Health, Housing & Adult Social Care Scrutiny Committee

19 September 2023

 

Report of Dawn Parkes – Interim Chief Nurse York and Scarborough Teaching Hospitals NHS Foundation Trust

 

CQC Inspection Update Report

Background

1.           In October 2022 the CQC conducted unannounced inspections of urgent and emergency care, medical services and maternity services across both York and Scarborough hospital sites. This was followed by well-led interviews between November 2022 and March 2023.

 

2.           On the 25 November following the initial Well-led interviews the CQC formally notified the Trust of their decision to impose conditions on our 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. The concerns raised related to the following issues:

·        Assessment and management of risk

·        Fetal monitoring

·        Cardiotocography (CTG) training

·        Audit

·        Assessment and triage

·        Governance and oversight including Incident reporting.

·        Post-Partum Haemorrhage

·        Fire safety and security

·        Availability of Scrub nurse and recovery roles in maternity theatres

 

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

4.           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 number of repeated themes so these were amalgamated to form 73 improvement actions. The Trust improvement plan was submitted to the CQC on 20 July 2023, which they have approved.

5.           On a monthly basis the Trust is required to provide assurance to the joint ICB and NHSE chaired Quality Improvement Group, in relation to the delivery of the improvement plans.

6.           The purpose of this report is to provide the Health, Housing & Adult Social Care Scrutiny Committee, with assurance in relation to the approach that the Trust is taking to address the issues identified by the CQC inspection.

Journey to Excellence: A focussed Improvement Programme

7.           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 – CEO oversees the delivery of the programme, which comprises of 8 workstreams designed in response to known risks in addition to the findings of the CQC:

•         Maternity Services

•         Governance

•         Staff Engagement

•         Urgent care

•         Leadership and Culture

•         Safe Staffing

•         Fundamentals of Care

•         Elective recovery

 

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

 

9.           An Executive Lead has been assigned to each workstream and ‘plans on a page’ have been developed and presented to the Journey to Excellence meeting on 21 August 2023.

 

10.        Executive led ‘check and challenge’ meetings for Care Group level improvement plans will be held in September 2023, with delivery of the plans overseen through the Care Group Oversight and Assurance meetings.

 

11.        If an 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 through the Journey to Excellence meeting.

 

Leading Improvement

 

12.        The Trust has made some key appointments since October 2022, Karen Stone – Medical Director, Dawn Parkes, Interim Chief Nurse, Claire Hansen – Chief operating Officer and Sascha Wells-Munro Director of Midwifery. The trust is supported by two Improvement Directors – Ellen Armistead and Adele Coulthard in addition to the NHSE intensive support team and Lorna Squires – Deputy Director of Quality Governance for NHSE.

 

13.        An essential component of successfully leading change is the visibility of senior leaders and this is supported by the Department to Board Walkabout Programme and the Back to the Floor initiative. The Department to Board Walkabout Programme is a rolling programme of focussed ward and department visits by non-executive and Executive colleagues to provide clinical areas with support in identifying, addressing and escalating key issues. The Back to the Floor initiative commenced 1st September 2023 and is led by the Chief Nurse and senior nursing and AHP 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.

 

Quality Assurance Framework

 

14.        Rapid quality reviews have been undertaken across all wards. This has 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 is in development as part of the framework.

 

15.        Themes from the analysis of data, rapid reviews and back to the floor visits has informed the development of a Year of Quality Calendar. Each month will have a specific quality focus with September being Infection Prevention and Control.

 

The sustainable review of quality at ward level will be maintained by the Quality Assurance Framework.

 

Governance

 

16.        With the support of NHSE the Trust has refreshed the Quality Governance structure to ensure that ward to board visibility of issues and assurance is strengthened. A new Care Group structure is being implemented which offers further opportunities to align governance resources.

 

Workforce

 

17.        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.

 

Recommendations

 

18.        The Health, Housing & Adult Social Care Scrutiny Committee are asked to note the Trust response to the CQC inspection and wider Journey to Excellence focused improvement programme.

 

Reason: To keep the Committee updated on the Trust’s response to the CQC inspection,

 

Contact Details

 

 

 

 

Dawn Parkes

Interim Chief Nurse

York and Scarborough Teaching Hospitals NHS Foundation Trust

 

 

Report Approved

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Date

11/09/23

 

 

 

Wards Affected:  List wards or tick box to indicate all

All

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For further information please contact the author of the report