HEALTH OVERVIEW AND SCRUTINY COMMITTEE
22 September 2022
South East Coast Ambulance SERVICE NHS FT Update
Report from: Emma Williams, Executive Director of Operations
Author: Ray Savage, Strategic Partnerships Manager (SECAmb)
Executive Summary
The Trust during the past few years has been inspected by the Care Quality Commission on three occasions. In 2017 the published report, following inspection, recommended that the Trust be placed into special measures. Subsequent inspections in 2018 and 2019 acknowledged the progress that the Trust had made in addressing the concerns raised in 2017 and due to this progress, the Care Quality Commission recommended that the Trust came out of special measures and have an overall rating of ‘good’ recorded.
The inspection carried out during February 2022 and the final report published in June 2022, saw the formal rating of the ‘well led’ domain reduced from ‘good’ to ‘inadequate’, with the Chief Inspector of Hospitals making the recommendation to NHS England and NHS Improvement that the Trust be placed in the Recovery Support Programme and as a result, the Trust has had its ratings suspended.
Through the Recovery Support Programme, the Trust will receive intensive support from NHS England to help it improve and the Trust must set out clear actions and objectives on how it will bring its services up to the required standard.
It is important to note that throughout the inspections 2017 – 2019 and the most recent one in February of this year, the Care Quality Commission has always reported the care which staff have demonstrated when treating patients has been ‘good’ or ‘outstanding’.
However, following the findings in the recent publication of the Care Quality Commissions inspection and the results of the NHS Staff Survey, the Trust’s Leadership Team has set out the key priorities for the year, including building a culture that reflects the Trust’s values, supports its vision and ensures the satisfaction and wellbeing of its people as well as embedding quality improvement.
In June 2022, the Trust also announced the appointment of an Interim Chief Executive, Siobhan Melia, following the resignation of Philip Astle. Siobhan joins the Trust from the Sussex Community NHS Foundation Trust where she was the Chief Executive and formally took up her position with the Trust in July.
1. Care Quality Commission (CQC) Inspection February/March 2022
1.1. The CQC undertook a focused inspection of the Trust, concentrating on the domain ‘well led’. This is one of five domains that are normally inspected. The remaining four were not formally inspected for the Trust as a whole, however, the inspectors did review the Emergency Operations Centre and NHS 111 service as a part of a wider inspection into the urgent and emergency care services across Kent and Medway.
1.2. Overall, the findings from the inspection of the Trust’s 111 service found that it had good systems in place to manage risk and learning took place when incidents happened to improve process. It was evidenced that the effectiveness and appropriateness of care was regularly reviewed, and staff treated people with dignity, respect, kindness, and compassion. There was also a focus on continuous learning and due to the nature of this integrated service, patients were able to access care and treatment to meet their needs.
1.3. It was acknowledged that some of the key performance indicators were not being met e.g., clinical call back times, call response times and call abandonment rates. However, for 111, the overall rating stayed the same as the previous inspection and was rated as ‘good’.
1.4. The inspection of the Emergency Operations Centre (999) highlighted numerous concerns. Some of these concerns were: staffing levels along with staff training and development; lack of senior management visibility/support; non-completion of statutory and mandatory training as well as a low number of appraisals. Incident management was also a concern with incidents not being investigated within an appropriate timeframe and little or no feedback was being given, following an investigation to the wider workforce.
1.5. Leadership at a local level was found to be supportive of staff and staff treated patients with kindness and compassion as well as staff working together to meet the needs of patients despite the pressures of activity. Staff also assessed risks to patients and acted on them ensuring that patient records were kept.
1.6. The CQC did acknowledge the steady growth in call volume that has not been met with equivalent workforce growth, combined with increased levels of staff absenteeism due to sickness and delays in ambulance crews handing over their patients at emergency departments have all reduced the service’s ability to respond to patients in the community and therefore not meet its response time targets. It recognised the pressure that this was creating for staff when there were calls outstanding with no immediate resource to send.
