Agenda item

This report advises the Committee of the findings of the Care Quality Commission (CQC) Inspection of Medway NHS Foundation Trust Medway Maritime Hospital published in July 2014 and sets out the initial response from Medway NHS Foundation Trust. The Acting Chief Executive and the Chairman of Medway NHS Foundation Trust will be present to respond to Members’ questions. 

Discussion:

The Chairman welcomed everyone to this special meeting of the Committee which had been set up to scrutinise the initial action plan from Medway NHS Foundation Trust (MFT) in response to the recent Care Quality Commission (CQC) Inspection report which had rated Medway Maritime Hospital (MMH) as inadequate.

Dr Barnes, the Acting Chief Executive of MFT was congratulated on his appointment and thanked for attending the meeting. The Chairman invited Dr Barnes to introduce the report. Dr Barnes started by reading out a statement provided by Mr Christopher Langley, the Interim Chair of MFT who had been requested to attend the meeting but was not present. The statement provided an update on the recruitment process for the appointment of a permanent Chair of MFT, which had been agreed on 16 July 2014 at a joint meeting of the Council of Governors and Board of Directors at MFT. The statement advised the Committee that interviews were scheduled for early September and that it had been agreed that Mr Langley would leave the Trust as soon as a new Chair was appointed. Monitor had agreed this approach. Mr Langley’s statement explained that, as an experienced interim Chair, he had been asked by Monitor to support Medway in January 2014 on a fixed term contract of 12 months starting in February. His sole aim had been to guide the Trust out of special measures by improving the quality of care. The statement concluded by recognising the many challenges still to be overcome by the Trust and the commitment of the hospital staff to delivering safe and high quality care for the people of Medway.

Members of the Committee collectively expressed their disappointment that Mr Langley had decided not to attend the meeting given he was still in post and the meeting had been arranged on a date when he could attend to answer questions and be held to account for the failings and lack of progress identified by the CQC. Members asked for Monitor to be advised of Mr Langley’s decision not to attend the meeting, the disappointment of members and the wish of the Committee that any future Chair of MFT should be advised of the expectation they will attend Overview and Scrutiny Committee meetings on a regular basis.

In response to a question the legal adviser confirmed the Committee could discuss and debate the role and performance of the Interim Trust Chair insofar as this related to the findings of the CQC relating to governance and leadership at MFT.

Dr Barnes introduced the action plan included on the agenda, clarifying that this was the plan taken to the CQC Quality Summit on 4 July. He highlighted five core actions underway to address key issues and areas of risk, principally relating to A and E:

• Additional medical and nursing support was being provided in A and E with enhanced levels of support and challenge
• There was a new clinical lead in A and E who was providing focus on care as well as targets
• Immediate closure of the Vanguard unit which had been used for the A and E triage service as it did not provide an adequate clinical environment for patients. (Reprovision of rapid assessment and triage had been made back in A and E.)
• Work to refurbish A and E had been agreed by the MFT Board in June with expected completion in December 2015.
• Strengthening of the relationship between MFT and partners, and in particular social care, with a recent system wide summit where Medway Council had been represented by the Director of Children and Adults.

At the invitation of the Chairman, Dr Mark Beech, representing Healthwatch Medway, presented a comprehensive written submission to the Committee providing an overview of Healthwatch Medway activity during 2013-2014 in relation to understanding the patient/consumer experience in connection with MFT. He referred to some of the positive commentary received and highlighted some key themes emerging from patient engagement by Healthwatch Medway including the importance of consistent good practice and caring staff. One principal finding was the wish of patients and their families for MFT to develop a listening culture. He said that patients needed to be able provide feedback whether positive or critical and should have access to information about what good care looks like. Dr Beech referred to the importance of patient voice and safety being central to the Trust’s governance arrangements, structures and systems. Dr Beech emphasised the commitment of Healthwatch Medway to work in partnership with the Trust to develop a culture of listening to the patient voice. He reminded the Committee of the Healthwatch motto “No decision about us without us” and expressed the hope that real progress would be evident at the next round of patient engagement facilitated by Healthwatch Medway. Dr Barnes welcomed the Healthwatch Medway submission and the work being done by the organisation to assist the Trust to cultivate a listening culture.

