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PUBLIC BOARD 26 March 2020

Care Quality Commission (CQC) Provider Well-Led Review - Update

Presented for: Information and Assurance

Presented by: Lisa Grant, Chief Nurse

Author: Craig Brigg, Director of Quality

Previous Committees:

Quality Assurance Committee 27 February 2020

Trust Goals

The best for patient safety, quality and experience

The best place to work

A centre for excellence for research, education and innovation

Seamless integrated care across organisational boundaries

Financial sustainability

Key point/Purpose

1. The CQC revised its inspection framework in 2018/19,

introducing a more focused, risk orientated approach

to inspection. This involved a new inspection cycle

that included a provider well led review.

For information

2. The CQC undertook a provider well led review at

Leeds Teaching Hospitals NHS Trust in September

2018.

For information

3. A high level self-assessment has been undertaken

against the key lines of enquiry for the well led domain

and the specific requirements to achieve an

outstanding rating.

For information

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1. Summary This report provides an update on progress related to Provider Well-Led following the last CQC inspection in September 2018.

2. Background

Leeds Teaching Hospitals NHS Trust was required to register with the Care Quality Commission (CQC) under Section 10 of The Health and Social Care Act 2008 from 1 April 2010. The Trust is required to be compliant with the fundamental standards of quality and safety.

The CQC revised its inspection framework in 2018/19, introducing a more focused, risk orientated approach to inspection. This involved a new inspection cycle that included a core service inspection (a maximum of four core services), use of resources review and provider well led review.

3. CQC Inspection September 2018 – Provider Well-Led

The Provider Well-Led review was carried out by the CQC at Leeds Teaching Hospitals NHS Trust in September 2018, achieving a rating of Good. The Provider Well-Led inspection took place over two days, involving a wide range of interviews with senior leaders, including board members, executive directors and non-executive directors. In addition to this, interviews were held with senior clinicians and management leads for a number of areas, including workforce, quality and safety, freedom to speak up, safeguarding and equality and diversity. This was the first time the Trust had been inspected under the revised framework. The final report from the CQC included a comprehensive summary of good practice relating to leadership, governance and culture at Leeds Teaching Hospitals NHS Trust, commenting on the way this was used to drive improvements and deliver high quality person centred care to patients. There were 15 points of good practice identified in total, these are set out in appendix 3 of the provider well led self-assessment that accompanies this report. The CQC identified five areas for improvement in the provider well led assessment, which is set out in appendix 2 of the provider well led self-assessment.

4. Provider Well-Led self-assessment

A self-assessment has been undertaken against the key lines of enquiry that are set out in the CQC document: Key lines of enquiry, prompts and ratings characteristics for health care services (2017). This has involved undertaking a high level self-assessment against the key lines of enquiry for the well led domain and the specific requirements to achieve an outstanding rating. This has followed the model used for the use of resources self-assessment that was presented to the Trusts Finance and Performance Committee in November 2019, comparing the position to when the inspection was undertaken in September 2018. This represents a high-level table top assessment that has been undertaken by senior managers, in conjunction with Executive Directors, providing a summary position to inform

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discussions about progress that has been made. This includes a suggested rating against each key line of enquiry to reflect this progress. The key indicators of improvement are related to embedding the Leeds Way values, culture and framework for quality improvement using lean methods, in conjunction with progress that has been made relating to engaging staff in quality and safety. This self-assessment forms part of the wider framework for preparing the Trust for the next inspection to realise its ambition to achieve and overall outstanding rating. Alongside this review, a framework has been developed to assess quality and safety at individual ward level using the five domains: safe, effective, caring, responsive and well led. This has been led by the Trusts Patient Safety and Quality Managers, working in conjunction with CSU’s and corporate teams to seek assurance on quality and safety at ward level. This will be used to inform progress regarding core services in preparation for the next inspection. This was subject to a separate report to Quality Assurance Committee in February, including the timetable for implementation and consultation with clinicians and managers across the organisation.

