The report at Appendix 1 provides an update on progress since the Trust last attended the Committee in August 2019, with there being a particular focus on the impact of Covid-19 and the Care Quality Commission’s (CQC) inspection report that was published on 30 April 2020.
The Chief Executive of MFT introduced the report, highlighting the Trust response to the Covid-19 pandemic. Half of the hospital’s 525 beds had been made available to care for Covid-19 patients and critical care capacity had increased from 18 to 53 beds. The maximum capacity that had been needed was 28. Half of the wards had only been available for Covid patients during the peak and emergency admissions during April were under half of their usual number.
Most non-urgent operations, outpatient appointments, diagnostics and elective care had been cancelled in line with national guidance although the hospital had decided to continue some elective care, trauma work and cancer treatment. While levels of Personal Protective Equipment (PPE) had been a national issue, the hospital had seen good levels of PPE throughout the pandemic with a system having been put in place to notify management if stocks fell below a certain level. In accordance with national guidance, with limited exceptions, hospital visits had not been permitted during the pandemic. Alternative solutions, such as using video conferencing had been put in place to help patients stay in touch with friends and family, particularly for end of life patients.
There were currently 13 patients with Covid-19 being treated in the hospital, a further two cases being treated in the intensive care unit. During a 12 week period there had been 370 discharges of patients who had been treated for the illness and 172 deaths of patients with it. Consideration was being given as to how to remember the patients who had died.
Members raised a number of questions and comments, which included:
Staff Welfare – in response to a question about how staff were being supported, the Chief Executive said that levels of staff sickness had been higher than usual with many staff having lived away from their families. Much work had been done to support staff with good feedback having been received. Mental and occupational health provision for staff had been increased in the last few weeks.
Staff accommodation – It was asked whether accommodation had been available for staff who wanted to stay on site. The Committee was advised that less than five staff had stayed on site with most of those staying away from home having made alternative arrangements.
Digital Provision, BAME Staff and PPE Provision – It was questioned whether the digital provision put in place would be retained post pandemic. It was also asked what precautions were being taken to keep Black, Asian and Minority Ethnic (BAME) staff safe in light of evidence suggesting they could be more at risk from Covid-19 and whether there was confidence that enough PPE would be available in future. The Chief Executive said that the enhanced digital provision would be retained with the Trust looking to expedite work on a digital strategy. A national risk assessment had been undertaken in relation to BAME staff and the Chief Executive had highlighted the issue to ensure that BAME staff were well represented. There had been national reports that suggested that a deficiency of vitamin D could be a risk factor in some BAME populations. BAME staff had been contacted in this regard. Risk assessment of the specific risk to BAME staff would continue while Covid-19 was in circulation. Hospital visitors would be required to wear a face covering rather than a face mask so it was not anticipated that there would be resulting shortages of PPE. Face masks would be available for visitors who did not bring a face covering and hand sanitiser was made available.
The Director of Public Health added that a Kent and Medway action plan relating to the impact of Covid-19 on BAME groups had been returned at a regional level. Preventative work was taking place to reduce the number of infections and reduce the likelihood of patients needing to be admitted to hospital.
Testing, outpatients transformation, admission figures, PPE and Covid-19 impact – It was asked whether patients had been tested before being discharged to care homes; How outpatients work had been transformed; whether work was being undertaken to look at low hospital attendance during the pandemic and; how it would be ensured that sufficient PPE stocks would be maintained. It was also noted that Medway Councillors had discussed the creation of a memorial to remember those in Medway who had died with Covid-19.
The Chief Executive said that there had been a planned approach in relation to discharges to care homes. Patients had not been discharged if they were unwell but national guidance had changed during the pandemic. Initial guidance meant that patients were not initially tested on admission to hospital. When this changed, the number of patients tested increased and the time taken to obtain results also increased.
