Review into the Quality of Care & Treatment provided by 14 Hospital Trusts in England RAPID RESPONSIVE REVIEW REPORT FOR RISK SUMMIT

Report for The Dudley Group NHS Foundation Trust Review into the Quality of Care & Treatment provided by 14 Hospital Trusts in England RAPID RESPONSIVE REVIEW REPORT FOR RISK SUMMIT July 2013

Contents 1. Introduction 3 2. Background to the Trust 6 3. Key Lines of Enquiry 10 4. Review findings 10 Governance and leadership 13 Clinical and operational effectiveness 19 Patient experience 25 Workforce and safety 31 Pressure ulcers 38 5. Conclusions and support required 43 Appendices 45 Appendix I: SHMI and HSMR definitions 46 Appendix II: Panel Composition 48 Appendix III: Interviews held on announced visit 50 Appendix IV: Observations undertaken 51 Appendix V: Focus groups held 52 Appendix VI: Information available to the RRR panel 53 Appendix VII: Unannounced site visit 57

1. Introduction Overview of review process On 6 February 2013 the Prime Minister asked Professor Sir Bruce Keogh, NHS England Medical Director, to review the quality of the care and treatment being provided by those hospital trusts in England that have been persistent outliers on mortality statistics. The 14 NHS trusts which fall within the scope of this review were selected on the basis that they have been outliers for the period April 2010 to March 2012 on either the Summary Hospital level Mortality Indicator (SHMI) or the Hospital Standardised Mortality Ratio (HSMR). Definitions of SHMI and HSMR are included at Appendix I. These two measures are intended to be used in the context of this review as a smoke alarm for identifying potential problems affecting the quality of patient care and treatment at the trusts which warrant further review. It was intended that these measures should not be reviewed in isolation and no judgements were made at the start of the review about the actual quality of care being provided to patients at the trusts. Key principles of the review The review process applied to all 14 NHS trusts was designed to embed the following principles: 1) Patient and public participation these individuals have a key role and worked in partnership with clinicians on the reviewing panel. The panel sought the views of the patients in each of the hospitals and also considered independent feedback from stakeholders, related to the Trust, which had been received through the Keogh review website. These themes have been reflected in the reports. 2) Listening to the views of staff staff were supported to provide frank and honest opinions about the quality of care provided to hospital patients. 3) Openness and transparency all possible information and intelligence relating to the review and individual investigations will be made publicly available. 4) Cooperation between organisations each review was built around strong cooperation between different organisations that make up the health system, placing the interest of patients first at all times. Terms of reference of the review The review process was designed by a team of clinicians and other key stakeholders identified by NHS England, based on the NHS National Quality Board guidance on rapid responsive reviews and risk summits. The process was designed to: Determine whether there are any sustained failings in the quality of care and treatment being provided to patients at these Trusts. Identify: i. Whether existing action by these Trusts to improve quality is adequate and whether any additional steps should be taken. ii. Any additional external support that should be made available to these Trusts to help them improve. iii. Any areas that may require regulatory action in order to protect patients. The review follows a three stage process:

Stage 1 Information gathering and analysis This stage used information and data held across the NHS and other public bodies to prepare analysis in relation to clinical quality and outcomes as well as patient and staff views and feedback. The indicators for each trust were compared to appropriate benchmarks to identify any outliers for further investigation in the rapid responsive review stage as Key Lines of Enquiry (KLOEs). The data pack for each trust reviewed is published at http://www.nhs.uk/nhsengland/bruce-keogh-review/documents/trust-datapacks/data-pack-dudley.pdf. Stage 2 Rapid Responsive Review (RRR) A team of experienced clinicians, patients, managers and regulators (see Appendix II for panel composition), following training, visited each of the 14 hospitals and observed the hospital in action. This involved walking the wards and departments, interviewing patients, trainees, staff and members of the Board. The report from this stage will be considered at the risk summit. Stage 3 Risk summit This will bring together a separate group of experts from across health organisations, including the regulatory bodies. They will consider the report from the RRR, alongside other hard and soft intelligence, in order to make judgements about the quality of care being provided and agree any necessary actions, including offers of support to the hospitals concerned. A report following each risk summit will be made publically available. Methods of investigation The two day announced RRR visit took place at the Trust s main site Russells Hall Hospital on Tuesday 7 and Wednesday 8 May 2013. A variety of review methods were used to investigate the KLOEs and enabled the panel to consider evidence from multiple sources in making their judgements. The visit included the following methods of investigation: Interviews Seventeen interviews took place with members of the Board and selective members of staff based on the key lines of enquiry during the visits. See Appendix III for details of the interviews undertaken. Observations Ward observations enabled the panel to see the Trust undergo its day to day operations. They allowed the panel to talk to current patients, and their families where observations took placed during visiting hours. They allowed the panel to speak with a range of staff and observe the quality of care and treatment being provided to patients. The panel was able to observe the action by the Trust to improve quality in practice and consider whether any additional steps should be taken. Observations took place in twelve areas of Russells Hall Hospital. See Appendix IV for details of the observations undertaken. Focus Groups