5. Next Steps

The purpose of the high level self-assessment is to lay the foundations for the preparation for the next provider well led assessment. Discussions are being held with the Trust Company Secretary and Chief Nurse to make arrangements for an external review to be undertaken to support the Trust in planning for the Provider Well-Led inspection. The Chief Executive participated in a review of a partner organisation in conjunction with Advancing Quality Alliance (AQuA), who provide support to Trusts to undertake tailored well-led governance reviews. The company secretary has contacted WYAAT Trusts at Airedale, Calderdale and Huddersfield, Bradford and Mid-Yorkshire Trusts to consider the external agencies that could provide this support. Once the preferred provider has been agreed arrangements will be made for an external review to be undertaken. Consideration will be given to requesting a Provider Well-Led assessment to be undertaken towards the end of 2020. The Trust will continue to work in conjunction with the local CQC engagement lead to highlight areas of continued improvement to feed into the future assessment process.

6. Recommendations Trust Board is asked to note the high-level Provider Well-Led self-assessment that has been undertaken to summarise the progress that has been made since the last CQC inspection in 2018 and note the proposal regarding an external review to support the Trusts preparation in advance of the next inspection. Craig Brigg Director of Quality March 2020

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Appendix 1 Provider Well-Led Assessment

Self-assessment against the outstanding characteristics of well-led.

“By well-led, we mean that the leadership, management and governance of the organisation assures the delivery of high-quality and person-

centred care, supports learning and innovation, and promotes an open and fair culture”

Proposed (self-assessed) rating against the outstanding characteristics set out in the CQC Key lines of enquiry, prompts and ratings

characteristics for healthcare services (June 2017):

Outstanding Good Requires Improvement

Outstanding: The leadership, governance and culture are used to drive and improve the delivery of high-quality person-centred care.

Proposed movement on 2018 Assessment

December 2019 update and supporting evidence

W1: Is there the leadership capacity and capability to deliver high-quality, sustainable care?

There is compassionate, inclusive and effective leadership at all levels. Leaders at all levels demonstrate the high levels of experience, capacity and capability needed to deliver excellent and sustainable care. There is a deeply embedded system of leadership development and succession planning, which aims to ensure that the leadership represents the diversity of the workplace.

The Trust has a leadership strategy and succession plan in place, which is reviewed on a regular basis. Executive Director appointments made internally – Chief Operating Officer (2019), Chief Medical Officer (February 2020). A range of leadership development, coaching and mentoring programmes are available to leaders and potential leaders at all levels of the organisation, co-ordinated by the Head of Organisational Learning. The Trust has implemented a specific programme to enhance career opportunities for BME staff (Moving Forward), overseen by the Equality and Diversity Group. The Executive team take a strategic approach to developing leadership and managing talent to ensure there are enough appropriately skilled, diverse and system focused leaders to deliver high quality, effective, continuously

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improving, compassionate care. Staff induction led by Chief Executive. Executive Directors meet new leaders weekly (Monday Exec meeting). Chief Executive chairs West Yorkshire Association of Acute Trusts (WYAAT). Leadership master class delivered by Chief Executive to CQC inspectors October 2019. Annual staff appraisal completion 2018/19 > 95%. Fit and proper Person test 100% compliant - annual report to Public Board.

Comprehensive and successful leadership strategies are in place to ensure and sustain delivery and to develop the desired culture. Leaders have a deep understanding of issues, challenges and priorities in their service, and beyond.

The Trust’s 5-year strategy and vision was reviewed and updated by the Board and Clinical Service Unit’s (CSU) in 2019 to be (published in March 2020) and all CSU’s have a vision and clear strategy. Leeds way values incorporated into recruitment and appraisal processes. Corporate objectives revised 2019/20 to underpin the strategy. The Trust continues to engage with the Lean for Leaders programme and embed the Leeds Improvement Method. To date 101 staff have completed the lean for leaders training programme; 35 staff have completed the advanced lean training programme. CSU strategies and vision develop in 2019/20; collaborative event at Trust Board time-out October 2019. Trust 5-10 year strategy presented to Board time-out October 2019. Leadership successes and achievements shared with all Trust staff through weekly Chief Executive bulletin (Start the Week).

W2: Is there a clear vision and credible strategy to deliver high-quality sustainable care to people, and robust plans to deliver?

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The strategy and supporting objectives and plans are stretching, challenging and innovative, while remaining achievable. Strategies and plans are fully aligned with plans in the wider health economy, and there is a demonstrated commitment to system-wide collaboration and leadership.

