Agenda item A3 THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST Minutes of the Board of Directors Meeting held on 17 th December 2014 Part A: Public Session Present: Mr K W Smith Chairman Professor P H Baylis Non-Executive Director Dr B C Dobson Non-Executive Director Mrs A Dragone Finance Director Sir Leonard Fenwick Chief Executive Ms S Kler Non-Executive Director Mrs H Lamont Nursing & Patient Services Director Mrs H A Parker Non-Executive Director Mrs L Robson Business and Development Director Mr D Stout Non-Executive Director Mr E Weir Non-Executive Director Mr A R Welch Medical Director In Attendance: Mr S R Reed Mrs A O Brien Trust Secretary Director - Quality & Effectiveness (minute ref. 14/165(ii) only) 14/161 Apologies for Absence No apologies were received on this occasion. 14/162 Declarations of Interest Mr Weir declared an interest in all matters pertaining to Newcastle City Council. 14/163 Minutes of the Meeting held on 26 th November 2014 These were agreed to be a correct record. 14/164 Strategic Items i) Report of the Chief Executive Sir Leonard spoke of a number of topics of current interest. The Chancellor of the Exchequer had recently visited the Campus for Ageing & Vitality and Sir Leonard had taken the opportunity to press the case for sustaining NHS Foundation Trust freedoms. The current service pressures were multi-factorial, including the challenges for the North East Ambulance Service and in primary care. Caseload within the Trust included increasing numbers of older patients with long lengths of stay and who were often difficult to discharge due to their social circumstances. In this regard, the Trust 1
was scoping community opportunities, including short-term placements in care homes. In relation to Ebola virus, a number of external bodies were now interfering. There had been problems with the media recently. The identified isolation cubicles had been upgraded in just four weeks and two Trexler tents were being brought in to commission. Sir Leonard advised Directors that he had recently participated in a BBC documentary about PFI schemes in the NHS. The broadcast date was not yet known. Achievement of national performance objectives was proving more and more challenging, given the increasing volume of emergency care activity across the Trust. In this respect, the Great North Trauma & Emergency Centre had received extensive media coverage in week commencing 8 th December 2014. The BBC had however chosen to broadcast coverage of James Cook Hospital, Middlesbrough. As ever, the Executive Team had been monitoring the financial stability of the Trust. A formal submission had been made to NHS England in response to the Children s Heart Disease Standards and Service Specifications. Co-location of heart surgery services with other paediatric care was being pushed by NHS England. There had been no mention in the specifications of external devices and bridge to transplant. A Risk Summit held by the Area Team had been briefed on the poor behaviour of the review team during its visit to Newcastle. The Executive Team had been focusing on improvements in staff recruitment, particularly nurses, given the national issues of a wave of impending retirements of older staff and a shortfall in the numbers of students undertaking nurse training. The Team was also much exercised about the continuing legal dispute over the closing phases of the Transforming Newcastle Hospitals investment programme. It was pleasing to note that planning permission had been received for the proposed Children s Cardiothoracic Services building. A business was now in preparation. Attention was drawn to a number of key impact documents received from government and regulators. Attention was drawn in particular to the Department of Health guidance on the use of surplus land, which did appear to be a thinly veiled attempt at seizing some of these assets. The Trust was currently holding three sites for health and social care development. It was noted that the General Medical Council had announced a national programme of check visits in relation to Undermining and Bullying and one such visit had been scheduled for Women s Services at the Royal Victoria Infirmary. With regard to the Care Contact Time guidance issued by NHS England, Mrs Lamont commented that it was not clear as yet as to what constituted direct contact time. Nursing Directors in the Shelford Group were discussing this. The Chancellor s Autumn Statement was highlighted, given the number of commitments made in relation to NHS funding. It was noted that the NHS Trust 2
Development Authority had been called to account by the Public Accounts Committee in relation to the 0.5 billion of additional funding provided to in essence bail out failing Trusts. ii) Publication of the Dalton Review A summary was received of Examining new options and opportunities for providers of NHS care - The Dalton Review which had been published by the Department of Health on 5 th December 2014. Overall, it did not appear to contain anything new. The Review stated that it is not only currently challenged providers who should strategically consider their future alongside that of their wider health economy partners. The NHS Five Year Forward View signposts the need for new models of care to respond to the challenges faced by the NHS. Even the best providers will struggle to meet the challenges of the future without looking outside traditional organisational boundaries and considering how their form could better support new clinical models and ways of working. The organisational forms considered in the Review had different characteristics, benefits and barriers. The review acknowledged that many were already being used in the NHS. It was clear that