Buckinghamshire Healthcare NHS Trust
Review into the Quality of Care & Treatment provided by
14 Hospital Trusts in England
RAPID RESPONSIVE REVIEW REPORT FOR RISK SUMMIT
July 2013
Contents
1.
Introduction
3
2.
Background to the Trust
7
3.
Key Lines of Enquiry
10
4.
Review findings
11
5.
Governance and leadership
14
Clinical and operational effectiveness
21
Patient experience
28
Workforce and safety
33
Conclusions and support required
Appendices
45
49
Appendix I:
SHMI and HSMR definitions
50
Appendix II:
Panel composition
52
Appendix III:
Interviews held
54
Appendix IV: Observations undertaken
56
Appendix V:
58
Focus groups held
Appendix VI: Information available to the RRR panel
59
Appendix VII: Unannounced site visit
66
Appendix VIII - Patient Stories
68
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1.
Introduction
This section of the report provides background to the review process and details of the key stages of the review.
Overview of review process
On 6 February 2013, the Prime Minister asked Professor Sir Bruce Keogh, NHS England Medical Director, to review the quality of the care and treatment being provided by
those hospital trusts in England that have been persistent outliers on mortality statistics. The 14 NHS trusts which fall within the scope of this review were selected on the
basis that they have been outliers for the last two consecutive years on either the Summary Hospital level Mortality Indicator (SHMI) or the Hospital Standardised Mortality
Ratio (HSMR). Definitions of SHMI and HSMR are included at Appendix I.
These two measures are intended to be used in the context of this review as a ‘smoke alarm’ for identifying potential problems affecting the quality of patient care and
treatment at the trusts which warrant further review. It was intended that these measures should not be reviewed in isolation and no judgments were made at the start of the
review about the actual quality of care being provided to patients at the trusts.
Key principles of the review
The review process applied to all 14 NHS trusts was designed to embed the following principles:
Patient and public participation – these individuals have a key role and worked in partnership with clinicians on the reviewing panel. The panel sought the views of the
patients in each of the hospitals and also considered independent feedback from stakeholders related to the trust being reviewed, which had been received through the
Keogh review website. These themes have been reflected in the reports.
Listening to the views of staff – staff were supported to provide frank and honest opinions about the quality of care provided to hospital patients.
Openness and transparency – all possible information and intelligence relating to the review and individual investigations will be publicly available.
Cooperation between organisations – each review was built around strong cooperation between different organisations that make up the health system, placing the interest
of patients first at all times.
Terms of reference of the review
The review process was designed by a team of clinicians and other key stakeholders identified by NHS England, based on the NHS National Quality Board guidance on
Rapid Responsive Reviews (RRR) and Risk Summits. The process was designed to:

Determine whether there are any sustained failings in the quality of care and treatment being provided to patients at these trusts.
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
Identify:
Whether existing action by these trusts to improve quality is adequate and whether any additional steps should be taken.
Any additional external support that should be made available to these trusts to help them improve.
Any areas that may require regulatory action in order to protect patients.
The review follows a three stage process:
Stage 1 – Information gathering and analysis
This stage used information and data held across the NHS and other public bodies to prepare analysis in relation to clinical quality and outcomes as well as patient and staff
views and feedback. The indicators for each trust were compared to appropriate benchmarks to identify any outliers for further investigation in the rapid responsive review
stage as Key Lines of Enquiry (KLOE). The data pack for each trust reviewed is published at http://www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/trust-datapacks/buckinghamshire-data-packs.pdf.
Stage 2 – Rapid Responsive Review (RRR)
A team of experienced clinicians, patients, managers and regulators (see Appendix II for panel composition), following training, visited each of the 14 hospitals and observed
the hospital in action. This involved walking the wards and departments, and interviewing patients, trainees, staff and Board members. The report from this stage was
considered at the risk summit.
Stage 3 – Risk Summit
This brought together a separate group of experts from across health organisations, including the regulatory bodies. They considered the report from the RRR, alongside
other hard and soft intelligence, in order to make judgments about the quality of care being provided and agree any necessary actions, including offers of support to the
hospitals concerned. A report following each risk summit has been made publically available.
Methods of Investigation
th
th
A three-day announced RRR visit took place at the Buckinghamshire Healthcare NHS Trust (“the Trust”), on Monday 10 to Wednesday 12 June 2013. The Stoke
Mandeville, Amersham and Wycombe sites were visited during this period. A variety of review methods were used to investigate the KLOEs and enable the panel to consider
evidence from multiple sources in making their judgements.
The visit included the following methods of investigation:
Listening events
Public listening events give the public an opportunity to share their personal experiences of the Trust, and to voice their opinion on what they feel works well or needs
improving at the Trust. A listening event for the public and patients was held on the evening of 10 June at the Aylesbury Council Offices and 11 June 2013 at the Wycombe
Hospital site. This was an open event, publicised locally, and attended by approximately 60 members of the public and patients on each evening.
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The panel would like to thank all those attending the listening event who were open with the sharing of their experiences and balanced in their perceptions of the quality of
care and treatment at the Trust. The panel found the listening events extremely useful as it identified a number of positive themes around patient experiences, along with
highlighting a number of areas for further investigation.
Information obtained about the quality of care and treatment at the Trust from the listening event was used to drive the panel's agenda for the second and third day of the
announced site visit and for the unannounced site visit. Relevant themes emerging have been included within this report.
Interviews
21 interviews took place with key members of the executive team, non-executive directors and selected members of staff based on the KLOEs during the visits. See
Appendix III for details of the interviews undertaken.
Observations
Observations of clinical areas and meetings enabled the panel to see the Trust undergo its day to day operations. They allowed the panel to talk to current patients, and their
families where observations took place during visiting hours. They also allowed the panel to speak with a range of staff and assess any observed handover processes within
wards, to ensure that the staff that was coming on duty was appropriately briefed on patients.
During the RRR announced visit, observations took place in 20 areas of the Buckinghamshire Healthcare NHS Trust. See Appendix IV for details of the observations
undertaken.
Further observations were undertaken as part of the unannounced site visit, see below.
Focus Groups
Focus groups provided an opportunity to talk to staff groups individually to ask each area of staff what they feel is good about patient care in the Trust and what needs
improving. They enabled staff to speak up if they feel there is a barrier that is preventing them from providing good quality care to patients and what actions might the Trust
need to consider to improve, including addressing areas with higher than expected mortality indicators.
Focus groups were held during the announced site visit with 10 staff groups, including a focus group open to all staff. See Appendix V for details of the focus groups held.
The panel would like to thank all those who attended the focus groups and were open with the sharing of their experiences and balanced in their perceptions of the quality of
care and treatment at the Trust.
Review of documentation
A number of documents were made available to the panellists by the Trust as part of the RRR. Whilst the documents were not all reviewed in detail, they were available to
the panellists to validate findings. See Appendix VI for details of the documents available to the panel.
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Unannounced visit
The unannounced visit focused on areas identified at the announced site visit and took place over 4 sites as follows:




Stoke Mandeville (A&E, SSU, Surgical Ward) on the evening of Sunday 16/6/13
Wycombe (Minor Injuries and Illness Unit, Surgical Ward, Cardiac, Stroke and Receiving Unit, Contact Junior Doctors) on the evening of Tuesday 18/6/13
Amersham Community Hospital on the evening of Tuesday 18/6/13
Stoke Mandeville (Gynaecology, Elderly, Medical Ward) on the morning of Wednesday 19/6/13
See Appendix VII for details of the agenda completed.
Next steps
This report has been produced by Nigel Acheson, Panel Chair, with the full support and input of panel members. It has been shared with the Trust for a factual accuracy
check. This report was issued to attendees at the risk summit, which focussed on supporting Buckinghamshire Healthcare NHS Trust (“the Trust”) in addressing the actions
identified to improve the quality of care and treatment.
Following the risk summit the agreed action plan will be published alongside this report on the Keogh review website. A report summarising the findings and actions arising
from the 14 investigations will also be published.
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2. Background to the Trust
This section of the report provides background information on the Trust.
Context
Buckinghamshire Healthcare NHS Trust (“the Trust”) is not currently a Foundation Trust. The Trust has two acute hospital sites: Stoke Mandeville Hospital (which includes a
hospice for palliative care) and Wycombe Hospital In addition, the Trust provides services at five community hospitals: Amersham Hospital , Buckingham Community
Hospital, Chalfont and Gerrards Cross Community Hospital, Marlow Community Hospital, Thame Community Hospital. The Trust is integrated with community services and
has seven Adult Community Healthcare Teams in place working twenty four hours a day, seven days a week. The Trust has a higher bed occupancy rate than the national
average, offering a large range of services, in 2012 serving 94,116 inpatients and 476,074 outpatients.
14% of Buckinghamshire’s population belong to non-White ethnic minorities. Incidents of malignant melanoma, violent crime and infant death are significantly higher than the
national average in parts of Buckinghamshire.
A review of ambulance response times shows that the South Central Ambulance Trust meets the national 8min response target, but not the 19min response target.
Finally, the Trust’s HSMR level has been above the expected level for the last 2 years and it was therefore selected for this review.
Trust size and focus
Buckinghamshire Healthcare NHS Trust in the South Central of England services a population of about 500,000, which places the Trust within the higher range of the size
recommended by the Royal College of Surgeons. The Trust has a total of 739 beds. It has a 74% market share of inpatient elective activity within a 5 mile radius of the Trust’s
acute hospitals. However, the Trust’s market share falls to 48% within a radius of 10 miles, and 15% within a radius of 20 miles.
FACT BOX
Population
500,000
The Royal College of Surgeons recommend that the "...catchment population size...for an acute general hospital providing the full range of facilities, specialist staff and expertise for both elective
and emergency medical and surgical care would be 450,000 - 500,000."
nd
Index of Multiple Deprivation (IDM)
Of 149 English unitary authorities, Buckinghamshire is at 142
place, which means that is one of the least deprived.
Ethnic diversity
In Buckinghamshire, 13.6% belong to non-White minorities, including 4.2% Pakistani.
Rural or Urban
Buckinghamshire is a rural-urban region.
Incidence of malignant melanoma
In parts of Buckinghamshire, and particularly in Aylesbury Vale, incidents of malignant melanomas are significantly more common than in the country
Road injuries and death
In parts of Buckinghamshire, and particularly in South Bucks, road injuries and death are significantly more common than in the country as a whole.
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Buckinghamshire area overview
Buckinghamshire, in South East England, is one of the least deprived areas in the country. The age distribution in Buckinghamshire is largely similar to that of England as a
whole; however, Buckinghamshire has significantly fewer women and men in their 20s. Incidents of malignant melanoma and infant death are particular health concerns in
parts of Buckinghamshire compared to the country as a whole. 14% of Buckinghamshire’s population belong to non-White minorities.
Key messages from the data analysis
The Trust data pack identified a number of key concerns that were used to inform the KLOEs, which are outlined below.
Mortality
The Trust has an overall HSMR of 117 for the period January 2012 to December 2012, meaning that the number of actual deaths is higher than the expected level. This is
statistically above the expected range. Deeper analysis of this demonstrates that non-elective admissions are the primary contributing factor to this figure, with an HSMR of
117, also above the expected range. Elective admissions are within the expected range, with an HSMR of 90.
Currently, Buckinghamshire has a SHMI of 114, which is statistically above the expected range. The non-elective admissions are seen to be contributing primarily to the
overall Trust’s SHMI with a figure of 114, which is above the expected range. The elective admissions are within the expected range, despite a relatively high SHMI of 113.
The Trust was selected on the basis of its HSMR, but its SHMI has been higher than expected over the last 12 months. Its HSMR has been higher than expected for 3-4
years.
Mortality concerns appear to be focused within respiratory medicine/elderly care, strongly associated with a mortality outlier alert for patients admitted with pneumonia. CQC
has issued mortality outlier alert notices to the Trust relating to Pneumonia and Acute and Unspecified Renal Failure. The Trust raised issues around clinical coding as well as
process actions around the emergency care pathway for patients with pneumonia.
Buckinghamshire report above average activity associated with palliative care.
The key lines of enquiry (KLOEs) for the RRR included a review of the specialties in the Trust with higher mortality indicators and these informed the panel’s
observations and interviews.
Governance and leadership
The Trust Board has had two recent to its executive membership; the Chair joined the Trust in September 2012 and the Chief Operating Officer joined the Trust in Feb 2013.
The Director of Human Resources (non-voting, in post since Jan 2013) is an interim post but all the other executive positions are substantive. There is also a recently
appointed interim Medical Director, who is in the process of taking over responsibilities from the previous Medical Director.
The Healthcare Governance Committee is chaired by a non executive (Keith Gilchrist) and reports directly to the Trust Board. The Trust has also established a Mortality Task
Force, which has been meeting since October 2010.
A review of quality governance was performed by KPMG in October 2012. This review compared the governance arrangements in the Trust against Monitor’s Quality
Governance Framework. KPMG scored the Trust 3.0 (trusts must achieve a score of 3.5 or below to be authorised as a foundation trust).
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Key patient safety risks identified by the Trust relate to Accident & Emergency, staffing, the National Spinal Injuries Centre, theatres and Care of Older People.
A high level review of the effectiveness of the Trust’s quality governance arrangements was a standard KLOE for the review.
Clinical and operating effectiveness
The Trust is at the lower end of the distribution for the percentage of diabetic patients receiving a foot risk assessment due to low scores at both Stoke Mandeville and
Amersham Hospitals. A key measure of clinical effectiveness is the percentage of discharged patients who are prescribed beta blockers and Stoke Mandeville was outside
the control limits and is therefore an outlier on this measure.
The Trust failed to meet the 95% target level for A&E patients seen within 4 hours in 2012/13. The percentage of patients seen within 4 hours generally decreases during
2012. 93.7% of patients start treatment within the 18 week target time which is above the target level. This has been a consistent trend from April 2012 to March 2013.
The Trust’s crude readmission rate is among the lower readmission rates of the trusts in the review as well as nationally, at 9.2%. The Trust’s standardised readmission rate
shows a level of performance that is statistically within what is expected. The Trust’s average length of stay is shorter than that of the national average, at 4.92 days.
The PROMs dashboard shows that Buckinghamshire was a consistent performer overall. None of the indicators fell outside of the control limits for the 3 years shown in the
dashboard.
A high level review of clinical and operating effectiveness measures was a standard KLOE for the review.
Patient experience
Of the 9 measures reviewed within Patient Experience and Complaints the Trust was rated ‘red’ on two measures: The “inpatient survey” and a report from the complaints
ombudsman.
On the inpatient survey, the Trust was poor on delays allocating patients to a ward, information given to discharged patients, communication on medication side effects,
cleanliness, hospital food and noise at night from other patients.
A separate report by the Ombudsman rates the Trust as C-rated for satisfactory remedies, which indicates a high risk of non-compliance with its recommendations. This is the
lowest category rating. The Ombudsman investigates complaints escalated to it by complainants who are not satisfied with the Trust's response. It rates Trusts on whether
they have implemented the recommendations made at the end of an investigation in a satisfactorily and timely manner, helping to ensure that Trusts learn from mistakes. The
Ombudsman rates each Trust’s compliance with recommendations and focuses on monitoring organisations whose compliance history indicates that they present a risk of
non-compliance.
KLOEs were included in the review focusing on what patients say about the quality of care and treatment and what the Trust was doing in response to this
feedback.
Workforce and safety
The Trust is a net contributor to the Clinical Negligence Scheme for Trusts. Contributions to the scheme have exceeded payouts to litigants in each of the last 3 years, and in
total by £10.7m. There has been two rule 43 Coroners Reports related to the Trust since 2009.
The Trust is a medium reporter of incidents when compared to similar trusts. Since 2009, five ‘never events’ have occurred at the Trust, classified as that because they are
incidents that are so serious they should never happen.
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Throughout the last 12 months, the new pressure ulcer rate at Buckinghamshire has been below the national average. However, the Trust has a higher total pressure ulcer
rate than the national average and has been above the national average in seven out of the last eight months. The Trust is aware of the high rate, which they attribute to the
National Spinal Injuries Centre and inclusion of community services.
The Trust is ‘red rated’ in 12 of the workforce indicators and the remaining 8 indicators are green. It notably has sickness absence rates for medical, nursing and other staff
above the national mean rate and has a higher staff leaving rate and lower staff joining rate than the median within the region. For training of its doctors, it has a lower score
on ‘undermining’ than the national average. In addition, it is being monitored by the GMC’s ‘response to concerns’ process.
KLOEs were included in the Trust review focusing on incident reporting within clinical and operating effectiveness and workforce measures, including workforce
planning and staff support.
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3. Key Lines of Enquiry
The KLOEs were drafted using the following key inputs:
The Trust data pack produced at stage 1 (and made publicly available) to tailor the KLOEs to address any areas the Trust was an outlier in, see section 2 for more details.
.

