Agenda item

6.1       Service update following CQC report

Dr Chris Hilton outlined the Trusts current activities in response to the recent Care Quality Commission (CQC) report which had highlighted several areas of concern.  The safety domain had moved from “requires improvement” to “inadequate”, and that the Trust “required improvement” overall.  Positive feedback had been received regarding the Mental Health Integrated Network Team (MINT), details of which were summarised in paragraph 2.6 of the report. He acknowledged the challenges faced by the Trust which had arisen from a difficult and disruptive period during the pandemic.  Dr Hilton indicated that the CQC had not highlighted any concerns that the Trust was not unaware of through its own internal governance procedures. The Trust had previously agreed to keep the committee informed of progress in addressing vacancy rates and waiting times.  Commenting on the negative impact of vacancy rates, Dr Hilton acknowledged that this had hindered the Trust’s delivery of a consistent and high quality service. The CQC report had recorded staff concerns to mitigate risks identified in clinical assessments and the committee had previously also noted the difficulties in achieving waiting time targets resulting in significant delays for patients accessing treatment. 

At the time of the CQC report, Dr Hilton reported that the Trust had decided to migrate from using two patient record systems and consolidate this into a single system which had resulted in added complexities.  In addition, there had been other issues highlighted including lone working practices, and inadequate clinical premises in Ealing and Hounslow, not H&F. Dr Hilton referred to additional information in a slide deck that had been circulated to members of the committee and officers, but these were not received in time for inclusion in the agenda papers (appendix 1). Key elements of this were the implementation of clinical controls with regards to the Trusts risk register system, better integration of business intelligence data, the successful implementation of links between operating systems, a review of standard operating procedures, the establishment of a clinical action group to undertake follow up work with patients who missed appointments to ensure co-ordinated care and simplification of the Trusts patient record system. 

It was confirmed that there were several actions that the Trust was in the process of implementing to address the areas of concern identified in the CQC report, categorised as either suggested or required, and to be in place by March 2023.  The Trust intended to work with the Health and Care Borough Partnership to help address the demand on services.  Dr Hilton thanked the council’s specialist support and independent living social care team and Sobus for their support.

Councillor Genevieve Nwaogbe referred to paragraph 2.6 of the report and enquired what immediate actions were being undertaken taken by the Trust to improve staff safety in relation to lone working, poor supervision breaks and staff feeling unsupported.  Councillor Nwaogbe asked if there were any legal consequences resulting from health and safety breaches. Co-optee Keith Mallinson commented that he welcomed the report, and he outlined the positive feedback received for MINT and the support that Dr Hilton and Jo Baty had provided.  Co-optee Jim Grealy asked how likely it was that the Trust would be able to recruit staff given the scale of the vacancy rates and what the impact of this would be on patient safety and the implications for continuity of care.  The waiting period of 64 days exceeded the waiting time target, the figure for which was not included in the report. The combined effects of austerity, cost of living and post-pandemic recovery would significantly impact on mental health and wellbeing and this was likely to lead to delays in treatment.  Jim Grealy also requested a breakdown of the waiting list figures by ethnicity and income.  Co-optee Lucia Boddington expanded on these points and reflected that the current economic climate would be a key factor in waiting time delays impacted by increased demand, for example, face to face family therapy, for which there were long delays that she was aware of locally.

Dr Hilton explained that the current actions around measures to mitigate workforce issues to appoint permanent staff rather than temporary or agency staff.  The headline figure excluded additional clinical staff.  The Trust also had also identified workforce recruits at source (university graduates specialising in mental health) and many dozens of staff had been recruited in this way.  Workforce was a challenging issue influenced by difficult market factors, and some disciplines were harder to fill than others. The Trust recognised that there were barriers to recruitment and were exploring other options such as recruiting from abroad or identifying refugees or asylum seekers with clinical skills. The Trust was engaged in business transformation activities which would address the issue of safeguarding staff highlighted in the CQC report. There were a number of actions focused on improved risk assessments to address inadequacies and to mitigate risks.  The mean wait time was 64 days and currently there were no patients awaiting triage at the Claybrook facility.

Lisa Redfern welcomed the report and asked who was leading on the performance improvement plan and the extent to which staff had been involved in developing this. Dr Hilton described the leadership and oversight structure which include multiple levels of governance.  A quality committee was chaired by a non-executive director, Professor Stephen Barber, and a monthly MINT specific board had oversight of a more granular action plan, which he chaired himself. There were also individual working groups chaired by Dr Julia Benton, a clinical director. It was anticipated that remedial work would be needed to support the transformation process which would take a number of years, but satisfactory progress was being made to mitigate against staffing pressures.  Dr Hilton shared a personal frustration about the two electronic patient record systems which he was keen to see resolved to reduce risk and to implement a definitive solution.  In terms of staff involvement, information was being cascaded through the organisation, with staff working in in subgroups to contribute to the process involving clinical directors, operational managers and clinical leads.

