Shrewsbury and Telford Hospital NHS Trust ·

Shrewsbury and Telford Hospital NHS Trust Evidence appendix Mytton Oak Road Shrewsbury Shropshire SY3 8XQ

Tel: 01743261000

www.sath.nhs.uk

Date of inspection visit: 12 to 26 November 2019 to 10 January 2020 Date of publication: 8 April 2020

This evidence appendix provides the supporting evidence that enabled us to come to our

judgements of the quality of service provided by this trust. It is based on a combination of

information provided to us by the trust, nationally available data, what we found when we

inspected, and information given to us from patients, the public and other organisations. For a

summary of our inspection findings, see the inspection report for this trust.

Facts and data about this trust Shrewsbury and Telford Hospital NHS Trust is the main provider of district general hospital

services for nearly half a million people in Shropshire, Telford and Wrekin and mid Wales. The

trust has two main hospital sites: Royal Shrewsbury Hospital and Princess Royal Hospital in

Telford. The two hospitals have approximately 650 inpatient beds. Royal Shrewsbury Hospital has

nine operating theatres, and Princess Royal Hospital 10 operating theatres. The trust employed

6,146 staff as of July 2019.

Princess Royal Hospital is the trust’s specialist centre for inpatient head and neck surgery. It

includes the Shropshire Women and Children’s Centre, the trust’s main centre for inpatient

women’s and children’s services.

The trust provides acute inpatient care and treatment for specialties including cardiology,

clinical oncology, colorectal surgery, endocrinology, gastroenterology, gynaecology,

haematology, head and neck, maternity, neonatology, nephrology, neurology, respiratory

medicine, stroke medicine, trauma and orthopaedics, urology and vascular surgery.

(Source: Routine Provider Information Request (RPIR) – Context acute tab; trust website)

Hospital sites at the trust

A list of the trust’s acute hospitals is below. Both hospitals provide acute hospital inpatient

services and outpatient services to Shropshire, Telford and Wrekin and mid Wales.

Name of hospital site Address

Princess Royal Hospital Apley Castle, Telford, Shropshire TF1 6TF

Royal Shrewsbury Hospital Mytton Oak Road, Shrewsbury, Shropshire, SY3 8XQ

(Source: Routine Provider Information Request (RPIR) – Sites tab)

Background intelligence:

• The trust has 721 acute beds (+9% from June 18), 22 critical care beds (+5% from June 18)

and 37 maternity beds (0% change).

• From March 2018 to February 2019, there were 123,851 inpatient admissions (+8%

compared to previous year). 9,068 of these were children, approximately 8.6% of all

admissions.

• There were 718,882 outpatient attendances (+12% from previous year).

• There were 121,442 accident and emergency department attendances (+9% from previous

year).

• The trust employs 5,108 WTE staff.

Demographics

There are two local authority areas within Shropshire (Telford and Wrekin and Shropshire). Public

Health England (PHE) published local authority health profiles in July 2018. These highlight the

variation in the health of people from the two local authorities.

Telford and Wrekin

About 20% (7,000) of children live in low income families. Life expectancy for both men and

women is lower than the England average. In Year 6, 20.8% (403) of children are classified as

obese. The rate of alcohol-related harm hospital stays is 673. This represents 1,091 stays per

year. The rate of self-harm hospital stays is 174. This represents 305 stays per year. Estimated

levels of adult physical activity are worse than the England average. The rate of hip fractures is

worse than average. Rates of violent crime and early deaths from cancer are worse than average.

Shropshire

About 12% (5,800) of children live in low income families. Life expectancy for both men and

women is higher than the England average. In Year 6, 16.9% (422) of children are classified as

obese, better than the average for England. The rate of alcohol-related harm hospital stays is 656.

This represents 2,188 stays per year. The rate of self-harm hospital stays is 143, better than the

average for England. This represents 415 stays per year. Estimated levels of adult excess weight

are worse than the England average. Rates of violent crime, early deaths from cardiovascular

diseases, early deaths from cancer and the percentage of people in employment are better than

average.

Is this organisation well-led? Our comprehensive inspections of NHS trusts have shown a strong link between the quality of

overall management of a trust and the quality of its services. For that reason, we look at the

quality of leadership at every level. We also look at how well a trust manages the governance of

its services – in other words, how well leaders continually improve the quality of services and

safeguard high standards of care by creating an environment for excellence in clinical care to

flourish.

Leadership

There was a lack of stability in the executive team with several interim members, although to increase stability these individuals had agreed to stay in post until substantive postholders were in place. The board had some knowledge of the current challenges and were acting to address these however this had not made the sustained improvements required to deliver high quality care and in some areas the quality of care had deteriorated. Not all leaders at all levels had the capacity and capability to lead effectively. The trust had a leadership team that had experienced significant change over the last nine

months, with three interim executive posts including the chief executive. There had been

significant changes to the board since our 2018 inspection. The chief executive was interim having

been in post since July 2019. A substantive chief executive had been appointed and was due to

take up post in February 2020. The medical director commenced in June 2019 and chief operating

officer commenced in February 2018 both were substantive post holders. The director of nursing

(May 2019) and finance director (June 2019) were interim positions. These four directors were

executive directors. There were several other director posts which included the director of clinical

effectiveness who had previously been the medical director since 2013, director of corporate

services (1986), acting workforce director (2019) and director of transformation and strategy

(September 2019) who had previously been the interim deputy CEO from June 2019. These

directors attended board meetings but were non-voting roles. The interim post holders had held

executive posts before and brought experience of how an executive team and board should

function. Additionally although initially recruited for a fixed term they had agreed to stay in the roles

until permanent postholders were in post to prevent further instability and change.

In addition to the chair, the board also comprised of six non-executive directors and an associate

non-executive director who had a range of tenures the longest from 2013 and the most recent

September 2019. The non-executive directors chaired several committees within the trust and

brought a variety of experience and skill to the board, enabling them to perform their roles. The

immaturity of the board and demand on their time to manage basic operational issues meant they

were not operating as a strategic unitary board.

The trust leadership team had knowledge of some current priorities and challenges

and were acting to address these; however, there was a history of action and improvements not

being sustained. All of the board were open and honest about these challenges. They had

undertaken an assessment of the issues and developed a 100 day plan, however this was not

having an impact on improving services at the required pace. Due a poor learning and safety

culture we were not assured they had knowledge of the whole range of issues affecting the quality

and safety of patients.

Some middle managers lacked the skills, knowledge and capacity to lead and manage

effectively. The trust recognised the training needs of managers and were working to provide

leadership and development opportunities; however, this was at an early stage. The board

recognised recruitment and culture as two of the key factors to improvement.

Senior leaders planned to visit departments on a regular basis and recorded these visits on a

whiteboard in the executive corridor. We saw that there was an extensive list of visits, however,

the staff perception of the visibility of the executive team was not positive. Staff told us that they

did not regularly see them in their areas. Some staff at both hospitals told us they were not sure

who all the members of the trust board were and would not necessarily recognise them. Some

senior staff informed us they did not always feel supported by the executive team and informed us

of poor interactions and behaviours in front of ward staff and patients by trust leaders. In the free

text comments of the Staff Friends and Family Test, 30% related to poor leadership and

management, demonstrating this as the top theme of concern

The non-executive directors confirmed that monthly ward visits had been introduced and were

carried out before the trust board meeting. There was a lack of systematic feed back to the

board from these visits to discuss challenges staff and the services faced.