Mr Howard-Jones, the Acting Local Area Team Director for NHS Kent and Medway assured the Committee that over the past few weeks MFT had been actively listening to partners, as well as for example, the Ambulance Trust. He was confident the Trust was now openly responding to feedback, which had not been the case previously.

The Committee then had a wide ranging discussion about the initial response of MFT to the CQC findings and raised a number of questions and issues as summarised below:

Confidence in current plans – in response to a question about whether or not the Committee could have confidence in the plans and assurances provided by MFT Dr Barnes stated the Trust was working closely with commissioners who were undertaking daily reviews of progress and providing regular feedback on the state of play in the Emergency Department. The confidence held by commissioners in the MFT plans should provide assurance to the Trust Board and the Overview and Scrutiny Committee. He emphasised the focus of the executive team on the sustainability of new initiatives and the improvement journey to ensure agreed actions were deliverable. Mr Wheat, the Chief Nurse from North Kent CCG confirmed he and colleagues were working closely with the Chief Nurse at MFT and a secondment from the CCG had been arranged to support the MFT Chief Nurse with improving care standards. Evidence of what can be achieved was visible in maternity services. Alison Burchell, Chief Operating Officer at NHS Medway CCG stated that partnership working in Medway and Swale had been significantly enhanced of late with a shared commitment to improving flow across the system.

CQC follow-up visit to MMH on 27 and 28 July 2014 – Dr Barnes was asked about the findings of the CQC at its follow-up visit ten days earlier and stated that the CQC had found insufficient progress had been made since its visit in April 2014. The CQC had expressed concern that little had changed, that the Vanguard unit was still in use and that basic standards were still lacking. This had galvanised further action including additional clinical support and the decision to close the Vanguard unit.

Basic standards – Dr Barnes confirmed that there was now an additional Head of Nursing/Ward Sister in A and E with a view to raising basic standards of care and hygiene and improving operational efficiency.

Financial sustainability of hospital – Dr Barnes acknowledged that questions about the financial sustainability of the hospital were difficult although he believed there was no structural reason why the hospital could not be financially sustainable given the medium size of the Trust, the absence of any large PFI legacy and the basic demography of Medway and Swale. He said there was more to be done to avoid expensive quick fixes and to ensure expenditure was cost-effective and generating ongoing good quality care. In response to a question about the affordability of the refurbishment of A and E and associated contingency planning Dr Barnes said that the aspiration was to create an improved environment for patients and staff and that it would be difficult to continue in the current setting. However he expressed the view that improved standards were not conditional on a new building.

Visible leadership – in response to a question about the degree to which clinical and business leadership was linked across the organisation, mutually supportive and becoming more visible to MFT staff Dr Barnes said this was work in progress. He explained there had been 32 different Board members over the last two years, which had generated instability and made the creation of ongoing organisational links difficult. The aim now was to streamline structures and reduce the number of layers between Board and Ward. Dr Barnes confirmed recruitment of a new Chief Executive for the Trust would proceed once a new Chair had been appointed and that in the meantime he had agreed to act into the role to provide much needed stability. It was noted that it could take approximately six months before a new Chief Executive was in post.

Proliferation of action plans and need for rationalisation – members asked whether there was a need to rationalise and streamline action plans as work had been required by the Trust to respond to Keogh, the Francis Enquiry and now the CQC generating a wide range of plans. Given poor levels of compliance across the Trust members asked if the proliferation of plans was causing confusion among staff as evidenced in the CQC report. Dr Barnes agreed there were risks attached to having multiple action plans and rationalisation of these had been one of the immediate set of actions discussed at the CQC Quality Summit. A fuller action plan had been in development in the four weeks since the Quality Summit with the aim of wide dissemination beyond the executive level. Dr Barnes agreed a new approach would be required in order to penetrate the whole organisation. He also highlighted the importance of good management of clinical and non-clinical information as one of the most important lessons for the Trust arising from the CQC Inspection and joint working with University Hospital Birmingham over the last five weeks. He welcomed the comments from members about the commitment of staff and reported positive feedback from Birmingham about the numbers of good staff at MFT.

The Acting Local Area Team Director for NHS Kent and Medway echoed this and reinforced the risk attached to too many plans and the importance of a focus on the actions that will make the biggest difference quickly. He said the Trust was being supported in this and referred to the recent systems summit which had taken place in July to clarify the most effective actions required across health and social care.