1.7. The rating for this part of the service was ‘requires improvement’.
1.8. Some of the areas of concern that the Trust-wide inspection highlighted were:
· Leadership experience, capacity and capability was evident however the executive team did not work as effectively as needed
· A disconnect between executive and senior management and staff, leading to a lack of awareness of the challenges that front line staff were facing
· Leaders did not demonstrate the Trust’s values
· Levels of bullying and harassment and inappropriate sexualised behaviour
· Governance systems not working as they should in order to protect staff and patients
1.9. Some of the areas that the CQC reported positively against were:
· The wellbeing hub providing invaluable support to staff
· The progress being made within the equality, diversity, and inclusion agenda
· The maturity of the digital programme and the investment into the IT programme
· As a result of the pandemic the Trust had improved its visibility within its operational geography
1.10. Despite the concerns raised, the Trust was pleased that the excellent care provided by staff towards patients was recognised and satisfied with the acknowledgement that staff are compassionate and have a supportive approach to those accessing both 999 and 111.
1.11. Following the results of the staff survey and the subsequent high-level feedback from the CQC prior to the formal report being published, the Trust promptly embarked on an action plan and improvement programme.
1.12. The CQC undertook an unannounced urgent and emergency care and resilience inspection on the 26th July. Verbal feedback was given following the inspection and for the two key points raised, actions to address these were already being covered in the Improvement Journey to address the point.
2. Trust Priorities and Improvement Journey
2.2. The Trust’s plan is to deliver short-term targeted actions that will address the CQC warning notices, must-do and should-do actions, as well as providing a vehicle for the delivery of improvement beyond the initial period of recovery.
2.3. It has identified six key themes that urgently require addressing:
· SECAmb is not the great place to work that the Trust wants it to be
· A lack of consistent vision and direction of travel
· Trust in the Leadership Team is lacking
· Lack of a ‘Quality’ thread across the organisation
· Disconnect between Leadership and the rest of the Trust
· Significant concerns raised over culture
2.4. In response to these concerns the Trust has developed four pillars for its Improvement Journey (Appendix A):
· Quality Improvement
· Responsive Care
· People and Culture
· Sustainability and Partnerships
2.5. Each of the four pillars will be led by a Trust executive:
· Quality – Robert Nichols, Executive Director of Quality and Nursing
· Responsive Care - Emma Williams, Executive Director of Operations
· People and Culture – Ali Mohammed, Executive Director or Human Resources and Organisational Development
· Sustainability and Partnerships – David Ruiz-Celada, Executive Director of Planning and Business Development
2.6. The Trust Board recognises that the Improvement Plan will develop over time and that actions will need to be transformational and sustainable. It recognises that some of the actions will be required to be delivered at pace and, as a result, the Trust has already begun a process to create capacity through portfolio working and recruit additional resources to support the delivery of the plan.
2.7. The Board also recognises that there must be a ‘zero’ tolerance to inappropriate behaviours, this must be called out and the Trust’s Board members need to demonstrate the Trust’s values though out all they do.
2.8. To highlight some of the work already in progress:
· Quality Improvement: “We listen, we learn and improve”
o A review of Terms of Reference and quality governance structure had already begun when the report was published
o All policies that are due for review will have a sustainability section embedded
o The Trust has also aligned its Integrated Quality Report (IQR) to ensure that the focus is on patient service, people, and sustainability.
o The development of a quality dashboard to be completed by October 2022 which will aim to focus on the triangulation of quality information with workforce financial information, colleague well-being information and patient quality outcomes
o The internal Quality Summit is a first for the Trust with a focus on reviewing the whole patient journey, identifying any risks, particularly when there is significant demand being placed on the Trust and working with system partners to find solutions. This will involve local NHS partners, NHS england and IC24
o Sub committees feeding into the four pillars will be carrying out ‘deep dives’ to ensure that there is appropriate Board scrutiny of the impact and challenges being faced and that the improvements required can be delivered
o Work has started to reduce the backlog of incidents and to ensure that any learning from outcomes is used to improve services. Since July, the back log has been halved and the aim is that by October all outstanding incidents will have been reviewed with key themes identified. The investigations into incidents create rich learning and it is recognised that the individuals directly involved in a Serious Incident will benefit from this learning, but the wider workforce does not. Therefore, work is in progress to communicate this learning with the wider workforce with the aim of preventing similar mistakes happening to others. This will be done through anonymised case studies.