Lisa Redfern expressed concern about the staff supervision rate which was closely linked to monitoring staff performance. Dr Hilton acknowledged the concern and stated that supervision was being undertaken regularly at a team level and during routine performance meetings.  There was variation between services, for example, mental health teams had consistent and high rates of supervision and by comparison, community adult health services had poorer rates of supervision. Two factors influenced this: first culture of “doing” supervision, and second, the process of recording this, both of which the Trust was working to improve.

Lisa Redfern outlined additional concerns about the reduction of 13 mental health beds in Ealing and clarification was sought about the correlation between this and the strength of community health services, which needed to be sufficiently robust to cope with local demand.  All health and social care providers were routinely inspected but there was always scope for improvement despite the lack of investment in community mental health services.  Dr Hilton responded that he shared the concerns and Helen Mangan described the front end diagnostic work being undertaken with RW Health (business intelligence consultancy) on patient flows to understand the interdependencies between community and hospital services. This together with some focused engagement work and a task and finish group had produced a useful MINT (liaison Psychiatry) dashboard highlighting a continuity of care need for those who were seen infrequently and who might be at high risk.

Merril Hammer commented that the additional paper lacked clarity because it contained a lot of jargon and need to be more accessible.  Referring to page 37 of the agenda pack and related graphs, an explanation of the decrease in new referrals was sought and additionally, the variations in the number of referrals between the different primary care networks.  Dr Hilton apologised for the use of anacronyms recognising that this was unhelpful.  He clarified the context of the graphs which offered more assurance about the data which indicated that a post-pandemic increase was now stabilising.  With reference to the primary care network referral data, information from the MINT team used weighted population data which anticipated demand to calculate the deployment and distribution of resources rather than reflecting the historical patterns of access.  It was recognised that further work was required to address this to address and inherent health inequalities.

Councillor Lloyd-Harris sought further context about the high number of suicide figures and what preventative actions could be taken. Lisa Redfern responded highlighting an initiative by the leader of the council, Councillor Steve Cowan that had led to the establishment of multiagency suicide preventative working group.  Commonly, many who did take their own lives were found to have had a dual diagnosis of mental health and substance misuse issues.  Dr Lang explained that there were other factors locally such as higher rates of unemployment which could correlate to higher rates of suicide.  Fingertips public health data indicated that the borough had the fifth highest rate of suicide in London. A segment of 58 suicides in the borough was examined, of which two thirds were linked to substance misuse or an underlying mental health condition.  The council’s work on this would be published shortly and available for further scrutiny. This included recommendations working across the mental health trust with children's services and working with Emergency Services as well. Dr Lang commended instrumental contributions to this work by Helen Mangan, together with the Hammersmith and Fulham Care Partnership and the mental health campaign group, reflecting the value of adopting a multiagency and universal approach.  Another significant piece of work was a peer review with the Local Government Association which had undertaken an audit of individuals who self-harmed, presenting at A&E, and contained 23 recommendations.

Councillor Ben Coleman emphasised that the council had recognised the significant concern about the rates of suicide in the borough and commended the initiative. The adoption of a multi-agency approach incorporating insights from a range of expert health partners and organisations reflected the importance of this work.  Full data and information about the work would be published on the councils Joint Strategic Needs Assessment website page and a link circulated to the committee. Dr Hilton offered to share information about suicide preventative work supporting bereaved families and activities undertaken by the Trust with third sector organisations.

Councillor Coleman congratulated Dr Hilton on his new appointment as Chief Operating Officer (Local and Specialist Services) and commended the partnership work undertaken.  Helen Mangan directed the committee to an embedded document within the additional information which offered details of all the organisations that were involved reflecting the synergies arising with work undertaken with the most complex families.

Linda Jackson welcomed the additional information about the required improvement action plan covering areas where regulations had been breached and provided shortly before the meeting.  In the interests of transparency, a request was made for the Trust to share the 16 “should do” recommendations.

ACTIONS:

1.       Dr Hilton to provide a figure for the number of staff recruited at source from colleges and universities;

2.       WLT to share waiting list on the number of those exceeding a 28 day waiting period;

3.       WLT to share data about waiting list numbers broken down by ethnicity and income;

4.       WLT to share and discuss the issue of referral data further with the committee;

5.       The Director of Public Health to circulate a report from the Local Government Association on self-harm, and, a link to the council’s suicide multi agency prevention work to be circulated, when available; and

6.       Dr Hilton to share information about suicide preventative work supporting bereaved families and activities undertaken by the Trust with third sector organisations.