there should be no national blueprint or one size fits all solution. Accordingly, the Review did not seek to impose wholesale change. Seven different organisational forms were identified in the Review, with the full report setting out an evaluation of the purpose, benefits and risks of each model in greater depth, alongside examples of where these models are already in operation within acute, mental health and community based sectors. Mrs Robson noted the proposal that the distilled recipes for success were to be planted elsewhere and this seemed improbable on a number of counts. A new kitemark, beyond Foundation Trust status, was cited to enable commissioners to identify organisations with the capability and greatest likelihood of successfully spreading their systems into organisations that were in persistent difficulty. The Chairman wondered whether the Review would survive post-election. It was highlighted that the Trust did many of the things cited in the report but under different banners. There might however be some funding opportunities, which could be picked up via the 2015/16 Plan. In the context of the models described, Sir Leonard advised of the Sherwood Forest Hospitals NHS Foundation Trust buddying arrangements falling away, as that Trust had now sought different and more hands on support than Newcastle had wished to provide. to receive the briefing. 3
14/165 Safety, Quality and Performance i) Healthcare Associated Infections Mrs Lamont introduced the report for November 2014. For Clostridium difficile, the year-to-date total had reached 55, with five cases reported in November. Eight cases of C. difficile had been successfully appealed so far this year (including four in November) and a further five had been submitted to the Appeals Panel. These appeals had brought the running total below the trajectory to the year-end target of no more than 80 cases. A further, third, case of MRSA bacteraemia (national target = 0) had been reported in recent days and a rapid review was being undertaken. The Trust was one of four surge sites in England that would deal with suspected and confirmed Ebola patients when and if the need arose. A great deal of work had been undertaken and was continuing, in order to prepare for the potential admission of these patients. Facilities on Ward 19 RVI (the Infectious Diseases Unit) were having Estates work carried out in order to accommodate Ebola patients. Staff training on the wearing and use of specialised personal protective equipment (PPE) was ongoing. As new national guidance emerged, this was being incorporated into Trust guidance, which was available for staff on the intranet. The Medical Director had recently circulated a letter to all staff, advising of the work across the Trust and reassuring staff regarding potential risks, and the Trust s approach to ensuring that staff safety was paramount. Tuesday 18 th November 2014 had been European Antibiotic Awareness Day, with Newcastle Hospitals once again using the date to raise awareness and highlight best practice in antibiotic prescribing and use. Professor Baylis commented on the excellent record overall in infection prevention and control across the Trust and especially in comparison with the position of, say, five years ago. to receive the report and note the content. ii) Quality Report Mrs O Brien, Director of Quality and Effectiveness, was in attendance and presented the report for November 2014. Patient Falls, needlestick and sharps injuries and higher-graded pressure ulcers had all declined in number compared with the previous month. One higher graded pressure ulcer acquired by a patient in the community had been reviewed using the Serious Incident Review approach. There had been no never events in the period reported, for the fifth consecutive month. 4
Mr Welch advised Directors that the new criteria for what constituted never events would inevitably drive an increase in the number of cases reported but dilute their significance. Mrs O Brien was to consider reporting any cases against both the current and new lists, in order for the Board to see what impact the changes had made. Dr Dobson enquired about the incorrect laboratory result and how laboratories were accredited. In this instance, a national laboratory in Glasgow had issued an incorrect analysis, which had affected a patient s treatment plan. However, clinical staff had identified the error before any potential harm could arise. to receive the report and note the content. iii) Providing Clinical Assurance (Clinical Assurance Toolkit) Mrs Lamont presented the latest results for the Clinical Assurance Toolkit (CAT), which provided assurance of the care given to patients. It was based upon selfassessment by the Ward Sister/Charge Nurse (or equivalent), as well as environmental cleanliness checks by the Matrons (in the acute setting). The Matron checks were peer reviewed quarterly and the next peer review would be conducted in January 2015. As previously reported, CAT scores had dropped from 97% to 95% following changes to the question set in October 2014, which had been expected based on experience of previous question changes. The November CAT data had not been available, due to the timing of the December Board meeting. With regard to the Friends & Family Test results and feedback, these continued to demonstrate the Trust s favourable performance in relation to the percentage of patients who would recommend the Trust. Low response rates in the Emergency Department were of concern, however, particularly as they were linked to CQUIN payments for 2014/15. The payments were linked to response rates rather than outcomes. Commissioners would not accept a compromise target. Mr Welch commented that the sample sizes were small and Clinical Commissioning Groups ignored the content of the feedback received. However, there were some indications of an improving position. Directors were aware that the focus of the CAT report varied each month as a particular aspect of practice is reviewed. This month the practices and documentation relating to maternity checks had been reviewed (using October s data) had had demonstrated a high level of compliance. In line with the revised CAT Strategy, the escalation of red scores to the Board took place in the second month of occurrence. A detailed report on these areas was presented on the private side of the Agenda. to receive the briefing and note the current position. 5