Focus groups provided an opportunity to talk to staff groups individually to ask each area of staff what they feel is good about patient care in the Trust and what needs improving. They enabled staff to speak up if they feel there is a barrier that is preventing them from providing good quality care to patients and what actions might the Trust need to consider to improve, including addressing areas with higher than expected mortality indicators. Focus groups were held with nine staff groups during the announced site visit. See Appendix IV for details of the focus groups held. The panel would like to thank all those who attended the focus groups who were open and balanced with the sharing of their experiences and their perceptions of the quality of care and treatment at the Trust. Listening events Public listening events give the public an opportunity to share their personal experiences with the hospital, and to voice their opinion on what they feel works well or needs improving at the Trust in relation to the quality of patient care and treatment. A listening event for the public and patients was held on the evening of 7 May 2013 at Russells Hall Hospital. This was an open event, publicised locally, and attended by about 70 members of the public and patients. A listening event was also held for the Trust s governors attended by about 12 members of the Trust s Council of Governors. The panel would like to thank all those attending the listening event who were open in sharing of their experiences and balanced in their perceptions of the quality of care and treatment at the Trust. Review of documentation A number of documents were provided to the panellists through a copy being available in the panel s base location at the Trust during the site visit. Whilst the documents were not reviewed in detail, they were available to the panellists to validate findings as considered appropriate by the panellists. See Appendix VI for details of the documents available to the panel. Unannounced visit The unannounced out-of-hours visit took place at Russells Hall Hospital on the evening of Tuesday 14 May 2013, and a further unannounced working hours visit took place on Wednesday 15 May 2013. This focused observations in areas identified from the announced site visit, see Appendix VII. Next steps This report has been produced by Dr Ruth May, Panel Chair, with the full support and input of panel members. It has been shared with the Trust for a factual accuracy check. This report was issued to attendees at the risk summit, which focussed on supporting The Dudley Group NHS Foundation Trust ( the Trust ) in addressing the actions identified to improve the quality of care and treatment. Following the risk summit the agreed action plan will be published alongside this report on the Keogh review website. A report summarising the findings and actions arising from the 14 investigations will also be published.

2. Background to the Trust This section of the report provides relevant background information for the Trust and highlights the areas identified from the data pack for further investigation. Context The Dudley Group NHS Foundation Trust ( the Trust ) serves more than 450,000 people in Dudley and the surrounding areas. The Trust has three hospital sites, including Russells Hall in Dudley (for inpatients), and Corbett and Guest Outpatient Centres. The Trust was the first in the area to receive Foundation Trust status, in 2008. The Trust s services focus on long-term conditions, acute care needs, rehabilitation and end-of-life care. It acquired adult community services in 2011 which are largely delivered in the local community outreach to patients homes or through the two outpatient centres. Dudley is not a particularly deprived region within England although the Trust s catchment does include some of the most deprived wards in England in north Dudley and Sandwell. It has a sizeable proportion of ethnic minorities, particularly from South Asia. Those aged 60 and above constitute a relatively larger proportion of the population in Dudley compared to their proportion of the population nationally and the population is older than the national average. Obesity is more common in the region than in England as a whole, and breastfeeding is relatively less common than in England as a whole. Dudley s health profile outlines that there are a number of aspects for which children s & young people s and adult s health is significantly lower (worse) than the national average. It also shows that life expectancy in Dudley is below the national average. The Trust is considered medium sized for both inpatient and outpatient activity and is the third largest from the 14 trusts chosen for this review. General Medicine and Paediatrics are the largest inpatient specialties while Clinical Haematology and Nursing Episodes are the largest specialties for Outpatients. The Trust has 68% market share of inpatient activity within a 5 mile radius of the Trust sites. However, this share falls to 15% within a radius of 10 miles and 4% within a radius of 20 miles. The main competitors in the local area are Sandwell and West Birmingham Hospitals NHS Trust, The Royal Wolverhampton Hospitals NHS Trust, University Hospitals Birmingham NHS Foundation Trust, and Worcestershire Acute Hospitals NHS Trust. The Trust s market share is also affected by the proximity in Birmingham of specialist hospitals for children, women and orthopaedics. Key messages from the Trust data pack Mortality indicators The Trust has been selected for this review as a result of its HSMR being above the expected level over the period April 2010 to March 2012. Currently the Trust is reporting an HSMR of 98 and is within the expected range for the latest data (January 2012 to December 2012). The Trust has an overall SHMI of 106.5 for the period December 2011 to November 2012 meaning that the number of actual deaths is higher than the expected level. Deeper analysis of this demonstrates that non-elective admissions are the primary contributing factor to this figure, with a SHMI of 110, compared to a level of 105 for elective admissions. The specialities with the highest excess deaths contributing to the SHMI and HSMR indicators in the period under review were general medicine, which includes cancer, and geriatric medicine (elderly care). These specialities were therefore identified as a focus for the key line of enquiry on mortality and the RRR visit included observations of the general medical and elderly care wards and interviews with patients and staff in these areas.

