Health, Housing and Adult Social Care Scrutiny Committee	10 July 2024
Report of Dawn Parkes – Chief Nurse Designate, York and Scarborough Teaching Hospitals NHS Foundation Trust

Care Quality Commission (CQC) Inspection Update Report

Summary

1. The purpose of this report is to provide the Overview and Scrutiny Committee with assurance in relation to the approach that the Trust is taking to address the issues identified by the CQC inspection.

Background

2. In October 2022 the CQC conducted unannounced inspections of Urgent and Emergency Care, Medical services and Maternity services across both the York and Scarborough hospital sites. This was followed by well-led interviews between November 2022 and March 2023.

3. On the 25 November 2022, following the initial Well-led interviews, the CQC formally notified the Trust of their decision to impose conditions on its registration in relation to regulated activity for maternity and midwifery services. This was undertaken under section 31 of the Health and Social Care Act 2008.

4. An improvement plan was immediately developed against which the Trust provides the CQC with an assurance report on the 23^rd of each month which will continue until such time that the CQC is satisfied that the issues have been fully addressed.

5. The Trust received the full inspection report in June 2023, within which they were issued with 95 must do actions and 45 should do actions. There were a few repeated themes so these were amalgamated to form 73 improvement actions.

6. On a monthly basis the Trust is required to provide assurance to the Integrated Care Board (ICB) and NHS England (NHSE) chaired Integrated Quality Improvement Group (IQIG), in relation to the delivery of the improvement plans.

7. The CQC have been invited onsite by the Chief Nurse Designate to view the York Hospital Urgent and Emergency Care Centre on the 29 July 2024. The invite has also been extended to Maternity Services and this visit is being arranged for September 2024.

Journey to Excellence: A Focussed Improvement Programme

8. In response to the findings of the CQC inspection, a focussed improvement programme has been established entitled Journey to Excellence. A fortnightly programme Board chaired by Simon Morritt – Chief Executive Officer oversees the delivery of the programme, which comprises of seven workstreams designed in response to known risks in addition to the findings of the CQC:

· Maternity Services

· Governance

· Urgent care

· Leadership and Culture

· Safe Staffing

· Fundamentals of Care

· Elective recovery

9. Although the programme is not focussed solely on the CQC actions, each of the Must and Should actions are clearly mapped to the workstreams. This broader approach recognises that the required improvements must extend beyond the narrow scope of the CQC inspection if long term sustained improvement is to be achieved.

10. If an improvement action is considered ‘complete’ by the Care Group, and sustained impact of the action is evident, then a proposal can be made to close the action. Closure of the action must be supported by the Executive Lead and approved at the Journey to Excellence meeting.

11. As of the 30 June 2024, the Trust has approved 40 actions for closure through the Journey to Excellence meeting. The evidence to support the closure of actions is shared with the CQC.

12. Included below are examples of improvements delivered by the Trust as part of the Journey to Excellence Programme:

· Registered Nurse oversight of all waiting areas within the  Emergency Department. Volunteers are also providing food and drink to patients while they wait for treatment.

· Referral to treatment times of over 78 weeks were eliminated in March 2024, and waits over 65 weeks has reduced in line with the trajectory. The plan is to have zero 65 week waits by September 2024.

· Double flow oxygen meters have been installed for all beds at York, Scarborough, and Bridlington Hospital sites. The double flow meters are also held in both equipment library stores should they be needed.

· The new build Urgent and Emergency environment has opened at York Hospital and due to open in October 2024 at Scarborough Hospital.

· Positive feedback was given as part of the recent JAG accreditation visit and the Trust is progressing with the required actions to gain accreditation.

· The method of assurance on the continued implementation of National Patient Safety Alerts has been built into the alert closure process.

· Procurement of the mortality module in Datix (DCIQ) which is now used to capture structured judgement case reviews and track the implementation of improvement actions.

· An improved audit and assurance process has been developed within Maternity services which incorporates regulatory requirements, local priorities and NICE guidance.

13. The Trust held a Board development workshop on the recently published CQC Single Assessment Framework on 17 April 2024, following publication of the CQC guidance on 8 April 2024. An independent external Well Led assessment is also being commissioned for completion in Q4 of 2024/25.

