Agenda and minutes

Councillor Michael Edwards  -  personal reasons

Councillor Maria Joannou  -  on leave

Councillor Sajid Mohammed  -  unwell

Councillor Matt Shannon  -  personal reasons

None

Minutes of the meeting held on 19 December 2024, for confirmation

The Committee confirmed the Minutes of the meeting held on 19 December 2024 as a correct record and they were signed by the Chair.

Report of the Statutory Scrutiny Officer

Jan Sensier, Executive Director for Partnerships and Strategy, Diane Hull, Chief Nurse, and Anna Hiley, Deputy Medical Director at the Nottinghamshire Healthcare NHS Foundation Trust (NHT); and Rosa Waddingham, Chief Nurse at the NHS Nottingham and Nottinghamshire Integrated Care Board (ICB), presented a report on the work being done to ensure the safety of mental health in-patients as part of delivering NHT’s wider Integrated Improvement Plan. The following points were raised:

a)  In October 2023, NHT received two ‘inadequate’ ratings from the Care Quality Commission (CQC) in relation to Adult and Older Adult In-Patient Services, which set out clear areas where improvement was needed. A comprehensive programme of work has since been developed to tackle the issues highlighted by the CQC, in the context of the following ‘Section 48’ report and the current financial pressures that NHT is facing. Although there is still work to be done, activity is ongoing and improvements have been made, and NHT is committed to developing this further.

b)  The Patient Safety Response Framework has been fully implemented and has helped to develop a more robust approach to learning with better thematic oversight, allowing for a more proactive approach across NHT. Regular ‘safety huddles’ have been introduced, enabling staff and patients to communicate quickly and efficiently to ensure a good understanding of safety issues at any given time on wards. Many of these ‘huddles’ are led by patients, giving staff a better understanding of the safety issues. More consideration is being given to ward design in terms of balancing the need for privacy, dignity and patient safety, and initial feedback as has been generally positive. NHT is also part of the Culture of Caring Programme, which is a national initiative to improve the experience of in-patient care. The initial improvement work has begun and dedicated staff are in position to support it.

c)  Improvements have also been made around the physical health of in-patients, with the appointment of an Associate Director for Physical Health and dedicated consultant leads for falls and nutrition in the Older Adults teams. Another senior appointment is an Associate Director for Co-Production, with a focus on increasing engagement with patients, carers and communities. There are leads for carer support, carer listening events and community meetings being developed and implemented to ensure that improvement around patient safety involves carers, while a Carers Strategy is being developed. Following a review of staffing, additional roles have been created within each care group consisting of a Care Group Director, a Director of Nursing and an Associate Medical Director, a total of five additional Care Group Nurse Directors and an Associate Director of Nursing for Inpatient Services. NHT is committed to ensuring the right clinical leadership team is in place moving forward.

d)  A Quality Improvement Programme has been established around observations, making them more meaningful and improving patient experience. Similar improvement programmes have been put in place around therapeutic activities and leave management, with similarly positive improvements. Work has been done to start to reduce the use of restrictive practice and, through conversation with patients and feedback, alternative practices are being promoted, such as safety report plans and establishing how best to care for each patient when they are at their most distressed. This work is in early stages and is starting to show positive outcomes.

e)  All of the improvement work is monitored and outcomes are triangulated through the overall Improvement Board and its sub-groups. The ICB is fully involved in monitoring and tracking the assurance around improvement, and is providing check and challenge at all stages. The ICB acknowledges that there is more work to be done in this programme, but is also assured that there is solid evidence of improvement from NHT.

The Committee raised the following points in discussion:

f)  The Committee asked how NHT had addressed the problems around ward staffing levels identified by the CQC. It was reported that there had been an establishment review early on in the Improvement Programme work that resulted in an increased number of staff and the introduction of additional senior posts. Alongside purely staff numbers, other factors were considered to improve safety such as risk management, the skill mix of staff and the length of qualification and clinical experience, ensuring that there is always one Level 6 nurse on shift. There have been difficulties recruiting more experienced staff, which has been a national issue. There is a good number of newly qualified nurses, but more experienced nurses are harder to recruit. Despite this, vacancy rates have been improving and the focus is now shifting to the retention of existing staff, trying to ensure they feel nurtured and developed professionally.

g)  The Committee asked what initiatives were in place around supporting staff wellbeing, particularly in high pressure environments. It was explained that this is an area that NHT has paid significant attention to in order to support staff. The Wellbeing team is in place and there is a comprehensive package of interventions from support services to activities and incentives. There is also particular attention being given to the staff specifically impacted by the ‘Section 48’ report. Overall, the supervision rate has increased and reflective practice is widespread and well established, with staff involved in debriefs and safety ‘huddles’. There are always experienced staff on shift to ensure good levels of clinical expertise to help support and develop less experienced staff.