The Trust strategic objectives are reviewed on an annual basis to reflect the current position of the Trust and wider health economy, each of these objectives has a set of measures to be monitored against. These objectives are published within the Chief Executive’s annual report each March. The Trust’s objectives are contained within every staff member’s appraisal documentation which is used to set individual objectives. Trust strategy and goals reviewed with CSUs and corporate teams November/December 2019, led by Director of Strategy – presented at senior leader’s meeting to engage CSUs and to Board development workshop in January 2020. Focus on strategic goals for quality and patient experience, financial sustainability, staff engagement/workforce, research and innovation, education, integrated care (system). Leadership walk rounds embedded through weekly programme of visits, additional daily executive/senior manager safety visits to clinical areas to engage with staff re operational pressures/system flow. Integrated working across the health care system, building on the recommendations in the Leeds system review (October 2018). Patient stories shared to facilitate cross-system learning, overseen with partners through “how does it feel for me” group. Clinical Quality Strategy being reviewed to provide an over-arching framework to embed quality improvement, staff engagement and achieve outstanding rating at the next CQC inspection; collaborating with partner organisation (Newcastle Upon Tyne Hospitals NHS Trust). Patient and Public Involvement Strategy developed, including training programme to involve patients in QI programmes. QI collaboratives established, set out in QI Strategy 2017-20. QI strategy being refreshed 2020/21, to be incorporated into Trust Quality Strategy 2020/21.

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Quality goals 2019/20 and priorities agreed with partners, including NHS Leeds CCG and Healthwatch Leeds, set out in Quality Account to be published June 2020.

There is a systematic and integrated approach to monitoring, reviewing and providing evidence of progress against the strategy and plans. Plans are consistently implemented and have a positive impact on quality and sustainability of services.

The Trust has a clear committee and governance structure in place; formal committees of the Board refreshed in 2019/20: Workforce, Digital & Informatic, Workforce and Building Development Committees established in year and the closure of the management Committee RET and establishment of Research & innovation Committee. The Trust records performance against strategic objective and monitors progress through committee reports and Board. These are then further reviewed annually during the objective setting process with the Trust Board. Board Assurance Framework (BAF) refreshed to focus on the high level strategic threats to achieving the Trust’s objectives; reviewed with Executive Director leads during 2019/20; controls, assurance and mitigating actions reviewed at Board development workshops and time-outs. 6 monthly report to Public Board and Audit Committee. Re-focus of the Audit Committee has resulted in focused reviews to test the controls, mitigating actions and assurances of the BAF with respective Executive Directors in attendance. Oversight of corporate risks embedded through Risk Management Committee, chaired by Chief Executive, attended by all Executive Directors, reporting to Trust Board, and observed by the Chair of the Audit Committee The Trust has hosted visitors to observe the Risk Management Committee, including Newcastle Upon Tyne NHS Foundation Trust, Stockport NHS Foundation Trust and Hull and East Yorkshire Hospitals Foundation Trust. 5-year capital programme agreed, priorities identified to provide safe, high quality services to patients. Progress of Rapid Process Improvement Workstreams (RPIW) presented to staff through weekly report-out, to share successes and learning and

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engage staff in the Leeds Improvement Method.

W3: Is there a culture of high-quality, sustainable care?

Leaders have an inspiring shared purpose and strive to deliver and motivate staff to succeed. There are high levels of satisfaction across all staff, including those with particular protected characteristics under the Equality Act. There is a strong organisational commitment and effective action towards ensuring that there is equality and inclusion across the workforce.

Staff survey results 2019 – staff engagement score 7.21 (7.3 in 2018) – remains > national average for all trusts and acute trusts. The Trust has established a Workforce Committee of the Board to report assurance against the delivery of the seven people priorities that have been agreed with staff. Equality and Diversity Strategic Group led by Director of HR and Chief Nurse, focusing on equality objectives and providing equal opportunities for staff with protected characteristics under the Equality Act. LGBT network established. Learning Disability and Autism team strengthened, supported by Get Me Better Champions. Health and wellbeing strategy published. BME network developed, including Moving Forward Programme, providing career and development opportunities for BME staff. Presentations by participants at team brief. Second programme in 2020/21.

Staff are proud of the organisation as a place to work and speak highly of the culture. Staff at all levels are actively encouraged to speak up and raise concerns, and all policies and procedures positively support this process.

Staff survey results 2019 – staff engagement score 7.21 (7.3 in 2018) – remains > national average for all trusts and acute trusts. Response rate of 42% (7,313 staff completed survey): 4% improvement compared to 2018. FFT – December 2019 - 88% would recommend LTHT to friends or family if they needed treatment. 72% would recommend LTHT to friends and family as a place to work. Plan is place to identify improvements based on staff survey results, focusing on staff reporting violence at work from other members of staff, led by HR.

