Review into the Quality of Care & Treatment provided by 14 Hospital Trusts in England RAPID RESPONSIVE REVIEW REPORT FOR RISK SUMMIT

Transcription

1 United Lincolnshire Hospitals NHS Trust Review into the Quality of Care & Treatment provided by 14 Hospital Trusts in England RAPID RESPONSIVE REVIEW REPORT FOR RISK SUMMIT June 2013

2 Contents Appendix VI: Information available to the RRR panel 81 Appendix VII: Unannounced site visit Introduction 3 2. Background to the Trust 7 3. Key Lines of Enquiry Findings 18 Governance and leadership 22 Clinical and operational effectiveness 30 Patient experience 35 Workforce 40 Safety 48 General Medicine and Elderly Care 52 Urgent Care 56 Obstetrics 61 Critical Care and Surgery Conclusions and support required 70 Appendices 73 Appendix I: SHMI and HSMR definitions 74 Appendix II: Panel Composition 76 Appendix III: Interviews held on announced visit 77 Appendix IV: Observations undertaken 78 Appendix V: Focus groups held 80 2

3 1. Introduction Overview of review process On 6th February the Prime Minister asked Professor Sir Bruce Keogh, NHS England Medical Director, to review the quality of the care and treatment being provided by those hospital trusts in England that have been persistent outliers on mortality statistics. The 14 NHS trusts which fall within the scope of this review were selected on the basis that they have been outliers for the last two consecutive years on either the Summary Hospital level Mortality Indicator (SHMI) or the Hospital Standardised Mortality Ratio (HSMR). Definitions of SHMI and HSMR are included at Appendix I. These two measures are intended to be used in the context of this review as a smoke alarm for identifying potential problems affecting the quality of patient care and treatment at the trusts which warrant further review. It was intended that these measures should not be reviewed in isolation and no judgements were made at the start of the review about the actual quality of care being provided to patients at the trusts. Key principles of the review The review process applied to all 14 NHS trusts was designed to embed the following principles: 1) Patient and public participation these individuals have a key role and worked in partnership with clinicians on the reviewing panel. The panel sought the views of the patients in each of the hospitals and also considered independent feedback from stakeholders, related to the Trust, which had been received through the Keogh review website. These themes have been reflected in the reports. 2) Listening to the views of staff staff were supported to provide frank and honest opinions about the quality of care provided to hospital patients. 3) Openness and transparency all possible information and intelligence relating to the review and individual investigations will be publicly available. 4) Cooperation between organisations each review was built around strong cooperation between different organisations that make up the health system, placing the interest of patients first at all times. Terms of reference of the review The review process was designed by a team of clinicians and other key stakeholders identified by NHS England, based on the NHS National Quality Board guidance on rapid responsive reviews and risk summits. The process was designed to: Determine whether there are any sustained failings in the quality of care and treatment being provided to patients at these Trusts. Identify: i. Whether existing action by these Trusts to improve quality is adequate and whether any additional steps should be taken. ii. Any additional external support that should be made available to these Trusts to help them improve. iii. Any areas that may require regulatory action in order to protect patients. 3

4 The review follows a three stage process: Stage 1 Information gathering and analysis This stage used information and data held across the NHS and other public bodies to prepare analysis in relation to clinical quality and outcomes as well as patient and staff views and feedback. The indicators for each trust were compared to appropriate benchmarks to identify any outliers for further investigation in the rapid responsive review stage as Key Lines of Enquiry (KLOEs). The data pack for each trust reviewed is published at Stage 2 Rapid Responsive Review (RRR) A team of experienced clinicians, patients, managers and regulators (see Appendix II for panel composition), following training, visited each of the 14 hospitals and observed the hospital in action. This involved walking the wards and departments, interviewing patients, trainees, staff and members of the Board. The report from this stage was considered at the risk summit. Stage 3 Risk summit This brought together a separate group of experts from across health organisations, including the regulatory bodies. They considered the report from the RRR, alongside other hard and soft intelligence, in order to make judgements about the quality of care being provided and agree any necessary actions, including offers of support to the hospitals concerned. A report following each risk summit has been made publically available. Methods of investigation The three day announced RRR visit took place at the Trust s three acute sites: Grantham Hospital, Lincoln County Hospital and Pilgrim Hospital Boston on Monday 17 June, Tuesday 18 June and Wednesday 19 June A variety of review methods were used to investigate the KLOEs and enable the panel to consider evidence from multiple sources in making their judgements. The visit included the following methods of investigation: Interviews Nine interviews took place with members of the Board and selected members of staff based on the key lines of enquiry during the visits. See Appendix III for details of the interviews undertaken. Observations Ward observations enabled the panel to see the Trust undergo its day to day operations. They allowed the panel to talk to current patients, and their families where observations took place during visiting hours. They allowed the panel to speak with a range of staff and observe the quality of care and treatment being provided to patients. The panel was able to observe the action by the Trust to improve quality in practice and consider whether any additional steps should be taken. 4

