Agenda item

1.1.        The Committee considered a report on the findings of a recent Care Quality Commission (CQC) inspection of Brighton & Sussex University Hospitals NHS Trust (BSUH) and the Trust’s response.

1.2.        Lois Howell, Director of Clinical Governance, BSUH, provided an update and answered a number of questions from HOSC in relation to the CQC report and BSUH’s quality improvement programme.

A&E Department waiting times

1.3.        HOSC asked whether the improvements to the A&E Department made since the CQC’s warning notice was issued in April had made any difference.

1.4.        Lois Howell said that improvement in the A&E Department had been significant. BSUH has reduced the number of 12 hour waiting time breaches from 12 during April 2016 to five in total between May and the end of September 2016. The longest a patient had to wait since April had been more than 26 hours, but this had been for patient safety reasons and was now the subject of a serious incident review. BSUH had also improved 4 hour waiting times to 86% compliance, although the 95% target is unlikely to be met until after this financial year when building works at the Royal Sussex County Hospital (RSCH) – designed to improve patient flow and capacity in other wards – are completed.

1.5.        Lois Howell said that the improvements to the A&E Department included:

·         changing staffing rotas at both hospital sites, in particular altering staffing levels at the Princes Royal Hospital (PRH) to match the increased attendance levels during the evenings;  

·         requiring staff to use a checklist to monitor patients’ welfare and a checklist to monitor signs of patient’s deterioration, based on the National Early Warning Scores. There is currently a 100% compliance with both checklists;

·         carrying out audits of patients’ notes to ensure that they are being treated properly and that staff are using checklists.

Patients in corridor area at A&E Department

1.6.        HOSC asked whether it was acceptable to allow patients to wait in corridors, and what BSUH was doing to reduce or eliminate the need for this practice.

1.7.        Lois Howell explained that a corridor area is used when there are no available cubicles for patients who have entered the A&E Department on ambulance trollies, or who are too sick to go into the waiting room; it is safer to have them in the corridor area where a nurse is allocated to them than to put them in the waiting area. She said that putting a patient in the corridor is a difficult judgement call based on what is the safest place for the patient within the circumstances. It is not a situation that the Trust is happy with and is one that the Chief Executive has apologised for.

1.8.        Lois Howell said that if more than five patients are in the corridor a trust wide escalation policy is initiated. Less than 10% of patients now have to spend any time in the corridor, these patients have to wait in the corridor for about an hour on average, and it is rare for five patients to be there at any one time.

1.9.        In response to the CQC’s findings on the use of corridors, Lois Howell said that BSUH has:

·         Replaced some offices with four new assessment cubicles to reduce the use of the corridor area;

·         improved the privacy and dignity of patients by ensuring that all treatment and assessment is conducted in a cubicle area and not in a corridor;

·         bought more substantial screens for patients to allow more privacy in the corridor area;

·         begun building works in the A&E Department and work to improve patient flows elsewhere in the hospital and increase available beds; and

·         improved ambulatory care areas so that some patients can avoid A&E and go directly to the newly opened surgical assessment unit, for example, those referred by their GP. 

1.10.      Lois Howell said that BSUH is working towards a target of patients spending no more than 15 minutes in the corridor. However, improvements to patient flows throughout the rest of both hospital sites would need to be completed before a target of no one waiting in corridors could be achieved. This is because a lack of available beds in the rest of the hospital is often the cause of A&E cubicles becoming fully occupied.

Leadership and clinical governance

1.11.      HOSC asked whether the Trust’s senior leadership has the capacity to address the findings of the CQC.

1.12.      Lois Howell clarified that there had been significant changes to the Board since the inspection. There is a new Chair and Chief Executive in place, along with a number of new non-executive and executive directors.

1.13.      She also said that clinical governance at BSUH is in the process of being overhauled. The Trust is aiming to achieve this by:

·         developing a leadership programme for clinical directors and other clinical leads;

·         holding monthly senior management team meetings of all clinical and executive directors to ensure that there is a better link between the two;

·         Holding improvement meetings for senior nurses and ward managers.

1.14.      Lois Howell acknowledged that there is a serious cultural issue at the Trust and previous attempts to address it have failed. The Trust is investing significant money in recruiting external assistance to help it work more effectively with staff with particular protected characteristics. Some of the projects underway include:

·         a regular staff forum;

·         a commitment by the senior management team to 1,000 hours of participation with staff in frontline services;

·         the establishment of an equalities group to ensure that the needs of all staff with protected characteristics are looked after across the Trust;

·         an Equalities Committee to seek assurance and generally provide governance around the question of service provision – to ensure that when it is delivering services, the Trust is doing so in fair and equitable ways for all patients with protected characteristics.  

 Sharing good practice from the Children’s Services Department

1.15.      HOSC asked why the Children’s Services Department was outstanding when the rest of the Trust was not, and what lessons could be learned from it and applied across the Trust.

1.16.      Lois Howell said that the performance of the Children’s Services Department was in part due to factors that could not be applied across the Trust, for example, the modern Royal Alexandra Children’s Hospital building was designed with modern patient flows in mind, whereas many other parts of the RSCH site were built during the Victorian era. In addition, there are different commissioning requirements for children’s healthcare, for example, lower demand for children’s A&E services, which could not be applied elsewhere. However, the Children’s Services Department’s governance, teaching, learning and supervision methods will be shared as part of the overhaul of clinical governance.

Staffing in clinical areas

1.17.      HOSC asked what was being done to recruit staff to clinical areas, in particular critical care areas, and reduce the use of agency staff.

1.18.      Lois Howell said that BSUH’s neuro-intensive care unit was of most cause for concern to the CQC. In response, the Trust has reduced capacity at the ward by one bed, and developed an in-house training programme for neuro-intensive care staff. The additional capacity will be reinstated once the ward has developed the right staffing skills to meet patient needs and the demonstrable ability to provide that additional capacity safely.

1.19.      Lois Howell said that BSUH is attempting to recruit additional staff but recruitment is a national problem, particularly for roles such as A&E doctors. By way of illustration, PRH already had 4 consultant vacancies in its A&E Department that have not been filled and, in response to the CQC inspection, BSUH has now committed to providing further senior medical cover creating an additional 5 vacancies in A&E. The Trust is therefore looking at alternatives, for example, using senior doctors who are not consultants but have significant medical expertise and have received additional training.

1.20.      BSUH has increased nursing staff and healthcare assistants in key areas and is recruiting and training its own bank staff in key areas rather than relying on agency locum staff wherever possible. The Trust is also developing clinical fellowship roles in a number of posts that allow staff to work part time clinically and part time in a research role. Agency staff are used when there is not sufficient permanent staff available.

1.21.      The Committee RESOLVED to:

1)    note the reports and its appendices;

2)    agree to establish a joint working group with West Sussex County Council and Brighton & Hove City Council HOSCs to scrutinise the BSUH Quality Improvement Plan;

3)    nominate Cllrs Belsey, Howell and O’Keeffe to the joint working group;

4)    circulate papers to the rest of the committee in advance of the joint working group meetings; and

5)    report back the findings to HOSC at a future date.