Agenda and minutes

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To confirm the minutes of the meeting held on 17 November 2022

Subject to the addition of comments made by Committee members about poor acoustics in the Ground Floor Committee Room and the difficulties this causes, especially for those who experience hearing difficulties, the minutes of the meeting held on 17 November 2022 were confirmed as an accurate record and signed by the Chair.

Antony May, Chief Executive, and Richard Goold, Acting Assistant Director of Programmes, from Nottingham University Hospitals NHS Trust attended the meeting to provide an update on progress in addressing the issues identified by the Care Quality Commission through its 2021 inspection of the Well-Led domain.  They highlighted the following information:

a)  The Trust was rightly criticised by the Care Quality Commission (CQC) following its inspection in 2021, and the Trust is committed to improvement.  It has plans in place against which it is able to demonstrate good progress.  The assessment of progress is evidence-led to prove that change is being made sustainably.

b)  Since starting in post, the Chief Executive has had over 1800 interventions with staff, carries out announced and unannounced visits to wards and surgeries, including at weekends and out-of-hours, and attends events and conferences with staff across the organisation including nurses and allied health professionals, consultants and facilities and estates colleagues to help him understand what it is like to work at NUH.  This understanding is then being used to identify ways of fixing the problems that exist with the aim of achieving an organisation that is a good place to work and delivers good care and outcomes.  He highlights issues identified to the Board as appropriate.

c)  Some improvement actions have focused specifically on core services, which are particularly under pressure.

d)  Additional resource has been brought in to support improvement where necessary, for example in relation to maternity services.

e)  The first phase of response is coming to an end and many of the actions have been completed.  12% of actions are under review with some being assessed for further action.

f)  The Trust is looking at how corporate governance interfaces with clinical governance, and working with colleagues from NHS England to improve incident investigation and management, risk management and clinical audits.  The recruitment of a new Director of Governance will be important in supporting this work and ensuring that the Trust is appropriately governed.

g)  Compliance hubs are being introduced to align improvement across the whole Trust.

h)  The Trust is held to account for its improvement by the Nottingham and Nottinghamshire Integrated Care Board and regionally by NHS England.  The Trust is expecting a national review meeting in March 2023.

i)  A report on progress will be taken to the Trust Board in January 2023.

j)  Going forward, the biggest challenges for the organisation are leadership and culture, hospital flow and recruitment and retention.

Amanda Sullivan, Chief Executive of Nottingham and Nottinghamshire Integrated Care Board (ICB), attended the meeting to provide insight from the ICB, and specifically the Oversight and Assurance Group, on the Trust’s progress.  She highlighted the following information:

k)  The Oversight and Assurance Group, which is co-chaired by the Integrated Care Board (ICB) and NHS England, looks at evidence of activity that the Trust has been undertaking and has seen evidence as described in the report submitted to the Committee by the Trust.

l)  The outcomes from the new Chief Executive’s 100 Day Plan and significant levels of engagement are starting to show and there is evidence of things changing but, for such a large organisation, it will take time.

m)  The ICB is supporting the Trust’s hospital teams to work across community teams covering the whole patient journey and these connections are starting to feel different, although it will take time.

n)  Previously, the Trust was under-classifying and under-reporting Serious Incidents and, as a result, there was insufficient oversight of incidents.  There has been a lot of joint work on thresholds and the ICB now feels more comfortable with the classification of Serious Incidents when they occur and the process for investigating them.  There is more transparency and the Trust is now in a better place on this issue.

o)  Phase One of improvement focused on the actions identified by the Care Quality Commission as ‘must do’.  There has been progress on these actions and the compliance hubs are supporting more systematic improvement across the whole Trust.  Phase Two will be really important for embedding improvements and supporting continuous improvement on longer term culture change.  The ICB is supportive of this two stage approach.

During subsequent discussion and in response to questions from the Committee the following points were made:

p)  New Board members are being recruited to address criticisms from the Care Quality Commission about issues with insufficiently robust leadership at Board level and a lack of permanent Board members.  The managerial posts being recruited to have been vacant for some time and are largely frontline managerial posts.

q)  A lot of work has been done to ensure that systems and processes encourage staff to come forward with any concerns, including anonymously if they prefer. The Trust has three Freedom to Speak Up Guardians who meet regularly with the Chief Executive and Chair of the Trust Board and attend Trust Board meetings.  Themes raised would be recognised in the findings of the CQC.  It was apparent that staff were not as aware of these Freedom to Speak Up Guardians as they should have been so there has been publicity to ensure staff are aware and, in particular, increase their visibility in those areas where there have been the most concerns, such as maternity and estates and facilities services.  The Freedom to Speak Up Guardians have reported that this work has had a positive impact.  They seem comfortable with their capacity but have requested analytical support and administrative support which will be provided.

r)  The Trust has established an Inclusion Committee, chaired by a non-executive director and including people who are representative of colleagues across the organisation.  The Committee has been tasked with developing an Inclusion Policy by autumn 2023 and, demonstrating a commitment to inclusion, ensuring an Inclusion Policy is in place is one of the objectives for the Chief Executive.