5 Observations took place in sixty one areas of The Trust split across the three hospitals; Grantham Hospital, Lincoln County Hospital and Pilgrim Hospital, Boston. See Appendix IV for details of the observations undertaken. Focus Groups Focus groups provided an opportunity to talk to staff groups individually to ask each area of staff what they feel is good about patient care in the Trust and what needs improving. They enabled staff to speak up if they felt there was a barrier that was preventing them from providing good quality care to patients and what actions might the Trust need to consider improving, including addressing areas with higher than expected mortality indicators. Focus groups were held with seven staff groups during the announced site visit, with mixed groups being held across the three main hospital sites. See Appendix IV for details of the focus groups held. The panel would like to thank all those attending the focus groups who were open with the sharing of their experiences and balanced in their perceptions of the quality of care and treatment at the Trust. Listening events Public listening events give the public an opportunity to share their personal experiences with the hospital, and to voice their opinion on what they feel works well or needs improving at the Trust in relation to the quality of patient care and treatment. A listening event for the public and patients was held on the evening of 17 June 2013 at The White Hart Hotel in Lincoln and on the evening of 18 June 2013 at The White Hart Hotel in Boston. These were open events, publicised locally, and attended by c.65 members of the public and patients at each event. The panel would like to thank all those attending the listening event who were open in sharing of their experiences and balanced in their perceptions of the quality of care and treatment at the Trust. We would also like to express our thanks to those families and patients who have contacted us through the patient voice website or through Cure the NHS Lincolnshire. The panel has considered each story in detail and whilst we cannot respond to individual complaints we want you to know that the panel will take on board your comments as part of the review. Review of documentation A number of documents were provided to the panellists at the Trust during the site visit. Whilst not every document was reviewed in detail, they were available to the panellists to validate findings as considered appropriate. See Appendix VI for details of the documents available to the panel Unannounced visit The unannounced out-of-hours visit took place at Lincoln County Hospital and Pilgrim Hospital, Boston on the evening of Thursday 19 June This focused observations in areas identified from the announced site visit, see Appendix VII. 5

6 Next steps This report has been produced by Dr Ruth May, Panel Chair, with the full support and input of panel members. It has been shared with the Trust for a factual accuracy check. This report was issued to attendees at the risk summit, which focussed on supporting United Lincolnshire Hospitals NHS Trust ( the Trust ) in addressing the actions identified to improve the quality of care and treatment. Following the risk summit the agreed action plan will be published alongside this report on the Keogh review website. A report summarising the findings and actions arising from the 14 investigations will also be published. 6

7 2. Background to the Trust This section of the report provides relevant background information for the Trust and highlights the areas identified from the data pack for further investigation. Context United Lincolnshire Hospitals NHS Trust is the principal acute provider of healthcare across the three main hospital sites (Boston, Grantham and Lincoln) for the residents of Lincolnshire. The Trust also provides a number of services within smaller community hospitals (at Louth, Gainsborough, Skegness and Spalding) owned by other organisations. Lincolnshire s resident population of 700,000 exceeds the Royal College of Surgeons preferred catchment population for an acute general hospital providing a full range of facilities. Lincolnshire is the second largest county in England (2700 square miles), and the Trust provides its services across its three main sites. Transport and road links between the sites are poorly developed compared with many other parts of England, with travelling time between sites of 50 minutes to one hour. To maintain local access the Trust replicates service provision across the county. The Trust and wider health community has recognised the future challenges to sustaining the current service configuration across all services in Lincolnshire, including acute provision. The whole health and social care community is committed to a sustainability review for Lincolnshire. The Trust provides a full range of District General Hospital (DGH) based services with General Medicine and General Surgery being the largest inpatient specialties; and Ophthalmology being the largest for outpatients. Lincoln County is unusual in that it is a DGH providing Radiotherapy Services, normally a tertiary centre function. In 2012 the Trust had 657,315 outpatient s attendances and 157,391 inpatient attendances. The day case rate over the same period was 82%, that is, patients entering and leaving hospital on the same day. With a total of 1,079 beds it has a market share of 78% for inpatient activity within a 5 mile radius of the Trust sites. The market share falls to 74% within a 10 mile radius and 49% at a 20 miles radius. In the three localities covered by the Trust, 2.4% of Lincolnshire s population belong to non-white ethnic minorities. The Trust s HSMR level has been above the expected level for the last 2 years and the Trust was therefore selected for this review. The health profile of the area is generally similar to that of England s average with some areas that are worse than the national average with several indicators that fall lower than what would be expected. The Trust covers seven district/borough council areas: Boston, East Lindsey, West Lindsey, North Kesteven, South Kesteven, South Holland, the City of Lincoln Council; and one County Council: Lincolnshire. The following matters are pertinent to this review: Long term unemployment in Lincoln is higher than the national average but both Boston and South Kesteven show above average employment 7

