Quality account 2020/21 by LNWH_NHS

Quality account 2020/21

Contents Part 1: Quality summary 2020-21 3 Welcome from the Chief Executive Statement of directors’ responsibilities Priorities for improvement and statements of assurance from our board

4 7 8

Part 2: Review of our achievements

Our approach to quality improvement

Quality improvement achievements against priorities during 2020-21

Review of our quality performance

The NHS outcomes framework: quality indicators

Standardised Hospital Mortality Indicator

VTE risk assessment

C. difficile infection rate

MRSA bloodstream infection rate

Trust’s responsiveness (patient experience of hospital care)

Secondary Users Service: quality data

Overview of patient safety incidents

Patient Safety Alert compliance

Patient-led assessments of the care environment

Statements of assurance

Part 3: Quality Priorities 2020-21

Priority 1: Safe care - Infection prevention and control Priority 2: Caring – Improving staff wellbeing Priority 3: Responsive – Improving staff experience for Black, Asian and Minority Ethnic focused actions for improvement

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Summary

Annex – Stakeholder feedback

2 London North West University Healthcare NHS Trust

Part 1: Quality summary 2020-21 This section includes: • Welcome from our Chief Executive, Chris Bown • Statement of directors’ responsibilities • Priorities for improvement and statements of assurance from our board.

Staff working across London North West University Healthcare NHS Trust (LNWH) are dedicated to ensuring high quality, patient-focused care. We pride ourselves on living our HEART values and putting patients at the heart of everything we do. Each year, all NHS hospitals in England are required to publish a report for the public about the quality of their services. This is called the quality account. The quality account makes the Trust more accountable and helps to drive improvement in the quality of our services. This quality account provides assurance to our patients, partners and other key stakeholders about the progress and achievements we have made against our quality and safety priorities from 2020. It also allows us to focus on the plans we make to support continuous care quality improvement throughout 2021. To ensure that we provide a fair assessment of the progress we have made, the quality account has been reviewed by key stakeholders and by the board, including our nonexecutive directors.

Quality Account 2020-21 3

Welcome from the Chief Executive In a year like no other, the people who make up LNWH have shown an extraordinary capacity for unrelenting hard work, resilience, and above all, compassion. In March 2020, the Trust became the first in the country to declare a critical incident in relation to the Covid-19 pandemic, seeking support from neighbouring hospitals across north west Laondon to make sure that every patient got the care they needed. We know now what we did not know then: our local communities were to be among the hardest hit by the virus anywhere in the country. We therefore saw a very high number of people requiring care for Covid-19. There was an immediate and remarkable response from our teams. The very physical environment of our hospitals changed dramatically – in some cases overnight – as wards were moved or reconfigured to allow us to treat patients as swiftly and effectively as possible. One thousand polythene airlocks were produced and installed across Ealing and Northwick Park hospitals to support infection control measures. Members of our estates team lived on site for months on end to do their bit while also protecting their families, while clinical staff of all professions set aside traditional specialty boundaries and stepped forward to help, sometimes at great personal cost. In response to this immense pressure, our teams developed exciting and innovative ways to help our patients in truly challenging circumstances. Our infectious diseases team were the first in the country to start both community and drive-through testing for Covid-19, in models subsequently adopted across the country. Our critical care team became the first in the country to use mobile dialysis units in an intensive care setting, in a remarkable achievement now being emulated by other organisations. And we saw an immense digital transformation right across LNWH, but nowhere more than in outpatients, where our teams continued to see more than 300,000 people, with over 160,000 appointments taking place over the phone. There are too many other examples to count. As we move forward, our transformation programme will draw on this remarkable capacity for innovation, harnessing new ideas to create better ways of providing care.

4 London North West University Healthcare NHS Trust

As a result of this remarkable response, a recent Getting It Right First Time report identified LNWH as having a significantly lower than average mortality rate for Covid-19. The report selected the Trust as one of a handful picked to identify good practice. I am truly proud to report that, by March 2021, our teams had helped more than 4,000 people go home after having been admitted with the coronavirus.

Maintaining our focus on quality Despite the immense amount of work generated by all this activity, our teams managed to maintain their focus on quality and safety. For the period January – December 2020, we had the eleventh lowest mortality in the country when measured on the Standardised Hospital Mortality Index (SHMI), while also seeing reported improvements in key safety initiatives such as reducing harm from pressure damage. Our Emergency Department now regularly reports the best performance against the four hour target of any acute Trust in the country, while also remaining the busiest in London. We continue to focus on the quality, safety, and effectiveness of our maternity department, particularly in view of recent developments such as the Ockenden Report. We are absolutely committed to making significant improvements to the care we provide to the local people who use the service. In early 2021, we developed a new maternity improvement plan, which maps out the precise changes that will make the service work better for both staff and service users. New leadership for the unit will also support us to develop a supportive and safety-oriented culture. The CQC visited the department in April 2021, and (at the time of writing) we await their report, which we will use to further develop and reinforce our improvement plan.

Quality priorities Throughout the year, we have focused on the three key quality priorities identified in last year’s quality account. Rigorous infection prevention and control has of course been absolutely critical during this last year and I am delighted that we have met all three of the ambitions we set for ourselves in this area. We can always do more, and in particular, as we learn more about the virus, our guidance will adapt to reflect our growing understanding of how best to limit its spread. For that reason, infection control will continue to form a key part of our focus on safety in the coming year as part of our new quality priorities. The wellbeing of our staff is intrinsically linked to patient outcomes and experience. Our high compliance with Covid-19 risk assessments remains an important part of Quality Account 2020-21 5

keeping our people safe, as are our eighty personal protective equipment champions. Initiatives such as the Project Wingman lounges, and our new Live Well Work Well programmes have made a difference for staff. Nevertheless, there is still much progress to be made, particularly in continuing to signpost staff to emotional support, and in delivering on our ambition to offer staff full health checks. Therefore staff wellbeing will remain among our quality priorities, with a key ambition of developing a three year health and wellbeing strategy. Finally, we remain deeply committed to improving the working lives of our ethnic minority staff. We have made taken significant steps to make our workplace not only more equitable but more inclusive: with fairer hiring processes, better information about recruiting managers’ decisions, and new leadership development programmes. Ongoing conversations with our colleagues from ethnic minority backgrounds are helping us be more alive to the issues they experience every day, and take action to improve them. But we know that this is not yet enough, and this remains a key priority for us going forward. The year ahead will see us focus on compassionate leadership programmes and positive actions to support colleagues from ethnic minority backgrounds into senior roles.

The road ahead The NHS continues to face an immense challenge. We set out the principles by which we would respond to that challenge earlier this year in The Way Forward, a document that outlines our approach to the issues we will need to navigate as we come through the pandemic. At every stage, we are committed to working in partnership with our patients, colleagues and local communities to make our care better.

Data and interpretation Reporting on quality and performance involves a certain level of judgement and interpretation. To ensure that the quality account fairly presents our position it has been reviewed by key stakeholders and by the board, including our non-executive directors. I can confirm, in accordance with my statutory duty, that to the best of my knowledge, the information provided in this quality account is accurate.

Chris Bown

Chief Executive 6 London North West University Healthcare NHS Trust

Statement of directors’ responsibilities The Directors are required under the Health Act 2009 to prepare a quality account for each financial year. The Department of Health has issued guidance on the form and content of annual quality account (which incorporates the legal requirements in the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 (as amended by the National Health Service (Quality Accounts) Amended Regulations 2011). In preparation the quality account, directors are required to take steps to satisfy themselves that: • The quality account presents a balanced picture of the Trust’s performance over the period covered. • The performance information reported in the quality account is reliable and accurate. • There are proper internal controls over the collection and reporting of the measures of performance included in the quality account, and these controls are subject to review to confirm that they are working effectively in practice. • The data underpinning the measures of performance reported in the quality account is robust and reliable, conforms to specified data quality standards and prescribed definitions, and is subject to appropriate scrutiny and review. • The quality account has been prepared in accordance with Department of Health guidance. • The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the quality account. By Order of the Board Date: Date:

Lord Amyas Morse Chris Bown Chairman Chief Executive

Quality Account 2020-21 7

Priorities for improvement and statements of assurance from our board We are committed to providing safe, high quality care to all patients and service users. As we look to the future, our focus will be on delivering quality improvement and a patient centred transformation of services. The aim of the quality account is to review performance against quality priorities and standards for the year 2020 and to outline our proposed focus on the quality priorities for 2021. As a result of the Covid-19 pandemic, the publication of the quality account for 2020 was deferred nationally. As a result, quality priorities for this period were developed for publication at the latter end of 2020. Quality priorities identified for 2020 outlined below will be reviewed within part two of this document. These quality priorities were developed to enhance our focus on patient safety, learning from experience of the pandemic and the associated impacts upon patients, staff and organisational experience and are closely aligned with organisational objectives, systems and national strategies.

8 London North West University Healthcare NHS Trust

Priority 1: I mproving and sustaining the safety of our patients and staff with enhanced focus on infection prevention and control. Priority 2: Improving staff wellbeing through a program of focused support. Priority 3: Improving staff experience for members of our Black, Asian and Minority Ethnic community with positive action initiatives focused on professional development, career progression and learning from experience.

The following sources were used to identify our quality priorities for 2020-21: • Stakeholder and regulator reports and recommendations • CQC inspection report and CQC insight reports • Clinical Commissioning Groups and Sustainability and Transformation Partnership feedback and observations following their quality visits • Commissioning for Quality and Innovation (CQUIN) priorities • National inpatient, outpatient and maternity service surveys • Feedback from our Trust board • Emergent themes and trends arising from complaints, serious incidents and inquests • Feedback from senior leadership assurance visits • Nursing and midwifery quality assurance tools including: national clinical key performance indicators, excellence assessments and perfect ward assessments • Quality and safety priorities dashboard and reports • Internal and external reviews including NHS Improvement • National policy • Feedback from Healthwatch through partnership working • Feedback from stakeholders, partners, regulators, patients and staff in the development of the quality priorities.

Quality Account 2020-21 9

Part 2: Review of our achievements during 2020-21 This section includes: • Our approach to quality improvement • Continuous improvement and training • Quality improvement achievements against priorities during 2020 • Review of our quality performance • Review of performance against care quality indicators • Trust performance for 2020-21 against the NHS outcomes • Secondary Uses Service data quality • Overview of the patient safety incidents reporting rates and actions taken to improve incident reporting across the organisation • Overview of Serious Incidents and Never Events • Trust compliance with National Patient Safety Alerts • Information on the ward/service Excellence Assessment Tool (EAT) • Duty of candour • Patient-led assessments of the care environment (PLACE).

Our approach to quality improvement Our goal is to provide outstanding patient focused care that is sustainable, high value, high quality and delivered in partnership with health and social care organisations across north west London (NWL). Over the last 12 months, the Trust has expanded the transformation programme to support efforts across the trust to provide better care for patients, better staff experience, and better use of resources. The programme includes a dedicated team, incorporating clinical and quality improvement expertise that works with staff across the organisation on strategic priorities and CQC recommendations. The programme is overseen by the transformation group, which meets monthly, is chaired by our CEO and includes patient representatives. The transformation team were redeployed to support staff across the Trust to make rapid changes and improvement during the first and second waves of Covid-19, including: • Implementing a new digital system with the intensive care unit to support real-time patient information and capacity reporting to support improved decision making. In the second wave, this was built upon to create an 10 London North West University Healthcare NHS Trust

innovative four-day critical care bed forecast that was then implemented across our integrated care system to support collaboration and improved patient care across the major acute hospitals in NWL. • Reorganising services between our sites, including moving our same day emergency care service adjacent to accident & emergency, which has expanded the range and responsiveness of services. • Covid-19 led to closer, collaborative working, with our partners across NWL in several clinical areas. This included the development of fast-track surgical hubs, to support better patient outcomes and improved productivity. Central Middlesex Hospital was converted into a Covid-19 secure site and received £2m of funding to become an orthopaedics elective hub for NW London. • Engaging with our ward staff, site teams and discharge team to improve processes and ways of working across the Trust. From September to November, our average length of stay was one day less than the same period the previous year, supporting patients return to their homes sooner. • Set up innovative rapid Covid-19 testing capabilities. In April, we became the second trust in the NHS to use Samba II rapid Covid-PCR tests which returned results within four hours (rather than thirty-six hours plus which was standard at the time). Since then, we have piloted other point of care Covid-19 diagnostic tools, including publishing our research on them which has informed NHS-wide guidelines. This has supported improved decision making, infection control and patient flow, as patients get to the right location first time. • We also led the opening of the second mass vaccination centre in London at Wembley in January 2021, working with the local authority, CCG and volunteers. The centre vaccinated over 15,000 people in its first month.

