WLMHT Initial Response to Report of the Mid Staffordshire NHS Trust Public Inquiry –Report to the Board

Introduction

The report of the Mid Staffordshire NHS Trust Public Inquiry chaired by Sir Robert Francis was published in February 2013 and includes 290 recommendations, many of which relate to national professional, statutory and regulatory bodies and require a response from those agencies before the Trust will be in a position to describeplans to implement any required actions. Therefore, this report contains details of the Trust’s initial response to the recommendations and refers to areas where compliance has been established or where plans are in place to implement change in the light of the recommendations of the public inquiry.

Background

Concerns about mortality rates, patient safety and standards of care delivered at Mid Staffordshire Trust arose circa 2007. As a result, a number of investigations and reviews were commissioned, including one by the Health Care Commission which published its report in March 2009 and an IndependentInquiry chaired by Sir Robert Francis, the report of which was published in February 2010. What emerged from the investigations, reviews and first Francis inquiry was a horrifying picture of the Board of an acute Trust preoccupied with achieving challenging financial recovery and savings plans at the expense of patient care and safety in order to gain Foundation Trust status. The chainof negative impacts on quality of care has been well described in terms of extreme staff shortages, reliance on poorly trained and stressed, often unregistered staff at the clinical front line who were often uncaring and blunted to distress, paralleling the uncaring, bullying way they were in turn treated by their managers. Indeed, a culture of threat and bullying was revealed which permeated every level of the organisation, with the most vulnerable patients experiencing the greatest harm. Elderly, confused and frail patients were found to have been treated in dehumanizing ways, being denied dignity and support for the basic activities of living they were unable to manage because of their ill health. Also, patients whose admissions occurred as an emergency and who were treated through the Trust’s emergency care pathway were amongst those who suffered most, becoming victims of a target culture whereby pressure was applied on clinicians to accelerate patients through the pathway, prioritising the achievement of waiting time targets for example, over the care and treatment patients needed as a result of their health conditions. Failures at every stage of the pathway from triage to discharge were identified.

Patient safety was greatly compromised due to failure to meet cleanliness and infection control standards, not administering medications as prescribed, poor support and management of the care of people with mobility difficulties leading to falls, and poor care with regard to prevention and treatment of pressure ulcers. Essential equipment for patients’ treatment was in poor repair or lacking. The Trust was found to be inward looking, with the Board meeting in private and detached from the reality of the wider organisation, whilst inappropriately relying on external agencies and regulators for quality assurance. Data that suggested poor quality of care delivered at the Trust was met with denial followed by undue scrutiny around coding and data issues rather than concern about possible implications for patient safety.Senior clinicians, mainly consultants were described as disengaged from Trust management.

In June 2010the secretary of state for health announced a Public Inquiry into Mid Staffordshire NHS Foundation Trust to be chaired by Sir Robert Francis. Having established a clear and consistent description of the failings at the Trust in previous inquiries, the remit of the Public Inquiry was to examine the functioning, cultures and systems of commissioning, supervisory and regulatory organisations and other agencies in relation to their monitoring role at Mid Staffs and establish why problems were not identified sooner and to identify lessons to be learnt about assuring quality of patient care and safety.

Findings - Report of the Mid Staffordshire NHS Trust Public Inquiry (2013)

Many reviews had occurred and much data was available about aspects of care and safety at Mid Staffs but this had not been identified by the Trust or other agencies as predictive of or associated with extremely poor quality, including risk to patients. ‘Vestigial’ governance processes were described which were not fit for purpose and did not focus on the effect of the service on patients while the Trust took false assurance from the findings of external agencies whose assessments inevitably lacked depth. The Trust also took assurance from the fact other health care providers performed as badly rather than acting in a patient centred way and responding with concern about anydetrimental effects on patient experience and safety. ‘Specious’ complaints and incident reporting occurred whereby exploration did not occur beyond surface presentations. There was not found to be any management culture of listening to patients or carers and no quality impact assessment of the major staff reductions that occurred to make financial savings. Poor medical but mostly nursing standards and performance were associated with a failure to take up the challenge of building a positive culture. Patient safety failures were associated with not appreciating the risks associated with disruption and also lack of corporate memory and focus due to repeated, multi – level reorganisations. External regulatory agencies were described as doing the system’s business not patients.’