h)  The Committee asked what processes were in place to allow NHT to learn from patients’ feedback on negative experiences. It was set out that, where patients have had a poor experience, they are able to meet with staff and discuss these either as individuals or as a group, so that NHT can understand the concerns and incorporate solutions into the Improvement Programme. Progress on change is triangulated through the complaints process and fed back to patients on a face-to-face basis. There are volunteers that work on each ward who gather feedback from patients and carers to support them to feeling heard. A new Patient and Carers Reference Group has been set up that helps to model the way in which NHT engages. The Improvement Board works to triangulate evidence and is assured that the activity being undertaken is effective and that the culture within NHT is shifting in the right direction.

i)  The Committee sought assurance that proper oversight was in place to ensure all in-patient safety issues were now being responded to swifty and at the right level. It was reported that NHT has worked hard to embed a culture of listening, with Engagement teams in place to address issues with both patients and their families. There is oversight of NHT’s overall improvement by the ICB, which reviews progress in relation to delivery of the Improvement Programme through the Improvement Board. The ICB has been working closely with NHT to ensure that all safety issues are addressed properly and it provides challenge on the pace of improvement where required.

j)  The Committee asked how the need for the implementation of mandatory training highlighted by the CQC had been addressed. It was explained that there are a number of different mandatory training sessions required by the CQC that the Improvement Programme intends to develop. Whilst risk training compliance is currently good, the CQC identified that uptake of the Oliver McGowan training modules could be increased. Online training is mandatory and a rolling programme to address this has been initiated for all staff, with NHT maintaining a proportion of around 85% being trained, in the context of staff turnover. Priority is being given to clinical staff for the face-to-face modules, although this is anticipated to take until March 2026 to complete due to the number of staff at NHT and the need to balance staff numbers on the wards. The Culture of Care Programme is also supporting the learning from this training, but more work is needed to increase the take-up of non-mandatory training.

k)  The Committee asked what percentage of wards had been fully reviewed and risk assessed. It was set out that there are regular safety checks on all wards, which feed into the risk register. There is a specific Safety Nurse who completes the checks, looking at potential blind spots, how easily observations can be completed without being intrusive and when enhanced observations are necessary. Recently, a new type of torch has been tested so that sleeping patients are not disturbed through the night observations. There are regular CCTV audits and the frequency of observations for each patient is monitored throughout the day. This has all led to in improvement in the quality of observations.

l)  The Committee asked how safety incidents on in-patient wards were categorised and whether there were any emerging themes. It was explained that each incident is reviewed and categorised. Any incident considered to be moderate harm or higher is reviewed at a specific meeting and fed into the weekly Safety Board, which is attended by all Care Groups. This is designed to ensure a wide range of experience is involved in reviewing each incident, and the Safety Board then establishes the learning response. Any serious incidents are reported to the ICB, and the outcomes of incident reviews are forwarded to the CQC and NHS England.

The Chair thanked the representatives from NHT and the ICB for attending the meeting to present the report and answer the Committee’s questions.

Resolved:

1)  To request that, as part of the upcoming item on Patient Involvement, case studies and data is used to show how specific engagement with patients and their families has informed changes of practice within the Nottinghamshire Healthcare NHS Foundation Trust (NHT), to demonstrate that the transformation process is having an impact at an individual level.

2)  To request that further information is provided on the categories, numbers and trends of in-patient safety incidents that have occurred in NHT settings overall over the last year.

3)  To recommend that consideration is given to how the language and terminology used in reports on NHT’s improvement journey intended for the public domain can be clear and understandable to as wide an audience as possible.

Report of the Statutory Scrutiny Officer

Councillor Pavlos Kotsonis, Executive Member for Health and Adult Social Care; Councillor Jay Hayes, Executive Member for Housing and Planning; Patricia O’Connell, Interim Director of Adult Social Care; Jon Tomlinson, Interim Director of Commissioning and Partnerships; Geoff Wharton, Consultant Strategic Director of Housing; and Ana De-Almeida, Integrated Lead for Housing, Adult Social Care and Children’s Services, presented a report on the progress being made to strengthen partnership working across Adult Social Care and Housing Services. The following points were raised:

a)  An Integrated Lead for Housing, Adult Social Care and Children’s Services has been put in place to establish links across the Council’s Housing and Social Care teams. Social Care referrals are starting to be made through the post to Housing Services and are being processed. A universal referral form is being developed with clear information on basic details, housing need and complexity of care needs so that Housing colleagues can liaise with care providers to ensure that the right wrap-around care is delivered.

b)  An initial pilot of 12 cases is being run to establish good process and pathways but, as there is a limited level of Council housing stock, work needs to be done to mitigate any potential impacts on people waiting for Council housing who are currently homeless. Housing Services has met with other social housing providers across the city and surrounding areas who are keen to work with the Council where an enhanced Housing Benefit model could be used to maximise funding that would otherwise not be available to the Council directly. In the long term, this would increase housing stock and reduce costs to the Council, leading to better outcomes for people.

