East Lancashire Hospitals NHS Trust
Review into the Quality of Care & Treatment provided by
14 Hospital Trusts in England
Key Findings and Action Plan following Risk Summit
July 2013
Contents
1.
Overview
3
2.
Summary of Review Findings, Trust Response and Risk Summit Discussion
6
3.
Risk Summit Action Plan
17
Appendices
Appendix I:
22
Risk Summit Attendees
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1. Overview
A risk summit was held on 5 July 2013 to discuss the findings and actions from the Rapid Responsive Review (RRR) of East Lancashire Hospitals NHS Trust (“the Trust”).
This report provides a summary of the risk summit including the Trust’s response to the findings and an action plan for the urgent priority actions from the RRR. The action
plan includes any agreed support required from health organisations, including the regulatory bodies.
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 Mortality Indicator (SHMI) or the Hospital Standardised Mortality Ratio
1
(HSMR) .
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 judgements 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:
1)
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 this is reflected in the reports. The Panel also considered independent feedback from stakeholders related to the Trust, received
through the Keogh review website. These themes have been reflected in the reports.
2) Listening to the views of staff – staff were supported to provide frank and honest opinions about the quality of care provided to hospital patients.
3) Openness and transparency – all possible information and intelligence relating to the review and individual investigations will be publicly available.
4) 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.
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Definitions of SHMI and HSMR are included at Appendix I of the full Rapid Responsive Review report published here http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/published-reports.aspx
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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 and risk summits. The process was designed to:
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Determine whether there are any sustained failings in the quality of care and treatment being provided to patients at these Trusts.
Identify:
i.
ii.
iii.
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 followed a three stage process:
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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 (KLOEs). The data pack for the Trust is published at http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/published-reports.aspx
Stage 2 – Rapid Responsive Review (RRR)
A team of experienced clinicians, patients, managers and regulators, following training, visited each of the 14 hospitals and observed the hospital in action. This involved
walking the wards and interviewing patients, trainees, staff and the senior executive team. This report contains a summary of the findings from this stage of the review in
section 2.
The two day announced RRR visit took place at the Trust’s main site on Tuesday 4 and Wednesday 5 June 2013 and an out of hours unannounced site visit on the evening of
Thursday 13 June 2013 at the Royal Blackburn Hospital and the evening of Wednesday 19 June 2013 at the Burnley General Hospital. A variety of methods were used to
investigate the Key Lines of Enquiry (KLoEs) and to enable the panel to analyse evidence from multiple sources and follow up any trends identified in the Trust’s data pack.
The KLoEs and methods of investigation are documented in the RRR report for East Lancashire Hospitals NHS Trust. A full copy of the report was published on 16 July 2013
and is available online: http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/published-reports.aspx
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Stage 3 – Risk summit.
This stage brought together a separate group of experts from across health organisations, including the regulatory bodies (Please see Appendix I for a list of attendees). The
risk summit considered the report from the RRR, alongside other hard and soft intelligence, in order to make judgements about the quality of care being provided and agree
any necessary actions, including offers of support to the hospitals concerned.
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The Risk Summit was held on 5 July 2013. The meeting was Chaired by Richard Barker, NHS England Regional Director (North), and focussed on supporting the Trust in
addressing the urgent actions identified to improve the quality of care and treatment. The opening remarks of the Risk Summit Chair and presentation of the RRR key
findings were recorded and are available online: http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/published-reports.aspx
Conclusions and priority actions
During the RRR, the review panel identified consistent themes at the Trust around the inadequacies of its quality governance assurance systems, escalation processes and
Board assurance of safe staffing levels. Furthermore, the review panel identified capacity issues at the Trust that required a whole health economy approach to address
including understanding patient flow to be able to deal with additional pressures. Finally, the review panel strongly considered that the Trust needed to engage better with its
patients through effective communication and being seen to respond and learn from patient complaints and feedback.
The RRR identified a number of areas of good practice, although these generally related to specific areas, wards or specialities. Therefore there was more for the Trust to do
in ensuring good practices were in evidence across the organisation, all of the time. The Trust has responded positively to the review process with some urgent issues
already addressed, for example, the establishment of a multi-professional Mortality Steering Group. The Trust is working very closely with the TDA and others to address
other key priorities. From a CQC perspective, the review had provided a comprehensive overview with a clear set of findings and recommendations. The CQC had already
sought assurance from the Trust in a number of areas and would consider the need for any further regulatory action in light of the review report and the actions of the Trust
and other agencies. These views were also supported by the two CCGs who stated the depth of the issues identified were a concern and they would work closely with the
Trust over their assurance and patient experience processes.
The Trust recognised that there were a number of areas where it needed to improve and management are committed to delivering excellence in care and they welcomed the
support of risk summit members to aid them achieve this. It was acknowledged by the risk summit members that the Trust cannot do this in isolation and that it would require
engagement with other stakeholders within the health economy.
