Report for The Dudley Group NHS Foundation 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
6
3.
Key Lines of Enquiry
10
4.
Review findings
10
5.
Governance and leadership
13
Clinical and operational effectiveness
19
Patient experience
25
Workforce and safety
31
Pressure ulcers
38
Conclusions and support required
Appendices
43
45
Appendix I:
SHMI and HSMR definitions
46
Appendix II:
Panel Composition
48
Appendix III:
Interviews held on announced visit
50
Appendix IV: Observations undertaken
51
Appendix V:
52
Focus groups held
Appendix VI: Information available to the RRR panel
53
Appendix VII: Unannounced site visit
57
1. Introduction
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 period April 2010 to March 2012 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 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 also considered independent feedback from stakeholders, related to the Trust, which had been 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 made 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.
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:


Determine whether there are any sustained failings in the quality of care and treatment being provided to patients at these Trusts.
Identify:
i.
Whether existing action by these Trusts to improve quality is adequate and whether any additional steps should be taken.
ii.
Any additional external support that should be made available to these Trusts to help them improve.
iii.
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 (KLOEs). The data pack for each trust reviewed is published at http://www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/trust-datapacks/data-pack-dudley.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, interviewing patients, trainees, staff and members of the Board. The report from this stage will be
considered at the risk summit.

Stage 3 – Risk summit
This will bring together a separate group of experts from across health organisations, including the regulatory bodies. They will consider 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. A report following each risk summit will be made publically available.
Methods of investigation
The two day announced RRR visit took place at the Trust’s main site Russells Hall Hospital on Tuesday 7 and Wednesday 8 May 2013. A variety of review methods were
used to investigate the KLOEs and enabled the panel to consider evidence from multiple sources in making their judgements.
The visit included the following methods of investigation:

Interviews
Seventeen interviews took place with members of the Board and selective members of staff based on the key lines of enquiry during the visits. See Appendix III for details of
the interviews undertaken.

Observations
Ward observations 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 placed during visiting hours. They allowed the panel to speak with a range of staff and observe the quality of care and treatment being provided to patients.
The panel was able to observe the action by the Trust to improve quality in practice and consider whether any additional steps should be taken.
Observations took place in twelve areas of Russells Hall Hospital. See Appendix IV for details of the observations undertaken.

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 with nine staff groups during the announced site visit. See Appendix IV for details of the focus groups held.
The panel would like to thank all those who attended the focus groups who were open and balanced with the sharing of their experiences and their perceptions of the quality
of care and treatment at the Trust.

Listening events
Public listening events give the public an opportunity to share their personal experiences with the hospital, and to voice their opinion on what they feel works well or needs
improving at the Trust in relation to the quality of patient care and treatment. A listening event for the public and patients was held on the evening of 7 May 2013 at Russells
Hall Hospital. This was an open event, publicised locally, and attended by about 70 members of the public and patients.
A listening event was also held for the Trust’s governors attended by about 12 members of the Trust’s Council of Governors.
The panel would like to thank all those attending the listening event who were open in 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 provided to the panellists through a copy being available in the panel’s ‘base location’ at the Trust during the site visit. Whilst the documents
were not reviewed in detail, they were available to the panellists to validate findings as considered appropriate by the panellists. See Appendix VI for details of the documents
available to the panel.

Unannounced visit
The unannounced out-of-hours visit took place at Russells Hall Hospital on the evening of Tuesday 14 May 2013, and a further unannounced working hours visit took place
on Wednesday 15 May 2013. This focused observations in areas identified from the announced site visit, see Appendix VII.
Next steps
This report has been produced by Dr Ruth May, 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 The Dudley Group NHS Foundation 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.
2. Background to the Trust
This section of the report provides relevant background information for the Trust and highlights the areas identified from the data pack for further investigation.
Context
The Dudley Group NHS Foundation Trust (“the Trust”) serves more than 450,000 people in Dudley and the surrounding areas. The Trust has three hospital sites, including
Russells Hall in Dudley (for inpatients), and Corbett and Guest Outpatient Centres. The Trust was the first in the area to receive Foundation Trust status, in 2008. The Trust’s
services focus on long-term conditions, acute care needs, rehabilitation and end-of-life care. It acquired adult community services in 2011 which are largely delivered in the
local community outreach to patients’ homes or through the two outpatient centres.
Dudley is not a particularly deprived region within England although the Trust’s catchment does include some of the most deprived wards in England in north Dudley and
Sandwell. It has a sizeable proportion of ethnic minorities, particularly from South Asia. Those aged 60 and above constitute a relatively larger proportion of the population in
Dudley compared to their proportion of the population nationally and the population is older than the national average. Obesity is more common in the region than in England
as a whole, and breastfeeding is relatively less common than in England as a whole.
Dudley’s health profile outlines that there are a number of aspects for which children’s & young people’s and adult’s health is significantly lower (worse) than the national
average. It also shows that life expectancy in Dudley is below the national average.
The Trust is considered medium sized for both inpatient and outpatient activity and is the third largest from the 14 trusts chosen for this review. General Medicine and
Paediatrics are the largest inpatient specialties while Clinical Haematology and Nursing Episodes are the largest specialties for Outpatients.
The Trust has 68% market share of inpatient activity within a 5 mile radius of the Trust sites. However, this share falls to 15% within a radius of 10 miles and 4% within a
radius of 20 miles. The main competitors in the local area are Sandwell and West Birmingham Hospitals NHS Trust, The Royal Wolverhampton Hospitals NHS Trust,
University Hospitals Birmingham NHS Foundation Trust, and Worcestershire Acute Hospitals NHS Trust. The Trust’s market share is also affected by the proximity in
Birmingham of specialist hospitals for children, women and orthopaedics.
Key messages from the Trust data pack
Mortality indicators
The Trust has been selected for this review as a result of its HSMR being above the expected level over the period April 2010 to March 2012. Currently the Trust is reporting
an HSMR of 98 and is within the expected range for the latest data (January 2012 to December 2012).
The Trust has an overall SHMI of 106.5 for the period December 2011 to November 2012 meaning that the number of actual deaths is higher than the expected level. Deeper
analysis of this demonstrates that non-elective admissions are the primary contributing factor to this figure, with a SHMI of 110, compared to a level of 105 for elective
admissions.
The specialities with the highest excess deaths contributing to the SHMI and HSMR indicators in the period under review were general medicine, which includes
cancer, and geriatric medicine (elderly care). These specialities were therefore identified as a focus for the key line of enquiry on mortality and the RRR visit
included observations of the general medical and elderly care wards and interviews with patients and staff in these areas.
Governance and leadership
The Trust’s Board of Directors has seven sub-committees with a Clinical Quality, Safety and Patient Experience Committee (CQSPE) to oversee quality governance
arrangements. The CQSPE has a number of sub-groups covering a wide range of quality and safety matters.
The governance risk rating for this foundation trust was amended from GREEN to AMBER-RED in May 2013 due the trust's breach of the 62 day Cancer (Urgent GP referral
target) and A&E maximum 4 hour waiting time target in Quarter 4 2012/13, although recent Care Quality Commission (CQC) inspections which tested all governance
standards did not raise any concerns.
The Trust has a relatively stable Board of Directors over the last three years but has made amendments to the Director portfolios from April 2013 to introduce a new Director
of Strategy and Transformation.
A high level review of the effectiveness of the Trust’s quality governance arrangements were a standard key line of enquiry for the review.
Clinical and operating effectiveness
In 2012, the Trust’s accident and emergency department (A&E) assessed and then treated, admitted or discharged as appropriate 96.3% of its patients within 4 hours, which
is above the 95% national standard level. This is above national averages but the Trust’s performance on this target has fallen slightly over the past 12 months.
The Trust’s referral to treatment within 18 weeks for admitted patients was higher than the national standard level and above the national average achieved by all trusts.
The readmission rate may indicate the appropriateness of treatment offered, whilst average length of stay suggests the efficiency of the treatment, with low rates being
positive indicators. The Trust’s crude readmission rate is 10.8% of patients which is relatively low and it is in the second quartile of national trusts. The Trust also has a
comparatively low standardised readmission rate and a shorter length of stay than the national mean average, with 3.8 days.
In 2011/12 the Trust was eligible for 42 out of the 56 national clinical audits and contributed data to all mandatory audits. The Trust chose not to submit data for the Risk
factors (National Health promotions in Hospitals Audit) and Care of dying in hospital (NCDAH) audits. It was noted that the acute stroke audit (SINAP) was delayed nationally
and the Trust has now submitted data, however due to the timing of this, it was not possible to incorporate the findings in this review.
The data in this area did not highlight any specific key lines of enquiry.
Patient experience
Of the 9 measures reviewed within Patient Experience and Complaints the Trust scored higher than national average on:

The friends and family test
However, the Trust was rated “red” for 4 of the 9 measures as they scored below the national average on:

Inpatient Survey Score undertaken in 2012 (published in 2013) – lower scoring areas included including time for getting onto a ward, getting clear answers from doctors,
involvement in decisions, delays at discharge and quality of food.

Cancer Survey - deciding best treatment and feedback on ward nurses were noted as areas of concern

Patient Voice Comments via CQC - of 170 individual comments from patients and public in the two years to 31 January 2013, 92 were negative (54%). Key themes
centred on communication, information provision and staff attitude, with some comment on waiting times in A&E and poor discharge arrangements.

