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 NHS Trust: Care Quality Commission Re-Inspection – consideration of action plan

 

·       Southern Health NHS Foundation Trust: Care Quality Commissioner Re-Inspection – update on progress

 

 

The Chairman agreed to take the second issue under Item 7 first.

 

Southern Health NHS Foundation Trust – Care Quality Commission Re-Inspection

 

Representatives from Southern Health NHS Foundation Trust presented a report updating the HASC on the progress of actions relating to the Care Quality Commission (CQC) and Mazars reports (see report, Item 7 in the Minute Book).

 

Members heard that Dr Nick Broughton, the new Chief Executive, had now taken up his post, and a new Chair, Lynne Hunt, was also now in position.  As a result of these Executive roles being filled, Julie Dawes, who had been the Interim Chief Executive, had now returned to the position of Chief Nurse.  The Executive Board felt new, and would take some time to embed.

 

Since this item had last appeared before the Committee, the CQC had undertaken an inspection of the Elmleigh and Antelope House adult mental health units, as a result of information received from whistleblowing.  This inspection had not resulted in the Trust being required to take any actions, although there were some ‘should do’ recommendations which Southern Health would integrate into its action plans.

 

An internal review had been commissioned from Niche Grant Thornton which considered the progress of all of the actions the Trust had needed to implement.  The report gave an ‘A’ to ‘E’ rating of 80 actions, with ‘A’ being the most advanced and ‘E’ the least progressed.  All of the actions had been given an ‘A’ or ‘B’ rating, and the comments received were positive.  Although the report highlighted some areas for improvement, the overall commentary noted that there was now a robust ‘Serious Incident Requiring Investigation’ (SIRI) process in place.

 

The Trust were subject to two ongoing prosecutions, one which related to a service user in Hampshire and another in Oxfordshire, with both being publically known cases.  Southern Health were not defending these suits.  Both related to health and safety, and the Trust felt that the considerable amount of work undertaken since the time of these incidents had resulted in environments being as safe and ligature-free as possible.  Going forward, it would be important that the Trust continued to build confidence in staff and service users, as well as the public, about these improvements.

 

In response to questions, Members heard:

·       That the most recent CQC report detailed concerns reported by staff about miscommunication between the Executive team and staff in Antelope House about expectations around the Hamtun ward reopening.  The Trust were aware of these concerns before the CQC inspection, and had discussed learning with staff.  The Trust believed that the ward had been opened safely, and with a new management team in place now, there would be a better relationship from floor to ward.

·       Antelope House staff may have previously felt disenfranchised in previous years due to the nature of the service, and how the service was managed, but recent engagement with staff had shown that this was no longer the case.

·       In relation to the death of a service user where it is not clear who has been the most recent provider of their care, it had been agreed that the Trust that had been the most significant provider would lead the SIRI process, and would do so within the 48-hour window.

·       The biggest issue facing the Trust which it felt still needed to be tackled fully was that of parity of esteem.  Often patients with mental health needs require physical health support, and vice versa.  One of the CQC actions was for mental health practitioners to be trained on physical health needs and how to pick up deteriorations of condition, and this was ongoing.  The Niche Grant Thornton report showed that this had been a fully implemented recommendation.

·       That many of those members of the public involved in the Trust were ex-complainants or service users who wanted to work with the organisation to improve it.  In addition, the Trust were keen to increase the number of service users who return to employment, and were working with stakeholders on this aim, but was already a nationally-leading mental health provider in this area.

 

The Chairman and members of the Committee thanked Ms Dawes for her leadership and the progress she had made to the Trust’s improvement journey whilst Interim Chief Executive.

 

RESOLVED

 

That Members:

 

a.  Note the update from the Trust.

 

b.  Request that a further consideration of progress made against the recommendations of the Care Quality Commission and Mazars report is heard in September 2018.

 

c.  Request an interim update on progress made against the Trust’s actions plans, for information.

 

d.  Request the assessment report by Niche Grant Thornton, once available.

 

Portsmouth Hospitals NHS Trust: Care Quality Commission Re-Inspection

 

The Chief Executive and Interim Chief Nurse from Portsmouth Hospitals Trust were joined by the Director of Nursing and Quality from Hampshire CCG Partnership, in order to speak to a further update on the Trust’s Quality Improvement Plan, which had been published following the most recent CQC report (see Item 7 in the Minute Book).

 

Members heard that further changes had been made to the Executive Board since the Trust last appeared before the HASC in September, with a new Chair in position, Melloney Poole, who took up the role on 1 November.  Further work was being undertaken to recruit three other Non-Executive Director roles, and a strong list of candidates were due to be considered.  It was hoped that appointments would be made at the end of November 2017.  In terms of Executive Directors, all appointments had now been made, with successful candidates having already started in post, or due to begin on 1 December of 1 January.  This was the first time the Trust had seen a substantive Board in place for a considerable period of time, and it was hoped that this would give the organisation greater stability to take forward improvements.