The RRR identified a number of areas of outstanding concern across all ten KLOEs. For some areas the review panel identified some improvements either already underway
at the Trust or planned actions. A number of urgent and high priority actions identified by the RRR panel were agreed for the Trust to address. Whilst some of these actions
would take longer to address entirely, assurance in respect of patient flows in A&E and concerns over staffing in the midwifery unit had already been sought by CQC.
Next steps
The risk summit focused on the high and urgent priority actions, and the Trust agreed to provide a detailed action plan, working with the TDA, to all outstanding concerns and
recommended actions included in the RRR report by 19 July 2013.
A follow up risk summit will be held in September 2013 to monitor progress and provide an updated action plan for ongoing review and monitoring arrangements.
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2. Summary of Review Findings, Trust Response and Risk Summit Discussion
Introduction
The following section provides a summary of the RRR panel’s findings and the Trust’s response presented at the risk summit. The detailed findings are contained in the
Trust’s RRR Report. The Trust’s response was presented by Mark Brearley, Chief Executive, supported by Catharine Schram, Medical Director. The agreed action plan in
response to the urgent priorities is included in the following section.
Overview of Trust response
The Trust thanked the review panel for their commitment to the RRR and recognised that there are a number of concerns where there was a need to improve and expressed
apologies over the concerns raised. The Trust stated that there was a zero tolerance to poor patient care and it was reassuring that some areas of good practice had been
identified.
The Trust stated that it can improve and that it would use the RRR report as a key driver for making improvements and would work with key stakeholders to embed a culture
of change recognising that the response needs to be system wide to change mindsets.
The Trust concluded by stating they will do their utmost to ensure that patients are always at the heart of decisions, that they will inspire staff and patients in helping them to
deliver the care that everyone wants to see delivered, and to hold them to account if the Trust falls short. The Trust stated that its governance processes need to evolve with
the changing needs of its patients and public and they commit to openness and transparency in all that they do.
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Summary of Review Findings
1. Governance and Leadership
The RRR review team considered that the Board’s quality governance processes were not cohesive and failed to use information effectively to improve the quality of
care. The governance systems are not providing the expected level of assurance to the Board and escalation of risks and clinical issues is inconsistent. The
governance committee structure is onerous and provides insufficient challenge to enable decisive actions to be taken; consequently the Board is provided with
insufficient intelligence on the quality of care, including mortality data and review findings. There is limited evidence to demonstrate that effective improvement
ambitions are being agreed or action and monitoring of improvements is taking place.
The review team observed that very few staff could articulate what risks to clinical quality and patient care existed within the organisation and therefore what was a
priority for action. Whilst there was evidence of many audits, there is recognition in the Trust that better quality information is still needed. Further Board papers
indicated that some quality issues have been considered in the private part of the board that could have been discussed in the public meeting to improve transparency
on this important area.
The Board Assurance Framework is not being used as an effective strategic governance tool and the Board is not sighted on the Divisional Cost Improvement Plans
(CIPs) and quality impact assessments. The Board could not share a strategic overview of the risks to quality and the BAF is not effective in supporting assurance with
too many risks and inconsistent risk ratings. The Board does not review Divisional CIPs and the accountability and governance of Divisional performance is unclear and
poorly monitored by the Executive Directors, as such it cannot be sure of the impact these initiatives are having on service performance. Given the weakness in the
quality governance systems and in the escalation process to the Board, the panel consider that members are not sighted on the risks to quality at a divisional level.
There is silo working in the divisions, especially with regard to sharing good practices or lessons learned (e.g. from mortality reviews). The review team did observe
good practices within individual teams, but limited sharing between wards and departments. A consistent approach is required in selected areas, such as in response
times and processes for complaints.
Recommendations
a. Commission an independent review of the quality governance framework to assess all gaps and implement quality reporting including:
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Review lines of reporting, involvement and engagement between the Board and its divisions / services, to strengthen assurance processes. This should
include putting in place procedures and review periods to review organisational development and risk mitigation as well as escalation processes so issues,
such as, the level of still births are escalated appropriately.
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Substantial review of the Trust’s CRR and BAF and a consistent approach to the identification and mitigation of risks at both corporate and divisional level as
well as risks arising from the Francis gap analysis.
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A review of Non-Executive Director governance capability including the ability to interrogate quality intelligence and appropriate training provided.
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Performance information should be made more public to focus on quality and outcomes and encourage greater transparency.
b. CIPs should undergo full quality impact assessments which are signed off by the Medical Director and Chief Nurse. These should be assessed for their aggregated
impact on the trust.
c. The Board needs to examine and interrogate mortality figures and gain assurance from methods other than external audits or the safety thermometer. This needs
to manifest itself into explicit action and monitoring. The Board members should each undertake their own unannounced visits to wards and other clinical areas to
understand the priorities of the staff and patients.
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1. Governance and Leadership
Trust response
The Trust agreed to take the following actions:
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Seek a renewed third party assurance on both the Quality Governance Framework and the Board Governance Assurance Framework.
