Agenda item

Tees, Esk & Wear Valleys NHS Valleys NHS Foundation Trust - Response to recent CQC inspection

The Chief Executive at Tees, Esk and Wear Valley NHS Foundation Trust (TEWV) and Lead Inspector from the Care Quality Commission (CQC) will be in attendance to provide an update in respect of the CQC’s recent inspection report findings.



The Chief Executive at Tees, Esk and Wear Valley NHS Foundation Trust (TEWV), the Chair at TEWV NHS Foundation Trust and the Lead Inspector from the Care Quality Commission (CQC) were in attendance to provide an update in respect of the CQC’s recent inspection report findings.


The Chief Executive thanked the Committee for providing the opportunity to update Members on the action that had been taken by the Trust in response to the CQC’s recent report. In terms of the presentation, a copy of which had been provided to the Committee in advance of the meeting, it was advised that information on the following would be covered at today’s meeting:-


• Our Journey To Change and key improvements.

• An overview of our recent Care Quality Commission (CQC) core service inspection (Jul-Aug 2021).

• An update on our secure inpatient service – key actions, improvements and impact. • An update on our community child and adolescent mental health services – key actions, improvements and impact.

• Other services inspected and the feedback from the CQC.

• Adult mental health and psychiatric intensive care unit (PICU) follow up inspection progress. • Wider challenges and how we're addressing them.

• Continuing Our Journey To Change.


In terms of the Trust’s Journey to Change it was noted that a number of improvements had been made following the CQC inspection including; an organisational restructure, the introduction of improved governance arrangements, an increased leadership capacity - including the appointment of two lived experience directors, additional Board development work, increased oversight of the work of the Board and its sub-groups, the introduction of revised risk management arrangements, numerous recruitment and retention initiatives – resulting in a 5 per cent increase in FTE equivalents in the Trust’s overall headcount, the implementation of enhanced quality assurance programmes, the development of an improved organisational learning infrastructure – development of a learning library and an increase in compliance with statutory and mandatory training.


With regard to the report itself, the CQC inspection had been held between June and August 2021 and the report had been published in December 2021. An action plan, as produced by the Trust was submitted to the CQC in January 2022 and the Trust had been working collaboratively with the CQC, colleagues in NHSEI, the CCG’s, staff, patients and carers to bring about improvements. The improvement plan submitted to the CQC was co-created and frontline staff and patients were directly involved in its development. The Chief Executive stated that the Trust was confident in the approach it had adopted to bring about improvements. In terms of its CQC overall rating the Trust remained at requires improvement. The Trust had been rated as being good for caring and effective and required improvement for being well-led, responsive and safe. The Chief Executive advised that since the CQC inspection significant progress had been made and that the focus now was on embedding and sustaining those changes.


The Chief Executive advised that he wished to focus specifically on the delivery of secure inpatient services (SIS) as this was one of the main areas of concern alongside the delivery of child, adolescent and mental health services (CAMHS). It was advised that the SIS was a regional, specialised service and the concerns raised by the CQC in respect of this service had related to staffing, safeguarding and the governance systems in place to ensure quality and safety. In terms of progress the Trust had undertaken a number of measures including; undertaking reviews of safety plans and safety summaries to ensure they accurately reflected the current and real risks faced by individuals, improved compliance with safeguarding training, the embedding of a safeguarding expert within the service to deliver a more timely and responsive approach to safeguarding issues, the introduction of SafeCare to ensure the Trust maintained safe staffing levels, improvements to the flow of patient safety information through revised governance structures and a new model of care and professional practice had recently been launched (February 2022).         


The Chief Executive stated that at the heart of some of the challenges faced by the secure inpatient service were issues around culture, which had been well documented within the CQC report. Secure inpatient services were by definition a closed environment and the Trust needed to ensure that it addressed any pockets of poor culture or behaviour issues that could influence the experience and safety of patients and colleagues that worked in this service. In terms of progress made since the inspection it was highlighted that very few requests for leave were now cancelled owing to staffing constraints and there had been positive impacts in terms of recruitment, with more offers of work progressing through the Trust’s employment channels that were due to come to fruition in May / June 2022. In addition there had been a reduction in the use of bank staff, which was proving effective in addressing some of the cultural challenges.