One member asked about monitoring of delivery of the action plans. It was explained that all action plans are monitored by a lead Director via divisional management arrangements and an overview is kept at executive level.

Resources for training and teachingand information management– the Committee suggested that effective training on-line and in other formats was critical to achieving better levels of compliance, information flow and engendering a stake in organisational plans by staff. Members asked if there was sufficient support and financial resources for the development of IT and training systems given the pressure to invest in the clinical side of the operation. Dr Barnes stated that too many of the existing systems required manual input and that whilst on-line training resources were excellent there was a disconnect with the record keeping systems which undermined capacity to track training take-up and produce statistics to demonstrate compliance. He was confident up to date training records would be accessible shortly which would place the Trust in a better position to sustain standards.

Direction of travel and sustaining progress – members expressed concern that the latest CQC Intelligent Monitoring Report showed that between October 2013 and March 2014 MFT had moved from 5 to 6 elevated risks and from 3 to 6 ordinary risks seemingly representing a worsening position. Reference was made to the progress made across the 14 Foundation Trusts found by the CQC to be in a similar position to MFT and the fact that of those 14 MFT was the only one that had failed to make sufficient overall progress. Members also referred to the factors identified as making the most contribution to improvement ie leadership, acceptance of the scale of the challenge, alignment of managers and clinicians and willingness to accept support from another Trust. In response Dr Barnes said a representative of one regulatory body had expressed the view in the last few days that while MFT had not moved forward, it had not stood still, likening the current position to the gradual turning of a super tanker. He assured the Committee that action was being taken to provide stable leadership, which was the key factor in maintaining a single way forward. Benefits were already being derived from the support, insights and advice being provided by the visiting teams from University Hospital Birmingham under new buddy arrangements. He acknowledged that alignment across the clinical body of MFT had not been easy and had only happened significantly in the last few weeks. Dr Barnes said he was convinced the MFT clinical body was now very much engaged in the priority actions with a palpable sense of wishing to restore pride among staff. 

Discharge of patients to care in the community – in response to a question about measures to ensure patients are only discharged after appropriate care plans have been put in place and any safeguarding issues addressed Dr Barnes explained that the integrated discharge team was now doing better than when it was initially established and that feedback would be valued to further improve the service provided by the team.

University Hospital Birmingham – in response to a question about the role of, and value added by University Hospital Birmingham in the MFT improvement journey Dr Barnes stated that MFT had asked for assistance rather than had it imposed. University Hospital Birmingham had a long standing reputation of strength in leadership and operational management and was providing valuable challenge to MFT. He expressed the view that MFT could learn much from Birmingham. In particular Birmingham colleagues had provided feedback and an independent check on the project plan for replacement of the MFT patient administration system. In addition they were advising on governance and management structures. The Good Governance Institute was a partner of University Hospital Birmingham. Dr Barnes said he had been impressed with the focussed and disciplined approach applied by Birmingham over the five weeks of their involvement with MFT.

High dependency beds – in response to a question about delayed discharges and the impact on availability of high dependency beds Dr Barnes said this was not usually an issue as patients were stepped down from high dependency beds to another ward at an appropriate point and plans for discharge then commenced via the integrated discharge team to ensure the most suitable arrangements are made. Discussion took place on the high standards of care provided in the MFT Dementia Unit and the aspiration to replicate that across the hospital.

Recruitment, retention and development of staff – Dr Barnes outlined for the Committee the work underway to support and retain staff. The aim was to have arrangements in place to review systems where standards were falling short, to offer teaching and education and ongoing support but to also require accountability for poor performance. He confirmed that staff leaving the organisation were offered exit interviews. Regular open days were held to encourage local trained nurses to return to work and the Trust has good links with the University of Greenwich Nursing School. Recruitment from overseas does happen. Recruitment from Spain in particular had helped to plug some gaps in areas like chemotherapy specialist nursing for example.

Dr Barnes also provided an assurance that MFT recognised the importance of creating a culture where training and appraisal is not optional. He acknowledged the potential risks to the Trust as a consequence of failure by staff to attend training but stated that MFT needed to find a way of dealing with the impact of staffing shortages or problems on wards in undermining the capacity of staff to attend training.

Feedback mechanisms – Dr Barnes explained that feedback from staff and incident reporting was improving but could be better and that there were varying degrees of comfort with speaking out. The Speak Out Safely Campaign had helped and he recognised that use of the Datix system to provide feedback on the outcome to people who had reported incidents was inconsistent. More work was required to strengthen feedback mechanisms.