Recommendations

As mentioned previously, not all of the 290 recommendations made by Francis (2013) require an immediate response from WLMHT as they either refer to actions required by external agencies or require those external agencies to make an initial response to which WLMHT will then be required to react.

WLMHT Response

Immediate Response

The immediate response by WLMHT Board was to undertake critical self assessment during Board development sessions, identifying any obvious indicators or performance approximating the findings at Mid Staffs. The Trust identified a lead for the implementation of recommendations from the Mid Staffs Public Inquiry, the Interim Director of Nursing and Patient Experience. The Trust also agreed to cascade the findings of the Mid Staffs Inquiry throughout the Trust in order to generate comments and feedback from staff groups regarding any parallels with Mid Staffs and also with regard to ideas about improvement. To date numerous presentations have taken place within the Trust with more planned. Also, the Interim Director of Nursing and Patient Experience will support nominated staff from across the trust to present the report and generate feedback from within their teams, deeper into the clinical and corporate services. The Mid Staffs Inquiry was presented at the Trust Leadership Forum on 25th February and at the Trust Health Care Assistant and Support Worker conference on 18th March. It was central to the Trust learning lessons event on 1st May and the Trust annual safeguarding conference on 17th May. The Trust annual nursing conference on 3rd July will focus on compassion in mental health nursing. Therefore, the Trust response will be continuous and evolve as part of an iterative process which incorporates feedback, ideas and actions from staff, service users and carers. Importantly, it will build on current good practices.

Culture of Putting Patients First

Whilst maintaining a strong focus on individual accountability, the Trust also recognises the impact of culture on staff attitudes and behaviour. The Trust accepts that patients must come first in all that we do. With regard to culture of the organisation, the Trust recognises that good staff engagement and support is a prerequisite for patient centred-ness and the high quality therapeutic relationships we want patients, service users and carers to experience as part of their recovery. The Trust is also aware that some members of staff feel alienated from the business of the Trust and that they are ‘done to’ rather than actively involved in decisions that affect them. Some staff also report feeling bullied. Additionally, some senior managers and directors feel unable to understand what generates and sustains this position. Furthermore, actions developed to resolve this picture appear to have failed tomake a difference year on year. A number of new initiatives are planned to address this. Included is the drive towards a culture of engagement that encourages staff to speak out about their experiences at the Trust. That is evidenced by a series of listening events facilitated by the CEO, the introduction of a Staff Engagement Committee reporting to the Board, the introduction of staff reporters whose task is to each interview a cohort of colleagues about their experiences at the trust and then report to the Board in a specially organised session utilising the fishbowl approach. The Board listen to the reporters’ feedback and then set time aside to carefully consider what they have heard. Action is then taken to improve staff experience and this will be planned and monitored through the Staff Engagement Committee. Each time staff reporters feed back to the Board, the consequent actions agreed are communicated within the Trust in a newsletter entitled ‘Action for Change.’ Also, feedback from the Health at Work team who have a specific perspective regarding staff experiences of the Trust will be used to inform strategies to improve. An organisational consultancy will be engaged whose remit will be to support the Trust to address complex aspects of workplace culture that may require work to occur ‘below the surface’ as well as above the surface.

Openness, Transparency and Candour

A principle of putting patients first involves acknowledging, apologising and providing clear support and information to patients and their families when things have gone wrong or safety compromised including how the organisation has responded and what lessons have been learnt. The Trust has in place a ‘Being Open’ policy which addresses these principles and will adhere to any further standards specified by the NHS Commissioning Board.

Listening to Patients and Carers

Patients and Carers are listened to within the Trust with several patient or service user and carer forums in place. The Meridian Patient Experience Feedback system has been invested in as a means of achieving real time feedback. Clinical teams are embedding the practice of improving the quality of patient and carer experience based on their feedback. All in- patient services have regular community meetings where patients and staff come together and patients are able to feedback on their experiences. Patient representation is included in local clinical improvement groups and governance meetings throughout the trust. Patients and carers regularly provide narratives prior to Board meetings, reporting their experiences of Trust services. Patients and carers provide training to staff throughout the trust regularly, based on their lived experiences at the Trust. The Trust is open to exploring further methods of gaining feedback, such as the ‘mystery shopper’ approach. Enhanced use of complaints feedback is being explored.

