NHS Trust Quality Accounts 2018/19
The Chairman invited the following to the table:
· Dr Chris Streather - Chief Medical Officer and Deputy Chief Executive, Royal Free London NHS Foundation Trust
The Chairman asked Dr Streather for an update following the Care Quality Commission (CQC) report on the Trust (Barnet, Chase Farm and the Royal Free Hospitals) published on 10 May 2019. She also requested that he attend the next HOSC meeting on 11 July to provide a full update on the actions being taken to address the two areas which were rated ‘Requires Improvement’ in the CQC report.
Dr Streather reported that the Trust’s overall rating had fallen to ‘Requires Improvement’ since the previous CQC assessment in 2016, with failings found in the areas of ‘Are Services Safe?’ and ‘Are Services Responsive?’. The CQC had found 89 areas to be ‘Good’ and 19 ‘Requires Improvement’. In addition, 21 areas were noted as areas of outstanding practice compared with 11 areas in 2016.
The CQC report stated that the following areas needed improvement:
· Some of the areas that the Trust had been advised as needing improvement in 2016 had still not been put right.
· The Trust had not met its own targets for mandatory training.
· Staff did not consistently follow best practice when managing medicines.
· There was an insufficient number of staff with the required skills and qualifications in some services. However, there were no unfilled shifts and Wards were staffed at required levels. There were currently problems with recruitment and retention as in many other NHS organisations.
· The majority of staff feeding back through the Staff Survey were indicating that the Organisation’s culture had improved. The behaviour of senior staff appeared to have improved. However, in particular at the Royal Free site, there were problems with the work culture in the operating theatres with particular concerns being raised around senior staff.
· A&E waiting times – targets not met. Regularly attendance was around 400 people daily at Barnet Hospital and this was a large number for a district hospital. There had also been delays in the 18-week referral to treatment pathway and the 62-day treatment target for cancer This had been one of the reasons for the lower rating in ‘Are Services Responsive?’.
The CQC report made the following positive comments:
· Staff treat patients with dignity, kindness and respect.
· Staff teamwork was good.
· The Trust conducted a large amount of clinical research which has helped to reduce variation in care, improve waiting times and reduce neonatal admissions.
· Staff were being trained in Quality Indicator methodology and this was being applied. The Trust aimed to train 20% of its staff in this.
· ‘Are Services Well-led’ received a ‘Good’ rating.
· The Trust was a sector leader in areas such as its urology prostate cancer pathway, technology in dermatology and reducing admissions to its neonatal units.
· 40 ‘Speaking Up Champions’ had been trained and further training was underway to help tackle bullying. The Trust’s work on educating staff on behaviour was ongoing.
Dr Streather reported that no enforcement action was recommended but the Trust Board would meet the following week to discuss an action plan to cover the 19 issues which required improvement. He also commented that the Trust had a low healthcare-associated infection and mortality rate which was 15% lower than the national average.
The Chairman enquired why the CQC report was not mentioned in the Chief Executive Statement. Dr Streather said that he felt sure this could be referred to in the Statement before the Quality Account was published.
· The Committee congratulated the Trust on reaching its landmark 2000th liver transplant.
· The Committee was pleased to see interventions to improve patients’ experience, such as the introduction of ‘silent saws’ for removal of plaster casts. This was particularly helpful for children, people with learning disabilities and older people with dementia.
· The Committee praised the Trust for continuing to make improvements to care for dementia patients, one of which was the decoration of the 8 West Ward with a seaside theme. The Committee was pleased to see that the Trust had focused on such workable interventions as well as clinical ones. This was one example of significant improvements that had been made in the management of dementia care.
· The Trust was commended for a reduction in the cases of C.diff to well below the threshold.
· The Committee praised the Trust for its innovation in many areas and for becoming a world leader in many specialist treatments.
· The Trust was congratulated by the Committee for making improvements to the consistency and quality of information it provided for patients, resulting in it achieving Information Standard Certification before the Scheme closed.
· The Committee was pleased to see that the Trust’s progress around its digital transformation and development of clinical pathways was going well.
· The Committee commended the Trust on the extensive work done around quality improvement and the rolling out of the Quality Improvement (QI) methodology across many specialities, with Clinical Practice Groups established as the hubs for this work.
· The Committee was pleased to see that the Trust had prioritised ‘Learning from Deaths’ for the past year and would continue to prioritise this in the coming year.