Continuous Improvement, training and development Continuous improvement training for Trust staff is led by the transformation team. Since its launch in 2019 we have trained: • 1,410 staff at Improvement for All, a short training programme that took place during Trust induction sessions • 502 through Change Makers, which provides team-based training around using improvement boards and team based improvements • 177 Improvement Leaders (including. 48 Black, Asian and Minority Ethnic leadership programme colleagues), which is a day-long programme. • 89 Improvement Fellows who took part in a three-month programme which combines training workshops and delivery of an improvement project. In response to Covid-19, the curriculum was redesigned to be delivered virtually, which will continue in 2021. Improvement Fellow projects over the last year included: Quality Account 2020-21 11

• Digital solution for musculoskeletal physio outpatients which is saving 15 minutes per appointment • Integration of assessment forms that reduces errors and delays, while saving 15 minutes per assessment • A&E triage of paediatric patients, which has supported a step change in time taken to complete triage so that more than 80% of patients are triaged within 15 minutes

Alumni from the training programmes told us that the skills they developed through this programme greatly assisted them organising rapid changes and improvements during the course of the pandemic. Transformation plans To continue efforts to engage staff from all levels in improving services and the transformation programme will continue to grow next year. Plans include: • Trust-wide project tracking tool called TrakIt, which has been developed in partnership with the Transformation team at Imperial College Healthcare NHS Trust. This will support collaboration on making improvements across the Trust, benefit tracking from implemented projects, and a clearer record between improvement recommendations such as responses to CQC actions and initiatives that were then taken. • Expanded continuous improvement training programmes, including Improvement Fellows+ which is to support idea and experience sharing across the network of programme graduates and provide them with opportunities to learn more advanced skills. • Creation of new Innovation Funds to support testing new ideas suggested by staff more quickly and easily

Quality improvement achievements against priorities during 2020-21 This section of the quality account highlights achievements against the priorities set for 2020. Goal achieved Partially achieved Goal not achieved

The achievement of each quality priority will be measured with the triangulation of key performance indicators and associated quality metrics, patient and staff feedback. 12 London North West University Healthcare NHS Trust

Progress will be underpinned by the Trust assurance processes, with formal monitoring and measurement reported through established committees and groups that in turn report through the Quality and Safety Committee, a sub-committee of Trust board. Priorities outlined below will be reflected as achieved, partially achieved or goal not achieved and will be supported by a brief supporting statement to rationalise the position.

Priority 1: Infection prevention and control Our priority objective during 2020 was to maintain patient safety with enhanced focus on specific elements of infection prevention and control.

A. Fit testing – We aim to achieve fit testing of 90% of Trust staff working in accordance with national standard.

B. Hand hygiene – we aim to complete quarterly audits evidencing an improvement in compliance with hand hygiene standards.

C. We aim to have every department complete biannual infection prevention and control audits to evidence compliance with standards and will report on the basis of overall percentage compliance. Ambition A Achieved

Fit testing compliance

90% of staff working

in high risk areas were

Ambition B Achieved

Hand hygiene

Ambition C Achieved

IPC audits

Ambition A: achieve fit testing of 90% of Trust staff working in accordance with national standard. The Trust has a legal responsibility to provide and maintain a safe working environment, so far as is reasonably practicable. The requirement includes providing the correct respiratory protective equipment (RPE). Fit testing is a method for checking that a specific model and size of tight-fitting face piece matches the wearer’s facial features and seals adequately to the wearer’s face. The Health and Safety Executive (HSE) provide guidance to employers about RPE / fit testing and as an organisation we are required to evidence compliance with the standard. The Trust identified a total of 2249 staff working in high risk areas or exposed to aerosol generating procedures who required RPE. A comprehensive fit testing programme was established during 2020.This programme provides fit testing to multiple different makes/ models of RPE, captures the outcomes of the fit test, provides advice to staff about Quality Account 2020-21 13

checking the RPE, manages new models of RPE as they become available and maintains stock of RPE. The graph below shows the cumulative number of high-risk staff that attended fit testing.

Ambition B: complete quarterly audits evidencing an improvement in compliance with hand hygiene standards. The infection control team completed audits using the National Infection Prevention Society Audit tool in November 2020 and again in February 2021. This is based on the ‘5 Moments’ for hand hygiene at point of care that directly where the risk of transmission via healthcare workers hands is the highest. The main opportunity for learning was after touching the patient surroundings. Each ward area has also completed a monthly KPI using the same audit tool to provide immediate feedback on healthcare workers hand hygiene compliance. Ambition C: improve patient safety with the completion of biannual infection prevention and control audits, to evidence compliance with standards. Each ward area has had an infection prevention and control audit. The audit was developed in response to Covid-19 infection control precautions to provide assurance that standards were being met. The first audit was completed in August 2020 and was conducted by peer assessment and the senior nursing team to provide a critical eye. The audit was modified in February 2020 using the same criteria but applying a scoring system to provide feedback in terms of percentage compliance. This audit provided a broader view of infection control at ward and department level and specifically related to infection prevention control during the pandemic.

14 London North West University Healthcare NHS Trust

Priority 2: Staff wellbeing The key health and wellbeing (H&W) priorities to support staff have emerged from a combination of data from occupational health (OH) management referrals, employee assistance programme (EAP) usage reports, OH queries and from the pandemic. Key priorities for improvement 2020 A. T o ensure clear messaging and reduce anxieties, all services will have at least one personal protective equipment (PPE) champion identified to support and update staff on the safe use of PPE. B. 5-8% of staff will have had a health and wellbeing check by the end of 2021. C. I ncrease usage of the employee assistance program by 2% to ensure that psychological wellbeing is prioritised Ambition A Partially achieved

Ambition B Achieved Ambition

C Not achieved Ambition

D Partially achieved

Ambition A - staff support Ambition B - staff safety and PPE Ambition C - improving staff health and wellbeing checks 5-8% Ambition D - increased utilisation of the employee assistance program by 2%

As an organisation, we know that good staff health and wellbeing can reap significant results for patient care and patient outcomes. In 2020, the global pandemic highlighted the inextricable link between the health and wellbeing of our staff and their ability to continue to deliver excellent care to our patients and the communities we serve. This meant a significant investment by the Trust in resources to support and care of our staff during this difficult time. Ambition A: develop a robust process to determine staff supports required evidencing progress and responsiveness, with quarterly reporting. Over the last year the Trust has provided significant support for its staff through its health and wellbeing programs. We are conscious that due to the impact of the pandemic we were unable to deliver full support plans in 2020-21. We have therefore revised plans and enhanced our focus on this priority for 2021. Quarterly reporting to date suggests that this aim is partially achieved. Due to the detail required to evidence compliance and sustainability of approach, along with the longer-term actions associated with the required improvements, it is not yet possible to Quality Account 2020-21 15

confirm this aim as fully achieved. The People Plan 2020-21 created further opportunities for additional support, building upon our priorities to strengthen our focus on staff wellbeing. Examples are provided below: • Fresh fruit, hot food and donations: throughout the pandemic we received amazing generosity from the LNWH Charity and our local communities. Their support helped staff across the Trust cope with the difficult challenges presented by Covid-19. Fresh fruit and hot food was donated and delivered to staff in the wards to sustain them during the long hours they worked. Self-care was a key focus of our wellbeing messages. • Project Wingman: the initiative was a joint effort between various airline employees who volunteered their time to establish ‘first-class lounges’ for NHS staff. These lounges, supported by the LNWH Charity, offered our staff a relaxed and comfortable area to unwind and recuperate during their breaks Ambition B: ensure clear messaging and reduce anxieties all services will have at least one PPE champion identified to support and update staff on the safe use of personal protective equipment. The development of over eighty PPE champion roles within clinical areas has been achieved. The role of these champions has been pivotal to improving communication around staff safety. They have worked to increase awareness and reduce anxieties with a focus on observational assessment of practice and real time feedback to individuals and teams, in addition to dissemination of information and access to supports. Over 93% of our staff received a personal risk assessment from either their managers, though self-assessment or at the point of recruitment. This ensured that line managers were able to have informed wellbeing conversations with staff about and agree with them appropriate support to minimize their exposure to Covid-19 and to support their mental health. As the impact of the Covid-19 became clearer to the global healthcare community and on our workforce, we focused on protecting our staff and empowering them to keep themselves safe by • reviewing and improving our working practices and how we delivered care • securing and promoting Covid-19 safe work settings • minimizing the risk of staff exposure to Covid-19 through the supply of PPE • undertaking personal risk assessments and supporting our colleagues who were shielding

16 London North West University Healthcare NHS Trust

Ambition C: 5-8% of staff will have had a health and wellbeing check by the end of 2020-21. This was not achieved. Although plans were in place to run staff health and wellbeing clinics, the second wave of Covid-19 meant that this could not take place. Greater focus was placed instead on Covid-19 personal risk assessments to ensure staff were safe and protected. Our aim is to deliver on this priority in 2021 and this action now forms part of our health and wellbeing plans going forward. We aim to achieve a minimum of 5% staff H&W checks on our workforce in 2021-22. Ambition D: increase usage of the employee assistance program (EAP) by 2% to ensure that psychological wellbeing is prioritised. The annualised EAP use in 2020 was 4.7% and included access to counselling and advice. In the first three months of 2021, this increased to 6.0%, which was a positive move with an increase of 1.3% on our anticipated 2% increase. This was due to a diversification of support available to our staff through other routes such as face to face and the NHS keeping well service which also provides emotional and psychological support (not available previously). While demand for health and wellbeing support will increase, we do not envisage that the use of EAP services will increase beyond 6% in the next year. This is due to the multiplicity of similar services currently offered to staff through other routes. Nevertheless we expect an upward movement in staff survey responses on health and wellbeing questions in 2021-22.

A robust approach to provision of psychological support has been undertaken across the organisation in the form of Covid-19 psychological support sessions, listening events and staff wellbeing events. The employee assistance program continues to provide a 24/7 confidential telephone support and advice to our staff and their families. This offer includes counselling, financial, legal, childcare, alcohol and drugs. Following the first wave of Covid-19, this resource was routinely accessed by staff and has been particularly important during the second wave of the Covid-19 pandemic. Psychological and emotional wellbeing resources such as the employee assistance program and the ‘keeping well’ service are available for staff. These are promoted via our internal communication channels and on our health and wellbeing intranet pages. Business cases have been submitted for specific staff psychological support, based in occupational health.

Quality Account 2020-21 17

The psychological impact of the Covid-19 on the present and long term health on healthcare professionals is now widely known. During both the first and second wave of the pandemic we have made resources such as counselling, bereavement and trauma support team debrief intervention available to individual staff and teams. This service has continued through the NHS keeping well service providing free and confidential psychological support for NHS staff. Locally we have strengthened in-house support for staff mental and emotional health.