Amend procedures to ensure that it is absolutely clear that divisional cost improvement programmes with risk assessments are signed off by the Medical
Director and Chief Nurse.
Evolve processes to understand the aggregated risk of CIPs.
Ensure direct oversight of the Board of the delivery of mortality action plans.
Increase the ratio of unannounced to announced visits by Board members.
Highlight action plans and evidence of progress in all Mortality reports.
Update mortality action plan based on AQUA’s report.
Strengthen linkages of other quality improvement activities (e.g. 24/7, Ambulatory Care, Frail elderly pathway) to mortality reduction strategy.
Ensure Mortality Steering Group multi professional membership (already completed).
Roll out weekly ward based meetings for mortality case discussion (already commenced in certain areas).
Complete mortality case review format and implement recommendations.
It was commented by the Trust that it would also seek support from the NHS Improving Quality (NHSIQ) in the Boards on Board programme. Further discussion ensued
around agreeing clear direction and timescales with the two CCGs in setting the future direction of the Trust. The Area Team raised an issue around the need to ensure
that clear messages are communicated to staff, patients and the public about the Trust’s response to the RRR and the need for real actions to be demonstrated. The
review team commented there is a disconnect between what staff know and what the Board think they know. Clear direction and leadership is needed to clearly
articulate the Trust’s goals and aspirations and a further action was agreed to undertake targeted communications at staff.
The TDA stated it will work with the Trust to develop a clear message and effective communications plan.
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2. Local capacity
Existing capacity within the Trust could be used more effectively to improve quality and patient experience. The review team noted a need to improve the relationships
in the local healthcare economy so the Trust was working closely with partners in relation to care pathways for emergency and urgent care, as well as admissions and
discharges.
Capacity at the Royal Blackburn Hospital was fully utilised during the visit due to the number of patients presenting at the emergency department (ED). Reduced staffing
levels are impacting on length of stay due to patients being discharged early, whilst in contrast, the review team observed empty beds in Burnley General Hospital. This
was supported by evidence and complaints about early discharge levels and readmission rates. The review team noted a relatively short length of stay (which is
positive) but also high levels of re-admission for some specialties and a high incidence of patients re-admitted for the same condition.
The Trust should consider utilising beds at Burnley General Hospital as “step down” beds rather than beds at Royal Blackburn. It should ensure the flow of patients is
managed more effectively to improve the use of each site and more consistently manage them as “hot” in the case of Royal Blackburn or “cold” in the case of Burnley.
Workforce strategies within the Trust are based on national strategies and do not outline how it will develop its staff or address the skills gaps that will assist in
overcoming its capacity issues, excessive clinical workload and improve employee morale. The review team considered the staff at the Trust to be a huge asset and
individual areas of good and effective care was noted in caring for patients, often working at full capacity.
Recommendation
a. There needs to be a health and social care economy wide approach to reducing the number of emergency admissions, by providing alternative support in the
community, empowering and aiding patients to effectively manage their long term conditions at home and to promote healthy living to stay well.
b. Care pathways should be reviewed to avoid delayed discharges and a review of the causal factors behind its readmission rate and length of stay needs to be
undertaken. Once these factors are better understood and an action plan put in place this will provide assurance for the Board.
Trust response
The Trust agreed to take the following actions:
 Develop the Pennine Lancashire Unscheduled Care Group (established with 4 hour performance management focus to date). Update Membership and focus to
oversee pathway reform, e.g. frail elderly pathway.
 Review of bed use (Point Prevalence study) undertaken by the Utilisation Management Team.
 Redesign Emergency Care pathway to avoid delayed discharges.
 Introduce a fast track Continuing Health Care Needs process.
 Refresh the health Economy Urgent Care Strategy.
 Implement the recent Capita proposal to map the existing capacity of alternatives to hospital admission against the growing demand (should be fully adopted
rather than phase 1 only – needs agreement across the health economy.
 Use the Emergency Care Delivery Plan in place that facilitated 4 hour recovery in Q1. ECIST to revisit ELHT on 7 August 2013.
 Develop an action plan following the Re-admissions audit undertaken week commencing 17 June 2013, and monitor this plan through the Board.
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2. Local capacity
It was recognised by the risk summit members that representatives from Social Services were not in attendance and that the Risk Summit Chair identified a further
action for the CCG to engage with Social Services in ensuring a coordinated approach to health and social care.
Discussion also took place with regards the Urgent Care Board’s role in reducing admissions and the timescales in the action plan need to reflect that change has to
happen now to enable it to embed as winter pressures will soon affect the Trust.
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3. Clinical and operational effectiveness
The Trust needs to understand its patient flow better to be able to deal with additional pressures, for example, during surges in activity due to additional winter
pressures. The review team noted a relatively short length of stay (which is positive) but also high levels of re-admission for some specialties and a high incidence of
patients re-admitted under the same HRG chapter (i.e. admitted for the same condition).
