Item 7. For Assurance For decision For discussion To note

Transcription

1 Item 7 Report to Trust Board 26 th January 2017 Report title CQC inspection: outcomes and next steps Report from David Probert, Chief Executive Officer Prepared by Ian Tombleson, Director of Corporate Governance Kaajal Chotai, Head of Compliance and Quality Improvement Previously discussed at Management Executive Attachments Appendix 1: CQC overarching provider report Appendix 2: CQC recommendation / action tracker Appendix 3: CQC quality summit draft agenda Brief summary of report Explanation of the CQC inspection in May and its process Inspection report summary Summary of our process for action plan delivery and process of monitoring Forthcoming Quality Summit meeting and its purpose and desired outcome Action Required/Recommendation The Board is asked to note the inspection outcome as GOOD. Progress with action planning and delivery has started. As required by the CQC a Quality Summit is being organised. For Assurance For decision For discussion To note 1

2 2 Executive Summary This paper provides a summary of the outcomes of Moorfields CQC inspection in May 2016 including receipt of a final inspection report in January 2017 and next steps. Section 1, p3: introduction overview of inspection activities and initial feedback from the CQC. Section 2, p4: background briefly describes the organisation s journey from May 2014 to the announcement of inspection including how the CQC inspection has been incorporated within our quality improvement journey. Section 3, p7: inspection report summary highlights from the inspection report about areas of good practice and areas for improvement. Section 4, p11: post inspection action planning and improvement works summarises the action planning process and actions that have already commenced. Section 5, p12: quality summit and next steps describes the purpose of the quality summit and the desired outcome, as well as the next steps post-inspection and the future CQC regulatory model. A more detailed report analysing the learning for the project team and the organisation as a whole will be available in due course.

3 3 1. Introduction The Care Quality Commission (CQC) undertook an announced inspection of Moorfields Eye Hospital NHS Foundation Trust for five days from 9 to 13 May Scheduled inspections took place across nine of our sites: City Road, St George s, Queen Mary s Roehampton, Croydon, Purley, Barking, Bedford, Ealing and Mile End. The CQC also undertook an unannounced inspection of Northwick Park and unannounced pre-inspection medicines management checks at Mile End and Barking. The CQC undertook further unannounced inspections between May, and revisited Queen Mary Roehampton and City Road, re-inspecting outpatients and surgical services. As part of the inspection, the CQC spoke to patients, visitors, carers and staff (in the hospital, in focus groups and formal interviews) to gain a view of Moorfields four core services - outpatients, surgery, urgent & emergency services and children & young persons services. The CQC methodology seeks to rate each of these in relation five domains: Were services safe? Were services effective? Were services caring? Were services responsive to people s needs? Were services well led? Starting in December 2015, during and after inspection, the Trust provided large amounts of documentation to the CQC via a process called the Provider Information Return (PIR). The CQC use this information to provide focus during their inspection and triangulate their inspection results. Requests for information continued until October 2016, when the trust received its draft reports for factual accuracy review. All responses were provided within deadline and the trust s final reports were received on Tuesday 3 January Robust communications and engagement plans were initiated to ensure as many staff as possible were sighted on the embargoed outcome prior to publication by the CQC on 6 January. Moorfields was rated Good overall. The inspection ran smoothly as a result of robust preparation and engagement with staff at all levels and the CQC commented very positively on how timely the Trust s responses had been.

4 4 2. Background In September 2014, the CQC confirmed a new inspection regime and a revised methodology, resulting in Ofsted style outcomes, reports and improvement measures. This comprehensive assessment method includes inspection teams (the size of which is be determined by the size of the organisation being inspected) made up of experts (inspectors and patients) and specialist advisers (i.e. peers from relevant backgrounds), making judgements about quality of care and whether or not a service is safe, effective, caring, responsive and well led. This would be achieved using a mixture of announced and unannounced inspections and multiple sources of evidence to support findings. The quality and safety team commenced preparation for a new style CQC inspection during the last quarter of 2014/15. The major activity for the first two quarters of 2015/16 was a self-assessment baseline by all clinical and non-clinical areas and subsequent improvement action planning. Strategic corporate planning took place in parallel. A summary of the timeline is as follows: Inspection notification was received on 21 December 2015.

5 5 A summary of the inspection timeline is set out below: Once the inspection was announced, a number of phases (as per a full project plan) commenced: 1. Data requests (provider information returns, or PIR) commenced from 22 December PIR 1 was requested over Christmas 2015 and submitted on 12 January PIR2 was requested mid-february 2016 and was delivered mid-march 2016 in line with the CQC's requirements. PIR2 was a much more detailed request compared with PIR1, and a pre-emptive process and working group were established to collate vast sets of data. 2. Continued data requests and general inspection planning (in conjunction with the CQC) took place right up until the week before the inspection. This included arranging interviews with staff and focus groups for the medical, nursing, allied health professionals and administrative staff. The CQC also had a patient stall at City Road on 4 May 2016 collecting up to date patient feedback. 3. An internal CQC hub (staffed by the quality and safety team and supported by the communications and performance and information teams) was set up to manage and coordinate both the data requests and the feedback received from staff about their inspection experience. The hub also managed communications with staff about the inspection, and provided the executive team with a daily update.