o The risk register has raised concerns around medicines management and a peer review is currently underway.
o Each directorate has a Business Support Manager who will take on the responsibility for reviewing the risks logged on the risk register
o Clinical input and a clinical voice are key to improvements in quality and while clinicians are already involved in serious incidents it is recognised that further clinical input is required and, therefore, the aim is to establish a clinical senate/advisory body to understand what medicines we have, how we use them, and how they work
o The Trust’s Risk and Assurance Group has restarted
o The Trust is appointing a Quality Improvement Lead to support the delivery of the plan
· Responsive Care: “Delivering modern healthcare for our patients”
o All band 5 to 7 managers (first line managers) have been or are enrolled on to the Fundamental’s course. The Fundamentals one day course is run by NHS Elect
o Made @ SECAmb is another NHS Elect run course but targeted towards senior managers and will fully role out in 2023
o Comprehensive review of the Trust’s fleet: Is what we have right for the delivery of the service and the future demands it will face? (Consideration for type of resource required e.g., ambulances versus cars). The Fiat ambulances, based on a national specification have been a frustration to staff who have complained about a number of the features of this type of ambulance. The Trust has paused on the conversion of the latest batch of FIAT ambulances while it undertakes a review of the design specification
o Review of the way in which ambulances are dispatched within the EOCs to improve decision making and how this impacts front line staff who are often experiencing shift overruns
o Effective working with the Private Ambulance Providers (PAPs) to whom the Trust sub-contracts
o Trust wide rota reviews with staff involvement. The rotas parameter procedure has been rewritten to improve both work life balance for staff and enable delivery of timely ambulance responses
o Rota vacancies (workforce) is a significant concern
o The current workforce plan needs to expand to encompass recruitment and retention, absence management and staff wellbeing. Front line staff attrition is seen as a significant risk
· People and Culture: “Everyone is listened to, respected, and well supported”
o The leadership team has been working on improving their effectiveness in how they communicate and work with the wider organisation. Since June 2022, the Trust’s Board have undertaken over 100 site visits listening events to hear what staff are saying
o During June, the Trust launched its ‘Until it Stops’ campaign to address the inappropriate behaviours highlighted in the CQC report
o The CQC positively recognised the Trust’s provision of Health and Wellbeing Services and the work done on equality and inclusion. This gives the Trust an opportunity to build upon and test all that the Trust does against wellbeing and inclusion as principles
o A focus on cultural change, core values, policies (previous point)
o The fundamentals one day course is run by NHS Elect and the Trust’s Organisational Development team and is aimed at first line managers to equip them with the skills, tools, and knowledge to effectively lead and manage their teams.
o Middle managers have been engaging with a programme to support their development in compassionate leadership and leadership capability
o Communication with staff now has a focus on shortened e-bulletins with a focus on taking action when concerns are raised and using short videos to deliver key messages
o Collecting ideas and suggestions to empower local teams to drive improvement with local ownership
o The new specific email address gives staff the opportunity to submit feedback on the improvement journey
· Sustainability and Partnerships: “Developing partnerships to collectively design and develop innovative and sustainable models of care”
o A part of mapping the patient journey during the Quality Summit, will be to evaluate the job cycle time and understanding how to be most efficient with our time spent with a patient
o Using every resource available to the Trust in the most effective way
o Improving Hear and Treat through effective telephone triage
o Evaluating how the Trust works collaboratively with the Integrated Care Boards (ICB)
o Accessing alternative pathways for patients that require an intervention in the community setting or direct conveyance to a hospital speciality (avoiding the Emergency Department)
o Working with the acute trusts to improve ambulance handover delays
o Working with ‘Arcadis’ (sustainability consultancy) as the Trusts moves toward a ‘net-zero’ carbon footprint
o Developing a longer-term plan that accepts there will be ‘peaks and troughs’ and takes this into account with flexibility but maintains the direction of travel
3. Recommendations
3.1 The committee is asked to note and comment on the update provided.
Lead Officer Contact
Ray Savage, Strategic Partnerships Manager (SECAmb)
Background papers
None
Appendices - Appendix A
