Agenda item

The attached report from London North West Healthcare sets out their progress in responding to the findings and recommendations of the Care Quality Commission (CQC) inspection of Northwick Park Hospital.

The Chair advised that the London North West Hospital Trust (LNWHT) had been subject to an inspection by the Care Quality Commission (CQC) in late May 2014. The subsequent report published by the CQC on 20 August 2014 had identified a number of areas where the LNWHT and Northwick Park Hospital (NPH) were found to require improvement. The findings in relation to the A&E service at NPH were particularly concerning and in recent months the length of wait times at the unit had been amongst the worse in the country. The reports before the committee updated members on the progress achieved by LNWHT against the CQC Compliance Improvement Plan and the development of the Trust Quality Improvement Plan. Representatives of the LNWHT were present to address the committee’s queries.

Carol Flowers (Chief Nurse, LNWHT) introduced the Compliance Improvement Plan and advised that the recommendations of the CQC had been grouped into actions that had to be completed within three months and those that should be taken with a longer time frame. It was emphasised that the ‘must do’ actions had all either been completed or were on track to be completed by the deadlines set.  This included the creation of a new database to capture information on the safety and quality of care and treatment provided within critical care and the appointment of a lead clinical officer to oversee this. A series of actions had been undertaken in response to concerns that the maternity service did not actively seek women’s feedback including the appointment of a designated Patient Experience and Quality Improvement Lead and the development of a Women’s Feedback Plan. The Trust Quality Improvement Plan would be made available to the committee following its circulation to the CQC in the coming week. The Plan had been submitted to the LNWHT Board earlier that day and included actions such as increasing compliance with mandatory training rates and integrating policies and procedures across the Trust. It had been agreed with CQC that monthly meetings would be held to monitor improvement at the Trust and provide assurance to providers and stakeholders. A compliance manager would be appointed to sustain this work. In concluding the presentation, Carol Flowers advised that the issues raised by CQC regarding the A&E unit at NPH had principally related to the need to appoint permanent staff into several posts. These issues had largely been addressed by the transfer of staff from CMH A&E to the unit at NPH.

In the subsequent discussion, a member queried how many reports had been received as a result of the ‘see something say something campaign’ which had been launched to encourage staff to raise their concerns. It was further queried how the campaign worked in practice and to whom staff were asked to report their concerns. Comment was sought on the findings relating to the maternity service. A question was raised regarding whether LNWHT had been challenged on their Whistleblowing Policy. An update was sought on the low levels of medical staffing in critical care which had been identified by the CQC and further details were requested regarding the employment of locum staff. It was queried whether the staffing levels in the A&E unit at NPH were sufficient and an update was sought on the performance of the unit. The Committee queried the total number of beds at NPH and CMH and requested a breakdown of this latter figure by category of use. Concerns were raised regarding the poor waiting times, including for patients arriving by ambulance, paramedics being overstretched and confusion regarding which hospitals patients should be directed to. In light of these concerns, the committee queried whether there had been any impact on the hospital’s mortality rates. It was queried what steps had been taken locally to manage the additional pressure on A&E services and an update was sought on improving patient access to primary care. The committee questioned whether the number of beds to be removed via the Shaping a Healthier Future (SaHF) programme had been reviewed in light of the shortage of beds described and a request was made for confirmation of the current planned figure to be provided in writing. Queries were raised regarding the process of discharging a patient and whether consideration was given to the time of day or night and the condition of the patient.  An update was sought on Delayed Transfers of Care

Responding to the committee’s queries Carole Flowers advised that the CQC had commented on the open and frank culture amongst staff. There had been approximately twelve reports made thus far as a result of the ‘see something say something’ campaign and staff were encouraged to report their concerns to their managers, or directly to either the Chief Nurse or the Director of HR as appropriate. The campaign was linked with the re-launch of the Trust’s Whistleblowing Policy. There had been no challenge of this policy but it had been recognised internally that the Trust could take a more robust approach and learn from best practice. There had been some feedback from patients on the Maternity Ward that they felt that the service they had received was not satisfactory. The Midwives had been quite upset at the feedback and had developed their own standards of behaviour to be implemented alongside the existing Trust guidelines. These standards sought to help staff be more sensitive to a patient’s feelings and help them manage stressful situations with this in mind.

Carol Flowers further explained that a recruitment plan was being enacted to combat low levels of permanent staff in Critical Care and the majority of positions had now been filled. Where there were delays in filling some posts, a locum would be employed until the relevant appointments had been made. The preference was to utilise locum staff with experience of working in the particular hospital to ensure familiarity with the Trust’s policies. With regard to the medical staffing in the A&E unit, this comprised 180 nursing, 60 doctor and 16 consultant positions. There were approximately 20 nursing vacancies at the current time. It was emphasised that the A&E unit was one of the best staffed units at NPH.

Chris Pocklington (Chief Operating Officer, LNWHT) advised that there was significant pressure on the emergency pathway at NPH. The principle issue underlying this was a lack of bed capacity. Plans were in place to address this bed gap, some of which would come into fruition in the current year. However, a substantial increase in bed capacity was not planned to be delivered until the autumn of 2015. Whilst NPH was already a pressured site, it had been subject to increased pressure from late August 2014 due to a rise in the number of hospital admissions. It was emphasised that the increase in admissions were not the result of an increase in the number of patients attending the site, but rather a reflection of the acuity of the patients’ conditions. Steps were being taken to manage the increased pressure within the local healthcare system, including the addition of 32 new beds at the NPH site and 20 beds at Ealing Hospital. Work would be undertaken with partners to ensure that patients could be discharged into different healthcare settings as appropriate.  Rob Larkman (Accountable Officer, Brent, Harrow and Hillingdon CCG) added that Brent CCG was investing £10m into the local healthcare system to ensure a high quality range of services was available. Dr Ethie Kong (Chair, Brent CCG) advised that there were 4 locality GP hubs and a Saturday walk in centre to which patients were directed if they could not be provided with appointments at their GP practices.

Chris Pocklington continued that there were 600 beds at NPH, though not all of these were acute medical beds, and bed occupancy was currently tracking at 98 per cent. Tina Benson (Director of Operations, LNWHT) advised that there were 168 acute medical beds at CMH and a breakdown of the number of beds by category of use could be provided. The other beds at the site were utilised for those undergoing elective surgery. Chris Pocklington acknowledged that the pressures described had a broad impact across the healthcare system including on patients not on the emergency pathway and this was in part mediated by channelling a lot of elective surgery through CMH. He confirmed that mortality rates at NPH were routinely monitored by the Trust Board and there was no evidence that they were increasing. Dr Susan LaBrooy (Medical Director, Shaping a Healthier Future) added that NPH’s mortality rates were amongst the best in the county.

Professor Ursula Gallagher (Director of Quality, Brent, Harrow and Hillingdon CCGs) advised that there were sound clinical reasons which underpinned the decision to close the A&E unit at CMH and patient safety was paramount. With regard to concerns raised about times at which patients were discharged from hospital, it was confirmed that this was monitored. NPH’s performance for Delayed Transfers of Care was amongst the best in London. Addressing the committee’s queries regarding SaHF, Ursula Gallagher emphasised that it was a five year strategy which would direct future action but the bed capacity and clinical model were under constant review.

The Chair thanked colleagues from LNWHT and Brent CCG for addressing members’ queries. He advised that the committee would need to be reassured that the recommendations of the CQC were being addressed within the timescales set and in view of the risks posed to Brent residents would require a further update on the progress made at a future meeting.

RESOLVED:

That an update on the progress made in addressing the recommendations of the CQC be presented to a future meeting of the committee.