6 6 4. The onsite inspection took place from 9-13 May 2016, as detailed in the sections above. The CQC chose to visit a mixture of sites to ensure they obtained a broad view of our care models across all our services. 5. Post onsite inspection, two weeks of unannounced inspection followed for our City Road site as well as a visit to Queen Mary Roehampton, and data requests continued to come through until just before the draft reports were received. 6. Following receipt of the draft reports a factual accuracy process and response took place. Planning for that commenced in July The factual accuracy process commenced on the 10 October 2016 when the draft reports were received. The CQC aims to provide organisations with their draft inspection report 50 days post inspection - we received our report around 140 days post inspection. The factual accuracy response was submitted in the required timescales on 2 November. 8. Final reports were received on Tuesday 3 January Robust communications and engagement plans were implemented to ensure as many staff as possible were sighted on the embargoed outcome prior to publication by the CQC on 6 January. Moorfields was rated Good overall. Whilst it was a challenge for the organisation, solid preparation ensured that Moorfields was in a good position when the inspection was announced to respond to the Provider Information Requests (PIR), and to implement the inspection planning and preparation in earnest. Much was learnt from the first round of data submission about how the organisations manages data and information, how it is stored and how readily accessible it is. Data quality issues were also identified, and as a result streamlined processes and additional resourcing were put in place to support the next stage of data provision.

7 7 3. The inspection report summary To provide a view of Moorfields network, the CQC has presented its findings using six reports: an overarching provider report (summary report of all sites and services inspected) Bedford City Road St George s Outpatient and diagnostic imaging services satellite sites (which includes all satellite outpatients services other than City Road, St George s and Bedford) Surgical services satellite sites (which includes all satellite surgical services other than City Road, St George s and Bedford) These reports were published on the CQC and Moorfields websites on Friday 6 January The overall ratings for the trust by domain are: Safe Requires improvement Effective Good Caring Good Responsive Requires improvement Well-led Good How this translates into an overall rating In deciding on a rating, the CQC seeks to answer the following questions: Does the evidence demonstrate a potential rating of good? If yes does it exceed the standard of good and could it be outstanding? If no does it reflect the characteristics of requires improvement or inadequate? Each service inspected is rated against each domain: safe, effective, caring, responsive and well led. For the purposes of the inspection services are rated in isolation. However, they do not operate in isolation. Only by multi-disciplinary working and cohesive and supportive leadership have services achieved the ratings they have. In particular, outpatient and diagnostic services underpin our urgent and emergency and surgical services, contributing to our overall Good rating for Caring. Although not rated for Effective (the CQC does not rate trusts for Effective in outpatients) the reports contain robust indications that outpatients and diagnostic services deliver effective care comparable with other trusts.

8 8 The overall rating for the trust is Good with the following sub-elements: Satellite services City Road St George s Bedford

9 9 What we can be proud of The CQC found several areas of Outstanding practice including: The trust had a pivotal role in the development of ophthalmic services, as a lead in one of the hospital vanguard systems selected by NHS England to develop new models of care. The development of staff skills, competence and knowledge and the development of extended nursing and allied health professional roles. Staff reported that they felt well supported and received good training opportunities. There was an extensive research portfolio that was recognised at a UK and global level, directly benefiting patients. There was a clear proactive approach to seeking out and embedding new and more sustainable models of care from all staff levels within the services, and across the Moorfields network. The CQC noted the trust had made significant investments in leadership and quality improvement. At City Road services for children and young people and urgent and emergency services were rated Good overall. Services for children and young people were rated Outstanding for Caring at City Road. Surgical services were also reflected well across the trust. Services for children and young people Systems and processes were in place to promote the delivery of safe care. Children and young people benefited from a multi-disciplinary approach to care within a purpose built setting. Parents, children and young people were overwhelmingly positive about the kindness and compassion of staff and their cheerful and calm approach. There was good clinical leadership and staff felt supported. A comprehensive programme of research was being undertaken, new services were being developed and the expertise within the service was reflected by the published research in national journals. Urgent and emergency services The number of patients attending urgent and emergency services had risen by 15% at City Road in the previous two years. The service was able to respond to the increased demand and had consistently achieved the national quality standard for seeing 95% of patients in less than four hours. The department achieved this standard every month since August Care and treatment was evidence based and the hospital participated in national and local audits to monitor patient outcomes. Clinicians were involved in the development of national standards and guidelines. There were effective systems in place to protect patients from harm and a good incident reporting culture. Learnings from incident investigations were disseminated to staff in a timely fashion.

