Agenda item

To receive a presentation from the Barts Health NHS Trust, updating the Committee on their improvement plan and reporting back on matters raised at their previous visit to this Committee (9^th June 2015).

We hope to have Fiona Smith (Managing Director for Whipps Cross Hospital), together with Dr Heather Noble (Medical Director) and Felicia Kwaku (Interim Director of Nursing).

The Chairman welcomed officers from Barts Health NHS Trust who were there to update the Committee on their improvement plan from their last visit to this meeting in June 2015. In attendance was Fiona Smith, the Managing Director for Whipps Cross Hospital, with Dr Heather Noble, the Medical Director and Felicia Kwaku, the interim Director of Nursing.

Ms Smith noted that she was here to update the Committee on the measures undertaken since Barts NHS had been put into special measures  and Whipps Cross Hospital had received four warning notices issued by the Care Quality Commission (CQC). They had now finalised their improvement plan called ‘Safe and Compassionate’, with each site having the same headings for their improvement plans. The improvement was being delivered through seven key work streams with both a corporate and site based focus and key government structures (a copy of their presentation is attached to these minutes).

The trust had put in place “safety huddles” for each hospital every day, to discuss any safety or quality issues that would affect their patients. They also reviewed performance on a ward by ward basis against key quality and safety metrics that allowed them to track the measures in place.  They also held monthly learning reviews looking at learning and sharing of improvement actions.

The CQC had noted their notices on ‘do not resuscitate’, they had now extended their training on this, the Mental Capacity Act and on Safeguarding. They had also introduced a Trust wide campaign to reduce hospital acquired pressure ulcers.  They now had 6 wards that had no pressure ulcers for 100 days. They had also trained up 40 ‘safety companions’ on safety issues.

They had made progress in freeing up ward managers to manage ward fundamentals; nursing documentation had been had been streamlined; had started a ‘smile and care’ campaign and patient engagement workshops; put in a revised complaints process with a requirement to be much more responsive; and visitors and patients were able to identify the nurse in charge via a badge.

They had also ensured that there were appropriate care plans for those patients nearing the end of their life. Also the Margaret Centre had now been refurbished, making it a more safe and comfortable environment for patients and families.

They were also tackling the number of vacancies and engaging more with staff. They had reviewed safe staffing levels and increased funded nursing establishment by 532 posts (150 posts being at Whipps Cross). Their current fill rate was up to 82% and they wished to take it up to at least 90%. They were travelling around the county to recruit staff, especially where there were university schools; and had improved the temporary staff induction process.

They were now putting in place measures to ensure that patients got care and treatment in a timely way, using a whole hospital approach, not just changing certain departments. They were also recruiting new consultants and improving the flow through outpatients departments.

Whipps cross Hospital now had an integrated discharge team, working with CCGs, Council Social Care and Community Health Teams.

Medical Records were much better now than they used to be, call centre calls were answered within 60 seconds, floor walkers now provide extra training and support to staff in using the electronic health record system.

The Trust now had a new Chairman and a new Chief Medical Officer and a new Deputy Chief Executive. The Trust Board also had two new Non-Executive Directors to strengthen the Board. They also had new site teams in place accountable for operational delivery. They have a new programme called ‘listening into action’ to engage staff and also hold “Big Conversations” with staff (so far with over 1000 staff). This had resulted in lots of little improvements being made following suggestions from members of staff.

It was important they developed their staff and to this end they had completed a first phase of a career development programme for women and staff from a BME background. Their turnover had now gone down and they now had fewer leavers than starters.

They were also investing £2million in IT, the first steps in a wider programme; £17.5million was planned in investment in Whipps Cross improvements; there was also a ward improvement programme and £15million set aside for medical equipment across the Trust. It was noted that Whipps Cross was an old site, hard for staff to work in, but Barts Health was now investing in the site. A new High Dependency Unit was to be opened by July.

The meeting was then opened up to questions from members.

Q.        In reference to the A&E services provided at King George’s which I believe are to discontinue and so very likely to add pressure on the A&E departments at Queen’s and Whipps Cross. Given the projected increase in population a reduction in A&E provision was a concern.

A.        We are engaged in a process of planning for what might happen to King George’s Hospital; looking at what may happen and making sure we were happy with the modelling assumptions. We did not want to make a decision until we knew it was safe to do so.

Q.        I have noted that you are making massive improvements, but what about the elderly and assessments for when they could leave the hospital, even if they still needed hospital care. Were there enough places for intermediate care for them?

A.        We have an integrated discharge team that assesses all our vulnerable patients along with their doctors and physios.  It was important that we did not discharge our patients before we should. We also monitor our re-admission rates, which was now going down. We also work with the local social services and other partners.

We have come across situations where the patient really wants to go home although we or their family may not think it’s safe. In the end, no matter what we offer, we have to accept their decision.

Q.        You have told us of the changes being made, but how are these changes being monitored by senior management?

A.        We have an Executive Team and below that a Hospital Management Team monitoring them. They all come from a clinical backgrounds and monitor things on a daily basis. The Chief Medical Officer also walks around the wards and talks to junior staff to monitor the situation. We also have paper based monitoring systems, but you really can’t beat walking around.

Last week we had a clinical review from officers from other organisations who gave us pointers on what we needed to do.

We are also trying to peer review our various wards and are trying a lot of different ways to monitor our work, not just by paper records.

Q.        Is there a catchment area for Whipps Cross, and also how was ‘bed blocking’ being dealt with?

A.        The majority of patients come from the Waltham Forest area and a small percentage from Epping and surrounding areas. We do not use the term ‘bed blockers’, they are patients whose discharge has been delayed for various reasons.  Today we have 15 of those. These are different from medically fit patients delayed from going home. Last year, we used to have anything from 5 to 53 of these cases a week. We have worked hard to get down to a target of 15 and now that we have achieved that we will work to get it down to 10.

Q.        You said that you almost had a full compliment of staff, to keep them you need to keep them engaged and satisfied. How do you make sure staff moral was kept up?

A.        This was an important question; we have initiatives such as the big consultation and speaking to and engaging with the staff. We are getting full recruitment by filling our vacant posts and are now at 82%. This was a major campaign for us. We are doing other things such as regular appraisals and staff exit and entry surveys, asking them why they wished to come and work for us etc.

Q.        You mentioned a reduction in re-admission rates; have you achieved your target. Also, how long do people spend on trollies waiting to be admitted? And are the new visa rules affecting new staff?

A.        Re-admission rates are going down but we are still not meeting our targets yet (of 95%). Our current rate is at about 80 to 85%.

As for how long patients wait, that depends on the nature of the patients ailments. It is a struggle for us to put people into wards, and it can be up to a 10 hour wait. We have opened additional beds and have active management of this.

As for changes in immigration rules this particularly affects nurses and was now being reviewed.

Q.        Could you get to your 95% target if people could see their own GP?

A.        The reasons why people go to A&E are complicated; there are a mixture of reasons. Whipps Cross already has a GP to assess the patients that come through the front door at A&E.

Q.        One of the concerns of the CQC report was that there were not enough paediatric nurses where there should have been.

A.        Our Paediatric wards are only staffed by paediatric nurses. Last year we had to close some beds because we did not have enough paediatric staff. We have now opened more beds as our staff levels are up. We now have 23 beds.

Q.        Was there a date by which all services should be up and functioning properly?

A.        That depends on what you mean by properly. First and foremost we needed to know our services were safe; we then need to improve our services to pass the next CQC assessment and get out of special measures.

The Chairman thanked the representatives from the Barts Health NHS Trust for their excellent presentation and their full and helpful answers and congratulated them on the work they had done so far.