The review team was told by staff of clinical concerns that do not appear to have been addressed, including, known high mortality at the weekends and high levels of
patients not ventilated in the Critical Care Unit (CCU) at the time of the announced visit. Other quality issues noted by the review team were the lack of understanding by
staff of the ambition and trajectories for reduction levels of: pressure ulcers; falls, and ventilator acquired pneumonia. Additionally, the governance processes did not
support the identification to the Board of exceptional events, for example, the Trust’s Board Assurance Framework does not reflect all the strategic risks identified during
the RRR and in some cases risks were duplicated; and the increase in the level of still born babies (8 recorded in a single month, March 2013) was not reported to the
Board in a timely manner. Escalation processes need urgent review by the Trust.
The review team also expressed concern over the appropriateness of the location of two close observation beds (referred to as high dependency beds by some staff) in
the Delivery Care Centre in the maternity unit which were used for pre and post delivery pre-eclampsia. Monitoring of these patients can only be done at the side of the
bed and not from the nursing station which put pressure on the midwifery staff. The review team noted issues with toilet and wash facilities which were found to be
insufficient. Whilst some assurance was gained by the review team during the unannounced visit, concerns still remain over the use of these beds, including, the length
of stay of some patients which could be up to 5 days (a shorter length of stay would normally be expected) and the impact on the capacity of midwifery staff to respond
to periods of high demand.
Recommendation
a. The Trust needs to ensure that there is appropriate delegation of authority to the division, including that of professorial advice.
b. Develop an updated, single, cohesive quality strategy that takes account of external reports, mortality concerns, feedback from patients and staff, clinical audit
recommendations, current identified risks and current Trust performance. As part of this, agree quantifiable and measurable improvements. Linked to this, the Trust
needs:
 To urgently review the imbalance in demand and act upon findings, before the next set of winter pressures arrive. As part of this investigation the Trust should
benchmark the numbers of attendees against similar sized trusts and also benchmark the staffing profile of these. Additionally, the Trust should review the
scope available to relieve bed pressures at Blackburn by using beds in Burnley differently.
c. The Trust should review the criteria for patient placements, make explicit service improvement priorities and support the delivery of these addressing shortfalls in
nursing levels.
d. An independent review over the close observation beds in the Maternity Unit should be undertaken including a review of case notes of patients using the close
observation beds.
e. The Board should assure itself immediately that patients are clinically safe and receiving a dignified experience, particularly in escalation areas. Escalation
arrangements should be reviewed in association with ECIST support. The revised escalation arrangements must ensure that patients stay no longer than 18 hours
in an escalation area; the case mix of patients admitted is appropriate; and clear strategy model is in place to flex staff in support of additional capacity.
f. The Trust should review:
 Skill mix on rotas,
 Discharge planning; and
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3. Clinical and operational effectiveness

Provision of specialist services across both sites.
Trust response
The Trust agreed to take the following actions:
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Review why escalation to Board did not happen earlier (March still births have now been escalated to the Board).
Set thresholds for stillbirths and other serious incidents for immediate escalation to Board.
Consider an independent review of the Maternity Unit’s processes.
Commission a third party review on the use of the close observation beds.
Review divisional governance processes with thresholds, advice and escalation.
Update quality strategy and provide a clear focus on key quality improvements, including, seeking evidence for organisational ‘buy-in’, development of systems
to better understand workload pressures and review the use of beds in Burnley.
Review patient placement criteria, regularly evaluate the adherence to these criteria and ensure that any remedial action is timely.
As a Board review arrangements for safety and dignity with a focus on the use of escalation.
In association with ECIST review and amend escalation processes to ensure that they are focussed on the patients experience and that risk is managed
appropriately.
Develop a process to routinely benchmark skill mix and understand impact of vacancies.
Review with health economy partners the effectiveness of discharge planning.
Review the provision of specialist support services across sites.
A further discussion took place over the need to open up alternative sources of patient access to relieve pressures on A&E and wider economy health working to include
GPs is required. The CCG committed to working with the Trust on this agenda. The CCG also stated clear targets need to be set for premature discharges so the
Trust’s performance can be monitored. The CQC stated it had already sought assurance from the Trust about A&E patient flow and staffing on the maternity unit and
they are in the process of considering the Trust’s response. A discussion also took place over the Trust’s review of mortality data and the need to ensure the basics are
covered off.
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4. Patient experience
The review team considered the Trust’s complaints process to be poor and lacking a compassionate approach. The complaints response times and the outcomes with
respect to organisational learning or changes to practices were lacking across the Trust. People are not offered face to face meetings with there being a preference for
communication to be through formal written responses. Common complaint issues relate to; premature discharge; continuity of care; poor communication of information
relating to care; poor provision of basic care adequate nutrition, hydration, provision of hygiene following incontinence. These issues seem to be exacerbated through
the high use of bank and agency staff. The review team also witnessed an insensitive conversation taking place regarding end of life care on the ward rather than in an
appropriate area.