High percentage of complaints about clinical aspects of care – of 375 written complaints received by the Trust in 2011/12, 63% of complaints related to clinical treatment
(compared to the national average of 47%). Of 373 complaints received by the Trust in 2012/13, 79% related to clinical treatment.
It is B-rated by the Ombudsman for compliance with their recommendations. The Trust has a high conversion rate of complaints going from the Trust process to the Health
Service Ombudsman (15.5%). Although the Trust has highlighted that only one complaint was upheld by the Ombudsman in the period under review, there were a number of
others which the Trust was asked to undertake further work on. 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.
Keogh review patient voice comments
The patient voice comments received directly to the Keogh review website (at the time of writing this report) identified the following themes from 16 emails and letters:
Positive
Negative
Excellent care received from nurses and doctors
A&E waiting times
Urgent action and emergency surgery saved life of patient and excellent care at ICU.
Lack of communication from staff
Hard working staff
Shorter bed stays for patients being rushed through the system
Departments are very informative
Complaints not adequately responded to and not able to meet the Chief Executive
Patient care and treatment complaints
Pharmacy and prescribing issues
Lack of nursing care and compassion.
Key lines of enquiry 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 has a “Harm” status in all four of the NHS safety thermometer measures, and is “red rated” in a total of six of the safety indicators in the data pack including
“Serious Harm” incidents and “Harm” indicators. The number of patients with pressure ulcers and the C-Difficile infection rates are both higher than the national average.
In the period April 2012 to March 2013, the Trust had a higher percentage of patients with pressure ulcers than the national average. Its rate of patients with new pressure
ulcers following admission has been reducing since April 2012 but there were three months when its rates were above the national average.
Specific key lines of enquiry were designed for the Trust to address incident reporting, infection control and pressure ulcer management concerns.
A review of the workforce data flagged seven ‘red rated’ indicators. Most notably, it had a lower than national average nurse staffing levels per patient episode and lower than
average registered nursing ratios. It also had a much higher than average level of expenditure on agency staffing in 2011/12.
The staff response rate to the staff survey rate has fallen noticeably in 2012 compared to 2011 and is now clearly below the national average for response rates. The Trust’s
staff engagement is at the same level as the national average.
Key lines of enquiry were included in the review focusing on workforce measures and what staff say about the quality of care and treatment.
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
3. Key Lines of Enquiry
The Key Lines of Enquiry (KLOEs) were drafted using the following key inputs:

The Trust data pack produced at Stage 1 and made publically available.

Insights from the Trust’s lead Clinical Commissioning Group (CCG), Dudley CCG.

Review of the patient voice feedback received specific to the Trust prior to the site visit.
These were agreed by the panellists at the panel briefing session prior to the RRR site visit. The KLOEs identified for the Trust were the following:
Theme
Key Line of Enquiry
Governance and leadership
1. Can the Trust clearly articulate its governance processes for assuring the quality of treatment and patient care? Can
staff at all levels of the organisation describe the key elements of the quality governance processes, i.e. policies and
procedures, escalation processes, incident reporting, risk management?
Clinical and operational effectiveness
2. What actions is the Trust taking to improve mortality performance, particularly in general medicine, elderly care and
stroke wards? How does the Trust manage deteriorating patients?
3. How is the Trust addressing its infection control standards, particularly Clostridium Difficile?
Patient experience
4. How does the Trust seek views from patients about their experience? What are the key themes from patients on their
experiences? What action is the Trust taking to address the key themes emerging?
Workforce and safety
5. How engaged are staff in the Trust’s quality strategy? What do staff groups interviewed (including trainee groups) say
are the main barriers in the Trust to delivering high quality treatment and care for patients?
6. How does the Trust support its staff with adequate training, including safeguarding and other mandatory training?
Trust specific – palliative care coding
7. How is the Trust continuing to take action on its depth and accuracy of coding, particularly in palliative care?
Trust specific – CIPs quality impact
assessments
8. What is the Trust’s process to assess the impact of cost savings plans on quality of patient care and its workforce?
Trust specific – Pressure ulcers
9. What actions is the Trust taking to reduce avoidable pressure ulcers?
Trust specific – Nurse staffing
10. How does the Trust approach workforce planning to ensure that patient care and safety is managed effectively
including nurse staffing levels? How is clinical cover managed out of hours particularly on the emergency pathway?
4. Review findings
Introduction
The following section provides a detailed analysis of the panel’s findings, including good practice noted, outstanding concerns and prioritisation of actions required.
Summary of findings
The high priority areas identified for action in each of the key lines of enquiry themes are as follows:
Leadership and governance:

Review of quality governance – the Trust should review its governance structure to reduce the complexity of arrangements and improve the information flows. This
should enable greater challenge from the Board and its sub-committees on all quality priorities. The governance structure should be communicated to staff to enable
them to understand and deliver their roles effectively. This was particularly noted as an issue for clinical leadership in the Trust, as the Clinical Directors need to all
understand their important role.

Embedding a learning culture – the Trust has significant amounts of information from complaints, incident reporting and ward level data on performance but does not
appear to systematically review themes from this information and disseminate learning across the organisation.
Clinical and operational effectiveness:

Understanding of mortality - the Trust has taken steps to improve its coding in 2011 and 2012 which has in turn improved its mortality indicators recently and put it in a
better position to identify opportunities to improve patient care and treatment in specialties or care pathways. It was not clear to the panel that the Trust has fully
understood its mortality data and how it uses this to undertake systematic reviews of improvements that may be required in the organisation.

Bed management and patient flow – the Trust’s system for bed management, patient flows and discharge need to be urgently reviewed and improved to address
operational effectiveness issues and improve patient experience.
Patient experience:

Embedding a patient experience strategy – the Board should urgently review its approach to patient experience to ensure it has a clear strategy, is consistently
monitoring key metrics and identifying actions to improve this area.

Responding to complaints – the Trust needs to review its approach to responding to complaints to ensure it is compliant with requirements and really responds to
complainants effectively.
Workforce and safety:

Staffing and skill mix – the Trust should review its current staffing levels for nursing and medical staff and action any changes required for improving quality and safety
of care. There is an urgent action for the Trust to make sure that the registered nursing ratio is assessed using an evidence base methodology. This should be
undertaken in conjunction with clinical teams to review appropriate nurse staffing on all wards, especially in higher risk wards which also have higher rates of incidents
and complaints (such the 72 and 48 bedded general medical and elderly care wards).

Safety checks – the Trust should review its processes to ensure all equipment and safety checks are undertaken appropriately, given a number of examples of
incomplete checklists.

Staff engagement – the Trust should address its low response rates to the national staff survey and consider more innovative ways of listening to staff views. The Trust
should also review whether the issues noted in reviews of theatres have been adequately addressed by the actions taken.
Pressure ulcers:

Consistency of staffing using care bundles – the Trust needs to continue to promote and audit the consistent use of its pressure ulcer prevention and care bundles.

Equipment availability – the Trust should take action where staff do not have access to the right equipment to deliver effective pressure ulcer care to patients.
Governance and leadership
Overview
The panel’s governance and leadership focus was on the Trust’s governance processes for assuring the quality of treatment and patient care, as well as how well embedded
this was throughout the organisation.
Through staff interviews, focus groups and review of governance documentation, the panel tested whether staff at all levels could describe the key elements of the quality
governance processes, i.e. policies and procedures, escalation, incident reporting, risk management. The panel also reviewed the Trust’s process to assess the impact of
cost savings plans on quality of patient care and its workforce.
Summary of findings
The following good practices were identified:

The Board members interviewed, including non-executive directors, could clearly articulate the Trust’s quality priorities and governance processes. The Trust’s quality
priorities are: infection control, pressure ulcers, nutrition, hydration and patient experience.

Many staff reflected the strong leadership of the Board on quality, led by the Chief Executive.

A good working relationship was noted between the Director of Nursing and Medical Director which sets the tone for the positive clinical working relationship in the Trust.

The governors appeared very engaged and supportive of what the Trust Board was doing.
The following areas of concern were identified:

Board papers and interviews with Board members identified that the Trust’s clinical governance structure is complex and not all senior staff could clearly demonstrate
sufficient understanding of it.

The Trust had recognised that there was not sufficient time available to focus on patient experience and workforce the Board’s quality sub-committee. It has planned to
restructure quality into two separate board sub committees but was awaiting the outcomes of the review before addressing this.

Staff understanding of the quality priorities was largely embedded, but not universal.

The Trust could not demonstrate how it disseminates the learning it gathers through incident reporting, root cause analysis (RCAs) and other information such as mortality
reviews

Whilst it is recognised the Council of Governors has a secondary governance function, the governors should consider how they can work with the non-executive directors
to support them more proactively in the Board’s quality assurance processes and thereby maximise the opportunity for independent scrutiny on this important area.

Quality impact assessments of cost improvement plans (CIPs) did not appear to be consistently undertaken by the Trust on all CIPs and the process was not fully
understood by all the clinical leaders that were interviewed. Further, the Board needs to review how the Executive team are monitoring the ongoing impact once CIPs
have been implemented to ensure there is an ongoing assurance process.
For all the above areas of concern, we identified a number of improvements already planned or underway at the Trust.
Detailed Findings
Good practice identified
The Board of Directors, including non-executive directors, could describe the Trust’s quality priorities and articulate how the high level governance processes
supported the organisation to identify risks to achieving these. The recent Board papers reviewed validated this focus and that risks affecting were a top priority
on the agendas. The Trust’s quality priorities are: infection control, pressure ulcers, nutrition, hydration and patient experience.
There were a significant number of positive comments from staff interviewed about the leadership of the Trust, particularly in terms of improving quality, staff
engagement and patient experience. The panel also observed a good working relationship between the Medical Director and Director of Nursing in interviews,
particularly when focusing on the aspects of quality governance that required board level clinical leadership.
The governors listening event demonstrated a high level of engagement and support for the Trust’s leadership team.
The Director of Nursing could clearly articulate a robust process for clinical sign off of CIPs at Executive level. There is a Red-Amber-Green (RAG) rated system
for each of the plans to determine their impact on quality; Red rated plans are rejected, Amber rated get the agreement to go ahead with follow up at
performance management meetings.
Doctors who attended the focus group felt that there was a systematic approach to review CIPs and that they had not seen the quality of care impacted as a
result. Examples were provided which demonstrated potential CIP plans that had been rated as a 'red' impact on quality and therefore rejected, these included
a suggestion to stop wall washing which was rejected on an infection control basis.
However, it has been noted in the outstanding concerns section below that this systematic approach to providing quality assurance to CIPs is not always being
followed by the Trust.
Some directorates had put in place Preceptorship, an effective development programme for newly qualified clinicians. The clinical practice supervisor
programme in trauma and orthopaedics also appeared to be very effective.
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
i. Quality governance structure
The Trust has committed to
reviewing its quality
governance committee
urgently following the review.
The Trust should undertake a
comprehensive review of the effectiveness
of its governance structure. This should
review all committees and group agendas
and the information reviewed to ensure that
High
The committee and group structure of the Trust is complex which makes
it difficult to understand how they support the overall quality governance
framework. There are many groups and committees, with duplication
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
between some and apparent gaps in other areas which appear to have
less scrutiny. Directorate mortality reviews, which are explored further in
the clinical and operational effectiveness session, do not appear to be fed
into the overall governance structure.
The Trust has been working
with the HAY Group under the
NHS Leadership Academy for
six months to up-skill Clinical
Directors and senior
consultants to fulfil their roles
more effectively in relation to
leadership and governance.
This programme is nearing
completion.
all the Trust’s quality priorities have a clear
focus at the appropriate level. The
information flows within the Trust should be
reviewed to ensure that they are operating
effectively.
Management information presented to the Board does not appear to be
brought together to identify common themes and issues, for example a
focus on high risk services could be made by triangulating information on
mortality, falls, high agency staffing levels and complaints. The
information presented does not enable the Board to effectively challenge
on all aspects of quality.
The Board minutes and panel interviews demonstrated that the non
executive directors had challenged whether the agenda for the CQSPE
Board sub-committee had sufficient time for reviewing patient experience
and workforce measures.
Priority – urgent,
high or medium
The Board should consider how it reviews
management information provided to it to
demonstrate adequate challenge on the
progress being made on the Trust’s quality
priorities.
Following the HAY Group training the Trust
should ensure that all senior clinical staff are
aware of their responsibility for governance
in their directorate and are held accountable
for this. If this is still not embedded, further
training may be required.
The relationship and cross over between the patient safety group, red
incident group, risk and assurance committee and the CQSPE in
particular was quite difficult to follow in the documentation and committee
minutes provided by the Trust.
A number of senior staff interviewed could not articulate how the
governance processes were working in practice in the Trust and in their
own directorate, for example the escalation procedures and clinical
supervision policy. A number of the clinical directors could not describe
how their directorate governance processes operated in practice and how
issues fed into the overall Trust governance arrangements.
ii. Understanding of Trust’s quality objectives in the organisation
The Trust’s quality objectives in its strategy are:
 To become well known for the safety and quality of our services
through a systematic approach to service transformation, research
The Trust has communicated
its quality objectives and
priorities through the strategy,
its website and through staff
newsletters.
The Trust should ensure that its quality
priorities are embedded at ward level
through dissemination at regular ward and
directorate meetings.
High
Outstanding concerns based on evidence gathered