There had been an increased number of calls to NHS 111 which could explain some of the fall in attendance at GP surgeries and the hospital. Work was ongoing to look at how the hospital could return to business as usual with it being expected that elective patients would start to be seen again from the end of June. Should PPE stocks fall below a certain level the hospital was able to escalate this regionally and nationally to obtain additional supplies. Work had started to assess the impact of Covid-19 on communities in Medway and across the healthcare system and it was acknowledged that there was a need to communicate to the public that the hospital and the Emergency Department was open for business.
The Director of Public Health said that a report had recently been published by Public Health England. This had established the groups most likely to have been impacted by Covid-19. Work was taking place across the South East to analyse these findings.
Testing of Patients Discharged to Care Homes – In response to a question that asked when testing of patients to be discharged to care homes had started, the Medical Director of Medway Foundation Trust said that as hospital patients had not been routinely tested in the early stages of the pandemic it had been difficult to ascertain which patients had Covid-19. Only those clinically suspected were tested, now all patients were tested. Where patients tested positive for the first time more than 14 days after admission to hospital there could be confidence that they had acquired it in hospital. 8% of Medway patients with Covid-19 had contracted it in hospital. This compared to a national average of 12%. The majority of this transmission was from staff to patients and it was considered that Medway’s figure was lower than average because it had required staff to wear masks early in the outbreak. The national instruction for every patient to be tested before discharge to a care home had been made at the end of April and the testing of all hospital admissions had been required from mid-May. It was acknowledged that there was a need to reflect on what the risk had been of discharging patients to care homes before routine testing had been in place.
Care Quality Commission (CQC) Report – In relation to there having been little improvement in the CQC report findings compared to the previous visit, it was asked how the action plan to drive forward improvements would be sustained more effectively than previous action plans. The Chief Executive said that MFT was disappointed by some of the CQC findings. More positively, critical care had been rated outstanding with end of life care rated good in every domain. Some of the issues identified were relatively simple to resolve, such as the locking up of substances hazardous to health and poor infection control practices. The Trust was required to present an action plan to the CQC within 28 days of publication of the report to cover the must do actions and should do actions that had been identified by the CQC. There was a need to ensure that the hospital’s improvement plan would be clinically led and central to the hospital’s work. A draft Improvement Plan was due to be shared with staff across the hospital by the end of June with the aim for it to be finalised by the end of July and signed off in August. A number of actions set out in the Plan had already been completed with reviews being undertaken in areas where ratings had declined since previous inspections. It was hoped that the Trust would be rated good at its next inspection.
Facilities for children – Highlighting the inspection report that set out that there were inadequate facilities for children post operation and that staff were not aware of the plan, it was asked how this was being addressed. The Chief Executive said that it was possible that the CQC inspectors had spoken to a newer member of staff and that he would hope that most staff would be aware of the plans. Using separate recovery bays for child patients was challenging due to the layout of the hospital but work was taking place through a Kent and Medway CCG work plan, that would see enhanced recovery provision within hospitals for child patients.
Safeguarding Training and safety – Concern was expressed that the CQC report had highlighted that not all medical staff were up to date with safeguarding training and that some on-site safety concerns had been found relating to the safety of children, with safety information not always being shared. The Committee was advised that the number of staff who were up to date in relation to safeguarding training was the highest for three years. Changes had been made to ensure that training physically took place within the relevant hospital department. The online training provider had been changed with NHS Select now being used for most level 1 training. Ward managers had been contacted to ensure they were aware of their responsibility for safety issues, such as keeping kitchen doors shut and cupboards locked. These issues would also be addressed in the Action Plan.
Measurability of actions and Dickens Ward – concern was expressed that actions contained in plans could be difficult to measure and it was questioned how it would be ensured that future plans were more effective than previous ones. It was also asked why shortcomings that the Hospital had already been aware of had not been addressed before publication of the report and whether there was confidence in the MFT Board. A question was also asked about the closure of Dickens Ward.