s)  Staff are well-supported by trade unions.  The Chief Executive has met with representatives of some trade unions and has a meeting scheduled with Unison.

t)  There are both bottom up and top down approaches being taken to culture change.  Frontline staff are asked for their views and supported to contribute to change.  In his engagement with staff the Chief Executive is listening, making note and following up on issues raised and, for example, in maternity services there is a Maternity Oversight Committee with an independent chair.

u)  It will take a long time for cultural change to trickle down through a big organisation, but progress is starting to be seen.

v)  The Assurance and Oversight Group brings together regulators and professional bodies to ensure that it gets a full perspective on the position and doesn’t just rely on information provided by the Trust.  The Group considers that there have been improvements in transparency and access, with more access to the inner workings of the Trust, which helps to give confidence.  The ICB’s Chief Nurse has overseen the investigation of Serious Incidents and attends lots of the Trust’s internal committees which helps to triangulate information and there is a more open relationship with clinical teams.  Everything is not yet fixed but there is more confidence in progress and the extent of improvement.

w)  The Trust is not a particular outlier in terms of the national recruitment and retention issues, but it is acknowledged that some issues may relate to the Trust’s particular circumstances.  Lots of work has been done before on understanding the issues and identifying what can be done to address them, for example working with the University of Nottingham regarding medical students and looking at education and training to increase workforce supply in the future.  A Recruitment and Retention Working Group, which is representative of all areas of the Trust, has been stood up.  One of the issues for the Trust has been a lack of capacity to drive work on recruitment and retention and systems that don’t support getting people into post quickly enough.

x)  Phase one of the response has focused on making changes quickly and gathering information for the longer term.  A programme management approach will be more appropriate for the second phase of improvement which will involve longer pieces of work that need bringing together.  All activity will be co-ordinated by a Programme Management Office. 

y)  Risks to programme delivery are regularly reported, with risks fed into monthly performance meetings incorporating information from the service itself.  This feeds into reports to the Trust Board.  It is acknowledged that past processes couldn’t have been flagging up risks effectively otherwise the Trust wouldn’t have got into its current position.  There is a risk management road map to ensure that risks are actively managed and further work will be taking place to ensure data and risk registers are up-to-date; put a risk management training package in place; and ensure refreshed reports to the Board.  This will contribute to ensuring that the Trust reaches a steady state.

z)  A Committee member expressed surprised that racism issues were not directly mentioned in the report submitted to the Committee, given that it was one of the most significant concerns raised by the CQC.  The Trust’s Chief Executive acknowledged that the data is shocking, and outlined that when he started in post he wrote to all staff explaining his position on bullying and harassment, especially racism.  This received a good response from colleagues and it resulted in concerns being raised directly and via the Freedom to Speak Up Guardians.  He has met with colleagues, including BAME employees, to help him understand what it is like to work for the Trust.  This understanding has been one of the drivers for establishment of the Inclusion Committee.  The Trust has a comprehensive action plan for addressing issues affecting BAME staff and is recruiting a Director of Inclusion to lead on drawing all of this work together.  He reiterated that the Trust has the will and commitment to do better, although it will take time for things to improve across the whole organisation.  In terms of progress on equality and diversity actions within the action plan, the initial priority has been to build an understanding of the issues to ensure that the actions being taken are the right actions and this will put the Trust in a stronger position for longer term actions in phase two of improvement.  The Chief Executive stated that, in the meantime, based on his interactions with staff he would be surprised if data from the most recent staff survey is substantively better.  The ICB’s Chief Executive added that all aspects of the system and all organisations are focused on these issues and, in her view, a specific focus on racism is needed.  She agreed that it is unlikely that findings from the Trust’s most recent staff survey will show substantial improvement, but hopefully there won’t be deterioration.

aa)Lots of work has taken place to improve the management of patient safety since the CQC raised concerns in June 2021 about the number of open patient safety incidents and lack of risk stratification.  There has been an increase in transparency with all Serious Incidents reported in the public domain and improvements in systems and processes, and the Trust is transitioning to a new reporting system.  Given the size of the organisation there will be a significant number of incidents and there needs to be sufficient capacity to deal with them and learn from them.  The Trust is working with the ICB on stratification and ensuring that investigations are properly signed off to completion.  The ICB Chief Executive confirmed that its Chief Nurse is working with the Trust on managing the risks associated with the backlog of investigations.

Resolved to:

(1)  request that Nottingham University Hospitals NHS Trust provide the following additional information:

  i.  the number of complaints from the public relating to bullying and harassment, the proportion this is of all complaints and how this compares to previously;

  ii.  how many racial motivated grievances there have been and how many have been upheld;

  iii.  progress in rolling out unconscious bias to staff and how many staff have been trained so far; and

  iv.  the current number of open patient safety incidents

(2)  review how the Trust is tackling issues of racism and bullying in its workforce at a future meeting.

The Committee noted its work programme for the remainder of municipal year 2022/23.