Agenda item

To consider an annual update report from The Rotherham NHS Foundation Trust (TRFT) in respect of actions, challenges, and achievements of the Trust for the financial year ending 31 March 2022.

Consideration was given to a report presented by representatives of TRFT providing an update on the financial year 2021/22. The discussion of this report was followed by a presentation of court findings relating to a CQC children’s safeguarding investigation. Representing the Trust were the Deputy CEO, Deputy Chief Nurse, and Director of Performance. In respect of the Annual Report, it was noted that the Trust is organised into several divisions: medicine, surgery, urgent and emergency care, community, family health, and clinical support. The presentation noted key decisions and changes that had been implemented throughout the year, including setting up community as its own division, and responding to significant challenges presented by COVID-19. Successes were highlighted, including the award of funding which had been utilised for evolution and development of IT and command centre functions, and the return of the Trust to a financially balanced position following a cost improvement of £5 million. Areas for improvement were also noted, including the outcome of CQC inspections which rated two areas as requiring improvement: urgent and emergency care and medicine. It was noted that the outcomes are not a focus; the focus of the Trust is safe and effective care. Good CQC outcomes will be a positive by-product of the work being done to deliver safe and effective care. The response to the staff survey had been the highest ever for the Trust, and one of the better response rates nationally, with 60%. The new strategy Our Journey Together was launched during the year, with focus on patients and partners. Improvements in results went from bottom quartile to the median within a two-year period. Developments in the capital plan and strategic investments were noted, including a web-based platform to improve accessibility, a refurbished stroke unit, energy efficiency, and staff wellbeing developments. In terms of performance, Referral to Treatment Times (RTT) had consistently remained in the top fifteen to twenty Trusts nationally. The emergency department was not working within standard on the pilot. This was an area where other Trusts had also experienced similar challenges. The possibility of returning to the 4-hour target had not been confirmed in writing. Challenges regarding cancer waiting times were noted, as well as successes in elective care with reducing the waiting lists. Staff sickness had fluctuated between 7 and 11 percent, with requirements to use agency staff during the most challenging parts of the pandemic.

Consideration was then given to a presentation of court findings regarding a CQC investigation into historical cases, of October-December 2019 leading into January-February 2020, of four children involved in nonaccidental injuries which were appropriately highlighted to the Trust. Serious incident reports were completed as a result, with investigations internally. The CQC was not satisfied that the actions to take were fully embedded at the time. Going through to court proceedings, the Trust reflected on these historical cases that this was not an adequate level of care that the Trust would expect to deliver to children within Rotherham. The court were clear that no children came to harm as a result of the nonadherence to policy and procedure, but clearly there were missed opportunities. No clinical staff were found at fault for this, but rather the policies, education and training that had been delivered and the embedding of the actions from sustainable learning.

Significant change to safeguarding had been made within the last years in response, including an increase in workforce and a new training programme for staff through the Think Family approach, accessible online. Mandatory training levels were now acceptable wherein most staff are now trained across safeguarding procedures to meet statutory requirements. There was now evidence supported by partners to show the Trust is meeting statutory requirements. These measures were in place to ensure these incidents do not or are unlikely to happen again. The court recognised that the Trust had made significant improvements and had taken ownership of the failings at that time to make the right steps and approaches for prevention in the future. The Trust had been working with Public Health/NHS England and would continue to do so over the next two years to ensure that the Trust were making sustainable changes. Public Health/NHS England had observed that it was evident that significant resource had gone into to making changes to ensure this does not happen in future. Changes to policies had made these easier to follow, with changes to practice around safeguarding huddles to pick up any missed opportunities to provide an additional safety net.

Members proceeded first to discuss the annual report.

In discussion of the annual report, Members requested more information regarding impact of industrial action on the delivery of safe and effective care. The latest position was that industrial action would not be taking place in Rotherham. If this changed, it would be a challenge, but emergency care would continue with a skeleton staff.

