Agenda item - Care Quality Commission Inspection Report on Maternity and Surgical Services at the Royal Sussex County Hospital: Update

Report of the Executive Director, Governance, People & Resources (copy attached).

16.1    The Chair told members that she had agreed that items 16 and 17 would be jointly presented, as both concern Care Quality Commission (CQC) inspections of University Hospitals Sussex NHS Foundation Trust (UHSx) services.

 

16.2    Dr George Findlay, Chief Executive of UHSx, and Dr Maggie Davies, UHSx Chief Nursing & Midwifery Officer, presented on items 16 and 17.

 

General Issues

 

16.3    Dr Findlay told the committee that UHSx manages seven hospitals across Sussex, including acute hospitals in Chichester, Worthing and Hayward’s Heath and the Royal Sussex County Hospital (RSCH) in Brighton. In September 2021, the CQC undertook an inspection of maternity services in all of these hospitals, and additionally of surgery at RSCH. The CQC published its findings in January 2022, downgrading its rating for maternity at all Trust hospitals, and for surgery at RSCH. The CQC re-inspected in April 2022, and simultaneously conducted an inspection of RSCH urgent & emergency services. It published inspection reports in July 2022, noting some improvements in RSCH surgery but with unchanged ratings; and downgrading its rating of urgent & emergency services at RSCH.

 

16.4    The downgrading of CQC ratings of hospital services is disappointing, but needs to be seen in the context of national pressures: Sussex hospitals remain comparatively good. Following the CQC reports, significant improvements made to maternity services. There has been less improvement in terms of surgery and urgent & emergency, but the capacity issues at RSCH have a major impact on these services. It is important to stress that staff across the Trust are amazing, a fact recognised by the CQC.

 

16.5    Cllr Grimshaw asked a question about what the Trust was doing about staff accommodation, noting that she had spoken to an NHS worker who had been unable to find a room in a shared house in the city. Dr Findlay acknowledged that the cost of living in Brighton & Hove poses a significant challenge. The Trust has limited staff accommodation, but this needs to be reserved for newly recruited staff moving in from another area. UHSx is working closely with charities and Housing Associations to support staff through the cost of living crisis.

 

16.6    Cllr O’Quinn asked why BAME staff experiences were not mentioned in the CQC inspection report. Dr Findlay responded that the CQC had found no issues with BAME staff in its inspection. However, the Trust recognises that, as with any other large employer, it needs to improve experiences for BAME staff and this is a key improvement workstream.

 

16.7    Cllr O’Quinn  enquired about the UHSx attitude to overseas recruitment, given that there has been criticism by the WHO on the negative impact this has on health systems in the developing world. Dr Findlay replied that UHSussex actively recruits oversees staff, in accordance with Government policy. The Trust is proud of the measures taken to integrate oversees workers into the workforce. The Trust is also proud of the work it does with local universities, including Chichester, to develop local talent in areas such as nursing and allied health professions. Dr Davies added that Chichester runs a more traditional nurse training course than many universities, with a focus on supporting students with an aptitude for nursing rather than people with high A level results.

 

16.7    In response to a question from Cllr O’Quinn about the Trust’s lack of improvement progress in recent years, Dr Findlay argued that this was inaccurate: Brighton & Sussex Universities Trust had seen major improvement in 2018, when its CQC rating was increased. Services remain generally good despite the very severe pressures caused by Covid.

 

16.8    Cllr O’Quinn asked a question about the Trust’s use of agency staff. Dr Davies responded that UHSx aspires to use agency staff only for specialist roles, hence the focus on local and international recruitment of permanent staff.

 

16.9    Cllr West asked a question about staff retention rates and about support for staff welfare. Dr Findlay responded that staff retention rates are good, although there is more work to be done, particularly with Band 2 Health Associates. The Trust offers all staff wellbeing appraisals and will signpost staff to independent financial advice, foodbanks etc. UHSx provides some limited direct financial support to staff.

 

16.10  Geoffrey Bowden commented that Healthwatch had contributed to the recently published CQC reports, and also to two further inspections: of leadership across the Trust and of neurosurgery. Dr Findlay told members that neither inspection report has yet been published, but that feedback from the CQC has been positive, particularly for neurosurgical services.