Priority 3: positive action. Focused actions for improving the working lives of Black, Asian and Minority Ethnic colleagues The Trust’s focus on improving workforce experience has acknowledged the need to improve the working lives of Black, Asian and Minority Ethnic employees. These initiatives are geared at weakening organisational structures, systems and processes that work against positive change. This work has already begun at the highest level to create: • A more inclusive board membership • Senior leadership enablement • The establishment of a coalition of internal and external advisory groups that brings the whole Trust community together to make a difference. At an operational level the Trust: • Has increased the diversity of its recruitment and selection panels – holding panels to account for recruitment decisions • Is working to build the Black, Asian and Minority Ethnic talent pipeline through the launch of dedicated skills and career development programmes • Has launched the associate leadership programme to fuel the Black, Asian and Minority Ethnic leadership talent pipeline and increase representation in senior leadership roles • Has strengthened Black, Asian and Minority Ethnic leadership networks and representation in senior roles through a dedicated executive and non-executive mentoring and reverse mentoring programmes. This programme of work is support by the Workforce Race Equality Standard improvement plan, through which progress and milestones are monitored by the Trust board and board committee sub-groups.

18 London North West University Healthcare NHS Trust

Key priorities identified for improvement during 2020 were: A. We will evidence a 6% increase in the number of Black, Asian and Minority Ethnic staff who believe that the Trust provides equal opportunities B. 1% reduction of Black, Asian and Minority Ethnic staff going through disciplinary process C. Launch ‘management charter’ outlining good leadership and management behaviour by January 2021 D. Launch executive mentoring and ‘reverse mentoring’ program by from December 2020.

Ambition A Not achieved Ambition B Achieved

Evidence a 6% improvement on Black, Asian and Minority Ethnic staff who believe the trust provides equal opportunities 1% reduction in Black, Asian and Minority Ethnic staff going through disciplinary process

Ambition C Not achieved

Launch management charter

Ambition D Achieved

Launch mentoring programs

Ambition A: We will evidence a 6% increase in the number of Black, Asian and Minority Ethnic staff who believe that the Trust provides equal opportunities This has not been achieved. Progression activities and improvement initiatives were paused due to the pandemic. Specific positive initiatives have now been put in place which we believe will help drive improvements in the experience of Black, Asian and Minority Ethnic colleagues. It is however our view that these initiatives will take time to bed in and change perceptions. Therefore we would like to reduce this to 2% increase in 2021-22 (rather than 6%) as we believe that the original target too ambitious particularly because of the ongoing impact on staff health and wellbeing and their overall experience which does inform this indicator. Ambition B: 1% reduction of Black, Asian and Minority Ethnic staff going through disciplinary process This ambition was achieved, with a reduction of 26% of Black, Asian and Minority Ethnic staff being subject to disciplinary process during 2020.

Quality Account 2020-21 19

Ambition C: Launch ‘management charter’ outlining good leadership and management behaviour by January 2021 Due to the impact of Covid-19 we were unable to launch this initiative. As the organisation resets and we move to a new way of working and work to improve our engagement with our staff, we believe that this priority will be achieved in 2021-22. Ambition D: Launch executive mentoring and ‘reverse mentoring’ program by December 2020 This was achieved in 2020 with the launch of two programmes – reverse mentoring for Black, Asian and Minority Ethnic employees and Executive mentoring for participants on Black and Minority Ethnic (BME) leadership programme. This year’s staff race and disability standard self-assessments revealed that the Trust is making incremental changes in the areas of race equality. However, there is still a lot of work to do around the equality and diversity agenda. In response, the Trust has invested more people and system resources in ensuring that we meet our aspirations around equality diversity and inclusion. During 2020-21 our plan was to develop an equality diversity and inclusion strategy supported by an inclusion dashboard so bringing equality diversity and inclusion work streams together under one umbrella. We are fully aware of the impact of Covid-19 on our staff and our patients. This has informed our priorities over the next eighteen months. As the Trust works to restart its services, it is committed to strengthening the experience and working lives of Black, Asian and Minority Ethnic employees. As a large local employer, we strive to be an inclusive organisation, a place where staff feel valued and are treated with dignity and respect. We continue to promote equality and diversity in all aspects of the working lives of our staff and in delivery of inclusive services to our patients. During 2020-21, the Trust employed 75% women and 25% men. Most women in the Trust work flexible or part time hours, reflecting the national picture on working patterns. 65% of our employees declared as Black, Asian and Minority Ethnic up from 62% in the previous year. Two percent of our staff declared their sexual orientation as LGBTQi and the same number declared as having a disability. Over the past year, we have engaged our staff in an important conversation on how we celebrate and enrich the diversity of our workforce, strengthen positive inclusive behaviors and cultures, diversity our leadership and weaken that organisational barriers 20 London North West University Healthcare NHS Trust

that work against our staff. With leadership from the top of the organisation, we have seen a focused commitment and action that aims to improve the working lives of all our staff. Successes have included: • Increased staff engagement scores • Highest ever NHS annual staff survey response rate for the Trust, with 53% of our workforce taking part, an 8% increase over the previous year • More staff recommending the organisation as a place to receive care • More of our staff are motivated to come to work • Appointment of three new ethnic minority associate non-executive directors to our Trust Board • Establishment of inclusive recruitment panels and diversity reporting on appointment • Investment in staff networks to promote staff engagement and the employee voice • Launch of positive action initiatives to increase Black, Asian and Minority Ethnic representation in senior roles • Relaunch of the Disability Inclusion Network with an executive director as chair • Introduction of executive diversity champions across all protected characteristics • All-staff and Black, Asian and Minority Ethnic listening events helping staff to better engage with the Trust board • Awarded Disability Confident Employer level 2 status. This demonstrates that we operate a guaranteed interview scheme for any person with a disability who meets the essential criteria of a job profile. Our data tells us that despite these successes, there is still much to work to do. The Trust will therefore set itself an ambitious plan for transformative change through its new equality diversity and inclusion strategy. This vision for the future will be developed with the involvement of staff at all levels of the organisation.

Review of 2020 performance against care quality indicators We aim to deliver a consistently high standard of patient care in line with Trust objectives and national requirements. As part of focus on patient safety and quality assurance the following information outlines achievements over 2020-21 also providing an overview of the proposed improvement focus for the coming year.

The care quality audit profile is a tool that enables us to measure, monitor and provide Quality Account 2020-21 21

assurance around the quality of care our patients receive, in line with Trust objectives and national requirements. The changing environment of the pandemic has meant that the care quality audit profile has been streamlined this year, in line with national guidance and reporting requirements. Areas of continued priority focus were identified as outlined below Skin care; reducing harm from pressure damage A great deal of work has been completed during 2020 working towards improvements in skin care, reducing the incidence of moderate harm from Trust acquired pressure damage. A change in national reporting standards resulted in a detailed review of tissue damage acquired under the care of the Trust during the year. Opportunities for improvement that were identified included education and development, patient assessment, recording and reporting of incidents. These improvements are in addition to review and evaluation of care. Improvement plans provided an enhanced focus on specific areas for improvement and have realigned the organisational approach. Our governance and reporting processes have been strengthened with the development of patient assessment and referral pathways and implementing robust case review processes. During 2020, we improved reporting and successfully reduced the number of incidents of pressure related (moderate to severe harm) acquired within inpatient care, and have implemented systems and processes to facilitate improvement through shared learning. A Trust wide learning forum has been established. This provides a platform to discuss cases of interest and share learning across the organisation and has improved transparency with the development and circulation of monthly pressure ulcer prevalence reports. The reports are drawn from a live dashboard and help clinical teams to facilitate improvements in practice. Our improvement focus for 2021-22 will be to prioritise the application of learning and development to practice to improve patient care and experience and to reduce the prevalence of category two pressure damage within the inpatient setting. Nutrition & hydration Using feedback received from our patients and, on the basis of what we understand to be a fundamental element of care and recovery, we have improved our focus on nutrition and hydration. A new committee promotes ward to board visibility of reporting and steers improvements in holistic care with the implementation of a number of collaborative work streams. Quarterly audits are undertaken and triangulated with patient feedback to promote learning and identify areas of good practice which are then shared with clinical colleagues. 22 London North West University Healthcare NHS Trust

Our improvement focus during 2020-21 was aimed at standardising the approach to optimising patient mealtimes, promoting education and improving learning opportunities for all staff as part of the Trust induction. A meal time standard was developed and compliance monitored via audit process shown on the graph below below with the Trust’s annual average of 95.91%. Mealtime audit 2020-21 Mealtime audit 2020-21

In addition, new guidelines were developed for catering for patients in isolation beds in November 2020. The nutrition and hydration group was review and replaced with the nutrition steering and oral hydration committee (NSC) and the governance is now through nursing & midwifery and allied health professionals (NMAHP) to the Board. Medicines optimisation Learning from feedback, benchmarking and incident reporting mechanisms, we enhanced our focus on medications safety and security over the past year. We prioritised prescription and safe delivery of medical gases, safe storage and administrations of medications and improved our focus on patient education to improve safety with ‘take home’ medications. 2021-22 will see our improvement work focus on sustaining and building upon improvements that have been made with semi-annual audits, shared learning and standardisation of practice and updates circulated within a medicines management newsletter for all staff. Compassionate care for patients living with dementia. The Trust focus on care for patients and their loved ones living with dementia is led by a dedicated clinical nurse specialist for dementia services. In conjunction with the falls specialist, a strategic plan is being developed to improve care of older patients and enhance the care of those living with dementia. The strategy will be informed by the national Quality Account 2020-21 23

dementia audit (round 4) which was completed in 2018-19 and will involve the Trust becoming a member of the Dementia Action Alliance (DAA). Dementia training, which is part of induction for every employee, has been reviewed and implemented. Further dementia and delirium training packages are being redesigned in line with the dementia training standards framework. With dedicated specialist nursing resource, raising the profile of those patients within our care who are living with dementia, we are focusing on raising awareness of our staff to the complex care needs of this patient group, including their families and carers. With kindness and compassion at the forefront of care, we aim to provide an individualised approach to care provision, within a safe environment that is conducive to optimising dementia care. This is closely aligned with our patient and carer experience improvement plan and forms a key element of collaborative working with patient involvement and engagement. Key elements of our improvement focus include the organisation becoming a member of the DAA, engaging and empowering dementia champions and introduction of reminiscence dining room facility, focusing on dementia specific menu’s within at least one clinical area on each Trust site. Falls With a reinvigorated approach to harm reduction, a dedicated falls service has focused on working collaboratively with clinical teams to improve awareness around risk assessment, patient supervision and support. This has included a falls intranet page, guidance for staff on the wards, review of the e-learning packages, falls champions role definition and the development of leaflets and resources for families. Audit work is planned for 2021-22 to identify best practise and understand where gaps exist so that resources can be focused on priorities areas. These will be communicated to services via the falls collaborative meetings.. This is a key area for the Trust as the incident of reported falls remains high as shown in the graph below. Falls incident count 2020-21

24 London North West University Healthcare NHS Trust

End of life care The impact of Covid-19 has meant that our focus on end of life care was of paramount importance throughout 2020-21. We prioritised the provision of symptom control, support for families and carers and improved our communication guidelines around end of life care. In addition, the end of life care team have worked hard to support staff within inpatient areas facilitating clinical liaison between patient and family, providing updates and support on a daily basis. Patient information relating to Treatment Escalation Plans (TEP) were rolled out Trust-wide to support patients, carers and their family members in understanding treatment planning and process. These plans allowed teams to have discussions with patients and their carers to agree the levels of intervention that were possible in their care. The National Audit for Care at the End of Life was suspended for 2020 due to the pandemic. It will start again in 2021 and will help determine our improvement focus. Additionally, the Trust has committed to participate in research in the Serious Illness Care Programme to meet the NICE End of Life Quality Standard 13 guidance, recommending that timely conversations take place with patients/carers regarding what is important to them when planning for the future. Care quality assurance process: nursing The aim of a focused audit approach to nursing care is that it promotes ownership of care quality at the local level and supports improvement through a process of peer review and shared learning. Nursing-led quality rounds enable junior and senior multi-disciplinary staff to review audit data, visualise and participate in care, facilitating improvements with recommendations in real time. This approach helps to improve engagement, generating a team approach to bringing quality to life, while also exemplifying leadership standards. Assurance around this process is provided as actions are evidenced within care quality improvement plans for all areas. A process of review and showcasing of achievements and opportunities for improvement, within the existing governance framework, ensures broader organisational learning. A robust process of triangulation of all quality safety and experience related metrics provides a true picture of our performance aligned to the national standard and what is considered to be meaningful to patients. The combination of the quality audits and the excellence assessment tools (EAT) continues to provide evidence across the spectrum of patient safety and assurances around the quality of care being delivered across our wards. Quality Account 2020-21 25