Governance and leadership The Trust s Board of Directors has seven sub-committees with a Clinical Quality, Safety and Patient Experience Committee (CQSPE) to oversee quality governance arrangements. The CQSPE has a number of sub-groups covering a wide range of quality and safety matters. The governance risk rating for this foundation trust was amended from GREEN to AMBER-RED in May 2013 due the trust's breach of the 62 day Cancer (Urgent GP referral target) and A&E maximum 4 hour waiting time target in Quarter 4 2012/13, although recent Care Quality Commission (CQC) inspections which tested all governance standards did not raise any concerns. The Trust has a relatively stable Board of Directors over the last three years but has made amendments to the Director portfolios from April 2013 to introduce a new Director of Strategy and Transformation. A high level review of the effectiveness of the Trust s quality governance arrangements were a standard key line of enquiry for the review. Clinical and operating effectiveness In 2012, the Trust s accident and emergency department (A&E) assessed and then treated, admitted or discharged as appropriate 96.3% of its patients within 4 hours, which is above the 95% national standard level. This is above national averages but the Trust s performance on this target has fallen slightly over the past 12 months. The Trust s referral to treatment within 18 weeks for admitted patients was higher than the national standard level and above the national average achieved by all trusts. The readmission rate may indicate the appropriateness of treatment offered, whilst average length of stay suggests the efficiency of the treatment, with low rates being positive indicators. The Trust s crude readmission rate is 10.8% of patients which is relatively low and it is in the second quartile of national trusts. The Trust also has a comparatively low standardised readmission rate and a shorter length of stay than the national mean average, with 3.8 days. In 2011/12 the Trust was eligible for 42 out of the 56 national clinical audits and contributed data to all mandatory audits. The Trust chose not to submit data for the Risk factors (National Health promotions in Hospitals Audit) and Care of dying in hospital (NCDAH) audits. It was noted that the acute stroke audit (SINAP) was delayed nationally and the Trust has now submitted data, however due to the timing of this, it was not possible to incorporate the findings in this review. The data in this area did not highlight any specific key lines of enquiry. Patient experience Of the 9 measures reviewed within Patient Experience and Complaints the Trust scored higher than national average on: The friends and family test However, the Trust was rated red for 4 of the 9 measures as they scored below the national average on: Inpatient Survey Score undertaken in 2012 (published in 2013) lower scoring areas included including time for getting onto a ward, getting clear answers from doctors, involvement in decisions, delays at discharge and quality of food. Cancer Survey - deciding best treatment and feedback on ward nurses were noted as areas of concern

Patient Voice Comments via CQC - of 170 individual comments from patients and public in the two years to 31 January 2013, 92 were negative (54%). Key themes centred on communication, information provision and staff attitude, with some comment on waiting times in A&E and poor discharge arrangements. High percentage of complaints about clinical aspects of care of 375 written complaints received by the Trust in 2011/12, 63% of complaints related to clinical treatment (compared to the national average of 47%). Of 373 complaints received by the Trust in 2012/13, 79% related to clinical treatment. It is B-rated by the Ombudsman for compliance with their recommendations. The Trust has a high conversion rate of complaints going from the Trust process to the Health Service Ombudsman (15.5%). Although the Trust has highlighted that only one complaint was upheld by the Ombudsman in the period under review, there were a number of others which the Trust was asked to undertake further work on. The Ombudsman investigates complaints escalated to it by complainants who are not satisfied with the Trust's response. It rates Trusts on whether they have implemented the recommendations made at the end of an investigation in a satisfactorily and timely manner, helping to ensure that Trusts learn from mistakes. The Ombudsman rates each Trust s compliance with recommendations and focuses on monitoring organisations whose compliance history indicates that they present a risk of non-compliance. Keogh review patient voice comments The patient voice comments received directly to the Keogh review website (at the time of writing this report) identified the following themes from 16 emails and letters: Positive Negative Excellent care received from nurses and doctors Urgent action and emergency surgery saved life of patient and excellent care at ICU. A&E waiting times Lack of communication from staff Hard working staff Shorter bed stays for patients being rushed through the system Departments are very informative Complaints not adequately responded to and not able to meet the Chief Executive Patient care and treatment complaints Pharmacy and prescribing issues Lack of nursing care and compassion. Key lines of enquiry were included in the review focusing on what patients say about the quality of care and treatment and what the Trust was doing in response to this feedback. Workforce and safety The Trust has a Harm status in all four of the NHS safety thermometer measures, and is red rated in a total of six of the safety indicators in the data pack including Serious Harm incidents and Harm indicators. The number of patients with pressure ulcers and the C-Difficile infection rates are both higher than the national average.