 

16.11  The Chair asked why RSCH underperforms other UHSx hospitals. Dr Findlay replied that the core problem is that the RSCH site is too small for the level of demand. The hospital is consequently cramped and overcrowded, and this inevitably impacts on care and leads to frustrated staff who are unable to deliver the care they want to. 3Ts will help in this respect.

 

Urgent & Emergency

 

16.12  Dr Findlay told the committee that urgent & emergency services at RSCH had been downgraded from ‘good’ to ‘requires improvement.’ This was because of concerns about safety, largely due to overcrowding in the emergency department. This was a fair comment by the CQC, and is something being seen across the country. UHSx has done what it can to manage emergency department pressures: e.g. by opening an Urgent Treatment Centre (UTC), and remodelling the emergency department; but overcrowding remains a major issue. Staff have responded positively to the CQC report, and working is ongoing internally to improve flow through the hospital by reducing length of stay, and externally by working with partners to minimise discharge delays.

 

16.13  Nora Mzaoui asked why such high numbers of people with mental health issues were presenting for treatment at A&E. Was this due to local demographics, or a lack of mental health system capacity? Dr Findlay acknowledged that this is a real problem, both in terms of people presenting for treatment and in terms of the police bringing S136 detainees to A&E as a place of safety. Sussex Partnership NHS Foundation Trust (SPFT) is working to improve city mental health prevention and crisis services, and UHSx is also planning to open a dedicated mental health facility on the RSCH site, to be staffed by SPFT. This will be open by Christmas. These measures should help, but the growing number of mental health presentations is also likely to reflect increasing problems with mental health across the population.

 

16.14  Cllr Grimshaw told members that an elderly resident in her ward had experienced poor care at RSCH, being directed to the UTC after a long wait in A&E and then redirected to A&E after waiting in the UTC. Dr Findlay responded that things had clearly gone wrong for this patient, who should have been either dealt with by primary care services or signposted by the A&E streaming nurses. In future, all walking patients will enter via the UTC. Work is also needed on a better interface between primary and secondary care services. This will be advanced via the Sussex Integrated Care Board (ICB).

 

16.5    Cllr Rainey asked whether there was a need for more staff training to deal with people with mental health problems or multiple health needs seeking support. Dr Findlay responded that we are in uncharted waters in terms in the increase in mental health issues. UHSx is working closely with SPFT, and lots of staff training is available. However, the Trust does not want to normalise a situation where A&E becomes the default destination for people in mental health crisis as this is not how the system is intended to function.

 

16.6    Cllr Rainey suggested that the mental health pressures faced by A&E indicated a need for more acute mental health beds. Dr Findlay replied that he did not disagree, but this was not something for him to determine.

 

16.7    The Chair asked whether this winter was set to be unusually bad. Dr Findlay responded that every winter was challenging, but there were particular concerns for the coming winter in terms of staff resilience. There is a comprehensive winter plan to minimise admissions, provide additional bed capacity and reduce length of stay. Discharge delays are a real problem: at any given point between 10 and 25% of beds are occupied by patients who are medically ready for discharge but who are awaiting care packages. There is also a system focus, led by Sussex Community NHS Foundation Trust (SCFT), on supporting frail people and providing anticipatory care to avoid admissions.

 

16.8    In response to a query from the Chair on the Trust’s performance against A&E targets, Dr Findlay told members that the current  focus was on safety rather than targets. For information, the RSCH is currently reporting around 55% against the A&E target of 90% of patients seen within 4 hours. There are also numerous 12 and 24 hour breaches, and patient feedback is poor, without only around 75% of patients who would recommend urgent & emergency. This is just the reality of the current pressures being faced by the NHS.