8 The levels of deprivation in Lincoln are worse than the national average together with the proportion of children in poverty in Lincoln being greater than the national average. Both Boston and South Kesteven perform more favourably on these metrics Smoking during pregnancy throughout the county is worse than England s national average Teenage pregnancy levels (under 18) in Lincoln and Boston are significantly greater than the English national average, although for South Kesteven a lower than average prevalence is noted Alcohol specific hospital stays are significantly greater than the average in Lincoln and Boston although below average for South Kesteven Rates of smoking in adults is above the national average The number of physically active adults is below the national average Hospital stays for self harm are significantly higher in Lincoln than the national average but fall within the national average for Boston and South Kesteven Lincoln and Boston also witnesses a much higher level of drug misuse incidents than the national average Life expectancy for male and females is lower than the national average in Lincoln and Boston with the respective figures Population data indicate that early deaths related to cancer are higher in Lincoln than the national average Population data indicate that early deaths related to heart diseases are also higher in the trust, specifically, Boston and Lincoln Acute sexually transmitted infections are significantly greater in Lincoln than the national average The health profile for the Trust is complex, with some areas being more deprived than others and some facing greater health challenges than others for specific diseases as articulated above. The variety of health needs of the population it serves poses a significant challenge for this Trust. Key messages from the Trust data pack Mortality indicators The Trust has an overall HSMR higher than expected for the past two years; with scores of 113 and 111 for the FY 2011 and FY 2012 respectively; the number of actual deaths in the hospitals within the trust is higher than the expected level and above the statistically expected range. Further analysis of this demonstrates that non-elective admissions are the primary contributing factor to this figure. Elective admissions are within the expected range, with an HSMR of 80. 8

9 The official SHMI was within the expected range at 110 for the period October 2011 to September 2012 and therefore as the Trust was not an outlier for SHMI for two consecutive periods, it was not selected for review on the basis of its SHMI. It was noted that the Trust has a SHMI of 109 (December 2011 to November 2012), which is statistically above the expected range. There is variation between SHMI and HSMR data across the three sites at which the Trust provides services. Similar to the HSMR, non-elective admissions are seen to be contributing primarily to the overall Trust SHMI. The Trust had nine high mortality alerts for diagnostic groups since 2007 and five requests for investigation relating to mortality from the CQC since The Trust has provided full responses to each of these and no further action has been required by the CQC. In depth reviews of the Trust by CQC have revealed the following areas as common themes of concern: Fluid balance monitoring Delays in implementing treatment plans Clinical documentation issues Delays in implementation of the Liverpool Care Pathway Failure to escalate the deteriorating patient Risk of falling during stays in hospital Senior review, particularly post operatively Together with the Care Quality Commission (CQC) Healthcare Evaluation Data (HED), Health and Social Care Information Centre and Dr Foster reviews have notified the following 8 mortality indicators out of 13 used nationally, as outside the expected ranges: Overall HSMR Emergency specialty groups much worse than expected (CQC) Emergency specialty groups worse than expected (CQC) Diagnosis group alerts to CQC Diagnosis group alerts followed up by CQC 9

10 Non-elective mortality (SHMI and HSMR) 30 day mortality following specific surgery / admissions Mortality among patients with diabetes Diagnosis coding depth has an impact on the expected number of deaths. A higher than average diagnosis coding depth is more likely to collect co-morbidity which will influence the expected mortality calculation. For The Trust, it is apparent that for elective admissions, the Trust has been consistently performing below the national average for coding depth. The average diagnosis coding depth for non-elective admissions has also been close to the national average and the most recent quarter shows the trust is above the national average. The Trust make below average use of palliative care coding on admission (using diagnosis codes rather than treatment speciality). This may impact on the mortality indicators. Leadership and governance The Trust has had 9 CEOs in 11 years and has consistently experienced major turnover of directors during this time. In addition to existing substantive directors (Chief Executive, Deputy Chief Executive, Director of Operations) the current Board is also composed of 2 interim directors: the Director of Nursing and the Director of Facilities as well as an Acting Director of Finance. The current Medical Director is working on a part time basis. There is a new Director of HR/Organisational Development who is shared with another local provider. New substantive Medical, Nursing and Facilities Directors have recently been appointed but have not yet commenced in post. The Board also consists of a Chairman and 5 non executives. Two additional non-executives are in the recruitment process. The Governance Committee, a sub-committee of the Board that provides assurance on quality governance is chaired by a Non Executive Director. The Quality & Safety Committee reports to the Governance Committee and is chaired by the Medical Director. Since the departure of the last Medical Director, this has been chaired by a senior member of his team. The Trust set up the pan-trust Mortality Reduction Board in In 2012, this was further supported by a new system at site level; site-based mortality reduction committees at main hospital sites, which report into the pan-trust Mortality Reduction Board. The current Director of Nursing is an interim member of the executive team and the Trust has recently appointed a new Director of Nursing from within the Trust patient services team. Recent reviews by the CQC identified minor concerns in relation to two outcomes: staffing, and the care and welfare of people who use services. This represents a significant improvement on the Trust s CQC inspections in prior years, which had identified a number of major concerns. The Trust is not currently a Foundation Trust, however in December 2012 the Board conducted a self-assessment of its performance against Monitor quality governance framework. The Board self assessed a score of 14.0 (aspirant trusts must receive a score of 3.5 or lower to be authorised as a foundation trust). This score included two reds (indicators of major concern) and did not meet expectation in the following areas: Is the Board sufficiently aware of potential risks to quality? Are there clearly defined, well understood processes for escalating and resolving issues and for managing quality performance? 10