In the period April 2012 to March 2013, the Trust had a higher percentage of patients with pressure ulcers than the national average. Its rate of patients with new pressure ulcers following admission has been reducing since April 2012 but there were three months when its rates were above the national average. Specific key lines of enquiry were designed for the Trust to address incident reporting, infection control and pressure ulcer management concerns. A review of the workforce data flagged seven red rated indicators. Most notably, it had a lower than national average nurse staffing levels per patient episode and lower than average registered nursing ratios. It also had a much higher than average level of expenditure on agency staffing in 2011/12. The staff response rate to the staff survey rate has fallen noticeably in 2012 compared to 2011 and is now clearly below the national average for response rates. The Trust s staff engagement is at the same level as the national average. Key lines of enquiry were included in the review focusing on workforce measures and what staff say about the quality of care and treatment. The following definitions are used for the rating of recommendations in this review: Rating Urgent High Medium Definition The Trust should take immediate action to respond to these recommendations and ensure improvement in the quality of care The Trust should develop a response and action plan for these recommendations to ensure improvement in the quality of care The Trust should implement these recommendations to ensure ongoing improvement in the quality of care

3. Key Lines of Enquiry The Key Lines of Enquiry (KLOEs) were drafted using the following key inputs: The Trust data pack produced at Stage 1 and made publically available. Insights from the Trust s lead Clinical Commissioning Group (CCG), Dudley CCG. Review of the patient voice feedback received specific to the Trust prior to the site visit. These were agreed by the panellists at the panel briefing session prior to the RRR site visit. The KLOEs identified for the Trust were the following: Theme Key Line of Enquiry Governance and leadership 1. Can the Trust clearly articulate its governance processes for assuring the quality of treatment and patient care? Can staff at all levels of the organisation describe the key elements of the quality governance processes, i.e. policies and procedures, escalation processes, incident reporting, risk management? Clinical and operational effectiveness 2. What actions is the Trust taking to improve mortality performance, particularly in general medicine, elderly care and stroke wards? How does the Trust manage deteriorating patients? 3. How is the Trust addressing its infection control standards, particularly Clostridium Difficile? Patient experience 4. How does the Trust seek views from patients about their experience? What are the key themes from patients on their experiences? What action is the Trust taking to address the key themes emerging? Workforce and safety 5. How engaged are staff in the Trust s quality strategy? What do staff groups interviewed (including trainee groups) say are the main barriers in the Trust to delivering high quality treatment and care for patients? 6. How does the Trust support its staff with adequate training, including safeguarding and other mandatory training? Trust specific palliative care coding 7. How is the Trust continuing to take action on its depth and accuracy of coding, particularly in palliative care? Trust specific CIPs quality impact assessments 8. What is the Trust s process to assess the impact of cost savings plans on quality of patient care and its workforce? Trust specific Pressure ulcers 9. What actions is the Trust taking to reduce avoidable pressure ulcers? Trust specific Nurse staffing 4. Review findings 10. How does the Trust approach workforce planning to ensure that patient care and safety is managed effectively including nurse staffing levels? How is clinical cover managed out of hours particularly on the emergency pathway?

