review into the quality of care & treatment provided by 14 ......6 unannounced visit the...

Buckinghamshire Healthcare NHS Trust

Review into the Quality of Care & Treatment provided by14 Hospital Trusts in England

RAPID RESPONSIVE REVIEW REPORT FOR RISK SUMMIT

July 2013

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Contents

1. Introduction 3

2. Background to the Trust 7

3. Key Lines of Enquiry 10

4. Review findings 11

Governance and leadership 14

Clinical and operational effectiveness 21

Patient experience 28

Workforce and safety 33

5. Conclusions and support required 45

Appendices 49

Appendix I: SHMI and HSMR definitions 50

Appendix II: Panel composition 52

Appendix III: Interviews held 54

Appendix IV: Observations undertaken 56

Appendix V: Focus groups held 58

Appendix VI: Information available to the RRR panel 59

Appendix VII: Unannounced site visit 66

Appendix VIII - Patient Stories 68

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1. Introduction

This section of the report provides background to the review process and details of the key stages of the review.

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 bythose 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 thebasis that they have been outliers for the last two consecutive years on either the Summary Hospital level Mortality Indicator (SHMI) or the Hospital Standardised MortalityRatio (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 andtreatment at the trusts which warrant further review. It was intended that these measures should not be reviewed in isolation and no judgments were made at the start of thereview 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:

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 thepatients in each of the hospitals and also considered independent feedback from stakeholders related to the trust being reviewed, which had been received through theKeogh review website. These themes have been reflected in the reports.

Listening to the views of staff – staff were supported to provide frank and honest opinions about the quality of care provided to hospital patients.

Openness and transparency – all possible information and intelligence relating to the review and individual investigations will be publicly available.

Cooperation between organisations – each review was built around strong cooperation between different organisations that make up the health system, placing the interestof 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 onRapid Responsive Reviews (RRR) 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.

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Identify:Whether existing action by these trusts to improve quality is adequate and whether any additional steps should be taken.Any additional external support that should be made available to these trusts to help them improve.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 staffviews and feedback. The indicators for each trust were compared to appropriate benchmarks to identify any outliers for further investigation in the rapid responsive reviewstage as Key Lines of Enquiry (KLOE). The data pack for each trust reviewed is published at http://www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/trust-data-packs/buckinghamshire-data-packs.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 observedthe hospital in action. This involved walking the wards and departments, and interviewing patients, trainees, staff and Board members. The report from this stage wasconsidered at the risk summit.

Stage 3 – Risk Summit

This brought together a separate group of experts from across health organisations, including the regulatory bodies. They considered the report from the RRR, alongsideother hard and soft intelligence, in order to make judgments about the quality of care being provided and agree any necessary actions, including offers of support to thehospitals concerned. A report following each risk summit has been made publically available.

Methods of Investigation

A three-day announced RRR visit took place at the Buckinghamshire Healthcare NHS Trust (“the Trust”), on Monday 10th

to Wednesday 12th

June 2013. The StokeMandeville, Amersham and Wycombe sites were visited during this period. A variety of review methods were used to investigate the KLOEs and enable the panel to considerevidence from multiple sources in making their judgements.

The visit included the following methods of investigation:

Listening events

Public listening events give the public an opportunity to share their personal experiences of the Trust, and to voice their opinion on what they feel works well or needsimproving at the Trust. A listening event for the public and patients was held on the evening of 10 June at the Aylesbury Council Offices and 11 June 2013 at the WycombeHospital site. This was an open event, publicised locally, and attended by approximately 60 members of the public and patients on each evening.

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The panel would like to thank all those attending the listening event who were open with the sharing of their experiences and balanced in their perceptions of the quality ofcare and treatment at the Trust. The panel found the listening events extremely useful as it identified a number of positive themes around patient experiences, along withhighlighting a number of areas for further investigation.

Information obtained about the quality of care and treatment at the Trust from the listening event was used to drive the panel's agenda for the second and third day of theannounced site visit and for the unannounced site visit. Relevant themes emerging have been included within this report.

Interviews

21 interviews took place with key members of the executive team, non-executive directors and selected members of staff based on the KLOEs during the visits. SeeAppendix III for details of the interviews undertaken.

Observations

Observations of clinical areas and meetings enabled the panel to see the Trust undergo its day to day operations. They allowed the panel to talk to current patients, and theirfamilies where observations took place during visiting hours. They also allowed the panel to speak with a range of staff and assess any observed handover processes withinwards, to ensure that the staff that was coming on duty was appropriately briefed on patients.

During the RRR announced visit, observations took place in 20 areas of the Buckinghamshire Healthcare NHS Trust. See Appendix IV for details of the observationsundertaken.

Further observations were undertaken as part of the unannounced site visit, see below.

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 needsimproving. 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 Trustneed to consider to improve, including addressing areas with higher than expected mortality indicators.

Focus groups were held during the announced site visit with 10 staff groups, including a focus group open to all staff. See Appendix V for details of the focus groups held.

The panel would like to thank all those who attended the focus groups and were open with the sharing of their experiences and balanced in their perceptions of the quality ofcare and treatment at the Trust.

Review of documentation

A number of documents were made available to the panellists by the Trust as part of the RRR. Whilst the documents were not all reviewed in detail, they were available tothe panellists to validate findings. See Appendix VI for details of the documents available to the panel.

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Unannounced visit

The unannounced visit focused on areas identified at the announced site visit and took place over 4 sites as follows:

Stoke Mandeville (A&E, SSU, Surgical Ward) on the evening of Sunday 16/6/13

Wycombe (Minor Injuries and Illness Unit, Surgical Ward, Cardiac, Stroke and Receiving Unit, Contact Junior Doctors) on the evening of Tuesday 18/6/13

Amersham Community Hospital on the evening of Tuesday 18/6/13

Stoke Mandeville (Gynaecology, Elderly, Medical Ward) on the morning of Wednesday 19/6/13

See Appendix VII for details of the agenda completed.

Next steps

This report has been produced by Nigel Acheson, Panel Chair, with the full support and input of panel members. It has been shared with the Trust for a factual accuracycheck. This report was issued to attendees at the risk summit, which focussed on supporting Buckinghamshire Healthcare NHS Trust (“the Trust”) in addressing the actionsidentified 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 arisingfrom the 14 investigations will also be published.

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2. Background to the Trust

This section of the report provides background information on the Trust.

Context

Buckinghamshire Healthcare NHS Trust (“the Trust”) is not currently a Foundation Trust. The Trust has two acute hospital sites: Stoke Mandeville Hospital (which includes ahospice for palliative care) and Wycombe Hospital In addition, the Trust provides services at five community hospitals: Amersham Hospital , Buckingham CommunityHospital, Chalfont and Gerrards Cross Community Hospital, Marlow Community Hospital, Thame Community Hospital. The Trust is integrated with community services andhas seven Adult Community Healthcare Teams in place working twenty four hours a day, seven days a week. The Trust has a higher bed occupancy rate than the nationalaverage, offering a large range of services, in 2012 serving 94,116 inpatients and 476,074 outpatients.

14% of Buckinghamshire’s population belong to non-White ethnic minorities. Incidents of malignant melanoma, violent crime and infant death are significantly higher than thenational average in parts of Buckinghamshire.

A review of ambulance response times shows that the South Central Ambulance Trust meets the national 8min response target, but not the 19min response target.

Finally, the Trust’s HSMR level has been above the expected level for the last 2 years and it was therefore selected for this review.

Trust size and focus

Buckinghamshire Healthcare NHS Trust in the South Central of England services a population of about 500,000, which places the Trust within the higher range of the sizerecommended by the Royal College of Surgeons. The Trust has a total of 739 beds. It has a 74% market share of inpatient elective activity within a 5 mile radius of the Trust’sacute hospitals. However, the Trust’s market share falls to 48% within a radius of 10 miles, and 15% within a radius of 20 miles.

FACT BOX

Population 500,000

The Royal College of Surgeons recommend that the "...catchment population size...for an acute general hospital providing the full range of facilities, specialist staff and expertise for both electiveand emergency medical and surgical care would be 450,000 - 500,000."

Index of Multiple Deprivation (IDM) Of 149 English unitary authorities, Buckinghamshire is at 142nd

place, which means that is one of the least deprived.

Ethnic diversity In Buckinghamshire, 13.6% belong to non-White minorities, including 4.2% Pakistani.

Rural or Urban Buckinghamshire is a rural-urban region.

Incidence of malignant melanoma In parts of Buckinghamshire, and particularly in Aylesbury Vale, incidents of malignant melanomas are significantly more common than in the country

Road injuries and death In parts of Buckinghamshire, and particularly in South Bucks, road injuries and death are significantly more common than in the country as a whole.

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Buckinghamshire area overview

Buckinghamshire, in South East England, is one of the least deprived areas in the country. The age distribution in Buckinghamshire is largely similar to that of England as awhole; however, Buckinghamshire has significantly fewer women and men in their 20s. Incidents of malignant melanoma and infant death are particular health concerns inparts of Buckinghamshire compared to the country as a whole. 14% of Buckinghamshire’s population belong to non-White minorities.

Key messages from the data analysis

The Trust data pack identified a number of key concerns that were used to inform the KLOEs, which are outlined below.

Mortality

The Trust has an overall HSMR of 117 for the period January 2012 to December 2012, meaning that the number of actual deaths is higher than the expected level. This isstatistically above the expected range. Deeper analysis of this demonstrates that non-elective admissions are the primary contributing factor to this figure, with an HSMR of117, also above the expected range. Elective admissions are within the expected range, with an HSMR of 90.

Currently, Buckinghamshire has a SHMI of 114, which is statistically above the expected range. The non-elective admissions are seen to be contributing primarily to theoverall Trust’s SHMI with a figure of 114, which is above the expected range. The elective admissions are within the expected range, despite a relatively high SHMI of 113.

The Trust was selected on the basis of its HSMR, but its SHMI has been higher than expected over the last 12 months. Its HSMR has been higher than expected for 3-4years.

Mortality concerns appear to be focused within respiratory medicine/elderly care, strongly associated with a mortality outlier alert for patients admitted with pneumonia. CQChas issued mortality outlier alert notices to the Trust relating to Pneumonia and Acute and Unspecified Renal Failure. The Trust raised issues around clinical coding as well asprocess actions around the emergency care pathway for patients with pneumonia.

Buckinghamshire report above average activity associated with palliative care.

The key lines of enquiry (KLOEs) for the RRR included a review of the specialties in the Trust with higher mortality indicators and these informed the panel’sobservations and interviews.

Governance and leadership

The Trust Board has had two recent to its executive membership; the Chair joined the Trust in September 2012 and the Chief Operating Officer joined the Trust in Feb 2013.The Director of Human Resources (non-voting, in post since Jan 2013) is an interim post but all the other executive positions are substantive. There is also a recentlyappointed interim Medical Director, who is in the process of taking over responsibilities from the previous Medical Director.

The Healthcare Governance Committee is chaired by a non executive (Keith Gilchrist) and reports directly to the Trust Board. The Trust has also established a Mortality TaskForce, which has been meeting since October 2010.

A review of quality governance was performed by KPMG in October 2012. This review compared the governance arrangements in the Trust against Monitor’s QualityGovernance Framework. KPMG scored the Trust 3.0 (trusts must achieve a score of 3.5 or below to be authorised as a foundation trust).

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Key patient safety risks identified by the Trust relate to Accident & Emergency, staffing, the National Spinal Injuries Centre, theatres and Care of Older People.

A high level review of the effectiveness of the Trust’s quality governance arrangements was a standard KLOE for the review.

Clinical and operating effectiveness

The Trust is at the lower end of the distribution for the percentage of diabetic patients receiving a foot risk assessment due to low scores at both Stoke Mandeville andAmersham Hospitals. A key measure of clinical effectiveness is the percentage of discharged patients who are prescribed beta blockers and Stoke Mandeville was outsidethe control limits and is therefore an outlier on this measure.

The Trust failed to meet the 95% target level for A&E patients seen within 4 hours in 2012/13. The percentage of patients seen within 4 hours generally decreases during2012. 93.7% of patients start treatment within the 18 week target time which is above the target level. This has been a consistent trend from April 2012 to March 2013.

The Trust’s crude readmission rate is among the lower readmission rates of the trusts in the review as well as nationally, at 9.2%. The Trust’s standardised readmission rateshows a level of performance that is statistically within what is expected. The Trust’s average length of stay is shorter than that of the national average, at 4.92 days.

The PROMs dashboard shows that Buckinghamshire was a consistent performer overall. None of the indicators fell outside of the control limits for the 3 years shown in thedashboard.

A high level review of clinical and operating effectiveness measures was a standard KLOE for the review.

Patient experience

Of the 9 measures reviewed within Patient Experience and Complaints the Trust was rated ‘red’ on two measures: The “inpatient survey” and a report from the complaintsombudsman.

On the inpatient survey, the Trust was poor on delays allocating patients to a ward, information given to discharged patients, communication on medication side effects,cleanliness, hospital food and noise at night from other patients.

A separate report by the Ombudsman rates the Trust as C-rated for satisfactory remedies, which indicates a high risk of non-compliance with its recommendations. This is thelowest category rating. The Ombudsman investigates complaints escalated to it by complainants who are not satisfied with the Trust's response. It rates Trusts on whetherthey 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. TheOmbudsman rates each Trust’s compliance with recommendations and focuses on monitoring organisations whose compliance history indicates that they present a risk ofnon-compliance.

KLOEs 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 thisfeedback.

Workforce and safety

The Trust is a net contributor to the Clinical Negligence Scheme for Trusts. Contributions to the scheme have exceeded payouts to litigants in each of the last 3 years, and intotal by £10.7m. There has been two rule 43 Coroners Reports related to the Trust since 2009.

The Trust is a medium reporter of incidents when compared to similar trusts. Since 2009, five ‘never events’ have occurred at the Trust, classified as that because they areincidents that are so serious they should never happen.