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Transparent, positive learning culture promoted, including incident reporting. Positive incident reporting culture promoted, which was reflected in the patient safety section in the staff survey (2018): Incident (datix) reports 2017/18 33,374 2018/19 32,366 Serious Incidents 2017/18 86 2018/19 110. Staff support provided through Leeds Incident Support Team (LIST), co-ordinated by risk management team. Incident investigation training provided for staff, accessible to all CSUs and corporate teams to promote inclusion and involvement, encouraging a positive safety culture. Potential serious incidents, complaints and safeguarding notifications reviewed weekly in risk management, led by Director of Quality and Associate Medical Directors – followed by weekly meeting with Chief Medical Officer and Chief Nurse to discuss these and agree route for investigation and assurance. Debrief meetings held with staff following incidents, to encourage transparency, openness and facilitate learning. Learning from Never Events workshop held with partners, including NHS Leeds CCG, NHSE/NHSI and CQC to share learning, led by clinicians, October 2019. Shared learning network established with WYATT, Chaired by Director of Quality, Leeds Teaching Hospitals NHS Trust. 3 network meetings to date: Leeds, Airedale, Mid-Yorkshire. Meeting arranged at Calderdale in March 2020. Freedom to Speak Up process (FTSU) developed in 2018/19, 6 monthly reports to Trust Board, led by FTSU Guardian. FTSU champions trained 12; further 10 to be trained in 2020/21.

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Leeds Way Values embedded.

There is strong collaboration, team-working and support across all functions and a common focus on improving the quality and sustainability of care and people’s experiences.

Multidisciplinary team working established across clinical specialties, participation in GIRFT reviews, which are used to inform improvements based on peer comparisons. Collaboration between teams is promoted through the Leeds Improvement Method and value streams involving a wide range of pathways, eg ophthalmology outpatients, adult cardiac surgery, critical care step-down, breast cancer, emergency department. Value streams and RPIWs involve staff at all levels, including clinicians, managers and patient admin/support staff. Progress and achievements are shared with staff through weekly report-out, video published for staff to view and share. A number of QI collaboratives have been established and embedded, involving staff at all levels, set out in the QI Strategy 2017-20, including falls, deteriorating patient, pressure ulcers, sepsis, Parkinson’s disease, discharge collaborative. Safety huddles (daily) established and embedded in all wards, Trust has led regional implementation of safety huddles. Porter safety huddles established, recognised nationally for innovative practice. Research partnerships established with other Trusts. CSU Joint Accountability Assurance Framework established and used to hold CSU to account for workforce metrics to deliver the best practice standards defined by the Trust.

W4: Are there clear responsibilities, roles and systems of accountability to support good governance and management?

Governance arrangements are proactively reviewed and reflect best practice. A systematic approach is taken to working with other organisations to improve care outcomes.

The Integrated Accountability framework sets out the accountability of the CSU triumvirate management teams for quality, constitutional standards, finance and workforce.

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The Trust has reviewed and relaunched the Governance Framework (Quality Assurance Group/Quality Forum) based on the 5 domains (safe, effective, caring, responsive, well-led); this is being embedded across the Clinical Service Units. Governance leads forum established, led by Patient Safety & Quality Managers, to oversee governance framework, agree plans for improvement and promote consistency and rigour. Perfect ward framework developed to provide assurance at ward/department level, overseen by Head of Nursing/Matron to promote devolved accountability to CSUs. Quality and safety visit framework developed in conjunction with CSUs, focusing on safe, caring and well-led domains, to support clinical areas to improve and achieve good/outstanding rating at next CQC inspection. Tested in children’s wards, process for consulting with clinical and manager leads agreed. The Trust has a robust governance structure in place and assurance is sought by the Board of Directors through the committee structure – Finance and Performance, Quality Assurance Committee, Audit Committee, Risk Management, DIT, Workforce, DBC committees, with decisions recorded in the minutes. The ToR and work plans are reviewed annually, and a report provided to Audit Committee and Trust Board. CQC Leeds system review (October 2018) – action plan developed with partners to improve collaborative working across the system, including patient stories and establishment of How Does it Feel for Me group. Newton Europe work with partners (patient flow). To address the feedback from the CQC of inconsistencies of practices and recording of minutes of CSU governance meetings, NHS Providers have carried out training to 50 minute takers, in addition to 100 places for training on writing assurance reports during the year.

