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AGENDA ITEM 3.1 9 July 2014 Title of the Health Board Report AGENDA ITEM 3.1 9 July 2014 Title of the Health Board Report ‘TRUSTED TO CARE’ REPORT – HEALTH BOARD RESPONSE Executive Lead: Director of Nursing Author: Board Secretary / Director of Corporate Services and Governance Contact Details for further information: Robert Williams, 01443 744818 or email [email protected] Purpose of the Health Board Report The purpose of this report is to present the findings of the report “Trusted to Care” – the independent review into aspects of care and practice at Princess of Wales and Neath Port Talbot Hospitals, commissioned by the Minister for Health and Social Services in the Welsh Government to the Board and to consider the actions taken to date and planned, which are outlined within the responses provided to the Minister and also separately to the Older Peoples Commissioner. Governance Link to Health The Board’s key role is to ensure the Board’s Strategy Board Strategic is being progressed. Objective(s) – To ensure standards of good governance are in place and compliance with the regulatory framework. Supporting ‘Trusted to Care’ Report, Professor June Andrews and evidence Mark Butler (May 2014) Dignified Care?, Older Peoples Commissioner. Access link to UHB Internet page where all related information is provided. http://www.cwmtafuhb.wales.nhs.uk/news/32912 ‘Trusted to Care’ Health Board Page 1 of 7 University Health Board Meeting Response to the Minister & Older Peoples Commissioner 9 July 2014 Engagement – Who has been involved in this work? The Board, lead by work coordinated by the Director of Nursing and the Assistant Director for Quality Improvement and Clinical Governance. Health Board / Committee Resolution (insert √) To; APPROVE ENDORSE DISCUSS √ NOTE √ Recommendation NOTE the report and the responses submitted to the Minister and the Older Peoples Commissioner, which are also available on the UHB Internet site and DISCUSS any related issues. Summarise the Impact of the Health Board Report Equality and Care Standards should be of a standard and diversity quality for all patients receiving services including those in the protected groups. E.g. frail elderly and cognitively impaired. Legal implications It is essential that the Board has robust arrangements in place to assess, manage and mitigate risks faced by the organisation. Population Health No impact Quality, Safety & Ensuring the Board has robust assurance Patient Experience arrangements in place to minimise the risks of standards of care which falls below the standards reasonable to expect. Ensuring appropriate application of the Regulations and care standards to provide high quality and safe care. Resources Ensuring the Board commissions and delivers high standards of care within the available resource. Risks and Assurance Ensuring full compliance with Standards for Health Services in Wales that provide assurance relating to safe and effective care is essential. Standards for Health Access to the Standards can be obtained from Services the following link. http://www.wales.nhs.uk/sitesplus/documents/1 064/Doing%20Well%2C%20Doing%20Better.pdf Standard 1. Governance & Accountability. Standard 8, Care Planning Standard 10, Dignity & Respect Workforce There are significant workforce implications to ensure the learning and improvement agenda being followed by the UHB is embedded in practice. ‘Trusted to Care’ Health Board Page 2 of 7 University Health Board Meeting Response to the Minister & Older Peoples Commissioner 9 July 2014 ‘TRUSTED TO CARE’ REPORT – HEALTH BOARD RESPONSE 1. SITUATION / PURPOSE OF REPORT In March 2013, a cluster of concerns regarding the Princess of Wales Hospital was brought to the attention of the Abertawe Bro Morgannwg (ABMUHB) Board. These included a police investigation into “falsification of records”, two critical Ombudsman’s reports, relatively high (risk adjusted mortality) RAMI rates. A further serious complaint by a member of the public involving care at both Princess of Wales and Neath Port Talbot Hospitals was subsequently escalated to the Board and reported to the police. As a result the Abertawe Bro Morganwwg Board discussed these concerns at meetings in public and set up a quality and safety programme at Princess of Wales Hospital and commissioned an external review of safety and quality by AQuA. Following a meeting between the Health Minister and one of the complainants the Minister decided to commission an independent external review. The Review was undertaken between December 2013 and April 2014 by the Dementia Services Development Centre (DSDC) and The People Organisation (TPO). The “Trusted to Care” report “is about quality and patient safety. It includes a narrative and analysis of what the Review established, identifies a number of areas of concern and makes a series of recommendations for action. These recommendations largely consist of remedies which the Review Team believes are within the grasp of the local NHS leadership”. 