11 An independent assessment in March 2013 scored the Trust as 9.5, with an improvement in the area Are there clearly defined, well understood processes for escalating and resolving issues and for managing quality performance? The Trust continues to undertake actions to improve its quality governance performance although the panel found little evidence that some of these matters had been addressed. Key self identified risks for the Trust relate to service provision, demand and sustainability, mortality, progress reliability, staffing and skills, lack of whole system provision, patient records and culture. In 2012/13, the Trust achieved cost improvement savings of 14.5m. The Trust plans to save 22.4 million in 2013/14 through cost improvement programmes (CIPs) million has been identified as per submission to the Trust Development Authority (TDA) on 24 May The Trust currently has an amber Monitor governance risk rating, although it is not a Foundation Trust, indicating that there is minor or moderate concerns in terms of any future authorisation. A high level review of the effectiveness of the Trust s quality governance arrangements, including the use of mortality information on a local basis, was a key line of enquiry for the review. Clinical and operating effectiveness The Trust was reviewed on its clinical and operational effectiveness based on nationally recognised key performance indicators. The Trust has high rates of severe hypoglycaemic episodes and low rates of patients receiving a foot risk assessment in They were also an outlier for the percentage of discharged patients who are prescribed beta blockers following a myocardial infarction and for the proportion of patients having surgery within 36 hours following hip fractures. The Trust sees 93.7% of A&E patients within 4 hours which is below the 95% expected level. The achievement of the 95% expected level varies from site to site. For referral to treatment, 90.6% of patients start treatment within the 18 week expected time which is above the target level. This has been a consistent trend from April 2012 to March The Trust s crude readmission rate which is the percentage of patients that were discharged and then re-admitted within 30 days is within the expected range when compared against the national average, at 11.3%. The average length of stay is shorter than that of the national average. The Patient Reported Outcome Measures (PROMs) dashboard shows that there has been some decline in performance across the six measures, with one instance (Hip Replacement Oxford Hip Score) of being below the lower 99.8% control limit. The data in this area highlighted some specific key lines of enquiry including, Respiratory Medicine, Stroke and Diabetes, all of which were highlighted as areas to review in the key lines of enquiry under clinical and operating effectiveness. Patient experience Of the 9 measures reviewed with Patient Experience and Complaints there are seven which are rated red which means the indicators are outside of the expected range: 11

12 National Inpatient Survey: The national inpatient survey 2012 measured a wide range of aspects of patient experience. A composite overall measure is calculated for use in the Outcomes Framework. This measure uses a pre-defined selection of 20 survey questions to rate the Trust on aspects including access to services, coordination of care, information and choice, relationship with staff and the quality of the clinical environment. The Trust sits below the national average with an overall measure of 73.8 compared with the national average at 76.5 Cancer survey: of the 58 questions, 22 were ranked in the bottom 20% whilst only 2 were in the top 20%. The main negative focus relates to overall care and care and treatment for inpatients Patient Environment Action Team (PEAT - privacy and dignity: The scores for privacy and dignity were shown as acceptable across some sites this is a low rating on this indicator PEAT - environment: The scores for environment are routinely shown as acceptable across all sites this is a low rating on this indicator Friends and family test (FFT): The Trust showed a decline in scores for the Midlands and East FFT to an overall score of 63 placing the Trust in the bottom quartile of the submissions Patient voice comments: In the two years to 31 January 2013, there were 241 comments on The Trust of which 165 were negative (68%). The negative focus includes a lack of professionalism displayed by staff (notes not filled in for example), lack of organisation and too much focus on targets Complaints about clinical aspect: Within the Trust, 704 written complaints were submitted during of which 73% related to clinical aspects of care, compared to the national average of 47%. The Ombudsman currently rates the Trust as A-rated. The Ombudsman investigates complaints escalated to it by complainants who are not satisfied with the Trust's response. It rates Trusts on whether they have implemented the recommendations made at the end of an investigation in a satisfactorily and timely manner, helping to ensure that Trusts learn from mistakes. The Ombudsman rates each Trust s compliance with recommendations and focuses on monitoring organisations whose compliance history indicates that they present a risk of non-compliance. The complaints process and the appropriateness of language used in front of patients by doctors and the manner by which patients are treated are highlighted as areas to observe in the key lines of enquiry under patient experience. Keogh review patient voice comments The patient voice comments received directly to the Keogh review website (at the time of writing this report) identified the following themes from 33 s and letters: Positive Patient was happy with services provided by Pilgrim Hospital. Admitted to A&E where care was very good. Appointments are on time. Receptionist was attentive and professional. Nurse was supportive and the operation and physiotherapy went well. All the staff were brilliant and care was excellent. 12

