Agenda item

On 16 December 2014, England’s Chief Inspector of Hospitals rated the services provided by Imperial College Healthcare NHS Trust (ICHT) as Requires Improvement overall,  following a Care Quality Commission (CQC) inspection in September.

The attached documents set out a summary of the findings of the CQC and the Action Plan put in place by ICHT.

 

The full CQC reports can be found at http://www.cqc.org.uk/provider/RYJ.

 

 

Professor Baker and Dr Krishnamoorthy presented an overview of the Care Quality Commission (CQC) inspection of Imperial College Healthcare NHS Trust (ICHT), which had taken place in September 2014.

 

The CQC’s new approach focused on five key questions: Is the service safe, effective, caring, responsive and well-led? Eight core services had been identified for NHS acute trusts: A&E, Medical care (including frail elderly), Surgical care (including theatres), Critical care, Maternity and family planning, Children and young people, End of Life care and Outpatients (selected).

 

Each service was rated on each of the five key questions and overall. There was a four point scale: Outstanding, Good, Requires Improvement and Inadequate.

 

The overall trust rating for ICHT was Requires Improvement. The key questions in respect of Effective and Caring had been rated as Good.

 

The presentation provided the individual ratings for the four hospitals (St Mary’s (SMH), Charing Cross (CXH), Hammersmith (HH) and Queen Charlotte and Chelsea, by key question and overall.

 

SMH urgent and emergency services had been rated as Requires Improvement with the key question ‘well-led’ being rated as Inadequate. There were issues in respect of leadership and cleanliness and infection control in the A&E department.

 

Outpatients and diagnostic imaging had been rated as Inadequate across the three sites.

 

Professor Baker commented on the rating of the five key questions:

 

·         ‘Safe’ had been rated as Requires Improvement, and immediate steps had been taken to improve cleanliness.

·         Clinical outcomes were generally very good, and ‘effective’ had been rated as Good.

·         There was high quality compassionate care, and ‘caring’ had been rated as Good.

·         ‘Responsiveness’ had been rated as Requires Improvement, with outpatients being the most challenging area, and specifically appointment delays and cancellations.

·         ‘Well led’ had been rated as Requires Improvement. The CQC considered that ICHT had a history of unstable leadership and was impressed with the change in leadership, although this had not yet been embedded.

 

The CQC was impressed with ICHT’s response to the report and the immediate action to address the issues and develop long term plans.

 

Professor Baker responded to Councillor Carlebach that the Western Eye Hospital provided specialist services and had not been inspected on this occasion.

 

Professor Baker responded to Mr Naylor that some services had not been rated in the Effective category because of a lack of evidence on which to report.

 

Mr McVeigh noted that at the November inspection, ICHT, despite making significant improvements since the main inspection in November, had still been rated as Requires Improvement for the Safe category.

 

Professor Baker confirmed that the new inspections of hospitals were significantly more rigorous. 60% of hospitals had been rated as Requires Improvement. The inspections presented evidence which gave staff more insight into how to improve services.

 

Councillor Chumnery queried the potential impact of the inspection, if it had been undertaken before the closure of HH A&E. Professor Baker responded that the inspections did not relate to any proposals to reconfigure services and were not intended to inform any other decisions.

 

Dr Batten, Professor Sigsworth and Professor Harrison presented the top line findings overall of the CQC inspection and ICHT’s response and key action points. Whilst the report clearly set out ICHT’s challenges, it also recognised the positive impact of work over the past year and highlighted the good care that was being provided.

 

Councillor Brown queried whether ICHT had been disappointed with the results and whether they had been brought about by ICHT concentrating on ground breaking work at the expense of the basic aspects of healthcare. Professor Harrison responded that the Good rating achieved in the Caring category illustrated how doctors and nurses put effort into a caring service for local people, in addition to providing a specialist service for a much wider area.

 

Councillor Brown queried whether ICHT being spread over a number of sites was a contributory factor and how could the committee be re-assured that the leadership would continue to bring about improvements.

 

Dr Batten responded that ICHT was a complex organisation, spread over five sites, with some 10,000 staff. ICHT provided an extensive range of services and there were in the region of one million patients a year. The CQC inspection was the first time that there had been a comprehensive review of the quality of services delivered. The report was extremely constructive, and the feedback had been shared in an open forum with all staff. Although the overall rating was disappointing, there was optimism amongst staff. The changes to the executive team would ensure clear lines of accountability and robust clinical governance and would be embedded, going forward.  Further to the merger of two trusts in 2007, there was still not consistency of policy and practices across the sites.

 

Mr Naylor queried the involvement of other organisations and patient groups in providing information and correcting the issues. Dr Baker responded that as part of the preparation for the visit, information had been sought from a wide range of groups. The visit would have been planned to target issues raised.

 

A list of groups consulted to be provided.