The Chief Executive advised that the Improvement Plan was being led by clinicians. The Plan and the Trust’s board quality performance report did not use Red/Amber/Green performance monitoring because of concern that this system did not facilitate the addressing of issues behind the headline ratings. The CQC report template, which did use a RAG system, was not within MFTs control. In relation to the closure of Dickens Ward, this had been an MFT rather than a CQC decision as there had not been confidence that good care could be provided consistently. The latest staff survey showed the best morale and engagement scores for around five years. All indicators bar one in the survey suggested that staff felt the hospital was improving. Following publication of the CQC report, engagement had taken place with staff across the hospital. The Chief Executive did not consider the MFT Board to be weak or lacking empathy with the Board and executive team being committed to driving improvement.
Silo Working – In response to concern raised about teams working in isolation and not taking responsibility for other patients, the Chief Executive said that consideration was being given as to how to better share learning. Some services had been rated as outstanding, therefore there was a need to review learning from these areas and create multi-disciplinary teams that communicated more with each other.
Staff Survey and CQC results – Disappointment with the staff survey results was highlighted as it was suggested that results could have been expected to demonstrate stronger improvement. It was also asked whether levels of bullying and harassment amongst staff were still a concern, how morale was being maintained and staff retained. Issues identified by the CQC such as problems with infection control and a lack of equipment cleaning were concerning. The Chief Executive responded that cultural change usually took a few years to embed. However, the staff survey results showed a big improvement in relation to bullying and harassment. It was acknowledged that more work was required but there was confidence that staff now felt better able to speak up without fear of reprisal. The number of staff leaving the trust was decreasing with there being around 200 more nurses than three years previously. Pharmacy was one area that had previously seen poor engagement in the survey. Following intervention it was now one of the highest performers in the survey.
The hospital was currently in Phase 2 of 3 of a rebuild of its Emergency Department. It was noted that the department had originally only being built to accommodate 40,000 patients a year with the current number of patients being 115,000. The rebuild was due to finish in 2021 at which point there should be no need to treat and patients in open areas.
The Chief Executive of MFT introduced the second part of the report that was contained in supplementary agenda number 2. This set out that acute stroke services would be temporarily transferred, as an emergency measure, to Maidstone Hospital and Darent Valley Hospital from early July 2020. It had not been possible to provide the report sooner as MFT had been working to try to avoid the need for the change. The Committee was informed that the change was being made on safety grounds and did not amount to early implementation of the decision made by the Kent and Medway Stroke Review, which if implemented, would see acute stroke services moving away from Medway Hospital. However, the uncertainty around the implementation of Hyper Acute Stroke Units (HASUs) had impacted on the ability to recruit and retain the workforce.
Recent staff resignations had resulted in a situation where there would only be one clinical nurse specialist in the department from 1 July 2020. It was therefore not possible to safely provide a specialist stroke service with it having been requested that from 1 July services be provided at Maidstone Hospital, with some patients being cared for at Darent Valley Hospital. Work had taken place with an agency to see if an alternative solution could be found but this had not been possible. MFT was very disappointed that this situation had arisen and it was noted that MFT had been able to enhance some other services within the last two years.
Members raised a number of questions and comments, which included:
Patient numbers and specialist nurses - In response to a question raised, it was clarified that the Medway Stroke Services currently saw around 500 patients each year. It was also asked, given that there were already no specialist nurses available at night, whether the current arrangements could be maintained during the day pending recruitment of extra specialist nurses.
The Chief Executive said that the rota overnight was largely managed by emergency consultants and other nursing colleagues with timely intervention for stroke patients being critical. Night time provision relied on emergency consultants undertaking some of the specialist work. The majority of stroke cases presented during the day, including around 70-75% of cases requiring thrombolysis. As the emergency and medical teams had significant other work to undertake relying on them would result in delays in treating patients.