The review team used some of the anonymised stories from the public listening events to endorse the evidence in the RRR report that patients and their carers/family
members were not always treated appropriately when queries or concerns were raised about patient care. There were numerous examples where carers/family
members were treated with a level of condescension by medical staff when they enquired about the received or planned treatment. For instance a number of carers
reported that where they expressed concerns regarding patients being moved to different ward areas or hospital sites, they were often overruled without sufficient
explanation of whether it was appropriate or not.
The Trust has experienced poor press for an extended period of time and the publicity for the RRR review eliciting an initial angry public reaction at these events. The
review team felt the Trust could benefit from a more proactive and transparent approach to local communications with the public, including improving the relationship
with the local media.
Recommendation
a. A comprehensive public engagement strategy should be developed that clearly identifies how the board will engage with the public, so that public expectations
regarding communication and the required duty of candour and standards are met. The Trust should identify an Executive lead to address issues with
communication to patients.
b. The Trust needs to engage with the health economy in response to pressures within the Urgent and Emergency care pathway. Acute care pressures need to be
addressed through a whole economy response to ensure that effective health and social care needs of the local population are provided.
c. Provide real time complaints monitoring and introduce a system whereby the Board can provide itself with assurance about actions being taken to address deficits;
introduce a lessons learned forum and appoint a Board lead to report on this on a monthly basis.
d. Patient safety walkabouts need to target wards that are raised in patient complaints and be unannounced.
e. There were a number of specific complaints raised to the review panel during public listening events. These have been shared with the Trust and action taken
needs to be shared via the CCG.
f. The Trust should establish formal routes for sharing lessons learned from patient feedback throughout the Trust.
g. The Trust should review the internal incidents management function and processes. In particular, consideration should be given to the lessons emanating from the
Francis enquiry.
h. The Board should assure itself that there are no outstanding lessons learnt from actions that require implementation.
i. There needs to be a paradigm shift in the behaviour of those charged with this process from one of almost grudgingly administrating the process to one that
recognises the need for empathy and compassion.
j. The Trust should establish formal routes for sharing lessons learned with all stakeholders internal and external.
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4. Patient experience
Trust response
The Trust agreed to:
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Review arrangements for public engagement with an identified Executive lead to deal with patient communication.
Work with partners in the health economy to improve the associated pathways and bring forward a new delivery plan.
Assign a Board Lead to work with the newly appointed Complaints and Litigation manager to improve the visibility and learning arising from complaints
processes.
Increase the ratio of unannounced to announced visits by Board members particularly to high risk areas.
Share the actions arising from the complaints raised with the panel at the listening events with lead CCGs.
Review communications processes to enhance the learning culture.
Review its function in light of the lessons learned from the Francis enquiry.
Seek external assistance to ensure that there are no gaps in assurance.
Seek to gain a better assurance of the embedding of our values and reinstate a programme of learning and education around ‘customer care’
Develop a communications plan to promote a learning culture including:
 External - using the health economy’s Clinical Transformation Board to share learning.
 Internal - bringing together the Clinical Leaders Forum with the Nursing and Midwifery Forum on a quarterly basis to share learning (led by the Medical
Director and Chief Nurse).
The timing of the executive lead on patient communications was discussed and it was agreed that this needs bringing forward with immediate effect. The Trust agreed
to address this. The Trust sought support from the risk summit members in identifying an exemplar Trust so they can see what a good real time complaints system looks
like. Healthwatch were suggested as an appropriate source of support and the TDA are working with the Trust on this as well as improving public engagement. The TDA
stated that the process should include a review of how the board is assured that learning and sharing from incidents and good practice is maximised. Furthermore,
complaints management should be reviewed with a focus on empathy and support for the complainant identifying how the organisation can consistently learn and
improve services.
The CCG stated they are developing their own soft intelligence around patient stories and wish to work more closely with the Trust and GPs for collecting and learning
from patient stories and improving patient feedback. The Chair of East Lancashire CCG also expressed a wish to support the Trust on their Board unannounced visits.
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5. Workforce and safety
The review team considered that staffing levels were low for medical and nursing staff when compared to national standards. Particular issues regarding registrar cover
and medical staffing in the emergency department were identified by the review team. The review team also identified that within maternity, midwifery staff are operating
at a ratio of 1:31 (midwives to births) and not the national standard of 1:28. This is particularly evidenced in the ante-natal and post-natal staffing ward levels. Staff
reported that the level of Consultant cover and availability of allied health professions out of hours was a concern.
The review team consider the ward staffing levels in some cases to be insufficient to meet the basic needs of patients, in particular, staffing levels on medical wards
overnight. The observed impact on patients included delays for toileting, settling to bed and especially, delays in IV fluid or drug administration. Additionally, poor record
keeping on some wards for example incomplete fluid balance charts and care plans was also a concern.