Introduction The following section provides a detailed analysis of the panel s findings, including good practice noted, outstanding concerns and prioritisation of actions required. Summary of findings The high priority areas identified for action in each of the key lines of enquiry themes are as follows: Leadership and governance: Review of quality governance the Trust should review its governance structure to reduce the complexity of arrangements and improve the information flows. This should enable greater challenge from the Board and its sub-committees on all quality priorities. The governance structure should be communicated to staff to enable them to understand and deliver their roles effectively. This was particularly noted as an issue for clinical leadership in the Trust, as the Clinical Directors need to all understand their important role. Embedding a learning culture the Trust has significant amounts of information from complaints, incident reporting and ward level data on performance but does not appear to systematically review themes from this information and disseminate learning across the organisation. Clinical and operational effectiveness: Understanding of mortality - the Trust has taken steps to improve its coding in 2011 and 2012 which has in turn improved its mortality indicators recently and put it in a better position to identify opportunities to improve patient care and treatment in specialties or care pathways. It was not clear to the panel that the Trust has fully understood its mortality data and how it uses this to undertake systematic reviews of improvements that may be required in the organisation. Bed management and patient flow the Trust s system for bed management, patient flows and discharge need to be urgently reviewed and improved to address operational effectiveness issues and improve patient experience. Patient experience: Embedding a patient experience strategy the Board should urgently review its approach to patient experience to ensure it has a clear strategy, is consistently monitoring key metrics and identifying actions to improve this area. Responding to complaints the Trust needs to review its approach to responding to complaints to ensure it is compliant with requirements and really responds to complainants effectively. Workforce and safety: Staffing and skill mix the Trust should review its current staffing levels for nursing and medical staff and action any changes required for improving quality and safety of care. There is an urgent action for the Trust to make sure that the registered nursing ratio is assessed using an evidence base methodology. This should be

undertaken in conjunction with clinical teams to review appropriate nurse staffing on all wards, especially in higher risk wards which also have higher rates of incidents and complaints (such the 72 and 48 bedded general medical and elderly care wards). Safety checks the Trust should review its processes to ensure all equipment and safety checks are undertaken appropriately, given a number of examples of incomplete checklists. Staff engagement the Trust should address its low response rates to the national staff survey and consider more innovative ways of listening to staff views. The Trust should also review whether the issues noted in reviews of theatres have been adequately addressed by the actions taken. Pressure ulcers: Consistency of staffing using care bundles the Trust needs to continue to promote and audit the consistent use of its pressure ulcer prevention and care bundles. Equipment availability the Trust should take action where staff do not have access to the right equipment to deliver effective pressure ulcer care to patients.

Governance and leadership Overview The panel s governance and leadership focus was on the Trust s governance processes for assuring the quality of treatment and patient care, as well as how well embedded this was throughout the organisation. Through staff interviews, focus groups and review of governance documentation, the panel tested whether staff at all levels could describe the key elements of the quality governance processes, i.e. policies and procedures, escalation, incident reporting, risk management. The panel also reviewed the Trust s process to assess the impact of cost savings plans on quality of patient care and its workforce. Summary of findings The following good practices were identified: The Board members interviewed, including non-executive directors, could clearly articulate the Trust s quality priorities and governance processes. The Trust s quality priorities are: infection control, pressure ulcers, nutrition, hydration and patient experience. Many staff reflected the strong leadership of the Board on quality, led by the Chief Executive. A good working relationship was noted between the Director of Nursing and Medical Director which sets the tone for the positive clinical working relationship in the Trust. The governors appeared very engaged and supportive of what the Trust Board was doing. The following areas of concern were identified: Board papers and interviews with Board members identified that the Trust s clinical governance structure is complex and not all senior staff could clearly demonstrate sufficient understanding of it. The Trust had recognised that there was not sufficient time available to focus on patient experience and workforce the Board s quality sub-committee. It has planned to restructure quality into two separate board sub committees but was awaiting the outcomes of the review before addressing this. Staff understanding of the quality priorities was largely embedded, but not universal. The Trust could not demonstrate how it disseminates the learning it gathers through incident reporting, root cause analysis (RCAs) and other information such as mortality reviews Whilst it is recognised the Council of Governors has a secondary governance function, the governors should consider how they can work with the non-executive directors to support them more proactively in the Board s quality assurance processes and thereby maximise the opportunity for independent scrutiny on this important area. Quality impact assessments of cost improvement plans (CIPs) did not appear to be consistently undertaken by the Trust on all CIPs and the process was not fully understood by all the clinical leaders that were interviewed. Further, the Board needs to review how the Executive team are monitoring the ongoing impact once CIPs have been implemented to ensure there is an ongoing assurance process.

