Agenda item

The Health & Social Care Sub-Committee is asked to review the draft Quality Account for 2022/23, and to provide any feedback they feel would be valuable to the Croydon Health Services NHS Trust.

The Sub-Committee considered a report on pages 3 to 110 of the agenda which set out a draft version of the 2022-23 Quality Account for Croydon Health Service NHS Trust (CHS). A draft of the Quality Account had been provided for the comment of the Sub-Committee, which would be taken into consideration by CHS in preparing the final version of the document.

The Chief Executive of the Croydon Health Service NHS Trust (CHS) and Croydon’s place based leader for health, Matthew Kershaw attended the meeting for this item, to provide an introduction and answer questions arising.

During the introduction of the Quality Account, it was highlighted that the report had been structured into two parts, one reviewing the performance of CHS against the organisational priorities set the previous year and the other looking forward, by setting out the priorities for the year ahead.  It was advised that of the twenty priorities set for 2022-23, positive progress had been made in most areas and thanks was given to CHS staff for all their work.

There were a few areas where further improvement was needed, including the following: -

•              Although there had been improvement in the friends and family test response, the target had not been achieved. A new system had recently been installed which should make achieving the target easier in the forthcoming year.

•              The target to review 95% of risks within the required timeframe had also not been achieved, with 82% of risks overdue for review at the end of April 2023. However, the implementation of Radar, a new risk management system, would quicken the pace of improvement and help to ensure the target was achieved going forward. 

•              The target to ensure that 95% of all clinical and non-clinical policies were up to date and available online had not been met.  CHS were working to address this and in the short-term prioritising updating any policy that was no longer applicable. 

•              The target to reduce healthcare acquired infections had not been met. CHS had performed well on minimising Covid infections but post the pandemic there had been an increase of MRSA and C-Difficile infections above the targeted rate. These increases mirrored the performance across the health service nationally and CHS had put measures in place to reduce the rate of infection back below the targeted rate.

The six priorities for 2023-24, had been identified through the use of data. The priority areas were improving capacity assessments for all patients, improving the performance of public health nursing, improving timely access to critical medications, baseline ward accreditation assessments for all adult inpatient wards, improving patient experience of their environment across Trust services and ensuring the Trust had effective systems in place to maintain up to data risk registers.

Following the introduction, the Sub-Committee was provided the opportunity to ask questions and comment upon the information provided within the Quality Account report. The first comment highlighted that the report mentioned Croydon being the youngest borough in London but did not acknowledge it also had the ninth highest number of people aged over 60 as well. It was agreed that this would be picked up and reflected in the report. It was suggested that it may be helpful include graphs or diagrammatical indicators within the Quality Account to better help demonstrate performance.

Further information was sought on the barrier to achieving the priorities set out in the report and the lessons learnt through the process over the past year. It was advised that the barriers would be different for each priority. For instance, the volume of healthcare acquired infections had historically been reduced each year. The number of c-difficile infections had previously remained below the target of 20 infections annually year on year, but this year had increased to 36. The high volume of patients within the system made it increasingly challenging to maintain the flow through the system and infection control. There was also a view within the infection control community that there were new variants of c-difficile that were more easily transmitted. CHS continued to improve processes and practices to minimise the risk of infection within the hospital, but research on variants was beyond the control of CHS.

The importance of the workforce upon the delivery of services was highlighted, with it questioned whether workforce issues had impacted upon the performance of CHS. It was advised that staff had been required to work through a tough set of issues including going through the pandemic, ongoing industrial action, and a high level of vacancies. Targeted work had reduced the number of vacancies in the nursing workforce, with CHS having a lower level of vacancies than had in recent years. Both the health and wellbeing, and the support of and engagement with staff would continue to remain a top priority.

It was confirmed that CHS had undertaken local, national, and international recruitment campaigns for staff, with a fantastic lead in place helping to support staff from overseas to acclimatise. This had helped the Trust to reduce the use of agency staff and lowered vacancy rates. The recruitment of physio and occupational therapists remained a challenge, with avenues such as apprenticeships being explored.  

There was an ongoing programme of work targeted at improving staff culture and delivering cultural change. The delivery of this programme had been brought back in-house which was providing added value. The next stage of the process was due to be launched on 17 May 2023 with senior clinicians and managers looking at how the Trust could ensure staff felt supported and engaged. It was important to ensure that engagement with staff was used to improve service delivery on areas such as patient pathways. 

Regarding the priority on delivering the national patient safety strategy, it was acknowledged that the work on this had not been fully completed. Level one training was available and being accessed by staff, which demonstrated that progress was being made. The level two training would be implemented as quickly as possible, but this had been delayed by the readiness of partners involved in delivery.

Regarding priority 5 on clinical assessments, it was advised that this related to the prevention of blood clots and testing patients who were not very mobile. It was advised that this priority had been rated as green in the RAG rating provided in the Quality Account as the assessments were taking place, although it could sometimes be a challenge to provide documented evidence that all assessments had been delivered. There would be further work in the forthcoming year to continue improving the level of documentation.

It was confirmed that priority 6 aimed at improving patient discharge times had been met. It was also clarified that all the priority areas for 2022-23 would continue to be monitored going forward, but this would be as part of ‘business as usual’ rather than as specific priorities.

