Minutes:
Louise Barnett, Chief Executive TRFT, and Angela Wood, Chief Nurse, gave the following powerpoint presentation:-
2018 Inspection Timelines
- 25th-27th September, 2018 – Core Service Inspection: Acute
- 28th September, 2018 – Use of Resources Inspection
- 16th-18th October, 2018 – Core Service Inspection – Community
- 22nd-24th October, 2018 – Well-led Inspection
Overall Timeframes
- 23rd-27th February, 2015 – focussed announced inspection
- 27th-30th September, 2017 – focussed follow-up inspection
- 17th July, 2018 – focussed unannounced inspection
Services Inspected
- Acute
Urgent and Emergency Services
Medical Care
Maternity
Children and Young People
- Community
Children and Young People
Overall Position – Breakdown of Ratings
- 1 Outstanding
- 45 Good
- 16 Requires Improvement
- 2 Inadequate
Headlines from Re-inspection
- Some real positives
Our People, Digital, Multi-Disciplinary Teams
- Some real progress
Children and Young Peoples Services
- Some real challenges
Urgent and Emergency Services
- Some ongoing issues
Mandatory training, risks, incidents
Some Examples of Positive Findings
- Infection Control – Wards and department visibly clean
- Sepsis – tool used, staff had access to guidance and pathway
- Multi-Disciplinary Team Working – good throughout the Trust and work had been carried out to ensure the MDTs were aligned to prevent delays. Quick referrals and improved pathways had led to a reduction in lengths of stay
- Caring Staff – privacy and dignity maintained, compassionate and a real asset
- Outliers (people being cared for in non-speciality wards) – good arrangements, daily reviews
- National Recognition – acupin therapy (wrist band on pressure point to relieve nausea)
Outstanding Practice
- Digital
Innovative use of technology
Award-winning in-house SEPIA system with real time information about patients
Support clinical and operational staff
Great People
- Caring
We have some great people who really care
- Compassionate
People showed compassion, dignity, support for patients
- Open
People were open, honest, shared information
Challenges and Ongoing Issues
- Raining concerns and escalation
- Urgent and Emergency Services
- Staffing
- Medicines management
- Safeguarding
- Training
- Risks
Progress made since Inspection
- Staffing
- Training and development
- Leadership and support
- Safety and governance
Summary of Must Do (47) and Should Do (27)
|
Service |
Must Do |
Should Do |
|
Trust Level |
7 |
3 |
|
Urgent and Emergency Care |
12 |
10 |
|
Medical Care |
11 |
9 |
|
Maternity |
9 |
2 |
|
Children and Young People |
4 |
3 |
|
Community Children and Young People |
7 |
9 |
|
Total Overall |
47 |
27 |
Our Aim for the Future
- Ambitious
Strive for good and outstanding
- Caring
For our patients and each other
- Together
We all have a role to play
Further detail was provided for the Commission in relation to the principal challenges and ongoing issues identified:-
· Raising concerns and escalation – review of Freedom to Speak Up Guardian role and accessibility of that role in addition to making a permanent appointment. Looked at how staff could share information and established drop-ins for staff with the Chief Nurse and Interim Medical Director to share information around innovations and ideas as well as complaints and concerns. The drop-ins included community as well as hospital based staff
· Back to the Floor Friday – on the last Friday of the month members of the Senior Clinical Team from Nursing got back into uniform and worked on the wards and talked about the key themes for the month, medicine management, escalation and raising concerns, protected meal times had all been discussed. This enabled feedback and to be a visible presence. It was also an opportunity to talk to patients. The feedback was included in the quarterly report to the Quality Assurance Committee and a review of governance processes had taken place
· Urgent and Emergency Services – Paediatric Department – a review had been conducted of the skill mix of nurses, medical support and governance arrangements around huddles and checks. Representatives from Rotherham Clinical Commissioning Group (RCCG) had recently visited and had been very positive about the changes that had been made. The issues around staffing had been in the context of recent CQC guidance issued just before the inspection and the Trust now exceeded those recommended levels. The Paediatric area was now almost fully established
· Urgent and Emergency Services – the leadership had been increased and dedicated support provided to allow the changes and developments to be made. There was support from NHS Management who had sent a national team to undertake a review of the streaming and flow through the department. The Trust was also doing some work around the culture, leadership and management development and how things were working in there. An action plan had been in place since the inspection which had been enhanced as it progressed. Positive feedback was being received with regard to how staff were feeling and what was happening around patient flow and the monitoring of complaints/incidents
· Staffing – this was a national issue and not particular to Rotherham. A review of the skill mix and establishment review across all wards was being undertaken. The Trust was looking to enhance recruitment of both new and experienced staff including the new Nursing Associate role. The review had considered the current position and where the Trust needed to get to in 5 years to be sustainable
· Medical Staff – looking at international recruitment to fill some of the gaps that were unable to be filled locally and would be considered for nurses as well.