For all the above areas of concern, we identified a number of improvements already planned or underway at the Trust. Detailed Findings Good practice identified The Board of Directors, including non-executive directors, could describe the Trust s quality priorities and articulate how the high level governance processes supported the organisation to identify risks to achieving these. The recent Board papers reviewed validated this focus and that risks affecting were a top priority on the agendas. The Trust s quality priorities are: infection control, pressure ulcers, nutrition, hydration and patient experience. There were a significant number of positive comments from staff interviewed about the leadership of the Trust, particularly in terms of improving quality, staff engagement and patient experience. The panel also observed a good working relationship between the Medical Director and Director of Nursing in interviews, particularly when focusing on the aspects of quality governance that required board level clinical leadership. The governors listening event demonstrated a high level of engagement and support for the Trust s leadership team. The Director of Nursing could clearly articulate a robust process for clinical sign off of CIPs at Executive level. There is a Red-Amber-Green (RAG) rated system for each of the plans to determine their impact on quality; Red rated plans are rejected, Amber rated get the agreement to go ahead with follow up at performance management meetings. Doctors who attended the focus group felt that there was a systematic approach to review CIPs and that they had not seen the quality of care impacted as a result. Examples were provided which demonstrated potential CIP plans that had been rated as a 'red' impact on quality and therefore rejected, these included a suggestion to stop wall washing which was rejected on an infection control basis. However, it has been noted in the outstanding concerns section below that this systematic approach to providing quality assurance to CIPs is not always being followed by the Trust. Some directorates had put in place Preceptorship, an effective development programme for newly qualified clinicians. The clinical practice supervisor programme in trauma and orthopaedics also appeared to be very effective. Outstanding concerns based on evidence gathered Key planned improvements Recommended actions Priority urgent, high or medium i. Quality governance structure The committee and group structure of the Trust is complex which makes it difficult to understand how they support the overall quality governance framework. There are many groups and committees, with duplication The Trust has committed to reviewing its quality governance committee urgently following the review. The Trust should undertake a comprehensive review of the effectiveness of its governance structure. This should review all committees and group agendas and the information reviewed to ensure that High

Outstanding concerns based on evidence gathered Key planned improvements Recommended actions Priority urgent, high or medium between some and apparent gaps in other areas which appear to have less scrutiny. Directorate mortality reviews, which are explored further in the clinical and operational effectiveness session, do not appear to be fed into the overall governance structure. Management information presented to the Board does not appear to be brought together to identify common themes and issues, for example a focus on high risk services could be made by triangulating information on mortality, falls, high agency staffing levels and complaints. The information presented does not enable the Board to effectively challenge on all aspects of quality. The Trust has been working with the HAY Group under the NHS Leadership Academy for six months to up-skill Clinical Directors and senior consultants to fulfil their roles more effectively in relation to leadership and governance. This programme is nearing completion. all the Trust s quality priorities have a clear focus at the appropriate level. The information flows within the Trust should be reviewed to ensure that they are operating effectively. The Board should consider how it reviews management information provided to it to demonstrate adequate challenge on the progress being made on the Trust s quality priorities. The Board minutes and panel interviews demonstrated that the non executive directors had challenged whether the agenda for the CQSPE Board sub-committee had sufficient time for reviewing patient experience and workforce measures. The relationship and cross over between the patient safety group, red incident group, risk and assurance committee and the CQSPE in particular was quite difficult to follow in the documentation and committee minutes provided by the Trust. Following the HAY Group training the Trust should ensure that all senior clinical staff are aware of their responsibility for governance in their directorate and are held accountable for this. If this is still not embedded, further training may be required. A number of senior staff interviewed could not articulate how the governance processes were working in practice in the Trust and in their own directorate, for example the escalation procedures and clinical supervision policy. A number of the clinical directors could not describe how their directorate governance processes operated in practice and how issues fed into the overall Trust governance arrangements. ii. Understanding of Trust s quality objectives in the organisation The Trust s quality objectives in its strategy are: To become well known for the safety and quality of our services through a systematic approach to service transformation, research The Trust has communicated its quality objectives and priorities through the strategy, its website and through staff newsletters. The Trust should ensure that its quality priorities are embedded at ward level through dissemination at regular ward and directorate meetings. High

Outstanding concerns based on evidence gathered Key planned improvements Recommended actions Priority urgent, high or medium and innovation. To provide the best possible patient experience. There are a number of principle outcomes, which are: The Trust should also consider how it uses lessons learnt from the review of mortality indicators to further inform its quality priorities. To deliver effective clinical care to all patients. To maintain and improve patient safety. To ensure that the patient receives a good standard of care from his/her perspective through excellent customer service every time to everyone. To work in partnership with commissioners and comply with agreed quality standards. When interviewing ward level staff, the panel noted inconsistencies in both how the Board s quality priorities were talked about and also actions being taken within the Trust to improve patient care. For example, in a number of the focus groups and observations, nurses and junior doctors could not describe the main areas of quality focus in the Trust and could not describe the procedures put in place to address these. The Trust s quality priorities do not include reference to reviewing mortality indicators as part of understanding its overall performance on quality of patient treatment and care. iii. Quality impact assessment of CIPs The Trust has a 15m CIP target for 13/14 and have currently identified 12m of potential savings. However only 4m of these have been approved as a 'green' rated plan. A number of schemes are staged to start delivering in Q2 which mean any slippages in delivery are likely to increase the financial risk. The Medical Director and Director of Nursing are involved in all CIP sign offs. All CIPs should be fully assessed for their quality impact prior to implementation and should be regularly reviewed. Where a concern over quality is identified, this risk should be properly mitigated before the plan is allowed to go ahead / continue. High The Trust has put in place a process to ensure clinical engagement in reviewing the impact of cost improvement plans on quality and patient Executives and senior staff should be able to clearly and consistently articulate the impact assessment and monitoring process