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Throughout the last 12 months, the new pressure ulcer rate at Buckinghamshire has been below the national average. However, the Trust has a higher total pressure ulcer

rate than the national average and has been above the national average in seven out of the last eight months. The Trust is aware of the high rate, which they attribute to theNational Spinal Injuries Centre and inclusion of community services.

The Trust is ‘red rated’ in 12 of the workforce indicators and the remaining 8 indicators are green. It notably has sickness absence rates for medical, nursing and other staffabove the national mean rate and has a higher staff leaving rate and lower staff joining rate than the median within the region. For training of its doctors, it has a lower scoreon ‘undermining’ than the national average. In addition, it is being monitored by the GMC’s ‘response to concerns’ process.

KLOEs were included in the Trust review focusing on incident reporting within clinical and operating effectiveness and workforce measures, including workforceplanning and staff support.

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3. Key Lines of Enquiry

The KLOEs were drafted using the following key inputs:

The Trust data pack produced at stage 1 (and made publicly available) to tailor the KLOEs to address any areas the Trust was an outlier in, see section 2 for more details.. The data pack produced at stage 1 (and made publicly available) to tailor the KLOEs to address any areas the Trust was an outlier in, see section 2 for more details Insights from the Trust’s lead Clinical Commissioning Group (CCG), Chiltern CCG. Review of the patient voice feedback received via the Keogh review website, specific to the Trust prior to the site visit.

These were documented within the Panel Briefing Pack and agreed by the panellists at the panel briefing session prior to the RRR visit

The KLOEs identified for the Trust were as follows:

Theme Key Line of Enquiry

Governance and leadership Can the Trust clearly articulate its governance processes for assuring the quality of treatment and care? Are the leadership roles andresponsibilities clearly defined for the quality processes? Can staff at all levels of the organisation describe the key elements of the qualitygovernance processes (communication to staff)?

Governance and leadership How does the Trust assess and monitor the quality impact of the Cost Improvement Programme (CIPs)?

Clinical and operationaleffectiveness

What governance arrangements does the Trust have to monitor and address clinical effectiveness and operational performance data at asenior level?

What processes does the Trust have in place to support monitoring mortality data and clinical effectiveness? Has the Trust data identifiedany issues? What actions is the Trust taking to address issues noted?

Patient experience How does the Trust review patient experience data and engage with patients to seek views about their experience? What are the key themesfrom patients on their experiences? What action is it taking to address the key themes emerging?

Workforce and safety In the context of this review, can the Trust describe its workforce strategy?

How is the Board assured that it has the necessary workforce deployed to deliver its quality objectives?

What assurance does the Board have that the organisation is safe?

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4. Review findings

Introduction

The following sections provide a detailed analysis of the panel’s findings, including good practice noted, outstanding concerns and prioritisation of actions required.

A high level summary of the areas identified for urgent action is as follows:

Leadership and governance

In the past three to four years the HSMR has been consistently higher than expected. During this period, the Board has not effectively sought to understand the root causes ofthe higher than expected mortality, nor has it developed and implemented an action plan to address those causes. The Board has set up a Mortality Task Force but despitethis, the root causes of higher than expected mortality are still not fully explained or understood by the Trust. Furthermore, the review team feel that there is greater scope tounderstand and address the headline causes of mortality, which should include reference to care in the community, pathways of management within the hospitals includingstaffing and ward environment, and identification and management of deteriorating patients.

Leadership at Board level was described by a senior member of the Trust as "reactive" and there seems to have been limited challenge and examination of the datapresented to the Board (reassurance, not assurance). Governance relating to patient safety appears to rely heavily on DATIX incident reporting. Such incident reporting willonly capture a small percentage of incidents and other means of monitoring and capturing safety issues are required. The review team commend the introduction of othermethods, including Executive Safety walkabout and implementation of the Safety Thermometer. The Trust needs to urgently develop and implement an agreed performancedashboard to be used in every ward and reported to the Board along with patient experience data. The risk register is not sensitive or dynamic enough to present properissues to the Board. Examples of risks missing on the Corporate Risk Register at the time of the panel’s review were staffing of the Spinal Injuries Unit and risks associatedwith the new urgent care model, which have not yet been properly evaluated. The lower level Risk Registers do not adequately feed up to the higher level (Corporate)Register. The “benefits realisation plan” focuses on monitoring the realisation of benefits. The review team feels that the Trust need to include in this plan a strategy to identifyand manage emerging risks as the plan is implemented, as part of their business as usual.

Clinical and operational effectiveness

There is a lack of organisation-wide monitoring of clinical effectiveness and operational performance data, in that quality scorecards are not in place on all wards and it isunclear how the Board gains insight about the current and most significant quality and safety risks across its sites. The Trust needs more robust, organisation-widemonitoring of clinical effectiveness and operational performance data. A clear focus on monitoring performance and implementation of improvement projects would enable theTrust to move towards a culture that adopts national improvement initiatives and uses incident reporting as a positive and constructive tool. The panel note examples of theTrust adopting improvement initiatives such as the National Early Warning Scores, High Impact Actions, Safety Thermometer and the “6 C’s”.

The Mortality Task Group must focus its attention upon the identification of trends from the mortality data to inform improvement work. Evaluation of mortality data has beenprovided by both Dr Foster and the CQC, identifying pneumonia and acute renal failure as possible contributing factors to the high HSMR. An urgent priority is to develop astrategy for identifying and managing deteriorating patients on the medical wards – the review team understands that the current capacity on the respiratory ward isconsidered to be insufficient and that further dedicated respiratory beds may be provided. In addition, the HSMR is higher at weekends, and the review team heard evidenceof a lack of senior medical cover/review of patients at weekends. The review team did not see evidence to suggest that this was being addressed at pace in a systematic way.The review team acknowledges the improvement work that is taking place to address the care of patients with pneumonia (evidenced by the BTS audit data). However, thereview team feels that this work must proceed at greater pace and take account of the staffing and ward environment issues in addition to the introduction of widely available,

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evidence-based care bundles to address the treatment of patients with pneumonia, and to detect and manage deteriorating patients. As an example, whilst the recentintroduction of a new early warning score (NEWS) system in place of a previous EWS, is a positive step. Work is now required to ensure that action on the NEWS scoresresults in appropriate escalation and management of the deteriorating patient.

There has been a recent period of significant structural and organisational change in the Trust including the consolidation of A&E on the Stoke Mandeville site. Emergencyactivity remains on the Wycombe site for acute stroke patients and for emergency interventional cardiology procedures in hours, whilst 24 hour cover by consultants wasprovided, the review team noted this was not always by a cardiologist. Prospective evaluation of patient transfers between hospital sites for those presenting as emergenciesshould be urgently undertaken to assess patient safety and experience. This evaluation should cover all patients transferred following presentation as an emergency toensure that high quality care is provided for those who remain with Buckinghamshire Healthcare Trust as well as those who are transferred to other hospitals such as Oxfordor Harefield. This issue has been a significant reputational risk to the Trust, and the review team heard concerns from the public at both the public listening events and inwritten submissions. During the review visit the team saw patients who required transfer between the two sites and feel that urgent, prospective evaluation of this servicechange must be undertaken.

There appears to be a culture where some staff believe incidents need to be serious and involving harm before they are reported. Minor incidents, near misses or thoserelating to poor patient experience are often not reported. For example inter-hospital transfers at an early stage in the emergency pathway are not considered incidents.

The Board must develop a robust, proactive plan to improve the overall safety and experience of care for patients, particularly those admitted as emergencies, by adopting asingle strategy using a recognised patient safety improvement model. Clear ownership of the plan needs to be agreed with and supported by dedicated project managementexpertise to provide pace and ensure consistent implementation in every ward and site. During the review visit the team saw patients who required transfer between the twosites and feel that, whilst no immediate risks to patient safety were observed, urgent prospective evaluation of this service change must now be undertaken.

Patient experience

Many patients to whom the panel spoke were unreservedly complimentary about the quality of the nursing care they had experienced. Others, however, gave accounts whichraised serious concerns about the quality of nursing care and indicated that the quality of such care was variable. The review panel notes that introduction of the Friends andFamily Test began in February 2013.

The Trust must develop a systematic approach to gathering and reviewing patients’ views about their experiences. With regard to complaints, a process for sharing themesemerging from this trend analysis is required in order to demonstrate how the Trust evaluates the effectiveness of improvement actions and shares learning across theorganisation, from Board through to ward level. Complaints are not addressed in a timely way, and currently insufficient effort is taken to acknowledge and address validpatient concerns, which creates an appearance (at the very least) that there is a lack of concern for patients. From public events and reviewing written submissions, the panelis concerned about the Trust response regarding public and patient feedback related to key changes such as A&E consolidation, on a continuous basis.

The review team supports the proposal to rationalise the reporting of the PALS and complaints manager to a single manager.

The Trust must develop a systematic approach to gathering, reviewing and using patient experience/complaints to improve the patient experience and safety of care.


In order to address the problem of recruitment, retention and reliance on bank and agency nursing staff, and the poor national staff survey results, the Trust needs to urgentlybuild upon its strategy for staff engagement. The review team heard from many staff groups that two way communication from the staff to the Board was ineffective, and thisis reflected in a comment from the March 2013 Board papers that “communication between senior management and the workforce is not effective (perception thatcommunication is one way and directive)”.

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Concerns were repeatedly expressed by both nursing and medical staff about out of hours medical cover for the acute medical patients at Stoke Mandeville, particularly atweekends. There was evidence that this led to delays in patients receiving essential treatments such as intravenous antibiotics and intravenous fluids. The current level ofmedical care was described on more than one occasion as “unsafe”, by staff to panel members. Similar concerns were raised with regard to out of hours cover for patients inthe community hospitals.

Patients with specialist needs are not consistently treated on the relevant specialist ward or site resulting in patients on inappropriate wards who do not consistently haveaccess to medical and nursing staff with the necessary specialist skills, additionally this is likely to cause delays to ward rounds and timely assessment and discharge ofpatients. This increases the burden on medical staff and means that patients may not receive appropriate nursing care. For example concerns were expressed as to thesafety and sustainability of the current split of acute services between the Wycombe and Stoke Mandeville sites and with the respiratory ward.

The Trust has a People Strategy and a Workforce Plan, but the panel were concerned about the effectiveness with which operational risks arising from workforce issues are

being managed.

The Trust should review the process by which nursing rotas are produced – the perception of this process given to the review team is that the rotas are developed centrallywith little input from ward staff. Staff at ward level felt that this restricted the efficiency of staff deployment. Nursing staff reported workload pressure problems due to thenumber of staff permitted to administer IV treatments, as agency staff are not permitted to administer IV medication. There was also a perception that the paperwork workloadon staff had increased significantly without adequate assessment of the overall burden imposed upon staff; and that this was impacting upon the time available to staff.

Difficulties in recruiting nursing staff have been discussed as a key risk and there is significant variation in the make-up of staffing levels on individual wards between Truststaff and bank or agency staff. The spinal unit and other wards across sites are understaffed while other exemplar wards confirmed they had very low vacancy levels.

Training and development for staff varies and does not appear to be prioritised consistently. Some nursing staff said that it was difficult to obtain places on essential internalcourses (for example, in order to be permitted to administer IV antibiotics or fluids). Junior doctors reported that there is generally a lack of senior support which has beenmade poorer by the recent reconfiguration. The panel was told that some patients in Stoke Mandeville may go days without medical input and daily consultant ward roundsare not always carried out.

The review team heard from staff that they did not feel that their concerns were heard and acted on. The variety of two-way communications has been increased recently.These were seen as a significant step towards engaging Trust staff in the improvement journey and closing the gap between the Board and the Ward. However, Board toWard connectivity should be increased to fully inform the Board, through effective and diverse staff engagement.

The following definitions are used for the rating of recommendations in this review:

Rating Definition

Urgent The Trust should take immediate action to respond to these recommendations andensure improvement in the quality of care

High The Trust should develop a response and action plan for these recommendations toensure improvement in the quality of care

Medium The Trust should implement these recommendations to ensure ongoing improvementin the quality of care

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Overview

Two KLOEs in the governance and leadership area were the standard key line of enquiry for the review and Cost Improvement Plans.

Examples of good practice were identified in the following areas:

A variety of two-way communications have been introduced recently, for example coffee mornings with the CEO, the CEO’s blog, new staff intranet, weekly staff e-mailbriefings and Board Member visits to wards.

The Chief Nurse is clearly identified as responsible for quality and safety.

There have been some efforts to share good practice around ward leadership from exemplar wards with others (e.g. from the exemplar Haematology Ward to the SpinalInjuries Unit).

There is a policy on reporting of incidents, SI’s and never events with themes to be presented to the Board. A matron at Wycombe Hospital was able to talk about herinvolvement in the analysis of events.

CIP schemes are reviewed at Divisional Board and QIPP Board meetings. There is a detailed CIP Quality Assurance and Clinical Risk Framework which shows that clinicalrisk of all CIPs (patient safety, patient experience and clinical effectiveness) should be assessed, regardless of CIP financial value. Clinicians are involved in the process ofdeveloping and approving CIPs. Staff across the Trust described a “bottom-up” approach to CIP development, which encouraged staff to contribute ideas and challengeschemes.

The following areas of outstanding concern were identified:

The Board appears to place confidence in accepting the words of others in lieu of robust assurance processes for the quality of treatment and care. Roles and responsibilitiesfor quality are not clearly defined.

Risk scoring, reporting and mitigation systems are not well understood, nor are in place. The view of the panel was that the Board does not have adequate risk assurance.

The leadership at Board level accepts a reactive culture, responding to issues, in place of a proactive approach. The panel feel that there is scope for Board development toensure the Board ambition for quality and quality improvement can be delivered. The review team would urge the organisation to focus attention on trying to understand thecauses of the high mortality indicators as a higher priority than trying to justify the figures.

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The Board could improve their challenge to executives and quality data, in order to match their ambition to improve quality and quality improvement Lack of oversight of thequality impact of CIPs by the healthcare governance committee. There is currently no baselining of quality metrics pre-implementation of CIPs.The panel was told that until recently some senior executive staff was seldom seen on the Wards.