Focusing on the ‘essence of care’ and triangulated with other recognised care quality and safety metrics, the nursing audit profile provides us with the opportunity to acknowledge and reward good practice with shared learning being applied to care quality improvement planning throughout the organisation. Due to emerging priorities brought about by the pandemic the audit profile was streamlined during 2020.Our focus for 2021 will be to facilitate opportunities for application of learning to practice. We will develop a robust program of observational and experiential review to include participation of all clinical staff groups while working to develop an accreditation program improving local ownership and providing ward to board assurance.The table below shows the average score from EAT audits carried out during 2020-2021. Aligned with the five nationally recognised quality domains overall achievement within the excellence assessment process* is evidenced as good. *95-100% excellent, 85-94% good, 70-84% requires improvement, below 70% inadequate EAT Trust Summary Caring 92.9

Effective 90.5

Average % score Responsive 90.1

1/04/2020-31/03/2021 Safe 91.8

Well - led 88.3

This demonstrates staff commitment to patient quality and safety in ensuring standards are continuously monitored and acted upon. The focus in quarter four was the review of this metric along with all aspects of the nursing audit profile. This has identified that a radical approach is needed to consolidate theses audits in a user friendly process that enable all staff to benefit from the data collection through to the implementation and review of the action plans.

Maternity care The Trust has been prioritising culture and safety in our maternity service this year. In July, we noted a rise in perinatal mortality during the first wave of Covid-19. As a result, the Trust commissioned external support to review some of these cases. From this, we have established a programme of improvement in the department. The Chief Executive is the chair of our Maternity Improvement Group which is responsible for delivering the maternity improvement plan. Our plan has three pillars: workforce culture and leadership, women centred care, and safe and effective care. As well as working on our internal plan, we have significantly strengthened our relationships with the other local maternity units in the Local Maternity System (LMS), sharing learning resources and best practice. This is also assisting us in benchmarking the quality of our service. Along with all other maternity units 26 London North West University Healthcare NHS Trust

in the country the Trust has submitted its self-assessment against the Ockendon Report which has helped us to define our improvement journey further. We are absolutely committed to making significant improvements to the care we provide to the local people who use the service, and this focus will continue as a priority into 2021-22. Quality priorities for maternity in 2020-21 concentrated on three areas: • Normal vaginal delivery • Instrumental delivery • Grade 1 – 3 caesarean sections (emergency) Normal vaginal deliveries (NVD) have seen a reduction during the year from 58% to 44% at its lowest point. This is equally representative in the Grade 1 – 3 caesarean CS rate in an increase over the year from 17% to 30% at its highest. Instrumental deliveries have remained stable across the year and below the national limit of 15%.The clinical teams are auditing grade 1 – 3 CS to see if there are any common learning themes. The quality account for 2021-22 will look at breastfeeding rates, postpartum haemorrhages of 500ml and above, and episiotomy rates.

The NHS outcomes framework: quality indicators Measuring and publishing information on health outcomes is important for encouraging improvements in quality. The NHS outcomes framework sets out the high-level national outcomes that the NHS should be aiming to improve. The quality indicators that are relevant to the Trust are detailed below and relate to: • Standardised Hospital Mortality Indicator Quality Account 2020-21 27

• Readmission rate within 28 days of discharge

• Trust’s responsiveness (patient experience of hospital care)

• Venous Thromboembolism (VTE) risk assessment

• C. difficile infection rate

• Methicillin Resistant Staphylococcus Aureus (MRSA) bloodstream infection rate.

Standardised Hospital Mortality Indicator (SHMI) As benchmarked within the Dr. Foster report, we are proud to have consistently low rates of mortality and our performance is ‘better than expected ‘when assessed using both the Hospital Standardised Mortality Ratio (HSMR), and the SHMI. The overall SHMI value for this Trust is 0.85, with a total of 88,455 spells of care, 2,225 observed deaths, 2,625 expected deaths, which places the Trust in the ‘lower than expected’ range Trust Values Comparators Prescribed Previous Current National Best Worst Information Period Period Average Performer Performer The most recent available standardised data for the Trust is supplied by NHS Digital for the period November 2019 to October 2020. The closest previous period for comparison is between November 2018 and October 2020. Trust SHMI Value 0.839 0.853 1.001 0.678 1.177 Better than Better than Better than Worse than Trust SHMI As Expected expected expected Expected Expected Banding The percentage of patient deaths 34.0% 35.2% 36.3% 59.0% 8.0% receiving palliative care

The Trust has the 11th lowest mortality nationally, assessed using the SHMI. Using HSMR we can break down mortality by site and see that our figures are comparably low across all our hospital sites. This work is supported by robust clinical priorities, quality of data and our learning.

28 London North West University Healthcare NHS Trust

Overview of mortality:

The Trust is committed to accurately monitoring and understanding its mortality outcomes to ensure the highest possible standard of care for patients. The Trust introduced the medical examiner service in July 2020 to independently review the care patients receive, discussing the care with the clinicians responsible and sharing this information with bereaved family and carers. The clinical effectiveness team, medical examiner service and the bereavement team work in partnership to capture the learning from these reviews. Summary of findings where the Trust could improve:

• Setting early ceiling of care plans on admission for all patients

• The need for better documentation of treatment escalation and the importance of their use when transferring patients from other sites / trusts. This issue has now been addressed: there is a Trust-wide treatment escalation plan in place, and the plan, and the importance of its use, are communicated with staff regularly.

• The need for advanced care planning to take place in the community, prior to acute hospital admission.

• The need to transfer patients earlier into the care of a hospice.

• The need to offer families support, when discussing ceiling of care.

Quality Account 2020-21 29

Summary of findings where the Trust found good practice:

• There were many examples of good clinical care, with clear documentation.

• Examples of good communication between day-care nursing staff and the ward team, which facilitated early assessment and the prompt treatment of a patient.

• Many examples of continued good practice, good teamwork and high quality clinical care being delivered. • The majority of Coroners’ post mortems found no indication of poor care.

• Many examples of managing families’ expectations well and good communication with families, especially with the families of Covid-19 patients.

The Trust will continue to focus on the outcomes from mortality reviews and assess the impact of actions taken as a result. The percentage of patient deaths receiving palliative care reduced within 2020, and this is reflected by an underperformance of 0.2% on the previous year. This can be attributed to an increase in the number of patient deaths, related to rapid deterioration of patients during the first wave of Covid-19. By way of response , palliative care staff actively supported patients within clinical areas including intensive care and high dependency units to optimise patient care and support. Readmission rate within 28 days of discharge Prescribed Information

Trust Values Comparators Previous Current National Best Worst Period Period Average Performer Performer The most recent available standardised data for the Trust has been analysed using the Healthcare Intelligence Portal from Dr Foster Intelligence for the period October 2019 to September 2020. The previous period for comparison in October 2018 to September 2019. Patients aged 0-15 6.4% 6.2% 9.4% 3.3% 17.3% Patients aged 16 or 9.1% 10.0% 9.2% 5.5% 16.7% over Performance against this standard evidences compliance with the national average, despite challenges of the pandemic.

30 London North West University Healthcare NHS Trust

VTE Risk Assessment Prescribed Information

Trust Values Comparators Previous Current National Best Worst Period Period Average Performer Performer The most recent available data for the Trust has been supplied by NHS Improvement on a quarterly basis for the period April 2020 to December 2020. The previous period for comparison covers the same quarters in 2019-20. Adult inpatients who have been risk assessed for VTE on admission: These are internal figures; VTE suspended due to Covid-19 so published figures not available 96.6% 93.1% 2020-21 Q3 97.0% 92.3% 2020-21 Q2 96.3% 92.1% 2020-21 Q1

Audits of VTE risk assessment and thromboprophylaxis The pharmacy department has an annual audit programme. This includes audits on Trust compliance with VTE. Risk assessments standards and the prescribing of thromboprophylaxis. These audits are overseen by the Trust’s Thrombosis Committee. This audit programme was put on hold during the Covid-19 pandemic; however several audits were completed in 2019-20 just prior to the start of the pandemic. An audit to assess prescribing standards for venous thromboembolism prophylaxis at Ealing hospital in February 2020.The aim of this audit was to evaluate pharmacological and mechanical thromboprophylaxis prescribing on both a surgical and medical ward at Ealing Hospital, over one week. The audit found that 90% of surgical patients and 83% of medical patients had fully completed risk assessments on admission. The remaining patients had partially completed risk assessments. 93% of patients received the appropriate treatment in accordance with their risk assessment. The Trust also participated in the Getting it Right First Time Review thrombosis review. The data collection period was October 2019 to May 2020, with the final report published in October 2020. Data for at least 20 patients per month was submitted. The audit focused on provision of thromboprophylaxis on admission, missed doses of thromboprophylaxis, provision of patient information around hospital acquired VTE and use of mechanical thromboprophylaxis where appropriate. Based on responses, the Trust was benchmarked against 98 other respondents. The Trust performed well in most areas: 100% of patients were prescribed pharmacological thromboprophylaxis in line with NICE or local guidance and more than 95% of patients received their thromboprophylaxis within 14 hours of admission. No patients missed doses of Quality Account 2020-21 31

anticoagulant prophylaxis. The main area with below average performance was the provision of information to patients on VTE (in particular written information). The Trust now has a patient information leaflet available on the intranet which can be printed off for patients. C. Difficile infection rate Prescribed Information

There were no national objectives applied to Clostridium difficile in 2020-21. At the end of the year the Trust reported a total of 70 cases which is 6 less than the previous year. Nineteen of the 70 cases were categorised as community onset healthcare associated. This means that a patient presented with diarrhoea at time of admission or developed diarrhoea within the first 48 hours of admission but had been a hospital inpatient in the preceding 28 days. MRSA bloodstream Infection Rate Prescribed Information

Trust Values Comparators Previous Current National Best Worst Period Period Average Performer Performer The most recent available data for the Trust has been supplied by Public Health England for the period April 2019 to March 2020. The previous period for comparison is April 2018 to March 2019. Methicillin Resistant Staphylococcus Aureus (MRSA) blood1.4 0.5 0.8 0 4.1 stream infection (BSI) rate per 100,000 bed-days At the end of the year, the Trust reported a total of six cases: four at Ealing Hospital and two at Northwick Park Hospital. This represents a 50% increase from the previous year and an unwanted variance. Post infection reviews have been completed by the 32 London North West University Healthcare NHS Trust

infection control team. Three of the patients were known to have MRSA colonisation, which is a significant risk factor. Two patients missed an MRSA screening opportunity at the time of admission. This has been addressed by changing the responsibility for MRSA screening from the emergency department to the admitting ward within the first 48 hours of admission. Three of six were thought to be transient bacteraemia as follow up blood cultures were negative without antibiotic therapy. Two of the patients had Covid-19 and one of the two died as a result of chest sepsis. Trust responsiveness to patient experience Prescribed Information

Trust Values Comparators Previous Current National Best Worst Period Period Average Performer Performer The most recent available data for the Trust has been supplied by NHS England for the 2018 Adult Inpatient survey published in June 2019. This data has not been available due to suspension of collections nationally Overall Patient 74.6 70.9 76.2 88.4 68.5 Experience Score This year 8,302 people gave us feedback using the Friends and Family Test (FFT). The decline in numbers, last year is due to the pandemic and the impact it had on feedback collection methods that would of usually been used by the Trust. The national suspension of FFT collection started in March 2020, and following reinstatement the national guidance continued to advise Trusts to collect responses only where safe to do so. Due to infection prevention and control recommendations some areas have yet to be reinstated. Due to Covid-19, NHS organisations did not conduct the annual staff FFT during 202021. Nevertheless, we were able to measure the experience of our staff through the annual staff survey. The outcomes are presented in part three of this quality account.