10 10 Surgical services There were comprehensive and robust governance and risk management processes in place with appropriate systems to ensure information was shared. There were a low number of serious incidents. Good processes for reporting incidents and systems were in place for learning to occur. Clinical areas were visibly clean and there was good compliance with hygiene processes resulting in low infection rates. Friends and Family Test results were consistently good across surgery services. The satellite sites had systems in place to keep patients safe. Patient safety was protected on a day to day basis and patients were safeguarded from harm. Safeguarding processes were followed. Staff morale across satellite sites was high and most staff felt supported by their managers. Staff felt proud to work at the trust and enjoyed their work. There were many opportunities to progress and development was encouraged. Where we need to do further work There are many aspects of the CQC reports that are a fair reflection of the services the trust provides and the very positive experiences of our patients and staff. There are also elements of the reports that identify where the trust has further work to do. With our combined and concentrated efforts, we will now work together to address the areas identified for improvement by the CQC and have already started to address some of the more pressing of these in response to initial feedback after the inspection in May. Some of these we can do relatively easily and quickly, others require significant behavioural change across the trust. Fully embed the World Health Organisation safer surgery checklist, in terms of both documentation and the quality of staff engagement in the process, across the organisation. Ensure adequate audit and monitoring systems are in place to monitor performance and compliance of the WHO safer surgery safer surgery checklist to guide improvement. Continue to improve and monitor our record keeping practices. This includes addressing where storage space is lacking and ensuring that patient records are fully and legibly completed. Review the governance process around Service Level Agreements (SLAs) with partner organisations, and ensure these fit the existing and future models of care delivery. The next section provides more detailed information about the action plan to address the findings of the inspection report. Please see appendix 1 for the overarching provider report.

11 11 4. Post inspection action planning and improvement works Key areas for improvement from CQC s reports were explained in section 3. In total, reports contain 78 improvement actions set out in three priority categories of: 1. requirement notices 1 2. must do s 3. should do s Moorfields started planning and delivery of these after receiving CQC s draft reports in October. However, following the factual accuracy checking process a number were redefined or removed by the CQC by the time the final reports were published on 6 January. The final list of 78 improvement actions has been grouped and arranged into themes to support delivery. The compliance team have developed project tools and monitoring processes to support delivery. All actions have been allocated to Executive Directors to lead and delivery has commenced. Rigorous monitoring is taking place every two weeks at Management Executive. The Board will receive monthly summary progress updates. The table below summarises the CQC actions per report. CQC report Requirement Must / Should Must Do notice Should Do* Do Total Provider Satellite outpatients 4* 4 Satellite surgery 5* 5 Bedford City Road St Georges Total * *In some cases the CQC has provided an overlapping definition. The CQC require a Quality Summit to take place about one month after report publication. The purpose of the Quality Summit is for the CQC, NHSI and other key stakeholders to support the trust s action planning. This is explained further in the section below. Please see appendix 2 for a summary of the action plan. 1 CQC: Where a registered person is in breach of a regulation or has poor ability to maintain compliance with regulations, but people using the service are not at immediate risk of harm, we may use our power to require a report from the provider. We will do this by serving a Requirement Notice on the provider.

12 12 5. Quality Summit and next steps Purpose of the Quality Summit Following inspection publication the CQC requires a Quality Summit to take place. At this the trust meets with the CQC and the trust s key stakeholders. The purpose of the Quality Summit is to develop a plan of action and recommendations based on the inspection team s findings. This plan will be developed with partners from within the health economy and the local authority. Quality Summits consider: The inspection findings. Whether planned action by the trust to improve quality is adequate or whether additional steps need to be taken. Whether support should be made available to the trust from other stakeholders such as commissioners to help them improve. How does the Quality Summit fit into the inspection process? The inspection model for NHS providers (including acute, mental health, community combined and ambulance providers, both foundation and aspirant), is a specialist, expert and risk-based approach to inspection that allows the CQC to get at the heart of what really matters to patients and the public. It aims to better enable the CQC to highlight where care is good or outstanding and to expose where care is inadequate or requires improvement. All comprehensive NHS inspections follow the following stages: Preparation (including intelligence input and planning). Inspection visits. Reporting (including making judgements and ratings, quality assurance, and quality summits). Quality Summit agenda The session lasts approximately 3 hours and is split into two parts: Part one The CQC Inspection Team Leader / Head of Inspection (HOI) / Inspection Chair) chair this section and summarise the results of the trust s inspection report. Following the CQC presentation, the Chief Executive will present the trust s response to the inspection s findings, what the trust is doing to address the issues raised and where they feel additional support will be needed. Part Two The second part of the Quality Summit will be facilitated by a representative NHS Improvement and Moorfields and will be focused on agreeing a high level action plan in response to the findings of the inspection. The summit will provide a robust challenge to ensure that actions are not short term but are focused on sustainable change. The actions should be agreed by the trust, the CQC and other partners present.