Senior staff members were not as aware of issues/problems at Ward level as the Panel would expect. For example, the Medical Director’s response to the issues brought tohis attention by junior doctors in the Emergency Department suggests that he had previously been unaware.

Detailed Findings


KLOE 1: Can the Trust clearly articulate its governance processes for assuring the quality of treatment of care? Are the leadership roles and responsibilitiesclearly defined for the quality processes? Can staff at all levels of the organisation describe the key elements of the quality governance processes(communication to the staff)?

Good practice identified

The Chief Nurse is clearly identified as responsible for quality and safety and developed the nursing quality framework. The panel feel the document will require

supporting detail on how quality will be assured and the monitoring arrangements/timing intervals.

Some staff clearly articulated the processes for incident reporting (e.g. through ward observations on Intensive Care Unit (ICU), Urology, Care of the Elderly).

A variety of 2-way communications have been introduced recently, for example coffee mornings with the CEO, the CEO’s blog, new staff intranet, weekly staff e-mail

briefings and Board Member visits to wards. These were seen as a significant step towards engaging the Trust staff in the improvement journey and closing the gap

between the Board and the Ward.

There have been some efforts to share good practice around ward leadership from exemplar wards with others (e.g. from the exemplar Haematology Ward to the Spinal

Injuries Unit).

There is a policy on reporting of incidents, SI’s and never events with themes to be presented to the Board. A matron at Wycombe Hospital was able to talk about her

involvement in the analysis of events.

17

Outstanding concerns based on evidence gathered Key planned improvements bythe Trust

Recommended actions Priority – urgent,high or medium

The Board does not have robust risk assurance processes. Risk

scoring, reporting and mitigation systems are not well understood,

nor are in place.

The route for achieving unambiguous assurance at Board level is unclear(Healthcare Governance Committee and Audit Committee).

The risk register is not sensitive or live enough to present proper issues tothe Board. Examples missing at review are staffing of the Spinal injuriesunit and risks associated with the new urgent care model, not yet properlyevaluated. The benefits realisation plan focuses on benefits rather thanalso considering the need to mitigate emerging risks as the plan isaffected, as part of business as usual. Target dates are mostly in 2012 orup to April 2013. No evaluation report yet available.

Most risks are scored at a maximum of 12 (at divisional level). Only thosescoring 12+ are recorded in the Corporate Risk Register and of those onlyrisks scoring 15+ are highlighted to the Board. For example:

Mortality indicators were identified as a risk on the CorporateRisk Register on 25 February 2013. Where these have beenidentified, they were triggered through a concern arising of risk ofreputational damage.

It was not evidenced that, when maternity staffing ratios were at1:38, that the risk arising to patient safety from under-staffing wasraised through the Trust’s risk reporting process to Board level(note, national recommendation is for 1:28 ratio)

Ward-level and community-service level specific risks arisingfrom under-staffing were not identified on the Corporate RiskRegister, although some individuals, for example the ChiefNurse, reported their awareness of these issues. The BoardAssurance Framework (BAF) contained some information on

None identified There should be an immediate and

comprehensive audit (by an external

specialist) of the entire Trust’s

approach to risk assurance and

patient safety, using the Manchester

Patient Safety Framework or an

equivalent model.

Develop a refreshed coordinated

patient safety strategy and action

plan.

Identify an individual (1 WTE) for

implementing the patient safety

strategy supported by project

management office.

Put in place a Board development

programme covering quality

governance, risk, assurance (rather

than reassurance) and best practice

(national and international).

Clarify how the Board seeks

assurance from each sub-committee

(and, in turn, from the groups

reporting into sub-committees).

Clarify the respective roles and

responsibilities of each sub-

committee for;

quality and safety; and

risk management

processes that pro-actively

Urgent

Urgent

Urgent

Urgent

Urgent

18



risks in relation to reliance on temporary staff and safe staffinglevels in relation to organizational change.

Risks arising from service changes and patient transfers betweenhospital sites, for example the A&E consolidation, were notidentified on the Corporate Risk Register.

The Risk Monitoring Group should review how it scrutinises andchallenges the divisions about their risk registers, to ensure risks arescored appropriately and follow up on progress monitoring for identifiedrisk mitigation actions.

identify and take action to

reduce the likelihood of

risks transpiring.

The leadership at Board level accepts a reactive culture, responding

to issues, in place of a proactive approach.

The panel gained the impression that Governance arrangements are

founded on incident reporting through the DATIX system. This approach

relies on reactions to trends arising from reported incidents. This does not

comprise a pro-active approach to anticipating potential risks to patient

safety and proactively putting in place mitigating actions and monitoring

the effectiveness of the actions taken.

Diverse staff groups reported little confidence in improvement actions

arising from reporting incident data on the DATIX system. This resulted in

a reluctance to complete incident reports in some areas.

Little evidence of downward dissemination of lessons from Serious

Incidents or DATIX data. Junior Doctors reported that they raise incidents

but get no response and nothing changes as a result.

Junior doctors reported raising patient safety issues to the Medical Directorby letter. Although a response was received within 10 days, there appearsto have been a delay of 6 weeks before a meeting was set up to discuss

The Trust has brought in the

Emergency Care Intensive

Support Team (ECIST) team to

provide advice on improving the

outcomes delivered for the

urgent care pathway.

Governance leads have been

appointed in the SDUs.

Enhance the Trust performance

dashboard to improve information,

intelligence and analysis of business

and quality data. Include more

information from patients and staff,

including qualitative data and

mechanisms of responding in a timely

way.

Train and encourage all staff on the

importance of incident reporting.

Embed analysis of incident reporting

in the Trust performance dashboard,

which is discussed at the Board level.

Urgent

Urgent

Urgent

19



the issues raised. The Medical Director's response to the initial lettersuggests that he had not previously been aware of some, if not all, of theissues which concerned the junior doctors.

Some staff are not clear on incident reporting and what comprises an

incident. There appears to be a culture where some staff believe incidents

need to be serious and involving harm before they are reported. Minor

incidents, "near misses" or those relating to poor patient experience are

under -emphasised. For example inter-hospital transfers at an early stage

in the emergency pathway are not considered incidents. The policy on

handling incidents does not define or describe an incident, only giving

examples, most of which have significant harm.

Service Division Unit (SDU) Governance Leads do not appear to have time

dedicated to this element of their role, nor opportunities to meet together

(across directorates) to share best practice.

The Board could improve their challenge to executives and quality

data, in order to match their ambition to improve quality and quality

improvement.

i.

There was significant variation in how staff at all levels perceived the

visibility and 2-way feedback with Board members.

Quality Dashboards were not consistently evidenced at ward level. The

productive ward clinical dashboard was in place and on display in public

area of the exemplar ward (Haematology/Cancer/Medicine ward) however

care of elderly wards at Stoke and Wycombe did not have this in place.

Clinical Leads do not have time dedicated to their role. Some clinical

leads do not know how to use service line reporting.

Interviews with the Chairman and Non-Executive Directors suggest that

there is limited challenge and examination of the data presented to the

A variety of two-way

communications have been

introduced recently, for example

coffee mornings with the CEO

and Board Member visits to

wards. These were seen as a

significant step towards

engaging Trust staff in the

improvement journey and closing

the gap between the Board and

the Ward

The Chief Nurse confirmed the

use of a Nursing Quality

Framework and the intention to

roll this out to include services

such as pharmacy and therapies.

The Board needs to challenge

executives following the setting of

quality improvement goals/targets.

Once improvement trajectories have

been set, proper attention needs to be

placed upon monitoring progress

against plan, and evaluating the

benefits achieved.

Increase Board to ward connectivity

to fully inform the Board through

effective and diverse staff

engagement, for example through:

focus groups with staff, increased

visibility with walk rounds and

proactive engagements.

Urgent

High

20



Board (reassurance, not assurance). One example is the Board views on

SHMI. The review team felt that the Board focussed on justifying the

figures, rather concentrating on work to identify and address areas that

could improve the quality of care provided. There is limited analysis and

evidence of learning.

Some exemplar wards had

quality indicators on display in

the ward environment, for

example the Haematology /

Cancer / Medicine ward at Stoke

Mandeville and the Paediatric

Ward at Wycombe. The

maternity ward had its own

dashboard.

The new interim Medical Directorexpressed intention / wish toimprove quality and safety(quality markers within divisions).

The Trust needs to further develop

the current ward quality dashboards

to ensure they are comprehensive,

embedded in practice and extended

to community services. These quality

dashboards should be used at Board

level to identify areas of significant

variation and how improvement

trajectories are set and delivered for

achieving consistently high outcomes

in all wards/community services.

Urgent

Cost Improvement Programmes

KLOE 2: How does the Trust assess and monitor the quality impact of the Cost Improvement Programme (CIPs)?


There is a detailed CIP Quality Assurance and Clinical Risk Framework which shows that clinical risk of all CIPs (patient safety, patient experience and clinical

effectiveness) should be assessed, regardless of CIP financial value.

Clinicians are involved in the process of developing and approving CIPs. This was evident from both the Clinical Risk Framework and speaking to clinicians in various

Divisions.

21


Staff across the Trust described a “bottom-up” approach to CIP development, which encouraged staff to contribute ideas and challenge schemes. Clinical leads at SDU

level confirmed that quality was not compromised in order to meet CIP targets.

CIP schemes are reviewed at Divisional Board and QIPP Board meetings.


Recommended actions Priority –urgent, highor medium

Lack of oversight of the quality impact of CIPs by the healthcare

governance committee

There is no oversight of CIPs and their risk assessments at the Healthcare

Governance Committee. It is unclear how the Board gains assurance about the

impact on quality of CIPs during their design and implementation.

None identified The Trust Healthcare Governance

Committee should have formal

oversight over the quality impact

assessments and ensure post

implementation review takes place.

High

There is currently no baselining of quality metrics pre-implementation of

CIPs

There is no record of pre-implementation quality performance on the risk

assessments of planned CIPs. This limits the means of monitoring the impact of

CIPs on the quality of care given to patients once implemented. Obtaining

‘baseline’ measures for relevant metrics, against which to compare future (post-

implementation) performance, will facilitate clearer monitoring of CIP impact on

quality.

This issue was highlighted by

KPMG during the quality

governance review and a

recommendation was made to the

Trust to document performance

prior to implementation of the

scheme when undertaking quality

impact assessments.

Use baseline measures to Monitor

CIPs for their impact on quality of

care over an appropriate period of

time, during and after implementation.

High

22

Clinical and operational effectiveness

Overview

The two KLOEs in the clinical and operational effectiveness area focused on the Trust’s arrangements to monitor and address clinical effectiveness and operationalperformance as well as higher than expected mortality areas.


Some clinical areas showed high quality care environments and enthusiastic passionate approaches by staff, who felt very supported and reported good levels of staffing(e.g. Critical Care, Urology, and Surgical).

No central line infections at both ICUs (Wycombe and Stoke Mandeville) for a few years.

Mortality reviews have been completed using the Royal Berkshire structured mortality review.


There is a lack of organisational-wide monitoring of clinical effectiveness and operational performance data, in that quality scorecards are not in place on all wards.Quality scorecards are in place in some wards but it is unclear how the Board gains robust assurance about current and most significant quality and safety risks acrossits sites.

Some Trust Board members need to further develop their understanding of mortality data and causes. Depth of understanding is variable depending on the time spent onthe Board. There should continue to be training for Board members.

The Corporate Risk Register does not highlight significant risks to clinical effectiveness and operational performance. E.g. out of hours care and A&E serviceconsolidation.

The panel did not find evidence of adequate oversight of improvement plans to address the significant risks to clinical effectiveness and operational performance.

The panel did not find adequate evidence of the Board reviewing the metrics relating to significant risks to clinical effectiveness and operational performance, for exampleambulance transfers between sites, ward-specific or service-specific staffing levels.

There is a lack of strategic improvement of clinical safety.

23

Detailed Findings

Clinical and operational governance

KLOE 3: What governance arrangements does the Trust have to monitor and address clinical effectiveness and operational performance data at a senior level?


Observations in some clinical areas showed high quality care environments and enthusiastic passionate approaches by staff, who felt very supported and reported good

levels of staffing (e.g. Critical Care, Urology, Surgical).

No central line infections at both ICUs (Wycombe & Stoke Mandeville) for a number of years.

Some staff reported that the Trust’s clinical strategy had been sent out with pay slips last month, and the Non-Executive Directors identified this as an example of how

the Trust is making efforts to increase its communication with staff.

Outstanding concerns based on evidence gathered Key planned improvementsby the Trust


The Corporate Risk Register does not highlight significant risks toclinical effectiveness and operational performance. E.g. out ofhours care and A&E service consolidation

Inter-site transfers were identified as a risk during discussions but havenot been identified on the corporate risk register. Some pathways thatinvolve transfers are not clear. Examples of concerns about patienttransfers from site-to-site were reported to the Panel at the PublicListening Event. Concerns were identified about incident reporting. Thepanel witnessed one example where a patient was transferred from HighWycombe to Stoke Mandeville with a suspected fractured neck of femur.The family reported their perception of a significant time delay in theadministration of any pain relief. Staff did not report this as an incidentuntil strongly encouraged to do so. This example raised concerns aboutthe understanding of what an incident is, in this case the impact of a site-to-site transfer, and how the Board would be aware of risks arising from

The Chief Nurse is

reviewing quality standards

in A&E.

The Director of Strategy is

preparing a Report on the

benefits / issues post

reconfiguration.

To review the pathways for patients

presented urgently to the Trust to include

those transferred between sites following

initial presentation. Put in place robust

processes for capturing every incident

where a patient is transferred during their

acute episode. This must not depend on

voluntary incident reporting but be

achieved through a more robust process.

Cases need to be reviewed regularly and

actions taken if possible to reduce the

rates of these transfers.

Work with patient and carer group/NHS

Urgent

Urgent

24



patients transferring from site to site.

Improvements to access via NHS 111 service could provide assistanceto patients and the public, and therefore the Trust, by helping to signpostpatients better to the appropriate point of access within the Trust.