Promulgation of good practice – members asked what the Trust was doing to diffuse across the rest of the organisation the good practice found by the CQC in areas such as critical care and services for children and young people which had both been commended. Dr Barnes said MFT aimed to achieve the diffusion of good practice by getting people together, reducing the complexity of the organisational structure to minimise silo working and by improving flow through the hospital, particularly in A and E and for surgical patients.

Extension of Monday to Friday services – Dr Barnes confirmed that some progress had been achieved in extending hours with particular focus on the acutely ill and areas where flow would be enhanced. The Trust was seeking to reduce variations between weekdays and the weekend for acutely ill patients with a view to improving the quality of care. The extended hours for the pharmacy and imaging department were cited as examples.

Safeguarding – in response to a question about safeguarding the Director of Children and Adults assured the Committee there had been no finding of risk of access by inappropriate individuals to children at the hospital and that proper safeguarding arrangements were in place.

Other specific questionsand general commentary – In response to some specific questions and other commentary from members of the Committee Dr Barnes and the Chief Operating Officer from NHS Medway CCG advised as follows:

• Whilst compliance, co-operation, comparators and confidence levels were important in the improvement journey the over riding factor was consistency across the Trust
• In terms of use of A and E by out of area patients it varied. There would be occasions when people from other areas would come to MMH because other A and E departments were full but the same applied for Medway residents when MFT A and E was at capacity. It was possible there might be an increase in the number of out of area residents with surgical issues coming to Medway A and E following reconfigurations at hospitals in Maidstone and Tunbridge Wells but evidence was still anecdotal at this stage. The cost of treating out of area patients was recovered via the A and E tariff system.
• The new Interim Finance Director at MFT was in receipt of one salary even though he had involvement and roles in several organisations
• The cost of support being provided by MFT by University Birmingham was £0.75m (excl VAT); £0.83m with VAT
• Information about any ongoing legacy costs associated with the Vanguard unit to be met by MFT could be provided separately to the member who asked about it
• MFT will be planning to cope with the expanding population in Medway and Swale as part of the next phase of the improvement journey. Priority would be given to providing quality care to the acutely ill and capacity planning would be undertaken jointly with commissioners and in partnership with social care colleagues, particularly in relation to the Better Care Fund Plan.
• Whilst there was scope for a wide philosophical debate about the value of the role played by Monitor, Dr Barnes said that it was very clear that Monitor expected the Trust first and foremost to provide a safe hospital and also financial sustainability.
• Further work would be required to address failings in the operation of the equipment library which was an excellent facility in principle and to put a properly functioning electronic record system in place in response to the CQC finding in relation to stockpiling of outpatient records. MFT was not unique in having an outdated clinical record system which fell short of the standards now being achieved in the primary care sector.
• Dr Barnes welcomed suggestions about good management practice and systems and agreed to consider the potential value of BSI ISO 9001, Investors in People accreditation and an offer of links between Medway Council’s internal audit team and the audit team at the hospital. He acknowledged to the Committee the particular challenges in communication with medical staff especially on split sites and in terms of achieving standardisation across clinical areas.

At the conclusion of the meeting the Chairman and other members thanked Dr Barnes and other NHS representatives for attending the meeting and answering member’s questions. The Committee asked for its appreciation for the hard work and commitment of those staff striving to provide good quality care in difficult circumstances at Medway Maritime Hospital to be placed ion record.

Decision:

The Committee agreed :

a)     That Monitor should be advised in letter from the Committee of Mr Langley’s decision not to attend the meeting which is a failure to comply with his obligation to Overview and Scrutiny, the disappointment of members and the wish of the Committee that any future Chair of MFT should be advised of the expectation they will attend Overview and Scrutiny Committee meetings on a regular basis.;

b)     That the Acting Chief Executive of Medway NHS Foundation Trust be invited to attend the Committee meeting on 30 September 2014 to bring forward full details of the Trust’s action plan in response to the findings set out in the CQC Inspection report;

c)      To note that a representative from Monitor and the CQC had been requested to attend the Committee meeting on 30 September 2014 and;

d)      To formally request Healthwatch Medway to provide the Committee with feedback from users of the hospital for independent feedback on their experiences as the improvement actions are implemented.