Agenda item

The Chairman welcomed those present to the meeting and thanked them for attending.  He advised that he had attended the Quality Summit meeting held at Brunel University on 25 September 2018 to discuss The Hillingdon Hospitals NHS Foundation Trust’s (THH’s) recent CQC inspection report.  Dr Abbas Khakoo, Medical Director at THH, advised that there had been good engagement and support from all stakeholders at the summit meeting where the following key themes had been discussed:

·         Managing activity pressures and capacity;

·         Managing an aging estate;

·         Governance and accountability;

·         Supporting the workforce and improving culture – although maternity and paediatrics had a fairly stable workforce, only approximately 40% of Surgery staff were permanent; and

·         Infection prevention and control including sepsis care. 

 

The Trust was commended for the excellent work that had been undertaken to improve maternity, services for children and young people and end of life care.  However, Members of the Committee had received comments from residents regarding what Hillingdon Hospital being rated as ‘Inadequate’ meant for them.  Mr Richard Sumray, Chair of the Trust Board, stated that it was right that THH should be held to account.  He advised that the Board felt that the Trust’s performance had been unsatisfactory and had met the day after the report had been published to discuss a way forward.

 

Staff meetings had been held to discuss findings such as the presence of blood on beds between seeing patients.  There had also been an incident where the code for a lockable medicines cupboard had been written on a post-it note and left next to the cupboard.  These practices were not acceptable.  Mr Sumray acknowledged that some changes had not been properly embedded in some areas of the Trust. 

 

Although Hillingdon Hospital had received more ‘Good’ ratings than during the previous inspection in 2014, two areas in the Safe domain had been rated as ‘Inadequate’ which Mr Sumray believed had led to the hospital also being rated as ‘Inadequate’ for the Well-led domain.  He stated that it was the Board’s role to deal with the ‘Inadequate’ ratings that the Trust had received. 

 

It was essential that staff at THH did not jeopardise patients’ safety and policies and procedures had been put in place to prevent patients being put at risk of harm.  There had been some consultants that had not followed hand washing protocols or did not adhere to bare below the elbows.  Failing to uphold these basic safety standards and adhere to corporate policies was unacceptable.  Ms Jacqueline Walker, Director of Nursing at THH, advised that the Trust was one organisation and consideration was being given to how one department was able to achieve ‘Good’ in all domains whilst others were not.  It was recognised that the level of service demand at the hospital at the time of inspection was extraordinarily high but that was no excuse for unsafe behaviour which was unacceptable.  Furthermore, it was thought that there would be some members of staff that would, for example, not wash their hands properly even on quieter days.  The Infection Prevention and Control Team and the LINK Nurses were working with staff to promote good hand hygiene but the managers needed to reinforce a positive culture around the practice. 

 

It was noted that, despite being ill, the majority of patients had had good experiences at the hospital and, as such, it was important to not give residents the impression that the service provided was unsafe.  Dr Khakoo advised that the Trust made it clear to all staff that any concerns raised by members of the public should be taken seriously.

 

The CARES framework (Communication, Attitude, Responsibility, Equity and Safety) embraced a culture that empowered staff to report incidents and raise concerns about quality and patient safety in an open, blame-free working environment.  Dr Khakoo advised that the Trust needed to focus more on the ‘Responsibility’ element of the framework by setting a good example.  Irrespective of whether staff agreed with the practice, policies were in place and had to be followed.

 

Concern was expressed that a number of issues that had been highlighted in the Trust’s CQC inspection report for action and improvement in 2015 had again been highlighted in the 2018 report.  Despite an action plan being put in place in 2015, Hillingdon Hospital had regressed from ‘Requires improvement’ to ‘Inadequate’.  Mr Sumray recognised that this did not demonstrate progress and noted that, following the 2015 report, the Trust’s focus had predominantly been on the wards and not enough on other areas of the hospital.  This focus had now been broadened and a programme of Board to ward rounds had been set up for Executive and Non-Executive Board Members to see the staff practices for themselves.  As well as highlighting good practice, this had also shown that some staff were still not adhering to corporate policies with incidents witnessed such as medicine cupboards being left unlocked and unsecured patient records.  Lessons could be learnt across the Trust.  It was important that those individuals that did not follow policies were held to account. 