CHS was congratulated on its maternity services achieving a good rating by the Care Quality Commission (CQC). The hospital was one of only two maternity units in London that achieved a good rating on the safe care and well led aspects in the CQC inspection. CHS had a new Director of Midwifery in place who was leading the ongoing improvement work and had connected well with both staff and patients. It was important for CHS not to become complacent on the performance of the service, as the provision of midwifery was a tough challenge across the country, requiring a continued focussed.

In response to a question about the stroke facilities in the borough, it was advised that these had been reorganised several years ago, with St George’s University Hospital in Tooting becoming the local unit for specialised stroke care. Clinical evidence indicated that having specialised urgent care services for stroke patients located in one hospital improved patient outcomes. The stroke facilities available in Croydon provided rehabilitative support for patients in their recovery post-stroke, once they no longer required the urgent care provided by St Georges.

Given the priority for hospital acquired infection had not been achieved, it was questioned whether this should be a worry for residents. It was acknowledged that the risk of infection was a significant concern for patients, but the historic performance of CHS in this area was good and the hospital had good infection control processes. It was hoped that there would a reduction in the number of infections in the forthcoming year.

It was highlighted that there was a national issue within maternity services, with BME patients facing worse outcomes. As such it was questioned whether CHS could provide data on the performance at Croydon University Hospital. It was confirmed that this was a core issue in Croydon due to the diverse population with the Health Equity and Racial Disparity in Maternity (HEARD) campaign targeting improvement in this area. It was confirmed that metrics from the HEARD campaign and the core maternity service could be shared with the Sub-Committee. It was suggested that this may be an area of scrutiny to schedule in the forthcoming year. 

It was confirmed that although maternity services were not included as one of the six priorities identified for 2023-24, priority 4 - Baseline ward accreditation assessments for all adult inpatient wards, would include maternity wards. It was advised that improving business as usual services, such as maternity service, remained a high priority, even if not explicitly included as a priority in the Quality Account report.

It was clarified that a treatment escalation plan referred to under priority 5 for 2022-23, was aimed at ensuring patients had a plan of care in place to cover the potential need for advanced care, should escalation be required. Approximately 10% of patients would need an escalation plan.

A question asked about the support provided for staff as a result of the Mental Health Units (Use of Force) Act 2018. It was advised that there had been a lot of effort invested in training and support to best equip staff to help patients with mental health need. This included specific training for areas of high need such as the Accident & Emergency (A&E) services and wider general training for all staff. Trained mental health staff were based in A&E and CHS worked with the South London and Maudsley NHS Foundation Trust (SLaM) team to provide support along with mental health liaison staff. It was highlighted that it was a continual process to ensure staff had the experience and skills needed to support patients with mental health needs and there were longer term workstreams aimed at improving pathways for mental health patients.

Regarding patient complaints, it was acknowledged that there had been a slower level of response following the pandemic, which had created a backlog that was being addressed.  In the past two to three months CHS had brought in additional capacity to help respond to complaints, which was getting on top of the backlog, with responses sent to most of the outstanding complaints from 2022.

Regarding Priority 1 for 2023-24 related to improving capacity assessments for patients, it was questioned at what stage a capacity assessment would be needed. It was advised that the Mental Capacity Act was well established and an important part of the assessment process. Part of the standard process was to seek assurance that a patient had the mental capacity to be involved in decision making on their treatment. If it is determined that an individual does not have capacity, then CHS would look to engage with family members or friends where possible. Capacity assessments would be undertaken for most patients, but there will be occasions, such as in an emergency, when the documentation process needed to be improved. It was highlighted that the process to determine capacity was complex and needed to be routinely reviewed as an individual’s capacity could change depending on their condition.

It was agreed that health visiting was an important issue and although some progress had been made, it remained a massive challenge. New birth visits had been prioritised for improvement as these were a crucial point of assessment for the early identification of potential issues. It had been included in the Quality Account to ensure there was a greater level of focus on the Trust’s performance in this area. It was suggested that it may be helpful to share the work plan for the service with the Children & Young People Sub-Committee.

Regarding priority 5 focussed on improving the patient experience of their environment across Trust services, further clarity was provided on the target measure. Although the target was to set up a group to oversee the work on the patient environmental experience, setting up the group would not be the determination of success, instead it would be on the improvements to the patient experience delivered by the group. It was suggested that further text could be added to the target to provide this clarity.

At the conclusion of the item, the Chair thanked the officers and Members in attendance for their engagement with the questions and comments of the Sub-Committee.

Conclusions

Following the Sub-Committee’s discussion of this item, the following conclusions were reached: -

1.            The Sub-Committee welcomed the opportunity to review the draft Quality Account 2022-23 for Croydon Health Service NHS Trust and had been satisfied with the responses provided to their questions on the content.

2.            The Sub-Committee agreed that the six priorities identified for 2023-24 were reasonable, outlined the measures of success and in areas, such as health visiting, were strongly welcomed.

3.            Although the Sub-Committee raised a number of areas where it felt additional clarity would be beneficial, it was acknowledged that the Quality Account 2022-23 was a largely positive indicator of the performance of the Trust against a challenging environment for healthcare services nationally.