· The Committee noted and valued the Trust’s priorities for improvement including:
Ø trying to build capacity in the workforce
Ø working to reduce unwarranted clinical variation
Ø improving its involvement with patients and carers
Ø improving safer surgery
Ø learning from deaths
· The Committee was pleased with the amount of clinical research carried out by the Trust. It was noted that Barnet Hospital had recruited the first European patient to take part in an international study exploring a potential treatment for wet age-related macular degeneration.
· The Committee was pleased that a focus on sepsis was noted as one of the CQUIN Scheme priorities.
· The Trust was commended for its Haemophilia Treatment Centre and thought the new treatments for haemophilia were exciting and benefiting patients.
· The Committee was pleased with the trial at Chase Farm Hospital of an innovative respiratory monitoring device to help detect patient deterioration.
· The Committee commented that as the Quality Account was a document intended for use by the public, it should be clearly set out and easy to navigate: this was not felt to be the case. The draft report had no page numbers, the language was vague in places and it was suggested that SMART be used as a methodology (Specific, Measurable, Agreed upon, Realistic and Time-based). The overall presentation should be reviewed to make the report easier to assimilate and scrutinise. The audit data was unclear, for example the section on cancer (section 2.2) could not be deciphered at all by the layperson. Many figures were missing from the audit data and it was not clear how figures above 100% were possible. This did not give confidence to the Committee that other aspects were being recorded accurately.
· The Committee was disappointed that there was much data missing from the Commissioning for Quality and Innovation (CQUIN) Scheme Priorities section.
· The Committee noted that the target of zero ‘Never Events’ by the end of March 2019 had not been achieved. Instead there had been an increase to nine. The Committee noticed an effort from the Trust to reduce ‘Never Events’ but progress had not been made at the pace required to protect patients’ safety.
· The Committee reported that it was frustrating that data was missing from the report. The data on the number of deaths reviewed contained in the report related to April, May and June 2018 and more up-to-date data was needed. The mid-year data had previously been made available so it was inexcusable that the final figures were not available. There was no data therefore in relation to the Priority ‘Learning from Deaths’.
· The Committee noted some of the ‘Actions Taken During 2017/18’ were self-evident and should be routine, such as reviewing safeguarding processes and reviewing the medical rota.
· The Committee was disappointed with some of the Trust’s national performance targets. Its compliance for Referral to Treatment was below the national average - the latest compliance in January 2019 was 73.9% against a target of 92%. The Cancer 62-day target had also not been met although it was hoped that improvements would be achieved in the future since the Trust set up the Cancer Clinical Practice Group. Accident and Emergency targets had been at 87.4% for several months, below the 95% target, though it was acknowledged that the Trust received a huge volume of patients and was investigating how it might tackle this.
· The report does not mention the Walk-In Centres at Cricklewood and Finchley Memorial Hospital. It is believed that Finchley Memorial Hospital and Edgware Community Hospital are also run by the Trust.
· Some of the Quality Priorities, such as ‘further enhance and support dementia’, were vague and not measurable so it was not clear how the Trust would know whether its strategies were successful.
· The report detailed the Trust’s completed actions but it would be helpful if it also included the actions outstanding and a firm timescale for dealing with them.
· The Committee noted that many of the Quality Account priorities for 2018/19 were not achieved.
· The following had previously been noted in 2017/18 Q3 and Q4 Reports and there was no update in the 2018-19 Quality Account so these do not appear to have been followed up on:
Ø Deprivation of Liberty Safeguards (DoLs) were not in place.
Ø Oral care was not well documented in nursing notes and oral care plan not triggered on
admission. In addition under ‘patient care’ it was noted that staff were slow to act on poor oral intake. There has been no further update on this.
Ø Correct storage of medicine was not always adhered to ie not stored at the correct temperatures and not returned to locked cupboards.
In addition Members also asked Dr Streather about the following and he agreed to respond after the meeting:
- Some of the appendices are missing from the report – please provide this data?
- Section 3, point 2 of the report Improving Patient Experience mentions ‘organisation development’ – what is the time frame for this piece of work?
- Completed actions from 2016 are in the report but it would be helpful to see a list of the actions outstanding. Could these be included in the Quality Account?
The Chairman thanked Dr Streather for attending the meeting and providing helpful and open responses.
RESOLVED that the Committee would forward their comments for inclusion in the final Quality Account by 17 May.
NORTH LONDON HOSPICE QUALITY ACCOUNT 2018/19
Fran Deane - Director of Clinical Services, North London Hospice
Miranda Fairhurst - Assistant Director, North London Hospice
The Committee scrutinised the draft North London Hospice Quality Account 2018-19 and wished to put on record the following comments:
- The Committee commended the Hospice for producing an accessible report that was easy to navigate.