Accountability of executive roles was becoming clearer but it was recognised that further work was

required to ensure absolute clarity of accountability at board level. For example, the director of

clinical effectiveness, interim director of nursing and medical director has aspects of their role that

overlapped. The director of effectiveness reviewed and signed off many of the complaints letters

on behalf of the chief executive but there did not seem to be much alignment with the director of

nursing whose responsibilities included duty of candour and learning from complaints. There was

a lack of capacity and capability to influence effective change to address patient safety and staff

wellbeing concerns despite long standing awareness of issues and pressures. The chair was clear

that further changes within the governance framework were required. There was an expectation

that all leaders needed to change their approach, be clear of the challenges and be honest about

these.

The non-executive directors (NEDs) spoke positively about their relationship with the executive

team. However, we found inconsistent messages regarding the capacity of the executive team to

manage the trust’s priorities from the NEDs. Not all board sub committees were quorate, for

example. The NEDs we spoke with told us they engaged with staff to experience care at the front

line. Board development sessions considered the behaviour and accountability culture and how

engagement could be increased to ensure sustainable, effective services.

Clinical leadership at the trust was provided by four care groups. Each care group was led by a

triumvirate of a care group director or an assistant chief operating officer, head of nursing and care

group medical director. The women and children’s care group also had a head of midwifery that

sat on the women and children’s care group board. The trust recognised it needed to strengthen

its approach to leadership development was aiming to build capacity, capability and confidence in

the trust’s people managers and leaders with development workshops that were aligned with the

leadership and management framework. Determining what leadership competencies were

required to intervene and move the trust to an improved position delivering sustainable care.

The newly launched equality, diversity and inclusion committee set out the work towards improving

experiences of all staff in career progressions and fair treatment. This was intended to build an

inclusive and compassionate culture on a sustainable bases for all staff to flourish and will form

part of the people strategy over the next three years. The trust was launching the succession and

talent plan initiative, however at the time of our inspection there was not a specific leadership and

talent management strategy. The vision was to firstly address any immediate gaps in the

succession pipeline to senior roles; to build a strong succession pipeline to senior/critical roles for

the future; and to build expertise and capability across the trust. The organisational development

team were focusing on a programme that will offer targeted development to link all leadership

development with the Hospital Future Plans.

The trust did not have a set target of staff eligible for a form of leadership development. However,

the trust recognised the need to encourage leaders to grow and develop at all levels. They had

identified that there were 3,500 staff that would benefit from training that develops leadership

potential, however with a workforce of just over 6000 staff that was more than half the workforce.

Improving the culture, clinical engagement and targeted and long-term leadership development as

well as the development of a clinical strategy was seen to be key to improving. Board and

committee papers were beginning to use statistical process control (SPC) charts and dashboards

to illustrate quality metrics.

Fit and Proper Persons

Trusts are required to meet the Fit and Proper Persons Requirement: directors (FPPR)

(Regulation 5 of the Health and Social Care Act (Regulated Activities) Regulations 2014). This

regulation ensures that directors of NHS providers are of good character and have the right

qualifications and experience to carry out this important role. The fit and proper person protocol

was contained within the corporate fit and proper persons policy, which was approved in May

2018. The protocol was applied to all trust board members and directors upon appointment. To

ensure there was continued compliance with FPPR, directors, including NEDs were required to

complete an annual self-declaration. Although NEDs were recruited though NHS Improvement, the

trust processed NED recruitment in the same way as directors, following both the NHS

Employment Check Standards and Fit and Proper Persons Requirements; including processing a

Disclosure and Barring Service (DBS) check and by checking the director/insolvency registers.

DBS checks identify whether a person has a criminal record or is on an official list of people barred

from working in roles where they may have contact with children or adults who may be vulnerable.

We carried out checks to determine whether appropriate steps had been taken to complete

employment checks for executive directors, in line with the FPPR requirement. We reviewed

seven board member files to assess compliance against the fit and proper person legislation and

found not all the required checks had been carried out. We found gaps in some of the files we

reviewed. There were no references checks on file for two board members and a further two only

had one reference on file. Two did not have any record of a register of interests and hospitality and

one did not have any evidence of managerial supervision. One board member did not have

evidence of DBS check on file. DBS came into effect on 1 December 2012 when CRB merged

with the Independent Safeguarding Authority (ISA). During our inspection, we were informed that

one of the two board members had applied for a DBS check because of our findings. All files we

reviewed contained an annual declaration.

Board Members

Of the executive board members at the trust, none were Black and Minority Ethnic (BME) and

55.6% were female. Of the non-executive board members none were BME and 11.1% were

female.

Staff group BME % Female %

Executive directors 0% 55.6%

Non-executive directors 0% 11.1%

All board members 0% 33.3%

(Source: Routine Provider Information Request (RPIR) – Board Diversity tab)

Vision and strategy

The trust’s strategy, vision and values were developed in 2016 and had not delivered on all the objectives set. Progress against delivery of the strategy and plans was not consistently or effectively monitored or reviewed and there was little evidence of progress. Leaders at all levels were not always held to account for the delivery of the strategy. Staff informed us they did not always observe or experience members of the executive team displaying the trust values in their behaviours. The trust’s strategy, vision and were developed in 2016 and required review which the

trust were aware of. Some senior leaders advised that the values remained current; however,

strong feelings were expressed by some who felt they were not lived by all staff and required

review. The trust strategy was agreed in 2016 with a five year implementation phase. The vision

was to provide the safest and kindest care in the NHS, with a mission of developing the healthiest

half-million population on the planet. To support this there were strategic objectives:

• Listening to and working with our patients.

• Patients and staff feel they receive safe and kind care.

• Working with our partners and communities.

• Providing innovative and inspirational leadership to deliver our ambitions.

• Creating a great place to work.

The trust stated strategy and objectives were underpinned by the trust values which were not well

embedded across the organisation. The trust recognised that a refresh of the strategy was

required to acknowledge the changing NHS environment and the development of the NHS long

term plan response. Discussions had commenced at board level about how the trust could

become more collaborative in the services currently provided. Key areas for development were

the agreement of the clinical strategy and the people and organisational development strategy.

The WRES was not explicitly referenced in the current strategy, it was an increasing focus of the

trust and board focus (along with the need to address a range of diversity issues and inequalities)

and it was planned to be included in the refresh.

There was a lack of robust and detailed operational plans to underpin the delivery of the of the

strategy or pace of improvement. A plan was developed each year aiming to help the trust to

deliver its strategy. This was monitored through the performance committee. The performance

committee met monthly and progress was being made on some key aspects, whilst other areas

remained challenging. To strengthen monitoring and oversight, trust leaders recently changed the

format for reporting to ensure all aspects of the plan for performance and quality were captured.

Leaders were also a key member of the local sustainability and transformation partnership (STP)

and integrated care system (ICS) development group. Work had been undertaken to review and

strengthen the governance processes for the system to progress the development into an

integrated care system. Leaders were working towards a population based approach to strategic

thinking across the system enabled by the use of good data.

Medicines optimisation targets for the safe, effective and efficient use of medicines were clearly

defined in the strategy. This included benchmarking against other trusts as well as working

together with the local clinical commissioning groups (CCGs). The chief pharmacist had a good

understanding of the proposed targets with all staff actively involved in delivering the vision.

The trust stated that the values were embedded within the employment lifecycle. However, staff

informed us across the different services we inspected that they did not always observe or

experience members of the executive team displaying the trust values in their behaviours. Staff

were aware of the values of the trust. Some senior leaders advised that the values remained

current however strong feelings were also expressed by some who felt they were not lived by all

staff and required review. Not all staff were aware of the trust’s vision or strategy or how they

contributed to developing the strategy to deliver the vision.

The medicines’ optimisation strategy and business plan was closely aligned with the trust strategy.