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W5: Are there clear and effective processes for managing risks, issues and performance?

There is a demonstrated commitment to best practice performance and risk management systems and processes. The organisation reviews how they function and ensures that staff at all levels have the skills and knowledge to use those systems and processes effectively. Problems are identified and addressed quickly and openly.

Monthly Risk Management Committee, chaired by Chief Executive; annual programme in place for all CSUs and corporate teams to present high level risks, including controls and mitigating actions. There is a clear process and framework in place for identifying and escalating risks, including to Trust Board through the corporate risk register. CSU risk registers are well-embedded. CSU and specialty governance meetings are in place, framework refreshed in 2019/20 to reflect the 5 domains (safe, effective, caring, responsive, well-led). Implemented from Q3 2019/20, need to achieve consistency across all CSUs. The Trust has shared its risk management framework with partner organisations to share good practice, including Newcastle, Hull and Stockport. Submitted as an example of best practice to NHS Providers bi-annual governance conference in May 2020. The Trust has been paired with Hull University Teaching Hospitals NHS Trust to support them to achieve a Good rating at their next CQC inspection, focusing on governance, staff engagement and leadership. Staff are supported in the management of risks through training provided (risk management) and guidance from senior Risk Support Manager. Framework for the management and escalation of risks relating to nurse staffing developed and implemented in 2019/20, providing a coherent framework that is understood by all staff (NSSR – red flag system). A report on red flag areas and mitigating actions that have been taken reviewed at the weekly quality meeting with the Chief Medical Officer and Chief Nurse, with report to each formal Board meeting.

W6: Is appropriate and accurate information being effectively processed, challenged and acted on?

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The service invests in innovative and best practice information systems and processes. The information used in reporting, performance management and delivering quality care is consistently found to be accurate, valid, reliable, timely and relevant.

Data quality overseen by informatics team and subject to internal validation and review by Internal Audit (PWC). Revised IQPR implemented, based on the 5 domains – safe, effective, caring, responsive, well-led (see contents page below)

There is a demonstrated commitment at all levels to sharing data and information proactively to drive and support internal decision making as well as system-wide working and improvement.

The Trust has an open culture regarding sharing data and information, working constructively and proactively with partners and commissioners at NHS Leeds CCG, NHSI/NHSE. A monthly meeting is held with NHSI/NHSE to discuss risks to performance, finance and quality and how these are

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being managed. A quarterly joint quality meeting is held with NHS Leeds CCG, NHSI/NHSE and Specialist Commissioners, providing opportunity to discuss quality priorities and consider how these apply and are managed across the system. A quality review group “how does it feel for me” has been established to review the experience of patients across the health care system, including producing patient story videos and case note review (a recommendation from the Leeds system review, CQC October 2018). Internal Audit review of stakeholder and partnership working reported to March Audit Committee, with deep dive review (strategic risk described in the BAF) with Director of Strategy in attendance.

W7: Are the people who use services, the public, staff and external partners engaged and involved to support high-quality sustainable services?

There are consistently high levels of constructive engagement with staff and people who use services, including all equality groups. Rigorous and constructive challenge from people who use services, the public and stakeholders is welcomed and seen as a vital way of holding services to account.

The Trust has a Patient and Public Involvement Strategy. A QI collaborative is well established, including developing quality partners to involve patients and public. A rolling programme of presentations from CSUs is in place to provide examples of involving patients and public in quality improvements, reporting to Patient Experience Group. The Trust has introduced a programme of listening weeks, supported by the Patient Experience team, to receive real-time feedback from patients and families. These have been undertaken in outpatients and A&E and a programme is being developed for 2020/21. Patient Reference Group established. Complaints and PALS service embedded, with goals for improvement agreed relating to reducing response times. A well-established quality assurance process in place to improve the quality of complaint responses

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and reduce the number of re-opened complaints. Innovations include recorded complaint meetings, to reduce time taken to respond. External review of complaints and PALS in progress. Learning from Complaints workshop to be held in Q1 2020/21.

Services are developed with the full participation of those who use them, staff and external partners as equal partners. Innovative approaches are used to gather feedback from people who use services and the public, including people in different equality groups, and there is a demonstrated commitment to acting on feedback.