Key planned improvements
and innovation.
To provide the best possible patient experience.

Priority – urgent,
high or medium
The Trust should also consider how it uses
lessons learnt from the review of mortality
indicators to further inform its quality
priorities.
There are a number of principle outcomes, which are:



Recommended actions
To deliver effective clinical care to all patients.
To maintain and improve patient safety.
To ensure that the patient receives a good standard of care from
his/her perspective through excellent customer service every time to
everyone.
To work in partnership with commissioners and comply with agreed
quality standards.
When interviewing ward level staff, the panel noted inconsistencies in
both how the Board’s quality priorities were talked about and also actions
being taken within the Trust to improve patient care. For example, in a
number of the focus groups and observations, nurses and junior doctors
could not describe the main areas of quality focus in the Trust and could
not describe the procedures put in place to address these.
The Trust’s quality priorities do not include reference to reviewing
mortality indicators as part of understanding its overall performance on
quality of patient treatment and care.
iii. Quality impact assessment of CIPs
The Trust has a £15m CIP target for 13/14 and have currently identified
£12m of potential savings. However only £4m of these have been
approved as a 'green' rated plan. A number of schemes are staged to
start delivering in Q2 which mean any slippages in delivery are likely to
increase the financial risk.
The Trust has put in place a process to ensure clinical engagement in
reviewing the impact of cost improvement plans on quality and patient
The Medical Director and
Director of Nursing are
involved in all CIP sign offs.
All CIPs should be fully assessed for their
quality impact prior to implementation and
should be regularly reviewed. Where a
concern over quality is identified, this risk
should be properly mitigated before the plan
is allowed to go ahead / continue.
Executives and senior staff should be able
to clearly and consistently articulate the
impact assessment and monitoring process
High
Outstanding concerns based on evidence gathered
Key planned improvements
safety. A number of the clinical directors interviewed could describe this
process effectively but this was not consistent across all the clinical
leadership interviewed. The Trust could also not fully articulate the
monitoring arrangements to ensure the impact on quality was
continuously reviewed.
Recommended actions
Priority – urgent,
high or medium
within their area of responsibility.
The Trust has relatively large CIP schemes (>£1.2m) based on reduction
of beds. These schemes had not been fully quality assessed and given
the current bed pressures in the Trust this represents a significant risk to
quality.
The panel also noted examples of service developments being started
before any evidenced assessment of staffing needs or operational
arrangements to ensure quality. For example:

The PAU (Paediatrics Assessment Unit) was started in Nov 2012 but
it was not until Jan 2013 that a clear operational policy for the unit
was in place and assessment of staffing needs is yet to be
completed.

Opening of ward B4 as a contingency ward without a risk
assessment in support (noted from the minutes of patient safety
group April 2013)
iv. Role of governors in challenging the Board
The governors who attended the focus group appeared well briefed by
the Trust and noted a transparent relationship with the Board. They
could articulate their current focus on collating patient experience stories
and understanding of some of the Trust’s quality priorities, especially
pressure ulcers. However, the governors could not provide examples of
where they had challenged the Board and requested further information
and assurance, in particular on areas of quality and patient experience.
The governors also were not fully aware of the impact of the integrated
community services on the Trust’s operations and staff.
A review of the Council of
Governors’ effectiveness will
be undertaken this summer.
Governors should consider how they can be
more proactive in their role of holding the
Board to account on all aspects of quality.
High
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
v. Developing a learning culture
None noted
The Board should review its approach to
learning and ensure there is a clear focus in
the organisation on learning from incidents
and when things go wrong. It should
disseminate this approach through the
clinical and operational leadership and
ensure that regular audits are undertaken to
monitor progress.
High
The panel reviewed a number of the Trust’s responses to recent serious
incidents. While the process appeared to have been followed, the quality
of the analysis and the learning harnessed from these was not always
effectively evidenced.
The Trust did not demonstrate a systematic process for sharing
experiences and learning across different teams through the reporting
and monitoring it conducts. Many staff interviewed could not describe
how they reviewed wider information on serious incidents, root cause
analysis and complaints and built this learning into their directorate or
ward level processes. There did not appear to be a consistent
governance model embedded in the Trust at ward and directorate level to
enable learning. For example, ward level meetings did not appear to take
place regularly in all areas of the Trust that he panel visited and staff
could not articulate the management information they received to review
incidents and complaints.
This is discussed in specific sections on clinical and operational
effectiveness and patient experience later in the report, but is included
here as an over-arching area requiring improvement by the Board.
Clinical and operational effectiveness
Overview
The panel explored two KLOEs for clinical and operational effectiveness, focused on the following areas:

Actions the Trust has taken to improve mortality performance, particularly in general medicine, elderly care and stroke wards, including managing deteriorating patients
appropriately.

Action the Trust has taken to improve the depth and accuracy of coding, particularly in palliative care, and what impact this has had on mortality indicators.

How the Trust addresses infection control standards, particularly Clostridium Difficile, where it had notably higher than average incident rates.
Summary of findings
The following good practices were identified:

The Trust reviews the majority of deaths in hospital in detail. The Board and the Clinical Quality, Safety and Patient Experience Committee has reviewed mortality
indicators recently and demonstrated an improvement trajectory since 2009. It currently has a HMSR of 98 which is within expected range.

Action has been taken by the Trust to improve the quality and depth of coding so mortality reporting is more accurate. It has, in particular, made a marked improvement
in palliative care coding.

The Trust is on an improvement trajectory with infection control as it has clearly been a focus for the Board for several years. The panel observed infection control
procedures being followed in the majority of wards visited and some notable good practice, including nurses changing uniforms on site appropriately.
The following areas of concern were identified:

The panel considered that the Trust demonstrated limited analysis of mortality data in terms of understanding the improvements that might be needed in a speciality or
care pathway. The panel noted a tendency to explain above expected mortality indicators as a function of depth of coding or underlying health of Dudley’s population,
rather than analysis of what areas of care and treatment could be further improved. Whilst these are noted as important elements of understanding the mortality data,
there is a need to demonstrate that the Trust is more proactively looking for areas where it can improve care and treatment. The Trust has already demonstrated it can
do this in some defined areas, such as heart failure, but needs to make sure this is more systematically undertaken on all services it provides.

There was no clear evidence that lessons learnt from mortality reviews are disseminated effectively.

Examples of infection control concerns were noted in some areas, during panel observations, and there was a lack of awareness within some ward managers and
matrons of the audits taking place in the Trust to monitor compliance with procedures.