 

Surgery

 

16.9    Dr Findlay told the committee that there had been improvements in surgery following the CQC inspection report, with particular progress in infection control, incident management and recruitment. UHSx has commissioned external reviews of aspects of surgical services to help identify factors blocking improvement. Dr Findlay also told members that upper GI (gastro-intestinal tract) surgery had been suspended at RSCH following a CQC report. This affects only a small number of patients, with other upper GI treatments continuing as normal. Patients due for surgery have been redirected to the Royal Surrey in Guildford, with no delays to treatment. The CQC had been particularly concerned with levels of staffing at RSCH, although no unit in South-East England meets staffing requirements for upper GI and outcomes at RSCH had been good (the Trust commissioned an independent review of outcomes since 2019 to establish this). UHSx hopes to resume upper GI surgery at RSCH as soon as possible.

 

16.10  The Chair asked a question about the 3Ts development of RSCH as a tertiary centre, and whether this could be achieved without a negative impact on secondary services for city residents. Dr Findlay replied that he would not have personally chosen to name the development programme 3Ts (tertiary, teaching, trauma) as this gives the impression that it is focused on specialised services, whereas phase 1 of 3Ts is actually mostly focused on improving secondary services. There is a need to grow tertiary capacity in Sussex: currently more than 50% of patients requiring cardiac or neuro surgery have to travel to London or Southampton. However, the Trust is committed to providing secondary services for local people.

 

16.11  In response to a question from Cllr West on the threat of a ‘twin-demic’ this winter, Dr Findlay responded that this is something that the Trust is modelling. There is a particular focus on protecting planned (elective) procedures: e.g. working with Queen Victoria Hospital, East Grinstead, Eastbourne General Hospital and local independent sector providers to ensure that there is sufficient capacity to run the planned elective programme.

 

 

16.12  The Chair thanked Dr Findlay for his attendance, and also thanked everyone working locally in the NHS for their hard work and dedication.

 

Maternity

 

16.13  Dr Davies told the committee that there has been significant improvement in maternity services following the CQC report. Staffing levels have improved across the Trust, although it remains more difficult to recruit to Brighton & Hove due to cost of living issues. There is a good career offer for midwives, with the range of different maternity environments across UHSx hospitals, including the Trevor Mann intensive care unit, providing an attractive range of settings. A new Director of Midwifery has been appointed; sickness levels have decreased; weekly listening events have been implemented; a better maternity information system has been launched; there have been no recent ‘never events’; and staff morale has improved. There is still more work to be done, however.

 

16.14  In response to a question from Cllr Grimshaw on the role of the Director of Midwifery and on staffing, Dr Davies told members that the Director works across all four hospital maternity units, with a matron in operational charge of each site. The Trust has had recent successes in recruiting nationally and internationally for midwives, maternity support workers and maternity workers. Worthing and Chichester maternity units are currently at establishment. Dr Davies promised to circulate the figures for Brighton & Hove.

 

16.15  In answer to a query from the Chair about midwife to mother ratios, Dr Davies agreed that this was an important metric. The Trust holds daily huddles and will move staff between sites to maintain a good ratio in each unit, including one-to-one support for mothers in labour etc.

 

16.16  In response to a question from Cllr O’Quinn about staffing mix, Dr Davies responded that the Trust aims to have a good mix of experienced and inexperienced staff, with active recruitment at both ends of the experience scale. There is a focus on retaining staff and on ensuring that midwives in training continue to work at the Trust once qualified.

 

16.17  Geoffrey Bowden noted that Healthwatch had been asked to undertake a pilot study of mental health and maternity.

 

16.18  In response to a question from the Chair on 24/7 staffing levels, Dr Davies told members that there is a focus on maintaining safe staffing levels at nights and weekends. Staffing levels are not constant throughout the day and week as elective procedures tend to be scheduled for daytime in the working week. The Trust does its utmost to maintain rotas on all its sites, although this can be a challenge, particularly when staff report sick at short notice.

16.19  In reply to a question from the Chair about the institution of a listening culture, Dr Davies told members that there has been a good deal of work in this area, with listening events, senior officers maintaining an open door policy, a Non-Executive Director meeting each month with maternity staff, and a route for all staff to raise concerns directly with the Chief Nursing Officer. There have been concrete improvements in response to staff feedback, including improve staff rest areas.

 

16.20  The Chair thanked Dr Davies for her presentation.

 

16.21  RESOLVED – that the report be noted.