The data pack produced at stage 1 (and made publicly available) to tailor the KLOEs to address any areas the Trust was an outlier in, see section 2 for more details

Insights from the Trust’s lead Clinical Commissioning Group (CCG), Chiltern CCG.

Review of the patient voice feedback received via the Keogh review website, specific to the Trust prior to the site visit.
These were documented within the Panel Briefing Pack and agreed by the panellists at the panel briefing session prior to the RRR visit
The KLOEs identified for the Trust were as follows:
Theme
Key Line of Enquiry
Governance and leadership
Can the Trust clearly articulate its governance processes for assuring the quality of treatment and care? Are the leadership roles and
responsibilities clearly defined for the quality processes? Can staff at all levels of the organisation describe the key elements of the quality
governance processes (communication to staff)?
Governance and leadership
How does the Trust assess and monitor the quality impact of the Cost Improvement Programme (CIPs)?
Clinical and operational
effectiveness
What governance arrangements does the Trust have to monitor and address clinical effectiveness and operational performance data at a
senior level?
What processes does the Trust have in place to support monitoring mortality data and clinical effectiveness? Has the Trust data identified
any issues? What actions is the Trust taking to address issues noted?
Patient experience
How does the Trust review patient experience data and engage with patients to seek views about their experience? What are the key themes
from patients on their experiences? What action is it taking to address the key themes emerging?
Workforce and safety
In the context of this review, can the Trust describe its workforce strategy?
How is the Board assured that it has the necessary workforce deployed to deliver its quality objectives?
What assurance does the Board have that the organisation is safe?
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4. Review findings
Introduction
The following sections provide a detailed analysis of the panel’s findings, including good practice noted, outstanding concerns and prioritisation of actions required.
A high level summary of the areas identified for urgent action is as follows:
Leadership and governance
In the past three to four years the HSMR has been consistently higher than expected. During this period, the Board has not effectively sought to understand the root causes of
the higher than expected mortality, nor has it developed and implemented an action plan to address those causes. The Board has set up a Mortality Task Force but despite
this, the root causes of higher than expected mortality are still not fully explained or understood by the Trust. Furthermore, the review team feel that there is greater scope to
understand and address the headline causes of mortality, which should include reference to care in the community, pathways of management within the hospitals including
staffing and ward environment, and identification and management of deteriorating patients.
Leadership at Board level was described by a senior member of the Trust as "reactive" and there seems to have been limited challenge and examination of the data
presented to the Board (reassurance, not assurance). Governance relating to patient safety appears to rely heavily on DATIX incident reporting. Such incident reporting will
only capture a small percentage of incidents and other means of monitoring and capturing safety issues are required. The review team commend the introduction of other
methods, including Executive Safety walkabout and implementation of the Safety Thermometer. The Trust needs to urgently develop and implement an agreed performance
dashboard to be used in every ward and reported to the Board along with patient experience data. The risk register is not sensitive or dynamic enough to present proper
issues to the Board. Examples of risks missing on the Corporate Risk Register at the time of the panel’s review were staffing of the Spinal Injuries Unit and risks associated
with the new urgent care model, which have not yet been properly evaluated. The lower level Risk Registers do not adequately feed up to the higher level (Corporate)
Register. The “benefits realisation plan” focuses on monitoring the realisation of benefits. The review team feels that the Trust need to include in this plan a strategy to identify
and manage emerging risks as the plan is implemented, as part of their business as usual.
Clinical and operational effectiveness
There is a lack of organisation-wide monitoring of clinical effectiveness and operational performance data, in that quality scorecards are not in place on all wards and it is
unclear how the Board gains insight about the current and most significant quality and safety risks across its sites. The Trust needs more robust, organisation-wide
monitoring of clinical effectiveness and operational performance data. A clear focus on monitoring performance and implementation of improvement projects would enable the
Trust to move towards a culture that adopts national improvement initiatives and uses incident reporting as a positive and constructive tool. The panel note examples of the
Trust adopting improvement initiatives such as the National Early Warning Scores, High Impact Actions, Safety Thermometer and the “6 C’s”.
The Mortality Task Group must focus its attention upon the identification of trends from the mortality data to inform improvement work. Evaluation of mortality data has been
provided by both Dr Foster and the CQC, identifying pneumonia and acute renal failure as possible contributing factors to the high HSMR. An urgent priority is to develop a
strategy for identifying and managing deteriorating patients on the medical wards – the review team understands that the current capacity on the respiratory ward is
considered to be insufficient and that further dedicated respiratory beds may be provided. In addition, the HSMR is higher at weekends, and the review team heard evidence
of a lack of senior medical cover/review of patients at weekends. The review team did not see evidence to suggest that this was being addressed at pace in a systematic way.
The review team acknowledges the improvement work that is taking place to address the care of patients with pneumonia (evidenced by the BTS audit data). However, the
review team feels that this work must proceed at greater pace and take account of the staffing and ward environment issues in addition to the introduction of widely available,
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evidence-based care bundles to address the treatment of patients with pneumonia, and to detect and manage deteriorating patients. As an example, whilst the recent
introduction of a new early warning score (NEWS) system in place of a previous EWS, is a positive step. Work is now required to ensure that action on the NEWS scores
results in appropriate escalation and management of the deteriorating patient.
There has been a recent period of significant structural and organisational change in the Trust including the consolidation of A&E on the Stoke Mandeville site. Emergency
activity remains on the Wycombe site for acute stroke patients and for emergency interventional cardiology procedures in hours, whilst 24 hour cover by consultants was
provided, the review team noted this was not always by a cardiologist. Prospective evaluation of patient transfers between hospital sites for those presenting as emergencies
should be urgently undertaken to assess patient safety and experience. This evaluation should cover all patients transferred following presentation as an emergency to
ensure that high quality care is provided for those who remain with Buckinghamshire Healthcare Trust as well as those who are transferred to other hospitals such as Oxford
or Harefield. This issue has been a significant reputational risk to the Trust, and the review team heard concerns from the public at both the public listening events and in
written submissions. During the review visit the team saw patients who required transfer between the two sites and feel that urgent, prospective evaluation of this service
change must be undertaken.
There appears to be a culture where some staff believe incidents need to be serious and involving harm before they are reported. Minor incidents, near misses or those
relating to poor patient experience are often not reported. For example inter-hospital transfers at an early stage in the emergency pathway are not considered incidents.
The Board must develop a robust, proactive plan to improve the overall safety and experience of care for patients, particularly those admitted as emergencies, by adopting a
single strategy using a recognised patient safety improvement model. Clear ownership of the plan needs to be agreed with and supported by dedicated project management
expertise to provide pace and ensure consistent implementation in every ward and site. During the review visit the team saw patients who required transfer between the two
sites and feel that, whilst no immediate risks to patient safety were observed, urgent prospective evaluation of this service change must now be undertaken.
Patient experience
Many patients to whom the panel spoke were unreservedly complimentary about the quality of the nursing care they had experienced. Others, however, gave accounts which
raised serious concerns about the quality of nursing care and indicated that the quality of such care was variable. The review panel notes that introduction of the Friends and
Family Test began in February 2013.
The Trust must develop a systematic approach to gathering and reviewing patients’ views about their experiences. With regard to complaints, a process for sharing themes
emerging from this trend analysis is required in order to demonstrate how the Trust evaluates the effectiveness of improvement actions and shares learning across the
organisation, from Board through to ward level. Complaints are not addressed in a timely way, and currently insufficient effort is taken to acknowledge and address valid
patient concerns, which creates an appearance (at the very least) that there is a lack of concern for patients. From public events and reviewing written submissions, the panel
is concerned about the Trust response regarding public and patient feedback related to key changes such as A&E consolidation, on a continuous basis.
The review team supports the proposal to rationalise the reporting of the PALS and complaints manager to a single manager.
The Trust must develop a systematic approach to gathering, reviewing and using patient experience/complaints to improve the patient experience and safety of care.
Workforce and safety
In order to address the problem of recruitment, retention and reliance on bank and agency nursing staff, and the poor national staff survey results, the Trust needs to urgently
build upon its strategy for staff engagement. The review team heard from many staff groups that two way communication from the staff to the Board was ineffective, and this
is reflected in a comment from the March 2013 Board papers that “communication between senior management and the workforce is not effective (perception that
communication is one way and directive)”.
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Concerns were repeatedly expressed by both nursing and medical staff about out of hours medical cover for the acute medical patients at Stoke Mandeville, particularly at
weekends. There was evidence that this led to delays in patients receiving essential treatments such as intravenous antibiotics and intravenous fluids. The current level of
medical care was described on more than one occasion as “unsafe”, by staff to panel members. Similar concerns were raised with regard to out of hours cover for patients in
the community hospitals.
Patients with specialist needs are not consistently treated on the relevant specialist ward or site resulting in patients on inappropriate wards who do not consistently have
access to medical and nursing staff with the necessary specialist skills, additionally this is likely to cause delays to ward rounds and timely assessment and discharge of
patients. This increases the burden on medical staff and means that patients may not receive appropriate nursing care. For example concerns were expressed as to the
safety and sustainability of the current split of acute services between the Wycombe and Stoke Mandeville sites and with the respiratory ward.
The Trust has a People Strategy and a Workforce Plan, but the panel were concerned about the effectiveness with which operational risks arising from workforce issues are
being managed.
The Trust should review the process by which nursing rotas are produced – the perception of this process given to the review team is that the rotas are developed centrally
with little input from ward staff. Staff at ward level felt that this restricted the efficiency of staff deployment. Nursing staff reported workload pressure problems due to the
number of staff permitted to administer IV treatments, as agency staff are not permitted to administer IV medication. There was also a perception that the paperwork workload
on staff had increased significantly without adequate assessment of the overall burden imposed upon staff; and that this was impacting upon the time available to staff.
Difficulties in recruiting nursing staff have been discussed as a key risk and there is significant variation in the make-up of staffing levels on individual wards between Trust
staff and bank or agency staff. The spinal unit and other wards across sites are understaffed while other exemplar wards confirmed they had very low vacancy levels.
Training and development for staff varies and does not appear to be prioritised consistently. Some nursing staff said that it was difficult to obtain places on essential internal
courses (for example, in order to be permitted to administer IV antibiotics or fluids). Junior doctors reported that there is generally a lack of senior support which has been
made poorer by the recent reconfiguration. The panel was told that some patients in Stoke Mandeville may go days without medical input and daily consultant ward rounds
are not always carried out.
The review team heard from staff that they did not feel that their concerns were heard and acted on. The variety of two-way communications has been increased recently.
These were seen as a significant step towards engaging Trust staff in the improvement journey and closing the gap between the Board and the Ward. However, Board to
Ward connectivity should be increased to fully inform the Board, through effective and diverse staff engagement.
The following definitions are used for the rating of recommendations in this review:
Rating
Definition
Urgent
The Trust should take immediate action to respond to these recommendations and
ensure improvement in the quality of care
High
The Trust should develop a response and action plan for these recommendations to
ensure improvement in the quality of care
Medium
The Trust should implement these recommendations to ensure ongoing improvement
in the quality of care
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Governance and leadership
Overview
Two KLOEs in the governance and leadership area were the standard key line of enquiry for the review and Cost Improvement Plans.
Examples of good practice were identified in the following areas:
A variety of two-way communications have been introduced recently, for example coffee mornings with the CEO, the CEO’s blog, new staff intranet, weekly staff e-mail
briefings and Board Member visits to wards.
The Chief Nurse is clearly identified as responsible for quality and safety.
There have been some efforts to share good practice around ward leadership from exemplar wards with others (e.g. from the exemplar Haematology Ward to the Spinal
Injuries Unit).
There is a policy on reporting of incidents, SI’s and never events with themes to be presented to the Board. A matron at Wycombe Hospital was able to talk about her
involvement in the analysis of events.
CIP schemes are reviewed at Divisional Board and QIPP Board meetings. There is a detailed CIP Quality Assurance and Clinical Risk Framework which shows that clinical
risk of all CIPs (patient safety, patient experience and clinical effectiveness) should be assessed, regardless of CIP financial value. Clinicians are involved in the process of
developing and approving CIPs. Staff across the Trust described a “bottom-up” approach to CIP development, which encouraged staff to contribute ideas and challenge
schemes.
The following areas of outstanding concern were identified:
The Board appears to place confidence in accepting the words of others in lieu of robust assurance processes for the quality of treatment and care. Roles and responsibilities
for quality are not clearly defined.
Risk scoring, reporting and mitigation systems are not well understood, nor are in place. The view of the panel was that the Board does not have adequate risk assurance.
The leadership at Board level accepts a reactive culture, responding to issues, in place of a proactive approach. The panel feel that there is scope for Board development to
ensure the Board ambition for quality and quality improvement can be delivered. The review team would urge the organisation to focus attention on trying to understand the
causes of the high mortality indicators as a higher priority than trying to justify the figures.
15
The Board could improve their challenge to executives and quality data, in order to match their ambition to improve quality and quality improvement Lack of oversight of the
quality impact of CIPs by the healthcare governance committee. There is currently no baselining of quality metrics pre-implementation of CIPs.
The panel was told that until recently some senior executive staff was seldom seen on the Wards.
Senior staff members were not as aware of issues/problems at Ward level as the Panel would expect. For example, the Medical Director’s response to the issues brought to
his attention by junior doctors in the Emergency Department suggests that he had previously been unaware.
Detailed Findings
Governance and leadership
KLOE 1: Can the Trust clearly articulate its governance processes for assuring the quality of treatment of care? Are the leadership roles and responsibilities
clearly defined for the quality processes? Can staff at all levels of the organisation describe the key elements of the quality governance processes
(communication to the staff)?
Good practice identified
The Chief Nurse is clearly identified as responsible for quality and safety and developed the nursing quality framework. The panel feel the document will require
supporting detail on how quality will be assured and the monitoring arrangements/timing intervals.
Some staff clearly articulated the processes for incident reporting (e.g. through ward observations on Intensive Care Unit (ICU), Urology, Care of the Elderly).
A variety of 2-way communications have been introduced recently, for example coffee mornings with the CEO, the CEO’s blog, new staff intranet, weekly staff e-mail
briefings and Board Member visits to wards. These were seen as a significant step towards engaging the Trust staff in the improvement journey and closing the gap
between the Board and the Ward.
There have been some efforts to share good practice around ward leadership from exemplar wards with others (e.g. from the exemplar Haematology Ward to the Spinal
Injuries Unit).
There is a policy on reporting of incidents, SI’s and never events with themes to be presented to the Board. A matron at Wycombe Hospital was able to talk about her
involvement in the analysis of events.
16
Outstanding concerns based on evidence gathered
Key planned improvements by Recommended actions
the Trust
The Board does not have robust risk assurance processes. Risk
scoring, reporting and mitigation systems are not well understood,
nor are in place.
None identified
The route for achieving unambiguous assurance at Board level is unclear
(Healthcare Governance Committee and Audit Committee).
The risk register is not sensitive or live enough to present proper issues to
the Board. Examples missing at review are staffing of the Spinal injuries
unit and risks associated with the new urgent care model, not yet properly
evaluated. The benefits realisation plan focuses on benefits rather than
also considering the need to mitigate emerging risks as the plan is
affected, as part of business as usual. Target dates are mostly in 2012 or
up to April 2013. No evaluation report yet available.
Most risks are scored at a maximum of 12 (at divisional level). Only those
scoring 12+ are recorded in the Corporate Risk Register and of those only
risks scoring 15+ are highlighted to the Board. For example:

Mortality indicators were identified as a risk on the Corporate
Risk Register on 25 February 2013. Where these have been
identified, they were triggered through a concern arising of risk of
reputational damage.

It was not evidenced that, when maternity staffing ratios were at
1:38, that the risk arising to patient safety from under-staffing was
raised through the Trust’s risk reporting process to Board level
(note, national recommendation is for 1:28 ratio)

Ward-level and community-service level specific risks arising
from under-staffing were not identified on the Corporate Risk
Register, although some individuals, for example the Chief
Nurse, reported their awareness of these issues. The Board
Assurance Framework (BAF) contained some information on
Priority – urgent,
high or medium
There should be an immediate and
Urgent
comprehensive audit (by an external
specialist) of the entire Trust’s
approach to risk assurance and
patient safety, using the Manchester
Patient Safety Framework or an
equivalent model.
Develop a refreshed coordinated
patient safety strategy and action
plan.
Urgent
Identify an individual (1 WTE) for
implementing the patient safety
strategy supported by project
management office.
Urgent
Put in place a Board development
programme covering quality
governance, risk, assurance (rather
than reassurance) and best practice
(national and international).
Urgent
Clarify how the Board seeks
Urgent
assurance from each sub-committee
(and, in turn, from the groups
reporting into sub-committees).
Clarify the respective roles and
responsibilities of each subcommittee for;

quality and safety; and

risk management
processes that pro-actively
17
Outstanding concerns based on evidence gathered
Key planned improvements by Recommended actions
the Trust
risks in relation to reliance on temporary staff and safe staffing
levels in relation to organizational change.

Priority – urgent,
high or medium
identify and take action to
reduce the likelihood of
risks transpiring.
Risks arising from service changes and patient transfers between
hospital sites, for example the A&E consolidation, were not
identified on the Corporate Risk Register.
The Risk Monitoring Group should review how it scrutinises and
challenges the divisions about their risk registers, to ensure risks are
scored appropriately and follow up on progress monitoring for identified
risk mitigation actions.
The leadership at Board level accepts a reactive culture, responding The Trust has brought in the
to issues, in place of a proactive approach.
Emergency Care Intensive
Support Team (ECIST) team to
provide advice on improving the
The panel gained the impression that Governance arrangements are
founded on incident reporting through the DATIX system. This approach outcomes delivered for the
relies on reactions to trends arising from reported incidents. This does not urgent care pathway.
comprise a pro-active approach to anticipating potential risks to patient
Governance leads have been
safety and proactively putting in place mitigating actions and monitoring
appointed in the SDUs.
the effectiveness of the actions taken.
Diverse staff groups reported little confidence in improvement actions
arising from reporting incident data on the DATIX system. This resulted in
a reluctance to complete incident reports in some areas.
Little evidence of downward dissemination of lessons from Serious
Incidents or DATIX data. Junior Doctors reported that they raise incidents
but get no response and nothing changes as a result.
Enhance the Trust performance
Urgent
dashboard to improve information,
intelligence and analysis of business
and quality data. Include more
information from patients and staff,
including qualitative data and
mechanisms of responding in a timely
way.
Train and encourage all staff on the
importance of incident reporting.
Urgent
Embed analysis of incident reporting Urgent
in the Trust performance dashboard,
which is discussed at the Board level.
Junior doctors reported raising patient safety issues to the Medical Director
by letter. Although a response was received within 10 days, there appears
to have been a delay of 6 weeks before a meeting was set up to discuss
18
Outstanding concerns based on evidence gathered
Key planned improvements by Recommended actions
the Trust
Priority – urgent,
high or medium
the issues raised. The Medical Director's response to the initial letter
suggests that he had not previously been aware of some, if not all, of the
issues which concerned the junior doctors.
Some staff are not clear on incident reporting and what comprises an
incident. There appears to be a culture where some staff believe incidents
need to be serious and involving harm before they are reported. Minor
incidents, "near misses" or those relating to poor patient experience are
under -emphasised. For example inter-hospital transfers at an early stage
in the emergency pathway are not considered incidents. The policy on
handling incidents does not define or describe an incident, only giving
examples, most of which have significant harm.
Service Division Unit (SDU) Governance Leads do not appear to have time
dedicated to this element of their role, nor opportunities to meet together
(across directorates) to share best practice.
The Board could improve their challenge to executives and quality
data, in order to match their ambition to improve quality and quality
improvement.
A variety of two-way
The Board needs to challenge
Urgent
communications have been
executives following the setting of
introduced recently, for example quality improvement goals/targets.
i.
coffee mornings with the CEO
Once improvement trajectories have
There was significant variation in how staff at all levels perceived the
and Board Member visits to
been set, proper attention needs to be
visibility and 2-way feedback with Board members.
wards. These were seen as a
placed upon monitoring progress
significant step towards
against plan, and evaluating the
Quality Dashboards were not consistently evidenced at ward level. The
engaging Trust staff in the
benefits achieved.
productive ward clinical dashboard was in place and on display in public improvement journey and closing
area of the exemplar ward (Haematology/Cancer/Medicine ward) however the gap between the Board and Increase Board to ward connectivity
care of elderly wards at Stoke and Wycombe did not have this in place.
the Ward
to fully inform the Board through
High
effective and diverse staff
Clinical Leads do not have time dedicated to their role. Some clinical
The Chief Nurse confirmed the engagement, for example through:
leads do not know how to use service line reporting.
use of a Nursing Quality
focus groups with staff, increased
Framework and the intention to visibility with walk rounds and
Interviews with the Chairman and Non-Executive Directors suggest that
roll this out to include services
proactive engagements.
there is limited challenge and examination of the data presented to the
such as pharmacy and therapies.
19
Outstanding concerns based on evidence gathered
Board (reassurance, not assurance). One example is the Board views on
SHMI. The review team felt that the Board focussed on justifying the
figures, rather concentrating on work to identify and address areas that
could improve the quality of care provided. There is limited analysis and
evidence of learning.
Key planned improvements by Recommended actions
the Trust
Some exemplar wards had
quality indicators on display in
the ward environment, for
example the Haematology /
Cancer / Medicine ward at Stoke
Mandeville and the Paediatric
Ward at Wycombe. The
maternity ward had its own
dashboard.
Priority – urgent,
high or medium
The Trust needs to further develop
Urgent
the current ward quality dashboards
to ensure they are comprehensive,
embedded in practice and extended
to community services. These quality
dashboards should be used at Board
level to identify areas of significant
variation and how improvement
trajectories are set and delivered for
achieving consistently high outcomes
in all wards/community services.
The new interim Medical Director
expressed intention / wish to
improve quality and safety
(quality markers within divisions).
Cost Improvement Programmes
KLOE 2: How does the Trust assess and monitor the quality impact of the Cost Improvement Programme (CIPs)?
Good practice identified
There is a detailed CIP Quality Assurance and Clinical Risk Framework which shows that clinical risk of all CIPs (patient safety, patient experience and clinical
effectiveness) should be assessed, regardless of CIP financial value.
Clinicians are involved in the process of developing and approving CIPs. This was evident from both the Clinical Risk Framework and speaking to clinicians in various
Divisions.
20
Good practice identified
Staff across the Trust described a “bottom-up” approach to CIP development, which encouraged staff to contribute ideas and challenge schemes. Clinical leads at SDU
level confirmed that quality was not compromised in order to meet CIP targets.
CIP schemes are reviewed at Divisional Board and QIPP Board meetings.
Outstanding concerns based on evidence gathered
Key planned improvements by
the Trust
Recommended actions
Priority –
urgent, high
or medium
Lack of oversight of the quality impact of CIPs by the healthcare
governance committee
None identified
The Trust Healthcare Governance
Committee should have formal
oversight over the quality impact
assessments and ensure post
implementation review takes place.
High
There is no oversight of CIPs and their risk assessments at the Healthcare
Governance Committee. It is unclear how the Board gains assurance about the
impact on quality of CIPs during their design and implementation.
There is currently no baselining of quality metrics pre-implementation of This issue was highlighted by
CIPs
KPMG during the quality
governance review and a
There is no record of pre-implementation quality performance on the risk
recommendation was made to the
assessments of planned CIPs. This limits the means of monitoring the impact of Trust to document performance
CIPs on the quality of care given to patients once implemented. Obtaining
prior to implementation of the
‘baseline’ measures for relevant metrics, against which to compare future (post- scheme when undertaking quality
implementation) performance, will facilitate clearer monitoring of CIP impact on impact assessments.
quality.
Use baseline measures to Monitor
High
CIPs for their impact on quality of
care over an appropriate period of
time, during and after implementation.
21
Clinical and operational effectiveness
Overview
The two KLOEs in the clinical and operational effectiveness area focused on the Trust’s arrangements to monitor and address clinical effectiveness and operational
performance as well as higher than expected mortality areas.
Examples of good practice were identified in the following areas:

Some clinical areas showed high quality care environments and enthusiastic passionate approaches by staff, who felt very supported and reported good levels of staffing
(e.g. Critical Care, Urology, and Surgical).

No central line infections at both ICUs (Wycombe and Stoke Mandeville) for a few years.

Mortality reviews have been completed using the Royal Berkshire structured mortality review.
The following areas of outstanding concern were identified:

There is a lack of organisational-wide monitoring of clinical effectiveness and operational performance data, in that quality scorecards are not in place on all wards.
Quality scorecards are in place in some wards but it is unclear how the Board gains robust assurance about current and most significant quality and safety risks across
its sites.

Some Trust Board members need to further develop their understanding of mortality data and causes. Depth of understanding is variable depending on the time spent on
the Board. There should continue to be training for Board members.

The Corporate Risk Register does not highlight significant risks to clinical effectiveness and operational performance. E.g. out of hours care and A&E service
consolidation.

The panel did not find evidence of adequate oversight of improvement plans to address the significant risks to clinical effectiveness and operational performance.

The panel did not find adequate evidence of the Board reviewing the metrics relating to significant risks to clinical effectiveness and operational performance, for example
ambulance transfers between sites, ward-specific or service-specific staffing levels.