Recommendation
a. The Board should assure itself that there are adequate numbers of staff available to provide safe care and a dignified patient experience.
b. The Trust needs to conduct a full staffing review, considering clinical outcomes and costs, in order to identify staffing recruitment priorities.
c. The Board needs to assure its self that staffing skill mix and levels does not present any immediate risk to patient care or staff welfare. The Board should consider
immediate interim support to complete this action.
d. Develop a workforce strategy to support the clinical strategy and as part of this undertake an evidence based nurse staffing review to ensure safe standards of care
and dignified patient experience is achieved.
e. Review the governance of mortality improvement to bring rigour and pace to a comprehensive and coherent programme of work such that mortality reviews are of
adequate depth to produce recommendations.
Trust response
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The Trust agreed to obtain better assurance on safety and dignity by increasing the targeted use of unannounced visits.
The trust will systematically review its workforce and embed this as part of an on-going planning process.
New starters in Medical Division since April 2013: 12 net additional registered nursing staff and 11 net non registered.
Job offers and starting shortly: 40 registered nursing staff and 7 non-registered nursing staff.
The Trust will roll out the medical staffing review that started with the Medical Division.
The Trust will develop an analysis of workforce through the use of products such as ‘eWin’ and the Workforce Assurance Tool.
The Trust will commission a third party review to gain assurance on ward staffing levels and the associated risks to care and dignity.
The Trust will align its workforce strategy to its clinical strategy. The Trust will continue to test its nursing acuity modelling to ensure staffing levels and mix are
appropriate.
The Board will provide direct oversight to the mortality review process.
The Deanery raised a concern over the skills and attitude of the consultant workforce and whether they have the capacity to take on the additional responsibility of
training doctors. It was agreed they would work with the Trust on this and it was suggested that a robust organisational development strategy should be developed to
address this and other workforce issues. The TDA stated they will work with the Trust in developing an OD plan and work closely with the whole health economy. In
addition, the TDA medical director and nurse director will provide support to the clinical leadership on values etc. In response to the number of new posts being created
it was recognised that real transformation needs to take place as there is no more money available in the system. The Trust recognised that money is not being spent in
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5. Workforce and safety
the right places i.e., high agency and locum costs and that it needs to be more effective and productive.
6. Nursing
The review team considered that the nursing workforce needs more leadership, direction and support to achieve acceptable standards of care. There were many
examples of poor nursing processes and inadequate documentation, including, compliance with the controlled drug policy and a less than meaningful approach to
intentional rounding. The review team were particularly concerned regarding the inability of front line staff to describe nursing goals regarding patient safety initiatives
relating to pressure ulcers or falls. Whilst there was an established system for measurement of patient safety elements the review team could not find evidence that
specific targets for improvement were established or understood.
Band 7 and above nurses expressed strong working relationships with each other, but junior staff reported issues that were not expressed at more senior level, for
example, the use of chairs in bays of wards for patients awaiting discharge so that extra patients could be admitted to the ward. This meant that there were additional
patients within clinical areas without extra resource to care for them. The junior staff expressed concern regarding the closure of the discharge lounge but this was not
highlighted by senior nurses.
Recommendation
a. The Chief Executive and Chairman should expedite the recruitment to the Director of Nursing position to enable effective leadership of the improvements required.
b. The Board needs to assure itself that staffing skill mix and levels does not present any immediate risk to patient care or staff welfare. The Board should consider
immediate interim support to complete this action.
c. The Board should closely track the implementation of these newly agreed staffing increases.
d. The skill mix of night staffing should be addressed.
Trust response
The Trust agreed to:
 Appoint to the post of Director of Governance and Chief Nurse.
 Seek advice from the TDA Chief Nurse on the appropriate support to undertake this review in the interim.
 Support the continued development and deployment of its nursing strategy.
 Provide a monthly report to the Board highlighting vacancies and active recruitment in line with Board approved establishments.
 Commission a third party assessment to review ward staffing levels and the associated risks to care and dignity.
 Immediately review skill mix and agency usage during the night.
The CCG commented that the chief nurse post is critical and the Trust needs to review its advertised person specification to ensure they appoint the right person to the
post who can provide the right level of support and leadership. The Risk Summit Chair asked attendees to consider what support can be provided to the Trust to attract
nursing staff with new insights and fresh ideas and it was further commented that recruitment should be based on values and not numbers. The Trust agreed to take this
forward for further consideration.
16
3. Risk Summit Action Plan
Introduction
The risk summit development of an outline plan focused on the urgent and high priority actions from the RRR report. No information in addition to the RRR report was
presented at the risk summit. The following section provides an overview of the issues discussed at the risk summit with the developed action plan containing the agreed
actions, owners, timescales and external support.
Action plan
Key Issue
Agreed action and support required
Owner
Timescale
Governance & Leadership
Commission an independent review
of the Quality Governance
Framework and the Board
Governance Assurance Framework
Seek a renewed third party assurance on both the Quality Governance Framework and the
Board Governance Assurance Framework
CIPs and risk assessment
Amend procedures to ensure that it is absolutely clear that divisional cost improvement
programmes with risk assessments are signed off by the Medical Director and Chief Nurse.