13 13 This part of the Summit will consider: Whether planned action by the provider to improve quality is adequate and whether additional steps should be taken. Whether support should be made available to the provider from other stakeholders such as commissioners to help them improve. Any areas that may require regulatory action in order to protect patients. After the Quality Summit The CQC will circulate the minutes from the Quality Summit to all invited parties within a week of the Summit. The recommendations for action will be captured in a high level action plan(s). Further work will be required by the trust and its partners following the Quality Summit to develop the detail beneath the high level actions. This should be completed within approximately one month of the Quality Summit. Action plans are owned by the trust and the trust will use their own action plan templates and tools. CQC will expect to be consulted on the adequacy of the action plan before it is agreed. Once agreed, action plans should be shared with the CQC Inspection Team Leader / Head Inspection to ensure all key areas highlighted during the inspection have been appropriately addressed and stored on CQC systems. Future inspections As Moorfields continues work towards becoming an outstanding organisation we should assume that the CQC may re-inspect at any time in the future and should be ready for this. As well as delivering a timely and comprehensive action plan the trust will further embed quality improvement methods, systems and learning so this practice becomes business as usual across all services and business areas. The CQC s inspection regime is changing to be more light touch. The CQC are developing a risk based, combination model of self-assessment, inspection (or a form of investigation/deep dive review proportionate to risk) with continuous monitoring. This model is similar to the compliance assessment framework implemented by Moorfields in The CQC will undertake smaller, annual risk based inspections of organisations, and will inspect as a minimum, one service which has areas of improvement/concern, until there is evidence of improvement. They will review the well led domain every year. The CQC is currently consulting on its future inspection methodology. Please see appendix 3 for the quality summit draft agenda.

14 14 Appendix 1 - CQC Provider Report (Separate document attached or link here)

15 15 Appendix 2 - CQC recommendation status overview 78 individual actions have been grouped into 54 collated actions Action no. Theme Action ID 1. Anaesthesia Clinical effectiveness Controlled drugs Emergency cover Emergency cover (out of hours) CQC recommended action Ensure patient s body temperature is monitored during surgery under general anaesthesia Ensure staff are able to benchmark clinical outcomes and quality indicators Ensure all controlled drugs records are completed in line with Trust Policy and carry out regular audits to monitor compliance Ensure Mile End displays clear medical emergency arrangements and every staff member knows the procedure. Formalise and implement the agreement with St George s University Hospitals NHS Trust for the management of patients who became unwell out of hours. Reports where actions appear Satellite Surgery (Northwick Park) Bedford Bedford Satellite Surgery (Northwick Park) Provider St Georges CQC action priority type MUST take SHOULD take MUST take MUST take MUST take Executive Lead Declan Flanagan Declan Flanagan Declan Flanagan Declan Flanagan Declan Flanagan

16 16 Action no. Theme Action ID 6. Equipment Patient records Policies, procedures and clinical protocols Surgical safety checklist Surgical safety checklist Surgical safety checklist CQC recommended action Anaesthetic equipment checks Ensure that patient records are fully and legibly completed Ensure policies and clinical protocols are updated regularly and there is a system which allows effective monitoring of it. Ensure adequate audit and monitoring systems are in place to monitor performance and compliance of the WHO five steps to safer surgery checklist to guide improvement. Ensure the WHO safer surgery checklist is consistently implemented for all surgical procedures including the five steps of team brief, sign in, sign out and debriefing. Fully embed the WHO safer surgery checklist, in terms of both Reports where actions appear St Georges City Road Provider Bedford City Road Provider St Georges City Road St Georges Provider Satellite Surgery (Northwick Park) CQC action priority type SHOULD take Requirement Notice SHOULD take Requirement Notice Requirement Notice MUST take Executive Lead Declan Flanagan Declan Flanagan Declan Flanagan Declan Flanagan Declan Flanagan Declan Flanagan

17 17 Action no Theme Computer systems Duty of candour Incident reporting Managing risk Policies, procedures and clinical protocols Children and young people strategy Action ID CQC recommended action documentation and the quality and staff engagement in the process, across the organisation. Ensure all locations have access to and use the same computer systems and that additional systems used are compatible. Ensure all staff have knowledge and awareness of the duty of candour principles. Incident reporting process Improve recording of risks and ensure all information is included on risk registers. Ensure all policies and procedures are up to date and staff receive training as required for specific roles such as laser protection. Develop a strategy for services for children and young people Reports where actions appear Satellite Outpatient (Croydon) City Road City Road St Georges City Road City Road CQC action priority type SHOULD take SHOULD take SHOULD take MUST take SHOULD take SHOULD take Executive Lead Elisa Steele Ian Tombleson Ian Tombleson Ian Tombleson Ian Tombleson Johanna Moss