 

Mr Sumray believed in the importance of teams as they could enable significant change.  He stated that the huge improvement in inspection ratings for the end of life care service had been, in part, as a result of teamwork. 

 

Ms Walker noted that, although the same fundamental standards applied to all services and the same overarching training was given to all staff, those service areas that were rated as ‘Good’ were absolutely committed to improved service delivery and quality.  She advised that the Trust was now looking at a programme of peer review and support. 

 

Members were not satisfied with the answers that had been provided at the meeting.  It was thought that the Trust was making excuses about the weather conditions at the time and it was suggested that the leadership had not gotten to grips with fundamental issues following the 2014 inspection.  Mr Sumray profoundly disagreed with the claim in the report that the Board did not understand the impact of the condition of the estate on staff and patients and advised that there was no evidence to support that statement.  He noted that action was being taken to address the issues that the Trust had with its estate. 

 

Mr Sumray advised that Governors often wanted to help run the hospital.  However, their role was to hold the Non-Executive Directors to account.  In November 2017, Governors attended a training event which had helped them to stay focused on their actual role. 

 

Ms Walker noted that the inspection report had mentioned about the Trust not having a Duty of Candour policy.  Although not called the Duty of Candour policy, the Trust did in fact have a policy in place.  Similarly, THH had governance arrangements in place with regard to DoLS and the Mental Capacity Act.  An area of concern identified by CQC was in relation to THH not doing enough to follow up with the local authority on standard authorisations.  It appeared that there had been improvements with regard to DoLS but no improvements in relation to hand hygiene or medicines management. 

 

The CQC had identified a number of key issues / MUST dos which included action required in relation to:

·         infection prevention and control in Urgent & Emergency Care and Surgery;

·         medicines management and security issues in Urgent & Emergency Care;

·         a stand alone sepsis policy and increased staff awareness and procedure compliance in Surgery and Critical Care, Urgent & Emergency Care;

·         effective monitoring and governance for laser use in Outpatients;

·         demonstrating robust governance arrangements to some areas of the Well Led key lines of enquiry; and

·         managing activity issues and capacity restraints.

 

Ms Walker advised that the Trust had returned the requirement notice to the CQC which included dates for the completion of each action.  Some actions had already been addressed, for example, the laser protection policy had already been in draft format when the inspection was undertaken so was now in place.  Other actions would take longer, for example, once the Emergency Department (ED) redevelopment was complete, a separate paediatric waiting area would be included.

 

Although there had been an improvement in A&E performance at Hillingdon Hospital between August and October 2018, it was recognised that this was a fragile system where an increase in one area of activity could impact on A& E performance.  Whilst the service was not as robust as it should be, there was a better management of A&E staff now. 

 

Ms Walker advised that it would be important for the Trust to learn from the good practice already present in the hospital.  Overall, THH had achieved ‘Requires improvement’ for the Well Led domain.  However, this domain had been rated as inadequate in the ED and Surgery at Hillingdon Hospital.  Whilst the CQC had found that matrons and managers were under too much pressure, they needed to be able to achieve the standards required.  The CQC had also been positive about the presence of a Freedom to Speak Up Guardian, the well designed corporate risk register and the culture of openness, honesty and transparency. 

 

THH had developed an action plan to address the MUST / SHOULD dos identified by the CQC and consideration would be given to governance and accountability which would be a wider and more transformational piece of work.  As well as 121s, divisional meetings were now being held to raise staff awareness of issues, identify areas of concern and hold people to account for their actions/inaction.  It was noted that there was a collective and individual responsibility and accountability for addressing the issues that had been raised and that a culture change was needed with particular focus on the Responsibility and Safety elements of the CARES framework. 

 

Members were advised that THH had been working with NHS Improvement (NHSI) to co-design the services around a LEAN methodology to help the Trust get things right first time, every time.  Work had also been undertaken to learn from others via external support networks, deep dives and service reviews.  Staff had already visited Chelsea & Westminster and Ashford & St Peters and would be visiting Kingston in November.  Ms Jennifer Roye, Deputy Director Nursing and Quality at HCCG, noted that some work had been undertaken with NHSI and NHS England (NHSE) so that HCCG was now working more collaboratively with THH.  The significant number of actions identified by the CQC would need to be grouped, with swift action taken to address some and step changes applied for others.  She noted that THH staff were generally positive and felt listened to but that deep dives would need to be undertaken with them to develop ownership. 