Lateness of report and impact on referral – Discontentment was expressed that the report had only been provided on the day before the Committee. There was also concern that the move of the stroke service away from Medway would have an impact on Medway’s Secretary of State Referral and appeal against a Judicial Review decision in relation to the NHS decision regarding the Kent and Medway Stroke Review.
Rehabilitation Patient Transfer, staffing and health inequalities – in relation to a previous temporary transfer of patients undergoing rehabilitation away from Maidstone hospital, it was asked whether in the context of Maidstone now having capacity for Medway Stroke patients, the rehabilitation change was a permanent one. It was also questioned whether staff from Maidstone could be seconded to Medway and whether the provision of thrombolysis was now seen as being more important than previously. Concern was expressed that moving stroke provision away from Medway would worsen existing health inequalities.
The Chief Executive said recruitment opportunities were being explored but that there was a national shortage of stroke nurses. Moving staff from Maidstone to Medway would make staffing levels at Maidstone dangerous and therefore could not be considered. The temporary relocation of stroke services was being made purely on safety grounds. Staffing the service had been made more difficult by the ongoing uncertainty about where the hyper acute stroke units would be located. MFT had wanted to host a HASU and would have been able to deliver this within six months of a decision being made. The relocation of rehabilitation patients was temporary due to Coronavirus with it being expected that this would need to continue until 2021.
The Medical Director did not consider that the relocation of stroke services would impact the outcome of the Judicial Review or Secretary of State referral. Medway had already developed the ward capacity for a HASU to be developed. Predictions were that should there be a second peak of Covid-19, it could occur any time between July 2020 and March 2021. Thrombolysis was important for a particular group of patients but stroke nurses were also needed for other work with stroke patients. Ideally, this specialist provision would be available 24 hours a day.
Stroke provision in Medway – Further concerns were expressed that the Committee had only just been informed of the relocation of stroke services away from Medway and that it was unlikely that a service would return to Medway. It was also stated that Medway could and should have been chosen to host a HASU. Concern was expressed about the way in which the HASU decision had been made.
The Chief Executive said that if MFT was able to recruit specialist stroke nurses in the short term then it would look to move stroke services back to Medway. With regard to HASUs, Medway had been committed to developing a HASU and had been disappointed not to be chosen.
CCG Representation at meeting and staffing – Significant concerns were expressed that no one from the CCG was in attendance at the Committee and that the CCG decision not to select Medway for the development of a HASU was causing the stroke service staffing difficulties. It was stated that given that the document provided in the supplementary agenda had been signed by the CCG, their attendance would be expected. It was asked whether the use of agency staff had been considered in order to keep the Medway Stroke Service running.
The Chief Executive said that staffing levels would reduce to one clinical nurse specialist at Medway and that a further two would be needed in order to provide a stroke service safely. The Trust had worked with medical directors from other trusts to see whether there was a possibility of staff being seconded. Agency and permanent recruitment options had been considered but staff retention had been challenging due to the uncertainty. It was hoped that the outcome of the Judicial Review appeal and Medway’s Secretary of State referral would be known soon. Should a decision be made for Medway to become a HASU it would then have an improved ability to recruit staff.
Additional Committee meeting and CCG responsibility – The possibility of an additional Committee meeting to further discuss the issue was discussed. However, it was considered that such a meeting could not have an impact ahead of the relocation of the stroke service and that the case had been made by MFT that patient safety would be at risk if the stroke service continued to operate at Medway. It was also suggested that the CCG would be responsible should the relocation of the service away from Medway result in patient deaths.
i) Noted and commented on the report provided by Medway NHS Foundation Trust.
ii) Agreed for a letter to be sent to Medway Foundation Trust, on behalf of the Committee, thanking staff at the hospital for their work, particularly in relation to Covid-19.
iii) Agreed for a letter to be sent to Kent and Medway Clinical Commissioning Group, on behalf of the Committee, to express the Committee’s significant concern that no one from the CCG had attended the Committee meeting.