Feedback on progress was undertaken through the performance committee as well as the clinical

governance committee. A five-year workforce plan was in place. This involved increasing training

and development of pharmacist technician posts to deliver improved medicine reconciliation within

24 hours of patient admission. However, the service currently offered a six-day service with the

plan to ultimately work to a seven day service

Culture

There was an improving understanding of the importance of culture, however, there were

low levels of staff satisfaction, high levels of stress and work overload. Staff did not feel

respected, valued, supported or appreciated. Staff reported the culture was top-down and

directive. Staff told us about high levels of bullying, harassment and discrimination, and

the organisation was not taking adequate action to reduce this. When staff raised

concerns, they were not treated with respect, or the culture, policies and procedures do not

provide adequate support for them to do so. There was improving attention to staff

development and improving appraisal rates.

Leaders acknowledged the urgency to address the changes required in the trust culture. Some

staff reported a culture of bullying and harassment and this was supported in the staff survey. At

times we found a culture of defensiveness from some leaders. These were all issues raised at the

last well led inspection in 2018. We heard of executive leaders who had addressed

poor practice that was inconsistent with the vision, values and expected work practices. We also

heard that when poor practice was highlighted to staff by some executive leaders this was

perceived as bullying and harassment by those receiving the feedback with a lack of recognition of

individuals professional responsibility. There were other instances of managers at other levels not

taking action to address significant issues of safety and dignity. The trust was not

consistently acting as a result of concerns raised. Some staff felt nothing was done until a

grievance was raised.

Staff satisfaction was mixed and staff informed us they did not always feel actively engaged or

empowered. It was evident that staff cared about the services they provided and were committed

to providing the best possible care for patients however some poor practice was going unnoticed

and therefore we concluded had become normal accepted care.

Staff informed us they were not always listened to when they raised concerns regarding patient

safety. However, they informed us they generally felt supported by their colleagues and immediate

line managers. Due to the ongoing staffing pressures, staff felt tired and at times demoralised. Not

all staff we spoke with felt proud to work for the trust and we found, at times, a culture of being

embarrassed to work at the trust. Staff informed us there was ‘silo’ working and they felt the

executive team was not cohesive, with little focus on the key concerns and risks presented by staff

which resulted in poor morale. Staff within the hospital remained cautious with regards to changes

and some staff we spoke with were anxious.

Staff Diversity

The trust provided the following breakdowns of medical and dental staff, qualified nursing and

health visiting staff, and qualified allied health professionals by ethnic group.

Ethnic group

Medical and

dental staff

(%)

Qualified

nursing and

midwifery staff

(%)

Qualified allied

health

professionals

(%)

White 48.7% 88.9% 92.8%

Black and minority

ethnic 50.2% 9.2% 6.1%

Unknown / Not stated 1.2% 2.0% 1.2%

(Source: Routine Provider Information Request (RPIR) – Diversity tab)

NHS Staff Survey 2018 results – Summary scores

The following illustration shows how this provider compares with other similar providers on ten key

themes from the survey. Possible scores range from one to 10. A higher score indicates a better

result.

The trust was worst or joint worst in terms of the safety culture theme. In addition, the trust was

close to being the worst for the quality of care, safe environment (violence), and staff

engagement themes. These data are weighted to allow for fair comparisons between

organisations.

The trust’s 2018 scores for the following themes were significantly lower (worse) when compared

to the 2017 survey:

• Equality, diversity and inclusion.

• Health and wellbeing.

• Quality of care.

• Safe environment – bullying and harassment.

• Safe environment – violence.

• Safety culture.

• Staff engagement.

There were no themes where the trust’s scores were significantly higher (better) when compared

to the 2017 staff survey.

(Source: NHS Staff Survey 2018)

The trust performed worse than benchmark group average for the four questions relating to

communication and engagement from senior managers.

The trust performed worse than benchmark group average for the questions relating to staff experiencing violence in the workplace, bullying and harassment. The 2019 staff survey was published shortly after the inspection and it was noted that staff who personally experienced physical violence at work from patients / service users, their relative or other members of the public, from managers and from colleagues had decreased.

The trust performed worse than benchmark group average for all questions relating to staff

confidence in the safety culture at the trust. There was a lack of confidence in reporting incidents

and that staff that would do so would be treated fairly compared to benchmarked peers.

The top concerns highlighted within the Q4, Q1 and Q2 Staff Friends and Family Test (SFFT)

were:

• Advocacy,

• Involvement, and

• Management and leadership.

In the latest Q2 SFFT, 38% of staff agreed that they would recommend the Shrewsbury and

Telford Hospital NHS Trust as a place to work. Although there had been an increase this quarter,

recommending as a place to work was still 25% below the NHS Staff Survey (2018/19) average

and 28% below the SFFT (Q1) average. In addition, 46% of staff agreed that 'care is the

organisations top priority', this was 30% below the NHS Staff Survey average, with a 4% increase

compared to Q1 results (please note there is no national quarterly comparator).

54% of staff agreed that 'there are frequent opportunities to show initiative in their role', this was

18% below the national staff survey average, 56% of staff agree that they are 'able to make

suggestions', 18% below the national staff survey average and 39% feel 'able to make

improvements', 17% below the national staff survey average.

When the trust looked at the free text comments of the latest Q2 SFFT, out of the 526 comments,

163 related to poor leadership and management demonstrating the top theme of concern.

As evidence suggests, there were many reasons to ensure staff had a positive experience of

working in for the trust. Leaders were looking to develop a triumvirate relationship between

patient care, staff member and organisation.

(Source: RPIR)

The trust told us that the pulse surveys and staff focus groups feedback concurred with that of

the staff survey, i.e. at a team level, the scores were around benchmark average in the main;

however, when asked at an organisational level this was where the biggest variance occurred.

Overall, the staff survey and SFFTs did not represent the employment experience leaders

wanted staff to have in relation to morale, leadership and staff engagement.

Workforce race equality standard

The Workforce Race Equality Standard (WRES) became compulsory for all NHS trusts in April

2015. Trusts must show progress against nine measures of equality in the workforce. The scores

presented below are indicators relating to the comparative experiences of white and black and

minority ethnic (BME) staff, as required for the Workforce Race Equality Standard. The data for

indicators 1 to 4 and indicator 9 is supplied to CQC by NHS England, based on data from the

Electronic Staff Record (ESR) or supplied by trusts to the NHS England WRES team, while

indicators 5 to 8 are included in the NHS Staff Survey.

Notes relating to the scores:

• These scores are un-weighted, or not adjusted.

• There are nine WRES metrics which we display as 10 indicators. However, not all indicators

are available for all trusts; for example, if the trust has fewer than 11 responses for a staff

survey question, then the score would not be published.

• Note that the questions are not all oriented the same way: for 1a, 1b, 2, 4 and 7, a higher

percentage is better while for indicators 3, 5, 6 and 8 a higher percentage is worse.

• The presence of a statistically significant difference between the experiences of BME and

White staff may be caused by a variety of factors. Whether such differences are of regulatory

significance will depend on individual trusts' circumstances.

As of March 2018, one of the ESR staffing indicators shown above (indicator 2) showed a

statistically significant difference in score between White and BME staff:

2. In 2018, BME candidates were significantly less likely than White candidates to get jobs for

which they had been shortlisted (12.3% of BME staff compared to 21.1% of White staff). The

score had remained similar when compared to the previous year, 2017.

Of the four indicators from the NHS staff survey 2018 shown above (indicators 5 to 8), the

following indicators showed a statistically significant difference in score between White and BME

staff:

7. 72.7% of BME staff believed that the trust provided equal opportunities for career progression

and promotion compared to 84.5% of White staff. The score had remained similar when

compared to the previous year, 2017.