- The Committee congratulated the Hospice on the increase in the completion of the falls paperwork since the last falls review and noted that 100% of reviews had been completed.
- The Committee was delighted that nursing staff have been recruited to the Community Teams via the Sustainability and Transformation Plan and that the Hospice also welcomed nursing and social work students and offered placements for undergraduate and post graduate doctors.
- Infection prevention and control was excellent with no cases of C.diff again during the year.
- The Committee was pleased to hear about the implementation of the ‘Productive Ward’ on the Inpatient Unit to improve ways of working leading to “Releasing Time to Care”, enabling staff to spend more time with patients.
- The Committee noted that the number of new pressure ulcers had fallen from 78 to 63. This was partly attributed to the purchase of new mattresses in Spring 2018.
- The Committee noted that there had been an improvement to acceptable standards following the audit of both waste management and hand hygiene.
- The Committee was pleased that successful measures had been taken to address the problem of closed bed days down from 78 in 2017/18 to only 12.
- The reporting of ‘near misses’ had increased which indicated better awareness and surveillance. All ‘near misses’ had been ‘low harm’ or ‘no harm’.
- The Committee complimented the Hospice on its training, educational and other initiatives to improve care for patients and allow staff to spend more time on direct patient care. These included:
- Training 96 ‘Compassionate Neighbours’
- Setting up Journal Clubs to share information on various topics
- Introducing the One Page Patient Profile called ‘Things to Know About Me’ and a Dementia Chest to help staff care particularly for dementia patients
- Implementing the use of magnets to identify patients needs and care risks at a glance
- Running two Palliative Care courses for healthcare professionals
- Inaugurating a Falls Group for community patients which will run four times a year to increase patient awareness about falls, why they happen and how to manage them
- Training 25 volunteers for Bereavement support
- The service user experience was positive with 237 written compliments received.
- The Committee was pleased to see that the ‘Catching the Light’ photography group had continued with much success.
- The Committee congratulated the Hospice on having approximately 950 volunteers.
- The Committee commented that non-medical prescribing was a positive step and was pleased to learn that patients would continue to be supported to die at home if that was their preference.
- The Committee was concerned that the ‘Infection, Prevention and Control Audits’ had revealed areas of non-compliance including the need for improved treatment of lime scale, consistent completion of decontamination checklists and the correct labelling of sharps bins, but was reassured by the remedial action taken.
- Although there had been an improvement in the completion of bedrail risk assessments from the previous year, not all had been completed weekly in accordance with policy. The Committee noted that the Hospice had amended the policy to include risk assessments only being undertaken when a patient’s condition changes.
- The Committee was disappointed that the target of a minimum 80% occupancy had not been met due to a shortage of Inpatient Unit nurses and doctors. However, a rota of doctor availability was being set up.
- The Committee noted that 12 complaints had been received, with 11 upheld and one partly upheld. There had also been 23 ‘concerns’ raised by Users mainly relating to clinical care.
- The number of patient falls was of concern as it had risen from 53 to 62, despite the introduction of patient alarms and the purchase of low beds.
- Medication errors had increased to 40 this year, although below average compared with hospices of a similar size. The Committee was informed that the Hospice is now separating out non patient-related medication incidents from those directly affecting patients.
- The staffing issues were noted, including bullying, though this did not appear to be outside average figures.
In addition Members asked Fran Deane about the following:
- Why there had been an increase in the number of falls? She responded that this depended on the cohort of patients at the time with some keen to be more independent.
- Why the benchmarking data was not available for falls and medicines incidents to know how the NLH compare to other hospices? This information would be added to the table and forwarded to the Committee as soon as it was provided by Hospice UK.
- Whether Homeless Action in Barnet was a stakeholder? She would check this and respond after the meeting. She was asked about the referral process for homeless people and responded that referrals are accepted and the NLH was working with providers so they understand how to refer.
- How electronic patient record was working? Egton Medical Information Systems (EMIS) would be introduced this year as it interacts with GP records. It was also introducing ‘Coordinate My Care’ which helped to improve communication with Primary Care and the London Ambulance Service.
- What is the timescale for the Carer Strategy? Currently the NLH was consulting carers to find out what they required.
- What is the funding for the NLH as it appeared that Haringey provided more funding than Barnet? This was not the case as there were different funding models. She would provide further information after the meeting.