2. BACKGROUND / INTRODUCTION The Review Team was led by Professor June Andrews, Director of the DMDC at the University of Stirling and Mark Butler, Director of TPO. The remit for the Review concentrated on four areas: • The culture of the care of older patients, particularly in the medical wards; • The administration and recording of medicines, particularly how medicines are administered to patients who are cognitively impaired or have other challenges taking medicines orally; • How professional nursing standards are protected and delivered consistently and how the Health Board responds to lapses in delivery of these standards; • The response to complaints, how they are handled by the Health Board and how professionals are held to account for lapses in care identified through investigation including Protection of Vulnerable Adults (POVA) investigations. ‘Trusted to Care’ Health Board Page 3 of 7 University Health Board Meeting Response to the Minister & Older Peoples Commissioner 9 July 2014 The Review Team focused on the current position in the hospitals and report of previous experiences of older people in the care of ABMU over a three year period. 3. ASSESSMENT / GOVERNANCE AND RISK ISSUES The published report “Trusted to Care” is attached via the following link to the Cwm Taf internet site. http://www.cwmtafuhb.wales.nhs.uk/news/32912 Should any members of the Board require ‘hard copies’ of the related correspondence please notify the Board Secretary / Director of Governance. It should be noted that the authors state that “The Report provides a thorough account of the work of the Review Team and is intended to be read, and engaged with, as a whole”. The report, which needs to be read as a whole, as it is felt that Health Boards need to focus on the entire report content rather than just the 18 summarised recommendations (14 for action by Health Boards and four by Welsh Government). The review found that some of the poor professional practice which was evident in the past is still happening on some of the wards of the Princess of Wales and Neath Port Talbot Hospitals. The report states that “This is unacceptable and requires immediate concerted action, in addition to the required longer-term cultural and behavioural change. It is important to make it clear that these concerns are not of a scale to warrant action being taken by the Minister in respect of the current leadership of the Board”. It also states that “There are examples of exemplary practice throughout both hospitals.” The report contains a number of quotations from patients and relatives which convey the seriousness of concerns in a way that cannot be conveyed by statistics or dry discussion about professional practice. On 13 May 2014, Mark Drakeford, Minister for Health & Social Services wrote to all Chairs and Chief Executives of Health Boards and NHS Trusts in Wales to highlight the publication of the Andrews Report “Trusted to Care”. His letter is also accessible via the link to the Board’s internet page. In this he states “The review team’s findings and observations will be for everyone in the NHS. I am determined that nothing of this sort will be tolerated in any hospitals, any Health Board or Trust in NHS Wales in the future”. The Minister gave each NHS Wales organisation a four week period (by 11th June 2014) to absorb the findings of the report and satisfy themselves that such departures from basic professional standards are not present in their organisations. ‘Trusted to Care’ Health Board Page 4 of 7 University Health Board Meeting Response to the Minister & Older Peoples Commissioner 9 July 2014 In the immediate weeks after this, all district general hospitals will be visited, unannounced by a team of senior individuals to undertake a series of Ministerial “spot checks” in the following four areas of care: • In giving patients their medication; • In ensuring that patients are kept hydrated; • In the overuse of night-time sedation; and • In basic continence care. The findings will be reported directly to the Minister and Professor Andrews and her team have agreed to direct and guide this process. Sir Ian Carruthers will provide leadership to the activity. At the time of writing this report, unannounced visits had been undertaken at the Royal Glamorgan Hospital and Prince Charles Hospital, informal feedback was very good and the Board is awaiting the formal reports. Following the publication of the ‘Trusted to Care’ Report, the Chairman and Chief Executive agreed a series of immediate with the Executive team, some of which were immediate and others to take place over the four weeks prior to submitting the response to the Minister. A series of actions led by the Executive Director of Nursing and supported by the Assistant Director of Quality Improvement and Clinical Governance were undertaken. In the Minister’s letter, he asked Health Boards to assure themselves that matters raised within the report are not features of care being provided within their respective organisations. On this basis the Board shared with the Minister the work it was already doing or has planned, along with any supplementary work arising from our review and consideration of the ‘Trusted to Care’ Report.
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