Trust
By end of July 2013
Evolve processes to understand the aggregated risk of CIPs
Trust
By end of September 2013
Ensure direct oversight of the Board of the delivery of mortality action plans
Trust
By end of July 2013
Increase the ratio of unannounced to announced visits by Board members
Trust & CCG
By end of July 2013
Highlight action plans and evidence of progress in all Mortality reports
Trust
By end of July 2013
Update mortality action plan based on AQUA’s report
Trust
By end of July 2013
Strengthen linkages of other quality improvement activities (e.g. 24/7, Ambulatory Care, Frail
elderly pathway) to mortality reduction strategy
Trust
By end of August 2013
Ensure Mortality Steering Group multi professional membership
Trust
Completed
Roll out weekly ward based meetings for mortality case discussion (have commenced in
certain areas)
Trust
By end of July 2013
Board mortality assurance
Trust
By end of November 2013
Be end of August 2013
Board to Board Programme
Trust with support
from NHSIQ
17
Key Issue
Agreed action and support required
Complete mortality case review format and implement
Owner
Trust
Timescale
By end of July 2013July
Local Capacity
Economy wide approach to reduce
emergency admissions
Review of care pathways and
readmission rates
Develop the Pennine Lancashire Unscheduled Care Group (established with 4 hour
performance management focus to date). Update Membership and focus to oversee pathway
reform, e.g. frail elderly pathway.
Trust/CCG/AT
Review of bed use (Point Prevalence study) undertaken by the Utilisation Management Team.
Trust
By end of July 2013
Completed
Redesign Emergency Care pathway to avoid delayed discharges
Trust & CCG
By end of October 2013
Introduce a fast track Continuing Health Care Needs process
Trust & CCG
By end of September 2013
Refresh the health Economy Urgent Care Strategy.
Implement the recent Capita proposal to map the existing capacity of alternatives to hospital
admission against the growing demand (should be fully adopted rather than phase 1 only –
needs agreement across the health economy).
Trust
Trust/CCG/AT
By end of October 2013
By end of September 2013
Use the Emergency Care Delivery Plan in place that facilitated 4 hour recovery in Q1. ECIST
to revisit ELHT on 7 August 2013.
Trust
By end of August 2013
Develop an action plan following the Re-admissions audit undertaken week commencing 17
June 2013, and monitor this plan through the Board.
Trust
By end of September 2013
Engage Social Services to coordinate whole health and social care approach
CCG
By end of August 2013
Trust
By end of July 2013
Trust
By end of July 2013
Trust & CQC
By end of July 2013
Clinical and Operational Effectiveness
Immediate investigation into failures
to escalate
Review why escalation to Board does not happen earlier.
Trigger guidance for SI reporting should be reviewed.
Independent review of the Maternity
Unit’s processes
Follow up action in assurance provided to CQC, which is currently under consideration, to be
determined.
Close observation beds review
Commission a third party review on the use of close observation beds.
Trust
By end of August 2013
18
Key Issue
Agreed action and support required
Owner
Timescale
Review delegation
Review divisional governance processes with thresholds, advice and escalation.
Trust
By end of August 2013
Update the Quality Strategy
Update quality strategy and provide a clear focus on key quality improvements:
•
evidence will be sought for organisational ‘buy-in’;
•
develop systems to better understand workload pressures; and
•
review the use of beds in Burnley.
Trust
All by end of September 2013
except for workload pressures
which is by end of December
2013
Review patient placement criteria
Review criteria, regularly evaluate the adherence to these criteria and ensure that any
remedial action is timely
Trust
By end of August 2013
Safe and dignified care
As a Board review arrangements for safety and dignity with a focus on the use of escalation.
Trust
By end of August 2013
In association with ECIST, review and amend our escalation processes to ensure that they
are focussed on the patients experience and that risk is managed appropriately
Trust
By end of August 2013
Skill mix review, discharges and
service access
Develop a process to routinely benchmark skill mix and understand impact of vacancies.
Review with health economy partners the effectiveness of discharge planning.
Review the provision of specialist support services across sites.
Trust with support By end of September 2013
from Healthwatch
Trust/CCG/AT
By end of September 2013
Trust
By end of September 2013
Trust/CCG
By end of September 2013
Patient Experience
Public engagement
Review arrangements for public engagement.
Nominate an identified Executive lead to deal with patient communication
Trust
Trust/CCG/AT
By end of July 2013
Urgent care and emergency care
pathway
Work with partners in the health economy to improve the associated pathways and bring
forward a new delivery plan.
By end of September 2013
Real time complaints monitoring
Assign a Board Lead to work with the newly appointed Complaints and Litigation manager to
improve the visibility and learning arising from complaints processes.
Trust
By end of July 2013
Patient safety walkabouts
Increase the ratio of unannounced to announced visits by Board members particularly to high
risk areas.
Trust/CCG
By end of July 2013
Complaints action
Share the actions arising from the complaints raised with the panel at the listening events with
lead CCGs.