In terms of the delivery of CAMHS it was advised that this another key area of improvement for the Trust and the areas of focus were as follows; ensuring staffing levels met the demands of the service, reviewing young people waiting for treatment including specialist assessments and ensuring mandatory training compliance. The Chief Executive advised that the Trust had made significant inroads in respect of CAMHS. All of the young people waiting for treatment had been reviewed, the Trust had been in touch with all young people and their families waiting for treatment and they were being contacted regularly in line with their individual risk. Risks could now be reassessed and if an individual’s level of risk changed and was heightened, for example, they could be prioritised and brought forward. In terms of the concerns raised in respect of the level of caseloads clinicians were managing significant progress had been made. The Trust had ‘level loaded’ through detailed caseload review and ongoing supervision so that in a number of teams now, including in the Tees Valley, how some of those caseloads can be reduced. It was advised that staffing was a key issue and there were currently 111 job offers in the system at the moment and in May / June 2022 these appointments would begin to impact on caseloads.


It was highlighted that workforce and transformation were particularly important for the Trust and work had been undertaken with the Director of Children Services in Stockton, on behalf of his colleagues across the other Tees Valley authorities, to develop approaches around early intervention, schools and the VCS’s, as well as those children with some of the most acute needs. A significant amount of work was being undertaken in this whole area of children’s services transformation in conjunction with Local Authority colleagues. Stockton had served as a pilot and caseloads within Stockton had reduced by approximately 37 per cent. It was envisaged that this work would be rolled out to other areas by September 2022. Improvements in waiting times had been made and the Trust had on Teesside the average wait for a first appointment was 6 days and the average wait for a second appointment was 20 days.


Another area covered in the CQC inspection report related to crisis services and health based places of safety. It was advised that the CQC rated this area as good and a number of areas of good practice were highlighted within the inspection report including that staff treated patients with compassion and kindness, they respected patients’ privacy and dignity and leaders had the skills, knowledge and experience to perform their roles. Given that the crisis service received 250,000 to 300,000 calls per year this was a really positive outcome.


In respect of community based mental health services for adults of working age the CQC inspection had highlighted a number of areas of good practice. This included that staff assessed the mental health needs of all patients. They worked with patients and families and carers to develop individual care plans and updated them as needed. Care plan reflected the assessed needs, were personalised, holistic and recovery orientated. In terms of areas identified for improvement these included timely access to services and consistency of approach to caseload management. The community adult mental health service received an overall rating of required improvement.


Reference was made to an area that had been subject to a CQC report following a visit to TEWV in January 2021 in relation to care provided by the adult mental health acute inpatient admissions and psychiatric intensive care units. In terms of the concerns raised by the CQC these had been fundamentally focused on the complex systems that had been in place in respect of risk assessments and risk management. In terms of progress made a huge amount of work had been undertaken to redesign the systems used for the recording of risk assessment and risk management. In total 50,000 care plans, safety plans and safety summaries had been reviewed and updated. Through quality assurance and audit work the Trust was able to reassure itself that the improvements made were being maintained. A follow up inspection was undertaken by the CQC in May 2021 and the service was re-rated as required improvement.


In terms of the wider challenges and how the Trust was addressing these the Chief Executive advised all the work discussed was ongoing but it was acknowledged that there was still a significant amount of work to undertake. Workforce, recruitment and retention remained a challenge and the omicron phase of the Covid-19 pandemic had proved the most challenging for TEWV as an organisation. Thankfully, the impact of the pandemic was now reducing and staff absences were falling. Demand remained high and wards were often at full capacity, with patients needing to remain in hospital for longer due to their acuity of need. There had been a real focus on workforce with some significant successes. The volume of recruitment had resulted in the need to expand TEWV’s recruitment team and support had been provided by a business services agency. 


Further measures in respect of workforce included introducing incentives for people to come and work for TEWV, an online recruitment process that had been undertaken with Sussex University, which included an automated screening approach, work to refresh the induction and ongoing supervision processes and work to ensure TEWV’s reward and recognition package was favourable compared with that offered by other Trusts. As part of the organisational restructure TEWV was set to go live with its new operational, clinical restructure on 1 April 2022. Work was currently being undertaken with the corporate teams – people and culture directorate and support provided to staff in terms of workforce planning, health and wellbeing and staff engagement.


Reference was made to TEWV’s plan on a page document and it was advised that the Trust had spent a lot of time over the last 18 months listening to people to get a sense of what was important, how TEWV could drive the improvement agenda before bringing that together to identify TEWV’s vision and purpose. It was highlighted at stage 4 that TEWV had also developed a set of values – Respect, Compassion and Responsibility that were driving the organisation’s Journey To Change. It was emphasised that it was not simply a case of improving services to satisfy the CQC, TEWV as an organisation wanted to deliver the highest quality services where patients had the best experience and this would be achieved through the sustained work being undertaken to achieve these goals.