The Chairman thanked Ms Fairhurst and Ms Deane for attending.
RESOLVED that the Committee would forward their comments for inclusion in the final Quality Account by 28 May.
CENTRAL LONDON COMMUNITY HEALTHCARE NHS TRUST QUALITY ACCOUNT 2018-19
The Chairman invited the following to the table:
Kate Wilkins - Assistant Lead for Quality, Central London Community Healthcare NHS Trust
The Committee scrutinised the draft Central London Community Healthcare NHS Trust Account 2018-19 and wished to put on record the following comments:
- The Committee congratulated the Trust on its achievements against its Commissioning for Quality and Innovation (CQUIN) goals for Barnet and on winning ‘Organisation of the year’ at the HSJ Patient Safety Congress 2018.
- The findings of the last CQC inspection were positive and the Committee was pleased to see that ratings for Community End of Life Care had improved from ‘Requires Improvement’ to ‘Good’ since the previous inspection. The Committee complimented the Trust on receiving a rating of ‘Outstanding’ for the ‘Well-Led’ domain in the Community Health Services for Adults’ core service which was previously rated ‘Good’.
- The Committee complimented the Trust on producing a Quality Account which was accessible and easy to scrutinise.
- The Committee was pleased to note the Trust’s ambitious goals.
- The Committee was pleased that there had been an increase in ‘harm-free care’ with a significant reduction in the number of falls: 99.3% of patients had not experienced a fall during the reporting period.
- Although the Trust had not met its target for Pressure Ulcers, the Committee was pleased to see the actions that had been taken to improve this.
- The Committee noted that 0% of patient deaths ‘were judged to be more likely than not to have been due to problems in the care provided’.
- The Committee noted the Trust’s goals and achievements in relation to its workforce including:
· achieving an increased take-up of the staff ‘flu vaccine, achieving one of Barnet’s CQUINS.
· recognising outstanding individuals at its own internal Staff Awards Ceremony.
- Although the Committee noted that recruitment and retention of staff was currently a nationwide and particularly London-wide issue, it was concerned that the Trust’s staffing levels could impede its ambitious expansion plans. High standards could be difficult to maintain given staff shortages and there might be a danger that acute hospital attendances would increase due to vacancies in CLCH.
- The Committee noted that the Trust had received a CQC rating of ‘Requires Improvement’ in the ‘Safe’ domain in Community Health Services for Children and Young People, which was due mainly to higher-than-recommended caseloads within the Health Visiting Service.
- The Trust had only ‘partially achieved’ or ‘not achieved’ its quality priorities on staffing: Campaign Five – Here, Happy, Heard and Healthy. The Committee would await the mid-year update to see whether progress had been made.
- The Committee expressed concern about the possible adverse impact that moving some senior staff to expand its services into Hertfordshire might have on the leadership of Barnet services.
- The Committee noted the amber KPI regarding staff appraisals but was reassured that significant work had been undertaken to improve the appraisal rate.
- The Committee was disappointed that the Trust had failed to achieve three targets under the ‘Preventing Harm’ section of its Quality Campaign:
1. Eight falls were recorded in bedded units with harm (moderate or above) against a target of zero
2. 133 pressure ulcers category 3 & 4 were recorded against a target of 96 (although the Committee were informed that the number in Barnet had reduced)
3. Five CLCH acquired pressure ulcers category 3 & 4 were recorded in bedded units against a target of zero.
In addition Members asked Kate Wilkins about the following:
- Why were the Walk In Centres not included in the Quality Account? The Director of Public Health would ask the CCG about this following the meeting as this was not within the remit of HOSC to scrutinise as part of the CLCH Quality Account.
- The Trust’s Staffing Strategy? This information would be forwarded after the meeting.
- CLCH’s expansion plans into Hertfordshire and whether this might have a negative impact on Barnet particularly in terms of staffing? She informed the Committee that Kathy Walker who is currently the Divisional Director would cover the Hertfordshire area and a new appointment had been made for Barnet, Dennis Enright, who knew the area well.
- Recruitment issues regarding Health Visitors and District Nurses and whether this might impact on CLCH being able to prevent an increase in admissions to A&E? She would take this back and respond after the meeting.
- The numerous ‘partially achieved’ results in the Quality Account? These were conservative assessments as some areas were more nebulous and therefore more difficult to assess.
6. Omitted information in the local and national audit section? The Committee would be sent this as soon as it became available which should be before the end of May.
