Agenda item - University Hospitals Sussex NHS Foundation Trust: CQC Inspection Report (April 2024 HOSC)

34.1    This item was introduced by Dr George Findlay, CEO of University Hospitals Sussex NHS Foundation Trust (UHSx).

34.2    Dr Findlay explained the Care Quality Commission (CQC) inspection process, and the context in which the most recent inspections took place. Points included:

·         The recent inspection was of all 4 of the Trust’s general hospital sites

·         UHSx overall rating is ‘requires improvement’. This tallies with the Trust’s own assessment

·         The CQC inspected in August 2023, but inspection reports were not published until February 2024. This delay is unfortunate, not least because significant improvements have been made in recent months

·         The CQC found much good practice across the Trust, particularly in terms of the care provided to patients – the RSCH is rated ‘outstanding’ in the caring domain

·         However, there were also negative findings, including waiting lists being too long; services failing to get some basics right; and a perceived lack of senior leadership visibility

·         The CQC has acknowledged that improvements have been made since its inspections and has upgraded some scores accordingly

·         All the CQC’s ‘must-do’ actions will be implemented across the Trust (not just in the localities where a particular action is required).

34.3    In terms of specific areas highlighted by the CQC:

·         Training and staffing – there have been significant improvements in training and recruitment since the inspections

·         Equipment and checking – a daily safety check for key equipment has been instituted. This is reported via the UHSx Safety Dashboard

·         Incident reporting – the UHSx rate is now higher than the national average (a high rate is a positive)

·         Cancer – UHSx is now outperforming the national averages for cancer treatment

·         Document management – the Trust is rolling out a fully electronic system over the next 12-18 months

·         Culture – a member of the Executive Leadership Team is focusing on cultural improvement.

34.4    The Chair asked what was being done to make A&E more accessible for people with mental health issues and for the neurodiverse. Dr Findlay replied that the Trust works closely with Sussex Partnership NHS Foundation Trust to support patients who are neurodiverse or who have mental health needs. This includes having a 24 hour 7 day a week mental health liaison service at the RSCH. There is also an enhanced waiting space for people with mental health needs. However, there is no doubt that the mental health crisis pathway needs improving: a hospital emergency department will never be an optimal place for people with mental health problems to present for treatment.

34.5    The Chair asked whether there had been a missed opportunity to reconfigure the RSCH emergency department as part of the 3Ts redevelopment of the RSCH. Dr Findlay responded that emergency department redesign was never within the scope of 3Ts which received funding for the specific purpose of enhancing tertiary, trauma and teaching capacity. The Trust did enter into discussions about whether some of 3Ts phase 2 funding could be allocated to the emergency department, but this was declined, with around £50 million additional NHS capital funding instead allocated for ED improvement.

34.6    The Chair asked why UHSx does not buy beds at Craven Vale to ease discharge pressures. Dr Findlay responded that discharge is a system issue rather than just an issue for the acute trust. UHSx works closely with colleagues in adult social care to try to ensure the timely discharge of patients.

34.7    In response to a question from Cllr Shanks about working with primary care, Dr Findlay agreed that this is a key issue. It is not right to talk about ‘inappropriate attendance’ at A&E as very few people come to A&E without having serious concerns about their health. It is important that people are able to access primary care, and working between the hospital trust and local primary services is now really joined-up. The Trust is working with partners to refresh the Sussex Urgent Care Strategy which will also strengthen links with primary care. In addition, the Urgent Treatment Centre at the RSCH undertakes a really important role in treating and supporting people who do not require A&E.

34.8    Cllr O’Quinn noted that in her experience treatment at the RSCH A&E was consistently good, but waiting for treatment was consistently miserable, with lots of very vulnerable people waiting a long time to be assessed or treated. A&E feels chaotic and overcrowded, and this is not helped by some people using it for seemingly minor things like prescriptions which could be better provided elsewhere. Plans to expand A&E are welcome.

34.9    In response to a question from Cllr O’Quinn about the correct use of antibiotics, Dr Findlay assured members that this is an area of focus for the Trust.

34.10  Cllr O’Quinn asked a question about staff reporting feeling pressured to take on work they do not feel qualified to deliver or in unfamiliar settings. Dr Findlay responded by stressing that staff are not asked to work beyond their competency. Staff may be asked to move around to cover gaps in service. This is sometimes unavoidable, but the Trust is working to minimise its occurrence and to provide more training so that staff feel comfortable working across a range of environments.

34.11  Cllr Evans asked a question about cancellations of elective procedures. Dr Findlay responded that this is a significant long term problem. Post-operative recovery beds are required for many elective surgical procedures, but when a hospital is under great pressure, these beds may be required for other purposes leading to planned operations being cancelled. Better flow through the hospital is the solution to this issue, and this is principally about reducing delays in the discharge of patients, the most common delay being because patients are waiting for social care packages. There are other factors impacting on elective surgery also, particularly in terms of an increasing demand for emergency procedures and for complex surgery. The Trust is working to increase its theatre productivity and capacity to address these issues.