· Medication Management – medicines incidents and omitted doses and the reasons behind them were being looked at. An electronic prescribing system would soon be in place with electronic drug charts feeding information directly through to pharmacy which would reduce delays associated with physical charts. There were areas to improve on but also some areas of good practice and there would be cross fertilisation of this good practice
· Safeguarding – there had been a significant improvement in safeguarding across Rotherham and the Hospital. Some of the comments made during the inspection were around the training delivered, which was both on line and face-to-face, with a suggestion that the amount of face-to-face training was strengthened to meet the inter-Collegiate requirements. This was being reviewed
· Safeguarding - capture of information would be picked up through the digital system and immediate changes were made to systems to save referrals for review later following feedback at the time of the inspection
· Safeguarding – strengthening the team to support Deprivation of Liberty internally had been suggested and would be taken forward
· Mandatory and Statutory Training (MAST) – compliant across the Trust but there were some pockets in the medical teams with doctors not as compliant with the training as one would wish them to be. Ensuring a consistent approach across all areas was needed not just across the whole of the Trust. The training provision had been reviewed as to what was mandatory and what was statutory and how it could be made more accessible for groups of staff whether it be modular or full day training
· Risk Management – work was current underway on a risk management review i.e. how to capture risks, how they were escalated and reported and ensuring that the group with responsibility for overseeing them had full executive oversight. The Terms of Reference had changed and sub-groups established to look at the risks on a monthly basis with divisions. Extra risk management and risk assessment training was being put in place so that staff knew how to use the registers and to monitor/escalate them appropriately
· Patient Safety and Governance Culture – quality care was in everyone’s portfolio and the most important thing for people to take forward. The “Safe and Sound Framework” was the tool being used to drive forward all the improvements
· Safe Care and Sound Care and Listening to Patients and Staff – all the challenges and ongoing issues raised would be covered by 7 workstreams each led by the Executive Director with employees of different areas and levels within the organisation giving their opinion and support on how to take the organisation forward to the next level of quality
· Quality Improvement Faculty – the Trust was developing this and had staff on places on the NHS quality initiative. These people would be driving improvements through looking at culture, behaviour and leadership in the action plans for the quality objectives for the year, in Safe and Sound implementation and the CQC action plan. One of the main objectives would be to get the Urgent and Emergency Care Centre (UECC) from where it was currently to “Good” or “Outstanding”
Discussion ensued with the following issues raised/clarified:-
· Reiteration of concerns raised at the quarterly health briefing held on the day after publication of the CQC report whilst acknowledging that some inroads had been made. In particular the pace of progress since July, UECC staff numbers and skills/experience, safeguarding processes and training, leadership and staff engagement were highlighted
· Recognition of the changes required – not only within A&E but throughout the organisation, at all levels, and to ensure that the themes were built on with learning across the board
· CQC – had been invited back and the Trust would be re-rated but it was not known when it would take place. One of the operational objectives for the year would be very focussed on the UECC
· Visibility of senior leaders – the Chief Executive had spoken to the UECC team to understand their concerns, did they recognise the changes that had taken place and were they supportive of them particularly in Paediatrics where the changes were further advanced. The Paediatrics team was extremely positive about the changes in the staffing model and felt confident about the support they received and the service they were running despite the pressures they were under
· Paediatric A&E – the Chief Nurse was now the executive lead. Together with the Interim Medical Director, a new working model had been instigated including the closure of the paediatric area overnight and moved into the main area. Band 6 nurses with greater experience rather than Band 5 nurses now staffed the Unit with a supernumerary Band 7 leader employed to oversee staffing, training and competencies and the smooth running of the departments. Other changes included a Doctor based full-time within the department, installation of CCTV in the waiting room so it could be seen from the nurses’ station and other measures to include better visibility of patients
· Safeguarding Training – identified as part of the CQC action plan. Training on the deteriorating patient, induction for new starters and mentoring were also included, in addition to cross-support from the paediatric ward. A Children’s Board was to be set up as a forum for information, learning and best practice for all the children’s services within the Hospital
