Agenda item

This report relates to the Care Quality Commission’s (CQC) inspection report on Imperial College NHS Trust, published in February 2018. The CQC report recognises improvement in some areas but the overall rating is unchanged at ‘Requires improvement’.

Professor Julian Redhead, Interim Chief Executive and Professor Janice Sigsworth, Director of Nursing, of Imperial College NHS Trust, provided a brief introduction and presentation.  The Care Quality Commission (CQC) had visited in November 2017 to look at specific services. This had been followed in February 2018 by a ‘well led’ inspection survey.  Surgery at Charing Cross remained the same as previously designated in 2014 as ‘requires improvement’. St Mary’s remained as ‘requires improvement’ and leadership also ‘requires improvement’.  While this was disappointing, Professor Redhead said that he was pleased that the CQC recognised areas of good practice, although challenges remained on referral to treatment times (RTT) around elective care.  Other areas to work on specifically included maintenance in operating theatres at Charing Cross and Prof. Redhead was disappointed about the evaluation of the emergency department at Charing Cross, identified as performing 'requires improvement’.  There was considerable pressure on staff but the Trust had plans to ensure improvement.

Councillor Morton referred to the CQC report from 2014 and commented that there had been relatively little improvement in the intervening period and he asked whether the Trust should be looking for causes for the lack of improvement, particularly in case of Charing Cross.  Prof. Sigsworth replied that in May 2017, outpatients had improved significantly.  A second visit from CQC in October 2017 had looked at medical services, where Charing Cross was found to have performed well on stroke services and two services marked as outstanding.  Overall, this was a positive review but Prof. Sigsworth acknowledged that St Mary’s was an issue.

Referencing the various evaluations and their respective movements as to improvement or decline, Councillor Morton observed that it was disappointing that there were basic safety actions that the Trust needed to take, such as maintaining a key to access a locked medicine cabinet.  Prof. Sigsworth acknowledged that the primary focus was patient safety.   A clinician led team which included a doctor, nurse and general manager had been formed and changes implemented since 2014, but Prof. Sigsworth recognised that there was more work to be done.  Prof. Redhead added that the CQC evaluations had been a disappointment to the staff and that the Trust would support them in helping to bring about change.  He provided an assurance that the care provided was of a very high standard. 

Co-optee Jim Grealy commented that safety was not ticked in every box and that this was a concern.  He had observed that there was a repeat occurrence of delays in treatment which was above the national average and that the reason for this needed to be clearly identified.  Prof. Redhead said that there were a range of issues such as loss of staff (ward nurses at Charing Cross) and seven operating theatres not being entirely safe.  All of this meant that there was an enormous job to be undertaken to bring about improvement.  All the Trusts safety indices were good, except for statutory management training and estates. Imperial had the biggest maintenance backlog of any trust.  Prof. Redhead continued that delays in surgery were well documented.  The Trust’s root problem was with the lack of capacity. Issues were driven by A&E, which then impacted on elective work.  Home care issues were well documented, where there were areas to improve on.

In terms of staffing, Prof. Sigsworth recognised the difficulty retaining and training staff.  There were many large hospitals to work in within London and it was accepted that once trained, staff might then move on.  There have been national policy changes and this movement was understood but there was a parallel need to recruit. There had been a reduction in numbers of applications for nursing courses.  Charing Cross had vacancies in older peoples’ services but Prof. Sigsworth admitted that this was traditionally a more unpopular placement than critical care or surgery.  The Trust hoped to address this by recruiting to 50-100 apprenticeships and nursing assistant roles. 

Jim Grealy observed that there were significant concerns about the cut in the number of nurses, with a national shortage.  The added difficulties in recruiting to older peoples’ services given the aging local population was further exacerbated when considered in the context of the STP (Sustainability and Transformation Plan).   Janet Cree explained that work had been undertaken to get medical staff up to speed on dementia treatment innovations.  There was an increasingly older population to serve, and St Mary’s acute mental health and trauma services meant that they needed to look closely at the mix of the Trust’s workforce to meet future need. 

Addressing the point on future training focusing on mental health and older people, Bryan Naylor expressed concern about older people being referred to as “bed blockers”.  He questioned references made to the reduction in the number of step down beds and asked if this was the case, stating that more were needed to alleviate pressure.  Prof. Redhead said that there were undoubtedly many patients in the Trust whom he acknowledged may not be placed in the best environment for them. Support outside of hospital might be more suitable but it was necessary work together to identify the best service that the Trust could provide.  There was currently no physical capacity to include step down beds and this would require further conversations about best way to achieve this. 

Prof. Sigsworth added that removing a patient from the Trust sometimes added further difficulties as they would be removed from their locality.  Bryan Naylor observed that most older people could not be effectively treated at home, and that 47% lived alone.  Prof. Redhead commented that a lot of people in A&E needed support over a short period of time, but accepted that that there were certain patients who could not go home.

Councillor Coleman commended the extraordinary staff at Charing Cross.  Commenting on the earlier reference to staff bullying he suggested that these were not addressed or well managed.  Prof. Redhead acknowledged that there were always interpretations which concerned the Trust and its Board.  Action was taken last year to address bullying and harassment within the training undertaken by clinicians and managers.  In the last year, there were no registered complaints, demonstrating that the Trust would effectively address these areas when highlighted. The staff survey indicated that satisfaction low by comparison to other trusts but had improved. Professor Sigsworth had previously received unsolicited emails about staff feeling bullied, which they had escalated to her directly. The trust’s human resources staff had explored the use of case studies in training. 

Councillor Coleman acknowledged the difficulties in recruiting and retaining staff but expressed concern about moving patients outside the Borough.   He recognised that Prof. Redhead shared similar concerns about Charing Cross and observed that there had been a national failing by the NHS to predict the demands of the winter crises.  Councillor Coleman suggested that it was therefore time to ditch the Shaping a Healthier Future programme (SaHF) which was now holding the Trust back.  Prof. Redhead declined to publicly state that this was not what he wanted for Imperial, stating that SaHF was not a distraction as the Trust continued to invest in services at Imperial.

Jim Grealy focused on two key issues that were highlighted throughout the report: capacity of bed space and the availability of skilled staff.  Private investment in healthcare indicated that many trusts derived income from private patients.  He asked what proportion of staff and beds could be attributed to the treatment of private patients.  Prof. Redhead responded that income generated by private patients was reinvested in the NHS.  This was a dynamic symbiotic relationship which was also helpful in terms of providing elective care. 

Councillor Coleman expressed concern about the exercise of power and the implications of moving from one CCG to eight.  Prof. Redhead replied that while he understood Councillor Coleman’s concern around governance and its challenges, the advantage was that there would be stronger powers to co-ordinate acute services as a provider. 

Lisa Redfern expressed an interest in reviewing the methodology used to monitor performance and improvement plans at a future PAC, ahead of the next CQC inspection.     Performance, quality assurance boards and action plans provided focus.  Prof.  Redhead explained that within the Trust was an executive board committee tasked with scrutinising through many different internal mechanisms improvement and action plans. 

Councillor Vaughan commented that engagement remained an issue and that there was a lot of work to be undertaken, particularly given the verdict in 2014.  He asked the Trust if the CQC findings had come as a surprise, or were these areas ones that they had been cognisant of. He asked if the actions that followed were those that the Trust was taking in terms of those findings. Recognising the pressures faced by the Trust he asked how the Trust planned to address the issues. Prof. Redhead responded that they took the report very seriously and had implemented an improvement action plan.  Some of the findings were surprising, such as Charing Cross’s emergency department but, overall, it was not unexpected that challenges around RTT, patient waiting lists, and the huge backlog of estate maintenance had been identified.

Commenting on the issue of the estates backlog of maintenance, Councillor Vaughan asked if this was attributed to the lack of funding. He asked if there had been any improvement across Charing Cross and St Mary, comparing October to January, in the four-hour target figure which had dipped, and, issues of hygiene at Charing Cross and an infection control incident December 2017.  Prof. Redhead explained that in terms of the backlog, this amounted to approximately £1 million, however there was a programme of essential maintenance that was on-going.  Figures for the four-hour wait target were good this winter and there had been one ward closure at Charing Cross to protect other members of the public.  A bigger problem had occurred at St Mary’s, with a ward being closed because the ceiling had collapsed due to structural issues.  Given the age of the estate it was expected that these incidents would continue to occur, making the estate at St Mary’s a priority.

Councillor Vaughan requested that the PAC be provided with the action plan after the election, to better understand the estate priorities at St Mary’s, and to ascertain where the funding might come from to improve it for the benefit of residents. He expressed his thanks for the dedication and commitment of all staff at the Trust and hoped to see much sought-after improvement to scrutinise in the next municipal year.  Charing Cross Hospital was a much valued and needed local resource and many Councillors and residents were keen to ensure its survival.

RESOLVED

That the report be noted.