A review of service user and carer involvement was commissioned in 2012 and the report of this review was presented to the Trust Board at the end of May 2013. The recommendations were accepted. A working group has been convened to implement the recommendations, beginning with developing a centralised, supportive, co-ordinated infrastructure for service user and carer involvement. Funding has been made available to support this initiative. A further development is the introduction of a patient or service user and carer led group which will actively challenge and hold the organisation to account with regard to the nature and quality of services delivered.

The importance of carer involvement at all levels is positively encouraged. The Trust provides therapeutic family interventions with staff increasingly provided with encouragement, support and skills to work with families. Programmes of carer support and education are increasingly available within Trust services. Welcome meetings are being piloted in some adult in – patient settings. These meetings are a forum for carers to meet with the multi disciplinary team treating their friend or family member, soon after admission, providing the carers with an opportunity to become oriented to the services, provide information to the treating team about the patient’s strengths, resources and needs while also asking any questions or sharing any concerns they may have. Additionally, The Triangle of Care (National Mental Health Development Unit 2010) has been introduced to services.

Care, Compassion, Nurses and HCA’s

The Trust nursing strategy is currently under review. The revised strategy will contain the following themes which concur with the recommendations of the Francis Report and the 6Cs of the National Strategy for Nursing: Compassion in Practice:

  • Restructuring the Director of Nursing post. This will free up time for clinical practice and for support and engagement with front line nurses in both in-patient and community settings.
  • Promoting compassion and the value and privilege of delivering standards of basic care, which will be measured and reported into the Trust Quality Committee.
  • Centralised assessment centre for recruitment which will include an assessment of candidates’ aptitude for compassion, caring and the job overall.
  • A new, more focused and competency based preceptorship programme for newly registered nurses to be completed within their first twelve months of qualification.
  • Investing in quality of nursing within our Older People’s Services, including promoting its place amongst the other nursing specialties at the Trust and ensuring staff receive appropriate support, supervision, training and development within a career pathway.
  • Emphasising the nursing contribution to multi disciplinary teams by building up evidence based practice and investing in training and supervision to support the transition of learning into practice within the specialist areas of psychosis, personality disorder and dual diagnosis, child and adolescent mental health (as well as older people’s services). This applicable to both community and in-patient settings.
  • Investing in a staff clinical supervision project delivered by a team of international experts in the field. This project focuses on qualitative aspects of clinical supervision and aims for clinical supervision which is of an evidence based standard of effectiveness to be provided and received by staff within the Trust.
  • A HCA training programme informed by Trust HCA’s and Senior Nurses which is also in line with National HCA Training standards. Inclusion of the code of conduct for HCA’s and Support Workers in Trust job descriptions for these roles.
  • Nurse staffing will be reviewed annually and the findings presented to the Quality Committee.
  • A Trust-wide Senior Nurse ‘back to the floor’ programme will be initiated and centrally co-ordinated, increasing senior nurse visibility, role modelling and support to front line staff whilst ensuring senior nurses remain in clinical practice.
  • Continuing to support nurses to make a key contribution to implementing the Recovery Approach in community and in-patient settings
  • To embed a culture of nursing research, audit and evidence based practice supported by the key joint appointment with BuckinghamshireNewUniversity of the Professor of Mental Health

The revised strategy will be presented for consultation at the annual Trust nursing conference on 3rd July 2013 where the keynote speaker is Jane Cummings, Chief Nursing Officer for England who will be presenting ‘Compassion in Practice.’ The focus of the conference will be on implementing ‘Compassion in Practice’ within a mental health nursing context.

In March 2013 a HCA conference was held, which focused on Compassion, Recovery and the role of the HCA. Delegates identified their training needs and this information has been employed to inform a Trust wide standardised training programme for HCAs.

Nurse staffing has recently been reviewed and the findings presented to the Quality Committee. When benchmarked against other Trusts providing similar services, Trust nurse staffing was favourable. As mentioned above, nurse staffing will be reviewed on an annual basis.

Institute of Mental Health

In partnership with HEI’s and led by the newly appointed Professor of Mental Health, WLMHT is exploring the development of an Institute of Mental Health which will bring together, in an integrated way, the many strands of workforce transformation and development, quality priorities and staff training ‘under one roof.’ The focus will be on generating evidence based practical skills, leadership development and team working. Importantly, training programmes will be directly responsive to the needs of patients and carers and informed by lessons learnt from patient and carer experience feedback, serious incident reviews and complaints, as well as from workforce related data.