The Trust engages with a wide range of clinical networks, which includes participation from service users, including vascular, cardiac. Building the Leeds Way Programme Board established with input from service users. CSU examples shared at Patient Experience Group, including cystsic fibrosis and immunology/allergy user groups. You said, we did examples shared at Patient Experience group by CSUs, highlighting examples of actions taken in response to feedback from patients. Maternity consultation launched in January 2020

The service takes a leadership role in its health system to identify and proactively address challenges and meet the needs of the population.

The Trust Chief Executive leads the West Yorkshire Association of Acute Trusts (WYAAT) network, to address challenges and redesign pathways across the local system and implement the recommendations set out in Delivering Better Health and Care for Everyone 5-year plan. A Health and Well-Being Board is established across the local healthcare system, overseen by Executive Group (PEG). A Leeds Health and Well-Being Strategy is in place. Health and Social Care Board to Board meetings (population health management model driven) West Yorkshire and Harrogate Health and Care Partnership (ICS) and Trust Chairs meeting. Building the Leeds Way – Innovation District meetings with Local Authority, and University of Leeds and Beckett University, Chaired by Trust Chair.

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The Trust has been paired with Hull and East Yorkshire Hospitals NHS Trust to support them to achieve a GOOD rating with the CQC, reflecting the progress made at LTHT.

W8: Are there robust systems and processes for learning, continuous improvement and innovation?

There is a fully embedded and systematic approach to improvement, which makes consistent use of a recognised improvement methodology. Improvement is seen as the way to deal with performance and for the organisation to learn. Improvement methods and skills are available and used across the organisation, and staff are empowered to lead and deliver change.

The Trust has a well-established and coherent quality improvement strategy, based on the collaboration with Virginia Mason Institute and partner organisations. The Leeds Improvement Method is becoming increasingly embedded across the Trust, based on lean methods and to date, 101 staff have undergone Lean for Leaders training. A range of value streams have been identified for improvement, linked to the Trust’s performance against national standards, including breast cancer and adult cardiac surgery.

Safe innovation is celebrated. There is a clear, systematic and proactive approach to seeking out and embedding new and more sustainable models of care. There is a strong record of sharing work locally, nationally and internationally.

Staff innovation is celebrated through Chief Executive bulletin (Start the Week), leadership visits, team brief, annual Time to Shine awards, annual CSU celebration events. The Trust engages proactively with WYAAT to develop new and sustainable models of care, eg Yorkshire Imaging Collaborative, Vascular service review, procurement workforce, planning, pathology (with £12m awarded by DHSC for new centre on LTH site to deliver regional service), elective orthopaedic, ophthalmology, clinical strategy & service sustainability The Trust has engaged with the Getting It Right First Time (GIRFT) national programme, which aims to improve the quality of care by reducing unwarranted variations in service delivery and clinical practice, working with frontline clinicians. 18 reviews were undertaken in 2019/20, including ENT, vascular, renal, thoracic, spinal surgery, diabetes, paediatric surgery, gynaecology, orthopaedics, urology, cardiology, breast surgery, respiratory medicine with further reviews to be undertaken (40 medical and surgical specialties in total).

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The Trust has a well-established Research and Innovation Framework and committee, in 2018/19 the Trust recruited the second largest number of patients into clinical research trials. Research and Innovation Strategy consulted on 2019/20, to be refreshed and published March 2020. Leeds Health Record, collaboration with Mid-Yorkshire Hospitals. The Trust has led on a range of digital innovations, including the national Scan for Safety Programme. Scan for Safety and award of £4m to deliver across WYAAT. The Trust has a Lessons Learned Group, led by a clinician (ED consultant), to identify learning points for sharing widely across the Trust. Learning Points Bulletin produced and shared with all staff. Fortnightly quality and safety briefings are produced to raise awareness of risks from serious incident investigations, together with actions to be taken to mitigate the risks. The Trust hosts an annual leaning event (Never Events), with commissioners and partners, including local CQC engagement lead. The Trust leads on the WYAAT shared learning group, chaired by Director of Quality (LTHT) and Medical Lead (WYAAT), promoting shared learning from serious incidents and never events across the region. The Trust is an early adopter of the revised serious Patient Safety Incident Response Framework (2019), working in collaboration with local commissioners and NHSI/NHSE. LTHT is the largest teaching hospital to participate in this consultation. International collaboration with King Husain Cancer Centre Jordan for education and training, partnerships developed with Jamaica, Pakistan and Malta.