RESOLVED

The committee agreed a guillotine to extend the meeting by 15 minutes.

6.2       Reduction of Mental Health Beds Capacity, Ealing

Dr Hilton explained that an enhanced engagement period was currently underway regarding a proposal to remove inpatient mental health beds in Ealing, a decision that was also likely to impact the boroughs of H&F and Hounslow.  He apologised for any possible perception that there was a lack of engagement.  A three borough provision had been in place for many years and so a perception by residents that the beds were “out of borough” was not applicable.  The model of care provision had evolved, and Crisis intervention teams were now in place, aligned with a recovery house based in Ealing and available to the residents of all three boroughs as an alternative provision.  The Trust had struggled to maintain two wards built in 1831, which did not offer safe infection prevention and control and were not fit to deliver modern health care services, a criticism of the CQC. 

The proposal to permanently close the wards was based on clinical risk and the financial savings arising from this would be ring fenced to ensure reinvestment into the crises mental health system.  A total of 31 beds had been closed and 18 re-provided at Lakeside Mental Health Unit, West Middlesex Hospital, with an overall reduction of 13 beds. Staffing was also being provided to section 136 suites and other crises related care.

Councillor Perez expressed her concern and disappointment that news of the proposal had not been directly shared with the committee and that this information had been shared by the director of social care, Ealing.

Councillor Nwaogbe expressed her specific interest in how the proposal affected borough residents and the number of residents admitted as mental health inpatients.  An additional question was whether the Trust had a secondary plan, should this proposal not be implemented. It was explained that 25 H&F residents had been admitted to either the Ealing facility or Lakeside Mental Health Unit.  However, the Ealing facility was not fit for purpose. Since the start of the pandemic, a model of care had been operating without the Ealing beds as these wards had been temporarily closed.  The Charing Cross mental health unit had been utilised as another source of provision for the benefit of residents from all three boroughs. Dr Hilton assured the committee that since early 2020, the Trust had continued to retain patients with the system.  It was acknowledged that should the results of the enhanced engagement indicate that the wards reopen, this would present a significant and difficult challenge, given the condition of the hospital estate. Dr Hilton indicated that the Trust would prefer to commit to investing in new, purpose built inpatient mental health facilities in all three boroughs, however, this was unlikely to materialise in the short term.

Councillor Coleman reported that the information provided to H&F had lacked some of the information provided in the Ealing consultation document, together with a letter, and in addition a modified slide deck presented initially to Ealing had also not been provided. This had been unhelpful as Councillor Coleman explained that he had been working to understand the situation based on information given to Ealing, rather than what had been provided to the committee.  Addressing the Trust’s intention to reinvest ring fenced funding into community mental health services, Councillor Coleman expressed his concern that the CQC had evaluated existing provision as “requires improvement”, and “inadequate” in its lack of staffing safeguards.  He invited Dr Hilton to indicate how the Trust intended to improve community services to replace the 13 inpatient beds.  Dr Hilton responded that within his portfolio of work there were two sets of community services, one was planned care, (the subject of this discussion), and in addition, a range of non-elective, community-based crisis services which included Crisis teams, home treatment, Health based places of safety and the recovery house, Richmond Fellowship. Dr Hilton clarified that the funding that was being reinvested from the 31 beds had already been spent in part to address the estates issue, but the remainder would be ring-fenced.  The latter would also be applied to step down provision in supported living accommodation. 

Councillor Coleman reiterated the concerns outlined briefly by Councillor Perez about not informing the committee of the proposal.  He enquired if the Trust intended to properly consult.  Dr Hilton stated that there was no

holiday period in January, a period which would meaningful engagement with stakeholders less likely. Dr Hilton welcomed the suggestion and indicated that it would be possible to extend the engagement period.

Lisa Redfern reiterated that had she not been informed of the closure by a colleague the council would not have been aware of the proposal.  She expressed concern that the closure of 13 beds was significant and warranted formal notification and consultation.  While the substandard nature of the facility was not to be dismissed, her concern was that loss of the beds being redeemed by the provision of additional beds in Hounslow was an incomplete resolution.  Commenting on the provision of step down beds, these were not the same as acute, inpatient provision that usually supported seriously ill patients and required a higher level of care and intervention.  The travel and transport needs of H&F residents visiting loved ones with long term conditions placed at the Hounslow facility had also not been fully considered which was why a full consultation was needed.

Councillor Perez thanked members of the committee for their patience in discussing this important issue.  Dr Hilton also thanked the committee for their feedback to the report and reiterated a commitment to have further conversations about the proposals acknowledging the concerns of the committee. He added that the temporary closure of the beds over the previous two and half years had allowed the Trust to build a portfolio of evidence based on service performance and that the issue was about making a temporary closure permanent.

RESOLVED

That the report was noted.