 

The Trust were continuing to engage with staff, and in the Chief Executive’s first 100 days, he had met with over 4,000 members of staff, and had put in mechanisms in order to hear a range of staff views.  This had been successful in capturing views across the organisation, and time was being taken to translate this into coherent set of actions for the leadership team to take.

 

Elements of governance within the Trust were a key area of criticism by the CQC, and resultantly a clear plan was being put in place to strengthen this area.  It was felt the Trust were making good progress against these.  A key aspect of this was the quality improvement plan, which the Chief Executive noted felt different to previous strategies aimed at improving the Trust, as it gave greater weight to changing the culture, systems and processes within Queen Alexandra Hospital.  The aspiration was to be a Trust that in future does not rely on inspection regimes to highlight areas for action and improvement.  The plan had been developed and tested with 75 members of staff to refine the document and to make it one that staff from the ward to the Board could own and implement, and had content that genuinely meant something to those who work for the Trust.  The Chief Executive was pleased with the final document, which had been published on 31 October.  The Board was absolutely committed to delivering on all the actions, and had assigned dates by which it expected actions to be implemented and to have achieved its aim.

 

There were five key domains of the plan, which aimed to bring to life the key aspects of the CQC‘s findings.  The Trust had assigned Executive Board members to each of these to ensure each had the appropriate senior overview and monitoring of the changes and improvements expected.  These were:

·         Valuing the basics (sponsored by the Chief Operating Officer)

o   Putting patients at the centre of care

o   Delivering holistic care

o   Having courageous discussions

o   Involving patients, families and carers

·         Moving beyond safe (sponsored by the Director of Finance)

o   Urgent care

o   No ‘avoidable’ deaths

o   Stop harm to patients

o   Right patient in the right bed

·         Supporting vulnerability in patients (sponsored by the Director of Workforce and Organisational Development)

o   Safeguarding

o   Mental health

o   Dementia

o   Mental Capacity Act and Deprivation of Liberty

·         An organisation that learns (sponsored by the Medical Director)

o   Zero tolerance of bullying

o   Behaviours and compassion

o   Right staff with the right skills

o   Staff engagement

·         Leading well through good governance (sponsored by the Chief Nurse)

o   Leadership at all levels

o   Role clarity, responsibility and accountability

o   Standardising and consistency in processes

o   Being open and transparent

 

The issues around supporting vulnerability in patients remained a significant challenge for the Trust, as urgent care, for example, was an exceptionally busy environment and delivering the personalised care that was required for these cohorts of patients would require a different approach and thinking.

 

From the perspective of the CCG, the stability of the Board and recent appointments had seen a visible impact on the Trust, especially in the most recent months.  The wealth of knowledge and capacity of the leadership of the new Board, as well as the energy of staff across the Trust, had made a noticeable difference.

 

The CCGs continued to play multiple roles in the Trust’s journey to improvement, taking part in the joint oversight and assurance process alongside NHS England, NHS Improvement and the CQC.  These organisations had joined forces with the CCG to monitor line by line progress against the delivery of the actions through the process, and the Trust had been transparent on where it saw the advancement of actions and progress.  As part of this, the CCG had undertaken announced and unannounced inspections, including four visits to the Medical Assessment Unit to triangulate progress reported with how staff were working on the ground.  This had been helpful for all parties, and the Trust had used the findings from these as part of their own processes to improve and amend implementation plans.

 

The CCG had been very encouraged by the changes demonstrated to date that specifically focused on mental health and vulnerable patients.  This had been aided by a whole system approach to mental health through the set up of a cross-organisation Board.  This, in particular, was aimed at tackling how the Trust works with partners in the community and vice versa, and although there was still a long way to go in terms of the approach, it was felt that discussions were following the right path.

 

The CCG noted that from their perspective challenges remained in terms of actions in relation to mortality and workforce, but these were big challenges that wouldn’t change overnight.  There also remained pressures in the Emergency Department and the resultant flow issues through the hospital, but this wasn’t to say that there wasn’t lots of positive work ongoing.

 

The CQC’s enforcement actions had not yet been lifted, as the Trust and CCGs would need to understand from the regulator what actions should be evidenced before the overall rating of ‘inadequate’ was re-considered.  It was hoped that the CQC would deliver a view on this in the new year, and that by May 2018 the rating for the Trust would have improved.

 

In response to questions, Members heard:

·       That routine calls took place between the CQC, Medical Director and Chief Nurse to keep the regulator in the loop on progress.  The CQC had been sent the quality improvement plan, but they generally do not tend to give comments on whether such documents are right or wrong, but rather if they can demonstrate progress against the actions.