There is a lack of strategic improvement of clinical safety.
22
Detailed Findings
Clinical and operational governance
KLOE 3: What governance arrangements does the Trust have to monitor and address clinical effectiveness and operational performance data at a senior level?
Good practice identified
Observations in some clinical areas showed high quality care environments and enthusiastic passionate approaches by staff, who felt very supported and reported good
levels of staffing (e.g. Critical Care, Urology, Surgical).
No central line infections at both ICUs (Wycombe & Stoke Mandeville) for a number of years.
Some staff reported that the Trust’s clinical strategy had been sent out with pay slips last month, and the Non-Executive Directors identified this as an example of how
the Trust is making efforts to increase its communication with staff.
Outstanding concerns based on evidence gathered
The Corporate Risk Register does not highlight significant risks to
clinical effectiveness and operational performance. E.g. out of
hours care and A&E service consolidation
Inter-site transfers were identified as a risk during discussions but have
not been identified on the corporate risk register. Some pathways that
involve transfers are not clear. Examples of concerns about patient
transfers from site-to-site were reported to the Panel at the Public
Listening Event. Concerns were identified about incident reporting. The
panel witnessed one example where a patient was transferred from High
Wycombe to Stoke Mandeville with a suspected fractured neck of femur.
The family reported their perception of a significant time delay in the
administration of any pain relief. Staff did not report this as an incident
until strongly encouraged to do so. This example raised concerns about
the understanding of what an incident is, in this case the impact of a siteto-site transfer, and how the Board would be aware of risks arising from
Key planned improvements
by the Trust
Recommended actions
Priority – urgent,
high or medium
The Chief Nurse is
To review the pathways for patients
Urgent
reviewing quality standards presented urgently to the Trust to include
in A&E.
those transferred between sites following
initial presentation. Put in place robust
The Director of Strategy is processes for capturing every incident
preparing a Report on the where a patient is transferred during their
benefits / issues post
acute episode. This must not depend on
reconfiguration.
voluntary incident reporting but be
achieved through a more robust process.
Cases need to be reviewed regularly and
actions taken if possible to reduce the
rates of these transfers.
Work with patient and carer group/NHS
Urgent
23
Outstanding concerns based on evidence gathered
Key planned improvements
by the Trust
patients transferring from site to site.
Priority – urgent,
high or medium
111 provider and CCG’s to improve
functionality of NHS 111 for this
healthcare system.
Improvements to access via NHS 111 service could provide assistance
to patients and the public, and therefore the Trust, by helping to signpost
patients better to the appropriate point of access within the Trust.
Urgent
Put in place an effective process for
capturing and reviewing the experience
of patients and staff presenting acutely.
The Trust has been through a period of significant service
reconfiguration. Potential risks arising through reconfiguration, and the
associated mitigation measures, were not identified on the Corporate
Risk Register. The Medical Director discussed a report that is currently
being prepared to review the benefits/issues post reconfiguration. The
Panel heard evidence from the Patient Experience Leads how feedback
after the Surgical Floor Reconfiguration resulted in the Trust
subsequently putting in place significant changes. The lessons around
anticipating benefits and risks did not appear to have been learned and
put in place for the A&E consolidation.
There is a need to reinforce the
High
messaging as a health economy about
what services are at each hospital and if
in doubt they should present to the main
ED at Stoke Mandeville. The Trust
should work with focus groups and the
local media to achieve this. The Trust
should set out clear measures for how
they will evaluate the impact of their
information campaign.
A&E – The risk pertaining to the achievement of the national access
target had been identified by the Trust. However, concerns were raised
to the panel over poor patient feedback. We encountered real public
concern that they did not know where to go with different urgent care
needs (for example, the Minor Injury Unit (MIU) at Wycombe, A&E at
Stoke Mandeville) and poor patient information. One example was the
information given in some of the Trust leaflets for patients. One leaflet
advised patients about whether they should go to A&E at Stoke
Mandeville or to the MIU at Wycombe. This included the statement that
for burns and scolds - but not for the neck or head, they should go to
Wycombe.
The panel did not find evidence of adequate oversight of
improvement plans to address the significant risks to clinical
effectiveness and operational performance
Recommended actions
The Trust has brought in the
Emergency Care Intensive
Support Team (ECIST) team to
provide advice on improving
The Trust urgently needs a single visible Urgent
clinical safety strategy and action plan
based on a recognised patient safety
improvement model and underpinned by
24
Outstanding concerns based on evidence gathered
Key planned improvements
by the Trust
Whilst the panel appreciate that the Trust is taking action to resolve the the outcomes delivered for the
A&E pressure, the panel feels that, as with the mortality indicators, the
urgent care pathway.
Trust needs to frame these issues, and more importantly develop
potential solutions, specifically to the needs of patients in this healthcare
community. The review team urges the Trust to use the urgent care
board to help develop work in this area.
Priority – urgent,
high or medium
good intelligence (hard and soft data)
and systematic staff training and roll out.
Systems and processes to ensure
benefits realisation should be included
within the plan.
The Trust should have a clear plan of
Urgent
action with time scales and measures to
implement the ECIST recommendations
and this should be part of the overall
Patient Safety Strategy.
Complexities arising from multiple sites with varying practices specific to
each site e.g. the urology pro-formas used in Stoke and Wycombe are
slightly different as one does not cover Venous thromboembolism (VTE).
Concerns were raised to the panel about high dependency capacity.
Reports of acute wards managing patients with non-invasive ventilation
and tracheotomies. Reports of higher acuity patients transferring to
community hospitals. The lack of High Dependency Unit (HDU) beds
means that there is no adequate step-down from ICU, but equally no
adequate capacity to “step-up” the deteriorating patient.
Continue to work with urgent care board.
Urgent
Review the high dependency and acute
Urgent
care pathways to ensure sufficient
capacity and staffing.
Review and enforce the admission
criteria for HDU / ICU and patient
transfers between sites.
Clarity about actions arising for deteriorating patients appeared to be
variable and subjective.
Many staff commented about the lack of 24 hour outreach services. The
review team recognised that, when available, this appears to be a very
good service. However, many hospitals function without 24 hour
outreach and this should in no way be a substitute for robust NEWs,
recognition and escalation procedures by all clinical staff, of the
deteriorating patient.
Recommended actions
The National Early Warning
System was introduced by the
Trust in January 2013 (as
evidenced in the March BAF).
Urgent
The Medical and Nursing Director must Urgent
urgently agree a single model to assess
the deteriorating patient and a clear
protocol for escalating concerns which is
rapidly implemented on every ward, at
every site. All staff, including bank and
agency, must be trained in the system.
25
Outstanding concerns based on evidence gathered
Key planned improvements
by the Trust
The panel did not find adequate evidence of the Board reviewing the
metrics relating to significant risks to clinical effectiveness and
operational performance, for example ambulance transfers between
sites, ward-specific or service-specific staffing levels
Recommended actions
Priority – urgent,
high or medium
Put in place quality scorecard throughout
the organisation, in every ward and every Urgent
community service. Ensure sufficient
granularity of trend data is visible both at
ward and at Board.
There is an over-reliance on Datix incident reporting to capture harm.
Reinstate daily review of ventilated
Urgent
patients with ICU consultants and review
level of support provided to these
patients.
Service Line Reporting has not been put into practice. Although the data
is provided to the clinical leads by e-mail on a regular basis, they have
not all been able to take advantage of the managerial support and
training to enable them to make use of the data.
Urgently improve staffing levels and
practices in the spinal units.
Staff retention and recruitment appears difficult the Spinal Unit and
morale was reported as low. Patients are often delayed admission due
to difficulties in staffing, with the associated potential for these patients
may be highly disadvantaged by delays to their rehabilitation. Critical
members of staff in the spinal unit who were supporting the ventilated
patients have left and have not been replaced: Support to these patients
form an experienced Operating Department Practitioners (ODP) and
anaesthetic consultant input have all recently been lost. These ventilated
patients are currently managed by clinicians with no specific training in
the management of the ventilated patient. Whilst the panel did not regard
this as posing an immediate risk to patient safety, there is an urgent
requirement for the Trust to address this issue.
Diabetic foot assessment: Clinical leads agreed it was poor and had
been known to be poor for some time. It is not clear why the Trust has
not yet implemented national standards.
The Panel was told that the
Podiatrist is working up a
Business Case for delivering
improvements in relation to
diabetic foot assessment.
Urgent
Implement national standards in relation
Urgent
to diabetic foot assessment without
further delay.
26
Clinical and operational effectiveness - mortality
KLOE 4: What processes does the Trust have in place to support monitoring mortality data and clinical effectiveness? Has the Trust data identified any issues?
What actions is the Trust taking to address issues noted?
Good practice identified
Mortality reviews have been completed using the Royal Berkshire structured mortality review.
In response to the Trust having a priority to focus on care of older people, increased support through ward rounds by care of the elderly physicians had commenced at
the Community hospital sites.
Outstanding concerns based on evidence gathered
The Trust Board demonstrated a lack of understanding of mortality
data and causes
The review of 50 cases undertaken by the Mortality Task Force is
considered inadequate. The reviews are too mechanistic, do not involve
any microbiological analysis/input and focus on the question whether the
patient would have died in any event rather than the rigorous identification
of the broad areas where care could be improved. During interviews the
Panel noted that Divisional Chairs could not articulate areas where
mortality was occurring.
Key planned
improvements by the
Trust
Recommended actions
Priority –
urgent, high
or medium
None identified
Develop an Integrated Quality Report that
High
compares divisions and is reported to the
Governance Committee on a monthly basis and a
summary version reported to the Trust Board. The
quality report must routinely inform patient safety
action plans
Ongoing mortality
Develop a coordinated patient safety strategy and Urgent
reviews are looking to
action plan that incorporates issues such as
The Mortality Task Force noted that pneumonia mortality has been a
improve pneumonia care pneumonia mortality (see KLOE1).
problem on HSMR for the past two years, however an action plan has only pathway.
recently been considered for development. The action plan was a
Improve processes to monitor patient moves and Urgent
statement of ideal care and what was lacking was any understanding about
improve consistency of care. Ensure that
where the gaps in delivering ideal care were occurring, what the potential
handovers are structured, particularly important if
defect rates were, and where any focus might be required to produce the
there are frequent patient moves. Ensure
Lack of strategic improvement of clinical safety
27
Outstanding concerns based on evidence gathered
Key planned
improvements by the
Trust
Recommended actions
fastest results. (E.g. have they reviewed time to first antibiotics, what is the
percentage compliance with best practice - is this uniform across all
areas?).
consistent use of a structured handover tool such
as Situation, Background, Assessment,
Recommendation analysis (SBAR).
Junior Doctors reported that there have been multiple transfers of patients
between wards with no clinical input or no communication to clinicians.
Whilst the panel did not regard this as posing an immediate risk to patient
safety, there is an urgent requirement for the Trust to address this issue.
Further work is necessary to help plan for
increased respiratory ward capacity.
Priority –
urgent, high
or medium
Urgent
The Panel was informed that 3-5 non elective transfers take place per
week on the Urology ward. Nurses in training also observed that handovers
could be poor.
Ensure mortality reviews are designed in such a Urgent
way that outcomes identify ways to improve clinical
safety including pneumonia care.
Despite the Trust identifying care of older people as a priority and strong
trends showing pneumonia, stroke, and acute renal failure as possible
contributing factors to the high mortality rates, the review team did not see
evidence of developments focusing on processes of care for these
patients.
There is insufficient capacity on the respiratory ward; the Panel was told
that typically fewer than 50% of respiratory inpatients can be
accommodated on the ward. Although the bed manager’s log suggest the
percentage is much lower.
The Corporate risk register contained a reputational risk on mortality rather
than trying to understand the reasons behind it and mitigate risks to
patients’ safety.
28
Patient experience
Overview
The KLOE in the patient experience area focused on patient experience and engagement.
Examples of good practice were identified in the following areas:

Some individual staff members and specific wards demonstrated a good focus on patient experience and engagement and the panel heard positive stories from some
patients and members of the public on their experiences at the Trust. The panel also received and saw evidence of nursing of the very highest quality, with the needs of
individual patients being identified and addressed in ways which really were far above and beyond the call of duty. Patient stories are heard at Board, in accordance with
best practice.

Some positive examples of public and patient engagement were evidenced through some of the stories shared with the panel at the public listening events and by
patients and carers on observations.
The following areas of outstanding concern were identified:

There is evidence that the quality of nursing can be too variable. Within 24 hours of its arrival at site, the Panel had been given direct evidence of two separate incidents
in which elderly and immobile patients needing assistance to go the toilet had been ignored. At least one of those incidents appeared (on the evidence provided
independently by two other patients) to involve deliberate conduct by a nurse. The second incident could only be explained, if at all, on the basis that staff had become
desensitised to patient alarms.

Some of the Trust's procedures (or the approach by staff to their implementation) appear overly bureaucratic and insensitive to the needs of the patient. Cases which
exemplified this were heard during the public listening events, and some are provided in Appendix VIII.

There is evidence of patients who have been 'wrongly' admitted to the stroke/cardiac unit at Wycombe being left for some hours before being transported to Stoke
Mandeville - there is then the additional risk/probability that they will be admitted through the A&E department with up to a further four hour wait. There is no systematic
approach to gathering and reviewing patients’ views about their experiences. Where feedback is gathered there are limited mechanisms for sharing themes. It is unclear
how the Trust evaluates the effectiveness of improvement actions and shares learning across the organisation.

Complaints are not addressed in a timely way. Insufficient value is placed on addressing issues raised by patients, which creates the appearance of lacking concern.
There is a lack of knowledge sharing between departments, divisions and sites on patient feedback and trend analyses do not appear to be routinely carried out.
Inadequate resources are dedicated to patient engagement. The patient engagement group does not comprise an effective cross-section of patients: mainly
representatives from specific patient/illness groups. This misses the opportunity for direct patient feedback.

It is unclear how the Trust is taking action to improve effective communications between nurses and patients consistently across the Trust.
29

It appears that patient views were not gathered and responded to before and after significant changes were implemented, such as consolidation of A&E at Stoke
Mandeville.