Members felt that the annual report did not reflect the concerns reflected in people’s experiences and in the press, which make people not feel safe. Clarification was requested as to why the challenges were not articulated in the report. The response from the Deputy CEO of TRFT noted that recent events from this financial year will be covered in the report following this financial year. The response confirmed that there had been waits for ambulance handovers over an hour. This deterioration was not unique to Rotherham. Where ambulance waits were over an hour, these were escalated to the regulator, identifying what was being done to manage this. The Trust was experiencing significant pressures with acuity, flow, length of stay, and people requiring medical care for longer. The Trust had responded to these pressures by addressing capacity. The Trust was working with partners and with the ICB to find the right model whereby patients could be discharged into the appropriate setting, but an appropriate setting had not yet been found. Given that the greatest difficulty had been seen in the last few months, this will figure in the report that will be submitted next year.

Members requested more insight into whether it was felt that the current model for the urgent and emergency care centre is working. The response noted that the urgent and emergency care centre facility was a modern facility fit for purpose but seeing increasing numbers of patients. It was designed for 200, reaching to 250, patients at most. It frequently now saw 300, sometimes as many as 360 patients. In terms of how it was managed, a return to the previous 4 hour target was welcomed. It was clarified that, as a pilot site, the UECC worked to a new set of standards in a testing phase since May 2019. An emerging discussion of whether the 14 pilot sites would return to the previous 4-hour standard, which other Trusts currently work to. This meant a different way of working for teams, which created operational impact that in turn affected how patients are treated within the facility. At the moment, the UECC worked to a different set of standards which potentially meant that patients had a different experience. The outcome of this national discussion was not yet known but was imminent. The UECC compared to the traditional A&E department had the same functionality. The UECC brings primary care into the facility so there was a single front door. It saw the same types of patients, other than the fact that it was not a tertiary or major trauma centre. This was appropriate for this size of District General Hospital (DGH).

Members expressed desire to hear more frequent updates rather than receiving feedback on the previous financial year following the annual report. The response from partners identified the timescales associated with producing the annual report and welcomed the opportunity to bring periodic updates upon request. The information was released into the public domain, and the earliest opportunity to bring an annual report was in September. Members expressed interest in periodic updates, especially regarding the improvement and pressures in the emergency department.

Members requested information regarding pressures around discharge and increased length of stay for patients who are medically fit for discharge. The response noted that patients ready for discharge are monitored on a daily basis. Typically there were on average forty to fifty patients awaiting discharge. In difficult times, this number has reached 74. The Trust was not an outlier in this, as other Trusts had similar levels if not higher. There was one other Trust not far away that did have far lower patients waiting for discharge. This was achieved by using a home assessment model. Therefore, Rotherham was looking to pilot the discharge to assess model. The other approach was looking at care home capacity. Rotherham MBC colleagues had been proactive in securing additional care home capacity, in addition to home care support as well. As patients within an aging population had more co-morbidities and more complexity, it became increasingly more difficult to find the right setting.

Members sought more information around impacts on radiology and pathology on service provision and timely monitoring. The response described two business continuity incidents where systems went down, specifically related to routine IT development and maintenance. The Gold Group managed the incident. Services switched to manual, and in both instances were up and running quickly. There had been legacy issues on the more recent incident, which were resolved the next day. No patient harm was seen as a result. There were no delays in terms of radiology and results, as these systems stayed operational throughout. The electronic patient care records and prescribing were immediately reverted to paper.

Members sought assurances that it was felt that everything was being done through the ICS that could be, and that the right preparations were in place for use of Winter funding. In terms of the ICS and admission avoidance, there is GP out of hours, in terms of ICS cooperation support, we have worked to support the Trust with various schemes. It was felt that the Trust was receiving the support needed. The system was awaiting clarity on funding that would be received, as the moneys would be concentrated on areas of the system that were struggling, which was likely not to be seen in Rotherham. Whilst funding is eagerly received by the NHS broadly, the Trust were not yet clear on what that would mean for Rotherham. The response from the Deputy Place Director noted that Place partners were working on an integrated model for admission avoidance and discharge. This model involved working collectively on admission avoidance and discharge from hospital to improve flow. Regarding the funding, there was money for discharge and for mental health, it has to be spent on additional provision, so it was being considered what would be done with this fund over and above what is already in place in the Winter Plan.