The Trust has been through a period of significant servicereconfiguration. Potential risks arising through reconfiguration, and theassociated mitigation measures, were not identified on the CorporateRisk Register. The Medical Director discussed a report that is currentlybeing prepared to review the benefits/issues post reconfiguration. ThePanel heard evidence from the Patient Experience Leads how feedbackafter the Surgical Floor Reconfiguration resulted in the Trustsubsequently putting in place significant changes. The lessons aroundanticipating benefits and risks did not appear to have been learned andput in place for the A&E consolidation.

A&E – The risk pertaining to the achievement of the national accesstarget had been identified by the Trust. However, concerns were raisedto the panel over poor patient feedback. We encountered real publicconcern that they did not know where to go with different urgent careneeds (for example, the Minor Injury Unit (MIU) at Wycombe, A&E atStoke Mandeville) and poor patient information. One example was theinformation given in some of the Trust leaflets for patients. One leafletadvised patients about whether they should go to A&E at StokeMandeville or to the MIU at Wycombe. This included the statement thatfor burns and scolds - but not for the neck or head, they should go toWycombe.

111 provider and CCG’s to improvefunctionality of NHS 111 for thishealthcare system.

Put in place an effective process for

capturing and reviewing the experience

of patients and staff presenting acutely.

There is a need to reinforce themessaging as a health economy aboutwhat services are at each hospital and ifin doubt they should present to the mainED at Stoke Mandeville. The Trustshould work with focus groups and thelocal media to achieve this. The Trustshould set out clear measures for howthey will evaluate the impact of theirinformation campaign.

Urgent

High

The panel did not find evidence of adequate oversight ofimprovement plans to address the significant risks to clinicaleffectiveness and operational performance

The Trust has brought in the

Emergency Care Intensive

Support Team (ECIST) team to

provide advice on improving

The Trust urgently needs a single visibleclinical safety strategy and action planbased on a recognised patient safetyimprovement model and underpinned by

Urgent

25



Whilst the panel appreciate that the Trust is taking action to resolve the

A&E pressure, the panel feels that, as with the mortality indicators, the

Trust needs to frame these issues, and more importantly develop

potential solutions, specifically to the needs of patients in this healthcare

community. The review team urges the Trust to use the urgent care

board to help develop work in this area.

Complexities arising from multiple sites with varying practices specific to

each site e.g. the urology pro-formas used in Stoke and Wycombe are

slightly different as one does not cover Venous thromboembolism (VTE).

Concerns were raised to the panel about high dependency capacity.

Reports of acute wards managing patients with non-invasive ventilation

and tracheotomies. Reports of higher acuity patients transferring to

community hospitals. The lack of High Dependency Unit (HDU) beds

means that there is no adequate step-down from ICU, but equally no

adequate capacity to “step-up” the deteriorating patient.

Clarity about actions arising for deteriorating patients appeared to be

variable and subjective.

Many staff commented about the lack of 24 hour outreach services. The

review team recognised that, when available, this appears to be a very

good service. However, many hospitals function without 24 hour

outreach and this should in no way be a substitute for robust NEWs,

recognition and escalation procedures by all clinical staff, of the

deteriorating patient.

the outcomes delivered for the

urgent care pathway.

The National Early Warning

System was introduced by the

Trust in January 2013 (as

evidenced in the March BAF).

good intelligence (hard and soft data)and systematic staff training and roll out.Systems and processes to ensurebenefits realisation should be includedwithin the plan.

The Trust should have a clear plan ofaction with time scales and measures toimplement the ECIST recommendationsand this should be part of the overallPatient Safety Strategy.

Continue to work with urgent care board.

Review the high dependency and acutecare pathways to ensure sufficientcapacity and staffing.

Review and enforce the admissioncriteria for HDU / ICU and patienttransfers between sites.

The Medical and Nursing Director musturgently agree a single model to assessthe deteriorating patient and a clearprotocol for escalating concerns which israpidly implemented on every ward, atevery site. All staff, including bank andagency, must be trained in the system.

Urgent

Urgent

Urgent

Urgent

Urgent

26



The panel did not find adequate evidence of the Board reviewing themetrics relating to significant risks to clinical effectiveness andoperational performance, for example ambulance transfers betweensites, ward-specific or service-specific staffing levels

There is an over-reliance on Datix incident reporting to capture harm.

Service Line Reporting has not been put into practice. Although the data

is provided to the clinical leads by e-mail on a regular basis, they have

not all been able to take advantage of the managerial support and

training to enable them to make use of the data.

Staff retention and recruitment appears difficult the Spinal Unit and

morale was reported as low. Patients are often delayed admission due

to difficulties in staffing, with the associated potential for these patients

may be highly disadvantaged by delays to their rehabilitation. Critical

members of staff in the spinal unit who were supporting the ventilated

patients have left and have not been replaced: Support to these patients

form an experienced Operating Department Practitioners (ODP) and

anaesthetic consultant input have all recently been lost. These ventilated

patients are currently managed by clinicians with no specific training in

the management of the ventilated patient. Whilst the panel did not regard

this as posing an immediate risk to patient safety, there is an urgent

requirement for the Trust to address this issue.

Diabetic foot assessment: Clinical leads agreed it was poor and had

been known to be poor for some time. It is not clear why the Trust has

not yet implemented national standards.

The Panel was told that the

Podiatrist is working up a

Business Case for delivering

improvements in relation to

diabetic foot assessment.

Put in place quality scorecard throughoutthe organisation, in every ward and everycommunity service. Ensure sufficientgranularity of trend data is visible both atward and at Board.

Reinstate daily review of ventilatedpatients with ICU consultants and reviewlevel of support provided to thesepatients.

Urgently improve staffing levels andpractices in the spinal units.

Implement national standards in relationto diabetic foot assessment withoutfurther delay.

Urgent

Urgent

Urgent

Urgent

27

Clinical and operational effectiveness - mortality

KLOE 4: What processes does the Trust have in place to support monitoring mortality data and clinical effectiveness? Has the Trust data identified any issues?What actions is the Trust taking to address issues noted?


Mortality reviews have been completed using the Royal Berkshire structured mortality review.

In response to the Trust having a priority to focus on care of older people, increased support through ward rounds by care of the elderly physicians had commenced at

the Community hospital sites.

Outstanding concerns based on evidence gathered Key plannedimprovements by theTrust


The Trust Board demonstrated a lack of understanding of mortalitydata and causes

The review of 50 cases undertaken by the Mortality Task Force is

considered inadequate. The reviews are too mechanistic, do not involve

any microbiological analysis/input and focus on the question whether the

patient would have died in any event rather than the rigorous identification

of the broad areas where care could be improved. During interviews the

Panel noted that Divisional Chairs could not articulate areas where

mortality was occurring.

None identified Develop an Integrated Quality Report that

compares divisions and is reported to the

Governance Committee on a monthly basis and a

summary version reported to the Trust Board. The

quality report must routinely inform patient safety

action plans

High

Lack of strategic improvement of clinical safety

The Mortality Task Force noted that pneumonia mortality has been a

problem on HSMR for the past two years, however an action plan has only

recently been considered for development. The action plan was a

statement of ideal care and what was lacking was any understanding about

where the gaps in delivering ideal care were occurring, what the potential

defect rates were, and where any focus might be required to produce the

Ongoing mortality

reviews are looking to

improve pneumonia care

pathway.

Develop a coordinated patient safety strategy and

action plan that incorporates issues such as

pneumonia mortality (see KLOE1).

Improve processes to monitor patient moves andimprove consistency of care. Ensure thathandovers are structured, particularly important ifthere are frequent patient moves. Ensure

Urgent

Urgent

28



fastest results. (E.g. have they reviewed time to first antibiotics, what is the

percentage compliance with best practice - is this uniform across all

areas?).

Junior Doctors reported that there have been multiple transfers of patients

between wards with no clinical input or no communication to clinicians.

Whilst the panel did not regard this as posing an immediate risk to patient

safety, there is an urgent requirement for the Trust to address this issue.

The Panel was informed that 3-5 non elective transfers take place per

week on the Urology ward. Nurses in training also observed that handovers

could be poor.

Despite the Trust identifying care of older people as a priority and strong

trends showing pneumonia, stroke, and acute renal failure as possible

contributing factors to the high mortality rates, the review team did not see

evidence of developments focusing on processes of care for these

patients.

There is insufficient capacity on the respiratory ward; the Panel was told

that typically fewer than 50% of respiratory inpatients can be

accommodated on the ward. Although the bed manager’s log suggest the

percentage is much lower.

The Corporate risk register contained a reputational risk on mortality rather

than trying to understand the reasons behind it and mitigate risks to

patients’ safety.

consistent use of a structured handover tool suchas Situation, Background, Assessment,Recommendation analysis (SBAR).

Further work is necessary to help plan for

increased respiratory ward capacity.

Ensure mortality reviews are designed in such a

way that outcomes identify ways to improve clinical

safety including pneumonia care.

Urgent

Urgent

29

Patient experience

Overview

The KLOE in the patient experience area focused on patient experience and engagement.


Some individual staff members and specific wards demonstrated a good focus on patient experience and engagement and the panel heard positive stories from somepatients and members of the public on their experiences at the Trust. The panel also received and saw evidence of nursing of the very highest quality, with the needs ofindividual patients being identified and addressed in ways which really were far above and beyond the call of duty. Patient stories are heard at Board, in accordance withbest practice.

Some positive examples of public and patient engagement were evidenced through some of the stories shared with the panel at the public listening events and bypatients and carers on observations.


There is evidence that the quality of nursing can be too variable. Within 24 hours of its arrival at site, the Panel had been given direct evidence of two separate incidentsin which elderly and immobile patients needing assistance to go the toilet had been ignored. At least one of those incidents appeared (on the evidence providedindependently by two other patients) to involve deliberate conduct by a nurse. The second incident could only be explained, if at all, on the basis that staff had becomedesensitised to patient alarms.

Some of the Trust's procedures (or the approach by staff to their implementation) appear overly bureaucratic and insensitive to the needs of the patient. Cases whichexemplified this were heard during the public listening events, and some are provided in Appendix VIII.

There is evidence of patients who have been 'wrongly' admitted to the stroke/cardiac unit at Wycombe being left for some hours before being transported to StokeMandeville - there is then the additional risk/probability that they will be admitted through the A&E department with up to a further four hour wait. There is no systematicapproach to gathering and reviewing patients’ views about their experiences. Where feedback is gathered there are limited mechanisms for sharing themes. It is unclearhow the Trust evaluates the effectiveness of improvement actions and shares learning across the organisation.

Complaints are not addressed in a timely way. Insufficient value is placed on addressing issues raised by patients, which creates the appearance of lacking concern.There is a lack of knowledge sharing between departments, divisions and sites on patient feedback and trend analyses do not appear to be routinely carried out.Inadequate resources are dedicated to patient engagement. The patient engagement group does not comprise an effective cross-section of patients: mainlyrepresentatives from specific patient/illness groups. This misses the opportunity for direct patient feedback.

It is unclear how the Trust is taking action to improve effective communications between nurses and patients consistently across the Trust.

30

It appears that patient views were not gathered and responded to before and after significant changes were implemented, such as consolidation of A&E at StokeMandeville.

The Trust’s approach to cases where its treatment has clearly fallen below acceptable standards can appear overly defensive and, on occasion, inept. An example isprovided in Appendix VIII – “Patient Stories” with information from the public events.

Detailed Findings

Patient experience and engagement

KLOE 5: How does the Trust review patient experience data and engage with patients to seek views about their experience? What are the key themes frompatients on their experiences? What action is it taking to address the key themes emerging?


The panel was informed in interviews and on observations that senior nurses on exemplar wards run patient focus groups.

The panel was informed that patient experience feedback following the surgical floor reconfiguration resulted in changing the reconfiguration arrangements.

Some positive examples of public and patient engagement were evidenced through some of the stories shared with the panel at the public listening events and bypatients and carers on observations.

Friends and family test has been implemented since February 2013. The Friends and Family test is a simple questionnaire that currently asks adult inpatients if theywould recommend the hospital/ward/services to their friends and family. The March 2013 Board Papers show that whilst the number of responses is low, there was asignificant (almost 50%) response in relation to A&E relating to unlikely/extremely unlikely to recommend categories. The panel saw one nurse going through thequestionnaire with a patient.

Board papers show that complaints data is presented to the Board, such as 25 day response time. However, it is not clear how the Board is responding to poorperformance.

The panel was informed of a patient open event in ophthalmology and hearing aid department.

PALS/complaints team is stable and committed. PALS volunteer going around wards speaking to patients.

NEDs review a selection of complaints once a month and patient stories are shared at Board, although it is not clear how that they learn from these or challenge theexecutive team members over the issues raised. The panel spoke with patients who reported receiving a good standard of care on SSU, spinal and stroke units,maternity, surgical at Wycombe and ward 8 at Stoke Mandeville.

31



Complaints

Board papers show that complaints data is presented to the Board, such as 25day response time. However, the March Quality Performance report shows thatthe 85% target for this metric has consistently failed to be met for at least thepreceding nine months. Complaints are not addressed in a timely way and itappears that insufficient value is placed on addressing patient concerns, whichcreates the appearance of lacking empathy.

It was reported during a public listening event that a complaint registered withPALS took 90 working days for a patient response to be received.

Lack of knowledge sharing between departments, divisions and sites (to staff).Lack of trend analysis being carried out regularly. No proactive approach topicking up on key themes from complaints and playing these into the activity ofthe Patient Engagement Lead. Missed opportunity for shared learning. There islittle or no coordinated approach to the dissemination of patient experience.

Example of learning from patient feedback following surgical floorreconfiguration. No evidence of how the learning about seeking views fromstaff, patients and public is shared prior to such changes for example in themore recent A&E consolidation.

There is concern around transparency of learning from issues through sharingwith public/patient representatives. The Governance and Quality Committee forinstance has no patient rep / Health watch on the committee. The Trust’sapproach to complaints and/or concerns about its performance can appeardefensive and focused more on protecting its reputation than learning from pastmistakes.