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Appendix 2 – areas for improvement (referenced in 2018 inspection report)

Concerns highlighted relating to Provider Well-Led following 2018 inspection

Movement on 2018

Assessment of progress - March 2020

Shortfalls in nurse staffing were not always wholly captured in reports to the board and information provided in reports did not always indicate the full scale of the issue. Front line staff told us they were confused about the three levels of staffing (minimum, current and optimum), and professional judgement had been used in the majority of clinical areas to determine safe staffing levels. We discussed this with senior leaders during the inspection and they took immediate steps to address our concerns. An electronic system and new reporting system was rolled out across all wards.

Full nurse staffing review undertaken with all CSU’s. Introduction of ‘stop the line’. NSSR and safer staffing daily reports. Clear escalation process. Nursing investment approved by Board Nov 2019. External review of A&E nurse staffing.

During this inspection we saw deterioration in ratings for three core services at the St James’s hospital site. This meant there was a need with the trust to focus on this site to improve the quality and patient experience within these services.

Focus on (i) medicine (ii) emergency department and (iii) surgery at St James’s location Improvement in performance against constitutional standards – 4 hr emergency care, 52 weeks wait for surgery, cancelled operations re-booked in 28 days. Daily safety walks to engage with staff on operational pressures, staffing, patient flow. Strengthened partnership working.

We had some concerns around patients who were detained under the mental health act (MHA). There were incomplete records for over half of the patients who had been detained from 1 Apr-June 2018. This was pointed out to the trust and we were told since then the MHA team had expanded and the team now routinely met with detained patients to explain their rights to them.

All Mental Health Act documentation is scrutinised, corrections made and remedial actions taken within statutory timescales by LTHT MHA team. All approved MHA related records are uploaded contemporaneously onto the patient’s electronic patient record. There have been no fundamentally defective detentions since the last Inspection. The addition of an experienced RMN into to the MCA/MHA team means that the team can now aim to visit each patient detained to LTHT early; this is in addition to Ward staff S132 explanations. Copies of Rights information are given directly to patients but are also sent to nearest relatives and

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appropriate others; There is also a process in place to automatic referral to Independent Mental Health Advocacy to ensure further independent support for the patients.

There was no policy in the trust for rapid tranquilisation of patients with mental health needs. The trust was not compliant with NICE guidance for ‘physical health after rapid tranquillisation’ and frontline staff we spoke with were not aware of the NICE guidance. we pointed this out during the inspection and senior leaders told us the trust were in the process of reviewing the restraint policy and had put a draft protocol in place for use until the end of October 2018. This was an issue that was identified at the May 2016 inspection.

Managing acute behaviour disturbance with Rapid Sedation / Rapid Tranquilisation Policy produced and available on Leeds Health Pathway. Includes duty to report use of rapid sedation as an incident. The Policy and reporting requirements have been cascaded across the Trust. Requirements for the monitoring of patient during and after use of rapid sedation are mandatory fields on reporting system and are monitored jointly by the MCA/MHA and Safeguarding Adults teams. Chief Nurse has endorsed a Quality Improvement Collaborative to identify, test and evaluate a range of ‘interventions’ aimed at improving the Trusts response to unwell patients who may present with behaviours that challenge. 7 initial Pilot wards with Faculty support. Looking at a range of areas: education, risk identification, prevention care planning, workforce skills mix, Models of crisis response, whole systems approaches.

There had been significant delayed discharges and delayed transfers of care in the previous year before our inspection. This impacted on the trusts ability to deliver the four-hour emergency care standard, referral to treatment (RTT) standards and there were a number of 52 week and over long waits for patients as well as delayed transfers of care. The trust had started to collaborate with stakeholders and other health providers to make improvements but the impact of these were not fully realised at this inspection.

Discharge collaborative established, using QI methodology. Partnership working with Villa Care Achieving Reliable Care (ARC) project. City-wide work with partners, including Leeds Community Health, Social Care, LYPFT, CCG. Improvement in performance against constitutional standards – 4 hr emergency care, 52 weeks wait for surgery, cancelled operations re-booked in 28 days.

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Appendix 3 – Good practice (extract from 2018 inspection report) The CQC rated well-led at the trust as GOOD in 2018 because:

The leadership, governance, and culture at Leeds teaching hospitals were used to drive improvements and deliver high-quality

person-centred care. The board and senior leaders had experience, capacity, capability, and integrity to ensure that the strategy

could be delivered and risks to performance addressed.