Bed flows and management were not always operating effectively, reflective of the higher than expected capacity that the Trust was currently dealing with.
For the majority of the above areas of concern, we identified a number of improvements already underway or planned at the Trust.
Detailed Findings
Good practice identified
It was clear that there was a focus on mortality at a high level in the organisation and there is a mortality review process in place which had been operating for a
number of years. It was noted that current mortality indices are not outside expected limits. There was evidence of two processes in place to review mortality:
 An audit of every death at Directorate level; and
 A monthly meeting focused on individual Directorates attended by the Chair, Medical Director and Chief Executive. The CCG has also sent representatives.
Information supplied indicated that the monthly mortality review meetings had taken place in 2013 and that the relevant directorates were provided with mortality
data to review in the meeting.
The Trust has demonstrated that its Clinical Coding team is competent and compliant with national standards. Improvement has been made in the last year on
coding palliative care cases.
The management of deteriorating patients at ward level was consistently described by the clinicians interviewed including junior doctors and nursing staff. The
Medical Emergency Team (MET) system appeared to be an effective process and staff confirmed that in their experience there was a prompt and appropriate
response to escalation.
During the visit, examples of good levels of cleanliness were observed everywhere, including Accident and Emergency (A&E), Emergency Assessment Unit
(EAU), Maternity and Ward A2.
The Trust has made significant improvements in its infection control rates and has invested in a team to focus on supporting wards on reducing cases further.
There were a number of areas of good practice noted in infection control procedures including the panel observed all nursing staff on one of the Trust’s largest
wards changing into their uniforms on site.
There has been an increase in palliative care referral pathways and staffing allowing an increase in the number of non cancer patients benefiting from palliative
care input.
During the visit, examples of good practice were observed and staff and patients provided further examples, including:
 The diabetes outreach team and the community services were noted as having innovative staffing models and effective clinical teamwork between doctors
and nurses.
 There were effective clinical links noted between the community and hospital teams, in particular improving the palliative care services.
 A&E also had a number of good operational practices:
o The “Impact team” which included physiotherapists, social workers and occupational therapists to help prepare patients for discharge.
o New Hub – provided excellent information and communication for the emergency team.
 Heart failure - a targeted review had identified improvements to be made and the Medical Director described a 40% reduction in cardiac arrests since the
introduction of the MET and that the care of the deteriorating patient had benefited from this and the outreach process.
Outstanding concerns based on evidence gathered
Key planned improvements
i. Understanding of mortality issues throughout the Trust
The Trust demonstrated that some
action had been taken from review of
the mortality data. This included audits
of heart failure and insulin support
which led to improvements in these
services within the Trust.
The Trust was authorised by Monitor in 2008 with a side letter requiring
action to be taken to address the higher than expected mortality indicators.
As noted in the data pack, it has been an outlier on SHMI and HSMR up to
March 2012, although the panel recognised the improvement trajectory
achieved on these indicators over this period demonstrated in the current
HSMR levels.
In interviews, most Board members and staff within the organisation stated
that the Trust’s high mortality indicators reflected the underlying poor
health of many of the population it serves and also the historical accuracy
of coding. This rationale for high mortality indicators was reiterated in a
recent presentation by the Medical Director to the Trust’s governors which
was made available to the panel. The panel considered that the Board had
not scrutinised mortality data in sufficient detail to fully justify this rationale
and this may have led to a lack of focus on systematic learning and
improvement of patient care and treatment.
The Board’s review of mortality was discussed with the CQSPE committee
Chair and the lead governor; both noted that the deeper analysis available
in the review data pack had not been reviewed before at the Trust. This
type of analysis should be considered by the Trust to prioritise systematic
reviews of specialties or care pathways with higher mortality indicators, i.e.
general medicine, cancer and geriatric medicine. It was noted that the
Trust does undertake deeper analysis of SHMI mortality data at a
diagnostic grouping level rather than at Specialty level first. The Trust
should consider whether this level of analysis is appropriate and whether
analysis at specialty level would provide further insight to improving care
pathways.
Although not directly prompted by mortality reviews, external reviews have
Recommended actions
The Trust should review how it can
introduce more rigour and challenge
into the overall mortality review
process. This should include
developing a clearer understanding
of the root causes of mortality data
at both Board level and within
The panel met the diabetes team which Directorates and prioritised action
was created following the review of
plans to drive improvements in care
insulin care for patients. Their aim was pathways.
to focus on improving care across the
Trust. It was noted that the team
reviewed all deaths of patients with
diabetes, even if not the primary cause.
The clinical lead could clearly articulate
lessons learnt and disseminated in
improve practice from these reviews.
Priority –
urgent, high
or medium
High
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority –
urgent, high
or medium
been undertaken in renal and elderly care services which are specialities
with higher than expected mortality. The panel was not able to see how
the outcomes of these reviews had led to actions taken and dissemination
of learning.
ii. Mortality review process and dissemination of lessons learnt
Mortality data has been reviewed at Board meetings but the Trust’s
analysis of this does not appear to have had much challenge.
Departmental mortality reviews have taken place regularly since 2009 but
the lessons learnt from these have not been reviewed regularly at Board
meetings or shared systematically in the Trust.
The panel found they did not get a consistent explanation of the mortality
review process from the senior clinical leaders interviewed. In some cases
the Clinical Directors could not describe the reviews that took place in their
own directorates. There was general knowledge amongst staff that some
systems were in place but the panel found a lack of clarity about how these
allowed scrutiny of mortality in a way that was useful for learning and
improving practice at directorate level.
The Associate Medical Director with responsibility for this area considered
that there was work to do to ensure the review processes flagged up
concerns about a particular directorate, speciality or care pathway.
Nurses are also not routinely involved in reviewing why a patient has died,
or formulating lessons learnt, but do get asked to contribute to details of
care if required.
The Trust has developed a mortality
tracking process led by the Deputy
Medical Director. In 2012 the Trust
rolled out an automated database to
track mortality cases, downloading
directly from the patient administration
system.
The panel did observe some good
practices happening in relation to
mortality reviews, in particular trauma
and orthopaedics.
For example the Trust staff noted that
fractured neck of femur mortality
cases reduced since 2009. This was
achieved through team work by
nurses, clinicians and
physiotherapists and through having
on-site hip fracture practitioners.
The Trust has an opportunity to
High
build on the work already carried out
in this area. The current systems
could be better joined up to ensure
the benefits are being realised and
themes from reviews can be
summarised and shared more
effectively.
There is a need to engage clinical
teams more in the mortality review
process and emphasising clinical
director leadership of this issue.
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority –
urgent, high
or medium
iii Validation of mortality reviews by the Clinical Coding team
None noted
Consider having coding
representation in mortality review
meetings
Medium
Given the emphasis on Palliative
Care coding the Clinical Coding
team may wish to focus one of their
internal audits solely on this
Medium
The Director of Nursing stated that the
Trust has an infection control action
plan and a dedicated team to support
the wards in achieving reductions. The
Board reviews nursing care indicators
monthly, including infection rates.
Matrons attend each month to present
on the performance in their clinical
areas.
The Trust should review how it can
further embed the infection control
audit programme at ward level,
including the lessons learnt from the
overall board monitoring.
High
The Trust is working through the
recommendations of the Emergency
Care Intensive Support Team review
following their visit to the Trust in
November 12. This focuses on bed
management and patient flows. The
Trust has a business case for
implementation of electronic white
boards on each ward and enhancing its
electronic ADT system (Admissions,
Discharges and Transfers).
The Trust should discuss more
Urgent
sustainable solutions to the high
capacity levels and bed
management challenges with its key
stakeholders such as the CCG and
social care colleagues.
The Coding team send all mortality notes to the owning clinician for
validation. From the evidence of the minutes of the mortality review
groups, there appears to be no coding representation. Given that the Trust
asserts that their poor mortality rates are in part due to coding issues,
particularly appropriate coding of palliative care patients, this should be
addressed.
iv. Examples of infection control concerns
The panel observed some areas in the Trust where infection control
practice seemed less well embedded. This included staff and regular
visitors having to be prompted to wash their hands on entering wards and
some inconsistent practice on IV insertions. Staff also talked about
challenges that they faced achieving infection control, including agency
staff that were not aware of procedures, consistent support from medical
staff on general wards and access to timely MRSA screening. Ward
managers and Matrons interviewed were not clear on what audits of
infection control processes were regularly undertaken.
v. Managing capacity including bed management and patient flows
The Trust has had consistently high activity levels in recent months and
has challenges both with meeting A&E wait targets currently as well as
with increasing average length of stay. Staff and patients interviewed
consistently spoke of how busy the hospital was.
Throughout our visit, we identified evidence of poor bed management and
flows including the following:
 Use of escalation areas over extended periods such as the winter
pressure ward still being open and fully in use in late April.
 EAU was being used for longer term stays which was not the intended
use of the unit, although it was recognised that the circumstances were
Outstanding concerns based on evidence gathered



Key planned improvements
Recommended actions
Priority –
urgent, high
or medium
due to infection control procedures.
A number of patients were identified as outliers during the panel visit.
There were inconsistent explanations about how their care was being
managed.
A number of patients were found to be waiting on trolleys in EAU on an
early morning visit. When staff were questioned on this they confirmed
that they could not be admitted to a ward due to bed shortages.
Observations in A&E noted ambulances stacked outside waiting to
deliver patients to the Trust.
th
The bed management meeting observed on the morning of Wednesday 8
May was attended by a large number of nurses and was a tactical meeting
to try and mitigate current issues. It did not appear to be an effective use
of staff time or use the current patient information from ward rounds
effectively. It did not identify and escalate issues with discharge to unblock
beds, such as patients well enough to leave who were staying to wait for
diagnostic tests. It also did not involve community or social care input if
delayed discharge was an issue. The panel recognised that the meeting
observed was on a day when the Trust was dealing with very high capacity
levels following the holiday so this may not be fully reflective of its overall
bed management process.
vi. Care bundles
It was identified that the Trust was using a number of care bundles for
pressure ulcers (in place for over 12 months) as well as for fluid and falls
(just being rolled out) to improve patient care. However these were not
being consistently used on wards based on the panel’s observations.
The elderly care clinical leaders noted
The Trust should audit use of the
that regular meetings between nurses, new care bundles and sure that all
doctors and other clinical staff were
wards are using these effectively.
trying to improve the falls service. The
meetings included a focus on education
for staff and using a common triage
service for elderly patients to reduce
falls.
High
Patient experience
Overview
The panel focused on how the Trust understands and responds to patient feedback on their experience. The panel investigated this by talking to patients and staff on wards,
through feedback at the focus groups and listening events, in addition to reviewing board and ward level information on patient experience.
Summary of findings
The following good practices were identified:

Patient feedback is pro-actively sought by staff at the Trust.

Examples of good levels of patient care and treatment and positive experiences were noted by patients interviewed and at the listening events.

Patient experience is high on the Trust’s agenda and is a focus for the Board and governors.

The Trust has scored well in Friends and Family test so far with 72% scores.
The following main areas of concern were identified for patient experience:

There was not an embedded patient experience strategy that would enable the Board to measure and monitor its performance and demonstrate actions taken in response
to feedback and complaints.

There are some issues with the way that complaints are being handled. Some responses may not be fully compliant with the Ombudsman process. Many patients at the
listening events gave examples of not being satisfied with the Trust’s responses to their complaints.

The service provided at the Trust did not always meet patients’ expectations with a number of notable themes emerging including around communication, admission and
discharge and nursing care. It was not clear what actions the Trust was taking to address these themes.