Outstanding concerns based on evidence gathered Key planned improvements Recommended actions Priority urgent, high or medium safety. A number of the clinical directors interviewed could describe this process effectively but this was not consistent across all the clinical leadership interviewed. The Trust could also not fully articulate the monitoring arrangements to ensure the impact on quality was continuously reviewed. within their area of responsibility. The Trust has relatively large CIP schemes (> 1.2m) based on reduction of beds. These schemes had not been fully quality assessed and given the current bed pressures in the Trust this represents a significant risk to quality. The panel also noted examples of service developments being started before any evidenced assessment of staffing needs or operational arrangements to ensure quality. For example: The PAU (Paediatrics Assessment Unit) was started in Nov 2012 but it was not until Jan 2013 that a clear operational policy for the unit was in place and assessment of staffing needs is yet to be completed. Opening of ward B4 as a contingency ward without a risk assessment in support (noted from the minutes of patient safety group April 2013) iv. Role of governors in challenging the Board The governors who attended the focus group appeared well briefed by the Trust and noted a transparent relationship with the Board. They could articulate their current focus on collating patient experience stories and understanding of some of the Trust s quality priorities, especially pressure ulcers. However, the governors could not provide examples of where they had challenged the Board and requested further information and assurance, in particular on areas of quality and patient experience. The governors also were not fully aware of the impact of the integrated community services on the Trust s operations and staff. A review of the Council of Governors effectiveness will be undertaken this summer. Governors should consider how they can be more proactive in their role of holding the Board to account on all aspects of quality. High

Outstanding concerns based on evidence gathered Key planned improvements Recommended actions Priority urgent, high or medium v. Developing a learning culture The panel reviewed a number of the Trust s responses to recent serious incidents. While the process appeared to have been followed, the quality of the analysis and the learning harnessed from these was not always effectively evidenced. The Trust did not demonstrate a systematic process for sharing experiences and learning across different teams through the reporting and monitoring it conducts. Many staff interviewed could not describe how they reviewed wider information on serious incidents, root cause analysis and complaints and built this learning into their directorate or ward level processes. There did not appear to be a consistent governance model embedded in the Trust at ward and directorate level to enable learning. For example, ward level meetings did not appear to take place regularly in all areas of the Trust that he panel visited and staff could not articulate the management information they received to review incidents and complaints. None noted The Board should review its approach to learning and ensure there is a clear focus in the organisation on learning from incidents and when things go wrong. It should disseminate this approach through the clinical and operational leadership and ensure that regular audits are undertaken to monitor progress. High This is discussed in specific sections on clinical and operational effectiveness and patient experience later in the report, but is included here as an over-arching area requiring improvement by the Board.

Clinical and operational effectiveness Overview The panel explored two KLOEs for clinical and operational effectiveness, focused on the following areas: Actions the Trust has taken to improve mortality performance, particularly in general medicine, elderly care and stroke wards, including managing deteriorating patients appropriately. Action the Trust has taken to improve the depth and accuracy of coding, particularly in palliative care, and what impact this has had on mortality indicators. How the Trust addresses infection control standards, particularly Clostridium Difficile, where it had notably higher than average incident rates. Summary of findings The following good practices were identified: The Trust reviews the majority of deaths in hospital in detail. The Board and the Clinical Quality, Safety and Patient Experience Committee has reviewed mortality indicators recently and demonstrated an improvement trajectory since 2009. It currently has a HMSR of 98 which is within expected range. Action has been taken by the Trust to improve the quality and depth of coding so mortality reporting is more accurate. It has, in particular, made a marked improvement in palliative care coding. The Trust is on an improvement trajectory with infection control as it has clearly been a focus for the Board for several years. The panel observed infection control procedures being followed in the majority of wards visited and some notable good practice, including nurses changing uniforms on site appropriately. The following areas of concern were identified: The panel considered that the Trust demonstrated limited analysis of mortality data in terms of understanding the improvements that might be needed in a speciality or care pathway. The panel noted a tendency to explain above expected mortality indicators as a function of depth of coding or underlying health of Dudley s population, rather than analysis of what areas of care and treatment could be further improved. Whilst these are noted as important elements of understanding the mortality data, there is a need to demonstrate that the Trust is more proactively looking for areas where it can improve care and treatment. The Trust has already demonstrated it can do this in some defined areas, such as heart failure, but needs to make sure this is more systematically undertaken on all services it provides. There was no clear evidence that lessons learnt from mortality reviews are disseminated effectively. Examples of infection control concerns were noted in some areas, during panel observations, and there was a lack of awareness within some ward managers and matrons of the audits taking place in the Trust to monitor compliance with procedures. Bed flows and management were not always operating effectively, reflective of the higher than expected capacity that the Trust was currently dealing with. For the majority of the above areas of concern, we identified a number of improvements already underway or planned at the Trust.

