Notice is given that part of this item may be heard under Part 2.
Minutes:
Professor Nicola Ranger, Chief Nurse and Executive Director of Midwifery – King’s College Hospital NHS Foundation Trust (“Chief Nurse and Executive Director of Midwifery”) provided an update on the Trust and its Improvement Plan following the outcome of the Care Quality Commission (CQC) Inspection Report.
The Chief Nurse and Executive Director of Midwifery informed Members that she had been in post for around seven weeks. An overview of the King’s Executive Team was provided, which included Dr Clive Kay – Chief Executive and Bernie Bluhm – Chief Operating Officer who had attended the Health Scrutiny Sub-Committee meeting in July 2019. It was noted that the longest serving member of the King’s Executive Team had been in post for three years. A number of “fresh eyes” had come into the team, and they were aware of the impact that constantly changing the top team could have – they wanted to listen to staff and create a sense of stability. The Chief Nurse and Executive Director of Midwifery said that this was highlighted by the case of Frimley Park Hospital, which was the first to receive an ‘outstanding’ rating from the CQC and had a Chief Executive in post for twenty nine years. The King’s Executive Team were committed to being at the Trust, and to resolving issues for staff and patients. The Chairman enquired how many of the King’s Executive Team were in permanent roles. The Chief Nurse and Executive Director of Midwifery confirmed that the only post on a fixed term contract was that of the Chief Operating Officer. This contract had been for two years, however there were plans to make this post substantive.
The primary narrative of the Trust was for financial stability and addressing its huge reported deficit. Over the last two quarters, the Trust had reached its ‘control total’, and had been £1.6m ahead of plan at the end of August 2019. This had brought a sense of confidence and the aim was to stay on track, and reach the ‘control totals’ during the winter months which it was often harder to do. The Trust had significantly reduced the number of patients waiting over 52 weeks, from 450 to 130. It was intended that this would be reduced to zero in a maximum of six months. Fines were usually incurred for having 52 week waiters, but due to the Trust’s better financial performance these had not been issued. However, there were still challenging times ahead, at the Trust needed to “get on track”, but not at the expense of staff or patients.
A Member highlighted that in relation to the Trust’s financial performance, pay was £9.6m below budget, and queried what lay behind this. The Chief Nurse and Executive Director of Midwifery said that the Trust had one of the best fill rates at 80%, and they had recruited to posts rather than using agency staff. The Trust had one of the lowest vacancy rates, at just below 8%, and also one of the lowest staff turnover rates. The nursing vacancies at the PRUH were minimal, however the biggest challenge was the recruitment of medical staff to work at the hospital.
The Trust had been asked what impact the exit from the European Union (EU) would have on staffing. The Trust was planning for this according to the guidance published in December 2018 by the Department of Health and Social Care (DHSC), and subsequent communications from NHS England and NHS Improvement. The Trust had appointed an EU Exit Lead and there was a point of contact at a Sustainability and Transformation Partnership (STP) level. The Chief Nurse and Executive Director of Midwifery said that in terms of staff leaving, it was likely that they would have done so over that last couple of years, and in that time others would have applied for leave to remain. It was noted that there remained uncertainly around the UK’s departure from the EU, but staff had been warned that there may be more demand on their time, and they would work closely with colleagues to address this.
Members were provided with the attendance and performance figures for the PRUH’s Emergency Department (ED) and Urgent Care Centre (UCC) from April 2019 to September 2019. It was noted that the ‘Type 3’ performance, which was the more minor cases, had not been too bad. However, the ‘Type 1’ performance, which was patients that needed admitting and required a hospital bed, was a real concern. There was a significant way to go to improve the ‘Type 1’ performance figures, and work to be undertaken with partners to consider how to get patients out of hospital quicker. The PRUH had one of the best discharge lounges she had seen, and if they could get patients into it earlier in the day, other patients could be admitted into the vacant beds earlier as a result. In response to a question from the Chairman, the Chief Nurse and Executive Director of Midwifery confirmed that the attendance and performance figures for the PRUH’s ED and UCC could be produced on a monthly basis, and provided to the clerk for circulation to Members of the Sub-Committee.
The Chief Nurse and Executive Director of Midwifery noted that Members would be aware of the outcome of the CQC Inspection of the Trust, which had been published in June 2019. It had been pretty damning in relation to the ED at the PRUH, which had been a concern for staff and local residents. An oversight meeting had taken place in September 2019, at which the ED team had presented the action plan. This had then been presented to the CQC on the 12th September 2019, and they had been genuinely impressed with what they had heard. The CQC would make an unannounced visit to the ED over the next few weeks, and if they saw evidence of what had been presented, and it was echoed when speaking with staff, they may reconsider the inspection rating. The Chief Nurse and Executive Director of Midwifery said the Trust would be happy to send the presentation on the work being done to the clerk, for circulation to Members. It was noted that one area of concern raised related to resus, and too many patients using it at the same time. This had now been addressed, and no more inappropriate use had taken place. There had also been criticism that patients with mental health needs had potentially been exposed to non-ligature free areas, and to reduce this risk, a Mental Health Room was now in place. The Trust had actioned areas that the CQC had been most concerned about. These included: 90% of patients attending having a mental health assessment form completed in a timely manner; hot food and snacks were now available to patients, and hot drink rounds were in progress mid-morning and mid-afternoon in the ED and for relatives in the waiting rooms; and the completion of mandatory training for the medical team had improved to over 80%. However, there was more work to do and there were still issues of overcrowding with two patients being nursed in cubicles designed for only one person.