13 Excellent treatment and attention at orthopaedic ward. Physiotherapy was also very good. Patient had to wait 7 hours for a bed for an operation. Intensive Care ward was very good, staff were brilliant. As an outpatient there is a long wait to see a consultant but the staff are helpful and consultant is informative Negative Lack of communication between patient and staff at all levels. Mistakes in surgery and diagnosis Patient was undressed with the curtains not shut, no respect for dignity Delay in providing treatment and medical forms Buzzers not working and ward overcrowding, concerns about cleanliness Operations cancelled and appointments rearranged, long waits for diagnostic procedures and pain relief Poor attitude of staff with no respect for dignity of the patients, no help with basic tasks or personal hygiene Concerns about controlled drug management not being addressed Too few staff Inappropriate language and lack of sensitivity towards patients, staff being rude to patients Staff raised concerns in the following areas: Issues with staffing including recruitment, retention, use of agency, release of staff for training Poor escalation procedures Lack of stability within the Trust at senior level. Poor communication and engagement with staff and patients Poor communication, poor note taking, discrepancies in notes and communicated issues. Inappropriate use of do not resuscitate order, poor communication of test results No response or poor response in relation to a complaint made Poor management of medication being taken by a patient in advance of hospital admission 13

14 Disregard of available treatment due to age of patient, no assistance with eating Poor after care Key lines of enquiry were followed in the review based on what patients say about the quality of care and treatment of patients and what the Trust is doing in response to this feedback. Workforce and safety A review of the workforce data flagged a number of red rated indicators: The Trust s sickness levels across all staff types (medical, nursing, other staff and overall) are rated red. This means that staff sickness rates are above the national average for each of these groups. Turnover rate of staff is also higher than the Midlands and East Region median with a joining rate lower than the average at 5.7% compared to 5.9% and a leaving rate of 7.5% compared with 6.7%. This means that more staff than average are leaving the Trust and fewer staff than average are joining the Trust. The Trust s spend on agency staff was 5.1% of its total staff costs in 2011/12. This compares to an average in the Midlands and East region of 4.2% In addition to the above, a number of factors were identified from the General Medical Council s (GMC) National Training Scheme Staff Survey in These include: Worse than expected staff engagement The number of staff that would recommend the organisation as a place to work is below the national average The number of staff that, if a friend or relative needed treatment they would be happy with the standard of care provided by this organisation is below the national average Staff did not see care of patients as the organisation s top priority Further concerns were raised by the Deanery, when, in October 2011, it considered removal of junior doctors. However the Trust was able to sufficiently demonstrate that doctors in training were no longer working in wards without adequate supervision, and there was a more equitable workload. At Pilgrim Hospital in Boston, the Deanery conducted a full quality review of training in all specialties after student nurses were removed from the site by the Nursing and Midwifery Council in July The Deanery undertook five further visits in 2012 and confirmed that rotas had been reorganised to ensure appropriate workload and supervision for trainee doctors, who are also now receiving appropriate education. This site was noted as having persistent recruitment issues. The Deanery continues to undertake routine monitoring of arrangements. The NMC temporarily removed student nurses from one site during February 2011 following concerns expressed by the CQC. The situation was investigated and students were returned to the site in July

15 At Grantham and District Hospital, the Deanery quality management activity indicated that there were issues with handover and clinical supervision in medical and emergency medicine posts. The Deanery met with the Trust in November 2012 to discuss the issues. An action plan dated February 2013 indicated that there is now 24/7 middle grade cover, and the rota has been revised to improve handover. The Deanery continues to closely monitor the site. Key lines of enquiry were included in the review focusing on how the Trust is assured over its workforce in relation to out of hours cover and how it is responding to concerns raised by the Deanery in recent months and years. The Trust is red rated in the following two safety indicators: For methicillan resistant staphylococcus aureus (MRSA) infection rates, the Trust was in the bottom third of 143 trusts nationally over the three years from 2010 to The Trust s infection rate in relation to other Trusts has improved in 2012, and places ULH close to the average for all Trusts. The Trust has informed us that whilst its MRSA infection rates were above average nationally over the three years from 2010 to 2012, the rate of infection was significantly lower than the highest rates recorded across the country and the Trust has performed at or below the maximum acceptable ceiling for MRSA infection rates for the last 4 years. Clinical Negligence payments have exceeded contributions to the risk sharing scheme for two of the last three years. Payout exceeded contributions by a total of 4.9m over this period. The Trust has had 12 never events since Never events have potential to cause harm to patients and are judged as easily preventable by Department of Health (DH) guidelines. The Trust is above the average levels for all acute Trusts for pressure ulcers throughout the last 12 months. Between December 2012 and March 2013 there has been an increase in the percentage of ulcers from 1.1% to 2.9%. Key lines of enquiry were included in the review focusing on how the Trust is assured over the safety of care in its hospitals. 15