Leaders at every level were visible and approachable. Comprehensive leadership strategies were in place to ensure and sustain

delivery and to develop and maintain the culture. There were clear embedded priorities for ensuring sustainable, compassionate,

and effective leadership in the form of a talent and leadership development strategy. The people strategy outlined leadership

development methods at a range of levels.

There was a strong sense that leaders worked collectively and collaboratively. Non-Executive Directors felt well informed and

trusted. Executives and Non-Executives were engaged, enthusiastic, and proud of the staff and the trust.

The Executive team and Board were knowledgeable about issues and priorities for the quality and sustainability of services,

understood what the challenges were and were taking action to address them.

There was a clear vision and collective values and behaviours, driven by quality and sustainability and clear goals and known as

the ‘Leeds way’. The vision, values and strategy had been developed and coordinated with stakeholders, local patient involvement

groups, public consultation meetings, and aligned to local system wide sustainability and transformation plans. The Leeds way

was driven through staff engagement, creating a sense of community and pride and linked to delivering positive patient outcomes.

Staff in all areas knew, understood and supported the vision and values, and how their role helped in achieving them.

The strategy and plans were aligned with plans in the wider health economy, and there was commitment to system-wide

collaboration and leadership. The challenges to achieving the strategy, including relevant local health economy factors, were

understood and part of the action plan.

There was a systematic and integrated approach to monitoring, reviewing and providing evidence of progress against the strategy

and plans. Clinical support units delivered services to patients. Each clinical support unit was responsible for delivery of

performance, quality, safety and financial standards.

Agenda Item 10.2(v)

21

Agenda Item 3.1(i)

Leaders demonstrated and encouraged compassionate and inclusive working relationships among staff so that they felt

respected, valued and supported. There were processes in place to support staff and to promote well-being. Staff we spoke with

told us they said that they felt appreciated. Leaders encouraged pride and positivity in the organisation. Overwhelmingly staff were

positive about and proud to work in the organisation. In the last 3 years, the trust had moved from the bottom 20% of trusts to the

top 20% in the NHS staff survey.

There was a strong patient focussed culture, supported by collective responsibility between teams and services. When something

went wrong, people received a sincere apology and were told about actions being taken to prevent the same thing happening

again. There were processes for providing staff at different levels with the development they needed, including high-quality

appraisal and career development conversations.

The Board and governance structures within the trust were clearly set out, effective and understood. Governance arrangements

were proactively reviewed and reflected best practice. A systematic approach was taken to working with other organisations to

improve care outcomes.

The Board and Executive team had established processes from Board to ward to Board in order to gain assurance, identify gaps,

set priorities and put in place plans to address these gaps. Board to ward assurance in relation to risk and performance was

provided through the assurance committees and performance management structures. The quality and performance report set out

progress against a range of metrics relating to quality, performance and finance. Operational and corporate risks were monitored

through the risk management committee and via the Board Assurance Framework.

There was evidence of integrated reporting which was used to support decisions made at Board level, and performance

information was used to hold senior leaders and staff to account. We saw that information used in reporting, performance

management and delivering quality care was accurate, valid, reliable, timely and relevant, with plans to address any weaknesses

in performance. The trust had invested in information management and there was a central information quality department whose

function was to ensure the accuracy and completeness of data.

There were high levels of constructive engagement with staff and people who used services. The Trust used a range of

mechanisms to proactively capture people’s views. It was transparent, collaborative and open with all relevant stakeholders. The

trust continued to review and improve how people were engaged with their services. It took a leadership role in the local health

system to identify and proactively address challenges to meet the needs of the population.

Agenda Item 10.2(v)

22

Agenda Item 3.1(i)

There was an embedded and systematic approach to improvement, which made consistent use of a recognised improvement

methodology. Improvement was seen as the way to deal with performance and for the organisation to learn. The Leeds

Improvement Method was embedded and used across the organisation, and staff were empowered to lead and deliver change.

The trust’s waste reduction approach, which was integral to the Leeds Improvement Method, was fundamental to improvements,

including shorter waits for patients, improved clinical outcomes, and waste reduction across the Trust.

The Trust had made connections between the use of resources the Leeds Improvement Method, and the Leeds Way within the

Clinical Service Units. This has impacted positively on values and behaviours for the benefit of patients. Around 7,000 members of

staff had been trained in the Leeds Improvement Method and improvements were driven by clinicians and front line staff in the

clinical service units at the Trust.