 

Action: Care Quality Commission

 

Professor Sigsworth stated that ICHT received quite a lot of help from independent groups, for example in the mini mock inspections of cancer services at CXH and frail elderly services at HH. There had been patient led inspections of cleanliness. ICHT involved both staff and non-employees. Going forward, ICHT would invite much more input from patient and public bodies and peer scrutiny, as part of mock inspections to ensure that the action plan was implemented. ICHT liaised with GP commissioners and Healthwatch, but there would only be small numbers from each borough.

 

Mr Naylor queried if this input had been shown in the action plan. Professor Sigsworth responded that the outcomes of the Quality Summit had been quite detailed to show that ICHT had taken seriously the feedback from stakeholders.

 

Councillor Vaughan queried how ICHT took into account the range of opinion from other organisations and patients in continuing to monitor and develop services; and how ICHT planned to embed this into the process going forward and capture in its culture. Professor Sigsworth responded that ICHT would adopt a similar approach to  the CQC in a series of its own inspections, looking at areas in a more systematic way. Data from patients, Healthwatch, PALS and complaints would be cross referenced. ICHT would work with its internal audit to develop a framework to deliver the CQC’s standards.

 

Councillor Vaughan queried the role of the Trust Board. Members were informed that the Board’s Quality Committee monitored in depth how the Action Plan was being implemented across the organisation. A patient attended every Board meeting to talk about their experiences of care. This item was at the beginning of the agenda so that it fed into the remainder of the Board, and specifically performance and monitoring targets.

 

In addition, ICHT was really listening to staff about what it was like on the ground. Board members and senior managers were going out around the trust, and were able to demonstrate what they had seen and found.

 

Councillor Barlow queried whether ICHT had put in place measures to ensure that it met the CQC’s  requirements and whether it knew what it would have to achieve for the next CQC inspection. Professor Sigsworth responded that the Mid Staffordshire Inquiry and the Francis Report had impacted on the level of rigour  adopted by the CQC. There had been a big change very quickly and ICHT had to redouble its efforts in a number of areas and services. Whilst there were not national quality requirements, the CQC had been clear in what it expected and it was clear what ICHT needed to do.

 

Professor Baker stated that the CQC had not identified new standards. It identified standards which a hospital needed to apply consistently and reliably. A hospital needed to be realistic about where it was and what it needed to do to improve. Requires Improvement did not mean that it was a failing hospital, but that it needed to deliver the identified changes.

 

Mrs Bruce queried the top line findings overall in respect of not meeting the target for sending out appointment letters to patients within ten working days of receiving the GP referral; and shortfalls in how the needs of people with dementia and learning disabilities were considered.

 

Professor Sigsworth responded that, in respect of people with dementia and learning disabilities, the issue related to inconsistencies in staff responses, rather than interaction with patients. More work was required on environmental issues, particularly A&E which could be unsettling for these patients.

 

Dr Batten responded that the Action Plan addressed the problems associated with the administration of appointments which were leading to unnecessary delays and indicated the work across each of the sites. There were a number of different ways in which patients could access Outpatients; phase 2 would establish a single point of access. There had been some quick wins, for example standardisation of the appointments letter and sending out letters in a more timely manner. A new patient administration system had been implemented in April 2014; technical support to Outpatients was being expanded to improve the check-in and booking function locally and achieve consistency every time on each site.

 

Councillor Lukey requested that she and Mrs Bruce be sent the work with the joint forum on improving the pathways for people with learning disabilities and dementia. Councillor Lukey stated that the Council would like to support this work. Professor Sigsworth responded that there was still an opportunity to refine and strengthen the action plan.

 

Action: Imperial College Healthcare NHS Trust

 

Councillor Fennimore requested more information in respect of available languages. Professor Sigsworth responded that ICHT provided interpreters. However, this could be difficult to co-ordinate and the service was often provided by telephone.

 

Action: Imperial College Healthcare NHS Trust

 

Councillor Chumnery queried the action point in respect of registrars not always available out of hours on the ICU at CXH and cover being provided by junior doctors, none of whom had the required skills on that particular evening.  Professor Harrison responded that ICHT had addressed the issue as part of the review of critical care service to ensure that skills were available across the site, but this had not been in place at the time of the CQC inspection.

 

Councillor Chumnery queried the issues with the storage of medicines at the correct temperature in refrigerators. Professor Sigsworth responded that a twice monthly audit of some 200 refrigerators was now undertaken.

 

Councillor Holder suggested that negative feedback should have been included in the presentation, in addition to the positive feedback.

 

Councillor Fennimore queried how much of the report had been a surprise. Dr Batten responded that her presentation to the CQC before the inspection, had highlighted the areas which had a body of work in train, but this had not been embedded across the organisation. The report was therefore not entirely a surprise. ICHT would work towards all areas being rated Good and ultimately Outstanding across all domains of quality.