Trust/CCGs
By end of August 2013
19
Key Issue
Agreed action and support required
Owner
Timescale
Communicating lessons
learned/patients feedback
Review communications processes to enhance learning culture.
Trust
By end of August 2013
Incident management function
Review function in light of the lessons learned from the Francis enquiry and seek external
assistance to ensure that there are no gaps in assurance.
Trust
By end of August 2013
Empathy and compassion
Seek to gain a better assurance of the embedding of our values and reinstate a programme of
learning and education around ‘customer care’
Sharing lessons learned
Develop a communications plan to promote a learning culture including:
•
External - using the health economy’s Clinical Transformation Board to share learning.
•
Internal - bringing together the Clinical Leaders Forum with the Nursing and Midwifery
Forum on a quarterly basis to share learning (led by the Medical Director and Chief
Nurse).
Trust with support By end of August 2013
from TDA
Trust
By end of August 2013
Workforce and safety
Safe and dignified care
Obtain better assurance on safety and dignity by increasing the targeted use of unannounced
visits.
Staff and skill mix review
Systematically review our workforce and embed this as part of our on-going planning
processes:
•
New starters in Medical Division since April 2013: 12 net additional registered nursing
staff and 11 net non registered.
•
Job offers and starting shortly: 40 registered nursing staff and 7 non-registered nursing
staff.
•
Roll out the medical staffing review that started with the Medical Division.
•
Develop analysis of workforce through the use of products such as ‘eWin’ and the
Workforce Assurance Tool.
•
Commission a third party review to gain assurance on ward staffing levels and the
associated risks to care and dignity.
Trust
Review workforce strategy to ensure that it is aligned to our clinical strategy and continue to
test nursing acuity modelling to ensure that our staffing levels and mix are appropriate.
Trust
Workforce strategy
Develop organisational development strategy.
Governance of mortality
The Board will provide direct oversight to the mortality review process.
Trust/CCGs
By end of July 2013
By end of October 2013
By end of September 2013
By end of September 2013
By end of September 2013
By end of October 2013
Trust/TDA/Deanery By end of September 2013
/LETB with support
from TDA
Trust with support By end of July 2013
20
Key Issue
Agreed action and support required
Owner
Timescale
from TDA
Nursing
Recruitment to Chief Nurse position
Appoint to post of Director of Governance and Chief Nurse (revisiting person specification to
reflect values)
Trust/TDA
By end of August 2013
Review staffing and skill mix to
assure Board that there are no
immediate risks to patients or staff
Seek advice from the TDA Chief Nurse on the appropriate support to undertake this review in
the interim.
Trust/TDA
Report to July 2013 Trust
Board
Implement the nursing strategy
Support the continued development and deployment of our nursing strategy.
Trust
By end of August 2013
Gain assurance on staffing
recruitment
Provide a monthly report to the Board highlighting vacancies and active recruitment in line
with Board approved establishments.
Trust
From August 2013
Commission a third party assessment to review ward staffing levels and the associated risks
to care and dignity.
Trust
By end of September 2013
Immediately review skill mix and agency usage over night
Trust
By end of July 2013
Review skill mix of night staffing
21
Appendices
22
Appendix I: Risk Summit Attendees
Risk summit role
NHS England, Regional Director (North) and Risk Summit Chair
NHS England, Chief Nurse (North) and RRR Panel Chair
NHS England, Medical Director (North)
Name
Richard Barker
Gill Harris
Mike Bewick
NHS England, Deputy Director of Quality Assurance (North) and RRR Panel Member Regional Senior Support
Teresa Fenech
NHS England, Regional Director of Operations and Delivery (North) and RRR Panel Regional Senior Support
Jon Develing
RRR Panel Member and Lay Assessor
Trevor Fernandes
RRR Panel Member and Senior Nurse
Joanne Todd
RRR Panel Member and Junior Nurse
Lucy Giles
RRR Panel Member and Consultant
Alan Paul
East Lancashire NHS Trust, Chief Executive
Mark Brearley
East Lancashire NHS Trust, Medical Director
Catherine Scram
Area Team Director
CQC, Head of Regional Compliance – North West
CQC, Compliance Manager
CQC, Regional Director – North
Richard Jones
Ann Ford
Dawn Hodgkins
Malcolm Bower-Brown
CQC Compliance Manager and RRR Panel Member
Robert Taylor
TDA
Iain McInnes
TDA
Maureen Choong
23
Risk summit role
TDA
Deanery/HEE
Name
Nicky O’Connor
Jacky Hayden
East Lancashire CCG
Divian Ruitenbeek
East Lancashire CCG
Michael Ions
East Lancashire CCG
Jackie Hanson
Blackburn with Darwen CCG
Joe Slater
Blackburn with Darwen CCG
Debbie Nixon
Blackburn with Darwen CCG
Ann Asher
PwC Independent Moderator
Mark Wood
PwC Recorder
Catherine Leith
PwC Programme Manager
Rob Halewood
24