8. 14.1% of BME staff experienced discrimination from a colleague or manager in the past year

compared to 6.2% of White staff. The score had remained similar when compared to the

previous year, 2017.

At the time of submitting the WRES there were two BME voting board members at the trust,

which was not significantly different to the number expected, based on the overall percentage of

BME staff. However, it should be noted that by the time the trust submitted their RPIR in

September 2019, there were no longer any BME board members (see the table on page 3

above).

(Source: NHS Staff Survey 2018; NHS England)

The trust performed slightly better than benchmark group average for the first three questions

relating to staff experiencing discrimination.

The equality and diversity policy referenced the Equality Act 2010 and also referred to other

policies such as the dignity at work policy. The trust had delivered training in equality and diversity.

The trust board recognised that there were areas of identified inequality and planned to hold

listening events to address poor experiences of staff with disabilities as identified within the NHS

staff survey.

The trust demonstrated pockets of good practice and understanding of equality, diversity and

inclusion (EDI). The trust demonstrates good will and enthusiasm and the trust recognises the

importance of this agenda. The associate director of workforce demonstrated good level of

understanding however also recognised the need for expertise required to take the work forward.

To show their commitment, the trust has recruited an equality and diversity lead to take the

responsibility for leading the agenda at an operational level supported by a non-executive director

and the acting director of human resources and have recently formed an EDI sub-committee that

reports into the board. The acting director and NED show good level of understanding of EDI and

leadership commitment.

Friends and Family test

The Patient Friends and Family Test asks patients whether they would recommend the services

they have used based on their experiences of care and treatment. The trust scored 97.4% or

higher in every month from September 2017 and August 2019.

Friends and family test performance – Shrewsbury and Telford Hospital NHS Trust – September

2017 and August 2019

(Source: Friends and Family Test)

Sickness absence rates

The trust’s sickness absence levels from July 2018 to June 2019 were consistently similar to the

England average.

(Source: NHS Digital)

General Medical Council – National Training Scheme Survey

In the 2019 General Medical Council Survey the trust performed as expected for all 18 indicators.

(Source: General Medical Council National Training Scheme Survey)

The guardian of safe working hours reported to the workforce committee and provided reports to

the board on a quarterly and an annual basis. It was noted exception reporting remained low

although the guardian of safe working hours continued to promote the importance of it. Workload

intensity, gaps in the rota and cover for staff sickness were issues of concern in the guardian’s

report and were also raised at the junior doctor’s forum. There was a lack of detail in the report on

how these were being addressed.

However, a report entitled quarterly report was submitted to the board at the October 2019 board

meeting but did not clearly identify which quarter it was referring to. A further quarterly report was

submitted to the November 2019 board meeting which detailed it was for the period August to

October 2019. There were recommendations in both reports that were very similar. In the minutes

of the November 2019 board meeting it there was a report form the workforce committee that

sated it supported the recommendations. However, the recommendations were made to the board

to receive and approve however the minutes state the report was received and noted. The lack of

consistent wording made it difficult to see where decisions and approvals were being made.

Freedom to Speak Up Guardian

The Freedom to Speak Up review by Sir Robert Francis into whistleblowing in the NHS in 2015,

concluded that there was a serious issue in the NHS that required urgent attention if staff were to

play their full part in maintaining safe and effective services for patients. Several recommendations

were made to deliver a more consistent approach to whistleblowing across the NHS, including the

requirement for all NHS trusts to appoint a freedom to speak up guardian (FTSUG), and the

development of a single national integrated whistleblowing policy to help normalise the raising of

concerns. The trust had followed these recommendations. A freedom to speak up: raising

concerns (whistleblowing) policy was approved in August 2018. The trust has increased the

number of freedom to speak up guardians from two to three to ensure staff were able to raise

concerns and action was taken in a timely manner. All were part time in these roles. The

individuals were additionally supported by over 30 freedom to speak up advocates across the

organisation.

Leaders told us that the trust had increased the number of Freedom to Speak to Up Guardians to

support staff to raise concerns in a safe and supportive manner. There had been additional sub

board groups established to focus on key areas of risk including maternity services, chaired by the

chair; recruitment and retention, and emergency department group chaired by non-executive

directors. A trust medical appraisal lead had been appointed with the explicit objective to

strengthen the quality of medical appraisal. The ‘Monday Message from the CEO’ had been

introduced to share key issues and communicate personal message to staff. ‘Chatterbox’ had

been launched providing staff news of developments and initiatives across the organisation to

share best practice and the ‘SaTH APP’, that enabled 24 hour, seven day a week access to staff

to hear trust news, provide feedback, link to policies and a staff handbook. A new directorate has

been established, led by the previous medical director, to improve clinical effectiveness by

improving processes and governance in patient safety, learning from complaints and incident

reports, improved analysis of quality and performance metrics and embedding improvements from

audit.

The freedom to speak up guardians reported directly to the medical director and had direct access

to the chairman and the CEO. Reports were provided to the board on a quarterly basis and it was

noted that action was taken on some concerns raised, for example, there were concerns about

inconsistencies in granting compassionate leave. As a result, the relevant policy had been

updated to clarify the approach line managers should take when special leave requests were

made. It was noted in the themes reported that patient safety and behavioural were the most

common but the report did not give any indication on what sort of patient safety issues these were.

Whilst accepting that the number was relatively low at, five, this did not provide the board with any

indication of the severity of these or what was being done beyond reporting back to the relevant

ward manager.

The FTSU guardians had undertaken a wide amount of awareness work across the organisation

and most staff were aware of them. However, not all staff understood what their roles were the

trust recognised there were still pockets which required further support to fully understand this.

Staff told us they did not feel they were able to raise concerns without fear of retribution. The

following information was particularly concerning and supports the culture of not reporting

concerns and incidents:

‘It has been reported to the FTSU Guardians that colleagues have been told not to raise concerns

via incident reporting and when they have raised concerns these have not be acted upon in an

appropriate or timely manner. Incident reporting is not always encouraged and there is a strong

belief by colleagues that if they do incident report, nothing is acted upon and there is no feedback

given. Incident reporting is thought not to be taken seriously unless there is an element of severe

or moderate harm. In fact, incident reporting should be encouraged and acted upon. Feedback

when requested should always be adhered to and delivered in a timely manner’.

Whistleblowing matters raised with the human resources operational team were recorded on the

trust’s human resources activity sheet. A human resources practitioner was allocated to support

the relevant manager in managing the matter in accordance with the trust’s freedom to speak up

policy. Between 1 August 2018 and 31 July 2019 there were five matters raised with the team. In

addition, matters may be raised with the trust’s freedom to speak up guardians, and in their recent

report to trust board they recorded 37 matters lodged between 1 December 2018 and 21 May

2019, compared to 33 in the six months prior to this. These matters related to a range of concerns

(bullying and harassment, behaviour, managers, patient safety). In addition, staff could raise

matters direct with the nominated trust executive for whistleblowing.

There were examples of action taken to address behaviour and performance that was inconsistent

with the expected behaviours and values both formal and informal. Formal action was less

apparent in middle management roles and poor practice seen on our inspection suggests that

some practices had become normalised and acceptable.

Duty of Candour

From November 2014, NHS providers were required to comply with the Duty of Candour

Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The duty of candour is a regulatory duty that relates to openness and transparency and requires

providers of health and social care services to notify patients (or other relevant persons) of certain

notifiable safety incidents and reasonable support to the person. The trust had a policy (CG10)

that outlined the triggers, purpose and responsibilities for staff in relation to ‘Being Open and Duty

of Candour.’ The trust’s executive lead was the interim director of nursing. The trust’s patient

safety team, and other key workers such as the tissue viability team, provided local support for

nursing and medical staff when an incident occurred which met the criteria identified by the

statutory duty. Initial contact sheets for discussion purposes, information leaflets for patients, and

letter templates were also provided to support the process. Compliance was monitored through

the trust’s electronic incident reporting system and the serious incident process by the patient

safety team. Embedding of this process had been supported and encouraged during the past 12

months. Compliance was also monitored through the contracts process with local commissioners.