iv) Nurse Staffing Monthly Report 14/166 Finance Mrs Lamont presented the monthly report, which included Nursing and Midwifery staffing data as follows: a. Planned and actual staffing and average fill rates for all Inpatient areas within the Trust, with the numbers broken down between hours of Registered Nursing/Midwifery and Care staff, and between day and night shift. b. Information regarding the Care Summary and one week summary of the Safer Nursing Care Tool (SNCT) data collection, which was undertaken each month within the Trust. c. Discussion of staffing indicators, including turnover rates and vacancies. d. Identification of and discussion about any trends and development of levels and tolerance. Due to the early Board meeting in December, at the time of writing, data relating to staffing had been incomplete and validation was ongoing and hence cautious interpretation was required. It was highlighted that the Care Summary was proving to be very useful at ward level. The Nurse Staffing Review Phase II was due to report early in the New Year. In relation to recruitment, it was noted that a Senior Nurse was embedded in the HR department, to take a particular focus on Nurse and Midwife appointments. A national report had recently been published on overseas recruitment of nurses and the Trust was planning a targeted recruitment exercise in the Philippines. Dr Dobson commented on the Recruitment & Retention plan, which did not appear to include much on retention. A working group was addressing this. An attrition report would be available from January 2015 but the early evidence suggested that this was not as significant as expected. Sir Leonard spoke of the scope to do more with Northumbria University on the characteristics as much as qualifications of students entering the Nursing course. Mrs Lamont commented that attrition was reducing but a percentage of Nursing students studying in Newcastle were from outside of the region and did not always stay in Newcastle. Matrons from the Trust were now engaged in the student selection process. to receive the briefing and note the current position. i) Month 8 Finance Report Mrs Dragone presented the financial position as at 30 th November 2014 but highlighted that this was based on activity to the end of October 2014. In terms of Income & Expenditure, a surplus of 5.9 million had been delivered. 6
Cash holdings stood at 121.9 million but capital expenditure was slipping against Plan. The Capital Management Group was to review this, with a view to rephrasing of schemes. The Continuity of Services ratio stood at 3 (on a four point scale), which was good for a Trust with a large PFI scheme to take into account. In terms of activity, October had been the busiest month ever and hence the increase in income. It was forecast that the Trust would deliver a surplus at the year-end but emerging commissioner affordability issues made it challenging to predict the exact scale at this time. 14/167 Items to Receive To receive the briefing and note the current position. i) King s Fund Review of CQC - Well-led Boards A summary was received of a report published by the King s Fund in December 2014 which focused on how Boards could review their position in relation to the well-led domain included within the CQC inspection regime. ii) CQC Intelligent Monitoring Report November 2014 A summary overview of the Trust position in the four reports published since October 2013 was received. In the draft December 2014 report the Trust was positioned in risk band 6 (the least risky). Three indicators had been highlighted as a risk: In-hospital mortality - Trauma and Orthopaedic conditions SSNAP domain 2 - overall team-centred rating score for key stroke unit indicator and composite indicator A&E waiting times more than 4 hours (01-Jul-14 to 30-Sep-14). The A&E waiting time risk had then been removed between the publication of the draft version and the final version, due to an error in the CQC s calculations used to derive the A&E indicator. In the report published on the CQC site on 3 rd December 2014 the Trust position had altered to a band 5, where five indicators had been highlighted as a risk: In-hospital mortality - Trauma and Orthopaedic conditions SSNAP domain 2 - overall team-centred rating score for key stroke unit indicator A&E Survey Q7: From the time you first arrived at the A&E Department, how long did you wait before being examined by a doctor or nurse? (01-Jan 2014 to 31-March 2014) A&E Survey Q22: If you were feeling distressed while you were in the A&E Department, did a member of staff help to reassure you? (01-Jan 2014 to 31-March 2014) 7