18 18 Action no Theme Patient and staff engagement Patient information (including signage) Service Level Agreement Cancelled clinics Environment: outpatients Environment: outpatients Action ID CQC recommended action Improve engagement with patients, staff and member of the public in service development / improvement. Ensure patient information leaflets are available for visually impaired and blind patients Ensure SLAs with partner organisations are in place and that the governance processes fit the existing and future models of care delivery. Put a process in place to ensure that clinics are not cancelled because of consultant s annual leave. Ensure environment is appropriately assessed and adjusted to meet visually impaired patients needs. Ensure that the environment of the outpatient department is routinely monitored and appropriate actions are Reports where actions appear St Georges Bedford Provider Satellite Outpatient (Croydon) Bedford City Road CQC action priority type SHOULD take SHOULD take MUST take MUST take SHOULD take SHOULD take Executive Lead Johanna Moss Johanna Moss Johanna Moss John Quinn John Quinn John Quinn

19 19 Action no Theme Mixed sex breaches Patient records Patient records Patient records Patient safety Patient Safety Action ID CQC recommended action taken to ensure patient safety, comfort and welfare. Reduce the number of mixed sex breaches at the St George s site. Consider implementing the business plan for an electronic record system and scanning of casualty cards. This will free up space within the administration office and eliminate the risks of trips. Ensure patient s records are available when they attend for an appointment. Improve the availability and storage of medical records. Ensure that risks relating to patient waiting times are fully mitigated Ensure that the quality and safety of the outpatients and surgical services provided are fully assessed, monitored and improved. Reports where actions appear Provider St Georges City Road St Georges City Road City Road St Georges CQC action priority type MUST take SHOULD take SHOULD take SHOULD take Requirement Notice Requirement Notice Executive Lead John Quinn John Quinn John Quinn John Quinn John Quinn John Quinn

20 20 Action no Theme Patient safety Patient safety Privacy and dignity Action ID Staff safety Theatres: waiting times and cancellations Waiting times Environment: general CQC recommended action Ensure that the quality and safety of the outpatients service are fully monitored, including patient waiting times and clinic finish times. Ensure that the risks related to patient safety in outpatients and surgical services provided in outpatients provided are fully mitigated. Look for ways to improve patient privacy in the OPD, emergency department and day case wards Ensure emergency buzzers are available in radiology. Work to reduce patient waiting times for surgery and the theatre cancellation rate Ensure that the risks to patient waiting times are fully mitigated. Consider how reasonable adjustments could be Reports where actions appear City Road Provider St Georges City Road Provider City Road Satellite Surgery (Northwick Park) St Georges Provider St Georges CQC action priority type Requirement Notice Requirement Notice SHOULD take MUST take SHOULD take MUST take SHOULD take Executive Lead John Quinn John Quinn John Quinn John Quinn John Quinn John Quinn John Quinn

21 21 Action no Theme Environment: A&E Environment: theatres Action ID Appraisals Bullying and harassment Staff training Environment: outpatients Environment: outpatients CQC recommended action made for people with visual impairment. Make necessary environmental improvements (records storage, ventilation, and waiting area for children) in A&E at City Road Take action to ensure the environment in theatres is safe and meets with national guidance, and consider how the environment could be made more friendly Improve the uptake of appraisals Take necessary action to deal with reports of bullying and harassment among staff Ensure all staff complete all aspects of mandatory training, including adult basic life support Address the environmental conditions of outpatients at the St George's site. Richmond Desmond Reports where actions appear City Road Provider Provider St Georges City Road St Georges Bedford Bedford City Road Satellite Outpatient (Croydon) Provider St Georges City Road CQC action priority type MUST take MUST take SHOULD take SHOULD take SHOULD take MUST take SHOULD take Executive Lead John Quinn (PR02 & CR15) Steve Davies (CR13) John Quinn (SG17) Steve Davies (PR05 & SG05) Sally Storey Sally Storey Sally Storey Steve Davies Steve Davies

22 22 Action no. Theme Action ID 44. Equipment Infection control Pain relief Patient information (including signage) Privacy and dignity Safeguarding Staff training 45 CQC recommended action Children s Eye Centre - glass walls Accessibility of resuscitation equipment Slit lamp decontamination Ensure adequate pain relief is provided in a timely manner to all ophthalmic patients on the day surgery unit at Bedford Hospital. Consider how documentary information and signage could be improved for people visual impairment. Ensure Ealing patient s privacy and dignity is protected at all times. (see page 20 of draft report) Ensure all relevant staff receive safeguarding training at appropriate level as guided by job roles and duties. Ensure all staff are aware of their responsibilities in relation to the Mental Capacity Act Reports where actions appear St Georges Bedford Bedford City Road Satellite Surgery (Northwick Park) Bedford City Road CQC action priority type SHOULD take MUST take MUST take SHOULD take MUST take MUST take SHOULD take Executive Lead Tracy Luckett Tracy Luckett Tracy Luckett Tracy Luckett Tracy Luckett Tracy Luckett Tracy Luckett