34.12  Cllr Nann asked whether the problems at UHSx were fundamentally about senior managers not being good enough rather than flaws with systems. Dr Findlay disagreed that there was a problem with the quality of managers at the Trust. There has been recent recruitment of a number of new senior managers and non-executive directors, but many experienced leaders remain in post. The key to improvement is instituting effective processes rather than changing staff, and Dr Findlay is confident that the right leaders are in post, as evidenced by significant improvements across a range of service areas over the past 12 months.

34.13  Cllr Cattell voiced concerns about staff feeling confident that they can safely raise issues, noting that this is a long term problem for the NHS. Dr Findlay responded that this is a major focus at the Trust. Measures being taken include using the datix system to record incidents and commissioning an independent ‘Speak Out’ service, reporting directly to the Chief Executive on a monthly basis. Staff are speaking up and the focus is now on how their input is used: for example, a number of staff have raised concerns about the environment in A&E, but making improvements is not easy given the limitations of the current site.

34.14  In answer to a question from Cllr Hill on colorectal cancer cancellations, Dr Findlay told members that there have been fewer cancellations this year than last, in part due to the recruitment of more staff, in part because there is a ring-fenced colorectal theatre in the Louise Martindale Building. Where procedures have to be postponed, the aim is to reschedule as soon as possible. Both patient and staff feedback has been very positive about the relocation of this service.

34.15  In response to a question from Cllr Hill on staff training in autism, learning disability and in dementia, Dr Findlay told the committee that training is going well with more than 90% of relevant staff receiving this training as part of mandatory safeguarding courses.

34.16  Cllr Robins highlighted a CQC finding that staff do not always feel properly trained or competent to fulfil their roles. Dr Findlay told members that the CQC report reflects what staff have said to the CQC. However, the Trust has a robust onboarding process for all staff, and would never require staff to work beyond their competence. Many staff do feel uncomfortable being asked to work in unfamiliar environments, and whilst the Trust makes an effort to minimise this, it will sometimes happen. However, staff feeling uncomfortable in an unfamiliar environment is not the same as staff lacking competency.

34.17  In response to a question about meeting statutory waiting targets, Dr Findlay told the committee that strikes have had an impact on waiting times, as the Trust has had to prioritise emergency care. UHSx has been making improvements to waiting times nonetheless, although there is much more work to be done and no one thinks that the current position is good enough. In terms of the 4 hour A&E wait target, performance is currently around 70% (the national standard is 78%). New surgical and medical assessment units will help to improve performance, but the biggest obstacle to improvement remains people being unable to access a bed because of delays in discharge.

34.18  Geoffrey Bowden asked a question about the recruitment of international staff. Dr Findlay replied that the Trust is focused on having as high a percentage of permanent staff as possible. There is a major drive to recruit locally, for example, by working with Higher Education to offer a guaranteed position to people graduating. However, international recruitment is also key to recruiting effectively and the Trust has recruited around 120 international staff in the past year. This is done ethically, with the focus being on recruiting from countries that train more nurses than their own health systems require.

34.19  In response to a question from Cllr Nann on staff being required to work beyond scope, Dr Findlay reiterated that staff are never required to work beyond their competency. If staff feel that this is happening and flag their concerns then this will be addressed immediately.

34.20  Cllr Hill asked a question about surgical consultant recruitment, and whether the Royal Colleges are always involved in recruitment.Dr Findlayresponded that The Royal Colleges are invited to take part in all surgical consultant recruitment. However, it’s not always possible to find a diary slot that they can do without delaying recruitment to vital posts. The recruitment of surgical consultants is a rigorous process which always involves a Non-Executive Director, the Chief Medical Officer and the CEO/deputy CEO and others, so the process is a robust one whether or not the Royal Colleges accept a specific invitation to participate in a recruitment. The Trust only recruits consultants who are on the specialist register.

Dr Findlay subsequently wrote to the HOSC chair to apologise for inadvertently misleading the committee in the above response as Royal College representatives had not been as routinely invited to attend doctor appointment panels as he understood. This has since been rectified. To note, as a Foundation Trust, UHSussex is not required to do this but the Trust confirmed it appreciates Royal Colleges input and wishes for them to have an opportunity to participate.

34.21  In response to a question from Cllr Shanks on whether the provision of more key worker housing would make recruitment easier at the Trust, Dr Findlay told members that UHSx is a health provider only and that questions about the supply of key worker housing should be addressed to the city council.

34.22  Theresa Mackey enquired why the CQC had reported issues with the Trust collecting staff sickness data. Dr Findlay responded that it was unclear why the CQC stated this as UHSx has robust processes to monitor sickness and is performing relatively well.

34.23  In response to a questions from Ms Mackey on the assurance process for performance improvement, Dr Findlay told members that key metrics are measured daily and reporting via Trust systems in real time.

34.24  The Chair asked a question about late night discharge from hospital. Dr Findlay responded that discharge from in-patient beds should be early in the day. The current median discharge time is 5pm, but there is work ongoing to reduce this and some services now discharge more than 50% of patients by noon each day. Where patients are discharged out of hours, there will be community sector support to help people get settled at home. The process for discharging patients being assessed is somewhat different and these patients will be discharged whenever is appropriate.

34.25  The Chair thanked Dr Findlay for his contributions.

34.26  RESOLVED – that the report be noted.