16 3. Key Lines of Enquiry The Key Lines of Enquiry (KLOEs) were drafted using the following key inputs: The Trust data pack produced at Stage 1 and made publically available Insights from the Trust s lead Clinical Commissioning Group (CCG), West Lincolnshire CCG Review of the patient voice feedback received specific to the Trust prior to the site visit These were agreed by the panellists at the panel briefing session prior to the RRR site visit. The KLOEs identified for the Trust were the following: Theme Key Line of Enquiry Governance and leadership Can the Trust clearly articulate its governance processes for assuring the quality of treatment of care? Are the leadership roles and responsibilities clearly defined for the quality processes? Can staff at all levels of the organisation describe the key elements of the quality governance processes Clinical and operational effectiveness What governance arrangements does the Trust have to monitor clinical and operational performance data at a senior level? What processes does the Trust have in place to support monitoring mortality data and clinical effectiveness? Has the Trust data identified any issues? What actions is the Trust taking to address issues noted? Patient experience How does the Trust review patient experience data and engage with patients to seek views about their experience? What are the key themes from patients on their experiences? What action is it taking to address the key themes emerging? What do patients say about the quality of care in the Trust during our observations/interviews? Workforce How is the Trust addressing staffing issues as raised through the Deanery? How is the Trust responding to out of hours staffing issues? How is the Trust responding to issues with qualified nursing ratios, nursing hours to patient day and high sickness rates? 16

17 Theme Key Line of Enquiry Safety How engaged are staff in the Trust s quality strategy? What do staff groups interviewed (including trainee groups) say are the main barriers in the Trust to delivering high quality treatment and care for patients? How does the Trust review and monitor its patient safety indicators? What actions are taken to improve patient safety? Trust Specific General Medicine and Elderly Care What actions is the Trust taking to address issues in general medicine including treating elderly care patients? How is the Trust managing its stroke patients? How is the Trust responding to high mortality flags in oncology, respiratory and thoracic medicine? How does the Trust manage patients with Diabetes and what action is it taking to prevent avoidable deaths? Trust Specific Urgent Care How does the Trust manage its Urgent Care Pathway? Trust Specific Obstetrics What actions is the Trust taking to address issue relating to obstetrics and the high number of deaths attributed to perinatal conditions? Trust Specific Critical Care and Surgery How is the Trust managing its critical care pathway and what actions is it taking to address the higher than expected mortality rates in this area? How is the Trust responding to the contributing factors such as deteriorating EWS score rates, shock cardiac arrest triggers and deteriorating renal function triggers within its crude surgical mortality rate? 17

18 4. Findings Introduction The following section provides a detailed analysis of the panel s findings, including good practice noted, outstanding concerns and prioritisation of actions required. Summary of findings A number of areas of good practice were identified as part of our review, notably: We met with some dedicated, committed and loyal staff Monthly mortality reviews have good attendance with good clinical engagement The Interim Director of Nursing has provided strong leadership to the nursing team The Matrons at all sites displayed strong leadership, especially at Grantham Hospital Many wards displayed safety thermometer data sets Plan for Every patient on wards Evidence of innovation e.g. Red Lid Scheme for Hydration/medication; phlebotomy service at weekends which takes pressure off junior doctors The Colorectal team at Lincoln hold an annual patient listening event Patient experience and stories are now part of the Trust Board meetings Safety and quality dashboards displayed on the wards Proactive work around dementia in particular wards GP support within the Grantham A&E Department that enables the most appropriate care to be provided to the patient The Trust is embarking upon a major review of services, with its Health and Social Care partners in Lincolnshire, to address the sustainability challenges for the whole community The Chief Executive, who was fairly recently appointed, is sighted on the complex issues in the organisation of aligning a Board driven strategy into fabric of every part of the organisation 18