The Trust’s approach to cases where its treatment has clearly fallen below acceptable standards can appear overly defensive and, on occasion, inept. An example is
provided in Appendix VIII – “Patient Stories” with information from the public events.
Detailed Findings
Patient experience and engagement
KLOE 5: How does the Trust review patient experience data and engage with patients to seek views about their experience? What are the key themes from
patients on their experiences? What action is it taking to address the key themes emerging?
Good practice identified
The panel was informed in interviews and on observations that senior nurses on exemplar wards run patient focus groups.
The panel was informed that patient experience feedback following the surgical floor reconfiguration resulted in changing the reconfiguration arrangements.
Some positive examples of public and patient engagement were evidenced through some of the stories shared with the panel at the public listening events and by
patients and carers on observations.
Friends and family test has been implemented since February 2013. The Friends and Family test is a simple questionnaire that currently asks adult inpatients if they
would recommend the hospital/ward/services to their friends and family. The March 2013 Board Papers show that whilst the number of responses is low, there was a
significant (almost 50%) response in relation to A&E relating to unlikely/extremely unlikely to recommend categories. The panel saw one nurse going through the
questionnaire with a patient.
Board papers show that complaints data is presented to the Board, such as 25 day response time. However, it is not clear how the Board is responding to poor
performance.
The panel was informed of a patient open event in ophthalmology and hearing aid department.
PALS/complaints team is stable and committed. PALS volunteer going around wards speaking to patients.
NEDs review a selection of complaints once a month and patient stories are shared at Board, although it is not clear how that they learn from these or challenge the
executive team members over the issues raised. The panel spoke with patients who reported receiving a good standard of care on SSU, spinal and stroke units,
maternity, surgical at Wycombe and ward 8 at Stoke Mandeville.
30
Outstanding concerns based on evidence gathered
Key planned improvements by Recommended actions
the Trust
Action plans are initiated at
divisional level to address issues
Board papers show that complaints data is presented to the Board, such as 25 identified through patient
day response time. However, the March Quality Performance report shows that surveys.
the 85% target for this metric has consistently failed to be met for at least the
preceding nine months. Complaints are not addressed in a timely way and it
A&E – new complaints lead in
appears that insufficient value is placed on addressing patient concerns, which post recently which is improving
creates the appearance of lacking empathy.
complaint response times for
A&E.
It was reported during a public listening event that a complaint registered with
PALS took 90 working days for a patient response to be received.
Complaints
Lack of knowledge sharing between departments, divisions and sites (to staff).
Lack of trend analysis being carried out regularly. No proactive approach to
picking up on key themes from complaints and playing these into the activity of
the Patient Engagement Lead. Missed opportunity for shared learning. There is
little or no coordinated approach to the dissemination of patient experience.
Example of learning from patient feedback following surgical floor
reconfiguration. No evidence of how the learning about seeking views from
staff, patients and public is shared prior to such changes for example in the
more recent A&E consolidation.
Priority –
urgent, high
or medium
Put in place consistently high standards Urgent
for addressing patient complaints. The
Trust’s performance against its targets
for complaints handling should be
published on its website on a monthly
basis.
Training for existing PALS/PEG and
High
ensure that all complaints and learning
points are seen Trust wide and actions
implemented.
Ensure that ‘real’ patient views are
obtained prior to further planned
service changes.
High
There is concern around transparency of learning from issues through sharing
with public/patient representatives. The Governance and Quality Committee for
instance has no patient rep / Health watch on the committee. The Trust’s
approach to complaints and/or concerns about its performance can appear
defensive and focused more on protecting its reputation than learning from past
mistakes.
31
Outstanding concerns based on evidence gathered
Key planned improvements by Recommended actions
the Trust
Patient engagement
PALS Manager has joined
patient experience group
Through observations and interviews, the panel found there were inadequate
resources dedicated to patient engagement. The panel found that the resources Tablets introduced for matrons
both in terms of staff and finances are directed towards the work on moving
obtaining feedback
towards Foundation Trust status rather than actual patient involvement issues.
Patient engagement group does not comprise an effective cross-section of
patients: mainly representatives from specific patient/illness groups. This
misses the opportunity for direct patient feedback.
There appears to be a lack of cohesion and joined up learning across PALS,
complaints and patient experience. At the time of the visit the PALS and
complaints teams report to the Patient Experience Manager. The teams are split
across different sites and therefore the joint working and triangulation
opportunities impacted on the key issues really being focused upon and giving
the board direction.
The panel found that no proactive approach to patient surveys, no systematic
approach to seeking meaningful real time patient feedback and, during
interviews executives were not clear about emerging themes. There appeared
to be no Trust-wide budget for surveys, although the panel saw some surveys
carried out by individual departments, and no formal coordination.
There appears to be no shared learning from litigation complaints; the
complaints team does not review outcomes from litigation cases. At a public
listening event, concern was raised about the Trust’s legal representatives
requesting a short-form verdict, rather than a narrative verdict which might
include findings as to the care received by the patient.
At a public listening event, a concern was raised about the issuing of inaccurate
death certificates.
Priority –
urgent, high
or medium
Refresh the membership of the patient Urgent
engagement group and clarify how this
group is representative of patient
feedback.
Put in place effective and regular
review of all feedback identifying trends
for both good practice and concerns.
Ensure this is seen and discussed by Medium
the Board.
Ensure that the Friends and Family
Test is in operation on all of the wards
and that the information gathered is
Urgent
used.
The Trust should review legal
submissions to the coroner during
coroner’s inquests. The Trust should
High
consider the approach in relation to
requesting short-form coroner’s
verdicts for cases in which there is the
possibility of criticism of care, in order
to demonstrate that the Trust is open
and focused on learning from errors
identified to improve future care.
The Trust should also routinely remind
medical staff issuing death certificates High
of the need to ensure their accuracy.
The panel felt that little effort is being made to understand the impact on patient
32
Outstanding concerns based on evidence gathered
Key planned improvements by Recommended actions
the Trust
Priority –
urgent, high
or medium
experience on the new arrangements for cardiology and stroke. Clinicians
believe this is a good service but no patient related opinion is being collected at
Wycombe Hospital, for example on patients who are transferred back to Stoke
Mandeville on a ‘near-daily’ basis when a non-cardiac/stroke diagnosis is made
and a further wait in Stoke Mandeville A&E sometimes follows.
Communication
It is unclear how the Trust is taking action to improve effective communications Some surgical wards are in the
between nurses and patients consistently across the Trust, in response to the early stages of implementing
CQC patient survey showing this to be an area of dissatisfaction for patients.
enhanced recovery
Following Wycombe A&E closure, there is a serious public concern about loss
of service, confusion of pathways and where patients should go which could be
improved through communications from the Trust. The fact that site maps
handed out at reception still shows an A&E entrance suggests that the Trust’s
communication strategy is deficient and requires improvement.
Signage very poor at Wycombe Hospital. During the unannounced visit, with
nobody at reception, the visiting team found themselves re-directing at least
three patients where no obvious signs existed.
During observations, the panel saw instances of poor communication between
staff and their patients and carers, such as requests for dignity on mixed sex
elderly wards not being met and buzzers not being answered.
Further examples of poor communication were provided at the public listening
events and are identified in Appendix VIII.
It was noticed during the observation of the ward for dementia patients that the
toilets were re-batched male/female dependent on the number of male/female
patients on the ward and could change on a daily basis. This is very confusing
Full implementation of enhanced
recovery across surgical specialties.
Urgent
Review signage in the light of service
changes (now seven months old).
Appoint responsible officer for patient
issues at all sites.
Urgent
Arrange telephone contact points at
Wycombe so that patients’ relatives
can contact the hospital to find
information on which ward their
relatives are.
High
High
Improve dementia environments by
producing bedside boards with symbols
that work for cognitive impairments.
Trust wide review of pathways to other Urgent
hospitals to develop robust
communication to ensure patient safety
in cases where patients present as
emergencies at Bucks. An assessment
of the training needs for staff to ensure
appropriate management of these
patients should be undertaken, and
33
Outstanding concerns based on evidence gathered
for those suffering with dementia.
Concerns were raised about patients treated in other hospitals who returned to
Bucks as emergencies without adequate documentation about the treatment
that they had received.
Key planned improvements by Recommended actions
the Trust
Priority –
urgent, high
or medium
appropriate mechanisms put in place to
allow access to expert advice and
support if required.
In addition to the points above, public and patient feedback obtained through the review identified a number of areas of good practice and concern which have been reported
within the relevant KLOE.
34
Workforce and safety
Overview
The three KLOEs in the workforce and safety area focused on workforce planning and staff support including training.
Examples of good practice were identified in the following areas:

Coffee mornings between the Chief Executive and band 6 & 7 staff were introduced recently.

Board members carry out walk rounds at Stoke and Wycombe and community hospitals.

Recognise the issue related to out of hours medical support for community hospital and use of 111 (Bucks Urgent Care Service).

Nurse consultant who is spreading good practice with training and leading by example.

There is a People Strategy, which covers at a high level a range of developments to improve the quality, capability and motivation of those who work for the Trust.

Nurse recruitment plan (recruiting Portuguese nurses with 4 years experience, 10 WTE and 2 HCA at Waterside ward, and 7 WTE and 6 HCA on Chartridge ward in
Amersham.)

NEDs stated that the trust had developed staff trackers regarding staff experience to use in between annual staff survey.

Information relating to serious incidents and safety metrics are presented to Board.

Junior staff at Wycombe expressed satisfaction on the level of work and support received by Consultants and other staff.

The Early Warning System has been implemented across the Trust and is viewed positively by staff. The panel saw other examples of safety initiatives and practices
across the Trust.
The following areas of outstanding concern were identified:

Concerns were repeatedly expressed by both nursing and medical staff about out of hours medical cover for the acute medical patients at Stoke Mandeville, particularly at
weekends. There was evidence that this led to delays in patients receiving essential treatments such as intravenous antibiotics and intravenous fluids. The current level of
out of hours medical care was described on more than one occasion as “unsafe”.
35

Concerns were expressed as to the safety and sustainability of the current split of acute services between the Wycombe and Stoke Mandeville sites. The panel was told
that split site working increased the burden on the Trust’s workforce, can lead to delays in access to essential diagnostic services and can also result in poor quality
treatment of co-morbidities. The split of services between the two sites engenders an obvious risk that patients will be taken initially to the wrong site for their condition,
with a resultant delay in treatment. Some junior doctors at Stoke Mandeville expressed the view that the pressure upon out of hours medical cover at that site would be
considerably reduced if all acute services were being provided at a single site. Some of the transfer pathways between sites did not seem patient-focus as the patients
may be transferred from Wycombe to Stoke Mandeville A&E but the notes from the Wycombe have not been transferred to Stoke.

Patients with specialist needs are not consistently treated on the relevant specialist ward. For example, the Panel was told that the respiratory ward at Stoke Mandeville
has capacity for fewer than 50% of the typical level of respiratory inpatients although the bed manager’s log suggests the percentage is much lower. The dislocation of
patients from the appropriate specialist wards not only increases the burden on medical staff (who has to travel throughout the hospital to locate the patients for whom they
are responsible) but also means that patients may not receive appropriate specialist nursing care.

During a number of events and ward visits, nursing staff reported work load pressure problems especially in relation to the number of staff permitted to administer IV
medication. They stated as agency staff are not permitted to give IV medication. This issue was raised in the CQC’s recent report on Wycombe Hospital.

Based on staff and Board member interviews, observations and documentation, difficulties in recruiting nursing staff have been identified as a key risk. There is significant
variation in how staffing levels on individual ward are resourced safely. Spinal unit and other wards across sites are understaffed while other exemplar wards confirmed
they had very low vacancy levels.

There is a Trust People Strategy and a Workforce Plan to support this Strategy however, the panel were concerned about how effectively the Trust is managing
operational risks arising from workforce issues.

Disjointed rotas are developed centrally with no input from ward staff and the Trust does not seem to look at the efficiency of staff deployment.

The results of the staff survey presented significantly below the national average in certain areas, which was consistent with what the panel found in the staff focus groups
and ward observations.

Training & development for staff varies and does not appear to be prioritised consistently.

The junior doctors reported that there is generally lack of senior support which has become poorer by recent reconfiguration. The panel was told that some patients in
Stoke Mandeville may go days without medical input and daily consultant ward rounds are not always carried out.

The Board’s approach to ensuring a safe organisation is too reactive and over relies on an incident reporting system that will only capture a small percentage of harm.
Reporting of incidents is inhibited by a perceived culture of blame. It is not clear how the Board gains assurance that lessons learned are shared and implemented across
the Trust. The Board should review further safety metrics, which relate to the specific key risks faced by patients at the Trust.
36
Detailed Findings
Workforce strategy
KLOE 6: In the context of this review, can the Trust describe its workforce strategy?
Good practice identified
There is a People Strategy.
There was a recent coffee morning between the Chief Executive and band 6 & 7 staff and Staff Intranet (CEO Blog).
Board members carry out walk rounds at Stoke and Wycombe.
Recognise the issue related to out of hours medical support for community hospital and use of 111 (Bucks Urgent Care Service).
“You said, We did” monthly staff engagement initiative.
Nurse consultant on who is spreading good practice with training and leading by example.
Whole Time Equivalent (WTE) has been in place for nurses and the new bank system allows the use of the same temp staff.
There is a nursing recruitment plan (recruiting Portuguese nurses with 4 years experience,10 WTE and 2 HCA at Waterside ward, and 7 WTE and 6 HCA on Chaltridge
ward in Amersham).
Junior staff at Wycombe hospital expressed satisfaction on the level of work and support received by Consultants and other staff.
Outstanding concerns based on evidence gathered
Key planned
improvements by the
Trust
Recommended actions
Priority –
urgent, high
or medium
There should be a Workforce Plan to Urgent
deliver the People Strategy which sets
out the actions, key deliverables and
Annual
ward
staffing
review
measures of success which should be
There is a People Strategy which covers a range of developments to improve the
that
the
Chief
Nurse
at
monitored and reviewed, with progress
quality, capability and motivation of those who work for the Trust.
Board level signs off and
being fed back to the Board at regular
agrees
the
WTE
for
each
intervals.
The nursing rotas produced by very senior nursing staff left little room for ward level
ward.
senior nurses to adjust the skill mix according to the up to date ward requirements,
according to views expressed to the panel by this group of staff.
Understanding of workforce issues
Monthly workforce reports
go to the Board.
37
Outstanding concerns based on evidence gathered
Key planned
improvements by the
Trust
Working in silo & spilt of acute services
None identified
Connection and alignment between the recent reconfiguration, workforce strategy,
patients’ needs and redesigned pathways was not apparent. Split site working
increased the burden on the Trust’s workforce and poor quality treatment. Examples
are:



A Hip fracture patient was first taken to Wycombe as a possible stroke
or heart attack, then transferred back to Stoke Mandeville before being
fully examined and a broken hip diagnosed, a delay of some hours.
This is an example of specialist services dealing with their area of
disease but missing the needs of the whole patient.
The Panel was told that one patient was transferred eight times
between Wycombe and Stoke because of the absence of a
comprehensive acute service on one site.
The Panel was told of one patient with chest pains being taken to
Wycombe but it was subsequently established that the chest pains
were a symptom of Type 2 respiratory failure; there were then delays in
transferring the patient to Stoke Mandeville and (due in part to a
weekend) further delays before the patient was seen by a consultant by
which time 5 days had elapsed.
Recommended actions
Priority –
urgent, high
or medium
Board to use and triangulate multiple
sources of information to provide
transparency on issues register /
recruitment / staff survey / complaint
themes/mortality / audit (clinical,
qualitative / quantitative) clinical and
wider stakeholder (including CCG &
public) engagement.
Urgent
Review the whole Unscheduled care
Urgent
pathway, considering how better to
improve the patient experience. To
include patient representatives and the
wider public in this process. Record
and report such clinical incidents and
report to the Board.
The Panel was told that the respiratory ward at Stoke Mandeville has capacity for
fewer than 50% of the typical level of respiratory inpatients (although the bed
manager’s log suggests the percentage is much lower).The dislocation of patients
from the appropriate specialist wards not only increases the burden on medical staff
(who has to travel throughout the hospital to locate the patients for whom they are
responsible) but also means that patients may not receive appropriate specialist
nursing care. An account of a respiratory patient on a general medical ward being
left with an unsealed chest drain exemplified the foreseeable risks to patient safety
which may arise under the current arrangements.
There is an impression that the whole Emergency care pathway is fragmented in this
way, leaving an improved patient experience less well considered and a less
important goal. This was evidenced in a letter from the medical registrars to Medical
Director, dated 20/4/2013
38
Outstanding concerns based on evidence gathered
Key planned
improvements by the
Trust
Staffing, Recruitment and Retention
None identified
Junior doctors and nursing staff considered medical staffing for the acute medical
take at weekends to be insufficient and reported that at times this felt unsafe and
unmanageable. At the respiratory unit, commitments such as on-calls, training and
covering SSU means ward days occur at random. 1 registrar, 1 SHO and 1 F1 to
cover whole of medicine for weekends. The F1 is reported to have to cover 180 250 patients at the weekend and to feel unable to cope with demand, being
constantly interrupted by bleeps.
Recommended actions
Priority –
urgent, high
or medium
The Trust should urgently conclude its Urgent
review of respiratory beds to ensure the
provision of a high quality service for
these patients.
The review team were told that there was a lack of Consultant input for patients
admitted at the Stoke Mandeville site as medical emergencies over weekends.
High use of agency staff in community hospitals, care of elderly ward, critical care,
short stay ward, respiratory ward. During a number of focus groups and ward visits,
nursing staff reported workload pressures in relation to agency staff being unable to
administer IV medication, stating that this placed a heavy burden on permanent staff
who are required to perform this function in addition to other roles.
The divisional associate chief nurses’ and nurses’ focus group reported that the
recruitment process is very slow. The same message was received from the
Waterside ward in Amersham. The surgical unit use agency staff, but they have a
high proportion of post op patients needing IV's and therefore this workforce is not
helpful for them.
Difficulty attracting and retaining student nurses. A number of ward nurses
commented on slow recruitment processes with regards to nursing staff.
Difficulty attracting and retaining junior doctors who stated that the hospital has a
reputation for being a bad place to work for FY1s at weekends (stressful,
unmanageable, frightening due to lack of support). Junior doctors discuss that the
National Spinal Unit is very understaffed and the patients miss out on treatment. The
unit has to be supported by external staff from the cancer unit. The children’s ward
on the spinal unit had to close at weekends.
Engage with student nurses and
discuss what would make the Trust a
good place to work.
High
More senior medical supervision for 7
days a week.
Urgent
39
Outstanding concerns based on evidence gathered
Key planned
improvements by the
Trust
Recommended actions
Priority –
urgent, high
or medium
Inadequate response to the staff feedback
Urgent
Board need to develop a systematic
plan to understand and then address
The staff survey presented significantly below the national average on “care of
the concerns raised by staff.
patients / service users in the organisation”, “recommend the organisation a place to
work” and “if friend or relative needed treatment, I would be happy with the standard Address the issues raised in
of care”. HCAs and other clinical staff feel that it was not worth doing the survey as the letter from the medical Junior Doctors need a safe place
Urgent
where their concerns will be listened to
nothing changes.
registrars and invite their
and addressed.
attendance at the Urgent
The panel received evidence that the responses to the survey has been patchy with Care Board.
Board to consider listening support is
evidence that some wards performing small-scale staff surveys for themselves, the
put in place urgently for high risk areas
initiation of executive wards rounds and the Chief Executive coffee mornings. The
Urgent
(as junior doctors and elderly care and
panel saw no evidence that the Board or senior executives had sought
community services), feeding into the
systematically to drill down and understand the reasons for the feelings of the Trust's
board in relation to staff survey actions.
staff as indicated by the staff survey.
An example relates to:
Community nursing staff who reported to the review team workload
pressures primarily relating to problems accessing timely medical advice
and issues related to the electronic note system. The lack of effective
communication of these issues can be illustrated by the fact that this group
of staff had resorted to workarounds such as contacting doctors working
outside the “on call” system in place who were prepared to give advice (See
also KLOE 7 section 2).
Other examples include the letters sent in April from junior medical doctors and
Medical Registrars to the Medical Director, and referenced previously in this report.
Apply efforts to resolve the serious
concerns raised as rapidly as possible.
Urgent
Put into place mechanisms to allow
middle grade medical staff to raise
concerns in a more live and timely way.
Actively seek the opinions of front line
medical staff during the implementation
of clinical change programmes to
proactively monitor the effects of those
changes.
Programme these interventions as part Urgent
of the Trusts change methodology.
40
Staff support including training
KLOE 7: How is the Board assured that it has the necessary workforce (mix, number, skills) deployed to deliver its quality objectives?
Good practice identified
Executives and NEDs walk rounds.
Team briefs and Staff Magazine.
Surgical trainee confirmed that Bucks is very good for surgical training.
Some areas are good at sourcing funds for training from outside.
Ward 5 in Stoke Mandeville and Ward 12 in Wycombe are exemplar wards.
Outstanding concerns based on evidence gathered
Key planned improvements Recommended actions
by the Trust
Workforce data lacks detail
There is a general recruitment Board need HR reports to include more
Urgent
plan for this year for nurses. detail on key risk areas and actions, with
monitoring of delivery against milestones in
the workforce action plan.
There is no adequate workforce subcommittee to manage operational risks
arising from workforce issues. For example, the national spinal unit
recruitment issues appear to be understood, but these do not appear to be
stratified nor action planned.
Priority – urgent,
high or medium
Workforce data presented to the Board is not sufficiently detailed to indentify
outliers that might cause risks to patient safety (either staff numbers or
training). This was evidenced in the minutes of November Board
Management. Workforce concerns were rated below 12 on Divisional risk
registers and not visible at Board. As a consequence the workforce concerns
most worrisome to executives, such as the Chief Nurse, failed to become a
major concern at Board. This suggests limited Board visibility of problematic
but more diffuse systematic risks.
41
Outstanding concerns based on evidence gathered
Key planned improvements Recommended actions
by the Trust
Priority – urgent,
high or medium
Learning from incidents and complaints
None identified
We identified pockets of good practice of organisational learning. In the
doctors’ focus group, attendees spoke of good practice in identifying and
sharing lessons in medicine. We also identified learning on an ad hoc basis,
through involvement in a formal audit and through good practice of some
individuals. However, we did not identify a culture of systematic learning
throughout the Trust. For example, there appeared to be no consistent or
formal feedback loop for clinical staff as a result of serious or adverse
incidents, i.e. no formal structure for the organisation to share lessons learned
from these events, particularly to all staff throughout the Trust.
No linked analysis of incident reports and complaints/PALS.
Improve sharing of lessons learned and
actions from incident reporting.
Training
Training and development for staff varies and does not appear to be
prioritised consistently. The training is more focused on acute rather than
community services. There seems to be good training for critical care and
surgical ward but not good for community and IV training is not good for
permanent staff.
The staff focus group presented that there is difficulty in releasing team
members to attend training.
Review training – all types including
High
leadership and especially for bands 1 – 7.
Institute leadership programme for senior
clinical staff. Board ensure oversight and
management to reduce the variation (linked
to staff survey strategy and Recruitment
retention strategy).
Difficulties were expressed by some staff in getting onto the IV competency
courses although chief nurse stated there was a programme running
throughout the year.
Leadership development for leaders of teams/ community services / wards
does not appear to be consistently accessed. Matrons cover multiple sites
with limited presence per site so limited supervision. In many of our visits the
matrons were present yet when questioned it was clear that given their ward
responsibilities they were not able to attend the wards as often as they would
like, in one instance less that one day a week was quoted.
Good practice is identified in
“People Strategy” and
evidence supplied of some
leadership development for
divisional leads.
Urgent
An organisational development plan to be
transparent and communicated across the
Trust. Evidence of essential skills
(mandatory) training at ward level and staff
supported through charitable money in
High
cancer and cardiac for other courses,
however not so in less specialist areas.
To review the Matron arrangement to
provide regular supervision support.
Medium
42
Outstanding concerns based on evidence gathered
Key planned improvements Recommended actions
by the Trust
Inadequate senior doctor support
None identified
The medical cover for community hospitals is provided by General
Practioners. A recent improvement to this is the ward round performed by
elderly care physician in the community hospitals. Following the introduction
of the111 service, access to medical advice is now considered inadequate
during the out of hours medical (evidenced in a focus group, unannounced
visit in Amersham, and an interview with the Divisional Associate Chief
Nurse).
The nurses have to call the Bucks Urgent Care Service (111) but the service
is considered inadequate as:
(As reported to the Panel by staff at the community hospitals) the
acuity of the patients has become more challenging.
There are long delays in a doctor calling them back (up to 5 hours).
Thus, the nurses have “given up” on 111 and either call hospital
doctors / GP who they do not mind being called up to a time or 999 if
the patient’s health is dangerously deteriorating.
The junior doctors reported that there is generally lack of senior support which
has become poorer by recent reconfiguration. In Stoke Mandeville, patients
may go days without senior input and there are not daily ward rounds .
Review and improve the out of hours
medical cover for the community nurses
(both working in community hospital and
community itself).
Priority – urgent,
high or medium
Urgent
Renegotiate with OOH provider, using CCG
support, a direct line contact for all
High
community Hospital OOH needs with more
direct and timely access to a medical
opinion.
Safety
KLOE 8: What assurance does the Board have that the organisation is safe?
Good practice identified
Chief Executive and Chief Operating Officer were visible in carrying out frequent walk rounds at Stoke Mandeville and Wycombe, which is appreciated by staff.
Early Warning System has just been implemented across the Trust and is viewed positively by nurses and doctors we spoke to.
43
Good practice identified
The Board sees the Serious Incident Report which provides details on serious incidents and describes learning and action plans.
Divisional governance leads feel engaged with the overall Trust governance and feel upward reporting is adequate. They reported getting feedback from the Board on
issues which have been escalated from Division to the Board and subcommittees.
The Board and Healthcare Governance Committee review some appropriate metrics relating to patient safety in the performance report, including Pressure Ulcers.
Staff stated, and performance reporting indicates, that Pressure Ulcer rates were low.
We have seen evidence of Trust-wide initiatives to improve patient safety, which are reported to the Board e.g. reduction in Pressure Ulcers.
During observations, our team saw safe practices relating to drug management e.g. drug trolleys were locked.
Outstanding concerns based on evidence gathered
Key planned improvements by Recommended actions
the Trust
Board approach to ensuring a safe organisation is too reactive and relies None identified
upon an incident reporting system which could be improved
There is a reliance on systems such as DATIX identifying issues, which creates
a reactive approach to ensuring a safe organisation. In addition, there is not a
clear understanding among staff of which issues should be reported as
incidents, which means that the Board is relying on a system which could be
improved. We saw examples of events which should have been reported as
incidents, but were not as “they did not lead to patient harm”. The panel
witnessed one example where a patient was transferred from High Wycombe to
Stoke Mandeville with a suspected fractured neck of femur. The family
reported their perception of a significant time delay in the administration of any
pain relief. Staff did not report this as an incident until strongly encouraged to
do so.
Priority –
urgent, high
or medium
Training to be provided to all staff and High
Board members on the definition of
incidents and the importance of
reporting them e.g. Manchester Safety
Tool.
Ensure key risks are identified and
Urgent
given appropriately high ratings, such
as highlighting A&E consolidation, and
appear on the corporate risk register, to
enable the Board to proactively plan,
monitor and manage risks to patient
safety.
In addition, we have not seen a proactive approach to ensuring patient safety,
44
Outstanding concerns based on evidence gathered
Key planned improvements by Recommended actions
the Trust
Priority –
urgent, high
or medium
for example when planning and implementing changes such as the Accident
and Emergency consolidation. They were not highlighted on the risk register.
There is a perceived culture of blame in reporting incidents and
highlighting areas of concern
Some members of staff we spoke with described a blame culture and gave
examples of where they had received negative personal feedback in raising
incidents and areas of concern. This creates the risk that significant issues are
not being raised by staff and escalated to the Board, leaving the Board unaware
of safety concerns within the Trust. Examples of where staff have received
negative feedback included a Junior Doctor who reported an incident via an
anonymous GMC survey. This led to identification of the patient and doctor
involved and the survey was filed in the patient’s notes. The panel heard of one
incident where a chest drain had been left unsealed: The incident was not
reported because of concern that the Trust would respond by disciplining a
nurse who was considered by the witness to be extremely conscientious, rather
than addressing the systemic risk involved in treating patients with complex
needs on non-specialty wards. Also, two members of senior nursing staff raised
concern that incident investigations request disciplinary action without any
discussion with the line manager as to the appropriateness or outcome of the
investigation. Each raised the concern that the Trust has moved more towards
a blame culture rather than holding to account (both noted they expect
disciplinary action to be taken if the staff member did not act within the
expected standards).
None identified
A system of incident reporting that staff Urgent
can feel confident in which:




Promotes a no-blame culture
Is less personal and less focussed
on the performance of individuals.
Allows an appropriate and timely
response.
Facilitates clear analysis and
feedback of outcomes to staff.
The panel heard from staff who stated that the DATIX reporting system requires
too much information about the people involved, rather than the process at
fault. This creates a fear of blame and retribution and makes staff more
45
Outstanding concerns based on evidence gathered
Key planned improvements by Recommended actions
the Trust
Priority –
urgent, high
or medium
reluctant to fill the forms in about incidents involving themselves or colleagues.
The panel spoke with staff who had not received feedback on incidents they
had raised.
It is not clear how the Board gains assurance that lessons learned are
None identified
shared and implemented across the Trust
We have seen examples of where the Board hear about learning outcomes
from incidents, but it is not clear how the Board get assurance that this learning
is shared and/or implemented across the Trust, other than through reassurance
from individuals that this will occur. We heard from staff that lessons learned
are often not shared with them.
Clinical governance meetings at
High
department level should all be minuted.
These minutes should then be sent to
Divisional Boards and above, in order
for the Board to gain assurance that
learning from incidents happens at
ward level.
The Board could review more metrics to gain assurance over patient
None identified
safety at the Trust
The Board review general safety metrics such as pressure ulcers, but could
review metrics which are pertinent to the main risks to safety faced by patients
at this specific Trust.
The Board could review other metrics
that are specific to key risks at the
Trust, such as those relating to
transferring patient between sites and
how out-of-hours staffing impacts on
deteriorating patients.
Lack of written criteria for patient transfers
The panel was informed by a ward sister of a change in the acuity of patients
transferred to Amersham. Whilst the sister could articulate the admission
criteria verbally, there was no evidence of formally documented admission
criteria.
Written criteria for patient transfers to High
Amersham should be developed, which
are regularly reviewed and audited
None identified
Urgent
46
5. Conclusions and support required
Conclusions
The panel was welcomed to the Trust by all staff and patients and met some outstanding and dedicated individuals at all levels within the Trust. The Trust is not a Foundation
Trust but currently in the Foundation Trust pipeline. The Trust has recently undergone significant change, most notably the consolidation of the A&E department from
Wycombe to the Stoke Mandeville site and the creation of three large divisions from the original six. In response to the Trust’s higher than expected HSMR a Mortality Task
Force was set up in 2010.
The Trust and ward areas were observed to be clean and tidy, with patients generally seen to be well cared for during the visit. Many examples of good practice are included
in the body of this report, but for clarity this conclusion focuses upon six broad areas where more focus from the Trust will lead to significantly improved quality of care:

Governance (including risk management and reporting);

Urgent care (pathways);

Patient safety;

Governance organisation-wide monitoring of clinical and operational effectiveness;