·       The Trust were due to meet Professor Ted Baker, the CQC’s Chief Inspector of Hospitals, in two weeks’ time to discuss progress, but believed that it would be further into 2018 before a fuller inspection would take place.  The CQC had not advised the hospital on any dates for possible inspections, but the Trust were aware that they may inspect at any time.

·       The CQC had completed a re-inspection of the radiology department in July and the final report was due within the next week or so.  The Chief Executive would be writing to HASC on this topic, as it picked up further actions that must be taken.

·       That from the Trust’s perspective, urgent care remained the biggest challenge.  The Trust was one of the 20 systems determined by the Department of Health as needing the most support to improve arrival to treatment times and other metrics associated with urgent care.  For the year to date, the Trust remained in the bottom decile for performance, and many patients still needed to wait far longer than the Trust would like.  The Trust and its partners were fully committed to driving improvements, ensuring that capacity was in the right place in the system.

·       The quality improvement plan was not reliant on new funding to implement, and the Trust were committed to putting the resources in place to progress the plan, particularly in relation to staff training and development.  The Trust were cognisant that it would need to invest money where it will lead to tangible benefits relating to the plan, but would need to prioritise actions appropriately according to the funds available.

·       The view of the Trust was that the footprint of the Emergency Department is good, but the layout within it is poor, and doesn’t make the best use of resource.  Historically parts of other departments have been removed and added to the Emergency Department, but this had added complexity to pathways and didn’t result in better flow.  There were plans to refresh what the floorplan looks like for the Emergency Department and Medical Assessment Unit, ensuring that adjacent areas have the right diagnostic access.  However, the Trust still needed to be mindful of limited resource, although some funds had been made available to assist with this from the CCGs.

·       This winter the Trust would be executing new plans on patient streaming, utilising GP resource to route patients to this service if the Emergency Department was not the right place for individuals to be treated.

·       The CCGs had undertaken a piece of work to understand why some of the population attend accident and emergency if they do not need to.  It was hoped that the work around the GP forward view may help to aid this issue, with greater focus on out of hospital urgent care.

·       South Central Ambulance Service NHS Foundation Trust have among the best non-conveyance rate to hospital of any Trust nationally, and had developed significant skillsets in paramedics to keep people out of hospital when appropriate. 

·       Through the Trust’s work with vulnerable patients, there would be a focus on how they could meet the needs of those with autism, with this work planned in for January and February 2018.  The Trust would be utilising external advisors to strengthen their approach to this, and had already delivered some training for all Emergency Department and Maternity staff on meet the needs of vulnerable adults, as this is where the hospital had the highest points of contact.

·       The Trust now had 17 ‘freedom to speak up’ advocates, whose role was to be a focal point for any member of staff who had concerns about bullying.  It was hoped that this scheme would further expand across the Trust.

·       The CCG expected it to be a tough winter this year, with a potential increase in flu.  The focus would be on keeping people out of hospital who do not need to be there, utilising learning from the new models of care work streams which have had success in avoiding hospital attendance. T he CCG had increased the number of primary care services offering same day GP sessions and home visiting services to help contribute to this.

·       In reviewing the training and development of staff who join the Trust, and those who have been with it for a longer period of time, it had been found that a lot of overseas staff have the basic skills required in terms of respecting dignity and the humanity of basic care.  However, after a period of time staff can become desensitised to what good looks like, especially when faced with exceptionally busy services.  The focus would be on ensuring that staff had access to ongoing education which stops poor practice from occurring, and can develop staff in-house to train the clinician the Trust needs.

·       The language barrier for staff that have been recruited from overseas has been a trend seen in complaints, and is a great source of frustration for patients, their families and the staff themselves.  The Trust needed to ensure due diligence by checking that there is a basic consistency of English tested for those in clinical practice, and if not, to ensure that staff are supported to improve this before interacting with patients.

·       Timely discharge remained a high priority, both in terms of speedy discharge home once decided to be medically fit, and delayed discharge for those going to another setting of care, or home with a care package.  Pharmacy delays had been an issue, and work was ongoing to ensure that all wards and departments know the process for accessing medications before discharge. 

·       The Trust had been looking to other hospitals for best practice, and had discovered Northumberland Hospitals’ ‘criteria led discharge’ procedure, which may be applicable in Portsmouth. 

 

RESOLVED

 

That Members:

 

a.  Note the quality improvement plan from the Trust.

 

b.  Request that further consideration of progress made against the recommendations of the Care Quality Commission report, and the Trust’s Quality Improvement Plan, is heard in May 2018.

 

c.  Request an interim update on progress made against the Quality Improvement Plan, for information.