 

Mr Naylor queried the priorities and their outcome and timescale for older people, who often presented in Outpatients with a number of chronic conditions. Dr Batten responded that the Action Plan included: the reduction of clinical cancellations at short notice to an absolute minimum; the reduction of  patients who did not attend; support to doctors to arrive at clinics on time; review of bookings and timeslots; and improvements in correspondence with patients and GPs. ICHT would provide a joined up, less fragmented service.

 

Mr Naylor noted that transport was a common issue for older people.

 

A member of the public queried whether ICHT was building a relationship with the London Ambulance Service (LAS) and working to reduce spikes and the pressure on the LAS. Dr Batten responded that ICHT was particularly focused on ‘off- loading’, the time from which the ambulance arrived at the front door and ICHT received the patient and became the carer. In general, good times were achieved, enabling the LAS to get back on to the road quickly. ICHT aimed to smooth its demand and daily meetings were held across the sector. The data would be shared with the PAC.

 

Action: Imperial College Healthcare NHS Trust

 

A member of the public commented on the death rate figures across the country, published earlier that day, and queried the impact of the Stroke Unit moving out of CXH. Professor Harrison responded that ICHT morbidity rates were amongst the best in the country. In addition, Public Health had a role in supporting people to live healthier lives, and ICHT had a role to play in working with GPs, Public Health and Public Health England.

 

Dr Batten stated that it had always been intended to co-locate the Stroke Unit with the Major Trauma Unit at SMH, and there was a strategy for its relocation.

 

Councillor Vaughan queried whether IT in the Outpatients Department was actually working, and if there were plans to improve or replace. Dr Batten responded that a Cerner Patient Administration System (PAS) had been implemented in all Outpatients Department across ICHT in April 2014. Data quality was being monitored closely and was being tracked at Executive and Trust Board meetings. All data had been brought back to the levels recorded prior to go live of the Cerner PAS. The next step  would be the roll out of clinical documentation, which was currently being piloted, together with electronic prescribing, at which point there would be greater benefits and efficiencies from the system. The implementation of the Cerner modules for theatre management and for the emergency department was on track to go live in early March. 

 

Dr Batten responded to Councillor Brown that ICHT was working towards sending letters by e-mail. This opportunity would become available with one of the PAS modules. ICHT was also looking at good practice in other organisations. There were still some legacy systems in some Outpatient areas.

 

Councillor Vaughan asked for confirmation that the cleanliness issues identified by the CQC had been addressed. Professor Sigsworth responded that the CQC’s finding that cleanliness in SMH A&E had not been acceptable, related to the A&E cubicles not being cleaned in the way which they needed to be. The clinical schedule had been reviewed and processes improved to ensure equipment was always cleaned thoroughly and maintained to the required standards. Each cubicle now had an A4 checklist for completion with every patient coming in and going out. ICHT had worked through the cleaning pathway and clarified responsibilities and talked though in detail with staff.

 

Professor Baker responded to Councillor Carlebach that the CQC had inspected all services provided by ICHT, even if a joint venture but not services run by other providers. The Urgent Care Centres at CXH and HH  were commissioned by H&F CCG, but run by ICHT and a local out of hours provider.

 

Councillor Vaughan queried whether the Action Plan to reduce nursing vacancy rates was adequate to provide cover by various grades. Professor Sigsworth responded that staffing levels were a nationally mandated process, with reports being submitted to the Quality Committee and Trust Board twice a year. ICHT was confident that the level was adequate. Currently levels were benchmarked across London. However, there could be an influx of trained nursing staff leaving the trust. Ideally, cover would be provided through ICHT’s bank staff. Increasingly, less nurses were being employed through agencies. At the time of the CQC visit, there had been a high vacancy rate and a request for bank staff had not been filled.

 

The Action Plan included a focus on attracting student nurses into junior grade jobs and recruitment of experienced nurses. ICHT had a pool of nurse educators and specialist nurses who could be called upon to cover vacancies.

 

Professor Sigsworth stated that no beds had been closed as a consequence of the vacancies and confirmed that, should ICHT consider that staffing levels were not adequate, beds would be closed.

 

Professor Sigsworth stated that ICHT was confident that the Action Plan would achieve the CCG vacancy rate target of 5%.

 

Councillor Vaughan thanked the CQC and ICHT for attending and summarised the key points:

 

1.    The committee shared ICHT’s disappointment with the outcome of the CQC inspection.

2.    There were some basic areas of cleanliness upon which ICHT needed to improve.

3.    ICHT needed to build the feedback from patients, peers and  other organisations. into its review of systems and decision making process.

4.    The CQC was impressed with the current leadership, and the committee hoped that the CQC would continue to reach the same judgement in a year’s time.

5.    The committee requested that an update on the Outpatients PAS be brought back to a future meeting.

6.    The committee requested that ICHT provided assurance to a future meeting that the progress in respect of cleanliness had been sustained.