Patient and public engagement (including communication and complaints); and

Workforce development (including recruitment, training and leadership).
There has been a recent period of significant structural and organisational change in the Trust including the consolidation of A&E on the Stoke Mandeville site.
Emergency activity remains on the Wycombe site for acute stroke patients and “in hours” cardiac patients. Prospective evaluation of patient transfers between hospital sites
for those presenting as emergencies should be urgently undertaken to assess patient safety and experience. This evaluation should cover all patients transferred following
presentation as an emergency to ensure that high quality care is provided for those who remain with Buckinghamshire Healthcare Trust as well as those who are transferred
to other hospitals such as Oxford or Harefield. This issue has been a significant reputational risk to the Trust. During the review visit the team saw patients who required
transfer between the two sites and feel that urgent, prospective evaluation of this service change must be undertaken to assess the quality of care (i.e. clinical effectiveness,
patient safety and patient experience).
The Trust needs a more robust method to provide assurance on the quality impact of major service change with regard to clinical effectiveness, patient experience and
safety especially in regard to the consolidation of A&E at the Stoke Mandeville site. Leadership at Board level appears “reactive” to issues and there seems to have been
limited challenge and examination of the data presented to the Board (reassurance, not assurance). The current approach is over reliant on incident reporting and needs
strengthening to be sufficient to detect and address unforeseen quality concerns. Patient information and signage needs to improve especially for the benefit of out of hours
patients.
47
The Trust needs more robust, organisation-wide monitoring of clinical effectiveness and operational performance data. Quality scorecards should be in place on
every ward, and the Board needs to have more clarity in how it gains robust assurance about quality and safety risks across the sites. The Trust needs to move its focus on
mortality away from trying to explain the figures at the Mortality Task Force. It must concentrate more on the identification of trends in the data and the development of action
plans and improvement projects to address issues such as pneumonia and acute renal failure mortality rates – the approach seems to have been reactive in response to
information from Dr Foster (and recently confirmed by the CQC mortality outlier alert notices for these categories). While there are a number of recent developments which
focus on safety (e.g. National Early Warning Scores), the Trust needs to adopt national initiatives in developing a mature “safety culture” and use incident reporting positively
and constructively alongside more proactive tools.
A more systematic approach is needed to gathering and reviewing patients’ views about their experiences of care in the Trust. Better methods of sharing information
from the feedback that is gathered are required. The Trust needs to be more robust in using patient feedback and complaints as a means to informing and improving service
delivery, and to help it plan for the future and share learning across the organisation.
The Trust recognises difficult workforce issues such as recruitment, high levels of staff sickness and poor staff survey results, but needs a clear, more visible strategy to
overcome these challenges. There is good evidence of both ward level initiatives to increase staff engagement, and others such as the staff newsletter, and the CEO coffee
mornings – increasing the diversity of two way communication between Board and ward; developing this would provide a good opportunity for the Board to listen to staff.
Urgent priority actions for consideration at the Risk Summit
Problem identified
Recommended action for discussion
1.
Governance: Weak methods to provide
assurance on the quality impact of major service
change with regard to clinical effectiveness, patient
experience and safety. Board appears too reactive,
rather than proactive, and is not effective in challenging
information presented to it. Relies on reassurance over
assurance.
At this time of significant change within the Trust, there is an urgent need for
the Board to develop both its capability and capacity to work in a proactive way
and its ability to scrutinise and challenge effectively.
Support required by the
Trust
To be discussed with the
Trust and included in the risk
summit action plan.
The Board should urgently develop its approach to risk management. In order
for the Board to proactively plan, monitor and manage risks to patient safety,
there is a need to ensure the key risks are identified at all levels of the
organisation and appropriately feed through to the corporate risk register.
The Trust should review patient pathways between hospital sites to ensure
high quality of care to ensure clinical effectiveness, patient experience and
patient safety at all times.
To be discussed with the
Trust and included in the risk
summit action plan.
2.
Urgent care (pathways): The consolidation of
A&E on the Stoke Mandeville site has resulted in the
need to transfer patients between sites within the Trust
and to other hospitals.
Investigation of high mortality rates shows pneumonia
and acute renal failure as likely contributing conditions.
There is a lack of clear and formally agreed pathways for
the recognition and management of acutely ill and
deteriorating patient
The identification and appropriate management of deterioration of medical
patients admitted as emergencies is an area that the Trust should focus on.
The Trust must review medical staffing for out of hours/weekend medical
48
Problem identified
3.
Patient Experience: There is no systematic
approach to gathering and reviewing patients’ views
about their experiences of care at the Trust. Complaints
are not addressed in a timely manner and learning is not
shared effectively across divisions. Patient and public
expressed concerns about the quality of care for patients
presenting as emergencies.
Clinical and operational effectiveness: There
appears to be a lack of organisation-wide monitoring.
There are a number of improvement project in the early
stages of planning or implementation, which have not
been brought together as part of a Trust-Wide safety and
improvement strategy. In addition, although the Trust is a
medium reporter of incidents, feedback from staff
revealed some confusion around the definition of what
constitutes an incident, a reluctance to report incidents
due to fear of blame and lack of confidence in
improvement actions resulting from their reporting.
5.
Patient safety: Ineffective Bucks Urgent Care
Service (NHS 111) service for the Community Hospitals.
There is an opportunity for the Trust to work to enhance
the 111 service as an aid to the public in signposting the
appropriate point of entry to the Trust.
6.
Workforce: inadequate medical staffing levels
and skills mix – there was a concern over staffing levels
of senior grades in particular out of hours. The Nursing
staffing levels and skills mix was also found to be
suboptimal in places.
4.
Recommended action for discussion
cover.
The Trust should increase capacity for care on specialty wards. This should
include the establishment of a respiratory unit with double the capacity of the
existing respiratory ward.
The panel saw evidence of ward level collection and review of patient
experience data and recommend that this is urgently implemented across the
Trust. This should be linked to a single route of accountability within the
division structure and combine all patient related contact services (PALS,
complaints, patient engagement, claims)
Put in place consistently high standards for addressing patient complaints
across all divisions with clear Board level accountability. Put in place an
effective process for capturing and reviewing the experience of patients
presenting acutely to the Trust.
The Trust should bring together all improvement projects as part of a Trustwide safety strategy to address the causal factors associated with the
apparently high mortality. These should be incorporated as part of a
recognised improvement methodology and their progress reviewed.
Support required by the
Trust
To be discussed with the
Trust and included in the risk
summit action plan.
To be discussed with the
Trust and included in the risk
summit action plan.
The Trust need to commission an external safety culture review.
Training to be provided to all staff and Board members on the definition of
incidents and the importance of reporting them in a way that promotes the
development of a no-blame culture.
Work with patient and carer group/NHS 111 provider and CCGs to improve
functionality of NHS 111 for this healthcare system.
To be discussed with the
Trust and Commissioners,
and included in the risk
summit action plan.
The Trust should consider urgently the staffing levels and mix throughout the
organisation, particularly at the senior grades, to address concerns about
weekends and out of hours. In addition, the Trust should undertake a review of
the provision of services at its community hospitals and whether clinical staffing
levels are appropriate and provision of care continues to be sustainable at the
To be discussed with the
Trust Staff review support
and included in the risk
summit action plan.
49
Problem identified
Recommended action for discussion
Support required by the
Trust
current level of service use.
Training & development for staff varies and does not appear to be prioritised
consistently. Some nursing staff said that it was difficult to obtain places on
essential internal courses (for example, in order to be permitted to administer
IV antibiotics or fluids). Junior doctors reported that there is generally a lack of
senior support which has been made poorer by recent reconfiguration. The
panel was told that some patients in Stoke Mandeville may go days without
medical input and daily consultant ward rounds are not always carried out.
The review team heard from staff that they did not feel that their concerns were
heard and acted upon. There is good evidence to show that a well engaged
workforce has a very positive effect upon patient experience and safety. A
variety of two-way communications are in place and these must be developed
urgently in order to encourage effective and diverse staff engagement, in order
to close the gap currently described by members of staff between the Board
and the ward.
Difficulties in recruiting nursing staff have been discussed as a key risk and
there is significant variation in the make-up of staffing levels on individual
wards between Trust staff and bank or agency staff. The spinal unit and other
wards across sites are understaffed while other exemplar wards confirmed
they had very low vacancy levels.
50
Appendices
51
Appendix I: SHMI and HSMR definitions
HSMR definition
What is the Hospital Standardised Mortality Ratio?
The Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare quality that measures whether the mortality rate at a hospital is higher or lower than you would
expect. Like all statistical indicators, HSMR is not perfect. If a hospital has a high HSMR, it cannot be said for certain that this reflects failings in the care provided by the
hospital. However, it can be a warning sign that things are going wrong.
How does HSMR work?
The HSMR is a ratio of the observed number of in-hospital deaths at the end of a continuous inpatient spell to the expected number of in-hospital deaths (multiplied by 100)
for 56 specific groups (CCS groups); in a specified patient group. The expected deaths are calculated from logistic regression models taking into account and adjusting for a
case-mix of: age band, sex, deprivation, interaction between age band and co-morbidities, month of admission, admission method, source of admission, the presence of
palliative care, number of previous emergency admissions and financial year of discharge.
How should HSMR be interpreted?
Care is needed in interpreting these results. Although a score of 100 indicates that the observed number of deaths matched the expected number; in order to identify if
variation from this is significant confidence intervals are calculated. A Poisson distribution model is used to calculate 95% and 99.9% confidence intervals and only when
these have been crossed is performance classed as higher or lower than expected.
SHMI definition
What is the Summary Hospital-level Mortality Indicator?
The Summary level Hospital Mortality Indicator (SHMI) is a high level hospital mortality indicator that is published by the Department of Health on a quarterly basis. The SHMI
follows a similar principle to the general standardised mortality ratio; a measure based upon a nationally expected value. SHMI can be used as a potential smoke alarm for
potential deviations away from regular practice.
How does SHMI work?
Deaths up to 30 days post acute trust discharge are considered in the mortality indicator, utilising ONS data.
The SHMI is the ratio of the observed number of deaths in a trust vs. expected number of deaths over a period of time.
The Indicator will utilise five factors to adjust mortality rates by:
The primary admitting diagnosis.
The type of admission.
A calculation of co-morbid complexity (Charlson Index of co-morbidities).
Age.
Sex.
52
All inpatient mortalities that occur within a hospital are considered in the indicator.
How should SHMI be interpreted?
Due to the complexities of hospital care and the high variation in the statistical models all deviations from the expected are highlighted using a Random Effects funnel plot.
Some key differences between SHMI and HSMR
Indicator
HSMR
SHMI
Are all hospital deaths included?
No, around 80% of in hospital deaths are included, which Yes, all deaths are included.
varies significantly dependent upon the services provided
by each hospital.
When a patient dies, how many times is this counted?
If a patient is transferred between hospitals within two
days, the death is counted multiple times.
One death is counted once, and if the patient is
transferred, the death is attached to the last
acute/secondary provider.
Does the use of the palliative care code reduce the relative Yes.
impact of a death on the indicator?
No.
Does the indicator consider where deaths occur?
Only considers hospital deaths.
Considers in hospital deaths, but also those up to
30 days post discharge anywhere too.
Is this applied to all health care providers?
Yes.
No, does not apply to specialist hospitals.
53
Appendix II: Panel composition
Name
Role
Nigel Acheson
Panel Chair
David Turner
Lay Representative
Neeta Mehta
Lay Representative
Tim Thorp
Lay Representative
Priscilla Chandro
Lay Representative
Derek Prentice
Lay Representative
Nina Wilson
Junior Doctor
Vaughan Pearce
Doctor
Carol Peden
Doctor
Simon Donell
Doctor
Aidan Fowler
Doctor
Lowri Aldworth
Student Nurse
Judy Gillow
Senior Nurse
Nicola Lucey
Board Level Nurse
Jessica Zeff
CQC Inspector
54
Name
Role
Chris Gordon
Senior Trust Manager
Linda Abolins
Senior Trust Manager
Christina Button
Senior Regional Support
Harriet Luximon
Senior Regional Support
Stephen Thornton
Observer
Jane McVea
Observer
Randeep Nandhra
PwC Recorder
Khaleda Zaheer
PwC Recorder
Fotini Tsekmezoglou
PwC Independent Moderator
Nick Wright
PwC PMO Lead
Sarah Leavey
PwC- Quality governance reviewer
55
Appendix III: Interviews held
Interviewee
Anne Eden, Chief Executive
Fred Hucker, Chair
Graz Luzzi, Medical Director
Neil Dardis, Chief Operating Officer (COO)
Date held
10 and 12 June
10 June
10 and 12 June
10 June
Lynne Swiatczak, Chief Nurse and Director of Patient Care Standards
10 and 12 June
Keith Gilchrist, Non-executive Director, Chair of the Healthcare Governance Committee
10 and 12 June
Anne Walker, Assistant Director of Healthcare Governance Committee
10 June
Alison Knowles, PALS and Complaints Officer
Nick Bigwood, PALS and Complaints Officer
Becky Pipely, PALS and Complaints Officer
Paula Chapel, PALS and Complaints Officer
10 June
Tom Travers, Director of Finance
11 June
Juliet Brown, Director of Strategy and System Reform
11 June
Faeqa Hami, Divisional Chair
Andrew McLaren , Divisional Chair
David Taylor, Divisional Chair
11 June
Tracey Underhill, Head of Membership and Engagement
11 June
56
Interviewee
Date held
Divisional Assistant Chief Operating Officers and Associate Chief Nurses
Rosemary Finley
Tehmeena Ajmal
Rachael Corser
John Abbott
Carolyn Morrice
Sally Loring
11 June
Liz Hollman, Trust Board Secretary
11 June
Sharon Webb, Assistant Chief Nurse (Corporate)
11 June
Tracey Underhill, Head of Patient Engagement and Membership
11 June
Kathy Cann, Interim Medical Director
12 June
Ian Garlington, Director of Property
12 June
Chris Wathen, Consultant
12 June
Anne Robson, Interim Director of Human Resources and Organisational Development
12 June
57
Appendix IV: Observations undertaken
Observations were undertaken in the following areas of the Buckinghamshire Healthcare NHS Trust:
Observation area
Date of observation
Ward 2a, Coronary Care Unit, Wycombe
10 June
Ward 5b, Care of Elderly, Wycombe
10 June
Critical Care Ward, Stoke Mandeville
10 June
Spinal Unit, Stoke Mandeville
10 June
Ward 10, SSU, Stoke Mandeville
10 June
Ward 6, Respiratory, Stoke Mandeville
10 June
Ward 5, Acute Haematology, Oncology, Stoke Mandeville
10 June
Ward 16, Surgical Floor, Stoke Mandeville
10 June
Accident & Emergency Ward, Stoke Mandeville
10 and 12 June
Chartridge and Waterside, Amersham
11 June
Ward 8,9 Elderly, Stoke Mandeville
11 June
Rothschild Maternity Ward, Stoke Mandeville
11 June
Urology Ward, Wycombe
11 June
Critical Care Unit & MIIU, Wycombe
11 June
58
Observation area
Date of observation
12a Surgery Ward, Wycombe
11 June
Clinical Decision Unit, Stoke Mandeville
11 June
T&O Ward, Stoke Mandeville
11 June
Out of Hours, Paediatrics, Stoke Mandeville
11 June
Palliative Care and Hospice, Stoke Mandeville
12 June
CSRU & Stoke Ward, Wycombe
12 June
Further observations were undertaken as part of the unannounced site visit, see Appendix VII.
59
Appendix V: Focus groups held
Focus group invitees
Focus group attendees
Date held
All clinical staff, Wycombe
36-40 attendees majority from Wycombe with a few from Amersham (10 June focus group)
11 attendees (11 June focus group)
Trainee nurses, Stoke Mandeville
11 3 year student nurses from University of Bedfordshire
10 June
Consultants, Stoke Mandeville
31 consultants from various specialties
10 June
HCA, Stoke Mandeville
Mixed group of 12 community and hospital HCAs
10 June
Other clinical staff, Stoke Mandeville
32 other clinical staff
10 June
Non clinical, Stoke Mandeville
Mixed group of 30 non clinical staff
11 June
Junior doctors, Stoke Mandeville
35 junior doctors
11 June
Non-executive Directors
Brenda Kersting and Les Broude
11 June
Senior nurses, Stoke Mandeville
30 senior nurses
11 June
SDU Leads
Leads for Urology, General Surgery, GI, Diabetes, AM, Ophthalmology, ENT, Obstetrics and
Gynaecology, Pathology and Haematology , Plastic Surgery, Orthopaedics, Spinal Unit
12 June
rd
10 and 11 June
60
Appendix VI: Information available to the RRR panel
The following documents were provided to the panellists through a copy being available in the panel’s ‘base location’ at the Trust during the announced site visit. Whilst the
documents were not reviewed in detail, they were available to the panellists to validate findings.
Document requests
Confirm included
Comments from trust
1.
Board Quality strategy (incorporating Patient
Safety, Patient Experience and Clinical
Effectiveness).
Quality Improvement Strategy
1
Trust Mission
Corporate Objectives 2013/14
“Quality Improvement Strategy currently being updated with indicators
for 13/14”
2.
Board Assurance Framework and Trust Risk
Register.
Board Assurance Framework 12/13
Corporate Risk Register
“ BAF 13/14 under development”
3.
Clinical Audit plans for 2013/14 and latest Clinical Draft Clinical audit plans for 13/14
Audit Annual Report.
Clinical Audit Annual Report 11/12
Draft clinical audit submission for quality accounts 12/13
3
4.
List of all Cost Improvement Programmes for
2012/13 CIP delivery, 2013/14 efficiency plans
2012/13 and 2013/14 and details of the process Quality Assurance and Clinical Risk Framework:
for assessing the quality impact of these
Assessment, Reporting and Monitoring for 2012/13
4
5.
Most recent self assessment or external
assessment of quality governance (against
Monitor’s Quality Governance Framework or
equivalent)
5
KPMG review of Quality Governance Framework October 2012
“The Quality Governance review undertaken by KPMG in October
2012 commended our governance structures”
Folder Number
2
61
6.
Organisation structure and CVs of Executive
team
Organisation Structure
Mini-CV's of executive team
“ Full CVs can be provided if needed”
“ integrated medicine has a clinical and operational structure
supporting acute and community integration”
7.
Governance and committee structures and terms Governance Structures
of reference for assuring quality including
Terms of Reference Healthcare Governance Committee
mortality
Terms of Reference Audit Committee
TMC Terms of Reference
Extract from draft IBP about governance structure
“ The Trust has integrated governance arrangements at Board level
and down through the organisation through to ward level”
7
8.
Trust Board (private and public) papers and
minutes for the last 2 months
8
9.
Board sub-committee with delegated
Healthcare Governance Committee papers for January and March,
responsibility for assuring quality and safety.
including minutes
Papers and minutes for last 2 months (public and
private).
9
10.
Mortality review group papers and minutes for the Mortality Task Force papers April 2013 and March 2013.
last 2 months
10
11.
Summary of key performance measures for
2012/13 including finance, performance, quality
and patient experience
8
12.
Annual plan submission to Monitor or equivalent Suite of documents submitted to NTDA.
for NTDA for 2013/14
12
13.
CQC Mortality alert action plans and
implementation
13
Trust Board papers November 2012, January and March 2013
(includes minutes)
Included in the Trust Board papers in Folder 8
February and May 12 alerts with responses
6
62
14.
Any independent reviews of quality within the last CQC compliance reports
year
KPMG review is in folder 5
Deans Annual visit 2012
HOSC review
“ A recent CQC inspection has shared our concerns around staffing
and some supervision issues and declared these as moderate
concern although it did not have a concern around patient care”
“The recent Health Overview and Scrutiny Committee reports
evidence of good practice and we want to see best practice
consistently applied across the whole organisation”
14
15.
Local Providers - Services and Capacity that
support your models of care e.g. local
intermediate care beds
15
As we are an integrated organisation these services are part of our
services.
63
The following documents were requested by the panellists at the announced site visit and made available to those panellists attending the unannounced site visit. Whilst the
documents were not reviewed in detail, they were available to the panellists to validate findings:
Document requests
1.
2.
3.
Hospital at night paper
Annual Plan
Information on current litigation and action out of these
4.
All patient safety data from the last 72 hours from 12 June 2013
5.
E rostering
Scheduled rostering with KPI’s
Actual staff on shift (agency v Trust)
Grade and hours
For last month (May 2013)
6.
Capacity plan and “allied” business case for PFI building at SMH.
7.
Letter from junior doctors to the Board around staffing and safety
8.
Report from NHS TDA inspection
9.
Latest minutes from PEG and the terms of reference
10.
Two page summary of good practice from PEG
11.
Trust response to CQC understaffing at Amersham
12.
Number of patients moved from community beds to inpatient beds back to the community
13.
Number of patients transferred more than twice (December 2011 to May 2013)
64
14.
Number of patients transferred to a different site.
By LOS day band of move
By admin method
By origin of site
By CCs diagnostic group
By discharge description
From Dec 2011 to May 2013
15.
Transformation Board minutes
16.
QIPP Board minutes
17.
Example of CIP quality impact assessment
18.
Information on the ongoing monitoring of the CIPs
19.
Board Assurance Framework
20.
Training Costs Comparison
21.
Risk Management Process
22.
Complaints policy
23.
Benefits plan
24.
Royal College of Physicians: Sentinel Audit for Stroke Care
25.
Reports from Mortality reviews- up to 5 years of reports to come from Medical Director
26.
Data on number of student nurses retained for last 2-3 years
27.
Policy for managing deteriorating patients related to EAU
28.
Nursing Quality Framework from Chief Nurse
65
29.
7 action plans for reforming urgent care
30.
% of 1 to 1 care during delivery in Maternity
31.
The incident reporting from the 7 deaths mentioned in the data submission
32.
Any Root Cause Analysis policy
33.
PALS response to emails regarding Lydia Weeks (DOB 29/1/33)
34.
Training budget allocated and spent (if different) by specialty and site- split by whether source of funding is charity or commercial.
35.
From Patient Experience Leads- how many doctors are involved in the "making every contact count" training
36.
Job descriptions for Divisional leads, Assistant Medical Directors & Assistant Chief Nurses
37.
Annual Staffing review, dependency & acuity tool, Cover arrangements at WH at night for each area, papers on current review of impact of BHIB, CIP postimplementation assessment, risk assessment (all requested from Chief nurse)
38.
Information on Deanery reviews in the last year and evidence of action plans/ implementation from them
39.
People Strategy (from HR Director)
40.
External Peer Review of ITU
41.
Full documentation from two specific complaints- WII213652 15 Nov 2012, and 3728 19 Dec 2012
42.
What is the plan for recruitment and training of all staff groups? (Particular concerns cardiology, dermatology, Emergency medicine, endocrinology/diabetes,
geriatric, trauma/orthopaedic?) What are the current vacancies and cover plans for each department?
43.
CQC report on community hospitals
44.
ICU report
45.
Policy for Serious Incidents
66
46.
Specialist Services Register
47.
Mortality Review Tools
48.
WHO checklist
49.
Physiological observations of adult non-obstetric inpatients
50.
Recommendations on basic requirements for intensive care units: structural and organizational aspects
51.
Report on Critical care for Medical Director Bucks healthcare
52.
Briefing paper on The Adult Community Healthcare Teams (ACHT’s)
53.
Development of the Medicine for Older People Strategy, Write up from meeting held on Thursday 17 January 2013
53.
Corporate Risk Register 11 June 2013
th
67
Appendix VII: Unannounced site visit
Stoke Mandeville on the evening of Sunday 16/6/13
Amersham Community Hospital on the evening of Tuesday 18/6/13
Panel pre-meet.
Panel pre-meet.
Entry into Buckinghamshire Healthcare A&E and announced arrival to site manager.
Entry into Buckinghamshire Healthcare A&E and announced arrival to site manager.
Meeting held with clinical site manager to understand current staffing and patient levels
Meetings held with the ward representative to understand current staffing and patient levels
Observations undertaken of the following areas of the hospital:

A&E, SSU, Surgical Ward
Observations undertaken of the following areas of the hospital:

Neuro and Rehab unit

Waterside Ward
Observations / interviews undertaken of the following staff:

On duty clinical site manager

Anaesthetics consultant

Senior nurse on SSU

Senior nurse on Ward 6

Registrars following end of their shift
Observations / interviews undertaken of the following staff:

Deputy sister of Neuro and Rehab ward

Ward sister of Waterside Ward
Panel left Trust and announced exit.
Panel left Trust and announced exit.
Wycombe on the evening of Tuesday 18/6/13
Panel pre-meet.
Entry into Wycombe Hospital main entrance. Used the phone on reception to announce arrival to Trust
manager.
Stoke Mandeville on the morning of Wednesday 19/6/13
Panel pre-meet.
Entry into Buckinghamshire Healthcare A&E and announced arrival to Sandra Cotton, who
escorted the team to the wards
Meetings held with ward staff to understand current staffing and patient levels
Met by ward nurse. Panel split into two teams; one team was escorted to the surgical wards by ward
nurse. The other team went to the cardiac and stroke wards are were met by the Trust manager.
Observations undertaken of the following areas of the hospital:

Cardiac and stroke wards and receiving unit

Surgical Ward

Minor Injuries and Illness Unit (MIIU) reception
Observation undertaken of the following handovers:

Doctors on the surgical ward
Observations undertaken of the following areas of the hospital:

Ward 8, 9 Elderly Medicine, Ward 16b – Gynaecology, Radiology
Observations / interviews undertaken of the following staff:

Ward 8, 9 – Elderly Medicine: Susan Beech (Ward Senior), Jo Birrell (Matron), Liz
Matthew (Nurse Consultant), Linda Abolins spoke to patients, Tim Thorp spoke to HCA
and Band 5 nurse, Neeta Mehta spoke to patients and nurse.

Ward 16b – Gynaecology: Rachel Oliver (Sister), 3 patients, Tim Thorp spoke to Band 5
nurse, Linda spoke to Registrar

Radiology: Spoke to Richard Hughes (Radiology Superintendent)
Panel left Trust and announced exit.
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Observations / interviews undertaken of the following staff:

Contact Junior Doctors

Ward and staff nurses

Trust manager

Associate Chief Nurse

MIIU receptionist
Panel left Trust and announced exit.
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Appendix VIII - Patient Stories
The Panel was given many accounts by patients, both whilst visiting the Trust and also at the public listening events. All of those accounts have helped to inform the Panel’s
assessment of the Trust. Many of those accounts were unreservedly complimentary as to the quality of care provided by the Trust; others were not. A selection of patient
stories is set out below. They have been selected simply on the basis that they illustrate themes which are developed in the body of the Panel’s report and because each
provides an example of why and how the Trust can improve its services in the future.
PATIENT STORY 1
A patient on the respiratory ward at Stoke Mandeville told the Panel that his partner was due to have her first antenatal ultrasound scan shortly after he had been admitted.
On learning this, and without any request being made by the patient, the nursing staff established the time and location of the ultrasound appointment and arranged a
wheelchair and porter to take the patient to the relevant department so that he was able to accompany his partner to the scan.
Comment: This story demonstrates truly compassionate nursing, in which the interests of the patient were placed at the centre of the actions taken by the nurses which went
well beyond those required of them. It should be used by the Trust to encourage similar standards throughout the organisation.
PATIENT STORY 2
A patient with dementia was as an inpatient at Stoke Mandeville. His family witnessed significant shortcomings in the quality of the nursing care provided to the patient. These
included issues related to medication and nutrition; observation (including falls and possible medical deterioration) and provision of dignified and respectful care. The
discharge arrangements were unsatisfactory and the patient was subsequently readmitted and died shortly thereafter.
The patient’s family subsequently complained about the quality of care provided. The Trust failed to meet its deadline of providing a response to complaints within 25 working
days. The Trust’s complete response was not provided until approximately 90 working days had elapsed. The family was told that no notes had been kept in relation to
significant periods of the patient’s care.
Comment: See recommendations made in Section 4 for KLOE 5, particularly those relating to improving timely responses to complaints and issuing death certificates.
PATIENT STORY 3
A female patient was admitted to Stoke Mandeville suffering from pneumonia. She told the Panel that it was the first time she had been admitted to hospital for more than 40
years. She felt that she had received a brilliant service from doctors, nurses, cleaners and everyone else who was involved in her care. Whilst she thought that the nurses
were “worked off their feet”, this had not affected the quality of the care which they had provided. She observed that there was always someone available to help the less
mobile patients with their needs. Describing herself as a fussy eater with special dietary needs, she had found the food at the hospital to be excellent.
Comment: This story again defines the standards of care to which the Trust should aspire for all of its patients at all times, and should be used to encourage similar standards
throughout the organisation.
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PATIENT STORY 4
A patient was admitted to Wycombe Hospital via its Emergency Department (prior to the latter’s closure) in December 2011. Following the patient’s admission a medical plan
was drawn up which reflected the patient’s needs. The patient subsequently died and adherence to the medical plan by Trust staff was questioned and the family also had
other concerns about the patient’s care.
A coroner’s inquest was held at the request of the family where the Trust was legally represented. The Trust’s legal representatives submitted that the coroner should give a
short-form verdict rather than a narrative verdict which might include findings as to the care received by the patient. The coroner nevertheless delivered a narrative verdict.
Comment: Please see Section 4 (KLOE 5; ‘Patient Experience’) for relevant recommendations. In addition, NHS England should consider whether to give guidance as to the
circumstances, if any, in which it might be appropriate for any NHS organisation to request a short-form verdict at an inquest into the death of a patient at which the NHS
organisation is an Interested Party.
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