This report provides the Health, Care and Wellbeing Scrutiny Committee with the background and findings of the Care Quality Commission’s (CQC) inspection of Wye Valley NHS Trust: The County Hospital.

The committee considered a report on the background and findings of the Care Quality Commission’s (CQC) inspection of Wye Valley NHS Trust (WVT), The County Hospital: Link to the inspection report.

 

The slide pack was published as part of agenda: Link to the presentation 'Care Quality Commission Inspection: Emergency Department'.  The slides presented by WVT representatives are outlined below (in italics), with summaries of the responses provided to the key lines of questioning by the committee.

 

A       The Managing Director (WVT) introduced the presentation and welcomed the opportunity to update the committee on progress since the publication of the inspection report.  The committee was advised that: emergency demand had increased nationally since the Covid pandemic; the principal issue for the County Hospital was congestion in the Emergency Department (ED), this being the result of increased demand, discharge delay, and prioritisation given to offloading ambulances; and recent data (29 July 2024) showed the ED as being in the top quartile of performance nationally on ‘time to treatment’, and mortality indices were below the national average.

 

B       The Chief Transformation and Delivery Officer (WVT) presented:

 

Emergency Department: Overview

 

b.1     Clarifications were provided about attendance types and conveyances.

 

Emergency Department: Care Groups

 

b.2     Questions were asked about the inconsistent use of colours in the graphs.

 

b.3     It was noted that the slide pack had been updated following the postponement of the 28 May 2024 meeting, Link to the original presentation.

 

Minors by Herefordshire PCN (Primary Care Network)

 

b.4     It was considered unlikely that the ambulance service would dispatch a crew to attend a minor injury or illness; a ‘hear and treat’ approach triaged and directed callers to self-care, pharmacy or other services.  Examples were provided of scenarios where crews would respond but which might not result in conveyances to hospital, by providing care on-scene or through the deployment of different health resources.

 

b.5     The committee was advised that people with complex needs were driving the pressures in the ED, rather than those with minor injuries and illnesses; over 90% of minors were treated and discharged within four hours.

 

Emergency Department: Acuity

 

Emergency Department: Performance

 

Discharge Delays

 

b.6     It was reported that: a dashboard was being developed to combine health and social care data; there were significant discharge problems relating to Powys; and the Community Wellbeing Directorate was working jointly with WVT to reduce pressures in Herefordshire.

 

Acute Bed Occupancy

 

C       Chief Nursing Officer (WVT) presented:

 

Care Quality Commission

 

c.1    An overview was provided of the roles and background of the inspection team and their advisors.

 

CQC findings requiring urgent attention

 

c.2     The Chairperson outlined a personal experience involving triage at reception.  The Chief Nursing Officer explained that, given congestion and the findings of the inspection, the ED had returned to nurse led triage and risk assessment.

 

CQC safety summit – Friday 8^th December

 

ED Dashboard

 

c.3     It was reported that the dashboard provided the nurse in charge with a ‘helicopter view’ of the whole department to help manage risks and safety; the information system behind it contained additional details about patients.

 

c.4     The Chairperson suggested that visual indicators to highlight tests undertaken or pending could help to speed up patient flow in the ‘pitstop’ area.

 

CQC ratings – Emergency Department

 

c.5     The Managing Director explained that WVT had known that the ED was in difficulty and had been working hard to address congestion, but the situation had deteriorated between October and December 2023.  The committee was advised that the CQC findings were considered fair.

 

c.6     It was reported that: recruitment of nursing staff into the ED was generally good but it was acknowledged that the skill mix was more junior than it used to be; and a business case was being developed to increase the number of accident and emergency consultants from five to ten.

 

CQC report – what we did well

 

CQC report – what we need to improve

 

c.7     It was considered notable that only four actions ‘the service must take to improve’ had been identified in the final report, reflecting the progress that had been made between the initial dates of inspection (5 December to 7 December 2023) and the re-visit (20 December 2023).

 

Where are we now

 

c.8     The Managing Director said that the inspection report had added value to the organisation, as it provided the opportunity to pause and reflect on the redesign work being undertaken.  It was emphasised that WVT had a programme of review and audit of all its services.