A&E Survey Q30: Do you think the hospital staff did everything they could to help control your pain? (01-Jan 2014 to 31-March 2014). The Trust had been disappointed that the final version of the Intelligent Monitoring Report published on 3 rd December 2014 included additional indicators which had affected the Trust s banding. The indicators that were identified as a risk in the draft report were followed up with the CQC and the Trust was currently reviewing the results and developing an action plan. The Trust was committed to reducing risk and would continue to scrutinise data to ensure that not only was it prepared for the CQC inspections thoroughly but that the information represented the Trust fairly and accurately. It was becoming increasingly difficult to accurately predict the likelihood of additional risks as the indicators grew in number and complexity. iii) CQC Complaints Matter report A summary of the report was received, which described how complaints and concerns fitted into the CQC s new regulatory model, placing concerns and complaints and feedback at the heart of quality regulation, and presented an overview of the findings on the state of complaints handling in Hospitals, GP Practices, Mental Health Services, Community Health Services and Adult Social Care Services. The report built on the work detailed in earlier reports including the Francis and Clwyd-Hart reports and explained how complaints and concerns were to be embedded into the CQC s new regulatory model with two aims: To improve how the CQC used the intelligence from concerns and complaints to better understand the quality of care being provided by providers. To consider how well providers handled complaints and concerns, and to encourage improvement. It was important to note that the CQC, Parliamentary and Health Service Ombudsman (PHSO) and Healthwatch England had recently set out similar universal expectations of good complaints handling and also how this was to be used in inspection visits to review performance of each Trust. Whistleblowing in respect of concerns raised by staff was encouraged, especially reviewing the processes in place to handle victimisation or bullying. There was to be increasing improvement in data available to enable comparison of the wide variation in the way complaints were handled by different Trusts. The CQC was seeking a shift to a listening culture that encouraged and embraced complaints and concerns as opportunities to improve the quality of care for patients, and the CQC would treat numbers and rates of complaints high or low as indicators to prompt potential further investigations. CQC, PHSO and Healthwatch wanted Trusts to put people who used services at the heart of their work, and to check this they would use five questions to monitor the quality and safety of services: 8
- Are they safe? - Are they effective? - Are they caring? - Are they responsive to people s needs? - Are they well led? Following inspection, Trusts would now be awarded ratings on a four point scale: Outstanding there is active review of complaints and how they are managed and responded to, and improvements are made as a result across the services. Good it is easy for people to complain or raise a concern and they are treated compassionately when they do so. Requires improvement people do not find it easy to complain or raise concerns, or are worried about raising concerns or complaining. When they do, a slow or unsatisfactory response is received. Inadequate there is a defensive attitude to complaints and a lack of transparency in how they are handled. People s concerns and complaints do not lead to improvements in the quality of care. Trusts would be asked to complete a self-assessment report on Complaint Handling prior to a CQC inspection, covering: Leadership: identifying who is responsible for complaints at the Trust, including the Executive and Non-Executive leads, as well as the individual with day-to-day responsibility and the total number of staff dedicated to complaints. Governance: describing the Trust s governance arrangements for complaints; how often they are discussed at Board level; what committees review the handling of complaints and compliments, and any themes within them. Awareness: describing how patients and relatives were made aware of how they can raise concerns or make formal complaints, and the processes in place to resolve complaints before they become formal. Timeliness: What are the local standards for providing a response to complaints (timeliness) and how well is the Trust achieving this? Are there any areas that struggle to achieve the standards? Learning: How does the Trust disseminate learning from complaints? Can the Trust point to any changes made as a result of learning from complaints? Evaluation: How does the Trust ascertain whether or not complainants are satisfied with the complaints process and the outcome? On the site visit the intention of the CQC was to gather evidence of how well the Trust handled complaints. Relating to the concerns raised by staff (whistleblowing), the CQC would be assessing the leadership and culture of the organisation in more depth than previously attempted, especially staff confidence to raise concerns. Finally, the report acknowledged that there were wide variations in the way complaints are handled by the provider organisations, and that there was a need 9
for a more open culture where concerns were welcomed and learning from complaints was demonstrated. In this regard the CQC would take action on services that did not take complaints seriously and all future inspection reports on Trusts would include a description of how their complaints and concerns were handled. Ms Kler advised that many of the areas in Complaints Matter were already being addressed by the Complaints Panel and Patient Relations Team. to exclude members of the press and public in accordance with the Health Services Act 2006 (Schedule 7 Section 18(E)) (as amended by the Health and Social Care Act 2012) and in view of publicity being prejudicial to the public interest. The next scheduled meeting would be held at 12.45pm on Wednesday, 28 th January 2015. 10