Leaders told us that the trust had an active programme of recognition and reward for staff

including VIP of the month and an annual VIP awards. The new medical director was planning a

re-structuring of the medical leadership in order to address responsiveness, clinical quality and

effectiveness. Recently, a trust medical appraisal lead had been appointed with the explicit

objective to strengthen the quality of medical appraisal. The trust had applied for funding from

NHSE/I for a clinical leadership development programme. The trust was working with NHSE/I

partners to ensure levels of attainment and best practice rostering are achieved. Reviews had

been commissioned into adult safeguarding and tissue viability services to undertake a baseline

review with expected recommendations for the development of the services to ensure sustained

improvements in patient safety.

Governance

The arrangements for governance and performance management were not always fully clear and did not always operate effectively. Staff were not always clear about their roles, what they were accountable for, and to whom. Governance systems were ineffective to ensure quality services were provided. The governance arrangements were becoming clearer but levels of assurance and confidence in

the assurance processes were not yet mature. The board were mostly clear about their roles

and accountabilities, but this was not the case throughout the organisation. The trust had had

several external reviews about their governance arrangements all of which had similar

recommendations and it was only recently that the recommendations were being implemented.

Leadership development was not yet in place throughout the different levels of

the organisation and this was apparent in lack of knowledge and experience in holding difficult

conversations such as at middle management and ward level.

There were six public board meetings throughout the year which followed the private trust board

meeting. The agenda was extensive. The meeting consisted of presentations of awards to staff

and a patient story, following this it was split into six parts; patient and family, monthly overview

(which also consisted of the chief executive’s report), workforce (people), quality and learning

(safest and kindest), performance (sustainability) and governance (leadership). A variety of reports

from the executive directors from a range of topics from their individual portfolios were presented,

as well as reports from NEDs on the committee they chaired. We reviewed papers submitted to

the trust board and the minutes of the discussions held and actions agreed. We found that where

papers identified key areas for consideration, minutes of trust board meetings did not always

reference any discussions held or decisions made.

The trust board was supported in its role by the six subcommittees, each chaired by a non-

executive director:

• Quality and safety committee.

• Audit committee.

• Performance committee.

• Sustainability committee.

• Remuneration committee.

• Workforce committee.

There were several committees and groups that reported to the quality and safety committee. It

was not always clear how information flowed between these groups. We found when issues were

raised through the governance structure, they did reach the board and the board were aware of

the issues. However, key issues of risk and patient safety were not always represented within

board papers to the full extent of the concerns and minutes of meetings did not detail that these

issues were fully acknowledged and acted on. We saw that the emergency department oversight

committee report was deemed not relevant to the quality and safety committee but was presented

at the performance committee instead. Staff told us they did not understand why this was the

case.

The quality and safety committee had a clear and defined purpose in promoting medicines safety

in the trust. There was an active drug and therapeutics committee which had significant medicines

optimisation presence and included representatives from the local clinical commissioning group.

These two groups then fed into the board level clinical governance Committee. Since April 2018,

the chief pharmacist was invited to the senior leadership team meetings giving clear lines of

governance to ensure medicine safety risks and incidents were well managed.

At ward and department level, quality was reviewed through monthly or bimonthly meetings which

discussed ward issues, incidents, pressure ulcers, audit results and staff and patient feedback.

However, we found not all ward meetings were held regularly and not all ward meetings followed

up on actions identified. Each care group held a care group board which discussed the services

delivery with the operational plan, workforce reports, staff survey, falls, pressure ulcers, serious

incidents, complaints, mortality, finance, performance and the risk register. The care group boards

reported into the clinical governance executive which escalated concerns and risks to the quality

and safety committee. However, we were also informed that each care group was also required to

present to the quality and safety committee on a quarterly basis.

Leaders recognised that they had challenges with the quality of data and could not be assured of

its accuracy, however this was the data they were relaying in to provide assurance of

improvements or to identify challenges.

Board Assurance Framework The trust provided their board assurance framework, which details their five strategic objectives, the risk of not meeting each, and sub-objectives under each. A summary of these is below.

• “Patient and family: listening to and working with our partners.

• Safest and kindest: patients and staff feel they were safe and received kind care.

• Sustainability and healthiest half million: working with our partners for all our communities.

• Leadership: innovative and inspirational leadership to deliver our ambitions.

• Creating a great place to work.”

(Source: Trust Board Assurance Framework – August 2019)

The risks within the board assurance framework did not fully reflect the current concerns, nor did

the actions taken to mitigate risk. For example, a number of issues had gaps in controls and/or

assurance however the further planned actions section did not always address these. In some

instances there were actions that did not relate to the gaps identified.

The board assurance framework was presented at each board meeting. The minutes for the

August 2019 board meeting record the board assurance framework (BAF) was presented by the

chief executive and a significant number of the risk to the strategic objectives were presented. At

the October 2019 board meeting the BAF was presented by the director of corporate governance

with two updates of changes since the previous review

The finance director provided monthly reports to the trust board. Growing agency spend and the

inability to achieve cost improvement plans added to financial challenges. Accountability and

ownership of patient safety agendas at board level was not always clear, with an expectation that

clinical care groups would take ownership, identify and improve the concerns from the ground up.

The interim director of nursing, midwifery and quality was the board lead for safeguarding. The

post holder was supported by adult and children’s safeguarding specialists who worked in

partnership with the local health economy. There was a suite of safeguarding policies to underpin

professional practice. An operational safeguarding group met quarterly and this was being

transitioned into a board, to ensure robust governance, reporting quarterly to the clinical quality

review and monitoring group and quality and safety committee for both children's and adults

safeguarding. An external review of adult safeguarding had been commissioned to include

training and the review of the internal safeguarding group.

Staff were required to undertake mandatory safeguarding training relevant to their job role to

enable them to identify and respond appropriately to issues of an adult and children safeguarding

nature. We found variable compliance with this and in particular compliance was low for medical

staff.

Named safeguarding professionals attend the Shropshire Safeguarding Adult Board, the Telford

and Wrekin Safeguarding Adult Board and the local Children’s’ Partnership meetings; this

incorporated attendance at relevant sub groups for these boards. The safeguarding team worked

within the remit of both “Adult Safeguarding: Roles and Competences for Healthcare Staff “(2018)

and “Children Safeguarding: Roles and Competence for Healthcare Staff “(2019) and the

“Safeguarding Children, Young People and Adults at Risk in the NHS: Safeguarding

Accountability and Assurance Framework “(August 2019).

Medicines’ reconciliation (MR) was undertaken by a pharmacy technician on admission and was the

process of identifying an accurate list of a person’s current medicines, assessing the suitability of

any patient’s own medication, recognising any discrepancies, and documenting any changes. This

was audited monthly by the trust. Medicine optimisation was integrated into the trust’s governance

structure. There were clear reporting lines for medicine safety direct to board level. The medicines

safety committee reported to the clinical governance committee which then reported to the board

level quality and safety committee. Although it was acknowledged that the safe medicine committee

struggled at times with medical support.

