summary of the report with the LA partners. ","Completed November 2021 ","Completed ","Head of Patient Experience, Risk and Legal Services","To be added to agenda of Directors of Social Services meeting w/c 15/11/21."]
[]
["* structure for monitoring arrangements \n*the timescales for actions may change dependent on impact of Covid \n"]
[]
["Update to improvement Plan                                                                                                                         "]
["1st Update ","December 15th 2021"]
["2nd Update ","January 18th 2022"]
["3rd Update ","February 2nd 2022"]
["4th Update ","February 7th 2022"]
["5th Update ","March 23rd 2022"]
["6th Update ","April 6th 2022"]
["7th Update ","May 19th 2022"]
["8th Update ","July 5th 2022"]
["9th update ","August 25th 2022",null,"   Progress           "]
["10th Update ","September 1st 2022",null,"completed"]
["11th Update","October 6th 2022",null,"in progress"]
["12th Update ","November 7th 2022",null,"overdue"]
["13th Update ","January 4th 2023",null,"yet to commence"]
["14 th update ","February 23rd 2023"]
["15th Update ","March 30th 2023"]
["16th Update ","May 4th 2023"]
["17t Update ","July 19th 2023"]