The Chairman thanked Ms Wilkins for attending the meeting and for her helpful responses.
RESOLVED that the Committee would forward their comments for inclusion in the final Quality Account by 31 May.
The Chairman invited the following to the table:
· Rory Cooper, Manager, Healthwatch Barnet
· Claire Thorstensen- Woll – Research and Policy Officer, Healthwatch Barnet
Mr Cooper read out Healthwatch Barnet’s comments on the Royal Free London NHS Foundation Trust’s Quality Account:
· In reviewing the Quality Accounts, we look at the documents from a patient/carer point of view, and consider what would be important for them to know. We also review the feedback we have received from residents through the year, to see how the QA links with their actual experience of the service.
ROYAL FREE HOSPITAL QUALITY ACCOUNT
· We welcome the user-friendly lay-out, the use of visual images and case-studies.
· We are pleased to see the range of developments for patients, from the achievements with liver transplants to a Patient Group for Inflammatory Bowel Disease.
Review of priorities for achievement for 2018-19
· We welcome the Trust’s commitment to continuing to aim to reach the ‘Information Standards’ and we have noticed improvements to the website, with improved visuals and categorization of information. However, we were very concerned about the lack of patient information during the changes to the criteria and process for hospital transport in summer 2018. Changes were made, but patients were informed at short notice and the website was not updated at the time.
· We note that there was little detail on what was achieved for patient and carer involvement and are pleased to see that this will be a priority for 2019-20, with a suite of tools that include cultural considerations.
· Through the Quality Account, we welcome the information and transparency given about serious incidents, never events and learning from deaths, and emergency re-admission. We understand that BCCG has worked closely with RFL on these areas. However, we have had feedback from relatives about the lack of information and support when they have tried to find out more about the patients’ experiences or death, slow or no responses from the PALS team or other staff. These areas (and the overall complaints handling) cannot be improved unless RFL engages in a structured and empathic way with patients and their carers. This must be from the culture of senior management to ward and support staff.
Proposed priorities for 2019-20
· We welcome all the proposed priorities. We note the continued focus on patient involvement, however specific targets and measurements need to be set for this.
· We know that patients in principle support digital pathways and have received positive reports where this has worked well. We have also escalated individual patient cases where there seemed to be system difficulties for patients being referred or booking appointments in some clinics, such as gastroenterology and cardiology. It’s important that patients and carers are fully informed of changes and support is provided so that patients receive timely care.
During 2019 Healthwatch Barnet will aim to
· Undertake Enter and View visits to Royal Free Hospital sites, potentially covering pain management; patients and carers understanding of their diagnosis, medication and changes to medication; quality of care and responsiveness of staff. We will liaise with BCCG and RFL on this.
· We note the variable performance on cancer treatment. We are currently in initial discussions with BCCG to do some patient engagement on awareness and attendance of cancer screenings and potentially with inpatients and outpatients on the quality of the service.
Mr Cooper read out Healthwatch Barnet’s comments on the North London Hospice:
Priorities for Improvement 2018-19 (p5 onwards)
· We have been pleased to see NLH focus on addressing inequalities and their work with different cultural forums, on learning disabilities, and on homeless people. Their commitment is commendable. We would like to see how this engagement is making changes for these communities, to help improve the accessibility and reach of NLH’s services.
Priorities for Improvement 2019-20 (p10 onwards)
· These are important and welcome priorities and we are pleased to see the range of services and actions that have been identified, from developing a ‘Carers Strategy’ to ‘Productive Ward’.
General (p18 onwards)
· We are pleased to see that NLH works to develop good practice and improvements through the year across many areas, from a Kinship Support Co-ordinator, to the partnership working on the ‘Outcome Star’ to resources for children and young people.
The Governance Officer would forward Healthwatch Barnet’s full response to CLCH’s Quality Account as soon as it was available.
Action: Governance Officer
RESOLVED that the Committee noted Healthwatch Barnet’s Comments on the Royal Free London NHS Foundation Trust and the North London Hospice’s Quality Accounts.
- Quality Accounts 2018-19 Cover Report, item 11. PDF 180 KB
- Appendix 1 - Minute extract from HOSC meeting May 2018, item 11. PDF 97 KB
- Appendix 2 North London Hopsice draft Quality Acccount 2018-19 V10, item 11. PDF 2 MB
- Appendix 3 CLCH Quality Account 2018-19, item 11. PDF 835 KB
- Appendix 4 Royal Free Hospital Quality Account 2018-19, item 11. PDF 11 MB