Action plans are initiated at

divisional level to address issues

identified through patient

surveys.

A&E – new complaints lead inpost recently which is improvingcomplaint response times forA&E.

Put in place consistently high standardsfor addressing patient complaints. TheTrust’s performance against its targetsfor complaints handling should bepublished on its website on a monthlybasis.

Training for existing PALS/PEG andensure that all complaints and learningpoints are seen Trust wide and actionsimplemented.

Ensure that ‘real’ patient views areobtained prior to further plannedservice changes.

Urgent

High

High

32



Patient engagement

Through observations and interviews, the panel found there were inadequateresources dedicated to patient engagement. The panel found that the resourcesboth in terms of staff and finances are directed towards the work on movingtowards Foundation Trust status rather than actual patient involvement issues.Patient engagement group does not comprise an effective cross-section ofpatients: mainly representatives from specific patient/illness groups. Thismisses the opportunity for direct patient feedback.

There appears to be a lack of cohesion and joined up learning across PALS,complaints and patient experience. At the time of the visit the PALS andcomplaints teams report to the Patient Experience Manager. The teams are splitacross different sites and therefore the joint working and triangulationopportunities impacted on the key issues really being focused upon and givingthe board direction.

The panel found that no proactive approach to patient surveys, no systematicapproach to seeking meaningful real time patient feedback and, duringinterviews executives were not clear about emerging themes. There appearedto be no Trust-wide budget for surveys, although the panel saw some surveyscarried out by individual departments, and no formal coordination.

There appears to be no shared learning from litigation complaints; thecomplaints team does not review outcomes from litigation cases. At a publiclistening event, concern was raised about the Trust’s legal representativesrequesting a short-form verdict, rather than a narrative verdict which mightinclude findings as to the care received by the patient.

At a public listening event, a concern was raised about the issuing of inaccuratedeath certificates.

The panel felt that little effort is being made to understand the impact on patient

PALS Manager has joinedpatient experience group

Tablets introduced for matronsobtaining feedback

Refresh the membership of the patientengagement group and clarify how thisgroup is representative of patientfeedback.

Put in place effective and regularreview of all feedback identifying trendsfor both good practice and concerns.Ensure this is seen and discussed bythe Board.

Ensure that the Friends and FamilyTest is in operation on all of the wardsand that the information gathered isused.

The Trust should review legalsubmissions to the coroner duringcoroner’s inquests. The Trust shouldconsider the approach in relation torequesting short-form coroner’sverdicts for cases in which there is thepossibility of criticism of care, in orderto demonstrate that the Trust is openand focused on learning from errorsidentified to improve future care.

The Trust should also routinely remindmedical staff issuing death certificatesof the need to ensure their accuracy.

Urgent

Medium

Urgent

High

High

33



experience on the new arrangements for cardiology and stroke. Cliniciansbelieve this is a good service but no patient related opinion is being collected atWycombe Hospital, for example on patients who are transferred back to StokeMandeville on a ‘near-daily’ basis when a non-cardiac/stroke diagnosis is madeand a further wait in Stoke Mandeville A&E sometimes follows.

Communication

It is unclear how the Trust is taking action to improve effective communicationsbetween nurses and patients consistently across the Trust, in response to theCQC patient survey showing this to be an area of dissatisfaction for patients.

Following Wycombe A&E closure, there is a serious public concern about lossof service, confusion of pathways and where patients should go which could beimproved through communications from the Trust. The fact that site mapshanded out at reception still shows an A&E entrance suggests that the Trust’scommunication strategy is deficient and requires improvement.

Signage very poor at Wycombe Hospital. During the unannounced visit, withnobody at reception, the visiting team found themselves re-directing at leastthree patients where no obvious signs existed.

During observations, the panel saw instances of poor communication betweenstaff and their patients and carers, such as requests for dignity on mixed sexelderly wards not being met and buzzers not being answered.

Further examples of poor communication were provided at the public listeningevents and are identified in Appendix VIII.

It was noticed during the observation of the ward for dementia patients that thetoilets were re-batched male/female dependent on the number of male/femalepatients on the ward and could change on a daily basis. This is very confusing

Some surgical wards are in theearly stages of implementingenhanced recovery

Full implementation of enhancedrecovery across surgical specialties.

Review signage in the light of servicechanges (now seven months old).Appoint responsible officer for patientissues at all sites.

Arrange telephone contact points atWycombe so that patients’ relativescan contact the hospital to findinformation on which ward theirrelatives are.

Improve dementia environments byproducing bedside boards with symbolsthat work for cognitive impairments.

Trust wide review of pathways to otherhospitals to develop robustcommunication to ensure patient safetyin cases where patients present asemergencies at Bucks. An assessmentof the training needs for staff to ensureappropriate management of thesepatients should be undertaken, and

Urgent

Urgent

High

High

Urgent

34



for those suffering with dementia.

Concerns were raised about patients treated in other hospitals who returned toBucks as emergencies without adequate documentation about the treatmentthat they had received.

appropriate mechanisms put in place toallow access to expert advice andsupport if required.

In addition to the points above, public and patient feedback obtained through the review identified a number of areas of good practice and concern which have been reportedwithin the relevant KLOE.

35


Overview

The three KLOEs in the workforce and safety area focused on workforce planning and staff support including training.


Coffee mornings between the Chief Executive and band 6 & 7 staff were introduced recently.

Board members carry out walk rounds at Stoke and Wycombe and community hospitals.

Recognise the issue related to out of hours medical support for community hospital and use of 111 (Bucks Urgent Care Service).

Nurse consultant who is spreading good practice with training and leading by example.

There is a People Strategy, which covers at a high level a range of developments to improve the quality, capability and motivation of those who work for the Trust.

Nurse recruitment plan (recruiting Portuguese nurses with 4 years experience, 10 WTE and 2 HCA at Waterside ward, and 7 WTE and 6 HCA on Chartridge ward inAmersham.)

NEDs stated that the trust had developed staff trackers regarding staff experience to use in between annual staff survey.

Information relating to serious incidents and safety metrics are presented to Board.

Junior staff at Wycombe expressed satisfaction on the level of work and support received by Consultants and other staff.

The Early Warning System has been implemented across the Trust and is viewed positively by staff. The panel saw other examples of safety initiatives and practicesacross the Trust.


Concerns were repeatedly expressed by both nursing and medical staff about out of hours medical cover for the acute medical patients at Stoke Mandeville, particularly atweekends. There was evidence that this led to delays in patients receiving essential treatments such as intravenous antibiotics and intravenous fluids. The current level ofout of hours medical care was described on more than one occasion as “unsafe”.

36

Concerns were expressed as to the safety and sustainability of the current split of acute services between the Wycombe and Stoke Mandeville sites. The panel was toldthat split site working increased the burden on the Trust’s workforce, can lead to delays in access to essential diagnostic services and can also result in poor qualitytreatment of co-morbidities. The split of services between the two sites engenders an obvious risk that patients will be taken initially to the wrong site for their condition,with a resultant delay in treatment. Some junior doctors at Stoke Mandeville expressed the view that the pressure upon out of hours medical cover at that site would beconsiderably reduced if all acute services were being provided at a single site. Some of the transfer pathways between sites did not seem patient-focus as the patientsmay be transferred from Wycombe to Stoke Mandeville A&E but the notes from the Wycombe have not been transferred to Stoke.

Patients with specialist needs are not consistently treated on the relevant specialist ward. For example, the Panel was told that the respiratory ward at Stoke Mandevillehas capacity for fewer than 50% of the typical level of respiratory inpatients although the bed manager’s log suggests the percentage is much lower. The dislocation ofpatients from the appropriate specialist wards not only increases the burden on medical staff (who has to travel throughout the hospital to locate the patients for whom theyare responsible) but also means that patients may not receive appropriate specialist nursing care.

During a number of events and ward visits, nursing staff reported work load pressure problems especially in relation to the number of staff permitted to administer IVmedication. They stated as agency staff are not permitted to give IV medication. This issue was raised in the CQC’s recent report on Wycombe Hospital.

Based on staff and Board member interviews, observations and documentation, difficulties in recruiting nursing staff have been identified as a key risk. There is significantvariation in how staffing levels on individual ward are resourced safely. Spinal unit and other wards across sites are understaffed while other exemplar wards confirmedthey had very low vacancy levels.

There is a Trust People Strategy and a Workforce Plan to support this Strategy however, the panel were concerned about how effectively the Trust is managingoperational risks arising from workforce issues.

Disjointed rotas are developed centrally with no input from ward staff and the Trust does not seem to look at the efficiency of staff deployment.

The results of the staff survey presented significantly below the national average in certain areas, which was consistent with what the panel found in the staff focus groupsand ward observations.

Training & development for staff varies and does not appear to be prioritised consistently.

The junior doctors reported that there is generally lack of senior support which has become poorer by recent reconfiguration. The panel was told that some patients inStoke Mandeville may go days without medical input and daily consultant ward rounds are not always carried out.

The Board’s approach to ensuring a safe organisation is too reactive and over relies on an incident reporting system that will only capture a small percentage of harm.Reporting of incidents is inhibited by a perceived culture of blame. It is not clear how the Board gains assurance that lessons learned are shared and implemented acrossthe Trust. The Board should review further safety metrics, which relate to the specific key risks faced by patients at the Trust.

37

Detailed Findings

Workforce strategy

KLOE 6: In the context of this review, can the Trust describe its workforce strategy?


There is a People Strategy.

There was a recent coffee morning between the Chief Executive and band 6 & 7 staff and Staff Intranet (CEO Blog).

Board members carry out walk rounds at Stoke and Wycombe.

Recognise the issue related to out of hours medical support for community hospital and use of 111 (Bucks Urgent Care Service).

“You said, We did” monthly staff engagement initiative.

Nurse consultant on who is spreading good practice with training and leading by example.

Whole Time Equivalent (WTE) has been in place for nurses and the new bank system allows the use of the same temp staff.

There is a nursing recruitment plan (recruiting Portuguese nurses with 4 years experience,10 WTE and 2 HCA at Waterside ward, and 7 WTE and 6 HCA on Chaltridgeward in Amersham).

Junior staff at Wycombe hospital expressed satisfaction on the level of work and support received by Consultants and other staff.



Understanding of workforce issues

There is a People Strategy which covers a range of developments to improve thequality, capability and motivation of those who work for the Trust.

The nursing rotas produced by very senior nursing staff left little room for ward levelsenior nurses to adjust the skill mix according to the up to date ward requirements,according to views expressed to the panel by this group of staff.

Monthly workforce reportsgo to the Board.

Annual ward staffing reviewthat the Chief Nurse atBoard level signs off andagrees the WTE for eachward.

There should be a Workforce Plan todeliver the People Strategy which setsout the actions, key deliverables andmeasures of success which should bemonitored and reviewed, with progressbeing fed back to the Board at regularintervals.

Urgent

38



Working in silo & spilt of acute services

Connection and alignment between the recent reconfiguration, workforce strategy,patients’ needs and redesigned pathways was not apparent. Split site workingincreased the burden on the Trust’s workforce and poor quality treatment. Examplesare:

A Hip fracture patient was first taken to Wycombe as a possible strokeor heart attack, then transferred back to Stoke Mandeville before beingfully examined and a broken hip diagnosed, a delay of some hours.This is an example of specialist services dealing with their area ofdisease but missing the needs of the whole patient.

The Panel was told that one patient was transferred eight timesbetween Wycombe and Stoke because of the absence of acomprehensive acute service on one site.

The Panel was told of one patient with chest pains being taken toWycombe but it was subsequently established that the chest painswere a symptom of Type 2 respiratory failure; there were then delays intransferring the patient to Stoke Mandeville and (due in part to aweekend) further delays before the patient was seen by a consultant bywhich time 5 days had elapsed.

The Panel was told that the respiratory ward at Stoke Mandeville has capacity forfewer than 50% of the typical level of respiratory inpatients (although the bedmanager’s log suggests the percentage is much lower).The dislocation of patientsfrom the appropriate specialist wards not only increases the burden on medical staff(who has to travel throughout the hospital to locate the patients for whom they areresponsible) but also means that patients may not receive appropriate specialistnursing care. An account of a respiratory patient on a general medical ward beingleft with an unsealed chest drain exemplified the foreseeable risks to patient safetywhich may arise under the current arrangements.

There is an impression that the whole Emergency care pathway is fragmented in thisway, leaving an improved patient experience less well considered and a lessimportant goal. This was evidenced in a letter from the medical registrars to MedicalDirector, dated 20/4/2013

None identified Board to use and triangulate multiplesources of information to providetransparency on issues register /recruitment / staff survey / complaintthemes/mortality / audit (clinical,qualitative / quantitative) clinical andwider stakeholder (including CCG &public) engagement.

Review the whole Unscheduled carepathway, considering how better toimprove the patient experience. Toinclude patient representatives and thewider public in this process. Recordand report such clinical incidents andreport to the Board.

Urgent

Urgent

39



Staffing, Recruitment and Retention

Junior doctors and nursing staff considered medical staffing for the acute medicaltake at weekends to be insufficient and reported that at times this felt unsafe andunmanageable. At the respiratory unit, commitments such as on-calls, training andcovering SSU means ward days occur at random. 1 registrar, 1 SHO and 1 F1 tocover whole of medicine for weekends. The F1 is reported to have to cover 180 -250 patients at the weekend and to feel unable to cope with demand, beingconstantly interrupted by bleeps.

The review team were told that there was a lack of Consultant input for patientsadmitted at the Stoke Mandeville site as medical emergencies over weekends.

High use of agency staff in community hospitals, care of elderly ward, critical care,short stay ward, respiratory ward. During a number of focus groups and ward visits,nursing staff reported workload pressures in relation to agency staff being unable toadminister IV medication, stating that this placed a heavy burden on permanent staffwho are required to perform this function in addition to other roles.

The divisional associate chief nurses’ and nurses’ focus group reported that therecruitment process is very slow. The same message was received from theWaterside ward in Amersham. The surgical unit use agency staff, but they have ahigh proportion of post op patients needing IV's and therefore this workforce is nothelpful for them.