A pharmacist clinically reviewed the patient and communicated any interventions and

recommendations to the clinical team. Any medication required at this point and during their

journey was dispensed through pharmacy. The trust used a ‘dispense for discharge’ model. When

a medicine was prescribed on the drug chart it was labelled with directions of how to take and

stored in the patient’s bedside locker for the nurse to administer during the inpatient stay and

ready for discharge. This model resulted in at least half of patients requiring no medicines to be

dispensed on the day of discharge due to a proactive service by pharmacy. Patients were

reviewed by a pharmacist through their admission, highlighted by the nursing teams, to provide

clinical reviews, antibiotic stewardship, advice and facilitating discharges. Specialist advanced

pharmacists were in post in critical care, oncology, paediatrics and neonates and antimicrobials.

The trust also provided the distribution service to inpatients through stock medicine supply to

wards and departments. The aseptic service provided both parenteral nutrition and chemotherapy,

a mixture of prepared in house and outsourced. For outpatients, the trust dispensed urgent and

hospital only items providing FP10 prescriptions for routine, non-urgent items and an extensive

homecare service. The trust had a drug and therapeutics committee and safe medication practice

group.

In the end of life service there was a lack of audits being undertaken therefore we were not

assured the quality of care was reviewed. There was also no service level agreement in place for

the provision of the palliative care staff, this made the service vulnerable as the provision could be

removed at any time. This had not been addressed since the last inspection.

Management of risk, issues and performance

Although the trust had systems for identifying risks, planning to eliminate or reduce them,

and coping with both the expected and unexpected these were not working effectively.

Under the heading of the board assurance framework, the corporate risk register was presented at

each board meeting with an update from the operational risk group. The corporate risk register

listed all operational risks scoring 15 and over and it was updated in priority order monthly at the

operational risk group. The highest scoring risks, those 20 and over were at the sub committees

each month together with the BAF. These risks were also reviewed at the senior leadership team

meetings. As at November 2019 there 102 open risks of 15 and above.

At the last inspection systems did not support robust and corroborated information. There

was inconsistent completion of serious incidents investigation forms, with a lack of robust learning

from some serious incident investigations. This had not improved at this inspection.

If the level of harm was moderate or above, the incident was flagged through the incident reporting

system to a patient safety advisor and senior care group staff. All serious incidents and never

events were escalated by a senior member of the care group who was advised and supported by

a patient safety advisor. The clinical incident management policy, which was approved in May

2018, had a clear process to report and investigate serious incidents and never events.

A new process was in place for executive oversight of serious incidents. We reviewed twelve

serious incident investigations and found inconsistent use of the serious incidents template. We

found three different templates were used. Front sheets were missing from all templates reviewed

and there were varying levels of independence of the investigating officers. Any training received

by the investigating offers was unclear. We also found not all actions had been followed through

to ensure lessons learnt were implemented and embedded. In addition, there was not always clear

ownership of the actions, timelines for completion and follow up. We asked the trust to relook at

the actions from a specific serious incident as we did not feel these covered all the issues

identified.

Incidents resulting in no or low harm were not reviewed in a timely manner or thoroughly, nor

could it be clearly evidenced that appropriate action had been taken. The trust did not

have assurance low and no harm incidents were recorded appropriately, and it was difficult to map

trends and themes. We requested up to date information on the backlog of incidents as the

number had been high; we had conflicting verbal information on if it had reduced and by how

much. The data we received demonstrated a backlog of more than 1000 incidents awaiting review.

Although some staff informed us they were confident in reporting incidents and knew how to use

the incident reporting system, we were also told that some staff were discouraged from reporting

incidents and this had been raised as a concern to the freedom to speak up guardian. For

example, we were frequently told that staffing issues were not always reported. Where incidents

had occurred, there was a lack of learning or appropriate actions. We found incidents that

reoccurred, for example, the repeated lack of access to emergency medicines in the emergency

department, lack of falls assessment and patients who subsequently fell and came to harm as a

result.

The trust told us that there had been a number of changes in personnel since the last CQC visit

which had resulted in a ‘fresh eyes’ approach to seeking assurance regarding information flowing

from board to ward and vice versa. It was recognised that there was a meeting structure in place

incorporating care groups boards, specific safety and quality sub-committees and clinical

governance executive with assurance provided to board via the quality and safety committee,

which has an annual work programme. Examples of reporting included: complaints reports,

infection prevention and control annual report, clinical audit and ward exemplar programmes and

safer staffing. Where there are issues identified themed reviews were requested. Each executive

was taking a lead for each of the work streams following the last inspection to ensure ownership

and visibility. Board members undertook assurance visits to clinical areas and feedback findings of

positive issues and those which executives are required to act on.

Several actions were being taken to strengthen assurance including:

• A review of the use, analysis and feedback of incident reporting;

• Establishment of an executive serious incident review group;

• Redesign of the quality and safety monthly report to better reflect key quality and safety

priorities.

The findings from the core service inspections and a backlog of incidents for review suggests a

lack of a learning and safety culture, issues were not being recognised and poor practice not

challenged. For example, whilst there was evidence of sepsis being discussed at all levels

including the board, we found observations for national early warning scores not consistently being

undertaken therefore a significant risk of sepsis not being identified and managed appropriately.

Poor practices of infection prevention and control in particular, relating to isolation practice and

hand hygiene were not challenged and therefore accepted and normalised. Patients privacy and

dignity was not maintained.

The director of nursing was the executive lead for mental health. We had serious concerns relating

to the care of patients with mental health needs. Staff did not support patients who lacked capacity

to make their own decisions or were experiencing mental ill health in line with legislation and

national guidance. Deprivation of Liberty Safeguards (DoLS) was not implemented in line with

approved documentation with guidance on the criteria for and the timeliness of an application for

the authorisation of the DoLS inconsistent. For example, the trust’s own risk assessment for use of

bedrails stated that if a patient was restless or confused, staff should not use bedrails. We saw

evidence of unsafe and inappropriate use of bedrails in a confused patient. The risk assessment

form stated that the patient was restless, confused and was living with dementia. The patient had

a bedrail in place and no DoLS assessment was in place.

Managers did not monitor the use of Deprivation of Liberty Safeguards and did not make sure staff

knew how to complete them. In all the documents we checked, staff had not carried out daily

reassessments for patients who lacked capacity. On-going assessment of patients with fluctuating

capacity, such as when this was likely to improve with medical treatment was not always carried

out.

The trust had a number of conditions imposed on its registration relating to urgent and emergency

care and maternity. The issues found at the last inspection in urgent and emergency care had not

been addressed and therefore the trust was in breach of its conditions. We were not assured that

there was an: effective system in place to identify, escalate and manage patients who may present

with sepsis or a deteriorating medical condition; effective management of children along the

emergency care pathway; effective system to ensure patients were clinically assessed within 15

minutes of arrival in the emergency department.

Trust corporate risk register

The trust provided their board assurance framework, which details current risks and how they are

being managed. This included nine risks with a risk score of “high” as of August 2019.

The nine risks with a current risk score of “high” are shown in the table below. Date risk opened,

and next review date were not included in the board assurance framework.

ID Description Risk score (current)

Risk level (target)

423 We need positive staff engagement to create a culture of continuous improvement

High Very low

670

We need to deliver our control total and meet the trajectory to live within our financial means so we can meet our financial duties and invest in service development and innovation

High Medium

859 We need a recruitment strategy for key clinical staff to ensure the sustainability of services

High Low

1134 1158 1197 1235 1369 1426

If we do not work successfully in partnership, our current traditional service models for both unscheduled and scheduled care will be insufficient to meet escalating demand

High Low

1204 Our maternity services need to evidence learning and improvement to enable the public to be confident that the service is safe

High Low

1492 We need an agreed Digital Strategy to underpin service improvement

High Low

1533

We need to implement all of the ‘integrated improvement plan’ which responds to CQC concerns so that we can evidence provision of outstanding care to our patients (Identified December 2018)

High Low

1558 We need to have sufficient, competent and capable Directors to deliver the Trust's agenda.

High Low

1584 We need funds to invest in our ageing estate to replace old equipment so we can provide the highest quality of care in a safe environment.