 

Deloitte had been commissioned to undertake a review of governance and Well Led and would be looking at things such as financial performance.  It was anticipated that this would help the Board to understand what it should be doing around the Board Assurance Framework.  Furthermore, a dedicated senior nursing leader had been working closely with the A&E Matron and reported directly to the Director of Nursing. 

 

A review of the sepsis documentation and the development of a standalone policy was underway.  Mandatory e-learning module would be integrated into the Trust’s learning management system to enable accurate monitoring of compliance across the Trust and increased resources would be provided to support improvement work. 

 

Action was being taken to improve patient flow and the escalation policy, with risk assessments of patient acuity being undertaken prior to patients being admitted to beds.  Agreement to open additional beds would be needed from the Medical Director or Nursing Director in hours and the Director on call if out of hours.  It was anticipated that the expansion of A&E would help to improve capacity and patient flow. 

 

THH was keen to introduce a ward and department accreditation framework and themed clinical Fridays to demonstrate compliance.  These concepts had been successfully introduced at Salford, Chelsea & Westminster and Imperial and would be rolled out at THH in November 2018. 

 

Dr Khakoo advised that, with regard to managing safe emergency care patient flows, system partnership working had been continuing through the demand management and integrated discharge work streams.  Progress was being monitored through the Hillingdon A&E Delivery Board.  He noted that Trusts that had improved their performance had the following five elements (in order of priority): leadership; two-way engagement with staff; culture; governance; and quality improvement methodology.  More focus was needed on leadership rather than the quality improvement methodology. 

 

Action had been taken to reduce the demand for services at Hillingdon Hospital whilst also moving patients quickly along the care pathway.  Board rounds and reducing stranded patients were helped by daily morning meetings where each patients’ needs were discussed.  This had helped to reduce length of stay by medically optimising the patients.  Dr Khakoo had also been working on designing a new medical model to create capacity to improve ambulatory assessments.  Work was underway with partners to increase discharges and prevent readmission.  It was anticipated that the work with ambulatory and sensory conditions could save 20 beds which, if the two pathways could be in place by winter, would reduce demand for beds during the hospital’s busiest period. 

 

The Trust had a strong ambition to demonstrate the characteristics of a ‘Good’ organisation in relation to all areas of the Well Led framework.  It was committed to demonstrating robust governance arrangements and building a collaborative culture whilst providing an optimum environment of care and services that had the right staff with the right skills to ensure that the care delivered was always safe. 

 

Mr Sumray confirmed that, following the 2015 CQC inspection report, an action plan had been put in place which had been RAG rated and monitored by the Board at every meeting up until about a year ago.  The 2015 action plan had been designed in two parts and the accountability element had not been made clear enough to staff – staff needed to be challenged if they were not following corporate policies.  Doctors had been identified by other members of staff as not being bare below the elbows and had been advised that, if they were caught again, disciplinary action would be taken (these doctors were now advocates for the policy).  Accountability needed to be situated at ward level. 

 

Ms Caroline Morison, Chief Operating Officer at the Hillingdon Clinical Commissioning Group (HCCG), advised that the RAG rating had not been a good way to monitor progress against targets.  She noted that it would be important for THH to communicate effectively with staff and patients about what ‘Good’ looked like, what they should expect and what the Trust was committing to do to address the issues raised in the CQC report.  Ms Morison advised that HCCG would be happy to work with THH on these headline communications. 

 

Mr Sumray advised that the number of staff vacancies at Hillingdon Hospital had resulted in a greater reliance on bank and agency staff.  It would be important to ensure that these staff received appropriate training.  In addition, it was recognised that some permanent members of staff were set in their ways and it would be equally important to ensure that any bad habits they had were addressed. 

 

As recruitment continued to be a challenge, work was being undertaken regarding recruitment in India and retention but there was significant competition from other Trusts.  A cohort of 20 Nursing Associates would be starting in January 2019 who would then be able to go on and complete a nursing degree in 18 months. 

 

It was noted that a lack of flexible working, career development, engagement and bullying/harassment had been reasons cited by some staff leaving THH.  Work was being undertaken with staff to address these issues and would be aligned with the Trust’s People Strategy which was about nurturing the workforce and giving staff a positive experience. 

