Agenda item

To consider a report of the Director of Transformation and Governance on issues brought to the attention of the Committee which impact upon the planning, provision and/or operation of health services within Hampshire, or the Hampshire population.

·       Portsmouth Hospitals Trust: Care Quality Commission Re-Inspection

Portsmouth Hospitals NHS Trust: Care Quality Commission Re-Inspection Enforcement Notice – Urgent Care Update

The Chief Executive and representatives of Portsmouth Hospitals NHS Trust, together with the Chief Executive and representatives of Hampshire Clinical Commissioner Group (CCG) Partnership, spoke to the recent Care Quality Commission (CQC) re-inspection report of the Trust (see Item 7 in the Minute Book).

The Chief Executive of the Trust outlined to the Committee the issues arising from the CQC report, which detailed the findings from two inspections that took place earlier in 2017.  The report had made difficult reading for the Chief Executive, who had been in post for only a couple of weeks at the time of its publication, and for the Medical Director who had been in his role for a similar period of time.  However, they both accepted its findings in full, and had worked closely with the Board to take a number of immediate actions, in addition to those taken when the CQC first provided an overview of its concerns post-inspection.

The Chief Executive outlined that a number of actions were being taken by the Trust, and the feedback from staff to date was that they were absolutely committed to addressing the issues at pace, and to providing the best care to patients.  The challenges being faced by the hospital were not new, and those raised in relation to urgent care and flow through the hospital had been communicated previously to the Committee over the past two years.  The Trust accepted that they were not getting their delivery of care 100% right, and were committed to changing this, and making sure that staff were able to meet this challenge.  This was particularly the case in urgent care, where staff had faced an ongoing period of high demand for services, but remained resilient and focused on improvement.

The Chief Executive explained that in his view there were a number of conditions that weren't right in the organisation whilst the inspections took place, and part of his role was to create the right environment in the hospital to ensure that the best care could be provided.  The Trust subsequently had a new quality improvement plan, which had been reviewed and refreshed to ensure it could meet the areas where action needed to be taken.  A first draft of this had been submitted to the CQC and partners on 1 September, and this would be finalised for publication by 31 October.  In the meantime, a Quality Summit would be held with partners and the CQC to review the document, and ongoing engagement work would continue with staff to ensure they understand and can take ownership of the plan. 

There had been a number of leadership changes in the Trust since the inspections were held, and since joining the organisation in July the Chief Executive had been impressed with how colleagues were working collaboratively at a senior level.

The Medical Director was also newly in post but had been a consultant at the Trust for nearly 20 years.  His view was that the situation reported by the CQC was very uncomfortable for staff, but there was a clear sense of commitment from all levels that had at times been quite overwhelming.  It was important that the Board continued to build a strong team to take ownership of the report and its actions.

In response to questions, the Committee heard:

·         That the Trust were currently recruiting to the position of chairman following the retirement of the previous post-holder, and currently this position was held by an interim chairman.  Interviews for this role would be held at the end of September, and the Trust hoped to make an announcement shortly after.  In addition, the Trust had recently recruited new Non-Executive Directors who were better able to hold the Trust to account.

·         The Executive Board was still in a transitional state and would be for the remainder of the year.  Several positions were still held by interim placeholders, and further recruitment work would need to be undertaken.

·         The new Chief Executive was previously the Chief Operating Officer for NHS Improvement and therefore had significant experience of commissioning Board capability reviews.  This tool was usually used for assessing the ability of those who have been in post for a long period of time; the wider issue in the Trust was that many of the Board positions at the time of the inspection were filled by Interim or Acting Board Members, or there were vacant positions.  The Chief Executive would therefore have the ability to recruit individuals to these roles who have the right values and skills, and potentially experience of working for, or with, a provider which had improved despite similar difficulties.

·         That accountability for the day-to-day delivery of acute care in the hospital is with the Chief Operating Officer, and responsibility for aspects of how care is delivered also sits with the Chief Nurse and Medical Director.  Ultimately, the Chief Executive was accountable for how the hospital operates and took responsibility for the findings of the CQC report.

·         That one of the criticisms of the report related to how the Trust cared for patients with mental health issues, and this had been a deep dive element considered by the external review of the Trust’s approach.  This has been a particular focus of the Medical Director, who is the first nominated Executive Lead for mental health in the Trust.  As part of this champion role, the Medical Director held fortnightly meetings to discuss the Trust’s approach to the growing number of people with serious mental health issues attending the hospital, and how the hospital could implement best practice relating to their care 

·         The issues raised in the report around the incorrect recording of serious incidents, and safeguarding and wider governance concerns made troubling reading, and the Trust were taking these very seriously.  These parts of the report highlighted an alarming amount of inconsistency, especially where services were over-stretched or facing high levels of demand.  In response to these findings, the Trust had commissioned an external review of patient management across all vulnerabilities, in order to be absolutely sure of where the issues are and what action needed to be taken.  The aim was to ensure better and more embedded levels of understanding and standards amongst staff than the Trust were previously able to demonstrate.  The Chief Executive felt that the Trust was already able to demonstrate significant improvements in this area already, but there was more to be done.