14. A trust wide approach is being used to take the learning from the CQC visit and report, and other fundamental standards to develop and roll out our Year of Quality Programme. Delivery is overseen by Performance Review and Improvement Meetings (PRIM) and through our Quality Assurance framework. 

Leading Improvement

15. The Trust has made some key appointments:

· Martin Barcley – Chairman

· Karen Stone - Medical Director

· Dawn Parkes - Chief Nurse Designate

· Claire Hansen - Chief Operating Officer

· Adele Coulthard – Director of Quality, Improvement and Patient Safety

· Sascha Wells-Munro - Director of Midwifery

· Steven Bannister, Interim Managing Director

16. An essential component of successfully leading change is the visibility of senior leaders. This is supported by visits to clinical and non-clinical areas on all sites and in the community.  This is an informal ‘how are things’ session, with a loose structure of ‘what’s great/better if’ These are scheduled events with protected time after the Board of Director meetings. Service user feedback is also sought wherever possible.

17. The Back to the Floor initiative commenced on 1 September 2023 and is led by the Chief Nurse and senior nursing and Allied Health Professional colleagues. On a weekly basis, a number of wards are visited for focussed supportive reviews of key areas of potential concern. This enables supportive challenge, a visual check of quality and triangulation with quality related data such as complaints and incidents.

18. The Trust also has several key transformation programmes in place with a focus on Urgent and Emergency Care, Elective Care, the Community Diagnostic Centre, Our Voice Our Future, Leadership Development, Line Management Development and Estate Improvement.

Quality Assurance Framework

19. Rapid quality reviews have been undertaken across all wards. This provided a baseline of quality to focus targeted improvements. These reviews have also informed the initial focus areas for the Back to the Floor visits. A ward accreditation scheme has been developed as part of the framework.

20. Themes from the analysis of data, rapid reviews and back to the floor visits  informed the development of a Year of Quality Calendar. Each month will have a specific quality focus with June 2024 being End of Life Care.

Governance

21. With the support of NHSE, the Trust has revised the Corporate and Clinical governance arrangements with greater control and oversight on quality, performance, productivity, finance and efficiency. The Quality Governance structure to ensure that ward to board visibility of issues and assurance has been strengthened.

22. A Care Group restructure was completed in October 2023 and all key leadership posts within these structures have been appointed into substantively. The Trust is currently reviewing the implementation of the structure to ensure it is fit for purpose. A Governance and Accountability Framework is also being drafted to support the revised governance arrangements.

Workforce

23. In order to achieve our improvement ambition, workforce is essential. It is therefore essential that we can both recruit and retain staff. The Trust has welcomed a review by NHSE of nurse staffing and is working to implement the recommendations that they have made in relation to ensuring the correct level of staffing on wards through establishment reviews, effective use of rosters and wellbeing and development initiative to increase retention.

24. The Head of Nursing Workforce has been recruited to the Corporate Nursing Team and monthly roster assurance meetings for all Care Groups have been established. Positive progress has been made with an overall nursing vacancy position of 4% achieved and the Trust has ceased used of all ‘off framework’ agency usage for nursing staff.

25. The Trust 2023 staff survey results were disappointing and reflect the ongoing challenge of engaging meaningfully with 10,000+ staff spread over multiple acute and community sites across a large geographical area.

26. The Trust has recruited a team of change makers, made up of individuals from all grades and areas of the Trust and YTHFM, to engage with colleagues to discover what it is like to work here, and how we can make things better.  This is informing the actions the Trust needs to take and the areas to prioritise to deliver our culture change ambitions.

27. The Trust is following the NHSE culture change programme which is called Our Voice Our Future. The change makers are the ambassadors and champions for Our Voice, Our Future, supported by the Board and Executive Team, with Project Management input.

Recommendations

28. The Committee are asked to note the Trust response to the CQC inspection and the wider Journey to Excellence focused improvement programme.

Contact Details

Author’s name Title Dept Name Tel No.	Dawn Parkes Chief Nurse Designate York and Scarborough Teaching Hospitals NHS Foundation Trust 1 July 2024
Wards Affected:  List wards or tick box to indicate all		All	ü
For further information please contact the author of the report

Annex A: Scrutiny CQC Update Presentation