Secondary users service: data quality The Trust submitted records during 2020-21 to the secondary users service (SUS) for inclusion in the hospital episode statistics (HES), which are included in the latest published data. The percentage of Trust records for the period April 2020 to December 2020 which include a valid NHS Number were: • 98.3% for admitted patient care; • 99.2% for outpatient care; and • 95.7% for accident and emergency care. Quality Account 2020-21 33

The percentage of records in the published data which included the patient’s valid general medical practice code was: • 100% for admitted patient care; • 100% for outpatient care; and • 99.9% for accident and emergency care. The Trust is working to improve its clinical coding audit capability, with full results not yet available for 2019-20. The Trust improves data quality through: • Regular review of and compliance with the Trust data quality policy through cleansing, audit and feedback to clinical and non-clinical teams. • Working closely with clinicians to ensure the accuracy of coded data through regular and ad hoc joint reviews and through an education programme. • Reviewing the level of risk associated with data quality through the data quality management group and the corporate quality and risk committee. • Continuing the data quality assurance programme ensuring key elements of information reporting including data assurance, presentation and validation are delivered within national guidance and standards. • Validation of 18 week referral to treatment time and cancer pathways through audit, validation and education of both clinical and non-clinical teams.

Overview of patient safety incidents This section sets out the Trust’s work and progress during the period 1 April 2020 to 31 March 2021, in relation to reporting, management and learning from patient safety incidents (PSIs) including Serious Incidents (SI) including Never Events, detailing trends across types of incidents, categories and severity of harm. A strong reporting culture is encouraged across the organisation to support continuous improvement through learning and service improvement, thus enhancing patient safety and patient satisfaction. Our obligations in terms of Duty of Candour (DoC) compliance are monitored and have been audited this year. Finally, there is an overview of national alerts from the Central Alert System (CAS) and our performance in uploading patient safety incidents to the National Reporting and Learning Service (NRLS). Trends in reporting of patient safety related incidents The chart below shows patient safety incidents reported to Datix, the Trust’s risk management system, from April 2020 to March 2021 (12,936). Comparison is made with the previous period total of 22,341. The decrease in reporting across the last year is 34 London North West University Healthcare NHS Trust

likely to be attributable to the pandemic. In April 2020, the Trust experienced the first wave of Covid-19 infections and there was an immediate decrease in the number of PSIs reported. This began to recover after May 2020 but declined again in December 2020, coinciding with the second wave of Covid-19, with tentative signs of recovery at the time of writing. The fall in reporting is likely to be related to the sudden alteration in the nature of service activity (such as cessation of outpatient activity and non-urgent procedures), as well as the extreme clinical pressures, reducing clinical colleagues’ capacity to report incidents. We remain committed to improving our services to patients by reporting incidents and learning from them. We will continue training on accurate incident reporting during 2021/22 to support correct categorisation of incidents, as this is essential for local and national NRLS trend analysis. Monthly patient safety reporting (extracted from Datix 08/04/2021), 1 April 2020 to 31 March 2021 compared to the same period last year.

Top five themes in patient safety related incidents

Quality Account 2020-21 35

Implementation of care While this is most frequently reported category of incident the level of harm remains generally low: it includes pressure and moisture related injury. Within this, pressure ulcers acquired or that deteriorated during admission/care is the most prominent subcategory - similarly these are mostly low harm / minor injury incidents. This is consistent with the aim of our enhanced focus on improved reporting of low harm events. Accidents including falls Most incidents in this category between April 2020 and February 2021 resulted in no harm or low harm and were associated with an inpatient fall from a bed or chair. Access, appointment, admission, transfer, discharge Surges in Covid-19 saw increases in incidents related to admissions and heightened activity, with delays accounting for many incidents reported under this category, alongside challenges with intensive care unit and high dependency unit bed capacity. With an anticipated change in the nature of activity this year, there is an opportunity to identify early any areas where capacity and demand are found to lead to patient harm, via reviews. This is part of the work through the ongoing recovery delivery group as the Trust resumes normal activity. Medication The majority of medication errors fall into the sub-category ‘administration or supply of a medicine from a clinical area’. The most clearly defined sub-category of incident related to the ‘management, storage and transportation of controlled drugs’ with most of these relating to incorrect recording of drug quantities in stock records and therefore, low or no harm. Improvement opportunity and actions Infrastructure/resources (staffing, facilities, environment) Issues relating to bed capacity were the most commonly reported type of incident within this category. This was due to increased demand on the Trust during the peaks of the pandemic. The situation was closely monitored by Covid Gold Command and challenges with bed allocations within capacity were managed as they arose, as part of a sector-wide coordinated response.

36 London North West University Healthcare NHS Trust

Incident reporting by severity The chart below illustrates the number of patient safety incidents reported by level of harm/severity, shown against the trend in overall incident reporting already described.

All incidents are reviewed and investigated within the divisions and those of moderate and greater harm considered for closer scrutiny as potential serious incidents. The chart below shows reported incidents of moderate and greater harm with the trend across the period for moderate harm.

This provides some assurance that while incident reporting may have been lower across the year and negatively responsive to the pandemic, key opportunities for learning were present despite the pressures as moderate harm reporting remained stable and even rose over time. The increase in deaths reported in January 2021 relates to retrospective reporting of deaths related to confirmed hospital-acquired Covid-19 (per NHSE guidance), following development of a standard operating procedure to capture these instances for closer scrutiny.

Quality Account 2020-21 37

Serious Incidents In the period 1 April 2020 to 31 March 2021, the Trust declared 72 SIs on the strategic executive information system. Following investigation two of these SIs were deescalated, with approval from the clinical commissioning group, as investigation showed they did not meet the SI criteria. A comparison is provided below, against the number of SIs declared for the same period in 2020-21 and 2019-20. These were 72 and 83 respectively. There was a definitive downward trend towards the end of the year.

Categories of SIs reported are outlined below and the table describes the five most common categories of SI together with improvement opportunities. Serious Incidents: all categories reported for 1 April 2020 to 31 March 2021

38 London North West University Healthcare NHS Trust

The table below describes the five categories most commonly reported and a description of the improvement opportunity for each. Type of Serious Incident and number Improvement opportunity – what will this declared in period look like? How will we get there? What will be different? Delayed diagnosis (21): the largest A detailed inter-divisional review in collaboracategory. Within this, the majority tion with clinical colleagues from diagnostic, related to a delayed diagnosis for medical and surgical teams to better undercancer. Further analysis revealed three stand this category and the underlying causes broad types of root cause: with the aim of developing an action plan to communication breakdown; tracking, address recurrent themes. The objective is to pathways/referral processes and identify SMART actions to prevent recurrence. diagnostic review/follow up. A number The desired outcome is a measurable reducof incidents referenced more than one tion year on year of SIs relating to delayed/ of these themes and in several instances, missed cancer diagnosis communication breakdown played some part in the other two themes. Following a perinatal peer review and with Maternity incidents intrapartum death, perinatal morbidity (12): one SI input from the HSIB, the Trust has developed a maternity improvement plan, overseen by also investigated by HSIB.1 executives and reporting to the board. Appointment of additional senior support for review and governance in maternity is planned, and there will be enhanced working with the local midwifery system. Appointment of a non-executive director with special oversight for maternity has been made.

Slips, Trips and Falls2 (6): the theme emerging from investigations indicate a lack of documentation of patient falls risk assessments; these are a key tool in identifying a patient at risk of falls so that preventative actions are put in place. In some instances, multiple ward moves in elderly or frail patients were a feature in care where a fall with harm occurred subsequently.

The desired outcome is successful delivery of the maternity improvement plan bringing positive developments and benefits to the service provided to local women. The Trust will maintain its focus on these incidents through the work of falls nurse who will lead on reducing inpatient falls. One clinical division has used patient falls as the “focus of the month” during safety huddles and the aim is to export this learning approach more widely to other divisions. Falls will be a focus in our future virtual learning event hosted by the patient safety team. The desired outcome will be a reduction in the proportion of falls with harm.

Quality Account 2020-21 39

Pressure ulcer (PU) (4): The increase in PUs reported as SI came as a result of improved scrutiny via a dedicated group and better liaison with the Serious Incident review group (SIRG) .

Cardiac arrest (6): Although five SIs were declared in this category two were later de-escalated following investigation

The tissue viability nurse (TVN) reviews Trust acquired pressure ulcers and works closely with ward staff to support clinical management. In addition, the tissue viability collaborative will focus, alongside clinical staff, on investigation of Trust acquired PUs, development of action plans and learning. Bespoke investigation tools have been created for this category of incident, enabling a thorough and rigorous investigatory approach, intended to translate into measurable action. The desired outcome will be a reduction in the proportion of more serious categories of acquired pressure damage and reduce the numbers that deteriorate to become more serious. The SIRG monitor themes for this important category, to enable immediate learning and action where recurrent causes are identified which may make a difference to care and outcomes. The desired outcome will be to make recommendations where possible arising from learning from these incidents.

HSIB: Healthcare Safety Investigation Branch conducts independent investigations in NHS funded care, with the patient’s/family’s consent. 2 Slips, Trips and Falls : “an unintentional event whereby and individual comes to rest on the ground or another lower level, with or without loss of consciousness” (NICE 2004) <?>

Serious incidents arising from definite hospital acquired infection Covid-19 The Trust developed a process for identifying and investigating deaths relating to hospital acquired Covid-19 (meeting the NHSE criteria of definite hospital acquired infection, ie from day 15 post admission). This work is currently in progress at the time of writing for reporting in due course, when all incidents meeting the criteria have completed their review. The Trust has developed its approach in accordance with the guidance from NHS England and Improvement regarding a proportionate and practical response within available resources, noting the continued obligations around duty of candour.

40 London North West University Healthcare NHS Trust

Never Events Out of 72 SIs declared, three were Never Events3: a retained guidewire; a patient being administered air instead of oxygen from a wall port and a wrong site procedure/wrong patient. Two of these did not result in patient harm while the third caused moderate harm. All were investigated as SIs because existing safety recommendations had not been followed, directly leading to the incidents. Medical gases never event: a key improvement opportunity A task and finish group was set up in early 2020, chaired by the pharmacy team, to drive forward a comprehensive project plan to improve safety. This includes medical airflow meters being removed from terminal outlets when not in use and stored in designated containers. Medical gases employee learning management system (ELMS) training has been updated to reflect this, while standards for the storage of medical air flow meters have been written and launched. In addition, the medical gases ELMS training is now essential training and figures will be shared with divisional governance Leads every quarter to highlight levels of compliance. Medical airflow stickers were designed and distributed to all clinical areas with flow meters, to provide an additional safeguard. Monthly medicines management audits are being conducted to track and ensure compliance. Duty of candour Ahead of the revision of the duty of candour policy due this year, an audit of compliance was completed. A sample of 436 moderate or greater harm incidents occurring between 1 April 2019 and 31 March 2020 was used to generate a 20% randomised sample of 80 incidents. Each incident was then reviewed by three auditors from the quality and patient safety team, to confirm the verbal apology, assess the quality of the letters recorded within Datix, ie dates of verbal apologies, the date the duty of candout letter was given and the content of the letters. The audit showed a high level of compliance with the duty of candour requirement to offer an explanation and apology to patients following an incident of patient harm. Verbal compliance was audited at 86% in the sample analysed; however compliance with the written phase was lower, at 56%, indicating that work is required to support teams with the written phase of compliance. Overall duty of candour compliance (to include a written apology to the affected persons) is shown below. This data reflects what was recorded within Datix, and compliance may be better than this, but not recorded. Compliance was negatively affected by the two waves of the pandemic. Quality Account 2020-21 41

Duty of candour compliance by month

National Reporting and Learning System (NRLS) The official Organisation Patient Safety Incident Report (OPSIR) is published by the NRLS. This verified data includes incidents occurring between October 2019 and March 2020 and reported to NRLS by 30 May 2020 (published on 23 September 2020); this data is used for the purposes of this section of the account. Previously the data was published bi-annually six monthly in arrears, however the reporting schedule has now changed to annual publications, so full information for the 2020-21 financial year will not be available until September 2021. The Trust has effective processes in place to manage timely and accurate uploading of patient safety incidents to the NRLS. The Trust submitted 50% of its patient safety incident PSI reports by 34 days from the reported incident date. When compared to other acute (non-specialist) trusts there is no evidence for under reporting of incidents as the Trust remains within the expected range, as below.

