Agenda item

To update members about the inspection report by the Care Quality Commission (CQC) which was published this year and which examined services provided by the London North West Healthcare NHS Trust.

At the invitation of the Chair, Robert Throw (Investigation Manager, Care Quality Commission) introduced the report which provided the committee with a high level outline of the findings of the June 2018 Care Quality Commission inspection of the services provided by London North West Healthcare NHS Trust. The findings of the inspection, set out in full detail in the report, were based on a number of planned and unplanned visits with information gathered over a period of time, which assured the Committee of the representativeness of the reached conclusions. Mr Throw highlighted some of the key issues raised under each of the five categories (“domains”) against which the Trust had been inspected (safety of services, effectiveness of treatment, level of care, responsiveness to patient’s needs and leadership) and stated that despite some minor variations, the overall rating demonstrated that the Trust required improvement. He advised that a total of 39 “must dos” and 72 “should dos” were identified in the final report as well as 6 warning notices, with the Trust asked to develop and act upon an action plan in response to all these.

The Committee noted that this was the second CQC inspection of the Trust in the last 5 years which had awarded the same rating and while acknowledging some of the positive work of the Trust already underway, felt that further reassurance was needed on the adequacy and sustainability of measures in the long term. The Committee was critical of a number of areas including partnership working, staff retention and patient experience while also challenging the Trust on the internal scrutiny mechanisms in place prior to the June 2018 inspection.

The meeting was attended by Dame Jacqueline Docherty (Chief Executive, London North West Healthcare NHS Trust) who said that she and everyone in the leadership team had felt devastated about the report, and acknowledged that significant work was required to bring the Trust to the required high standard. However, she stated that some detail had been lost in the report and asked the Committee to interpret the CQC findings into the wider context of other Trusts across the country, with a number of other Trusts facing similar problems. Furthermore, she stated that the report provided only a snapshot of the overall work being carried by the Trust’s services and added that significant and measurable improvements had been made particularly in relation to its Accident and Emergency Department, ranking Northwick Park Hospital as eighth best for mortality rates in the country

As part of her presentation, Dame Jacqueline drew members’ attention to a number of immediate actions which had been put in place by the Trust following the CQC report published on 31 August 2018 and asked the Committee to recognize improvements made to date. Firstly, she stated that as part of the “must do” recommendations, an appropriate action plan and governance structure had been put in place, with improvement directors hired to drive progress forward and ensure implementation of the plan. Secondly, she added that the Trust had invested in a transformation programme with three quality improvement managers employed at its front and an Employment Improvement Group to oversee and steer the process. Amongst some of the improvements made were the reiteration of the HEART[1] values, developing a better culture of working as well as developments to the cardio-vascular centre and a 58% reduction in ambulance services delays. Thirdly, the Committee was reminded of the Quality Summit held on 6 November 2018 which included discussions and workshops around some of the issues set out in the report and sought to implement some of the required changes, improve staff engagement and expand partnership working.

Dame Jacqueline emphasised the Trust’s commitment to continuous quality improvement and patient flow but reminded Members that meaningful and long-lasting changes took time. She also asked the Committee to acknowledge that the Trust operated at high workload of some of the sites, which were amongst the busiest in the country. The Trust was exploring a wider delivery of services and looking specifically at a range of critical pathways in seeking to understand concerns in order to deliver on promises.

In the discussion which followed, member took opportunity to question the Trust’s representatives. The key points are summarised below as follows.

Partnership working

A key part of the meeting revolved around effective partnership working and engagement, which the Committee felt needed improvement and firm commitment from the Trust, particularly on its relations with the Council and local stakeholders. Members heard that as part of the plan to improve partnership working, a Quality Summit was held on 6 November 2018 during which a number of pledges were made including an effort to gain a better understanding of what could be improved in terms of joint working. A structure and action plan had been set up by the Trust’s Transformation Board and a greater engagement with various organisations and local user forums was being carried out through the Trust’s Continuous Improvement Group. Rosemary Head (Divisional General Manager for Maternity, LNWHT) added that a part time improvement advisor and an Interim Chief Nurse had also been appointed whose role was to ensure long-term strategy and sustainability of the Trust as well as seek to make a difference in the overall improvement journey.

Trust representatives also pointed towards their determination to learn from cultural issues, as part of their partnership engagement plan. This was being carried out through an ongoing collaboration scheme with the NHS, focusing specifically around national safety initiatives and team working. The initiative had been adopted by the Trust and was being progressed through the work of its staff.  Responding to the committee’s concerns on the clash between medical and social care element and lack of collaboration, the Trust stated that a specialist team was in place to address these issues and expressed confidence that they were liaising with the local sector and planning care packages collaboratively.

Spotlighting on the Summit, Members were particularly critical of the fact that key figures from the Council had not been invited, including the Lead Member for Young People and Designated Safeguarding Officer and Strategic Director Children and Young People of Brent Council. Chairs of the Council’s two safeguarding adults and children boards also commented that the Trust had not made any attempts to discuss safeguarding concerns and stressed the importance to maintain links on a local level and utilise available expertise in order to overcome existing challenges. Dame Jacqueline apologised for not inviting some representatives of the Council to the Summit and assured committee members of the Trust’s commitment to enhance partnership working going forward.

In conclusion of this part of the conversation, Dame Jacqueline emphasised that the Trust was determined to address the key issues identified in the CQC report and welcomed another meeting with Members to report on progress and discuss the recommendations in more details.

Maternity

Discussions moved on with Members spotlighting on the observed inadequacies and poor performance of the Trust’s maternity unit at Northwick Park Hospital, which had been issued with a warning notice. A question arose on maternity deaths over the past decade and how it compared to the national average. In response, Rosemary Head stated that maternal deaths were not seen as an issue for the Trust, which had only one such registered in 2018 and neither was the Trust an outlier in that respect. While no specific figures could be provides about maternity death over the past decade, Ms Heed agreed to investigate this further and update the Committee.

Responding to questions regarding the neonatal bleep system at Northwick Park, Trust representatives explained the system had been reviewed as a result of the warning notices issued by CQC but assured members that the immediate actions had been taken to resolve the technical issues, with further audits and tests planned to ensure system compliance. Trust representatives also addressed a question from a member on Intensive Care Units, which although not a feature of maternity wards, were being looked at and seeking to reduce number of beds to ensure adequate access is provided.

In response to a question on the security measures added to waiting areas of the Trust and whether they were a direct result of the CQC inspection, it was explained that security on Trust’s premises had always been in place but the inspection had highlighted some existing issues such as the likelihood of doors leading to the delivery suite from theatres being forced open. Ms Head acknowledged the need for more robust measures but stated they required a fundamental change of culture across the Trust as part of its long term improvement strategy. However, she informed the Committee that new doors had been installed and notices put up to further mitigate further the risk of unauthorised access to restricted areas.

Ms Head stated that the key to ensuring that mistakes were not repeated was developing a culture of communication and transparency. She added that there were no direct concerns about the clinical outcomes and maternity dashboard indicators was reporting good performance on most outcomes. Significant efforts were also being focused on improving clinical outcomes and Peer Reviews within the maternity ward were due to start soon.

Staff

A further line of enquiry by Members centred on the Trust’s workforce issues, with the Committee spotlighting specifically on staff retention and turnover figures.  Trust representatives said they had been experiencing recruitment difficulties but explained that these were mostly concentrated at Ealing Hospital and continued to say that much had been done to improve the situation despite the Trust’s heavy workload. Dame Jacqueline assured committee members that the Trust was determined to offer competitive jobs in order to retain staff and develop their careers within the Trust. Current staff shortages were seen as “patchy” and limited to certain areas such as Accident and Emergency doctors. A number of new doctors had been recruited and the Trust was drawing upon positive impact from trainees. Creative measures such as reviewing staff structure to identify potential gaps in the workforce and developing a nurse apprenticeships programme, had also been adopted to try and improve staff long term career prospects.

In response to a question on eliminating a culture of fear across its workforce specifically in terms of raising concerns, the Committee heard that the Trust was determined to listen to staff’s views and ensure they were comfortable in the workplace. As part of this process and in line with its HEART values, the Trust had also appointed HEART ambassadors in an effort to reiterate values across its workforce. Planned walkabouts and the growing popularity of the Trust’s staff excellence scheme were amongst the ways the Trust was using to reassure staff but also ensure visibility of senior managers.

When asked about the poor uptake of staff training, the Trust stated that there had been a decrease in face to face training, with a significant proportion of training now being done online. However, they noted that an added complication was the fact that some medical staff were from abroad which meant there were some differences in their qualifications compared to the UK equivalent. Furthermore, they stated the current system used by the Trust did not allow for external training to be logged, which was the case with many of their junior doctors but added that a new system was being introduced which was expected to resolve the issues.

Finally, the Committee enquired about staff shortage and contingency recruitment plans following Britain leaving the European Union (EU). It was explained that all EU staff working within the Trust had been written to offering to cover any costs associated with visas that me required in order for them to stay in the UK. However, the Trust acknowledged that there had been a gradual decline in staff numbers from certain areas but stated it was determined to ensure that staff was adequately supported during the Brexit process and had therefore put a robust workforce plan in place. The Trust was also looking at the pipeline of staff and seeking to maximise alternative resources such as volunteers.

Patient experience

The Committee discussed the overall patient experience from Trust services and heard that a framework was in place to adequately engage with patients and identify potential lessons to be learned. Representatives added that the Trust was looking at patient experience across the organisation and as part of it was developing a patient engagement strategy, including enhanced patient tracking.

A Member noted that safeguarding did not feature in the pledges made at the Summit and spotlighted on the number of safeguarding issues observed, especially in emergency departments, including lack of emergency assessments. In response, Trust representatives stated that safeguarding was not considered an issue but expressed commitment to develop a closer relationship with the Council going forward. Addressing the issue with emergency assessment, they explained that this was a known issue caused by frequent delays due to some partners relocating patients to other hospitals. In noting the complexity of the tasks at hand, they assured Committee Members that the matter was at hand and the issue was gradually reaching to a more manageable level.

At the close of the meeting, the Committee heard a statement by Cllr Shama Tatler, Lead Member for Regeneration, Highways and Planning who speaking in a personal capacity, said about Northwick Park Hospital and the quality of received treatment and overall patient experience. She noted that changes had not been felt by residents and encouraged the Trust to investigate further particularly as the hospital serves other boroughs.

The Chair thanked Councillor Tatler, the Trust representatives and Council officers for their time and contributions to the meeting.

RESOLVED:

1. That full compliance with CQC recommendations as set out in the report be expected from London Northwest NHS Healthcare Trust
2. That improved engagement with local safeguarding boards, the Strategic Director for Children and Young People and Lead Member for Children's Safeguarding, Early Help and Social Care be expected from London Northwest NHS Healthcare Trust
3. That an update on improved partnership working and staff engagement be provided to the Committee at an appropriate future meeting.
4. That regular progress monitoring updates be provided to the Committee.