 

D       The Chief Transformation and Delivery Officer presented:

 

Wider Strategy

 

d.1     Further details were provided about the Community Integrated Response Hub, including referral pathways and how local health and care services were working collaboratively to coordinate urgent and longer-term support for people at home.

 

d.2     It was confirmed that community nursing continued to play a significant role in a range of treatments to avoid unnecessary admissions to hospital.

 

d.3     The Managing Director commented on resourcing issues, particularly given the challenges of rural sparsity, and how this reinforced the need to work in partnership to achieve best value.  It was noted that further investment was needed in preventative and community care in order to reduce demand on emergency departments but this would require new funding and it would take time. 

 

d.4     With reference made to the Herefordshire Joint Local Health and Wellbeing Strategy 2023 – 2033, including the two core priorities ‘best start in life for children’ and ‘good mental wellbeing throughout life’, it was noted that an underpinning objective was to provide people with the right care, at the right place, at the right time: Link to the Herefordshire Joint Local Health and Wellbeing Strategy 2023 - 2033.  It was also noted that national policies and priorities would also drive how resources were received and allocated.

 

The principal points of the subsequent discussion included:

 

i.             Comments were made about the potential of partnership working on prevention programmes to reduce pressures in the ED.

 

ii.            In response to a comment about challenges in primary care, it was reported that Herefordshire general practice was in the top quartile nationally in terms of patient experience and access to appointments.

 

iii.          Committee members expressed opinions about the need to consider the reinstatement of minor injury units (MIUs) in the county.  The Managing Director advised that a review of minor injury units was underway across the NHS Herefordshire and Worcestershire Integrated Care System footprint but there had been no change in minors’ activity at the hospital following the closure of the MIUs.

 

iv.          A committee member noted that the original presentation for the May meeting showed minors’ activity over a longer time frame (April 2015 to April 2024) than the updated presentation (April 2019 to June 2024), and this showed higher levels of activity prior to the Covid pandemic, particularly during the summer months.  It was commented that the MIUs were missed by local people, and some travelled to MIUs in neighbouring counties.  It was suggested that the reinstatement of MIUs should be revisited, especially in view of the congestion issues in the ED.

 

v.           In response to a question about a hypothetical further inspection, the Chief Nursing Officer said that audits provided assurance that significant improvements had been made and were being sustained; it was reported that a ‘deep dive’ would be undertaken at a Quality Committee in August 2024.

 

vi.          The Chairperson noted that the government was reviewing the effectiveness of health and social care regulation, with a report expected in autumn 2024.

 

vii.         The Vice-Chairperson welcomed the fact that, despite the apparent problems, the ED had never closed.

 

viii.       With attention drawn to Appendix 3 ‘Overview of integrated working between Adult Social Care and Wye Valley NHS Trust’, comments were made about the strength of partnership working within the Herefordshire system by the Corporate Director Community Wellbeing and by the Cabinet Member Adults, Health and Wellbeing.

 

ix.          The Corporate Director Community Wellbeing said that work was ongoing with Powys in terms of discharge issues, but consideration could be given to raising matters through the Marches Forward Partnership.

 

x.           In response to questions, the Chief Nursing Officer: clarified the arrangements for nurses to undertake mandatory training; confirmed that a revised way of monitoring the cleanliness within departments had been introduced; commented on the need to communicate outcomes to staff members who reported incidents; provided an overview of internal governance processes to review risks; and outlined the enhancements being made to the food and drink offer.

 

There was a short adjournment to enable committee members to consider potential recommendations.  The meeting recommenced, the draft recommendations were read out by the Statutory Scrutiny Officer, and the following resolution was agreed by the committee.

 

Resolved:

 

1.           That the Wye Valley NHS Trust report back to the Health, Care and Wellbeing Scrutiny Committee on the outcomes of its work to review service performance to ensure patient safety and outcomes;

 

2.           That the Wye Valley NHS Trust consider the reintroduction of the Minor Injury Units to the market town community hospitals to alleviate the workload that is currently being experienced in the only emergency department in Herefordshire; and

 

3.           That the committee receive a briefing on the Integrated Care Board work to review Minor Injuries Units within the board and to report their findings to a future meeting of the Health, Care and Wellbeing Scrutiny Committee.