We propose to complete a validation exercise to assess potential over-reporting against the severity of harm incident criteria, with aim of improving accuracy over time. Results from the national staff survey 2020 showed that when asked about reporting: • We are given feedback about changes made in response to reported errors, near misses and incidents – We scored slightly higher than average among acute (nonspecialist) trusts (64.5% vs 61.9%) The chart below draws a comparison of the reporting rates of acute (non-specialist) organisations in England for the six-month period, 1 October 2019 - 31 March 2020, and 42 London North West University Healthcare NHS Trust

shows that the Trust is above average in the cluster. Patient safety incidents per 1,000 admissions October 2019 to March 2020

The NRLS considers that evidence of under-reporting is an indirect indicator of potential problems with an organisation’s culture around incident-reporting while an increase in reporting may indicate an improved reporting culture. The Trust has steadily increased incident reporting levels over time, including against the important metric of incidents per 1,000 bed days. Central Alerting System compliance The Central Alerting System (CAS) is the Department of Health’s electronic delivery and monitoring system for cascading National Patient Safety Alerts (NatPSAs) and other safety critical issues. The notifications contain clear and concise explanations of the risks and offer appropriate guidance for the prevention of incidents that may result in severe harm or death to patients. The Trust has effective processes in place to manage national alerts from the CAS. The Trust records its compliance with the alerts on the CAS website and on its own platform on Datix. Coordination of NatPSAs is carried out by the corporate quality and patient safety team. The team works with senior managers to facilitate compliance, capture assurance and monitor ongoing work or action plans required to address the issues raised by the alert. The Trust is currently fully compliant with all the actions and obligations required. NatPSAs issued April 2020 to March 2021 Reference

Title

Action status

NatPSA/2020/002/NHSPS

Interruption of high flow nasal oxygen during transfer

Action completed: the content of the alert was brought to the attention of the executive directors and information made available to all staff on the Covid-19 pages of the Trust intranet

NatPSA/2020/003/NHSPS

Blood control safety cannula and needle thoracostomy for tension pneumothorax

Action completed: all clinical areas using the devices were identified and actions were completed as required.

Quality Account 2020-21 43

NatPSA/2020/004/NHSPS

Risk of death from unintended administration of sodium nitrite

Action completed: all actions completed and a full review and update of the use and storage procedures was undertaken.

NatPSA/2020/005/NHSPS

Steroid Emergency Card to support early recognition and treatment of adrenal crisis in adults

Action required: ongoing. There is assurance that the required actions will be completed by the deadline date for actions to be completed as guidelines are being updated and clinicians informed.

NatPSA/2020/006/NHSPS

Foreign body aspiration during intubation, advanced airway management or ventilation

Action required: ongoing. Deadline for actions to be completed is 1 June 2021

NatPSA/2020/007/MHRA

Philips Respironics V60 ventilator – actions to be taken to avoid potential unexpected shutdown leading to complete loss of ventilation.

Action not required. The affected devices are not in use in the Trust.

NatPSA/2020/008/NHSPS

Deterioration due to rapid offload of pleural effusion fluid from chest drains

Action completed: the policy for managing chest drains has been updated to ensure compliance with the alert.

NatPSA/2021/001/MHRA

Supply disruptions of sterile infusion sets and connectors manufactured by Becton Dickinson (BD)

Action completed: he content of the alert was brought to the attention of the executive directors and actions completed by the clinical areas affected.

Patient-led assessments of the care environment (PLACE) Due to impacts and constraints in place directly related to the Covid-19 we have been unable to facilitate PLACE assessments during 2020. In acknowledgement of feedback from inspections within 2019 we have worked hard to ensure our focus on key aspects of care quality improvement, such as nutrition and hydration, including patient experience at mealtimes, all previously highlighted as areas for improvement, have continued within the nursing quality assurance program.

44 London North West University Healthcare NHS Trust

Statements of assurance Statements of assurance from the board include: • Review of services • Participation in clinical audit • Participation in clinical research • Goals agreed with commissioners (CQUINS) • What others say about the Trust • Patient reported outcome measures (PROMS) • Data quality, information governance and clinical coding • Staff survey.

Review of services During 2020-21, the Trust provided and or subcontracted the following services: • Emergency department • Admitted patient care for planned and emergency treatment • Critical care • Non-admitted patient care • Maternity services • Paediatric services • Integrated community services. The Trust has reviewed all the data available to them on the quality of care in these relevant NHS services.Income generated represents % of total income generated from the provision of NHS services by LNWH NHS Trust. A proportion of our income in 2020-21 was conditional on ensuring that reasonable endeavours were made to achieve the quality improvement and innovation goals agreed between the Trust and north west London Clinical Commissioning Groups through the commissioning for quality and innovation payment framework (CQUIN); please refer to CQUINS for further information. Our overriding focus is to ensure that quality is at the heart of everything we do. We strive for continuous quality improvement, transformation, and personalised care for the care across the services we provide. In order to ensure that quality is given the highest priority we formally report on our progress against our quality priorities through our governance and committee structure to the board of directors, our regulators NHS Improvement, NHS England, Care Quality Commission, our commissioners and the Integrated care partnership.

Quality Account 2020-21 45

Participation rates for national audits by financial year Clinical audit and effectiveness Clinical audit is an essential activity for all healthcare organisations, as it is used to evaluate clinical practice and identify areas for improvement. As an organisation, we encourage all services to review the care they deliver by undertaking local and national clinical audits. During 2020-21, the Trust has conducted 134 local audits. The Trust has participated in all but two relevant national clinical audits / National Confidential Enquiries, both due to capacity issues throughout the two waves of Covid-19 pandemic. The Trust encourages series to participate in these audits as it enables services to compare their practice against other similar Trusts and to benchmark their services. Each year, the Healthcare Quality Improvement Partnership (HQIP) publishes a quality accounts list on behalf of NHS England detailing the national clinical audits, clinical outcomes review programmes and registries on which NHS England would like each health service provider to report. During 2020-21, a list of 86 national audits was published, of which 73 were applicable to the Trust. As these national clinical audits / national confidential enquiries are not applicable to all sites, participation has been broken down by site for the period:

• Central Middlesex Hospital participated in 94% (33/35) national clinical audits

and 100% of national confidential enquiries in which it was eligible to participate.

• Ealing Hospital participated in 98% (49/50) of national clinical audits and 100%

of national confidential enquiries in which it was eligible to participate.

• Northwick Park Hospital and St. Mark’s Hospital participated in 99% (70/71) of

national clinical audits and 100% of national confidential enquiries in which it was eligible to participate. Please note that four of these national clinical audits were postponed due to Covid-19 and the Trust had no harms to report for the National Diabetes Audit – Adults 20-21 The table below lists the national clinical audits, clinical outcome review programmes and other national quality improvement projects, which NHS England advises trusts to prioritise for participation and inclusion in their quality accounts for 2020-21. For further information about the statutory function of this list, please refer to HQIP’s guidance on quality accounts. 46 London North West University Healthcare NHS Trust

National Clinical Audit and Clinical T r u s t Participating Sites Outcome Review Programmes Level Eligible to Participate Antenatal & New-born National Audit Yes 2019-022

BAUS Urology Audit 20-21: Renal Colic BAUS Urology Audit 20-21: Management of the Lower Ureter in Nephroureterectomy Case Mix Programme (CMP) 20-21

Child Health Clinical Outcome Review 20-21: Transition from Child to Adult Services Elective Surgery National PROMs 20-21: Hip Elective Surgery National PROMs 20-21: Knee

Central Ealing Middlesex N/A N/A

In progress

Yes

N/A

57134 (100%) -1 In progress

Yes

N/A

In progress

Yes

N/A

Yes

N/A

In progress 8760/8760 (100%) = 19/20 Not Yet Due

In progress 3285/3285 (100%) = 19/20 Not Yet Due

Yes

In progress

144/218 (66%) = 19/20 In progress

Yes

383/541 (71%) = 19/20 In N/A progress 20/20 (100%) = 19/20 N/A In progress

In progress

Yes

N/A

In progress

Yes

N/A

In progress

Yes

In progress

Endocrine and Thyroid National Audit Yes 20-21

Emergency Medicine QIPs 20-21: Fractured Neck of Femur Emergency Medicine QIPs 20-21: Infection control Emergency Medicine QIPs 20-21: Pain in children Falls & Fragility Fractures 20-21: In-patient Falls

Northwick Park

N/A

20/20 (100%) = 19/20

Quality Account 2020-21 47

Falls & Fragility Fractures 20-21: Hip Fracture

Yes

Inflammatory Bowel Disease (IBD) Registry: Biological Therapies Audit 20-21: Adult

Yes

Inflammatory Bowel Disease (IBD) Yes Registry: Biological Therapies Audit 20-21: Paediatrics Learning Disabilities Mortality Review Yes 20-21 Major Trauma Audit (TARN) 20-21 Yes

Mandatory Surveillance of Healthcare Yes Associated infection 20-21: E Coli Bacteraemia Mandatory Surveillance of Healthcare Yes Associated infection 20-21: Klebsiella spp bacteraemia Mandatory Surveillance of Healthcare Yes Associated infection 20-21: Pseudomonas Aeriginosa Bacteraemia Mandatory Surveillance of Healthcare Yes Associated infection 20-21: Methicillin resistant staphylococcus Aureus bacteraemia Mandatory Surveillance of Healthcare Yes Associated infection 20-21: Methicillin susceptible staphylococcus aureus bacteraemia Mandatory Surveillance of Healthcare Yes Associated infection 20-21: Clostridioides difficile Maternal, New-born & Infant Clinical Outcome Review Programme 20-21: Maternal Maternal, New-born & Infant Clinical Outcome Review Programme 20-21: Perinatal 48 London North West University Healthcare NHS Trust

N/A

In progress

N/A

36/36 (100%) = 19/20 N/A

337/337 (100%) = 19/20 In progress

N/A

33/33 (100%) =19/20 In progress

N/A

In progress N/A

In progress

249/249 436/436 (100%) =2019 (100%) = 2019 In progress 87/87 (100%) = 19/20 In progress 37/37 (100%) =19/20 In progress

15/15 (100%) = 19/20 In progress

3/3 (100%) =19/20 In progress

23/23 (100%) =19/20 In progress

Yes

68/68 (100%) =19/20 N/A N/A

2/2 (100%)

Yes

N/A

41/41 (100%)

N/A

Medical & Surgical Clinical Outcome Review 20-21: Alcoholic Liver Medical & Surgical Clinical Outcome Review 20-21: Crohn’s Medical & Surgical Clinical Outcome Review 20-21: Epilepsy National Asthma & Chronic Obstructive Pulmonary Disease Audit 20-21: Secondary Care