High Medium

(Source: Trust Board Assurance Framework – August 2019) All risks were recorded on an electronic risk management system, which the risk owner was

responsible for updating monthly. The operational risk group reviewed risks that required

executive action, including those with significant threat(s) to the operation, resources or reputation

to the trust. Capital action cost was included within the risk where applicable. The operational risk

register was presented to the trust board monthly. However, the controls and assurance of

mitigation was not always evident. Minutes from board meetings did not consistently evidence

challenges of risks or that assurances were being sought to ensure patient care and safety was

not compromised.

There was a good, established management of medicine safety alerts within the trust. Pharmacy

ensured that there was a clear evidence chain of communication to patients and clinicians through

the care groups. Action and learning from any medicine errors were undertaken and shared

across the trust. The pharmacy risk register and medicine management risks were contained

within the trust risk register.

The trust had deteriorating financial performance and had not met its control total in previous

years, this trend had continued in this financial year. The trust recognised its challenged financial

position and has identified some of the reasons for this performance. Interventions were in place;

however, no financial improvements were expected in this financial year. The trust had a planned

deficit of £17.351m for 2019/2020 which was worse than average for similar trusts. The trust was

not in financial special measures. The effect of workforce challenges led to an increased spending

on agency staffing and an inability to secure the full level of cost improvement savings.

Finances Overview

Financial metrics

Historical data Projections

Previous Financial Year

(2017/18)

Last Financial Year (2018/19)

This Financial Year (2019/20)

Next Financial Year (2020/21)

Income £359.1m £369.3m £381.1m Not available

Surplus (deficit) (£17.4m) (£18.7m) £0.0m Not available

Full costs £376.5m £388.0m £381.1m Not available

Budget (or budget deficit)

(£6.1m) (£8.6m) £0.0m Not available

The deficit reported in 2018/19 was higher than the previous year’s deficit. At the time of

submitting the PIR, the projections for 2019/20 indicated that the trust would break even.

(Source: Routine Provider Information Request (RPIR) – Finances Overview tab)

Non-executive directors demonstrated understanding of the drivers of the financial deterioration

and interventions in place but indicated that there has previously been a slow pace in

implementing improvement actions.

The trust was forecasting to deliver only 70% of its cost improvement plan (CIP). CIP delivery has

been a challenge in previous years, with the trust citing limited capacity and capability to develop

and deliver efficiency schemes as the main reason for this. The trust commissioned a

management consultancy firm to support with in-year delivery of efficiency programmes and

development of more robust CIP governance structures for future years. Interviews with

stakeholders revealed further work was required to fully engage substantive staff in development

of the CIP schemes and ensure future ownership by care groups.

Non-executive directors also highlighted that finance reports do not meet the information needs of

users, for instance there was no drill down capability, forward looking risk assessments, or

triangulation with non-financial information. The trust recognises that performance reporting

needed to be improved to ensure that key issues were immediately obvious and there was

coherency in information across finance, activity and quality. A review of the integrated

performance report to address this was ongoing, however timelines for completion were yet to be

defined at the time of the inspection.

Care groups were involved the in budgetary control processes including, in planning, monitoring

and forecasting financials. Additional meetings have been established to strengthen monitoring

and understanding of the financial position. A standard business case template has been

developed and approved by the performance committee but is yet to be implemented across the

trust. The trust expects that this will capture the right inform to support better investment decisions.

The trust’s learning from deaths process was established, and since 2017 the trust

published corporate mortality data quarterly as a dashboard. Thematic analyses of deaths,

with focused reviews generating identified areas for improvement, had been completed

each quarter. The mortality metrics for the trust, including HSMR, were within the expected

range.

An initial review was completed for all deaths by a consultant not directly involved in care. The

‘National Guidance on Learning from Deaths’ (2017) was followed. Information was collated from

these review forms and presented at speciality level mortality and morbidity meetings. A mortality

report was prepared on a quarterly basis; this followed the trust’s governance pathway, to

speciality care board, to clinical governance executive, to quality and safety committee, to trust

board and was shared with commissioners. An overall outcome was identified from the review

forms which identified the next steps as appropriate including a full investigation if it was identified

sup optimal care had been provided which might have made a difference or would reasonably be

expected to have made a difference.

There was a clear documented pathway for mortality reporting and escalation into serious

incidence investigation if warranted and evidence of serious incident report discussions at board

level exist. However, the mortality task force was limited in staff, with only one officer coordinating

the whole process who only worked few hours a week. There was no cover when they were away.

The oncology mortality reviews remained separate to the rest of the trust mortality reviews, the

rationale for this was unclear. There were two very similar mortality reviews about patients over 85

years of age with multiple comorbidities who underwent hip replacement and they died from

complications shortly after that. The reason for offering surgery was ‘patient choice’ and there was

no clarity whether other options were considered.

Staffing was raised as highest risk to the quality of care and safety of patients.

Safer staffing levels were submitted and published on the trust’s’ internet webpage monthly as per

national guidance. This was supported by a staffing paper that was reviewed at quality and safety

committee. The papers highlighted any areas of concern where fill rates fell below 85% and what

mitigation had occurred to support areas; it was noted that nursing workforce remains a significant

risk and the trust was working with NHSE/I and HEE Global on overseas recruitment. A standard

operating procedure had been written to enhance the process for the monthly data sign-off and the

report was currently being revised revision to provide more explicit links to quality and safety, as

from the September 2019 committee. Bi-annual staffing review papers (‘Safer nursing Care Tool,

NICE2014’) had been submitted to the board demonstrating variance to care hours per patient

day; however, these had not been crossed referenced to ward budgets and therefore changes

were not evident to support workforce reviews based on acuity as part of annual budget setting. A

review of funded ward posts against e-rostering templates had occurred for care groups and an

agreed programme of work to review staffing levels and new roles was underway, aligned to

exemplar. Data collection occurred in July 2019 and October 2019 and planned for January 2020

in line with national data collection working in conjunction with NHSE/I staffing lead. Maternity

staffing had been reviewed in line with Birth Rate Plus with investment to support

recommendations; this was next due in 2020. Paediatrics staffing had been benchmarked against

national guidance and further work was required.

There had been some successes with the overseas recruitment, with 176 nurses recruited from

India. The trust recognised the need to support these staff both as groups of staff but also on an

individual basis as they adapted to a new life style in the area.

Staff told us they were frequently asked to move clinical area to cover staffing shortages and this

caused anxiety and frustration. Some staff reported feeling unsafe working in unfamiliar areas and

described being asked to undertake clinical tasks for which they were not trained.

The lack of a service level agreement for the provision of the palliative care service had not been

recognised as a risk and therefore not addressed.

The trust was failing to meet a number of metrics:

• A&E four hour performance, target 95%, performance April to October 2019 ranged from

64% to 73%.

• Cancer 62 days targets were not meeting the targets. Sixteen patients waited over 104 day

for their received their first definitive treatment for cancer in September 2019, the target for

referral to treatment being 62 days

• Referral to treatment performance was consistency around 86% against a target of 92%,

with the volume of patents on incomplete pathways increasing each month for the last four

months.

• Diagnostic waiting times of less than six weeks had met the target for four of the seven

months April to September 2019.

However, performance was improving in the following areas;

• Cancer two week waits all cancers, target 93%, performance April to October 2019 ranged

from 82% to 93%, with improvements each month July to September.

