Agenda item

The Committee considered a report from the Leicestershire Partnership NHS Trust (LPT) and a report from the Care Quality Commission (CQC), both of which set out the current issues and challenges affecting LPT with specific reference to the CQC visit to the Bradgate Mental Health Unit in July 2013.  A copy of the reports, marked ‘Agenda Item 7a’ and ‘Agenda Item 7b’ is filed with these minutes.

 

The Committee also considered a supplementary report from LPT which described the psychology input for the Bradgate Unit, a copy of which is filed with these minutes.

 

Healthwatch had submitted written comments on this item, a copy of which is filed with these minutes.

 

The Chairman welcomed the following NHS representatives to the meeting:-

 

Sue Noyes, Acting Chief Executive, LPT

Satheesh Kumar, Medical Director, LPT

Cathy Ellis, Deputy Chair, LPT

Toby Sanders, Managing Director, West Leicestershire Clinical Commissioning Group (CCG)

Dr Graham Johnson, East Leicestershire and Rutland CCG

Tim Sacks, Chief Operating Officer, East Leicestershire and Rutland CCG

 

The Acting Chief Executive of LPT reported that CQC had made a follow up visit to the Bradgate Unit on Monday 9 September.  At that visit, CQC had seen some improvements but had requested more information and indicated that a further visit was needed before they could reach a robust judgement on whether LPT had met the requirements of the warning notices issued in July.

 

The Acting Chief Executive also reported that an inpatient at the Bradgate Unit had committed suicide during August.  An independent review into the suicide had been commissioned by LPT.

 

The Managing Director of West Leicestershire CCG reported that the CCGs had been aware of the challenges facing LPT.  However, the CQC inspection had highlighted issues where changes which the CCGs thought had been implemented had not been done with consistency.  This had led to a different approach to performance management of LPT.

 

The role of the CCGs during August had been to move the regulation of LPT by the Trust Development Authority, CQC, CCGs and NHS England Area Team into a single process so that there was clarity and consistency on outstanding issues and LPT were not overburdened with inspection.  This work had achieved a measure of success.  The proposal for a single quality improvement programme for LPT had been submitted to the regional Quality Surveillance Group on 19^th August, this had been followed up by a risk summit on 29^th August and a further meeting, including Healthwatch and Adult Social Care, to agree terms of reference or a Quality Improvement Assessment Group which would meet fortnightly and support LPT, assess and oversee implementation of the changes and hold LPT to account for delivery.

 

Arising from discussion the following points were raised:-

 

(i)      The open and transparent approach taken by LPT and its commissioners was welcomed.  However, the Committee shared the concerns of Healthwatch that the new plan would not deliver the required improvements in care and security and sought assurance from LPT on this matter.  The Committee was advised that the approach taken to respond to CQCs concerns was different from previous action plans because LPT was focussed on what success should look like and whether patients were seeing a difference.  The improvement plan was linked to the new CQC inspection regime as it was felt that this would help to deliver high quality care.

 

(ii)     The Committee was advised that changes at the Bradgate Unit were focussed on how staff worked and related to each other.  Nursing leadership had been improved by the appointment of two senior matrons, whose role included inspecting patient notes and inputting into the daily ward reviews and weekly in-depth reviews.  The importance of the weekly review had been lost over the last two years.  It had now returned to being a review of each patient’s care plan and discharge plan with multi-disciplinary input.  A structured template for information from nurses and junior doctors to be fed into the daily ward review had also been developed.

 

(iii)    LPT acknowledged that safe staffing numbers had not been adhered to.  This was now being addressed through the recruitment of 24 nurses and the daily monitoring of staffing levels and quality of care.  The Committee welcomed this change but remained concerned that it had not been addressed previously.

 

(iv)    The Committee was pleased to note that clinical supervision on the wards was being improved as this was an effective way to support staff development.  The involvement of senior clinicians in observing ward rounds and providing feedback was also felt to be a positive change.  In addition, LPT was now trying to learn from examples of good practice through four weekly meetings where staff from several wards would discuss issues and share practice examples.  It was recognised by LPT that the organisation had previously been too inward looking so it was also now working more with partners.

 

(v)     Members queried how LPT would know if the actions being implemented were having an effect at ward level.  LPT advised that performance would be evaluated through ward rounds, clinical supervision and audits carried out by the senior matrons.  Members expressed concern that these measures might not necessarily result in an improved understanding and management of risk.  With regard to this particular issue, LPT was now linking findings from risk assessments to meaningful actions and ensuring that they were captured in the care plan.  Training on risk management would also be provided to staff and it would be one of the areas of focus during clinical supervision.

 

(vi)    The Committee was assured that the use of agency and bank staff did not mean that LPT was in financial difficulty.  Bank staff had generally been working for LPT for a long time and were suitably qualified.  It was recognised that the use of agency staff involved more risk, hence the daily monitoring of staff levels.  LPT had also invested in staff and improved the ratio of qualified to unqualified staff from 40:60 to 60:40.

 

(vii)   Members emphasised the importance of having well written, good quality, procedural documents.  LPT confirmed that these documents were being reviewed to ensure they were sufficiently robust.  The personal accountability of staff in terms of understanding processes and following them correctly was also being emphasised.  Staff had been allowed one month in which to clarify their understanding of the operation of procedures.

 

(viii)  Serious concern was expressed that patients did not have sufficient one to one support from staff during the day.  Although therapeutic liaison workers were on the wards during daytime and nurses undertook one to one sessions with patients, this was not felt to provide the required quality of care.  Members were extremely concerned to hear that, although LPT felt it meet the staffing level for safe care, it did not have enough staff to provide quality care for inpatients.

 

(ix)    The range of psychological therapies available for patients was of particular concern to members.  The current service was not felt to be satisfactory; the psychology sessions on the ward and input from the personality disorder team were to support staff rather than patients and, despite NICE guidance to the contrary, Cognitive Behavioural Therapy for psychosis for each patient had never been commissioned for LPT.

 

(x)     The CCGs were considering a wide range of issues across LPT services, not just those relating to services at the Bradgate Unit and therefore had to ensure that each part of inpatient, crisis resolution and community mental health services were commissioned equitably.  The CQC inspection was being treated as an opportunity to ensure that the response came from the whole system.  For example, a forum for clinicians and GPs had been created by the new Medical Director prior to the CQC inspection to talk through problems across mental health services.

 

(xi)    It was acknowledged that LPT had not been satisfied with security at the Bradgate Unit.  Accordingly, a receptionist had been appointed to be on duty at weekends.

 

(xii)   ‘Near misses’ including incidents of self harm, absconding and medication errors and omissions were electronically recorded and investigated locally.  Serious incidents were investigated at Trust level.  Implementation of action plans relating to serious incidents had been a weakness at LPT; systems were now in place to identify and investigate trends and learn from them.

 

(xiii)  Leadership of the improvement plan would come from the Trust Board.  The Board had confidence in the Executive Team and would be looking for systematic delivery of actions across the organisation.  Wards would report to the Trust Board and Board members were carrying out regular ward visits.

 

The Chairman then invited Geoffrey Smith OBE to make comments on behalf of Healthwatch.  Healthwatch was encouraged that LPT was now committed to listening to the concerns of patients and would continue to support LPT through its role as consumer champion.

 

RESOLVED:

 

(a)     That the comments and concerns now raised be submitted to CQC and LPT for consideration;

 

(b)     That an update on progress with improving the quality and safety of patient care at the Bradgate Unit be submitted to the Committee in three months’ time.