The Strategic Director of Adult Care, Housing, and Public Health noted regarding challenges around discharge, that across the system, workforce was a significant challenge. After COVID-19, many adults in Rotherham did not return to work across all the employment opportunities in the Borough. Without the potential employees needed to deliver services, this created a pressured situation. Urgent meetings were held three times each week with the Trust and the Multi-Disciplinary Teams. As a Place, everything possible was being done, including placing staff in UECC to divert patients who did not need to be there. Any issues were escalated. If there were patients within the Trust from other local authorities, these were managed as quickly as possible to reduce local impact. Every opportunity was taken to make a difference, and a collective effort was being made, acknowledging that no one wants to stay in the hospital longer than necessary, but the challenge was understood. Regarding the £500 million that had just been announced, if there were time to plan, the workforce would be examined, but time to plan had not been allowed. Initiatives had to be formed around what could be delivered now, as it was not possible to recruit a workforce in the space of a few weeks.

Members then proceeded to discuss the court findings.

Members requested clarification around what led to the past failings and the role of culture change in preventing future failings. The response noted there had been complex policies that were not as accessible as these needed to be, and without the safety nets in place. Whilst this could appear as reflective of culture, this was why the Trust had brought in the education programme and the Think Family approach. It was not something that was caused by people not seeking out policy due to culture necessarily but was more to do with needing better policies and education and training to be provided. A different leadership structure had been put in place since the events, so the culture had changed also. From a governance perspective, there was now much closer scrutiny on reporting from ward to safeguarding board, and reporting against that was much more rigorous on this agenda than before. Changes to executive teams had been made as well. A monthly delivery group looked at delivery of key metrics on the “must” and “should do” actions advised by the CQC. Daily audits gave real time information on how the Trust was performing in these areas.

Members requested more clarification around how red flags and possible red flags were now progressed. The response noted that the changes in place now required red flags to be progressed for non-mobile babies, for example, or if a child had been in more than once before the age of one.  Safety net processes were in place if a red flag were to be missed, as the red flags can be fragile. There was a process now that every child now went through a safeguarding huddle the next day that was facilitated by the access to safeguarding team. There was access to safeguarding advice 24/7, either within the Trust or through social care. The referral system working in partnership with social care was receiving positive feedback.

Members expressed desire to understand how failings in children’s safeguarding could have been allowed to happen, given historic lessons learned in Rotherham about the importance of safeguarding. The response acknowledged that the Trust did not give the care that they would have expected at the time. It was felt that the Trust was in a position to be able to give assurances that learning had been implemented and the right support and care was in place now. The Trust looked not only internally at processes; there was attention given to recommendations from relevant cases and findings from elsewhere as well. These recommendations are reported through to the Trust, which informs how the Trust maps their own performance against safeguarding to ensure that the Trust was learning from other cases that were unfortunately very sad, to ensure that something was not being missed.

Members sought more information about how the findings in the Jay and Casey Reports for all the public agencies had not been embedded system wide. The response did not dispute that the Trust failed in its duties, which was exceptionally disappointing. So that it did not happen again, the Trust had seen there was commitment. The time had been provided to undertake the training. The Trust had changed a range of processes. NHS England had done a recent visit, and the findings from that had been positive. The past could not be changed, but could be learned from, and it was felt that the Trust had learned from this. The response from Members noted that more assurances were desired around pressures in the emergency service, and a further update at the next meeting was desired.

Resolved:-

1.    That the report be noted.

2.    That a further update be submitted to the next meeting in respect of the emergency department.