• Cancer two week waits breast, target 93%, performance April to October 2019 ranged from

12.5% in May to 91% in September. There had been significant shortages in breast

radiologists resulting in poor performance from April to August, however actions had

resulted in a significant improvement in September 2019.

• Cancer 31 day targets, by September were all above the target.

Information management

The information used in reporting, performance management and delivering quality care

was not always accurate, valid, reliable, timely or relevant. Leaders recognised the quality f

data was poor however they were relaying on and taking assurance from this data.

Information was used mainly for assurance and rarely for improvement. Required data or

notifications were submitted to external organisations. Arrangements for the availability,

integrity and confidentiality of patient identifiable data, records and data management

systems were not always robust.

There was heavy reliance on manual systems to provide information with a lack of trust in the data

available. This was recognised by the trust with a digital strategy in development. The trust told us

of the weaknesses in their record systems. Ward-based nursing forms were paper based and fed

the paper case note file which cannot not be omnipresent. In the emergency department there

were issues with the patients ‘cas’ cards being lost or mislaid. No bedside electronic clinical noting

took place. No electronic prescribing took place. There was a requirement for clinical information

asset owners and administrators to maintain access control, content and quality on a daily basis;

including duplicate entry reporting and cleansing.

The trust was working with NHS Digital Trust System Support Model (TSSM), on the first steps of

moving towards a primary electronic record with the implementation of an emergency department

system. Trust board had approved an outline approach for a new electronic patient record (EPR

system) for the organisation.

The trust recognised the need for an EPR system as the organisation had various systems

working in isolation along with manually collected data (on paper). In light of this a data warehouse

project was underway to align and structure existing data in readiness for a new EPR.

A digital change control board has recently been established which was looking at the prioritisation

of new requests or changes to existing systems. This was part of the wider digital governance

review in conjunction with NHS Digital TSSM. There were some good examples at the trust of

innovation in systems (including patient scheduling, patient-held cancer recovery apps, clinical

portal); however, there was not the bedrock of technical infrastructure, project, business analysts

and support staff to support and protect that investment going forward; increasingly with important

cyber security due diligence and care obligations. Investment was largely risk driven resulting in

serial underfunding of clinical informatics and supporting infrastructure. There was an accumulated

backlog of important technical infrastructure supporting clinical systems of £1.5 million per year.

The trust used a large number of information systems across the organisation, which captured and

recorded relevant clinical and demographic data about patients along their pathway. Together with

clinical systems, there were also non-clinical systems in place that captured such areas as incident

reporting.

The board and committee papers were beginning to use statistical process control charts to support

improved analysis. We saw evidence of this is in the papers reviewed and it was welcomed by board

members.

The responsibilities for the Caldicott guardian was held by the medical director. A Caldicott

guardian is a senior person responsible for protecting the confidentiality of people’s health and

care information and making sure it is used properly. It was unclear if information from the

Caldicott guardian was escalated to the board. The finance director was the senior information risk

officer who had overall responsibility for the organisation’s information risk policy. We saw

evidence to show information governance breaches were reported and investigated as

appropriate. The trust employed a dedicated information security manager who held the

appropriate qualifications and had the suitable experience.

Since the last inspection, the trust had purchased lockable notes trolleys and implemented a

standard operating procedure. The trust provided data and relevant notification to external bodies.

Engagement

The trust engaged with patients, staff, the public and local organisations to plan and manage services and collaborated with partner organisations. However, staff felt they were not listened to and were sometimes fearful to raise concerns or issues, these were issues at the last inspection.

There was improving relationships with partners but a need to develop shared vision with

supporting actions in order for the trust to deliver its improvements to patient care. There was

recognition from the board that improvement required support from the whole local care system

and relied on their partner organisations to support them to achieve the required improvements. A

risk summit took place in December 2019 between the core service inspections and the well led

inspection. A risk summit can be held where it is believed that the poor care identified may in art

be due to a system wide failure of health, social and primary care support leading to significant

failure in the trust. The purpose it to develop a plan with care partners to address the failures.

Whilst support was offered at the December 2019 risk summit this did not translate to the requires

actions to make sufficient improvement in the demand on the service or the quality of care patients

received.

The trust was part of the Shropshire and Telford and Wrekin Sustainability and Transformation

Plan (STP). This STP was a collaboration of 14 organisations across primary care, community

services, social care, mental health and acute and specialised services. Partnership conversations

were enabled through the strategic leadership group held monthly. An example of joint working

was looking at new models to deliver musculoskeletal services.

The board approved the patient experience strategy in July 2017. The strategy was informed by

and reflected the NHS Constitution, the trust values, the NHSI Patient Experience Development

Framework and the views and experiences of members from the patient experience panel. The

two key objectives developed from the strategy were:

• To listen to patients and their families to learn how to improve the care provided.

• To collaborate with patients and other community partners in designing, monitoring and

improving the care provided.

The strategy clearly identified the methods for obtaining patient feedback. Patient involvement was

integral to the delivery of the strategy and had identified four specific priorities for their work over a

two-year period. The trust captured patient feedback in various methods, including patient stories,

exemplar wards, observations of care, friends and family test, complaints, compliments,

stakeholder events, patient surveys, carer surveys, feedback websites and external agencies. This

information was then used to inform the trusts quality account. Themes from complaints and the

friends and family test were both featured in the quality account for 2018/19.

The trust was reviewing its approach to patients experience through the establishment of a

strategic patients experience, a gap analysis against the NHS Improvement patient experience

framework.

The trust told us of improvements in patient engagement with the following actions:

• The formation of the PaCE (patient and carer experience panel) with patient representation

looking at engagement and in all areas of the hospital including improvements and

feedback. This panel recently reviewed a sample range of hospital food to give feedback

during its review.

• A learning disabilities workshop took place for the first time in June 2019, bringing together

patients, carers and stakeholders from across the area to look at ways of engaging and

improving access for all.

• The introduction of an eye clinic liaison officer.

• Introducing yellow name badges to reduce barriers for patients with visual and cognitive

impairment.

• Improving accessible toilet facilities to become a stoma friendly trust.

• Access to translation services had been simplified with guidance available to staff enabling

translation to be booked at any time improving accessibility.

• Introducing Independent Domestic Violence Advisors to support men and women.

• The ‘Baby Buddy’ application has been introduced to provide information, support and

signposting to pregnant women, reaching across the diverse and rural population served by

the trust.

Staff feedback was captured through SaTH conversation / time to talk campaign, as well as

updates to the workforce committee from freedom to speak up guardians, staff side and guardian

of safe working hours. The latter two also provided updates to the trust board directly. Themes

were captured and integrated into an action plan with the staff survey results, which was

monitored through the workforce committee.

Staff informed us they did not feel listened to when they raised issues or concerns and at times felt

fearful to raise concerns due to potential repercussions, this was also an issue at the inspection in

2018. Whilst the executive team could provide evidence of a range of visits to wards and

department staff stated they were not visible and their perception was that the board did not

understand the extent or impact of issues and concerns on operational issues.

Since taking up post the interim chief executive had sent a weekly email to all staff, staff did

recognise this as a positive step. The trust was working collaboratively with Shropshire Council to

build a team of Veterans Aware Champions in the workforce. A number of events have been

organised and the trust hosted the Armed Forces Covenant Partnership meeting in September

2019. Training for volunteers will be provided by Shropshire Council's Armed Forces Covenant

Officer in the first instance.

Learning, continuous improvement and innovation

Improvements were not always sustained. The organisation did not react sufficiently to risks

identified through internal processes, but often relied on external parties to identify key risks

before they start to be addressed. Where changes were made, the impact on the quality and

sustainability of care was not

Documents

Shrewsbury and Telford Hospital NHS Trust ·