 

It was noted that Mr Sumray had been appointed as the Chair of the Board just after the inspection, Ms Walker had been Deputy Director at the time and Dr Khakoo had been in position.  Concern was expressed that the management team had not taken sufficient account of the problems that had been found during the last CQC inspection.  The Divisional and Executive teams had rarely attended some departments and the front line staff appeared to be the ones that were being made accountable.  Mr Sumray advised that the situation was unacceptable and that account had been taken of the issues raised in the 2015 report but that the Trust’s response had not been adequate.  Some areas of the hospital had not been visited by the management team as their focus had been on the wards – this had been a failing on the Trust’s part.  Since the 2018 inspection, areas such as the linen store and the mortuary had been visited and excellent practice had been witnessed.  Mr Sumray advised that the Trust was determined to get it right this time. 

 

Ms Walker noted that some of the Trust’s policies were quite detailed and, although available to them, staff would not be expected to know each one in detail.  However, the induction covered the mandatory training needed for all staff and, if they were unsure about something, they could always ask their manager or another appropriate person. 

 

Concern was expressed regarding staff morale at Hillingdon Hospital as it had been raised in the 2015 CQC inspection report and continued to be an issue in some areas.  Mr Sumray advised that NHS staff and services were under significant pressure and there was concern about how this would be affected by winter pressures.  Consideration would need to be given to how this could be alleviated as workforce was a major concern across the NHS.  However, it was noted that Hillingdon staff were very caring and continued to work and care for the patients despite the pressure that they were under and the feelings of deflation they felt as a result of the CQC report.  Consideration would also need to be given to how staff could be supported during emotional pressure. 

 

It was noted that no one person was accountable – everyone was responsible for adhering to corporate policies.  Champions were in place at the Trust for a range of issues, including a Freedom to Speak Up Guardian who had been working with the other Champions.  It was recognised that the 2018 report demonstrated that the Trust had a long way to go. 

 

Dr Steve Hajioff, the Council’s Director of Public Health, advised that THH had a high quality leadership team and front line staff but that there appeared to be a gap in middle management which led to issues around visibility of divisional leadership.  Identification of this gap meant that positive action could be taken to address it and bring the strategic leadership and front line staff closer together to deliver meaningful change.

 

Dr Hajioff stated that THH’s record keeping was a cause for concern as well as those services / domains that had remained static or declined in their CQC rating.  Record keeping had been highlighted as an issue in both the 2015 and 2018 CQC reports.  It was suggested that this issue should be at the forefront as records were an essential part of enabling staff to fulfil their roles.  Clearly, failures in record keeping were unacceptable.  Dr Khakoo noted that there had been some issues around record keeping but that this had not been the case in maternity, medical care and those services where care had been deemed to be safe.  There had been some areas of significant improvement but also one or two areas where there had been no minimum dataset of the required numbers.  The Trust was now using its high performance teams to show other teams at the hospital what ‘Good’ looked like. 

 

As there were two or three major sites in Borough, the hospital needed to be on top of its major incident planning.  Ms Walker advised that the Trust’s Emergency Planning Officer had met with the inspectors who had found hard copies of outdated plans in clinical areas.  These hard copies had now been destroyed and staff had been reminded to ensure that they only used the electronic action cards which were available on the intranet. 

 

The Chairman asked Mr Sumray if it would be possible for the Committee to see a copy of the Trust’s response to the draft CQC report.  Mr Sumray advised that the CQC had taken account of approximately 75% of the 100 comments that the Trust had made on the draft report.  He would need to determine whether it would be possible to share the list of changes that the Trust had requested.  Mr Sumray advised that, prior to the 2018 inspection, THH had had a number of outside bodies undertaking mock inspections at the hospital but that they had not identified many of the issues that the CQC had highlighted. 

 

Mr Sumray stated that the Trust did not underestimate how much work needed to be completed and that it was determined to make the necessary changes.  However, cultural changes would take longer.  Irrespective of it being anticipated that the CQC reinspection would take place before the end of the calendar year, it was important that the Trust addressed the issues of concern as quickly as possible.  Mr Sumray was confident that the actions being taken would lead to sustainable change. 

 

RESOLVED:  That the presentations be noted.