19 During our visit, an issue was identified in relation to inadequate staffing levels within all three hospital sites. The panel formally escalated this to the CQC after the unannounced visit. In addition, concerns around satisfactory completion of do not attempt resuscitation (DNAR) forms were also raised. This was escalated to the Trust management team for immediate action. The Trust has completed a review of all patients with DNAR forms across all three hospitals and every DNAR form has now been signed off by a consultant and discussed with both patients and relatives as appropriate. As part of the review process, the panel received a submission from a former Chief Executive of the Trust. As with all evidence received through the public communication channels, the panel has reviewed this and triangulated this with its findings. This submission highlights issues with governance and staffing levels which triangulate with the findings detailed in this report. The main priority areas identified for action in each of the key lines of enquiry themes are below. Leadership and governance: There is a disconnect between leadership at Board level and leadership at clinical levels within the organisation: The Trust should ensure there are clear and active discussion lines between the clinical leaders at ward level, the clinical directors and the Trust Board to ensure that leadership of the organisation is joined up and consistent. The Trust should focus on engaging clinical teams rather than specialties or separate professional groups. Clinical and operational effectiveness: The panel was unable to easily see or understand how escalation worked for both actions taken in managing deteriorating patients and also managing patient flow as there seemed to be no standardised process in operation across the specialties and sites: The Trust should seek to clarify its escalation policy and ensure that it uses the track and trigger system effectively across all the Trust sites. Staff should ensure that escalation responses are appropriate and well documented in response to managing deteriorating patients. In addition the Trust should ensure that patient flow is planned and managed appropriately. An IT solution needs to be found to allow the ambulance inbound system to be visible in A&E. Patient experience: The complaints process is confusing and not fit for purpose: The Director of Nursing and the Company Secretary should review the handling of complaints and the processes whereby complaints can be systematically fed back and used by staff teams to improve service delivery. This should include creating a PALs function. Complaints should be seen as everyone s responsibility not just the complaints team / board. Workforce: Patient experience is not seen by patients to be at the heart of the organisation and service improvement: The Trust should implement a patient experience action focussed improvement plan that should include: real time patient feedback, evidence of listening and responding and using and working with patients to codesign service improvement. 19

20 Staffing levels were, in some areas and at certain times of the day, low. The panel formally escalated its concerns to the CQC on 21 June 2013: The Trust should consider urgently the staffing levels and mix throughout the Trust, covering: nursing numbers and appropriate use of agency and bank staff; Matron cover at Pilgrim Hospital, Boston; dependency of patients including 1:1 care, assistance with eating and assistance using toileting facilities, and; middle grade cover and appropriate supervision of junior doctors, especially out of hours. Safety: Workforce planning is poor with no recruitment plans and no plans in place to cover maternity leave, sickness and annual leave other than through the use of agency, bank staff or, in the case of medical staffing, locums: The Trust should document and implement a recruitment plan with immediate effect to fill the short term vacancies but also consider its medium term requirements. The Trust should also seek to firm up its strategic plans, including the level of future service provision at all three main hospital sites and the community sites. This should be done in conjunction with stakeholders. Student nurse posts should be advertised earlier. Quality strategy could not be consistently articulated by all staff and non executive directors: The Trust should confirm the key quality priorities for the Trust and ensure these are widely understood by staff using campaigns and listening events as well as s, the intranet and Ward to Board initiatives. General Medicine and Elderly Care Lack of awareness of the Mental Capacity and Deprivation of Liberty Act 2005 in relation to the Trust s responsibilities in allowing patients to leave wards if they are deemed capable and wish to: Staff should ensure that they are fully compliant with mandatory training requirements and adult safeguarding is given clinical engagement as a matter of urgency. Urgent Care There were no urgent actions under this KLOE. Obstetrics There were no urgent actions under this KLOE. Critical Care and Surgery We observed a number of issues with the completion of DNAR forms: The Trust has already undertaken an immediate review of all patients with DNAR forms to ensure they are accurately and adequately completed. This was completed immediately by the Trust. The Trust should review its process and policies for the completion for DNAR forms to ensure they meet best practice and legal requirements. 20

21 The following definitions are used for the rating of recommendations in this review: Rating Urgent High Medium Definition The Trust should take immediate action to respond to these recommendations and ensure improvement in the quality of care The Trust should develop a response and action plan for these recommendations to ensure improvement in the quality of care The Trust should implement these recommendations to ensure ongoing improvement in the quality of care 21