A Member asked if there had been any improvement in relation to the endoscopy backlog that had been highlighted at the last meeting. The Chief Nurse and Executive Director of Midwifery said that there had been a real issue with capacity and the Trust recognised that this was a key priority area, particularly at the PRUH. Assessments had been undertaken of those patients that may have been put at risk due to the delays. It was suggested that an update could be brought to the next meeting of the Health Scrutiny Sub-Committee.
Members noted the comments made in the CQC Inspection report in relation to staff morale and the attitude of staff towards patients, and enquired if anything had been done to address this. The Chief Nurse and Executive Director of Midwifery agreed that out of all the comments made in the report, these had been the most upsetting. At the time of the Inspection, there had been twenty four vacancies for Band 5 nurses, which had a big impact. These vacancies had since been reduced down to five, and she had recently met with a group of student nurses, five of whom were looking for jobs at the PRUH. A review of nurse staffing at the PRUH and Denmark Hill had been undertaken the previous year, however some of the decisions made needed to be re-looked at. The feedback received in real time had shown there was a focus on getting things better, and the family and friends test figures had increased by 20%. In response to a question, the Chief Nurse and Executive Director of Midwifery said that the Trust’s staff survey had opened on the 27th September, and would run for at least six weeks. Previously, the results had been managed on an aggregate level and not enough had been done to break these down by site and department. This year, the results would be broken down which would allow each unit to listen to staff, work on staff morale and find out what frustrated staff at various level. A reoccurring factor was the amount of violence and aggression that members of the hospital staff were subjected to. In response to a question, the Chief Nurse and Executive Director of Midwifery said that some of the violence and aggression was due to people coming into the hospital short-tempered and staff not always de-escalating the situation, whereas others were physically unwell and did not mean to be violent or aggressive. A number of those that “acted out” were mental health patients, and staff needed to be aware and ensure that they asked the right questions.
The Chairman noted that a lot of the aggression in the ED was due to the long waiting times and total lack of information given to the patients waiting. The reception staff seemed to take the brunt of the aggression, and needed training on how to deal with those situations. The Chief Nurse and Executive Director of Midwifery agreed, and said that what patients did not always see when they were sat in the ED was the number of ambulances coming in. Reception staff needed to listen to patients, disseminate information, and respond to them as individuals. It was acknowledged that reception staff had a hard job – in previous staff surveys these were the staff who said they did not feel overly cared for.
The Healthwatch Bromley representative said that one of the key things that had been identified in the feedback they had received from service users was administration. As well as the lengthy wait times and lack of communication, it was the multiple appointments system which needed to be streamlined, and the bad grammar and spelling mistakes on the pre-assessment forms that frustrated patients. It was noted that all of the service user data on the ED was pulled together, and fed back to the Patient Engagement Lead at the PRUH on a quarterly basis. The Chairman noted that it was difficult to understand why in this digital age, the hospital was still dependent on sending out letters. The Chief Nurse and Executive Director of Midwifery said that the outpatient’s appointment system and pre-assessment would be looked at as part of a big piece of quality improvement work. There was a lot that needed tweaking, but there was the capacity to get it to the right place.
A Member noted that in the Trust’s Improvement Plan, it quoted that in relation to ‘ensuring the environment and equipment was suitable and fit for purpose’ a Business Case for expansion was to be approved by the Executive Team, and asked if this was still intended for this to happen by March 2020. The Chief Nurse and Executive Director of Midwifery said that there were a number of new members in the Executive, with fresh opinions and views, but it was felt that the environment at the PRUH was quite good compared to some other ED’s. Feasibility would be looked at before any money was spent on reformatting. The structure and process of behaviour was being worked through, and then it would be decided if any building or capital works were required. It was noted that where ‘Type 1’ performance was very low, it usually indicated that this was impacted by the rest of the hospital, rather than just the space in the ED. It was anticipated that in this time frame, a clear decision would have been agreed.
The Chairman extended her thanks to Professor Nicola Ranger and Sarah Middleton for attending the meeting of the Health Scrutiny Sub-Committee and providing an update on the Trust and the progress made against the Improvement Plan thus far.
RESOLVED that the update be noted.