Yes

In progress

Yes

N/A

Not Yet Due

Yes

N/A

Not Yet Due

Yes

N/A

In progress

N/A

465/465 (100%) = 19/20 In progress

490/490 (100%) = 19/20 In progress

N/A

331/331 (100%) = 19/20 In progress

506/506 (100%) = 19/20 In progress

N/A

13/13 (100%) = 19/20 N/A

24/24 (100%) = 19/20 In progress

National Asthma and Chronic Obstructive Pulmonary Disease Audit 20-21: Asthma

Yes

National Asthma and Chronic Obstructive Pulmonary Disease Audit (NACAP) 20-21: Rehabilitation

Yes

National Asthma and Chronic Yes Obstructive Pulmonary Disease (COPD) Audit (NACAP) 20-21: Children & Young People Asthma National Audit of Breast Cancer: Yes Older People 20-21 National Audit of Care at the End of Life 20-21

Yes

National Audit of Dementia (General hospitals) 20-21

Yes

National Audit of Seizures and Yes Epilepsies in Children & Young People (Epilepsy12) 20-21 National Cardiac Arrest Audit (NCAA) 20-21

Yes

In progress 246 = 2018 Postponed Nationally due to Covid-19 40/40 (100%) = 19/20 In In progress progress 25/25 50/50 100% 100% 19/20 19/20 N/A N/A

19/20 In progress

N/A

28/28 (100%) = 18-19 In progress

In progress 73/73 (100%) = 19/20

In progress

51/51 100%

218/219 (99.6%) = 19/20

Quality Account 2020-21 49

National Cardiac Audit 20-21: Myocar- Yes dial Ischaemia

National Cardiac Audit 20-21: Heart Failure

National Cardiac Audit 20-21: Cardiac Rhythm Management

Yes

50 London North West University Healthcare NHS Trust

In progress

363/442 (82%) 699/936 = 19/20 (75%)=19/20 In progress

In progress

359/495 (73%) 629/897 =19/20 (70%)=19/20 In progress

In progress

Yes

307/307 (100%) = 19/20 In progress 654/654 (100%) = 19/20 Postponed Nationally due to Covid-19

Yes

Postponed Nationally due to Covid-19

Yes

Postponed Nationally due to Covid-19

Yes

Postponed Nationally due to Covid-19

Yes

35/35 (100%)

Yes

No harms Recorded for Trust

Yes

TW 76/76 (100%)

National Cardiac Audit 20-21: Percuta- Yes neous Intervention

National Comparative Audit of Blood Transfusion: 20-21: Patient Blood Management in Paediatric Surgery National Comparative Audit of Blood Transfusion: 20-21: Survey of use of FFP, Cryoprecipitate, PCC and fibrinogen concentrate National Comparative Audit of Blood Transfusion: 20-21: Audit of NICE Quality standards National Comparative Audit of Blood Transfusion: 20-21: Audit of Blood Sample Collection & labelling National Diabetes Audit – Adults 20-21: Foot Health National Diabetes Audit – Adults 20-21: National Audit of Inpatients NADIA Harms National Diabetes Audit – Adults 20-21: Core

In progress 4/4 (100%) = 19/20 In progress 13/17 (76%) = 19/20 In progress 94/94 (100%) = 19/20 N/A

113/113 (100%) = 19/20 In progress 217/217 (100%) =19/20

National Early Inflammatory Arthritis Audit 20-21

Yes

National Emergency Laparotomy Audit (NELA) 20-21

Yes

In progress 1/1 (100%) =19-20 N/A

In progress

In Progress

33/33 (100%) =19/20

96/150 (64%) =19/20

In progress

National Gastro-intestinal Cancer Programme 20-21

Yes

56/60 150/208 93.3% = 18/19 72.1% = 18/19 In progress

National Joint Registry (NJR) 20-21: Knee Replacement

Yes

National Lung Cancer Audit (NLCA) 20-21

Yes

National Maternity and Perinatal Audit (NMPA) 20-21 National Neonatal Audit : Neonatal Intensive and Special Care 20-21 National Ophthalmology Database Audit 20-21

Yes

84 (65-74%) = 17/19 In In progress progress 578/579 2/2 (100%) = (99.8%) 19/20 = 19/20 In In progress progress 207/207 15/15 (100%) (100%) =19/20 = 19/20 In progress 237/237 (100%) = 2018 N/A N/A

Yes

N/A

Yes

*Did Not participate N/A

N/A

In progress

N/A

106/106 100% = 19/20 N/A In progress

National Joint Registry (NJR) 20-21: Hip Replacement

Yes

National Paediatric Diabetes Audit (NPDA) 20-21

Yes

National Prostate Cancer Audit 20-21

Yes

National Smoking Cessation Audit 20-21

Yes

N/A

In progress

16/17 (94%) = 19-20 In progress

36/36 (100%) = 19/20

In progress 418/418 (100%) N/A

Not yet due

362/362 (100%) = 18/19 Not yet due

100/100 100% = 19/20

Quality Account 2020-21 51

National Vascular Registry 20-21

Yes

National Vascular Registry 20-21: Yes Elective infra renal AAA National Vascular Registry 20-21: AAA Yes National Vascular Registry 20-21: Major Amputation

National Vascular Registry 20-21: Carotid Endarterectomy National Vascular Registry 20-21: Lower limb Angioplasty including revascularisation National Vascular Registry 20-21: Bypass Perioperative Quality Improvement Programme 20-21 (Research) Sentinel Stroke National Audit programme (SSNAP) 20-21

Yes

N/A

Yes

N/A

Yes

N/A

Yes

N/A

Yes

*Did not participate

Yes

N/A

In progress 374 = 19-20 20/19 (105%) = 19/20 6/6 (100%) = 19/20 23/22 (105%) =19/20 41/40 (108%) = 19/20 169/189 (89%) = 19/20 36/74 (49%) = 19/20

In progress 183/183 100% = 19/20

Serious Hazards of Transfusion: UK National Haemo-vigilance Scheme 20-21 Society for Acute Medicine’s Benchmarking 20-21 Surgical Site Infection Surveillance Service 20-21: Hip: All four Quarters submitted mandatory one condition for one Quarter Surgical Site Infection Surveillance Service 20-21: Knee: All 4 Quarters submitted mandatory one condition for one Quarter UK Cystic Fibrosis Registry 20-21

Yes

45/45 (100%)

Yes

N/A

01-Jan

01-Jan -100%

Yes

-100% In progress 166/269 (62%) = 19/20

Yes

In progress 456/553 (83%) = 19/20

N/A

The requirement to participate in the HQIP-commissioned National Clinical Audit and Patient Outcome Programme (NCAPOP) projects stems from the NHS standard contract. The requirement to participate in national clinical audits and enquiries does not extend to non-NCAPOP projects unless commissioners have chosen to add a requirement to 52 London North West University Healthcare NHS Trust

participate, by adding variations to the local contracts. In addition, the NHS Standard Contract gives commissioners the power to impose penalties on healthcare service providers who fail to participate in an NCAPOP project. Project providers inform HQIP if a trust has failed to participate and the Care Quality Commission (CQC) may investigate this during a trust inspection and levy a fine. All NHS England quality account audits should be considered as mandatory and each year the Trust has to declare compliance against these audits within the quality account. The clinical quality & safety committee reviews the progress for these audits quarterly and all the quality account audits are regularly to the Trust Board. Below is a list of the quality account and national clinical audits that the Trust was eligible to participate in during 2020-21:

National audits – reports received during 2020-2021 38 national clinical audit reports were published and recommendations were put into action by the Trust during the period. Below is a summary of the main changes made to services as a result of these national recommendations. Quality Accounts / National Audits: Emergency & Ambulatory Care Division Service

Site

Ambulatory Care

NPH

Audit Title

Society for Acute Medicine’s Benchmarking Audit (SAMBA) 2019-2020

Date National Audit Published

Changes or Improvements made to Clinical Care:

29-Apr-20

A business case has been approved by the Trust to expand the service and enable the recruitment of more ambulatory care consultants. Supporting the review of more patients by the service.

Quality Accounts / National Audits: Integrated Clinical Services Division Service

Site

Audit Title

Date National Audit Published

Changes or Improvements made to Clinical Care:

Quality Account 2020-21 53

Physiotherapy

NPH

UK Parkinson’s Audit 2019-20

05-Feb-20

The service has updated their local staff induction information to include NICE recommendations. The service has procured laptops for Physiotherapists to utilise with patients, allowing them to access the Parkinson’s UK YouTube channel and website. This is important as there are a number of resources available on this site for patients and enables staff to show patients where information is and how to access advice as part of their appointments.

Quality Accounts / National Audits: Integrated Medicine Division Service

Site

Audit Title

UK Parkinson’s Audit

Date National Audit Published

03-Feb-20

Changes or Improvements made to Clinical Care:

Local pathways have been established to identify and provide access for patients who are found to be suitable for clozapine prescription to have psychiatric input and monitoring.

Neurology

CMH

Service

Site

Audit Title

Date National Audit Published

Changes or Improvements made to Clinical Care:

Orthopaedics

Trustwide

National Elective Surgery: PROMs – 2018-19

13-Feb-20

Pathways established to reduce the risk of infection; dressings will remain in situ for two weeks and STARRS now refer directly to clinics or (out of hours) to A&E where patients will be seen by orthopaedic doctors.

Qality Accounts / National Audits: Surgery Division

The service has improved internal systems to ensure that discharge analgesia is prescribed in accordance with their inpatient usage both of regular and as required medication to ensure good pain relief at home as this will also have an effect of improved mobility. The service has developed specific training on this as part of departmental induction processes.

54 London North West University Healthcare NHS Trust

Quality Accounts / National Audits: Women and Children’s Division Service

Site

Audit Title

Women and Children’s

NPH

National Neonatal Audit Programme (NNAP) 2019

Date National Audit Published

Changes or Improvements made to Clinical Care:

12-Nov-20 Greater emphasis has been placed on informing parents that they are able to attend ward rounds and ensuring that parents know the timing of these rounds. Attendance at ward rounds by parents is then recorded onto the BadgerNet system (on the same day that the parent attended the ward round). Parents are also informed of the ward rounds and times via an information leaflet.

National confidential enquiries There were three national confidential enquiries in which the Trust was eligible to participate during the period 1 April 2020 to 31 March 2021, as below: NCEPOD studies in which the Trust participated National Confidential Enquires into perioperative Deaths (NCEPOD) Studies

Alcoholic Liver Disease

Submissions

Central Middlesex

Ealing

Northwick Park / St. Mark’s

Case notes

None requested

20 cases In progress

Organisational questionnaires

Not requested

In progress

Not due yet

List of cases

Crohn’s Disease

Case Notes

Not due yet

Clinician Questionnaire

Not due yet

Organisational questionnaires

Not due yet

Quality Account 2020-21 55

Child health studies that the Trust participated in during 2020-21 National Confidential Enquiries Child Health

Transition from Child to Adult Services

Submissions

Central Middlesex

Ealing

Northwick Park / St Mark’s

List of cases

Not due yet

Case Notes

Not due yet

Clinician Questionnaire

Not due yet

Organisational questionnaires

Not due yet

The Trust treats national audits listed by NHS England as ‘mandatory’ and monitors their completion, across publication years. The clinical audit and effectiveness team monitor these audits until they are ‘fully completed’. To ‘fully complete’ a national audit, a service must submit the national data, review the findings from national reports and produce an action plan

Continuous improvement through research The research and development (R&D) department leads, manages and develops research across the Trust. In 2020-21 we continued to be at the forefront of delivering world class research. The Trust has continued to expand its research portfolio and increased opportunities for patients and clinicians to take part in high quality and high-profile research projects including urgent public health. The R&D department has also increased its portfolio of service evaluations and quality improvement projects and is continuing to work through the R&D strategic aims: • Dedicated R&D footprint within the Trust • Financial stability and transparency • Dynamic digital data • Quality and service improvement • Increase staff and patient involvement in research Research performance In 2020-21, the Trust has continued to expand its research portfolio and increased a number of opportunities for patients and clinicians to participate in research projects, including urgent public health, and Covid-19 research studies.