·         The Chief Executive of the CCG noted that they were reassured by the Board’s acceptance of the CQC report and their commitment to actioning the recommendations. The CCG would be working closely with the Trust, both to be assured as a commissioner that actions are being taken, and as a partner to ensure that the wider health and social care system also assists with the actions to be taken.  A significant amount of work was progressing locally in relation to out of hospital care, which would see more traction in preventing individuals from being referred into acute care, and would improve flow out of the hospital.  It was important that the focus was not just on the internal processes of Trust, but also about what the wider health and social care system can do.

·         One of the benefits of the wide geography covered by the CCG was that lessons could be learnt from the organisation working with multiple hospital trusts, including outstanding Trusts such as Frimley Health, and applying these lessons, where appropriate, to Portsmouth.  The dissemination of best practice across all of the hospitals in Hampshire was a key feature of the Sustainability and Transformation Plan programme.

·         The CCG would be working in three ways to specifically hold the Trust to account.   First, it would be monitoring the Ward to Board culture and requesting assurance that Non-Executive Directors are able to effectively hold the Board to account, which the CCG believed had already developed in a more open and transparent way.  Secondly, the CCG had changed the conditions around contracting, and the Trust now worked to a new aligned incentive contract, which focused on rewarding the right behaviours.  Thirdly, the CCG would be working with partners to ensure that there was the right level of capacity and support in the community.  All of this work was not about trying to implement lots of new initiatives, but was more about getting the basics right.

·         The CCG have given the Trust a contract performance notice, which was in place before the CQC report was published.  This was one of the key focuses of the system wide urgent care delivery board, so some of the issues raised in the report were not of surprise to the CCG.  However, the parts of the report the CCG was not so cognisant of, and found difficult to understand, were the cultural issues around care delivery.

·         The Trust were aware of the need for a culture shift and better ownership by staff of the improvement journey.  The Board had held meetings with staff which had been cathartic, with a spirit of openness allowing concerns to be expressed and emotion to be shown; many staff were upset that they and their colleagues were reported to not be getting it right, but accepted this finding.  The meetings also showed a motivation to get it right, and an energy and enthusiasm to improve both quickly and permanently.

·         The issues raised around bullying and harassment had also been picked up in the staff survey, which was a surprise as the Trust were in the top quartile for staff satisfaction.  Since joining the Trust, the Chief Executive had held a number of engagement sessions with staff, of where some of the feedback received was that staff do not always feel confident enough to, or able to, express concerns about poor care or not following Trust policy.  This was not acceptable, to the Chief Executive, and he would be exploring how he could better encourage candour.

·         The Trust does have a whistleblowing policy, and the Chief Executive wrote a weekly blog to all staff that provided them with his direct contact details should they wish to raise concerns with him directly.  This had already seen a number of contacts

·         The Medical Director had lobbied with the Director of Education to begin a Chief Registrar post in the Trust, which was 50% funded by the Wessex Deanery to enable a split between clinical and management time.  The first Chief Registrar took up the post in August, and met at least once a week with the Medical Director to discuss concerns and upcoming issues.  They had also set up a junior doctor forum, which enabled new doctors to discuss their experiences with their peers, and to confidentially raise concerns they may have about existing practice in the hospital.  This forum recognised that the Trust needed to engage meaningfully in a way that was supportive with junior medical staff, especially as they often are a group that has intelligence from working in other care settings that should be tapped into.

The Chairman thanked the presenters for their honest answers to probing questions, and noted that the Committee would be keen to review the improvement plan of the Trust, and to understand timescales for delivering sustained improvements.  Therefore, the Committee would invite the Trust back to their next meeting, in order to consider this plan in greater detail.

RESOLVED

That Members:

1. Note the Care Quality Commission report and the update from the Trust.

2. Request the Trust’s improvement plan setting out actions to be taken in response to the recommendations of the Care Quality Commission report, once published.

3. Request that the Trust be further invited to the 21 November meeting, in order to present and speak to the improvement plan.

Councillors Alan Dowden, Jane Frankum, Steve Forster, and co-opted member Councillor Trevor Cartwright left the meeting at this point in proceedings.