22 Governance and leadership Overview The panel s focus for governance and leadership was on the articulation and understanding of the Trust s governance processes for assuring the quality of treatment and patient care and how well embedded this was throughout the organisation. Through staff interviews, focus groups and review of governance documentation, the panel tested whether staff at all levels could describe the key elements of the quality governance processes, i.e. policies and procedures, escalation, incident reporting, risk management. The panel also reviewed the Trust s process to assess the impact of cost savings plans on quality of patient care and its workforce. Summary of findings The following good practice was identified: The Chief Executive, who was fairly recently appointed, is sighted on the complex issues in the organisation of aligning a board driven strategy into the fabric of every part of the organisation. The Non Executive Directors report recent more detailed quality discussions at Trust Board and increased confidence that the work on the integrated dashboard should provide congruence on patient safety and quality, performance and finance. Monthly mortality reviews have good attendance with good clinical engagement. The voicing concerns policy has been reviewed with support from staff and is ready for roll out and adoption. The Interim Director of Nursing has provided strong leadership to the nursing team. The Matrons at all sites displayed strong leadership and many wards displayed safety thermometer data sets. The intensive approach and Shop in Shop has driven substantial improvements in services where there has been concern. Patient Stories feature at the Trust Board each month. The Trust Board is embracing the need for a Service Sustainability Review to work with health and social care partners to tackle the emerging clinical viability challenges across all health services including acute service providers. This will address the real challenges of providing specialist acute services across geographically distant sites. The following areas of concern were identified: There is disconnect between leadership at Board level and front line clinical teams in the organisation. There is also variation in the levels of medical engagement across the hospital sites with this being strongest at Pilgrim and Grantham Hospitals. 22

23 The constant change in leadership at the executive level has led staff to feel uncertain and has created cultural problems as identified in the recent organisational diagnostic. Staff feel there is no clear vision and direction for the Trust and subsequently there is a disconnect between individual, team, directorate and corporate objectives. The governance structures and processes reflect the complexity of a large organisation that provides care on three sites that are separated by significant distances. Staff on the ground were unable to articulate the governance processes for quality of treatment and patient care and patient safety or the Trust s Quality Strategy. It was not clear to the panel where the accountability for quality and patient safety lies between Medical Director/ Director of Nursing. There was some evidence of Board to Ward assurance, however this was not visible to all staff and so there was limited opportunity for the board to evidence to staff that they truly take ownership of governance of quality of care. Serious Incidents and Never Events are received by the board via the committee structure but complex structures build delay into this process. Staff report that they do not receive any feedback on these routinely or in a timely fashion. There is confusion in the organisation as to whether there is a PALs function to support monitoring of quality and patient experience and how the complaints process worked. There is no PALs function at ULH. The engagement of staff and clinicians in the governance processes for assuring the quality of treatment and patient care and the identification and implementation of the Trust extensive Cost Improvement Plans is variable. Not all CIPs have been assessed for impact on patients and the process for monitoring these is not known or owned by staff. Non Executive Directors and the Clinical Commissioning Groups reported that they were not sighted on the QIA of the 2013/14 CIP plans. The Chair of the Audit Committee had seen details about 180 line items but this was not reported at an appropriate level of detail. There was little evidence of strong medical consultant leadership for the patient safety and quality agenda. For some of the above areas of concern, the panel identified a number of improvements already planned or underway at the Trust. Detailed Findings Good practice identified The Chief Executive and Vice Chair recognise the culture is not as conducive as it needs to be to provide good patient care and have recently used their reference group to work with the Execs on a cultural diagnostic and rolling out Listening into Action. There were some areas within the Trust, such as Stroke Unit, where clinical leaders and staff were able to clearly articulate governance processes and knew their individual quality metrics. The established Mortality Review meetings gaining wider clinical support and the proposal to write these into the job plans of the Consultant body. The interim Director of Nursing has a clear understanding and insight into the shortfalls in the current governance processes and has provided strong leadership to the nursing teams to improve and raise standards of care. Wards display patient safety information and the plan for every patient methodology is applied to manage care in a coordinated way. 23

24 Outstanding concerns based on evidence gathered Key planned improvements Recommended actions Priority urgent, high or medium (i) There is a disconnect between leadership at Board level and leadership at clinical levels within the organisation The panel observed strong clinical leadership from the matrons at hospital and ward level but identified there was a disconnect between this clinical leadership at ward level, medical clinical leadership (especially at Lincoln County Hospital) and the clinical directors and the Board (both executive and non executive directors). The Trust accepts that there is more to do to connect Clinical Directors and the Board with clinical leadership at ward level. The panel was informed by the Trust that a number of initiatives are currently in progress however these were not observed by the panel on the review visit. The Trust should ensure there are clear and active discussion lines between the clinical leaders at ward level, the clinical directors and the Trust Board to ensure that leadership of the organisation is joined up and consistent. The Trust should focus on engaging clinical teams rather than specialties or separate professional groups. The Executive Team recognise the need to build stronger connections between leadership at Board level and leadership at clinical level. Urgent It is critical that this recognition is adopted across the entire Trust, by all staff groups and by the whole Board. (ii) Clarity is required on what the Trust s Quality Strategy is The panel could not clearly identify what the Trust s quality strategy is through discussion with staff as staff could not articulate it to us. There was no clear view on who is accountable for quality and the governance process is also unclear. The panel understand that the Trust is conducting a review which will lead to an integrated dashboard. The panel also understands that the following actions are underway: Frequent executive-led staff briefings Refined Team Brief process, involving a toolkit The Trust Board needs to clarify both the who and the what in the process for patient safety, quality and governance and to evidence strong visible leadership in this area. High 24