Following the presentation Members were afforded the opportunity to ask questions and the issues below were raised:-


·         Reference was made to the involvement of Health Care Assistants and people with lived experience in TEWV’s Journey To Change and a Member queried whether the two Directors with lived experience were yet in post. In response it was advised that although they were not yet in post both had been recruited to and offered the positions. In addition a new Head of Co-Creation post had been established to further strengthen the involvement of patients in the development of service delivery. Work was also being undertaken to expand TEWV’s Peer workforce so that the voice of lived experience would be working alongside all of TEWV’s professionals. A concerted and thorough approach was being adopted. It was advised that significant investment had been put into these senior leadership roles to bring patient voice and patient leadership to the heart of TEWV’s service delivery. It was anticipated that both of the lived experience were due to join the organisation in June 2022. 

·         Reference was made to sickness levels and the impact that the pandemic had had on staff. A Member queried whether any work had been undertaken to measure levels of stress amongst staff. It was advised that although no specific piece of work had been undertaken in relation to this issue. However, when recording staff absence the reasons were recorded and mental health / well-being was probably the second highest reason for staff absences. Psychological support was available to staff via the regional resilience hub and TEWV also had its own psychology service that staff could access. Good support systems were in place. In terms of the secure inpatient services sustained efforts had been made to ensure staff were now able to take their breaks whilst on shift. It was anticipated that the stresses would continue, even after the pressures caused by the pandemic. This was an area that TEWV would continue to prioritise.

·         An area that remained of concern to Members was the toxic culture, as referenced by the CQC, in relation to the delivery of inpatient secure services. A Member queried how that issue was being addressed and what specific progress had been made to date. The Chief Executive advised that culture was a challenge for big organisations and that some of the work undertaken involved bringing the patients’ voice into services through the lived experiences initiatives. Engaging with staff was another important factor and the development of the Health and Care Assistant Forum provided an opportunity for them to air any concerns and discuss with staff proactively how TEWV could create a better environment / positive culture for everyone to work within. A significant amount of work was being undertaken with regard to leadership in the area of inpatient secure services. It was emphasised that the comments made by the CQC in relation to a toxic culture related solely to this particular service area and was not endemic throughout the organisation. It was a focussed approach in this specific area. It was important to provide opportunities for staff to be able to raise any concerns and overt conversations were being held around accountability where there were any pockets of bad behaviour. Where such practices were found and evidenced then the leadership would challenge and deal with any issues.

·         Reference was made to the statistical data, as referred to in the CQC report, in relation to a decrease in satisfaction amongst staff who identified as Black, Asian and Minority Ethnic (BAME) or as having a disability. In addition the CQC report had highlighted that a greater proportion of BAME staff had stated that they were victims of bullying, abuse and hate crime and that the management responses were variable. A Member of the Committee queried as to what reassurances could be provided in relation progress being made by TEWV in respect of addressing these issues. In response it was advised that engagement work had been undertaken with a number of protected characteristics groups to ensure their perspectives were being heard and acted concerns raised acted upon. Reverse mentoring schemes had been introduced around the disciplinary processes, with representatives from BAME staff on those to ensure that there was no undue bias in any of those processes. Where issues did arise it was also a case of ensuring that there was fair accountability and demonstrating that these issues would be dealt with proactively. Talking to representatives from those networks it was felt that the Trust was making positive steps forward in respect of that agenda.

·         A Member made reference to a recent presentation on TEWV’s ‘Journey To Change’, as given by the Chief Executive at a recent Stockton Borough Council Adult Social Care and Health Select Committee meeting. It was stated that having had the opportunity to reflect on that presentation Members in Stockton felt that what was lacking was any information in respect of the impact the changes were having. It was also queried as to whether given that no work had been undertaken by the Trust to measure staff stress levels whether any wider staff survey had been conducted. Finally, reference was made to the Chief Executive’s staff blog and comments made in relation to dismissals. It was queried as to the number of dismissals that had taken place? As well as to how many bank staff shifts had been used in Forensic Services in 2022 compared with the 2021 figures? In addition, how much overtime had been used and what were the current Covid/non-Covid sickness levels? It was stated that the Health Care Assistant Council referenced in the presentation, as a mechanism via which staff would be able to raise any concerns was not yet in operation and would only come into effect later this month. This initiative was applauded, although it was felt that it should have been introduced earlier. The reference to 3 per cent of leave being cancelled did not provide sufficient information in respect of the impact. It was queried as to what this meant in terms of numbers of people impacted. The CQC report had been very damning right up to Board level and it was queried as to what changes had been made at Board level in terms of the Medical Director and Safeguarding Lead. It was questioned as to whether it was felt that the Trust in its current size was simply too big.