· Monitoring of Incidents within Paediatric Department – the Chief Nurse looked at incidents within the Department on a weekly basis, collated by themes and any Safeguarding concerns went straight to her. Staff also held a daily “huddle” at 3.00 p.m. on the unit to discuss staffing for the next 2 days and any issues. The minutes were shared with the Chief Nurse who was assured about the improvements made and that these would continue. Moving forward, it was the intention to have a similar process in the main UECC and ensure resources were used in a more effective way and to give people the time to make the necessary changes
· Timelines for achieving improvements on the ratings of “Requires Improvements” – there were internal milestone set out within the action plan which had been submitted to the CQC earlier that week after approval by the Board. It was a very comprehensive 42 page document detailing how the improvements would be made. All the must do’s and should do’s had been responded to in the submission to the regulator. Some actions were small and others very broad under the must do’s. Feedback from the CQC to the Trust on the plan would follow
· The improvement of the UECC was the top priority (actions to be completed by 31st August, 2019); the wider Trust actions would be completed by 31st March, 2020, following some audits that needed to be undertaken. It would be driven through the Safe & Sound initiative, pulling the workstreams and appropriate people together and driving that change. Changing culture and leadership styles would take longer and the Trust needed to ensure the physical actions were undertaken and would then introduce a “cultural barometer” and patient safety barometer to ensure where it was now and where it would be in subsequent years to ensure quality was embedded
· Shortcomings of UECC – there were increased numbers of patients attending A&E nationally which resulted in delays to patients being seen, assessments being delayed and pressures meant less time for staff to spend talking and listening in patients. Any incident that occurred was investigated to make sure that it could be learnt from. The journey through UECC was being reviewed looking at streamlining patients as they entered the door with various options ranging from on-site GP to ambulatory care unit rather than waiting in the main department with the aim of getting patients home as soon as possible.
· Agency Staff – in light of the CQC feedback on staffing numbers, there had been increased usage of specialist agency staff within the Paediatric Department. Currently the Department was almost fully established and the use of agency staff had reduced. The Chief Nurse was not unduly concerned about the numbers of agency staff and the ones used had appropriate skills
· Staff Shortages – across the wards there was a staff shortage and sometimes staff had to move around the Trust to cover and share the risk. An assessment would be conducted by the Senior Nurses across the organisation to identify where the gaps were and where there were opportunities to move staff. The Trust had supernumary ward managers which could fill in. A risk assessment would be completed to ensure it was addressed on a daily basis. Any escalation of “red incident” wards was escalated to the Chief Nurse and her deputy who looked to pull staff without clinical responsibility in from more corporate areas. Extra beds because of throughput from the UECC would not be opened without adequate staffing
· Why had some 2017 CQC “Requires Improvement” ratings still unchanged in 2019 and was there confidence now in moving to “Good” – some progress had been made with issues previously identified but there were others still to move on. In medical wards there had been good feedback on staff engagement and on being able to support staff taking into account the workforce issues. There was confidence in the team, the plans that had been drawn up and the progress made that the Trust could move forward to “Good”
· Adult and Children’s Safeguarding - there was no distinction in the CQC feedback between Adult and Children’s Safeguarding. The issues were with the training and processes to capture information
· Linking with partners for support on Safeguarding – the Trust had already invited themselves to present to both the Safeguarding Adults Board and the Local Safeguarding Children’s Board
· Local Plan to address the Better Births Agenda – the Interim Head of Midwifery was working on this and the issues from the inspection feedback would be tied into the plan
· Quality Care Improvement Plan – there was a significant focus on the UECC but it included all areas to make sure the Trust drove improvements across all areas that required improvement. There was no complacency regarding the areas rated “Good” (whether rated this time or previously) with the aim of moving these to “Outstanding”. The Plan would look across all the services and particularly the learning areas. The CQC were clear that on some of the areas historically identified the Trust had made a positive step change but there were others where insufficient progress had been made and these were re-highlighted. The Trust was confident in being able to embed and sustain the necessary changes through the plans