Difficulty attracting and retaining student nurses. A number of ward nursescommented on slow recruitment processes with regards to nursing staff.

Difficulty attracting and retaining junior doctors who stated that the hospital has areputation for being a bad place to work for FY1s at weekends (stressful,unmanageable, frightening due to lack of support). Junior doctors discuss that theNational Spinal Unit is very understaffed and the patients miss out on treatment. Theunit has to be supported by external staff from the cancer unit. The children’s wardon the spinal unit had to close at weekends.

None identifiedThe Trust should urgently conclude its

review of respiratory beds to ensure the

provision of a high quality service for

these patients.

Engage with student nurses and

discuss what would make the Trust a

good place to work.

More senior medical supervision for 7

days a week.

Urgent

High

Urgent

40



Inadequate response to the staff feedback

The staff survey presented significantly below the national average on “care ofpatients / service users in the organisation”, “recommend the organisation a place towork” and “if friend or relative needed treatment, I would be happy with the standardof care”. HCAs and other clinical staff feel that it was not worth doing the survey asnothing changes.

The panel received evidence that the responses to the survey has been patchy withevidence that some wards performing small-scale staff surveys for themselves, theinitiation of executive wards rounds and the Chief Executive coffee mornings. Thepanel saw no evidence that the Board or senior executives had soughtsystematically to drill down and understand the reasons for the feelings of the Trust'sstaff as indicated by the staff survey.

An example relates to:

Community nursing staff who reported to the review team workload

pressures primarily relating to problems accessing timely medical advice

and issues related to the electronic note system. The lack of effective

communication of these issues can be illustrated by the fact that this group

of staff had resorted to workarounds such as contacting doctors working

outside the “on call” system in place who were prepared to give advice (See

also KLOE 7 section 2).

Other examples include the letters sent in April from junior medical doctors and

Medical Registrars to the Medical Director, and referenced previously in this report.

Address the issues raised in

the letter from the medical

registrars and invite their

attendance at the Urgent

Care Board.

Board need to develop a systematicplan to understand and then addressthe concerns raised by staff.

Junior Doctors need a safe placewhere their concerns will be listened toand addressed.

Board to consider listening support isput in place urgently for high risk areas(as junior doctors and elderly care andcommunity services), feeding into theboard in relation to staff survey actions.

Apply efforts to resolve the seriousconcerns raised as rapidly as possible.Put into place mechanisms to allowmiddle grade medical staff to raiseconcerns in a more live and timely way.Actively seek the opinions of front linemedical staff during the implementationof clinical change programmes toproactively monitor the effects of thosechanges.

Programme these interventions as partof the Trusts change methodology.

Urgent

Urgent

Urgent

Urgent

Urgent

41

Staff support including training

KLOE 7: How is the Board assured that it has the necessary workforce (mix, number, skills) deployed to deliver its quality objectives?


Executives and NEDs walk rounds.

Team briefs and Staff Magazine.

Surgical trainee confirmed that Bucks is very good for surgical training.

Some areas are good at sourcing funds for training from outside.

Ward 5 in Stoke Mandeville and Ward 12 in Wycombe are exemplar wards.



Workforce data lacks detail

There is no adequate workforce subcommittee to manage operational risks

arising from workforce issues. For example, the national spinal unit

recruitment issues appear to be understood, but these do not appear to be

stratified nor action planned.

Workforce data presented to the Board is not sufficiently detailed to indentify

outliers that might cause risks to patient safety (either staff numbers or

training). This was evidenced in the minutes of November Board

Management. Workforce concerns were rated below 12 on Divisional risk

registers and not visible at Board. As a consequence the workforce concerns

most worrisome to executives, such as the Chief Nurse, failed to become a

major concern at Board. This suggests limited Board visibility of problematic

but more diffuse systematic risks.

There is a general recruitment

plan for this year for nurses.

Board need HR reports to include more

detail on key risk areas and actions, with

monitoring of delivery against milestones in

the workforce action plan.

Urgent

42



Learning from incidents and complaints

We identified pockets of good practice of organisational learning. In the

doctors’ focus group, attendees spoke of good practice in identifying and

sharing lessons in medicine. We also identified learning on an ad hoc basis,

through involvement in a formal audit and through good practice of some

individuals. However, we did not identify a culture of systematic learning

throughout the Trust. For example, there appeared to be no consistent or

formal feedback loop for clinical staff as a result of serious or adverse

incidents, i.e. no formal structure for the organisation to share lessons learned

from these events, particularly to all staff throughout the Trust.

No linked analysis of incident reports and complaints/PALS.

None identified Improve sharing of lessons learned and

actions from incident reporting.

Urgent

Training

Training and development for staff varies and does not appear to be

prioritised consistently. The training is more focused on acute rather than

community services. There seems to be good training for critical care and

surgical ward but not good for community and IV training is not good for

permanent staff.

The staff focus group presented that there is difficulty in releasing team

members to attend training.

Difficulties were expressed by some staff in getting onto the IV competency

courses although chief nurse stated there was a programme running

throughout the year.

Leadership development for leaders of teams/ community services / wards

does not appear to be consistently accessed. Matrons cover multiple sites

with limited presence per site so limited supervision. In many of our visits the

matrons were present yet when questioned it was clear that given their ward

responsibilities they were not able to attend the wards as often as they would

like, in one instance less that one day a week was quoted.

Good practice is identified in

“People Strategy” and

evidence supplied of some

leadership development for

divisional leads.

Review training – all types including

leadership and especially for bands 1 – 7.

Institute leadership programme for senior

clinical staff. Board ensure oversight and

management to reduce the variation (linked

to staff survey strategy and Recruitment

retention strategy).

An organisational development plan to be

transparent and communicated across the

Trust. Evidence of essential skills

(mandatory) training at ward level and staff

supported through charitable money in

cancer and cardiac for other courses,

however not so in less specialist areas.

To review the Matron arrangement to

provide regular supervision support.

High

High

Medium

43



Inadequate senior doctor support

The medical cover for community hospitals is provided by General

Practioners. A recent improvement to this is the ward round performed by

elderly care physician in the community hospitals. Following the introduction

of the111 service, access to medical advice is now considered inadequate

during the out of hours medical (evidenced in a focus group, unannounced

visit in Amersham, and an interview with the Divisional Associate Chief

Nurse).

The nurses have to call the Bucks Urgent Care Service (111) but the service

is considered inadequate as:

(As reported to the Panel by staff at the community hospitals) the

acuity of the patients has become more challenging.

There are long delays in a doctor calling them back (up to 5 hours).

Thus, the nurses have “given up” on 111 and either call hospital

doctors / GP who they do not mind being called up to a time or 999 if

the patient’s health is dangerously deteriorating.

The junior doctors reported that there is generally lack of senior support which

has become poorer by recent reconfiguration. In Stoke Mandeville, patients

may go days without senior input and there are not daily ward rounds .

None identified Review and improve the out of hours

medical cover for the community nurses

(both working in community hospital and

community itself).

Renegotiate with OOH provider, using CCG

support, a direct line contact for all

community Hospital OOH needs with more

direct and timely access to a medical

opinion.

Urgent

High

Safety

KLOE 8: What assurance does the Board have that the organisation is safe?


Chief Executive and Chief Operating Officer were visible in carrying out frequent walk rounds at Stoke Mandeville and Wycombe, which is appreciated by staff.

Early Warning System has just been implemented across the Trust and is viewed positively by nurses and doctors we spoke to.

44


The Board sees the Serious Incident Report which provides details on serious incidents and describes learning and action plans.

Divisional governance leads feel engaged with the overall Trust governance and feel upward reporting is adequate. They reported getting feedback from the Board on

issues which have been escalated from Division to the Board and subcommittees.

The Board and Healthcare Governance Committee review some appropriate metrics relating to patient safety in the performance report, including Pressure Ulcers.

Staff stated, and performance reporting indicates, that Pressure Ulcer rates were low.

We have seen evidence of Trust-wide initiatives to improve patient safety, which are reported to the Board e.g. reduction in Pressure Ulcers.

During observations, our team saw safe practices relating to drug management e.g. drug trolleys were locked.



Board approach to ensuring a safe organisation is too reactive and relies

upon an incident reporting system which could be improved

There is a reliance on systems such as DATIX identifying issues, which creates

a reactive approach to ensuring a safe organisation. In addition, there is not a

clear understanding among staff of which issues should be reported as

incidents, which means that the Board is relying on a system which could be

improved. We saw examples of events which should have been reported as

incidents, but were not as “they did not lead to patient harm”. The panel

witnessed one example where a patient was transferred from High Wycombe to

Stoke Mandeville with a suspected fractured neck of femur. The family

reported their perception of a significant time delay in the administration of any

pain relief. Staff did not report this as an incident until strongly encouraged to

do so.

In addition, we have not seen a proactive approach to ensuring patient safety,

None identified Training to be provided to all staff and

Board members on the definition of

incidents and the importance of

reporting them e.g. Manchester Safety

Tool.

Ensure key risks are identified and

given appropriately high ratings, such

as highlighting A&E consolidation, and

appear on the corporate risk register, to

enable the Board to proactively plan,

monitor and manage risks to patient

safety.

High

Urgent

45



for example when planning and implementing changes such as the Accident

and Emergency consolidation. They were not highlighted on the risk register.

There is a perceived culture of blame in reporting incidents and

highlighting areas of concern

Some members of staff we spoke with described a blame culture and gave

examples of where they had received negative personal feedback in raising

incidents and areas of concern. This creates the risk that significant issues are

not being raised by staff and escalated to the Board, leaving the Board unaware

of safety concerns within the Trust. Examples of where staff have received

negative feedback included a Junior Doctor who reported an incident via an

anonymous GMC survey. This led to identification of the patient and doctor

involved and the survey was filed in the patient’s notes. The panel heard of one

incident where a chest drain had been left unsealed: The incident was not

reported because of concern that the Trust would respond by disciplining a

nurse who was considered by the witness to be extremely conscientious, rather

than addressing the systemic risk involved in treating patients with complex

needs on non-specialty wards. Also, two members of senior nursing staff raised

concern that incident investigations request disciplinary action without any

discussion with the line manager as to the appropriateness or outcome of the

investigation. Each raised the concern that the Trust has moved more towards

a blame culture rather than holding to account (both noted they expect

disciplinary action to be taken if the staff member did not act within the

expected standards).

The panel heard from staff who stated that the DATIX reporting system requires

too much information about the people involved, rather than the process at

fault. This creates a fear of blame and retribution and makes staff more

None identified A system of incident reporting that staff

can feel confident in which:

Promotes a no-blame culture

Is less personal and less focussed

on the performance of individuals.

Allows an appropriate and timely

response.

Facilitates clear analysis and

feedback of outcomes to staff.

Urgent

46



reluctant to fill the forms in about incidents involving themselves or colleagues.

The panel spoke with staff who had not received feedback on incidents they

had raised.

It is not clear how the Board gains assurance that lessons learned are

shared and implemented across the Trust

We have seen examples of where the Board hear about learning outcomes

from incidents, but it is not clear how the Board get assurance that this learning

is shared and/or implemented across the Trust, other than through reassurance

from individuals that this will occur. We heard from staff that lessons learned

are often not shared with them.

None identified Clinical governance meetings at

department level should all be minuted.

These minutes should then be sent to

Divisional Boards and above, in order

for the Board to gain assurance that

learning from incidents happens at

ward level.

High

The Board could review more metrics to gain assurance over patient

safety at the Trust

The Board review general safety metrics such as pressure ulcers, but could

review metrics which are pertinent to the main risks to safety faced by patients

at this specific Trust.

None identified The Board could review other metrics

that are specific to key risks at the

Trust, such as those relating to

transferring patient between sites and

how out-of-hours staffing impacts on

deteriorating patients.

Urgent

Lack of written criteria for patient transfers

The panel was informed by a ward sister of a change in the acuity of patients

transferred to Amersham. Whilst the sister could articulate the admission

criteria verbally, there was no evidence of formally documented admission

criteria.

None identified Written criteria for patient transfers to

Amersham should be developed, which

are regularly reviewed and audited

High

47

5. Conclusions and support required

Conclusions

The panel was welcomed to the Trust by all staff and patients and met some outstanding and dedicated individuals at all levels within the Trust. The Trust is not a FoundationTrust but currently in the Foundation Trust pipeline. The Trust has recently undergone significant change, most notably the consolidation of the A&E department fromWycombe to the Stoke Mandeville site and the creation of three large divisions from the original six. In response to the Trust’s higher than expected HSMR a Mortality TaskForce was set up in 2010.

The Trust and ward areas were observed to be clean and tidy, with patients generally seen to be well cared for during the visit. Many examples of good practice are includedin the body of this report, but for clarity this conclusion focuses upon six broad areas where more focus from the Trust will lead to significantly improved quality of care:

Governance (including risk management and reporting);

Urgent care (pathways);

Patient safety;

Governance organisation-wide monitoring of clinical and operational effectiveness;

Patient and public engagement (including communication and complaints); and

Workforce development (including recruitment, training and leadership).

There has been a recent period of significant structural and organisational change in the Trust including the consolidation of A&E on the Stoke Mandeville site.Emergency activity remains on the Wycombe site for acute stroke patients and “in hours” cardiac patients. Prospective evaluation of patient transfers between hospital sitesfor those presenting as emergencies should be urgently undertaken to assess patient safety and experience. This evaluation should cover all patients transferred followingpresentation as an emergency to ensure that high quality care is provided for those who remain with Buckinghamshire Healthcare Trust as well as those who are transferredto other hospitals such as Oxford or Harefield. This issue has been a significant reputational risk to the Trust. During the review visit the team saw patients who requiredtransfer between the two sites and feel that urgent, prospective evaluation of this service change must be undertaken to assess the quality of care (i.e. clinical effectiveness,patient safety and patient experience).