23 23 Action no. Theme Action ID 51. Staff training Staff training Vulnerable patients Vulnerable patients CQC recommended action Ensure staff have the correct training and implement formalised systems to monitor and record staff training information for paediatrics within the theatre department. Ensure staff on the day surgery unit at Bedford Hospital received appropriate training to care for patients following ophthalmic surgery. Consider introducing an electronic flagging system for vulnerable patients, such as those living with dementia or a learning disability in the outpatients department. The trust should ensure that processes to support patients living with learning disabilities are consistent across the trust Reports where actions appear City Road Bedford City Road St Georges Satellite Outpatient (Croydon) CQC action priority type SHOULD take MUST take SHOULD take MUST take Executive Lead Tracy Luckett Tracy Luckett Tracy Luckett Tracy Luckett

24 24 Appendix 3 - CQC quality summit draft agenda Item Timing Lead Comments Welcome and 5 mins CQC introductions Presentation of inspection team key findings Questions and clarification Summary of key risks and actions Presentation by MEH Questions and clarifications 15 mins CQC The inspection team present the key findings from their visit. 10 mins ALL Opportunity for Quality Summit attendees to ask clarification questions of the inspection team and / or provide their own perspective on issues being considered. 5 mins NHSI 30 mins MEH 1. Tessa Green will provide a statement on behalf of the Board 2. David Probert will present MEH response to the inspection findings (focus on 3-4 key inspection findings) to feedback on what we have done already 3. Rosalind Given Wilson will provide assurance on behalf of the Quality and Safety Committee 4. Rob Jones will provide a statement on behalf of the Membership Council 10 mins ALL Opportunity to ask questions of the Trust to further develop an understanding of the Trust s perspective in the review findings and plans for improvement. Break 15 mins MEH Refreshments to be provided by MEH Development of outline action plan 45 mins MEH and NHSI External support offer Agreement to next steps Total time Workshop segment the attendees split into 3-4 groups, each taking on one of the 3 4 key inspection findings. They get 20 mins group working time and then 20 mins to summarise feedback on the action plans for each key finding. 15 mins NHSI Agree key areas in which external support may be required to enable implementation of the action plan. 15 mins NHSI Timescale for development of detailed action plan. Handling and communications plan. Monitoring arrangements. 165 mins (2h 45)

25 Moorfields Eye Hospital NHS Foundation Trust Quality Report 162 City Road, London EC1V 2PD Tel: Website: Date of inspection visit: 9-13 May 2016 Date of publication: 06/01/2017 This report describes our judgement of the quality of care at this trust. It is based on a combination of what we found when we inspected, information from our Intelligent Monitoring system, and information given to us from patients, the public and other organisations. Ratings Overall rating for this trust Good Are services at this trust safe? Requires improvement Are services at this trust effective? Good Are services at this trust caring? Good Are services at this trust responsive? Requires improvement Are services at this trust well-led? Good 1 Moorfields Eye Hospital NHS Foundation Trust Quality Report 06/01/2017

26 Letter from the Chief Inspector of Hospitals This was the first inspection of Moorfields Eye Hospital NHS Foundation Trust under the new methodology. We have rated the hospital as good overall, accounting for the delivery model of care and the large volume of activity which takes place at the City Road Hospital site. We carried out an announced inspection between 9-13 May We also undertook unannounced visits during the following two weeks. We inspected four core services: urgent and emergency care, surgery, outpatients and diagnostics, and children and young people's services. This trust operates across multiple outreach locations. Due to the unique delivery model of this organisation we inspected services at the City Road and Moorfields Eye Centre at St George's Hospital. We also inspected a range of the outreach sites as part including: Surgery and outpatients at Bedford Hospital Surgery and outpatients at Moorfields Eye Centre at St George's Hospital Surgery at Ealing Hospital Surgery at Croydon Hospital Surgery at Mile End Hospital Outpatient and diagnostics at Queen Mary's Roehampton Hospital Outpatient and diagnostics at Purley War Memorial Hospital Outpatient and diagnostics at Barking, Havering and Redbridge Hospital Our key findings were as follows: Safe Mandatory training levels in some areas were below trust targets including resuscitation training and adult life support. At the City Road site: The paediatric waiting area in the A&E was unsuitable for the purpose it was being used. We saw paediatric patients and their families waiting in the main waiting area with adult ED patients. There was a lack of storage space for patients notes in ED and the administrative office was overcrowded with boxes, which presented trip hazards and a barrier to evacuation. In surgery, improvement was required to fully embed the World Health Organisation safer surgery checklist, in terms of both documentation and the quality and staff engagement in the process. The availability of medical records was an on-going issue and temporary notes were used until the records could be located. In Outpatients we found omissions in some patient records including staff signatures and record entry dates. Some clinic waiting areas were extremely warm at times and, although temperature monitoring took place, actions did not fully address the heat. Space was limited and there was insufficient seating for the number of patients attending clinics. Availability of floorwalkers to monitor patient wellbeing in waiting areas was limited. Staff throughout the outpatient clinics were busy and told us they rarely had time to take their full breaks during their shift. No emergency buzzers were available in the radiology department, which could delay staff accessing help in an emergency. At Moorfields Eye Centre at St George s Hospital: In theatres, long standing problems with ventilation meant that at times theatre lists had to be cancelled. Air changes in one anaesthetic room did not always comply with best practice. The urgent care clinic reception area and treatment cubicles lacked privacy and confidentially was compromised. The outpatients department was crowded and the waiting area in was very cramped: the chairs for patients were very close together. There was a separate waiting area for patients in wheelchairs 2 Moorfields Eye Hospital NHS Foundation Trust Quality Report 06/01/2017