·         In response to the numerous questions posed above the Chief Executive advised that work was currently being undertaken within the Trust to split the Trust into two parts. One part to cover Durham and the Tees Valley and the other to cover North Yorkshire and York. It was felt that this would help to reduce the complexity of managing an organisation of that scale. In terms of the numbers these could be provided and the information would be forwarded to Members following the meeting. In terms of accountability the Chief Executive advised that the references made in his recent organisational blog demonstrated the Trust’s commitment to ensuring that where any issues of concern were identified action would be taken.  

·         The Chair of TEWV responded to the query raised in terms of the changes introduced at Board level. The Chair stated that he was a lay Member and the majority of those that served on the Board were Non-Executive Directors. There had been an almost complete turnover of the personnel on that Board in the last 18 months. It was very much a new Board focused on how to make services better. The Trust was currently out to recruitment for a new Medical Director, as the previous Medical Director was leaving the Trust and leaving the NHS. The Board continued to both support and challenge the Chief Executive and staff within the Trust on a daily basis. The Chair offered his reassurance to the Committee that the lay people on the Board, on behalf of the patients and populations they served, ensured that the Chief Executive and his colleagues were absolutely focussed on improving services for our communities.  

·         The Chair of the Trust offered the opportunity for Members of the Board to undertake a visit to the Trust and any of the services being provided, including the secure inpatient service. It was stated that there was very much a willingness from the Trust to be open and transparent. The Trust had no hesitation in inviting Members of the Committee to visit its services and see first-hand the delivery of service provision. The Trust would be delighted to welcome Members to meet staff and patients and see for themselves the improvements being made. The Chair of the Trust acknowledged that there were some pockets of bad practice but they were absolutely a handful compared with the nearly 8000 members of staff employed across the Trust. It was emphasised that there were multiple areas of good practice compared with any areas of concern.  

·         Reference was made to the issues raised in the CQC report in respect of culture and Members expressed the view that there was no quick fix. It would take a long time to change the culture of the organisation and evidence from staff surveys would demonstrate whether that shift in culture was starting to take place. It was queried whether there were any specific changes on the ground that could be reported in relation to this issue. The Chief Executive advised that there was no evidence to suggest that the issue in respect of culture was endemic and where there were issues action was being taken. The progress that had been made in terms of recruitment was encouraging, the fall in staff sickness rates in areas where there had been concerns was a further positive and the improved engagement in training. It was acknowledged that it was challenging, particularly in light of the impact of the pandemic. The Trust was due to undertake some pulse survey work over the next few weeks and it was anticipated that this would provide some evidence in respect of staff feedback. The offer was provided to update Members on this work at a future meeting of the Committee.   


The Chair introduced the CQC’s Lead Inspector and invited him to make any comments in respect of the information provided to the Committee and the discussion that had been held. The Lead Inspector advised that he wished to highlight a number of points. The first was in relation to the senior leadership within TEWV, as there had been significant changes in the leadership team. At the time of the inspection TEWV had developed plans to strengthen the leadership team to address the governance issues it had identified and this would be an area that would be revisited in the CQC’s follow up inspection. In an effort to ascertain whether those changes had had the desired impact on strengthening the governance processes within the organisation and making the necessary improvements in leadership.


The Committee was advised that the CQC continued to have regular engagement with the organisation. TEWV provided it with regular updates and information and the CQC participated in the additional oversight processes in place. These included the Quality Improvement Board, which was chaired by NHS England Improvement (NHSEI) and regular conversations with the provider collaborative, which had responsibility for the monitoring of the secure services in particular. The CQC had seen that action had been taken by TEWV to address the areas of concern raised. However, from a regulatory position ultimately the CQC’s assessment of whether it had received sufficient reassurance on improvement would be at the point it undertook a re-inspection and spoke to staff, patients and carers about what impact the changes had had for them.


The Lead Inspector advised that the re-inspection would be unannounced and the CQC generally re-inspected services within a six month period. If, however, any information came to light, which suggested that the level of risk had changed the CQC would be responsive and re-evaluate its timescales. The CQC had a range of enforcement powers available to it, both civil and criminal, but clearly the CQC’s hope was that the action taken by the TEWV resulted in an improvement in the safety and quality of care people received.


AGREED as follows:-


i)              That an additional meeting be arranged, if practical, given that purdah was scheduled to commence shortly, followed by each local authorities’ AGM, where membership of the Committee would be subject to change.

ii)             That the next meeting of the Committee be held at Roseberry Park Hospital and a visit to services, including the secure inpatient service, be undertaken following that meeting.  

iii)           That a copy of the key questions Members still had in relation to the CQC inspection report be forwarded to TEWV, in advance of the next meeting, for a written response to be provided.

iv)           That information in respect of the pulse survey work undertaken with staff be provided to Members at the next meeting of the Committee.

Supporting documents: