This report provides the Health, Care and Wellbeing Scrutiny Committee with the background and findings of the Care Quality Commission’s (CQC) inspection of Herefordshire and Worcestershire Health and Care NHS Trust (the Trust).  It also outlines the actions taken following the “Well Led” inspection.

The Chairperson invited representatives from the Herefordshire and Worcestershire Health and Care NHS Trust (the trust) to update the committee on the outcomes of the Care Quality Commission (CQC) inspection report of the trust.

 

The committee received the presentation ‘Herefordshire and Worcestershire Health and Care NHS Trust Improvement Plan’ (link to the presentation).  The Director of Strategy and Partnerships presented the slides: Background; Trust services in Herefordshire; Our communities and patients.  The Director of Nursing presented the slides:- Overview of our Improvement Plan; CQC inspection; Rating for mental health services; Overall rating; Areas for improvement; Current actions; and Six key elements of the Improvement Plan.

 

The principal points of the discussion included:

 

1.           The Chairperson noted that aspects of the inspection report on mental health services were relevant to Herefordshire and welcomed the Improvement Plan; the report also covered a broader range of services which were delivered by the Trust in Worcestershire.

 

2.           In response to a comment from a committee member about the ratio of ‘leaders’ to other staff, the Director of Nursing explained that leaders included anyone with line management responsibility.

 

3.           The Director of Strategy and Partnerships commented on the interdependencies within mental health and on the regulated activity delivered by the trust.

 

4.           The Vice-Chairperson questioned the level of awareness about the issues inherited through the transfer of the mental health and learning disability service to the trust in 2018. 

 

The Director of Strategy and Partnerships commented that due diligence had not identified any performance ‘red flags’ and outlined subsequent challenges which had arisen from the community mental health transformation process and from the COVID-19 pandemic.  It was noted that recruitment and retention was a significant issue for the trust, and for the NHS generally.

 

The Associate Director, Primary Care and Community Mental Health Services commented that there had been high vacancy rates in some community teams but this was now returning to typical levels, in the context of the characteristics of the health service nationally; the vacancy rate for adult mental health community services was around 12%.

 

5.           Attention was drawn to the slide Rating for mental health services which showed the position for ‘Acute wards for adults of working age and psychiatric intensive care units’ as ‘Inadequate’ for Safe, and there was decline to ‘Requires Improvement’ for Effective, Caring, and Responsive.

 

The Director of Nursing confirmed that the trust was looking at all areas.  An overview was provided of the challenges, exacerbated by the pandemic and workforce difficulties, in adult inpatient mental health services.

 

6.           In response to a question about the effects of the pandemic, the Director of Nursing explained that demand went down initially, as people avoided health settings, but many individuals’ mental health had deteriorated during that period which had resulted in increased demand for mental health services subsequently. 

 

The Director of Strategy and Partnerships added that this was particularly apparent for children and young people.  The Vice-Chairperson commented on the consequential challenges for learning providers.

 

7.           The Chairperson noted that the trust had experienced complications arising from a disruptive, national cyber security attack, and had undertaken a refurbishment scheme at the Stonebow Unit in Hereford.

 

8.           The Associate Director, Primary Care and Community Mental Health Services provided an overview of primary and secondary care but explained that the community mental health transformation process had sought to create a greater level of integration, recognising that patient care needs may vary over time.

 

9.           In response to a suggestion, the Director of Strategy and Partnerships agreed to provide an infographic guide to mental health services across Herefordshire.

 

10.        A committee member, noting that 700 out of c. 4,500 members of staff responded to engagement during July to December 2023, questioned whether the approach to the Improvement Plan was strong enough in terms of staff engagement.

 

The Director of Nursing commented that: the engagement was broader than the 134 members of staff involved in the CQC inspection; there was an annual staff survey, with a response rate of c.40%; a ‘pulse survey’ was being undertaken bimonthly in order to check on progress; and the trust was working with staff networks to encourage feedback.

 

The Director of Strategy and Partnerships commented that: an Improvement Director had been appointed; feedback from staff resonated with the findings of the inspection, and the trust was focused on moving forward in a positive way; the pandemic had limited opportunities for training and skills development but a leadership development programme had now been introduced; communications activity included weekly briefings from the Chief Executive Officer; and other intelligence was being captured, including through links with Healthwatch.

 

11.        In response to questions from a committee member, the Director of Nursing explained the nuances between: the CQC’s specific definition of a ‘closed culture’, i.e. ‘a poor culture that can lead to harm, including human rights breaches such as abuse’, and its guidance which the trust used to check its own services and to identify those potentially at risk; and developing an ‘open culture’, i.e. where staff could speak out and feel listened to, which was being supported by a ‘freedom to speak up’ guardian and the recruitment of 20 champions across the organisation.

 

12.        The Director of Strategy and Partnerships confirmed that the Chief Executive was accountable for the Improvement Plan ultimately, reporting to the quality and safety committee, but other executive officers were responsible for leading on the six improvement workstreams.

 

13.        In response to a question from the Vice-Chairperson, the Director of Strategy and Partnerships said that, although certain matters identified by the inspection might have been anticipated, the scale of some of the issues and the level of concern within the workforce had been unexpected.  Therefore, independent experts had been brought in to support the leadership team with its learning and development journey, this included exploration of how to make more agile and better informed decisions.  The Director of Nursing added that the report made uncomfortable reading but it was considered fair and just.

 

14.        The Deputy Chief Nurse outlined the role of the NHS Herefordshire and Worcestershire Integrated Care Board (ICB) in terms of planning and overseeing the delivery of good quality health services, and supporting providers to enable continuous improvement.  It was noted that the ICB had provided some additional capacity to the trust, and had been involved in the development of the Improvement Plan and related metrics.

 

15.        In response to questions from a committee member, the Director of Nursing advised that: recent CQC inspections had used the same set of regulatory standards, key domains, and lines of enquiry but a new assessment approach was to be introduced; and the trust was working to embed the CQC framework throughout its routine governance structure.

 

Later in the meeting, the Director of Nursing commented that the new rating system would be clearer, informed by a more rounded base of evidence.

 

16.        The Director of Strategy and Partnerships confirmed that non-executive directors were involved in the board effectiveness review, and training was being provided to new non-executive directors.

 

17.        The Associate Director, Primary Care and Community Mental Health Services provided an overview of issues around psychology waiting times in community-based mental health services for adults of working age in Worcestershire, and said that, whilst there were workforce vacancies, the situation was being managed within parameters in Herefordshire.

 

18.        The Director of Nursing acknowledged risks associated with the trust’s estate, confirmed that issues relating to premises and facilities were now being considered in governance meetings, and commented on some of the challenges with service delivery in sparsely populated rural areas. 

 

The Associate Director, Primary Care and Community Mental Health Services outlined plans to enhance accessibility at 27a St Owen Street, Hereford. 

 

19.        The Associate Director, Primary Care and Community Mental Health Services said that a significant issue for the trust’s workforce was the implementation of new parking restrictions in the vicinity of Rose Cottage in Ledbury and Etnam Street in Leominster, and requested the council to consider the potential for greater flexibility.

 

This matter was explored by the committee later in the meeting: a view was expressed that parking schemes involved broader issues for residents, businesses and other stakeholders; and another view was expressed that the specific request made by the trust should be looked at by the executive.

 

20.        The Director of Nursing confirmed that the CQC had spoken with patients and carers, and the inspection team worked alongside an expert by experience.

 

21.        With reference made to safety issues with the Mortimer ward, a committee member expressed concerns about mixed gender wards. 

 

The Director of Nursing commented on some of the challenges of the Herefordshire and Worcestershire footprint and enabling single gender wards without moving people away from their families and communities.

 

It was reported that a quality improvement project for the Mortimer ward had commenced, involving the separation of corridors and staffing, staff training, and the development of sexual safety charters.

 

It was also reported that the ‘Getting It Right First Time’ national programme was informing the redesign of adult inpatient wards.

 

22.        In response a question from the Vice-Chairperson, the Director of Strategy and Partnerships advised that provision for strengthening governance had been made corporately, so did not affect investments in frontline care or in the estates strategy.

 

23.        At the request of the Chairperson, an overview was provided of the links between the trust and Talk Community, both strategically and operationally, and the work being undertaken collectively to deliver the community mental health transformation model, including with the voluntary sector and primary care settings.

 

24.        In response to a question from a committee member, the Director of Nursing commented on the benefits of bank staff, particularly in terms of flexibility where there was an increase in clinical activity in an area, and reported that there was a project underway to examine the potential to reduce spend on agency staff.

 

25.        The Chairperson highlighted the importance of mandatory training being undertaken by staff, albeit the inspection report indicated that completion rates were higher in Herefordshire than in Worcestershire.

 

26.        In response to a question from the Vice-Chairperson, the Director of Nursing reported that a new estates and facilities tracking system had been developed, and items of equipment were being monitored.

 

27.        The Director of Strategy and Partnerships recognised that changing culture involved a longer term journey but noted that leadership development and training had commenced, and was being well attended.  The Director of Nursing added that the CQC expected to see sustained improvement over several years.

 

The Director of Nursing advised that ‘must do’ / basic standard matters identified through the inspection report had been actioned and would be monitored over the next twelve months.

 

28.        The Director of Nursing said that there had been an increase in incident reporting around sexual safety but was reassured that, reflecting clarifications in understanding, staff were identifying and reporting unacceptable behaviour.

 

29.        Responding to a question about the robustness of the data to monitor changes, the Director of Nursing reported that a new suite of metrics was being developed, with other metrics being used to assist in the short term.

 

30.        The Director of Strategy and Partnerships advised that, in addition to the surveys being undertaken, the trust was working with Healthwatch to explore patient and carer experiences.

 

31.        The Cabinet Member Adults, Health and Wellbeing: welcomed the presentation and debate; said that the inspection report highlighted difficult issues but also some positives; did not support mixed gender wards personally but noted the cost implications of other arrangements; noted that concerns about fairness and equality could have an impact on staff recruitment and retention; commented that changing culture in any public organisation was complicated, as it involved changing people’s perceptions; and commended the trust for recognising the problems and for acting upon them.

 

32.        The Director of Nursing clarified that the CQC did not have a set opinion on mixed gender wards, the issues identified in the inspection report related to management within that environment.

 

33.        The Director of Public Health emphasised that ‘Good mental wellbeing throughout life’ was one of the priorities of the Herefordshire Joint Local Health and Wellbeing Strategy 2023-2033 (link to the strategy), there was a positive working relationship with the trust, and good progress was being made with some of the shortcomings identified in the inspection report.

 

At the conclusion of the debate, the Statutory Scrutiny Officer summarised potential recommendations, as identified by committee members during the meeting.  Amendments and additions were discussed.  The following resolution was then agreed by the committee.

 

Resolved:  That

 

1.           Cabinet to consider how it can support NHS staff with parking availability and charges when undertaking locality based working, with specific regard to Rose Cottage, Ledbury and Etnam Street, Leominster;

 

2.           The trust be requested to provide an infographic guide to mental health services across Herefordshire; and

 

3.           The trust to provide the committee with an update on the six work streams of the improvement plan within twelve months.

 

[Note: there was a short adjournment before the next agenda item]