The Trust needs a more robust method to provide assurance on the quality impact of major service change with regard to clinical effectiveness, patient experience andsafety especially in regard to the consolidation of A&E at the Stoke Mandeville site. Leadership at Board level appears “reactive” to issues and there seems to have beenlimited challenge and examination of the data presented to the Board (reassurance, not assurance). The current approach is over reliant on incident reporting and needsstrengthening to be sufficient to detect and address unforeseen quality concerns. Patient information and signage needs to improve especially for the benefit of out of hourspatients.

48

The Trust needs more robust, organisation-wide monitoring of clinical effectiveness and operational performance data. Quality scorecards should be in place onevery ward, and the Board needs to have more clarity in how it gains robust assurance about quality and safety risks across the sites. The Trust needs to move its focus onmortality away from trying to explain the figures at the Mortality Task Force. It must concentrate more on the identification of trends in the data and the development of actionplans and improvement projects to address issues such as pneumonia and acute renal failure mortality rates – the approach seems to have been reactive in response toinformation from Dr Foster (and recently confirmed by the CQC mortality outlier alert notices for these categories). While there are a number of recent developments whichfocus on safety (e.g. National Early Warning Scores), the Trust needs to adopt national initiatives in developing a mature “safety culture” and use incident reporting positivelyand constructively alongside more proactive tools.

A more systematic approach is needed to gathering and reviewing patients’ views about their experiences of care in the Trust. Better methods of sharing informationfrom the feedback that is gathered are required. The Trust needs to be more robust in using patient feedback and complaints as a means to informing and improving servicedelivery, and to help it plan for the future and share learning across the organisation.

The Trust recognises difficult workforce issues such as recruitment, high levels of staff sickness and poor staff survey results, but needs a clear, more visible strategy toovercome these challenges. There is good evidence of both ward level initiatives to increase staff engagement, and others such as the staff newsletter, and the CEO coffeemornings – increasing the diversity of two way communication between Board and ward; developing this would provide a good opportunity for the Board to listen to staff.

Urgent priority actions for consideration at the Risk Summit

Problem identified Recommended action for discussion Support required by theTrust

1. Governance: Weak methods to provide

assurance on the quality impact of major service

change with regard to clinical effectiveness, patient

experience and safety. Board appears too reactive,

rather than proactive, and is not effective in challenging

information presented to it. Relies on reassurance over

assurance.

At this time of significant change within the Trust, there is an urgent need for

the Board to develop both its capability and capacity to work in a proactive way

and its ability to scrutinise and challenge effectively.

The Board should urgently develop its approach to risk management. In order

for the Board to proactively plan, monitor and manage risks to patient safety,

there is a need to ensure the key risks are identified at all levels of the

organisation and appropriately feed through to the corporate risk register.

To be discussed with the

Trust and included in the risk

summit action plan.

2. Urgent care (pathways): The consolidation of

A&E on the Stoke Mandeville site has resulted in the

need to transfer patients between sites within the Trust

and to other hospitals.

Investigation of high mortality rates shows pneumonia

and acute renal failure as likely contributing conditions.

There is a lack of clear and formally agreed pathways for

the recognition and management of acutely ill and

deteriorating patient

The Trust should review patient pathways between hospital sites to ensure

high quality of care to ensure clinical effectiveness, patient experience and

patient safety at all times.

The identification and appropriate management of deterioration of medical

patients admitted as emergencies is an area that the Trust should focus on.

The Trust must review medical staffing for out of hours/weekend medical



summit action plan.

49


cover.

The Trust should increase capacity for care on specialty wards. This should

include the establishment of a respiratory unit with double the capacity of the

existing respiratory ward.

3. Patient Experience: There is no systematic

approach to gathering and reviewing patients’ views

about their experiences of care at the Trust. Complaints

are not addressed in a timely manner and learning is not

shared effectively across divisions. Patient and public

expressed concerns about the quality of care for patients

presenting as emergencies.

The panel saw evidence of ward level collection and review of patientexperience data and recommend that this is urgently implemented across theTrust. This should be linked to a single route of accountability within thedivision structure and combine all patient related contact services (PALS,complaints, patient engagement, claims)Put in place consistently high standards for addressing patient complaintsacross all divisions with clear Board level accountability. Put in place aneffective process for capturing and reviewing the experience of patientspresenting acutely to the Trust.



summit action plan.

4. Clinical and operational effectiveness: There

appears to be a lack of organisation-wide monitoring.

There are a number of improvement project in the early

stages of planning or implementation, which have not

been brought together as part of a Trust-Wide safety and

improvement strategy. In addition, although the Trust is a

medium reporter of incidents, feedback from staff

revealed some confusion around the definition of what

constitutes an incident, a reluctance to report incidents

due to fear of blame and lack of confidence in

improvement actions resulting from their reporting.

The Trust should bring together all improvement projects as part of a Trust-

wide safety strategy to address the causal factors associated with the

apparently high mortality. These should be incorporated as part of a

recognised improvement methodology and their progress reviewed.

The Trust need to commission an external safety culture review.Training to be provided to all staff and Board members on the definition of

incidents and the importance of reporting them in a way that promotes the

development of a no-blame culture.



summit action plan.

5. Patient safety: Ineffective Bucks Urgent Care

Service (NHS 111) service for the Community Hospitals.

There is an opportunity for the Trust to work to enhance

the 111 service as an aid to the public in signposting the

appropriate point of entry to the Trust.

Work with patient and carer group/NHS 111 provider and CCGs to improvefunctionality of NHS 111 for this healthcare system.


Trust and Commissioners,

and included in the risk

summit action plan.

6. Workforce: inadequate medical staffing levels

and skills mix – there was a concern over staffing levels

of senior grades in particular out of hours. The Nursing

staffing levels and skills mix was also found to be

suboptimal in places.

The Trust should consider urgently the staffing levels and mix throughout the

organisation, particularly at the senior grades, to address concerns about

weekends and out of hours. In addition, the Trust should undertake a review of

the provision of services at its community hospitals and whether clinical staffing

levels are appropriate and provision of care continues to be sustainable at the


Trust Staff review support

and included in the risk

summit action plan.

50


current level of service use.

Training & development for staff varies and does not appear to be prioritisedconsistently. Some nursing staff said that it was difficult to obtain places onessential internal courses (for example, in order to be permitted to administerIV antibiotics or fluids). Junior doctors reported that there is generally a lack ofsenior support which has been made poorer by recent reconfiguration. Thepanel was told that some patients in Stoke Mandeville may go days withoutmedical input and daily consultant ward rounds are not always carried out.The review team heard from staff that they did not feel that their concerns wereheard and acted upon. There is good evidence to show that a well engagedworkforce has a very positive effect upon patient experience and safety. Avariety of two-way communications are in place and these must be developedurgently in order to encourage effective and diverse staff engagement, in orderto close the gap currently described by members of staff between the Boardand the ward.Difficulties in recruiting nursing staff have been discussed as a key risk andthere is significant variation in the make-up of staffing levels on individualwards between Trust staff and bank or agency staff. The spinal unit and otherwards across sites are understaffed while other exemplar wards confirmedthey had very low vacancy levels.

51

Appendices

52

Appendix I: SHMI and HSMR definitions

HSMR definition

What is the Hospital Standardised Mortality Ratio?

The Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare quality that measures whether the mortality rate at a hospital is higher or lower than you wouldexpect. Like all statistical indicators, HSMR is not perfect. If a hospital has a high HSMR, it cannot be said for certain that this reflects failings in the care provided by thehospital. However, it can be a warning sign that things are going wrong.

How does HSMR work?

The HSMR is a ratio of the observed number of in-hospital deaths at the end of a continuous inpatient spell to the expected number of in-hospital deaths (multiplied by 100)for 56 specific groups (CCS groups); in a specified patient group. The expected deaths are calculated from logistic regression models taking into account and adjusting for acase-mix of: age band, sex, deprivation, interaction between age band and co-morbidities, month of admission, admission method, source of admission, the presence ofpalliative care, number of previous emergency admissions and financial year of discharge.

How should HSMR be interpreted?

Care is needed in interpreting these results. Although a score of 100 indicates that the observed number of deaths matched the expected number; in order to identify ifvariation from this is significant confidence intervals are calculated. A Poisson distribution model is used to calculate 95% and 99.9% confidence intervals and only whenthese have been crossed is performance classed as higher or lower than expected.

SHMI definition

What is the Summary Hospital-level Mortality Indicator?

The Summary level Hospital Mortality Indicator (SHMI) is a high level hospital mortality indicator that is published by the Department of Health on a quarterly basis. The SHMIfollows a similar principle to the general standardised mortality ratio; a measure based upon a nationally expected value. SHMI can be used as a potential smoke alarm forpotential deviations away from regular practice.

How does SHMI work?

Deaths up to 30 days post acute trust discharge are considered in the mortality indicator, utilising ONS data.

The SHMI is the ratio of the observed number of deaths in a trust vs. expected number of deaths over a period of time.

The Indicator will utilise five factors to adjust mortality rates by:

The primary admitting diagnosis.

The type of admission.

A calculation of co-morbid complexity (Charlson Index of co-morbidities).

Age.

Sex.

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All inpatient mortalities that occur within a hospital are considered in the indicator.

How should SHMI be interpreted?

Due to the complexities of hospital care and the high variation in the statistical models all deviations from the expected are highlighted using a Random Effects funnel plot.

Some key differences between SHMI and HSMR

Indicator HSMR SHMI

Are all hospital deaths included? No, around 80% of in hospital deaths are included, which

varies significantly dependent upon the services provided

by each hospital.

Yes, all deaths are included.

When a patient dies, how many times is this counted? If a patient is transferred between hospitals within two

days, the death is counted multiple times.

One death is counted once, and if the patient is

transferred, the death is attached to the last

acute/secondary provider.

Does the use of the palliative care code reduce the relative

impact of a death on the indicator?

Yes. No.

Does the indicator consider where deaths occur? Only considers hospital deaths. Considers in hospital deaths, but also those up to

30 days post discharge anywhere too.

Is this applied to all health care providers? Yes. No, does not apply to specialist hospitals.

54

Appendix II: Panel composition

Name Role

Nigel Acheson Panel Chair

David Turner Lay Representative

Neeta Mehta Lay Representative

Tim Thorp Lay Representative

Priscilla Chandro Lay Representative

Derek Prentice Lay Representative

Nina Wilson Junior Doctor

Vaughan Pearce Doctor

Carol Peden Doctor

Simon Donell Doctor

Aidan Fowler Doctor

Lowri Aldworth Student Nurse

Judy Gillow Senior Nurse

Nicola Lucey Board Level Nurse

Jessica Zeff CQC Inspector

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Name Role

Chris Gordon Senior Trust Manager

Linda Abolins Senior Trust Manager

Christina Button Senior Regional Support

Harriet Luximon Senior Regional Support

Stephen Thornton Observer

Jane McVea Observer

Randeep Nandhra PwC Recorder

Khaleda Zaheer PwC Recorder

Fotini Tsekmezoglou PwC Independent Moderator

Nick Wright PwC PMO Lead

Sarah Leavey PwC- Quality governance reviewer

56

Appendix III: Interviews held

Interviewee Date held

Anne Eden, Chief Executive 10 and 12 June

Fred Hucker, Chair 10 June

Graz Luzzi, Medical Director 10 and 12 June

Neil Dardis, Chief Operating Officer (COO) 10 June

Lynne Swiatczak, Chief Nurse and Director of Patient Care Standards 10 and 12 June

Keith Gilchrist, Non-executive Director, Chair of the Healthcare Governance Committee 10 and 12 June

Anne Walker, Assistant Director of Healthcare Governance Committee 10 June

Alison Knowles, PALS and Complaints Officer

Nick Bigwood, PALS and Complaints Officer

Becky Pipely, PALS and Complaints Officer

Paula Chapel, PALS and Complaints Officer

10 June

Tom Travers, Director of Finance 11 June

Juliet Brown, Director of Strategy and System Reform 11 June

Faeqa Hami, Divisional Chair

Andrew McLaren , Divisional Chair

David Taylor, Divisional Chair

11 June

Tracey Underhill, Head of Membership and Engagement 11 June

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Interviewee Date held

Divisional Assistant Chief Operating Officers and Associate Chief Nurses

Rosemary Finley

Tehmeena Ajmal

Rachael Corser

John Abbott

Carolyn Morrice

Sally Loring

11 June

Liz Hollman, Trust Board Secretary 11 June

Sharon Webb, Assistant Chief Nurse (Corporate) 11 June

Tracey Underhill, Head of Patient Engagement and Membership 11 June

Kathy Cann, Interim Medical Director 12 June

Ian Garlington, Director of Property 12 June

Chris Wathen, Consultant 12 June

Anne Robson, Interim Director of Human Resources and Organisational Development 12 June

58

Appendix IV: Observations undertaken

Observations were undertaken in the following areas of the Buckinghamshire Healthcare NHS Trust:

Observation area Date of observation

Ward 2a, Coronary Care Unit, Wycombe 10 June

Ward 5b, Care of Elderly, Wycombe 10 June

Critical Care Ward, Stoke Mandeville 10 June

Spinal Unit, Stoke Mandeville 10 June

Ward 10, SSU, Stoke Mandeville 10 June

Ward 6, Respiratory, Stoke Mandeville 10 June

Ward 5, Acute Haematology, Oncology, Stoke Mandeville 10 June

Ward 16, Surgical Floor, Stoke Mandeville 10 June

Accident & Emergency Ward, Stoke Mandeville 10 and 12 June

Chartridge and Waterside, Amersham 11 June

Ward 8,9 Elderly, Stoke Mandeville 11 June

Rothschild Maternity Ward, Stoke Mandeville 11 June

Urology Ward, Wycombe 11 June

Critical Care Unit & MIIU, Wycombe 11 June

59

Observation area Date of observation

12a Surgery Ward, Wycombe 11 June

Clinical Decision Unit, Stoke Mandeville 11 June

T&O Ward, Stoke Mandeville 11 June

Out of Hours, Paediatrics, Stoke Mandeville 11 June

Palliative Care and Hospice, Stoke Mandeville 12 June

CSRU & Stoke Ward, Wycombe 12 June

Further observations were undertaken as part of the unannounced site visit, see Appendix VII.

