Care Quality Commission Report on hospital inspection published

 The CQC Report on their inspection of the RSCH was published today. It was very good. Staff can be proud to have been found caring, inclusive, open and skilled in what they do. The CQC were in receipt of some adverse comments of course but overwhelmingly patients and the public were complimentary. Maternity and Children’s services were found to be particularly good.

On the down side there was criticism of staffing levels on some wards and some OP services were deemed in need of improvement. The Eye Clinic was the focus of particular criticism and in terms of patient experience (not clinical outcomes) was seen as not fit for purpose. This was no surprise – see my earlier blogs. The hospital does have in hand draft plans to rebuild the Clinic and has been working hard to improve matters but the CQC felt that the pace needed to be accelerated.

Overall a good and reassuring result from the CQC’s new and very intense inspection regime.

 

 

Outsourcing

As reported in the Surrey Advertiser the RSCH has decided to out source a number of functions including housekeeping (cleaners). When the vogue for out sourcing was at its peak some years ago the RSCH, wisely to my mind, decided to keep cleaning in -house and expressed itself proud to have done so. They wished to keep a firm and direct hold of cleanliness.

The hospital has clearly changed its mind and to many it appears to have happened very quickly not least because there was no public, competitive tendering (Governors were not consulted or pre-warned). Hospital staff transferred will have their conditions safeguarded through TUPE but understandably are not happy.We must hope that cleanliness standards are upheld as of course they can be. The checks which governors have just agreed to undertake (see earlier blog) will help to ensure that.

Cleanliness, hygiene and maintenance checks

Cleanliness, hygiene and maintenance are extremely important aspects of any hospital. I used to be a member of the Surrey LINk RSCH Group and over a period of about 6 years I organised checks of these features throughout the hospital . When LINk folded to be replaced by Surrey Healthwatch (yet to get in to its stride) such checks lapsed. However I am pleased to say that the Council of Governors has recently agreed to a proposal from me that these checks should be undertaken by a volunteer group of 8 governors working in pairs.

We intend to cover all parts of the hospital other than the wards (wards are encompassed in a different manner and will also involve governors). Our first check visit (to Nuclear medicine and day Surgery) has taken place and we expect to cover all the ground over a 10 month period. Reports will be sent for action to the hospital's  Patient Quality and Safety Committee and to the appropriate head of department.

Mortality up-date

In my blog of 28 February I reported on mortality statistics (please see for background). At that time RSCH’s performance according to the national index ‘SHMI’ was good (and still is but according to statistics published by Dr Foster performance was poor. The reason suspected was the way the hospital was coding palliative care. This plus events in Mid-Staffordshire caused the hospital to mount a substantial review by examining the notes of all deaths in 2012, recoding where appropriate and resubmitting the data to Dr Foster for reprocessing. The work was checked by a group of GPs to ensure there was no bias.

 The hospital does not use Dr Foster’s services but uses another company CHKS. Recoded data was also sent to them for reprocessing.

 The results confirmed that the main reason for the poor results from Dr Foster was substantial undercoding of palliative care ( the criteria and guidance for palliative coding is open to interpretation and this is widely recognised). The position of RSCH compared with other hospitals changed from being near the bottom to approaching the average. Also the results from CHKS changed from around average to very good. The national index SHMI is unaffected by palliative coding and remains good (5 to 10 percent less deaths than expected).

This review has been followed not only by a focus on better coding but also has led to more formalised monthly reviews of statistics and deaths in all specialties and the formation of a top level Mortality Review Committee. This is all good news and will be reassuring to patients, I continue to keep an eye on mortality data and will be interested to see what the next Dr Foster publication has to say – it is due soon.

Dementia Quality Mark

I am a member of the Trust’s Dementia Steering Group. The hospital is making good progress in meeting the needs of patients with dementia and related conditions. More and more staff at all levels are being trained, patient information leaflets are now available around the hospital as is information on notice boards.  

Wisley and Ewhurst wards have just achieved the stage 1 ‘Quality Mark for care of elderly people’. This is a mark awarded by the College of Psychiatry and involves questionnaire surveys of dementia patients and their families/carers and staff questionnaires. These wards will be seeking the stage 2 mark next year based on even more rigorous criteria. Eashing ward is planning to seek Stage 1 soon.  This is good progress and greatly welcome. I am anxious to see this excellent work extended across all relevant wards.

Care Quality Commission (CQC) new inspection regime

Professor Sir Mike Richards the new chief inspector of hospitals has announced that from now on CQC will be beefing up its inspections – bigger teams (perhaps 20), longer inspections (perhaps a week) and a mix of real health professionals and trained members of the public. All acute hospitals will be inspected by the end of 2015.

The first step will be trial inspections starting soon of 18 hospitals selected to represent different levels of ‘risk’, There will be 6 ‘low’ risk, 6 ‘high’ risk and 6 with a ‘variety of risks between’. The Royal Surrey will be one of them being in the middle category so an inspection in the coming months can be expected.

Results will be published and every hospital will be given a rating of ‘outstanding; good; require improvement; or inadequate’. I can’t say I’m in favour of such a broad single rating – hospitals are far more complex than hotels and my fear is that a good overall rating will hide aspects which are not so good but leave the public believing everything is grand. However we will see – the proof is in the pudding!

 

ITU expansion

If you go round the back of the hospital you will see building works. Here a new £multi-million expansion of ITU is underway. Good news for us all.

PLACE inspection of the hospital

Every year RSCH is obliged by the DoH to conduct a survey of the hospital's environment with results being sent to the DoH for analysis. This year the arrangement changed under the acronym PLACE (Patient Led Assessment of the Care Environment) and had to increase the involvement of patients (at least 50%). Overall results, which will allow the public to see how their hospital performs compared with others, will be published in September.

I was pleased to join the inspection teams to look at cleanliness, décor/maintenance, hygiene, tidiness/clutter and food quality. Overall the inspections covered all the wards and OP Departments, Day Surgery, Short Stay Surgical Unit, Endoscopy, A&E, ICU and EAU - so very comprehensive. As you can imagine results were mixed - some excellent and a few not so good and the latter will now be addressed.

When the national results are published I will put up a blog. Meanwhile if anyone wishes to be involved next year's PLACE let the hospital know.

Shared Interest Forum created

My fellow Governors have agreed to my suggestion that there should be a Shared Interest Forum for understanding the clinical performance of the Trust. I will be the facilitator and I and eleven other governors will comprise the group. Governors tend to concentrate on patient experience which of course is very important. However to my mind the critical issue for patients is how good the clinical care is e.g. clinical outcomes,. The latter is not so clear to patients or the public and when I put myself forward for election that is what I promised to concentrate on.

The Forum will be seeking to understand clinical performance by looking to see what clinical standards the Trust sets for itself, from where those atandards derive and what they mean in terms of ambition. We will work to understand to what extent the Trust meets its own standards and how the Trust compares will others in the locality and more widely e.g. nationally. We have decided to start with clinical performance in avoiding venous throboembolism and pressure damage/pressure sores. I will report from time to time on the results.

Eye Clinic Update

I was recently briefed by the Ophthalmology team on progress with the Eye Clinic improvements. The Clinic Manager computer system is in place but it was agree that the screens could be better placed and another would be warranted. Also what is displayed is not very clear to patients. They will address both these issues.

New staff have now been recruited and the new rooms are in operation. Some extra waiting space has been created. A drinks machine is being installed.

A new system for getting and tracking notes has been implemented with significant improvements albeit I have heard from one patient that it is not perfect.

A 'time and motion' study is underway to identify bottlenecks in patient flow. This will be used to see how to improve the worst aspects of the clinic – extremely variable waiting experience.

By July all improvements which are deemed possible with the current restrictions on space and equipment will have been implemented. A longer term business plan for extensive changes will then be presented to the hospital Board. I have been briefed on its essence and it will, if it comes about, be great for patients.

Finally a weekly one page summary of progress is now being produced and will be handed out to Eye Clinic patients.

I am pleased to say that the team has agreed to include in their deliberations an Eye Clinic patient who I nominated.

So far so good but some way to go which the Board and the Chief Executive both acknowledge.

Maternity Services

20% of all litigation claims in England involve maternity care and these represent 61% by value. Thus the RSCH belongs to the CNST (Clinical Negligence Scheme for Trusts). This scheme routinely assesses maternity units to ensure they comply with best practice thereby ensuring patients are safe and the likelihood of claims is low.  There are 4 levels of achievement: zero, 1, 2 and 3. Levels 2 and 3 are the highest and involve a gruelling assessment every 3 years. RSCH's maternity unit has just been assessed and has achieved the highest Level 3. This is not only excellent for mothers and babies but also means that the hospital receives the maximum insurance premium discount.

Part of the assessment checks that the midwife to mother/birth ratio is appropriate.

The Royal College of Midwives  and the Royal College of Obstetrics and Gynaecology both recommend a ratio 1:28. However they also recommend that hospitals should determine the ratio appropriate for them by using the Birthrate Plus toolkit into which data about type and volume of work and case mix etc. are fed with the output being the recommended ratio for safe and effective care.

The CNST assessment expects the ratio to be as determined by Birthrate Plus. If it is not then there has to be a plan in place to achieve it otherwise Level 3 would not be awarded.

I have made Freedom of Information requests to the major hospitals in Surrey to ascertain what there midwife to mother/births ratios are/have been over the last 12 months and their plans in the context of the RCM and RCOG recommended 1:28 or Birthrate Plus appropriate levels.

RSCH has been between 1:34 and 1:41 during 2012 against a Birthrate Plus appropriate level of 1:30. The Trust recognises that this is not satisfactory. A Business case for improvement has been accepted and the appropriate ratio of 1:30 will be achieved by 2014 – recruitment is underway.

For Frimley Park the Birthrate Plus appropriate level is 1:31. Through 2012 the level has been in excess of this: the Chief Executive has decided on a level of 1:33. There is a plan to work to 1:31 by 2015.

At Ashford and St Peters the ratio as of March13 was 1:31. They seek to reduce this to "national requirements" over the next 3 years.

St Heliers state that over the last 12 months they have always complied with the RCM's recommended ratio of 1:28.

Car Parking

Very regretfully the RSCH will increase car park charges from 1 April and payment will now be by the hour instead of in 2 hour slots. The hospital claims that charges are in line with other major hospitals. On the brighter side the cost for parking for 6 to 24 hours has been reduced and there are no changes in the cost of weekly tickets or for the Oncology patients' car park. Blue badge holders will continue to have free parking in designated disabled bays. Why blue badge holders cannot have free parking in any bay is a mystery to me.

If there is an upside it is that the increased revenue will assist the hospital to move to a better parking system and get rid of the present hated way of paying up front and topping up. It is hoped in due course to return to pay on exit e.g. by automatic number plate recognition, as well as providing the opportunity for card payments. Strategically a multi-story car park is recognised as the answer.

Finally there will be more public parking spaces. 32 staff parking spaces are being converted to public spaces – good for the public, bad for staff!!

Dementia

I reported in an earlier blog that RSCH was becoming very active in providing care specific to patients woith dementia. That work is continuing well. I have now joined the Trust's Dementia Steering Group and have attended my first meeting. The Group is impressive and includeds representatives of the University which is active in research in this area, the County Council and the Alzheimers Society.

The hospital has just been subject to a National Dementia Audit  which includes an organisational checklist and an audit of the case notes of 40 patients. Overall performance was good. Of the 47 questions which relate to the most serious matters, the hospital needed to improve on 4. Of the 94 questions  on standards which RSCH should be expected to meet in normal practice, 12 needed improvement and of the 11 questions which RSCH should meet to achieve excellent practice there was just one where improvement was required. Action is in place to achieve improvement wherever that was deemed necessary.

Proposed staff reductions

I have been asked a variety of questions following reports in the media of proposed staff reductions in the Royal Surrey so this is what I know. As in all Trusts financial pressures are great putting pressure on the hospital to make savings. The following is what is proposed and is now subject to consultation with unions.

Ø All vacancies are being reviewed and cannot be filled without permission of senior management

Ø Strenuous efforts are to be made to reduce the use of agency nurses

Ø Loss of one specialist palliative nurse

Ø Loss of one specialist gynaecological nurse

Ø Loss of one care assistant on each ward

Ø Some sharing of medical secretaries

Ø Some loss of non-frontline staff

There will be no loss of consultants or other medical staff.

Governors have been assured that all this has been formally risk assessed to ensure that there is no danger to patients.

Naturally I and other governors do not welcome loss of staff particularly frontline staff such as nurses. Of course we will watch out for any significant deterioration of quality of care and should we have concerns will make our views clear. However it has to be recognised that is exceedingly difficult to associate any deficiency to a staff reduction with any degree of certainty not least because we all know that care staff will as always up their effort to ensure patients continue to be well cared for. I am particularly sad to see the loss of a specialist palliative nurse and the impact it will inevitably have on those who are experiencing the ultimate in suffering.

Mortality statistics

When I sought election I said I would concentrate on looking at information about clinical outcomes in areas which are life threatening or life changing. One of those areas is mortality statistics. I have spent the last 5 months collecting data on hospitals in the S.E. and getting to grips with the intricacies of the various mortality indices which hospitals use. There are five: one national from the NHS Information Centre (NHSIC) which everybody uses, two from the company Dr Foster  and two from the company CHKS. RSCH uses the CHKS's.

The first thing to say is that having five different indices is a mess. One of the indices from CHKS is terrible (NHSIC agrees) and its meaning is widely misunderstood including within RSCH. I am pleased that RSCH has agreed not to rely solely on this indicator. One of the recommendation from the recent Francis Report on Staffordshire Hospital recognises that it's all a mess and calls for an in-depth review. I intend to do what I can to encourage that review (I will report on that another time).

Pleasingly RSCH is in the top 15% judged by the national NHSIC index (an excellent indicator). Its value indicates that for RSCH deaths are about 10% lower than would be expected. However this index looks at deaths in hospital plus deaths outside within 30 days of discharge. It needs therefore to be used in conjunction with an index or indices which deal solely with deaths occurring within the hospital. For that purpose RSCH uses the two indices from CHKS.

I have examined RSCH's monthly Performance Reports for 2012 to see how it reports on mortality and have looked also at Dr Fosters indices for RSCH and various national data. Just before I was due to discuss what I found with hospital staff:

Ø Dr Foster published its 2012 statistics on mortality;

Ø The Francis Report was published throwing a spotlight on how hospitals handled their mortality statistics (it was Dr Foster's statistics which threw Staffordshire Hospital in to the limelight).

These events have caused a flurry of media interest with the Department of Health announcing an investigation of mortality in a number of hospitals where Dr Foster and NHSIC indices look particularly bad. RSCH is not one of them but, like all hospitals, it has been stimulated to look closely at its figures.

Even though its performance judged by the NHSIC index is very good, its performance judged by the recent Dr Foster publication is not. The hospital is determined to discover why. One of the likely reasons is technical in that, where a patient is receiving palliative

care and thus likely to die, the hospital is failing to capture that fact in its coding of the patient's care episode. Indeed in national statistics RSCH appears to have far fewer deaths coded palliative than the great majority of other hospitals. The affect of this deficiency in coding is to make the mortality index worse than it would be if coding was better.

I have met with the Medical Director and the Chairman of the Board and discussed the reporting on mortality in Performance Reports, NHSIC and Dr Foster's figures and the matter of coding of palliative cases. The meetings have been extremely constructive and results will be fed in to the major review of coding and mortality which the hospital is undertaking in the light of the Dr Foster data and backlash of the Francis Report. Nothing to date leads me to believe that quality of care is poor.  I am being kept in the loop. RSCH will not be the only hospital taking a good look at how it deals with its mortality statistics and that can only be good for patients.

I have also been looking at cancer survival rates – more later.

Eye clinic

One of my main preoccupations over the last month or two has been the Eye Clinic. I was aware of complaints about excessive waiting and the poor cramped waiting area. So I met with the lead clinician and sat in the clinic on two occasions to see what was going on. Whilst there I spoke with 30 patients and it was very apparent that all is far from well. Waiting is excessively variable even for the same sequence of events and can be from 1 hour to 5 hours. No information is given to patients and often there are so many people in the clinic there are no spare seats. Four of the patients had bad experiences with missing notes.

I have written a report and had a very constructive meeting with the Chief Executive and his senior staff. I also copied the report to the other governors who are now also seeking a resolution of the problems.

In essence the hospital recognises the problems and is determined to do something about them including

Ø Making more waiting space for the clinic;

Ø Implementing the computerised Clinic Manager as in other OP clinics which will provide overhead screens with information on clinic progress of patients;

Ø Reviewing the question of missing notes;

Ø Employing more clinical staff.

Already a new member of staff has been appointed to improve the flow of patients through the clinic and I hear she has had a very favourable impact.

The hospital is documenting a timetabled plan which it will soon share with me and the governors. They have also indicated they will produce a note on all of this so that patients can know what is going on.

So far so good but realising this all will take a bit of time.

Just before Christmas I joined some other governors to judge the Christmas decorations. Every ward was decorated and I was much taken by the effort many staff had put into making all sorts of hanging and standing figures and Christmas themed scenarios - most made in their own time at home and at their own expense. There was a real Xmas spirit.