· Leadership – the Well-led Domain covered a broad range of indicators within it. It absolutely went to the heart of leadership, whether everybody understood what that vision was, had an opportunity to contribute to it, sound governance frameworks in place and ability to monitor and oversee what was being done. It was about culture. There was confidence in terms of the teams that were in place to drive that change. Some of the frameworks around governance needed strengthening further/embedded and more consistency was required in what was being done. Staff engagement had to significantly improve. There was still some considerable work to go as an organisation and the Trust’s engagement plans had been refreshed and its approach to that as an organisation as a whole to ensure motivating and engaging with colleagues. Staff survey results would also be taken on board
· Leadership, management and changing culture without significant changes in personnel – leadership had been strengthened at various levels, including with the new Chief Nurse from a senior clinical perspective, and also within the UECC with a new experienced manager and Head of Nursing
· Awareness of the issues in the UECC – the UECC was a brilliant new facility and the staff worked incredibly hard. UECC work was complex and with unprecedented change in the new way of working, in a new environment and a different model of care and workforce mix. There had been significant scrutiny but a failure to pick up, particularly in Paediatrics, where staff were saying that it was not safe and wanted more support in terms of nursing and medical workforce to ensure appropriate care to patients. Whilst that was raised, the Trust needed to make sure that it was acted upon and dealt with in a far more effective way at pace than it had been. Work was taking place to ensure all staff had an immediate ability to escalate concerns with better joining up across all levels to be able to provide immediate support which was viewed as a key issue
· Patient voice – feedback was received via Friends and Family which was normally positive. The aspects identified in terms of Safeguarding were in relation to practice that had been observed rather than failure to pick up on comments made by patients
· Role of Scrutiny – the Trust had not sufficiently picked up on the critical issue in the Paediatric Department so it would made it extremely difficult for Scrutiny to have done so. The Trust was strengthening the way in which it audited reports and triangulated information within the organisation and ensuring the golden thread was clear at all levels. There may be an opportunity for scrutiny around the Safe and Sound Framework which delivered the services
· Given recent events in Rotherham, it was very disappointing to read the CQC’s comments about Safeguarding and CSE referrals. The Trust had made significant progress and had been working across Rotherham to support. The Safeguarding Team was working closely with the Paediatric Team to ensure professional curiosity and weekly meetings had been instigated to discuss cases and ensure a consistent approach
· Nursing Associates and internal staff development – the first national cohort of 1,000 Nurse Associates had qualified in January 2019 with the second cohort of 1,000 due to qualify in April. It was a 2 year programme run through different universities and colleges. 5 Nursing Associates had started in Rotherham 2 years ago and had just qualified. It was hoped to have a cohort of up to 30, recruited from the Trust’s Health Care Assistants, who would commence their training in April and supported to go to university one day a week, one day placement on rotation and 3 days within the nursing workforce on a Ward or within a Department. Within the 2 years there would be roles identified for them within the organisation. Financial support had been received from Health Education England provided funding for backfill for when the Nursing Associates were not on the Ward. One limiting factor was the need for basic Maths and English; in-house training was planned if people lacked this. A set of competencies had been agreed by the Nursing and Midwifery Council for Nursing Associates which would include dispensing of medicines
· Workforce Planning – work was taking place on where the Trust wanted to be, what the Trust needed from Registered Nurses and Senior Registered Nurses and Nursing Associates. It was planned to enhance other roles such as that of the Health Care Assistants and to create a bridging module to become a Registered Nurse. It was important to ensure adequate support and supervision for staff so this did limit the number of trainees at any one time. Having the right competencies, training and assessment and the same standards was important
The responses to Member questions provided some reassurance but the Commission agreed to have a future progress update, potentially in September, in line with the timescale for completion of the UECC actions.
Louise and Angela were thanked for their presentation.
Resolved:- (1) That the information presented and responses to the questions from Select Commission Members be noted.
(2) That, when appropriate, feedback be provided on the Safe and Sound Action Plan.
(3) That, when received, the CQC’s comments on the action plan be submitted to the Select Commission.
(4) That a presentation be made to the Select Commission on the workforce mix and Nursing Associates.