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Appendix V: Focus groups held

Focus group invitees Focus group attendees Date held

All clinical staff, Wycombe 36-40 attendees majority from Wycombe with a few from Amersham (10 June focus group)

11 attendees (11 June focus group)

10 and 11 June

Trainee nurses, Stoke Mandeville 11 3rd

year student nurses from University of Bedfordshire 10 June

Consultants, Stoke Mandeville 31 consultants from various specialties 10 June

HCA, Stoke Mandeville Mixed group of 12 community and hospital HCAs 10 June

Other clinical staff, Stoke Mandeville 32 other clinical staff 10 June

Non clinical, Stoke Mandeville Mixed group of 30 non clinical staff 11 June

Junior doctors, Stoke Mandeville 35 junior doctors 11 June

Non-executive Directors Brenda Kersting and Les Broude 11 June

Senior nurses, Stoke Mandeville 30 senior nurses 11 June

SDU Leads Leads for Urology, General Surgery, GI, Diabetes, AM, Ophthalmology, ENT, Obstetrics andGynaecology, Pathology and Haematology , Plastic Surgery, Orthopaedics, Spinal Unit

12 June

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Appendix VI: Information available to the RRR panel

The following documents were provided to the panellists through a copy being available in the panel’s ‘base location’ at the Trust during the announced site visit. Whilst thedocuments were not reviewed in detail, they were available to the panellists to validate findings.

Document requests Confirm includedComments from trust

Folder Number

1. Board Quality strategy (incorporating PatientSafety, Patient Experience and ClinicalEffectiveness).

Quality Improvement StrategyTrust MissionCorporate Objectives 2013/14“Quality Improvement Strategy currently being updated with indicatorsfor 13/14”

1

2. Board Assurance Framework and Trust RiskRegister.

Board Assurance Framework 12/13Corporate Risk Register“ BAF 13/14 under development”

2

3. Clinical Audit plans for 2013/14 and latest ClinicalAudit Annual Report.

Draft Clinical audit plans for 13/14Clinical Audit Annual Report 11/12Draft clinical audit submission for quality accounts 12/13

3

4. List of all Cost Improvement Programmes for2012/13 and 2013/14 and details of the processfor assessing the quality impact of these

2012/13 CIP delivery, 2013/14 efficiency plansQuality Assurance and Clinical Risk Framework:Assessment, Reporting and Monitoring for 2012/13

4

5. Most recent self assessment or externalassessment of quality governance (againstMonitor’s Quality Governance Framework orequivalent)

KPMG review of Quality Governance Framework October 2012“The Quality Governance review undertaken by KPMG in October2012 commended our governance structures”

5

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6. Organisation structure and CVs of Executiveteam

Organisation StructureMini-CV's of executive team“ Full CVs can be provided if needed”“ integrated medicine has a clinical and operational structuresupporting acute and community integration”

6

7. Governance and committee structures and termsof reference for assuring quality includingmortality

Governance StructuresTerms of Reference Healthcare Governance CommitteeTerms of Reference Audit CommitteeTMC Terms of ReferenceExtract from draft IBP about governance structure“ The Trust has integrated governance arrangements at Board leveland down through the organisation through to ward level”

7

8. Trust Board (private and public) papers andminutes for the last 2 months

Trust Board papers November 2012, January and March 2013(includes minutes)

8

9. Board sub-committee with delegatedresponsibility for assuring quality and safety.Papers and minutes for last 2 months (public andprivate).

Healthcare Governance Committee papers for January and March,including minutes

9

10. Mortality review group papers and minutes for thelast 2 months

Mortality Task Force papers April 2013 and March 2013. 10

11. Summary of key performance measures for2012/13 including finance, performance, qualityand patient experience

Included in the Trust Board papers in Folder 8 8

12. Annual plan submission to Monitor or equivalentfor NTDA for 2013/14

Suite of documents submitted to NTDA. 12

13. CQC Mortality alert action plans andimplementation

February and May 12 alerts with responses 13

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14. Any independent reviews of quality within the lastyear

CQC compliance reportsKPMG review is in folder 5Deans Annual visit 2012HOSC review“ A recent CQC inspection has shared our concerns around staffingand some supervision issues and declared these as moderateconcern although it did not have a concern around patient care”“The recent Health Overview and Scrutiny Committee reportsevidence of good practice and we want to see best practiceconsistently applied across the whole organisation”

14

15. Local Providers - Services and Capacity thatsupport your models of care e.g. localintermediate care beds

As we are an integrated organisation these services are part of ourservices.

15

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The following documents were requested by the panellists at the announced site visit and made available to those panellists attending the unannounced site visit. Whilst thedocuments were not reviewed in detail, they were available to the panellists to validate findings:

Document requests

1.Hospital at night paper

2.Annual Plan

3.Information on current litigation and action out of these

4. All patient safety data from the last 72 hours from 12 June 2013

5.

E rosteringScheduled rostering with KPI’s

Actual staff on shift (agency v Trust)

Grade and hours

For last month (May 2013)

6. Capacity plan and “allied” business case for PFI building at SMH.

7. Letter from junior doctors to the Board around staffing and safety

8. Report from NHS TDA inspection

9. Latest minutes from PEG and the terms of reference

10. Two page summary of good practice from PEG

11. Trust response to CQC understaffing at Amersham

12. Number of patients moved from community beds to inpatient beds back to the community

13. Number of patients transferred more than twice (December 2011 to May 2013)

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14.

Number of patients transferred to a different site.By LOS day band of move

By admin method

By origin of site

By CCs diagnostic group

By discharge description

From Dec 2011 to May 2013

15. Transformation Board minutes

16. QIPP Board minutes

17. Example of CIP quality impact assessment

18. Information on the ongoing monitoring of the CIPs

19. Board Assurance Framework

20. Training Costs Comparison

21. Risk Management Process

22. Complaints policy

23. Benefits plan

24. Royal College of Physicians: Sentinel Audit for Stroke Care

25. Reports from Mortality reviews- up to 5 years of reports to come from Medical Director

26. Data on number of student nurses retained for last 2-3 years

27. Policy for managing deteriorating patients related to EAU

28. Nursing Quality Framework from Chief Nurse

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29. 7 action plans for reforming urgent care

30. % of 1 to 1 care during delivery in Maternity

31. The incident reporting from the 7 deaths mentioned in the data submission

32. Any Root Cause Analysis policy

33. PALS response to emails regarding Lydia Weeks (DOB 29/1/33)

34. Training budget allocated and spent (if different) by specialty and site- split by whether source of funding is charity or commercial.

35. From Patient Experience Leads- how many doctors are involved in the "making every contact count" training

36. Job descriptions for Divisional leads, Assistant Medical Directors & Assistant Chief Nurses

37.Annual Staffing review, dependency & acuity tool, Cover arrangements at WH at night for each area, papers on current review of impact of BHIB, CIP post-implementation assessment, risk assessment (all requested from Chief nurse)

38. Information on Deanery reviews in the last year and evidence of action plans/ implementation from them

39. People Strategy (from HR Director)

40. External Peer Review of ITU

41. Full documentation from two specific complaints- WII213652 15 Nov 2012, and 3728 19 Dec 2012

42.What is the plan for recruitment and training of all staff groups? (Particular concerns cardiology, dermatology, Emergency medicine, endocrinology/diabetes,geriatric, trauma/orthopaedic?) What are the current vacancies and cover plans for each department?

43. CQC report on community hospitals

44. ICU report

45. Policy for Serious Incidents

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46. Specialist Services Register

47. Mortality Review Tools

48. WHO checklist

49. Physiological observations of adult non-obstetric inpatients

50. Recommendations on basic requirements for intensive care units: structural and organizational aspects

51. Report on Critical care for Medical Director Bucks healthcare

52. Briefing paper on The Adult Community Healthcare Teams (ACHT’s)

53. Development of the Medicine for Older People Strategy, Write up from meeting held on Thursday 17th

January 2013

53. Corporate Risk Register 11 June 2013

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Appendix VII: Unannounced site visit

Stoke Mandeville on the evening of Sunday 16/6/13

Panel pre-meet.

Entry into Buckinghamshire Healthcare A&E and announced arrival to site manager.

Meeting held with clinical site manager to understand current staffing and patient levels

Observations undertaken of the following areas of the hospital: A&E, SSU, Surgical Ward

Observations / interviews undertaken of the following staff: On duty clinical site manager Anaesthetics consultant Senior nurse on SSU Senior nurse on Ward 6 Registrars following end of their shift

Panel left Trust and announced exit.

Amersham Community Hospital on the evening of Tuesday 18/6/13

Panel pre-meet.

Entry into Buckinghamshire Healthcare A&E and announced arrival to site manager.

Meetings held with the ward representative to understand current staffing and patient levels

Observations undertaken of the following areas of the hospital: Neuro and Rehab unit Waterside Ward

Observations / interviews undertaken of the following staff: Deputy sister of Neuro and Rehab ward Ward sister of Waterside Ward


Wycombe on the evening of Tuesday 18/6/13

Panel pre-meet.

Entry into Wycombe Hospital main entrance. Used the phone on reception to announce arrival to Trustmanager.

Met by ward nurse. Panel split into two teams; one team was escorted to the surgical wards by wardnurse. The other team went to the cardiac and stroke wards are were met by the Trust manager.

Observations undertaken of the following areas of the hospital: Cardiac and stroke wards and receiving unit Surgical Ward Minor Injuries and Illness Unit (MIIU) reception

Observation undertaken of the following handovers: Doctors on the surgical ward

Stoke Mandeville on the morning of Wednesday 19/6/13

Panel pre-meet.

Entry into Buckinghamshire Healthcare A&E and announced arrival to Sandra Cotton, whoescorted the team to the wards

Meetings held with ward staff to understand current staffing and patient levels

Observations undertaken of the following areas of the hospital: Ward 8, 9 Elderly Medicine, Ward 16b – Gynaecology, Radiology

Observations / interviews undertaken of the following staff: Ward 8, 9 – Elderly Medicine: Susan Beech (Ward Senior), Jo Birrell (Matron), Liz

Matthew (Nurse Consultant), Linda Abolins spoke to patients, Tim Thorp spoke to HCAand Band 5 nurse, Neeta Mehta spoke to patients and nurse.

Ward 16b – Gynaecology: Rachel Oliver (Sister), 3 patients, Tim Thorp spoke to Band 5nurse, Linda spoke to Registrar

Radiology: Spoke to Richard Hughes (Radiology Superintendent)


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Observations / interviews undertaken of the following staff: Contact Junior Doctors Ward and staff nurses Trust manager Associate Chief Nurse MIIU receptionist


70

Appendix VIII - Patient Stories

The Panel was given many accounts by patients, both whilst visiting the Trust and also at the public listening events. All of those accounts have helped to inform the Panel’sassessment of the Trust. Many of those accounts were unreservedly complimentary as to the quality of care provided by the Trust; others were not. A selection of patientstories is set out below. They have been selected simply on the basis that they illustrate themes which are developed in the body of the Panel’s report and because eachprovides an example of why and how the Trust can improve its services in the future.

PATIENT STORY 1

A patient on the respiratory ward at Stoke Mandeville told the Panel that his partner was due to have her first antenatal ultrasound scan shortly after he had been admitted.On learning this, and without any request being made by the patient, the nursing staff established the time and location of the ultrasound appointment and arranged awheelchair and porter to take the patient to the relevant department so that he was able to accompany his partner to the scan.

Comment: This story demonstrates truly compassionate nursing, in which the interests of the patient were placed at the centre of the actions taken by the nurses which wentwell beyond those required of them. It should be used by the Trust to encourage similar standards throughout the organisation.

PATIENT STORY 2

A patient with dementia was as an inpatient at Stoke Mandeville. His family witnessed significant shortcomings in the quality of the nursing care provided to the patient. Theseincluded issues related to medication and nutrition; observation (including falls and possible medical deterioration) and provision of dignified and respectful care. Thedischarge arrangements were unsatisfactory and the patient was subsequently readmitted and died shortly thereafter.

The patient’s family subsequently complained about the quality of care provided. The Trust failed to meet its deadline of providing a response to complaints within 25 workingdays. The Trust’s complete response was not provided until approximately 90 working days had elapsed. The family was told that no notes had been kept in relation tosignificant periods of the patient’s care.

Comment: See recommendations made in Section 4 for KLOE 5, particularly those relating to improving timely responses to complaints and issuing death certificates.

PATIENT STORY 3

A female patient was admitted to Stoke Mandeville suffering from pneumonia. She told the Panel that it was the first time she had been admitted to hospital for more than 40years. She felt that she had received a brilliant service from doctors, nurses, cleaners and everyone else who was involved in her care. Whilst she thought that the nurseswere “worked off their feet”, this had not affected the quality of the care which they had provided. She observed that there was always someone available to help the lessmobile patients with their needs. Describing herself as a fussy eater with special dietary needs, she had found the food at the hospital to be excellent.

Comment: This story again defines the standards of care to which the Trust should aspire for all of its patients at all times, and should be used to encourage similar standardsthroughout the organisation.

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PATIENT STORY 4

A patient was admitted to Wycombe Hospital via its Emergency Department (prior to the latter’s closure) in December 2011. Following the patient’s admission a medical planwas drawn up which reflected the patient’s needs. The patient subsequently died and adherence to the medical plan by Trust staff was questioned and the family also hadother concerns about the patient’s care.

A coroner’s inquest was held at the request of the family where the Trust was legally represented. The Trust’s legal representatives submitted that the coroner should give ashort-form verdict rather than a narrative verdict which might include findings as to the care received by the patient. The coroner nevertheless delivered a narrative verdict.

Comment: Please see Section 4 (KLOE 5; ‘Patient Experience’) for relevant recommendations. In addition, NHS England should consider whether to give guidance as to thecircumstances, if any, in which it might be appropriate for any NHS organisation to request a short-form verdict at an inquest into the death of a patient at which the NHSorganisation is an Interested Party.