The Friends and Family test was not embedded fully in the organisation and many staff interviewed could not explain their role on wards in this important area.
For the majority of the above areas of concern, we identified a number of improvements already underway or planned at the Trust.
Detailed Findings
Good practice identified
Patient experience is high on the Trust’s agenda and is monitored by the Board and governors. The Trust has Patient Experience as one of its priorities and is
central to its vision and values. The CQSPE committee is a senior body that monitors patient experience and the Trusts response to complaints (although it has
been noted that sufficient time is not always available on its agendas for this area). The Governors have also looked at patient feedback and the Trust’s
response to complaints.
Good practice identified
It was clear that there were many examples of good patient experience from the panel’s observations, including:
 Good feedback was received from patients on the cardiology ward, in the acute stroke unit and also relating to the Diabetes team.
 Views from patients included that the A&E department had responded to patient feedback by providing food and water to patients in the waiting area.
 The dialysis service was described as very good by patients interviewed.
Key positive themes from the patient and public listening event included:




Being able to access consultants at outpatient clinics.
Examples of nursing care that was excellent.
Patients had positive experiences with longer term rehabilitation care and specialist treatment.
Patients were able to raise issues which were resolved quickly.
The Trust is performing well on Friends and Family tests and a number of wards could demonstrate good practice on collating and responding to patient
feedback, for example:



Friends and Family Test cards were clearly visible for patients to fill in.
Patient feedback has been regularly discussed by staff in weekly or monthly meetings.
Notice boards are used to show how feedback has been acted on and when this is expected to be implemented by (though not all of these had completion
dates filled in).
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
i. Patient experience strategy
The Non Executive Directors have
provided feedback that it needs further
development as evidenced at the March
2013 Board meeting.
The Board should review its
approach to developing a patient
experience strategy and ensure
it is clear how its priorities in this
area will be measured and
monitored.
High
There does not appear to be an embedded patient experience
strategy at the Trust. The patient experience document presented to
the Board was not a strategy document as it does not clearly describe
how it will measure patient experience outcomes and take action on
these systematically.
Staff interviewed could not consistently articulate the arrangements
for capturing patient experience insights and data. Although good
practices to capture patient experience was noted in some wards this
was not consistent. In particular the Friends and Family Tests (FFTs)
Ensure the Friends and Family
test is embedded across all
wards and all staff members are
aware of their responsibilities.
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
The Non Executive Directors fed back the
need to change the style of complaint
response letters to make them more
empathetic and to consider the feelings of
patients and their families more, but this
was not observed in the sample of
complaints that the panel investigated.
Review of the Trust’s
compliance against the
Department of Health and
Ombudsman requirements for
complaints management and
also to improve the patients
experience from this process,
including:
Urgent
were not embedded in all wards. Many staff could not say what
scores their ward received and what they did with the feedback.
When speaking to some Clinical Directors they could not articulate
their leadership role for patient experience – this was felt to be a
nursing issue.
It was noted that the FFT has not been in place for long but more
work is required to embed this as a core element of a patient
experience strategy.
ii. Complaints process
There is evidence, following a review of a sample of complaints by
the panel, which suggests the Trust is not fully compliant with the
regulations in respect to management of complaints. In particular the
Department of Health requires:




There should be a single lead and response.
Clear acknowledgement of what needs to be put right.
Using the information to identify potential service
problems, identify risks and prevent them from getting worse.
Investigating complaints fully and learning lessons from them.
Common themes noticed in the sample of complaints analysed were:
 Delays in responses to complaints being completed.
 Responses to elements of the complaints were vague or were
written in a way that is not easy for a non clinician to follow.
 There was little acknowledgement where there had been
shortfalls in care or apparent empathy for the patient and family’s
distress.
 Release of the letter appeared to mark completion of the local
resolution process, which does not demonstrate the Trust was
always trying to make it right for patients and carers when things
had gone wrong, for example offering a meeting or further
contact.


Ensuring responses to
complaints are timely and
patients’ expectations are
managed
Reviewing style of response
to complaints to address
patients in an empathetic
manner and use language
that is easy for nonclinicians to understand
Implement a more effective
process to capture learning for
the Trust from complaints and
ensure these are shared at ward
Outstanding concerns based on evidence gathered


There was no clear indication of the next steps or further
recourse for the complainants.
Some letters appeared defend the Trust and staff involved
against the complaints rather than providing a balanced
response.
Some patients and public at the listening event who had complained
to the Trust reflected that they had not always been able to get a
meeting with a senior staff member when they considered the
response letter was not adequate. This was inconsistent with the
process described by the Chief Executive and the Complaints team
who described an open and accessible route to the senior medical
staff and executive team so this needs to be reviewed further.
The management of complaints process reflects that the Trust is not
always using information sources available to effectively review and
identify learning to improve how care is delivered in the organisation.
As noted in the governance section, the Trust is also not using
complaints information alongside other information, such as ward
level data on patient feedback and incidents, to target areas of the
organisation which need more support to improve overall patient
experience.
Key planned improvements
Recommended actions
level
Priority – urgent,
high or medium
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
iii. Patient experience themes
None noted
The Trust should consider the
themes noted in the broad
patient experience feedback
obtained in this review. This
should be used to further review
its strategic approach to
responding to patient feedback.
High
Common concerns from speaking to patients during the visit and from
feedback through the Keogh Review website related to the quality of
care were:

Poor communication and engagement. Common areas of
feedback related to communication were:
- using medical jargon,
- throw-away comments by staff,
- having to repeat information and concerns to different doctors,
- inconsistent opinions from doctors.
 Issues relating to admissions and discharges, for example:
- Long periods spent (on trolleys) waiting to be admitted to
wards,
- Slow flow of patients through the hospital system,
- Discharges being delayed whilst others felt they were rushed
through the system,
- Discharge lounge was not considered a suitable environment
and patients often sat there for long periods of time without
clear communication from staff,
- Lack of communication from staff to set expectations on
discharge.
 Lack of nursing care, attention and compassion on the
wards - thought to be brought about by a lack of nurses or by
nurses being over-worked.
 A&E waiting times - examples of very long waiting times in A&E
and inadequate communication about expected waits and next
steps of treatment.
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
iv. Management of outpatient appointments
It is noted that complaint figures for
outpatient appointments are on a
downward trajectory (17 complaints in
2012/13 compared with 29 in 2011/12).
The Trust should review its
outpatient appointments process
to consider how it can address
the frequent complaints.
Medium
The Trust is using its Hub and staff
meetings to ensure wider understanding
amongst staff about routes for informal
feedback for patients and carers.
Continue to promote informal
feedback routes and ensure staff
and patients are aware of the
methods that can be used.
Medium
The management of the outpatient appointments was considered as
not efficient or well organised by a number of patients at the listening
events. Examples were given of instances of a number of
appointments arranged and then immediately cancelled, or follow up
appointments made in an untimely manner or which weren’t
organised with other treatment required. The panel did not observe
outpatients directly.
v. Process to capture informal feedback from patients
It was noted when interviewing a number of staff and patients that the
process for capturing informal feedback was unclear in some areas.
This means that some information on patient experience is lost and
all the work that staff are doing is not fully acknowledged/recognised.
Informal feedback from those who do not wish to submit a formal
complaint can be captured through a number of routes including
Governors, Matrons, Friends and Family, real time surveys and
PALS.
Workforce and safety
Overview
The three KLOEs in the workforce and safety area focused on:

Staff views of the main barriers in the Trust to delivering high quality treatment and care for patients.

The Trust’s approach to workforce planning to ensure that patient care and safety is managed effectively, including nurse staffing levels and clinical cover.

Whether there is adequate mandatory training for staff.
Summary of findings
The following good practices were identified:

The workforce interviewed were committed, loyal, passionate, caring and motivated.

Staff are behind senior management and feel listened to through the "Listening in action" programme.

The panel noted a good culture of reporting patient safety incidents, including when staff shortages put safe care for patients at risk e.g. through sickness.

Some wards and clinical areas reviewed in the Trust were well managed and staff demonstrated excellent clinical practice.
The following areas of concern were identified for workforce and safety:

Staffing levels and skill mix were not found to be adequate in a number of wards, most concerning were the registered nurse ratios in the two large general wards which
were well below the levels recommended as nationally recognised good practice. It was recognised that workforce planning is made more challenging with recent high
capacity levels noted in the Trust but the Board has not taken action to address this. The wards with the most significant concerns relating to staffing levels also had
higher numbers of incidents and complaints reported.

The Trust has a high usage of bank and agency which it appeared to be only just starting to address, although it has had a staff bank since April 2010.

The response to the national staff survey was very low at 36% but it was not clear that the Trust had reviewed why this was in or had taken action to identify underlying
themes or concerns.

The panel identified some concerns in relation to staff engagement and experience in Theatres. There was insufficient evidence that actions being taken by the Trust to
respond to whistleblowing and an external review in this area were fully effective.

There were a number of instances, identified by the panel during the visits, of important safety and equipment checks not being completed adequately.

Completion of mandatory training rates were lower than expected.
For the majority of the above areas of concern, we identified a number of improvements were planned or already underway at the Trust.
Detailed Findings
Staff issues
Good practice identified
Friendly, receptive and open staff, welcoming to the review panel. The staff were well briefed and prepared for the review.
Many staff the panel met said that they felt able to be open about concerns and were able to provide examples of the Trust Board acting upon feedback,
particularly noting where positive changes had been made in the last 3 years e.g. staffing investment
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or lower
i. Staff engagement and survey rates
The Trust is considering running a staff
survey of its own to see if there are any
underlying issues to address.
The Trust should continue to undertake
its own work on staff engagement to
understand what improvements staff
would like to see.
High
The Trust should review the staff
engagement in theatres and obtain
assurance that learning from the
whistleblowing case and external review
findings have been fully addressed.
Urgent
The response to the national staff survey was very low at
36%. The Trust management and staff interviewed generally
considered that this was because staff did not have time to
respond and did not recognise the impact this had.
ii. Theatres staff engagement
The panel were informed by a number of staff in theatres of a
number of historical issues related to staff management,
including raising concerns related to quality and the appraisals
process. The panel was referred to a whistleblowing case
and an external review report to which some staff considered
that the Trust’s response had not been adequate.
The Trust runs staff focus groups relating
to the national survey and has
implemented changes over the past two
years as a result. They also give staff time
to complete the survey at work including
providing a dedicated area to complete it.
None noted
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
iii. Mandatory training
The Trust is considering a three day catch
up period to address this issue.
The Trust should monitor and take action High
where mandatory training is below
expected levels, particularly on significant
areas where there have been recent
incidents such as information governance
and resuscitation.
There is regular mandatory training happening at the Trust but
high capacity levels have made this challenging to ensure all
staff are up to date. There has been recent catch up which
some staff indicated had been to due to the review process.
The completion rates on information governance,
resuscitation and safeguarding were often reported by ward
managers and matrons to be between 50% and 70% on
wards, where as they should be up above 90%.
Priority – urgent,
high or lower
Workforce planning
Good practice identified
Some good practices were noted in relation to staffing and capacity on some of the wards and clinical areas visited. For example:



Oncology – there was a Link nurse staff in place for medical devices to provide guidance on the ward.
Community services – the nursing team evidenced effective consultant input to the community provision.
Cleanliness and Nutritional Support Worker programme to address some of the capacity and recruitment challenges the Trust was facing.
The panel’s discussions with junior doctors noted that there had been investment in out of hours cover and that they considered consultant cover to be good and
supportive. General medicine was noted to be busy but there were no concerns expressed for patient safety as a result of this workload.
Outstanding concerns based on evidence gathered
Key planned improvements
i. Nurse staffing levels and skill mix
The Trust undertook a staffing
The Trust should take urgent action to Urgent
review in 2011 and has over the last ensure there are sufficient registered
two years invested in nursing
nurses to unregistered staff on all
The Board has not reviewed overall Trust staff levels since 2011 but
Recommended actions
Priority – urgent,
high or lower
Outstanding concerns based on evidence gathered
Key planned improvements
has reviewed staffing and invested in some high risk areas via business staffing and also on medical staffing.
cases including maternity, EAU and stroke. The Trust has considered a
further staffing review to address the issues in the Francis report but
The nurse staffing review used
this has not been completed yet.
Matrons and internal benchmarks to
design the ideal workforce around
There does not appear to be a detailed regular review by management the configuration of the wards.
of ward staffing levels including triangulation of available data to ensure
that staffing levels are safe, for example focusing on wards where
complaints, incidents and infection control rates are high.
It was noted that many of the
Matrons and senior nurses on the
Observations and interviews conducted with staff on wards gave a
wards demonstrated that they were
mixed and sometimes unclear picture of how the Trust managed the
proactive in managing staffing risks
planning of nurse staffing levels and skill mix. The following issues
such as responding to sickness
were noted:
absence or changes in patient
dependencies.
 E-rostering is not consistently used on wards and therefore rota
planning did not appear effective.
Specialist wards appeared to have
 The rationale behind the different staffing levels and mix was not
more appropriate staffing levels and
always clear when the panel inquired with the Ward Matrons and
registered ratios (For example
some General Managers.
 A number of wards, including the Trusts two largest wards (A2 and during the visit C4
Georgina/oncology had 1 nurse to 3
C1) had registered nursing ratios that were below nationally
patients and a staffing mix of 60:40).
recognised good practice (see the detailed findings below).
 A reliance on bank and agency staff on many of the general wards
The Trust is implementing the
noted by staff as a risk to quality in many of the ward observations
Allocate E-rostering system to
and focus groups.
address inconsistent rota planning.
 Trainee nurses stated in the focus group that they seemed to be
moved around plugging gaps in staffing and this sometimes
affected their learning.
The following staffing levels observed on wards visited during the RRR
did not meet nationally recognised good practice:
 On the Trust’s largest ward there was 1 registered nurse to 14
patients when the panel visited (A2 General and stroke rehab ward
with 72 beds) and skill mix ratios were planned at 40% registered
Recommended actions
Priority – urgent,
high or lower
shifts.
An updated review of nurse staffing
levels and staff mix should be
undertaken by the Trust which reflects
patient dependencies, ideally using a High
national accredited tool e.g. AUKUH
Safer Nursing Care Tool. This should
focus on reviewing staffing on the
high risk wards. The risk assessment
should take into account dependency
of patients and also other factors such
as high temporary staff usage and
high incident and infection rates. It
should also ensure Francis
recommendations are fully reflected in
the new staffing model.
The Trust should review its nursing
staffing rotas and embed the
consistent use of the Allocate erostering that it is implementing.
The Trust should review its use of
agency and bank staff to minimise this
as a solution for capacity challenges
and vacancy cover.
The Trust should consider conducting
an internal audit to check that the
hours worked by its bank nurses are
compliant with the European Working
Time Directive.
Outstanding concerns based on evidence gathered


Key planned improvements
Recommended actions
Priority – urgent,
high or lower
nursing staff to 60% unregistered staff.
On its second largest ward with 48 beds, C1 Renal/endocrinology
rehab ward, the ratios were 1 nurse to 12 patients plus a floating
band 6 and band 7 nurse. It was noted to have 50:50
registered/unregistered nurses. Issues were noted in July 2012
staffing report to the Board provided by the Trust. This related to
risks of managing infection control rates and achieving safe staffing
levels within the available budgets.
The mix between registered to non-registered nurses in the wards
visited was often below both the nationally recognised good
practice levels and the required levels identified in the Trust’s
staffing investment paper July 2011 (Examples include A2 and C7
GI Medicine overnight).
Safety issues
Good practice identified
The panel noted from the data and interviews with staff on wards that there was a culture of reporting patient safety incidents, including when staff shortages put
safe care for patients at risk e.g. through sickness.
The panel noted some good practice on ward B2 with the falls service telephone triage. This had made a positive impact on patient safety by identifying the
appropriate part of the service to refer patients to based on their needs.
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
i. Equipment and safety checks
None noted
The Trust should reiterate its processes
to staff to ensure important equipment
and safety checks. Compliance should
be regularly audited and non compliance
should be followed up urgently.
Urgent
Some areas of the Trust visited were found not to be fully completing
relevant safety and equipment checks. In particular the following
exceptions were noted:
Outstanding concerns based on evidence gathered






Resuscitation equipment in paediatrics had not been checked over
the bank holiday weekend before the announced visit. This issue
was also noted at the unannounced visit. More generally, the patient
safety group also identified an issue with regards to checking
resuscitation equipment in its April 2013 meeting, which suggests this
is more wide-spread.
Controlled drug checks were found to not taking place as required in
some areas of the Trust.
The consultant anaesthetist on the panel observed that a vital
emergency drug was missing in the resuscitation area of A&E. She
brought this to the attention of the Consultant in charge in the
department. On follow up this issue was not found to have been
addressed adequately and therefore on this occasion this important
drug was not available in the case of an emergency.
Suction machines were not found to be working in EAU.
Gaps in records of monitoring and checklists were noted in a number
of areas, including EAU and paediatrics.
A member of staff raised a concern that Do Not Attempt
Resuscitation (DNAR) procedures were being inconsistently followed
in the Trust.
Ward management often noted that the staff had been at full capacity and
therefore had not had time to complete the checks in these instances.
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority – urgent,
high or medium
ii. Quality of Root cause analysis (RCA)
None noted
The Trust should review its process for
RCAs to ensure there is sufficient time
and review built in to improve the quality
of analysis and learning to be shared
from the incident. The Trust may wish to
use the NPSA toolkit to support this
analysis.
High
The panel reviewed a sample of RCAs for reported patient incidents.
Whilst it was noted that the RCAs were completed on a timely basis there
were some improvements that could be made to the quality of the
analysis and reporting. The panel observations included:


Limited detail and analysis of the incident and what could be learned
from it.
Lack of recorded challenge and review.
It was not clear how the results of RCAs were fed into the Trust’s
governance processes and responded to.
Pressure ulcers
Overview
Pressure ulcer care and prevention was identified as a key line of enquiry based on review of the data pack and the information submitted by the Trust. Between April 2012
and February 2013, 56 serious incidents had been reported for pressure ulcers that had developed/deteriorated to a Grade 3 or Grade 4 whilst the patient was in hospital. A
further 24 were reported on the community case load. Pressure ulcers were also flagged as ‘outside of expected range’ in the data pack.
To gather evidence in relation to good practice and areas of concern for pressure ulcer care and prevention, the panel observed a number of areas in the hospital with a
particular focus on care of the elderly. Observations followed the pathway from admission into EAU from A&E through to ongoing care on the wards, assessing adherence to
guidelines and care pathways as well as availability of equipment. Staff were interviewed from Board to ward and patient notes were reviewed for a detailed view of their care.
The following good practices were identified:





Executive team commitment to reducing avoidable pressure ulcers.
Olympics campaign; awarding bronze, silver and gold medals to wards for consecutive days without pressure ulcers.
Tissue viability team steering education and pressure ulcer reduction targets (although the team is small and covers both acute and community patients).
Weekly meetings to discuss root cause analysis of pressure ulcers reported as serious incidents, to monitor action plans and share lessons learnt.
Pressure ulcer prevention and management pathways are commenced in A&E and follow the patient from there.
The following areas of concern were identified:





Divergence from guidelines and care pathways following assessment.
A lack of available equipment and delays from the external provider to support pressure ulcer care.
Inaccurate documentation on patient notes of pressure ulcer care.
Staff at ward level seemed unaware of the outcomes of key themes from RCAs.
Communication with patients regarding assessment and risk or pressure ulcer development needs improving.
Detailed Findings
Good practice identified
Since 2011, the Trust has undertaken two Board-led campaigns to raise awareness and reduce avoidable pressure ulcers. In 2011 they had the campaign ‘Love
Your Skin’, in which 6 directors modelled for an awareness poster campaign, with the aim to have zero pressure ulcers at the forefront of everybody’s minds.
This was followed in 2012 by a new campaign linked to the summer Olympics in which they challenged all ward teams to be free of pressure ulcers for 50
consecutive days.
Tissue Viability nurses (TVN) get 7.5 hours per week for learning and development. As a tissue viability team they meet every 2 weeks to share what is working
well and to escalate any issues to the Deputy Director of Nursing. There is also weekly meeting for discussion of root cause analyses which includes Director of
Nursing, safeguarding lead, infection control and tissue viability teams; this meeting also discusses action plans and shares lessons learnt.
Elderly care clinical leads could clearly articulate measures that have been implemented to reduce pressure ulcers. These included;
 Reporting grade 3 and 4 pressure ulcers as serious incidents.
 Using tissue viability nurses.
 The campaigns mentioned above to incentivise good practice.
 Using body maps on admission and a daily Waterlow assessment.
 Educating staff through the use of Link nurses
The following good practice was noted in A&E:
 Staff spoken to on the unannounced visit demonstrated good awareness of guidance and pathways in place to prevent and identify pressure ulcers.
 Pressure ulcer prevention and management pathways are commenced in A&E and documentation was readily available.
 Access to Repose trolley toppers.
Staff informed us that beds in the Clinical Decision Unit are utilised for those needing higher level of preventative care and dynamic pressure relieving
mattresses can be accessed for these patients.
Other teams noted as delivering particularly good practice pressure ulcers care for patients were trauma and orthopaedics and diabetes.
Ward and A&E visits demonstrated many patients were happy with the pressure ulcer care received and it was noted that:
 Patients visited had the correct documentation in place and bundles were completed at the planned times.
 Patients themselves reported awareness of skin inspection – although they did not know why this was being done.
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
i. Inconsistent pressure ulcer preventative care
It was noted that the Trust does
have an active campaign to
embed its pressure ulcer care and
prevention processes in nursing
practice.
Systems should be review to ensure staff
Urgent
can readily identify those patients with high
need for pressure ulcer preventative care.
White boards already in use on wards
could be used to identify patients more
effectively – using a magnet or silicone
identifier.
The culmination of observations, discussions with nurses and review of
patient notes demonstrated that pressure ulcer care and prevention is
not consistently implemented as per the care plan in all wards. The
issues discussed below in relation to equipment and divergence from
guidelines was apparent in more than one area of the Trust. Some of
the nurses we spoke to could not identify which patients on their wards
had pressure ulcers and very few spoke to the panel about the
campaign to reduce avoidable pressure ulcers.
ii. Availability of equipment and delays from external provider
During the announced observations, many examples were identified
where equipment such as pressure relieving mattresses were not
available on site. On these occasions the Trust use an external provider
to provide equipment and nurses can make an order for it to be
delivered. Ordering requests for mattresses were documented in the
nursing notes and delays in receipt and escalations with regard to this
were also documented.
Priority –
urgent, high or
medium
Systems are needed to ensure that staff
High
are made aware of how well their ward is
doing in terms of number of pressure ulcer
free days and of the themes coming out of
root cause analysis. Ward managers to
find effective methods to feedback to staff
how well their area is doing and how many
PU free days they have achieved.
Consider display poster in the clinical area.
TVN to ensure all ward managers are
looking at the 50 day dash charts available
via the Tissue Viability (TV) intranet site to
encourage competitiveness.
Medium
The Trust has met with Karomed
after the RRR visits to address the
equipment delays.
Repose mattresses were available in the
department – link nurses to promote and
encourage their use.
Urgent
A bid has been submitted for 20
trolley air mattresses for A&E and
AEU for improved care prior to
moving patients to a bed on a
ward.
Performance Indicators need to be
reviewed for the contract with Karomed
and penalties implemented where failings
are occurring.
Urgent
TVN team to work with A&E link nurses to
Outstanding concerns based on evidence gathered
Key planned improvements
Recommended actions
Priority –
urgent, high or
medium
The panel identified a number of cases where the external provider had
taken up to 24 hours to deliver pressure mattresses and therefore
leaving patients with grade 3 and grade 4 pressure ulcers on
inappropriate beds / trolleys for an unacceptable period of time.
Due to the delays being caused by
the external provider, access to
stock out of hours on site has
been arranged to provide
immediate access.
develop education in the department and
carry out weekly audits of equipment use.
Urgent
In A&E on the unannounced visit patients reviewed by the team did not
have repose on the trolley despite their assessments indicating this was
needed and repose being available. Also it was not clear how decisions
are made about which patients to risk assess for pressure ulcers in
A&E.
Pressure ulcer prevention
practices need to become
embedded into A&E practice. Link
nurses have been appointed to
facilitate this.
Discussions with nursing staff noted more than one example where the
ward had bid for charitable funds for basic pressure relieving equipment
such as mattresses and chairs.
iii. Divergence from guidelines and inaccurate documentation
Staff should report equipment delays via
Datix so management and the TV nursing
team are made aware of how often this is
occurring in real time.
Documentation audit by TVN team and/or
link nurses to identify extent of delays.
Consider use of Anderson score in A&E
rather than Waterlow to encourage
assessment of all patients.
None noted
Patient notes were reviewed for several patients with existing pressure
ulcers. Examples were identified where the Waterlow score had been
recorded inaccurately or the protocol had not been adhered to, based
on the specific circumstances for that patient. This has resulted in
patients not receiving the level of care which is stipulated in their
flowchart.
The vascular ward has recently opened a HDU area. The panel saw 3
The Trust has met with Karomed
to agree how a supply of
mattresses can be made readily
Medium
Medium
Ward teams to carry out weekly SSKIN
bundle audits of a minimum of 5 sets of
notes per area with an aim to achieve
100% compliance.
High
Action plans need implementing where
compliance is not reaching 100% with
particular focus on those elements of the
bundle most commonly not being followed.
High
TVNs to support link nurses to educate re
Waterlow assessments. Consider use of
flash cards or other quick grab educational
tools which can be displayed (posters etc)
iv. Post operative deficiencies
High
High
Link nurses and TV team to educate in this High
area.
Outstanding concerns based on evidence gathered
Recommended actions
Priority –
urgent, high or
medium
patients in here and reviewed 2 of them. Their Waterlow assessments
available for patients immediately
were inaccurate and they had no dynamic preventative mattress despite post operatively.
their need.
Link nurses to audit Waterlow
assessments and implementation of
preventative actions
High
v. Communication
TV Team and matrons to feedback the
themes to all involved and set actions for
staff locally to improve practice.
High
A patient information leaflet should be
designed if there isn’t one already in use.
Documentation should demonstrate that
the patient has received the leaflet and
their risk has been discussed.
High
When asked staff seemed to have limited knowledge of the key themes
emerging from Root Cause Analyses.
Patients themselves were not aware of why skin inspection was taking
place or that they were at risk of pressure ulcer development
Key planned improvements
None noted
5. Conclusions and support required
The Trust is clearly focused on improving quality and patient experience. The panel’s review identified a number of areas of good practice, although these generally related to
specific areas, wards or specialities such as trauma and orthopaedics, community and diabetes teams. Therefore there is more for the Trust to do in ensuring good practice
and learning is used systematically and consistently across the organisation, all of the time.
Our review also identified a number of areas of outstanding concern across all ten key lines of enquiry which will require urgent or high priority action to address as identified
in the detailed findings section. A number of these areas are recommended for discussion at the risk summit to consider what support may be required from the Trust to
address these.
Urgent and high priority actions for consideration at the risk summit
Problem identified
Recommended Action for discussion
Support required by the Trust
A review of quality governance and better
communication of the arrangements to staff is
required.
The Trust should review its governance structure to reduce the To be discussed – a detailed external review against
complexity of arrangements and improve the Board level
Monitor’s quality governance framework may be
challenge of quality information.
beneficial.
The governance arrangements to support the Trust’s quality
priorities should be communicated to staff to enable them to
understand and deliver their role effectively.
The Trust needs to embed a culture of learning
from when things go wrong and improve its
processes to capture themes from:



The Trust should develop an action plan to improve its
systems to review complaints, incident reporting and other
data related to quality and disseminate learning more
effectively across the organisation.
To be discussed with the Trust
Incidents and RCAs.
Feedback and complaints.
Mortality reviews.
The Trust needs to consider how it will review
mortality data more systematically and use this
alongside its learning from directorate reviews
to target improvement actions more effectively.
The Trust should assess how the mortality review process at
To be discussed with the Trust
Directorate level can more effectively feed into overall
governance process in terms of lessons learnt and highlighting
risks that may need further systematic reviews
Problem identified
Recommended Action for discussion
Support required by the Trust
The Trust’s system for bed management,
patient flows and discharge need to be urgently
reviewed and improved to address operational
effectiveness issues and improve patient
experiences
Key stakeholders should be involved with the Trust in
reviewing the admissions, bed management and discharge
arrangements and identify how improvements can be made
urgently. This should include consideration of key enablers
including IT systems.
To be discussed with the Trust
The Trust has more work to do to embed a
patient experience strategy and demonstrate
that it is effectively monitoring performance
The Board should urgently review its approach to patient
experience to ensure it has a clear strategy, is consistently
monitoring key metrics and identifying actions to improve this
area.
The CCG may wish to support the development of the
patient experience strategy and undertake an audit of
the Trust’s response to complaints.
It also needs to demonstrate it is learning from
complaints and managing these in line with
required practice.
The Trust’s nurse staffing levels and skill mix
were not found to be consistently in line with
nationally accepted good practice.
The Trust needs to review its approach to responding to
complaints to ensure it is compliant with requirements and
really responds to complainants effectively.
The Trust should review its current staffing levels for nursing
and medical staff using a nationally recognised tool and action
any changes required for improving quality and safety of care.
Access and support to undertake a staffing review using
a nationally recognised tool.
There is an urgent action identified to make sure that nurse
staffing levels are assessed using an evidence based
methodology. This should be reviewed in conjunction with the
clinical teams to ensure each ward has appropriate nurse
staffing levels and the appropriate ratio of registered to
unregistered nurses on all wards.
Consistency of safety and equipment checks.
The Trust should review its processes to ensure all equipment
and safety checks are undertaken appropriately.
To be discussed with the Trust
Consistency of pressure ulcer care including
prioritisation of patients and access to
equipment.
The Trust should review its processes to provide appropriate
care and equipment for patients that are high priority for
pressure ulcer prevention.
To be discussed with the Trust
The Trust should audit compliance with its pressure ulcer care
bundles.
Appendices
45
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?
1) Deaths up to 30 days post acute trust discharge are considered in the mortality indicator, utilising ONS data
2) The SHMI is the ratio of the Observed number of deaths in a Trust vs. Expected number of deaths over a period of time
3) The Indicator will utilise 5 factors to adjust mortality rates by
a.
b.
c.
d.
e.
The primary admitting diagnosis
The type of admission
A calculation of co-morbid complexity (Charlson Index of co-morbidities)
Age
Sex
46
4) 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
Are all hospital deaths included?
When a patient dies how many times is this counted?
HSMR
No, around 80% of in hospital deaths are included,
which varies significantly dependent upon the
services provided by each hospital
If a patient is transferred between hospitals within 2
days the death is counted multiple times
Does the use of the palliative care code reduce the
relative impact of a death on the indicator?
Does the indicator consider where deaths occur?
Yes
Is this applied to all health care providers?
Yes
Only considers in hospital deaths
SHMI
Yes all deaths are included
1 death is counted once, and if the patient is
transferred the death is attached to the last
acute/secondary care provider
No
Considers in hospital deaths but also those up to 30
days post discharge anywhere too.
No, does not apply to specialist hospitals
47
Appendix II: Panel Composition
Panel role
Panel Chair
Name
Ruth May
Lay representative (Patient/public representative)
Leon Pollock
Lay representative (Patient/public representative)
Alan Keys
Lay representative (Patient/public representative)
Anthony Glover
Junior Doctor
Veline L’Esperance
Doctor
Ronan Fenton
Doctor
Marcelle Michail
Doctor
Colin Johnson
Doctor
David Woolf
Student Nurse
Charlotte Johnston
Board Level Nurse
Heather Moulder
Board Level Nurse
Sue Doheny
Senior Nurse
CQC representative
Senior Trust Manager
Senior Regional Support
TV Nurse
Paul Webb
Di Chadwick
Batsirai Katsande
Alistair McIntyre
Heidi Guy
48
Panel role
Name
Coding expert
Trudy Taylor
CCG Observer
David Hegarty
CCG Observer
Paul Maubach
49
Appendix III: Interviews held on announced visit
Interviewees
Date held
Paula Clark, Chief Executive
7 May
Paul Harrison, Medical Director, and Denise McMahon, Director of Nursing
7 May
Elderly Care clinical leads and matrons
7 May
Speciality medicine clinical leads
7 May
Clinical Directors - Ambulatory Medicine & Critical care and Emergency medicine
7 May
Union representatives
7 May
Lead governor
7 May
Richard Cartell, Director of Operations, and Richard Beekan, Director of Transformation
8 May
Richard Price, Deputy Director of Finance
8 May
Annette Reeves, Deputy Director of HR
8 May
David Bland, Chair of CQSPE Committee, and David Badger, Deputy Chair and NED
8 May
Tessa Norris, Director of Community Services and Integrated Care
8 May
Trauma and Orthopaedics clinical leads and matrons
8 May
Benoit Ritzenthaler and Jo Bowen, palliative care consultants
8 May
Complaints team
8 May
Associate Medical Director
8 May
Clinical Directors for Anaesthetics and Surgery
8 May
50
Appendix IV: Observations undertaken
Observation area
Date of observation
Care of Elderly ward
7 May
Accident and Emergency (A&E)
7 May
Acute Stroke
7 May
Renal
7 May
Paediatrics
7 May
Cardiology
7 May
Maternity
7 May
Emergency assessment unit
8 May
Stroke/General rehab
8 May
Orthopaedics
14 May
Gastro Intestinal medicine
14 May
Paediatrics
14 May
Oncology
14 May
Accident and Emergency (A&E)
14 May
General surgery
14 May
Theatres
14 May
Respiratory/GI Medicine overflow
14 May
Acute medical unit/short stay unit
15 May
Renal
15 May
Stroke/General rehab
15 May
51
Appendix V: Focus groups held
Focus group invitees
Focus group attendees
Date held
Trainee Nurses
16 registered attendees
7 May
Senior Doctors
19 registered attendees
7 May
Health Care Assistants and other clinical
staff
22 registered attendees
7 May
Senior Nurses
28 registered attendees
7 May
Governors
12 registered attendees
7 May
Non-clinical staff
31 registered attendees
8 May
Diabetes team
Junior Doctors
8 May
18 registered attendees
8 May
52
Appendix VI: Information available to the RRR panel
Quality Strategy - FINALMarch 2013.doc
QualityFront sheet mar13qualstrat.doc
BOARD ASSURANCE FRAMEWORK April 13.doc
Corporate Risk Register as at 18 April 2013.doc
DGNHSFT Annual-Clinical-Audit-Report 2011-12
Final.pdf
DRAFT Clinical Audit Plan 2013_14.xlsx
CIP Clinical Quality Impact Assessment Template V3
310313.docx
CIP Information for DoH review Team 180414.xlsx
Clinical Quality Impact Assessment Process for CIP 1314.doc
CIP CQIA - 2012-13 Examples for Keogh Review.pdf
CIP Monitoring 2012-13 - Month 12.pdf
CIP Monitoring 2013-13.PDF
CIP Quality Focus - Internal Audit Report.PDF
Clinical Quality Impact Assessments.PDF
Action plan for quality gov frameworkfeb13.doc
Action plan for quality gov frameworkjuly12.doc
Action plan for quality gov frameworkmay12.doc
Action plan for quality gov frameworkoct12.doc
DGH Quality Governance Frameworkmay12b.docx
FandP Front sheet may12qualgovframe.doc
QualityFront sheet aug12qualgovframe.doc
QualityFront sheet mar13qualgovframe.doc
QualityFront sheet nov12qualgovframe.doc
Copy of Board structure April 2013.xls
Annette_Reeves CV.doc
Denise Mcmahon CV.doc
Dr Paul HarrisonCV.doc
Paul Assinder CV.docx
Paula Clark CV.docx
Richard Beeken CV.doc
Richard Cattell cv.doc
Tessa Norris CV.doc
Clinical Quality Safety Committee ToR - FINAL v4 Feb
12.docm
Risk and Assurance Ctte Terms of Reference V5
August 12.doc
Trust Board Organisational Structure - Sept 12 v4
revised.pptx
PrivateBoardMins4thApr2013.docx
PrivateBoardMins7thMar2013.pdf
PrivateBoardPapers4thApr2013.pdf
PrivateBoardPapers7thMarch2013.pdf
PrivateClinicalPresentationsBoardMins7thMarch2013.
pdf
PrivatePreBoardClinicalPresentationPapers4April2013.
pdf
PublicBoardMinutes4April13..docx
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PublicBoardMinutes7March13.pdf
PublicBoardPapers4April2013.pdf
PublicBoardPapers7March2013.pdf
CQSPE 11th April 2013.pdf
CQSPE March 13 Full Set of Papers.pdf
Clinical quality, safety & patient experience committee Terms of reference.PDF
Dermatology morbidity mortality february 2013.pptx
Dermatology, Endocrinology, GUM, Neurology
Mortality Report February 2013.pdf
Dudley Diabetes Footcare Profile 2013.pdf
Endocrinology_Mortality_Presentation_2013.pptx
M & M - MSH AR E b.pdf
M&M D&E 2013.docx
M&M Mtg Vascular Surgery March 2013 2.docx
MM Mtg ObsGyn March 2013.docx
NaDIA 2012 report.xlsx
OBS_Gynaecology_Morbidity_Mortality_2013.pptx
Obstetrics Gynaecology Mortality Report March 2013
(2).pdf
SCHEDULE OF DATES FOR MM PRESENTATIONS
2012 13(2) (2).doc
Vascular Surgery Mortality Report March 2013
Specialty Specific.pdf
Section 11 - Finance - F&P Enc 4 - I & E Report.pdf
Section 11 - Finance - F&P Enc 5 - Balance Sheet and
Cash.pdf
Section 11 - Finance - Risk Rating Tracker.docx
Section 11 - Patient experience - Performance for
Keogh review.docx
Section 11 - Performance - F&P Performance Report 201303 March - Summary.ppt
Section 11 - Quality - CQPE Performance Report 201302 February - Summary.ppt
Annual Plan 2012_13 Word Version for FP.docx
CQC Mortality Alert and action plans.doc
Mortality_Alerts_Item_13.pdf
2012 Peer Review Reports F & P.pdf
20130320191332_INS1-559917792_RNA01_Russells
Hall Hospital.pdf
20130415 ECIT report action list v1.1.xlsx
actioplanfallsnov12new.doc
FinaldraftreportEnquiry Visit Report to
DGFTrustfallsjan13.docx
Pre-implementaion QA visit report 290212 DGH
FINAL.DOC
QualityFront sheet jan 13qualcomm.doc
resources_reports_central_GMCN_report_20120626[1].
pdf
2013-15 draft Physio contract New Bridge and New
Swinford Combined.docx
DGFT Intermediate Care Briefing .15.4.13docx.docx
Dudley Rehabilitation Service profile.docx
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Occupational Therapy commissioning document v3
2010.docx
Occupational Therapy_Adults MS version 150211.docx
Reablement OTSLA.doc
Mandatory Fluid Balance Training.pdf
Fluid Balance Bundle - Monitoring observation and
recordings.pdf
Patient Fall Prevention and Management
Document.PDF
Patient Falls Prevention and Management.pdf
Fractured neck of femur - Integrated Care
Pathway.PDF
Quality Report 2012-13.PDF
Cadiology Mortality Report 2012-13.pdf
Root Cause Analysis Report.PDF
Whistle Blowing Policy.PDF
SHMI HSRM tree - high excess deaths.PDF
Risk Assessment.PDF
Board minutes - April 2012.PDF
Board minutes - May 2012.PDF
Board minutes - June 2012.PDF
Board minutes - July 2012.PDF
Board paper - Maternity services expansion business
case.PDF
Maternity services expansion business case.PDF
Round table discussion June 12 - Owen Jeremy
incident.PDF
Datix - Red incident form.PDF
Board paper - Acute medical unit business case.PDF
Board paper - Develop trust programme for junior and
middle grade trust doctors.PDF
C7 Staffing Weekly Allocation.PDF
Nursing Rotas - C1.pdf
Nursing Rotas - C4.pdf
Nursing Rotas - B1.pdf
Nursing Rotas - EC2.pdf
Nursing Rotas - 1.pdf
Report on staffing levels for C1.PDF
Risk Assessment - C1 Staffing.PDF
Nurse staffing establishment assessment.PDF
C4 Haematology & Oncology Services.PDF
Princess Royal Hospital, Telford
(Recommendation).PDF
RCA - Intrauterine Death.PDF
RCA - Falls 1.PDF
RCA - Falls 2.PDF
RCA - Retained Foreign Object Post-Operation.PDF
RCA - Suicide near miss.PDF
Feedback log.pdf
Friends and Family Test.pdf
Patient Experience Feedback.pdf
Patient Experience (A2,B2,C3).pdf
Patient Experience Strategy Paper.pdf
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Board of Directors Agenda 07.03.13 (Full).PDF
Board Meeting Minutes 07.03.13.PDF
acute-care-toolkit-1-handover.pdf
acute-care-toolkit-3.pdf
Dr Vaz's report DGH Review 19 June 2012.doc
Geriatric Medicine LAHD slides.pptx
Geriatric Medicine Lean Action Half Day Summary of
notes and actions.docx
NAO Report Delayed Discharges.pdf
Pollock Delayed Discharges.pdf
Removing_the_Policy_Barriers_Integrated_Care.pdf
silver_book_complete.pdf
SitReps DelayedDischarge.pdf
1 GMC NTS 2012 Results DGoH.xls
2 JEST Foundation Aug 2010 to Present.xlsx
3 JEST Specialties Aug 2010 to Present.xlsx
4 GMC NTS 2012 Results DGoH Programme.xls
5 DGOH GMC DR April 2013 Submission.xls
6 DGoH Quality Management Reports.pdf
DGOH L3 Paediatrics 19042013 Report Draft v3.pdf
theatre review DGH final 1 Oct 2011.ppt
PALS - ROUND FLORENCE.PDF
PALS CONCERN.PDF
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Appendix VII: Unannounced site visit
Agenda item
Panel pre-meet
Entry into Russells Hall Hospital and announced arrival to site manager
Observations undertaken of the following:
 Accident and emergency
 Orthopaedics
 Gastro Intestinal medicine
 Paediatrics
 Oncology
 General surgery
 Respiratory/GI Medicine overflow
 Acute medical unit/short stay unit
 Renal
 Stroke/General rehab
 Theatres
Meeting held with site manager to understand current staffing and patient levels
Meeting with Chief Executive
Interview with Coding team
Interview with Chairman and Non Executive Directors
Interview with Governance lead
Focus Group with Community nurses
Panel left Trust and announced exit
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