c)  Strategically, a number of cross-directorate working relationships have been established linking Social Care with Housing. Pathways are being considered and refreshed to make them easier to navigate for service users, ensure that there are fewer gaps and reduce waiting lists. There is a focus on prevention in relation to homelessness, with new policies and processes in development to work across directorates to find new and innovative solutions. The Co-Production Board continues to work to understand the market and to develop to improve commissioning intentions, and officers have sought learning from other similar Local Authorities that could be applied in Nottingham. Co-production with service users is in its early stages, but it is important that Nottingham people are able to help shape the direction of travel for the commissioning of services by feeding in ideas and contributing to pathway development. Co-production groups are being created and the aim is to launch these in the first quarter of 2025.

d)  In the first half of 2025, two strategic posts will be established to enable better communication and joined-up working between directorates, with more effective identification of those people most at risk of homelessness. These posts will work alongside the new Complex Care Housing Board, which will be able to provide strategic oversight and coordination of complex housing cases to ensure that vulnerable individuals and families receive housing and support services, and promote collaboration and integrated working. There have been joint workshops bringing together Housing and Social Care staff to build processes and pathways, but also to ensure people meet colleagues they otherwise would not to build solid working relationships. The work of the Lead for Housing, Adult Social Care and Children’s Services has been an integral part of this activity and future workshops will be held with both Occupational Therapy and Housing staff to consider the delivery of effective adaptations within Council housing.

The Committee raised the following points in discussion:

e)  The Committee asked how it would be ensured that services pathways were streamlined and not fragmented. It was reported that, with services working more jointly and liaising around complex cases, there are multiple opportunities to work more efficiently that have already been identified. The policies around good joint working are being reviewed, with one strand of activity looking at connecting housing and adaptation needs, and collaborative action is being taken identify blockages in pathways and aim to address them. A data dashboard is being put in place to identify issues in a timely way so that they can be resolved effectively.

f)  The Committee asked what the key aims of the Complex Care Housing Board would be. It was explained that the key objectives of the Board included ensuring that appropriate and robust policies and strategies are in place, with the joint review and revision of existing policies to make sure that they are fit for purpose. After this initial piece of work, there will be a review of the processes of how different directorates work together, which has already started with a recent workshop. Additional activity will be carried out to address waiting lists, thematically review complaints and consider the data and information around performance, which will be held within the new data dashboard. The overall aim of the Board will be to improve outcomes for Nottingham people by being able to offer and support sustainable tenancies, and so reduce costs with Housing and Social Care services.

g)  The Committee asked how co-production would be used as part of the 12-case pilot and what support would be available for the members of co-production groups so that they would achieve effective outcomes, given the particular vulnerability of many of the service users. It was set out that co-production has been used around the commissioning of services, and that terms of reference for the co-production groups have been developed. Going forward, the aim is to have a Co-Production Board with representation from all the main service user groups. This would be the hub of co-production, with specific sub-groups created for individual projects. Members of the co-production groups (both service users and Commissioning colleagues) will be given specific training around their remit, and officers would provide support throughout the process.

h)  The Committee asked how delivery progress would be monitored in relation to the Complex Care Housing Board, and how its performance would be evaluated. It was explained that the Board will have both senior officer and Executive Member oversight. The assessment of outcomes will be based on metrics and data, but also on feedback from service users.

i)  The Committee noted that there was a potential risk of initial health and housing needs escalating, if unmet, into potentially complex social care needs. The Committee considered, therefore, that it was vital that there was a joined-up approach across the Council to the identification of need at an early stage and the effective use of appropriate prevention work.

The Chair thanked the Executive Member for Health and Adult Social Care, the Executive Member for Housing and Planning, the Interim Director of Adult Social Care, the Interim Director of Commissioning and Partnerships, the Consultant Strategic Director of Housing and the Integrated Lead for Housing, Adult Social Care and Children’s Services for attending the meeting to present the report and answer the Committee’s questions.

Resolved:

1)  To request that further information is provided on the work that is taking place across the Council to improve outcomes for adults with both social care and housing needs in relation to the issues highlighted by the Care Quality Commission’s pilot inspection report of November 2023 and the Regulator for Social Housing’s inspection report of January 2025.

2)  To request that the Committee is kept informed about the data arising from the new Complex Care Housing Board and how its work is contributing to the delivery of improved outcomes.

3)  To recommend that a strong partnership approach is used to achieve the effective and meaningful co-production of integrated services at the community level, to ensure that the most vulnerable people are supported into appropriate housing based around their needs.

4)  To recommend that consideration is given to what health and housing service needs, if not fully met in a timely way, could give rise to a further need for social care services – and how the potential escalation to social care service need can be mitigated against.

5)  To recommend that full consideration is given to how different Council services work together to engage effectively with both each other and the Committee on cross-cutting Scrutiny issues where action must be delivered in cooperation between directorates.

Report of the Statutory Scrutiny Officer

The Chair presented the Committee’s current Work Programme for the 2024/25 municipal year. The following points were discussed:

a)  The Committee noted that it had not reviewed the local provision available through the Eating Disorders Service since October 2022 and felt that it should return to this topic. The Committee also considered it should take another item on access to NHS dentists, which it had last discussed in March 2024 ahead of the completion of the Oral Health Needs Assessment for Nottinghamshire.

The Committee noted the Work Programme.