27 however this only accommodated two wheelchair users. When we visited the ceiling leaked due to heavy rain, this meant that some of the chairs could not be used as they were wet. Staff working in treatment areas in a corridor outside the main outpatient area were isolated. A service level agreement had been developed to formalise the relationship between the trust and St George's University Hospitals NHS Foundation Trust but, this was not yet agreed and in place at the time of the inspection. At the Bedford site; We observed some poor infection control practice with regards to slit lamps decontamination. Patients undergoing surgery under a general anaesthetic were transferred to the day surgery unit at Bedford hospital but staff caring for these patients had not received ophthalmic training. However, we found many good examples of safe care including: Wards and other patient areas were clean and staff were seen to be adhering to hand hygiene policies and protocols. Audit results for cleanliness and infection prevention control demonstrated a good track record and improvements and infection rates were low. Adequate staffing levels and skills mix was a high priority and were planned, implemented and reviewed to keep people safe at all times. Minimal staff shortages were responded to by senior nursing leaders using internal bank staff and rarely agency staff. Safeguarding vulnerable adults was given sufficient priority by staff who were aware to ensure immediate safety and to discuss concerns. Radiation safety processes, including access to lead vests and radiation monitoring, were suitable. The environment in which radiation was used was fit for purpose and protected staff and patients from unnecessary exposure to radiation. Effective Care was evidence based and services participated in local and national audit. Care was delivered in line with relevant national guidelines and we saw appropriate policies, procedures and clinical guidelines, which referenced these. Care was delivered by an experienced team of ophthalmologists and ophthalmic trained nurses delivered care and treatment based on a range of best practice guidance. The continuing development of staff skills, competence and knowledge was recognised as being integral to ensuring high quality care. Nurses and health care assistants felt well supported with good supervision and good training opportunities. Consent practices and records are actively monitored and reviewed to improve how people are involved in making decisions about their care and treatment. Caring Feedback from people who use the service, and those who are close to them, was continually positive about the way staff treated them. Patients thought the care they receive exceeds their expectations. Friends and Family Test results were consistently good across surgical services. Staff were seen to spend time talking to patients, or those close to them to ensure they received the information in a way they could understand and were given time to ask questions. We observed staff providing compassionate care and treating patients with dignity and respect. Staff provided emotional support to patients and patients were able to access the hospital multi-faith chaplaincy services, when required. Patients also had access to the trust counselling service and the eye clinic liaison office. In children s and young people s services, staff demonstrated the relationships they developed with patient s using the service, and their commitment to ensuring they had a positive experience. 3 Moorfields Eye Hospital NHS Foundation Trust Quality Report 06/01/2017