Detailed Findings Good practice identified It was clear that there was a focus on mortality at a high level in the organisation and there is a mortality review process in place which had been operating for a number of years. It was noted that current mortality indices are not outside expected limits. There was evidence of two processes in place to review mortality: An audit of every death at Directorate level; and A monthly meeting focused on individual Directorates attended by the Chair, Medical Director and Chief Executive. The CCG has also sent representatives. Information supplied indicated that the monthly mortality review meetings had taken place in 2013 and that the relevant directorates were provided with mortality data to review in the meeting. The Trust has demonstrated that its Clinical Coding team is competent and compliant with national standards. Improvement has been made in the last year on coding palliative care cases. The management of deteriorating patients at ward level was consistently described by the clinicians interviewed including junior doctors and nursing staff. The Medical Emergency Team (MET) system appeared to be an effective process and staff confirmed that in their experience there was a prompt and appropriate response to escalation. During the visit, examples of good levels of cleanliness were observed everywhere, including Accident and Emergency (A&E), Emergency Assessment Unit (EAU), Maternity and Ward A2. The Trust has made significant improvements in its infection control rates and has invested in a team to focus on supporting wards on reducing cases further. There were a number of areas of good practice noted in infection control procedures including the panel observed all nursing staff on one of the Trust s largest wards changing into their uniforms on site. There has been an increase in palliative care referral pathways and staffing allowing an increase in the number of non cancer patients benefiting from palliative care input. During the visit, examples of good practice were observed and staff and patients provided further examples, including: The diabetes outreach team and the community services were noted as having innovative staffing models and effective clinical teamwork between doctors and nurses. There were effective clinical links noted between the community and hospital teams, in particular improving the palliative care services. A&E also had a number of good operational practices: o The Impact team which included physiotherapists, social workers and occupational therapists to help prepare patients for discharge. o New Hub provided excellent information and communication for the emergency team. Heart failure - a targeted review had identified improvements to be made and the Medical Director described a 40% reduction in cardiac arrests since the introduction of the MET and that the care of the deteriorating patient had benefited from this and the outreach process.

Outstanding concerns based on evidence gathered Key planned improvements Recommended actions Priority urgent, high or medium i. Understanding of mortality issues throughout the Trust The Trust was authorised by Monitor in 2008 with a side letter requiring action to be taken to address the higher than expected mortality indicators. As noted in the data pack, it has been an outlier on SHMI and HSMR up to March 2012, although the panel recognised the improvement trajectory achieved on these indicators over this period demonstrated in the current HSMR levels. In interviews, most Board members and staff within the organisation stated that the Trust s high mortality indicators reflected the underlying poor health of many of the population it serves and also the historical accuracy of coding. This rationale for high mortality indicators was reiterated in a recent presentation by the Medical Director to the Trust s governors which was made available to the panel. The panel considered that the Board had not scrutinised mortality data in sufficient detail to fully justify this rationale and this may have led to a lack of focus on systematic learning and improvement of patient care and treatment. The Trust demonstrated that some action had been taken from review of the mortality data. This included audits of heart failure and insulin support which led to improvements in these services within the Trust. The panel met the diabetes team which was created following the review of insulin care for patients. Their aim was to focus on improving care across the Trust. It was noted that the team reviewed all deaths of patients with diabetes, even if not the primary cause. The clinical lead could clearly articulate lessons learnt and disseminated in improve practice from these reviews. The Trust should review how it can introduce more rigour and challenge into the overall mortality review process. This should include developing a clearer understanding of the root causes of mortality data at both Board level and within Directorates and prioritised action plans to drive improvements in care pathways. High The Board s review of mortality was discussed with the CQSPE committee Chair and the lead governor; both noted that the deeper analysis available in the review data pack had not been reviewed before at the Trust. This type of analysis should be considered by the Trust to prioritise systematic reviews of specialties or care pathways with higher mortality indicators, i.e. general medicine, cancer and geriatric medicine. It was noted that the Trust does undertake deeper analysis of SHMI mortality data at a diagnostic grouping level rather than at Specialty level first. The Trust should consider whether this level of analysis is appropriate and whether analysis at specialty level would provide further insight to improving care pathways. Although not directly prompted by mortality reviews, external reviews have