28 Complex conditions and procedures were explained to children and young people in a way that enabled them to gain a full understanding of their treatment plan and take an active role in decision making. Responsive The trust met the target for the national referral to treatment pathway (RTT) target of 18 weeks for outpatient appointments. They had robust systems for monitoring RTT performance. The trust consistently met the 4-hour ED waiting time standard, and also measured against a locally derived 3-hour target. There were clear patient pathways that eased the flow of patients within the A&E. The department had implemented an active triage system whereby patients with non-emergency conditions were referred to the urgent care clinic. Patients and relatives told us they appreciated having local services which meant that they didn t have to travel far. The surgical services had implemented a number of improvements throughout the patient pathway, including a one-stop nurse led assessment clinic which including investigations if needed and a live patient tracking system. There was a proactive approach to understanding the needs of different groups of people and to deliver care in a way that meets that recognised and promoted those needs. Patients were given the flexibility to access services in a way and at a time that suited them. Outpatients clinics at City Road clinics were frequently overbooked and finished late. Patients consequently had a long waiting time in clinics and the hospital did not have a system in place to keep patients informed about the waiting time and did not monitor this performance data. In outpatients at City Road patients were seen in open bays within clinic areas. In some clinics this resulted in a lot of noise and it was difficult to hear what was being said by both patients and staff. At times these areas became very busy, with no seating availability for patients and relatives. At St George's there was no signage or information available for patients about waiting times and this meant that patients did not know how long they would need to wait. The department did not monitor this performance data. At St George's the main outpatient reception area was situated so that patient s confidentiality and privacy was maintained. However, the reception area where patients booked into the UCC was situated next to the waiting area close to where patients sat, which meant that patients privacy and confidentially was compromised. Cancellation rates were high for hospital cancelled appointments in Moorfields South (both St George s and Croydon). Service planning for satelite clinics at Moorfields North required improvement. We observed these clinics were often overbooked due to the lack of a system for knowing when consultants were on leave. We were told that at Moorfields Queen Mary s Hospital clinics were often cancelled at very short notice and that patients were not always informed and turned up for their appointment. We were informed this happened at least one a month. Well Led There were a clear set of vision and values within the surgical services that were driven by quality care and safety. Staff were clear of their involvement in delivering these objectives. We found a cohesive and supportive leadership team who functioned effectively, with well-established members of staff. Staff were complimentary about the support they received from their seniors and commented that they were visible and approachable. Structures, processes and systems were in place to ensure information sharing across the trust was effective. There was a clear proactive approach to seeking out and embedding new and more sustainable models of care from all staff levels within the trust. There are high levels of staff satisfaction across all equality groups. Staff were proud of the organisation as a place to work and spoke highly of the culture and opportunities. 4 Moorfields Eye Hospital NHS Foundation Trust Quality Report 06/01/2017

29 There was good governance and quality measurement. Numerous audits were undertaken regularly, including quality and safety audits. There were good risk management processes in place and risks were identified and acted upon. However; Key issues relating to flow within the outpatient clinics, such as patient waiting times and clinics overrunning, were not formally monitored by the leadership team and therefore the benefit of any service changes could not be effectively assessed. A service level agreement had been developed to formalise the relationship between the trust and St George's University Hospitals NHS Foundation Trust but, this was not yet agreed and in place at the time of the inspection. We were concerned that there was not a robust governance system around SLA's with partner organisations, which resulted in a lack of formal mechanisms or powers to drive improvement or make changes where required. The senior leadership team were open about the challenges the services at Moorfields Eye Centre at St George's Hospital faced and recognised the importance of improving the environment in which the service was provided. We saw evidence of a transformation programme to relocate patients, however there were no firm plans in place to improve the environment. In outpatients at St George s senior staff identified issues with the current environment and identified re-providing the services at St George s the means to addressing this. The trust advised us of its short/ medium term plans to address its current unsuitability. We saw several areas of outstanding practice including: The development of staff skills, competence and knowledge, and development of extended nursing and allied health professional roles. Staff reported that they felt well supported and received good training opportunities. There was an extensive research portfolio, which was recognised at a UK and global level, directly benefiting patients. There was a clear proactive approach to seeking out and embedding new and more sustainable models of care from all staff levels within the services, and across the Moorfields network. For example the Bedford team worked closely with a group of local optometrists and operated a system called Bedford Shared Care Cataract Pathway. The organisation had taken a pivotal role in the development of ophthalmic services, as the lead in one of the hospital vanguard systems selected by NHS England to develop new models of care. We noted the trust had made significant investments in leadership and quality improvement, and had invited international speakers to attend a specialist event following our inspection. However, there were also areas of poor practice where the trust needs to make improvements. Importantly, the trust must: Address the lack of storage space for patients notes in ED and the administrative office and remove barriers to evacuation. Fully embed the World Health Organisation safer surgery checklist, in terms of both documentation and the quality and staff engagement in the process, across the organisation. Ensure adequate audit and monitoring systems are in place to monitor performance and compliance of the WHO five steps to safer surgery checklist to guide improvement. Take action to ensure the environment in theatres is safe and meets with national guidance. Reduce the number of mixed sex breaches at the St George's site. Ensure that the quality and safety of the outpatients and surgical services at Moorfields at St George's are fully assessed, monitored and improved. Ensure that all risks related to patient safety in outpatients and surgical services at Moorfields at St George's are fully recorded with actions to mitigate them. Address the environmental conditions of outpatients at the St George s site. Ensure that the quality and safety of the outpatients service at the City Road site are fully monitored, including patient waiting times and clinic finish times. 5 Moorfields Eye Hospital NHS Foundation Trust Quality Report 06/01/2017