56 London North West University Healthcare NHS Trust

The Trust recruited 7323 patients to 46 clinical research studies. This includes 2,348 patients into urgent public health national priority Covid-19 studies, such as the Oxford Astra-Zeneca Vaccine trial, the NIHR RECOVERY trial sponsored by University of Oxford and the ‘platform trial’ REMAP-CAP trial. In line with national guidelines issued in March 2020, R&D instigated measures to suspend the setup of all new studies and patient recruitment into existing studies with the exception of nationally prioritised Covid-19 studies and specified urgent critical care and essential treatment studies. In total, 185 studies were paused to recruitment. These actions were taken to mitigate the unprecedented demands placed upon staff to support the clinical needs of the Trust and maintain the safety of patients. The Trust has successfully restarted over 75% of studies in addition to continued support for Covid-19 nationally prioritised studies. LNWH clinical research facility and growing research footprint The Trust has established a dedicated clinical research facility (CRF) at Northwick Park Hospital, to deliver treatments and interventions to research participants. It is a fully equipped facility with a sample preparation and storage lab, 4-5 treatment bays, on-site research pharmacists as well as having its own team of clinical staff with extensive research experience. A pipeline is being developed for the CRF with a national commercial Covid-19 vaccine trial set to start in April 2021. Future plans for growth include enhancing the R&D footprint at Central Middlesex Hospital. R&D is also working with clinicians to increase commercial portfolio in specialities including ophthalmology to ensure continuity of existing research as well as promoting new research into research naïve specialities across the Trust.

Quality Account 2020-21 57

Collaboration and research alliances We continue to work with our North West London Clinical Research Network (NWL CRN) to encourage more specialties and researchers to collaborate in delivering research across the region. We are forging closer relationships with Chelsea and Westminster NHS Foundation Trust and Imperial College Healthcare NHS Trust through the NWL CRF Alliance. We actively contribute to research activity across the whole of UK and have also undertaken international research with our global partners. The Trust has secured ‘preferred provider site’ status with three clinical research organisations (CROs), IQVIA, PPD, PRA, as well being selected as a preferred site alliance member with PAREXEL, one of only thirteen Trusts in the country. This demonstrates our ability to offer an excellent experience to commercial partners, and improve efficiency of clinical trial delivery to support the Life Sciences Industrial Strategy Sector Deal 2, as well as growing the research portfolio and income generation for the Trust. Global Clinical Site Accreditation The Trust was the first NHS organisation in the UK to be awarded the International Accrediting Organization for Clinical Research (IAOCR) bronze award in November 2019. Following our success in achieving this award, R&D is also in the process of applying for Global Clinical Site Accreditation, which will provide opportunities to collaborate further with international industry sponsors and drive further commercial research.

Quality improvements agreed with commissioners CQUIN is a payment framework that allows commissioners to agree payments to hospitals based on agreed quality improvements. Some of these are set on a national basis and others agreed with our local commissioners to reflect the needs of our local population. The CQUIN programme for 2020-21 was stood down due to Covid-19 and has been suspended for the first half of the 2021-22 financial year. There will be a review as to whether there will be any programmes in the second half of the financial year.

58 London North West University Healthcare NHS Trust

Quality improvement programmes 2020-21 Support for quality improvement programmes focused on the development of new ways of working to support recovery following the first wave of the pandemic. Key areas of improvement were as follows:

Same day emergency care This programme of work was facilitated by the associate director for CQUIN quality improvement and research with clinical leads and the multi-disciplinary team. This programme focused on recovery and improvement of same day emergency services for medicine post the first wave of Covid-19. The programme has identified key improvement areas to support patients having access to non-Covid- pathways which can support their care without the need for discharge. This is a national programme and the Trust has made great strides in meeting key standards. These include the implementation of key condition pathways. With the exception of community acquired pneumonia (which has been suspended during Covid-19), the Trust is compliant with all other pathways and has been are working closely with partners to develop direct pathways into the service. Workforce has been strengthened with recruitment of nursing and medical staff to move to cover for seven day working at the Northwick Park site with cover from the emergency department at Ealing Hospital. The team have developed new ways of working using electronic systems, adopting the Symphony software programme to enable monitoring of key performance indicators and reporting. Staff have now been trained in adoption of the new processes and both sites are utilising the new way of working. Data evidences improvement trends, from the first wave of Covid-19 and through the second wave, suggesting a quicker recovery time post wave 2 and an increase in the number of patients attending on a daily basis and monitoring of referral sources to support direct access from urgent care, emergency department and the medical take.

Quality Account 2020-21 59

Monitoring patient outcomes Safety The Trust continues to monitor the quality of care through its care bundle processes, with the following outcomes identified through the care bundle data bases. Sepsis The Trust has continued to monitor outcomes against standards for sepsis although this has been difficult due to manual recording of data. This process will move to an electronic process through the clinical systems in 2021-22. The chart below provides an overview of in-patient sepsis outcomes during 2020-21 for severe sepsis.

Sepsis screening outcomes 2020-21 severe sepsis

60 London North West University Healthcare NHS Trust

Use of SBAR The Trust uses a national early warning score to monitor patient risk of deterioration. This is strengthened by a medical emergency team and the use of SBAR (Situation, Background, Assessment, Recommendation) to give staff a focus for escalating deteriorating patients. There have been 16,707 patients monitored in this way. An audit of 680 patient SBAR charts found that the average time for patients to be seen by a first responder was 11.13 minutes. Safe initiation of nasogastric tube The Trust has continued to monitor the safe insertion of nasogastric tubes, with evidence of 3,858 patients receiving safe initiation according to best practice guidelines. Falls care bundle The Trust continues to focus on ensuring patients are assessed for their risk of falls and have identified that correct assessment and interventions have been initiated for 40,706 patients since its initiation. The care bundle identifies NICE guidance interventions, with the focus being on initial assessment , prevention interventions and follow up interventions should the patient fall whilst an inpatient. The database also offers longitudinal review of patients over a ten year period, with key patient information on age gender and ethnicity and admitting conditions to support research programmes to deliver baseline evidence with regard to falls. Safe initiation of central venous line The Trust has monitored the insertion of central venous lines to ensure patient safety. There have been 7,165 central venous lines monitored. using the Trusts care bundle approach. The care bundle focuses on patient safety including allergies, clotting treatment and events during or after insertion. A review of 482 patients has identified the following outcomes: Allergy

Number

Number of patients receiving CV Line

482

Number of patients where allergies discussed

476

Quality Account 2020-21 61

Percentage

98.34%

Clotting

Number

Number of patients receiving CV Line

482

Number of patients where clotting therapy given

473

Percentage

98.13%

Condition related care bundles Heart failure care bundle The Trust is continuing the quality improvement of patient diagnosed with heart failure. This programme of work has been delivered over the last seven years with a sustainable change to patient care implemented through the initiation of the heart failure care bundle. The outcomes of this programme have been assessed by external partners and will be published this year. This programme has seen over 4,000 patients receiving the bundle with the ability of clinicians to provide specialist in reach to non-cardiology wards. This has improved national audit outcomes and enabled the focus to be moved from inpatient care to integrated services.

What others say about the Trust The Trust is required to register with the Care Quality Commission (CQC) and its current registration status is requires improvement. The CQC did not take enforcement action against the Trust during 2020, The Trust has not participated in any special reviews or investigations by the CQC during the reporting period. Outcomes of the 2019 CQC inspection are below: Safe Ealing Hospital

Requires improvement

Central

Requires

Middlesex

improve-

Hospital

ment

Northwick

Requires

Park

improve-

Hospital

ment

Effective

Caring

Requires improvement

Good

Requires improvement

62 London North West University Healthcare NHS Trust

Good

Responsive

Well-led

Overall

Requires

improvement

Requires

improvement

Requires

improvement

Community services Overall Trust

Good Requires improvement

Requires improvement Requires improvement

Good

Requires

improvement

The Trust’s Quality Improvement Plan 2019-21 was developed after the inspection to: • describe the approach we are taking across our Trust to improve the clinical care and experience we offer our patients • recognise the issues that the CQC found during their inspection of our services in 2018 • identify the issues we need to overcome to provide outstanding care, and our plan to address them • bring together all the ways in which we are changing the way we work, not just to fix the issues raised by the CQC, but to provide truly outstanding care for our patients no matter when or where they need our services. The plan, alongside our transformation programme and organisational development programme, provides a framework for the Trust to prioritise and co-ordinate quality improvement initiatives to improve care and both patient and staff experience. Some quality improvements as a result of our CQC action plan have been absorbed in this work-stream. During the pandemic, the Trust has demonstrated its compliance with the relevant key lines of enquiry (KLOEs) through the infection prevention and control (IPC) Board Assurance Framework (BAF) devised by the CQC in August 2020. The BAF is presented to the Trust board for assurance and to the Trust’s infection control committee for review. It has been continually updated to ensure that appropriate IPC measures are in place, into the second wave of the pandemic. In November 2020, the Trust participated in the CQC’s ‘Project reset in Emergency Medicine - Patient FIRST’ and demonstrated significant achievements and improvements made in the emergency departments since the last inspection. Over the past year, occasional concerns were raised directly with the CQC by patients, their relatives and carers. These concerns are passed onto the Trust from the CQC for response. The main themes from these enquires centre around the discharge processes, communication and documentation. In each instance the Trust provides the CQC with a comprehensive response, for each enquiry, including where relevant, an action plan. The Trust uses these enquiries as an opportunity to learn and improve. Our 2021-22 focus will continue to be working towards achieving a ‘Good’ CQC rating.

Quality Account 2020-21 63

Patient Reported Outcome Measure (PROM) adjusted average health gain PROMs are outcomes reported by patients relating to specific procedures such as hip and knee replacement surgery. Feedback is collated to evidence percentage health gain benchmarked against the national standard. A change in reporting process and associated timelines of PROMs information nationally, limits the ability to report summatively. Of the two ongoing elements of care relating to patient reported outcome measures the available data relating to knee replacement surgery below identifies an under performance, against the national average in health gain.

Due to unavailability of outcome data, it is not yet possible to report on outcome measures related to hip replacement.

Data quality, information governance and clinical coding Since 2018, information governance has been working under the new Data Protection Act 2018 and the General Data Protection Regulations 2016 (EU) (GDPR). Both of these pieces of legislation required an overall review of IG practices and procedures. Transparency in relation to people’s data is at the forefront of this and we have provided guidance and a detailed privacy policy to help our users. We are required on an annual basis to self-assess our IG practices against the Data Security and Protection Toolkit (DSPT), formerly the Information Governance Toolkit. This is audited each year by our Internal Auditors who confirm our self-assessment. Since 1 January 2021 and the realisation of Brexit, some changes have had to be addressed and these work alongside managing data protection under both the UK GDPR and the GDPR (EU). As the Trust and the wider NHS have been operating under unprecedented and challenging times as a result of the Covid-19 pandemic, many aspects of work within the information governance department have been revised in order to give priority to the needs of work supporting the work to deal with Covid-19. As a result of this 64 London North West University Healthcare NHS Trust

revision of our work, the submission of our self-assessment against the DSPT for the year ending March 2021 has been set back by NHS Digital, for all DSPT organisations, until 30 June 2021. Currently the Trust is on track to achieve compliance by the end of June 2021. This will be based on the Trust achieving 100 mandatory assertions. The Trust takes its information governance obligations seriously and has worked hard in the last twelve months to improve its compliance with the DSPT. It is committed to making continual improvements year on year and implementing changes where these are identified from any lessons learned or best practice dictates or changes around data protection.

Submission of seven day self-assessment data 2020-21 The national programme for seven day working was implemented in November 2015. This programme of work was undertaken following the Academy of Royal College recommendations of the implementation of four standards which should be implemented as a priority to improve patient care The standards are:

• Standard 2: time to consultant review • Standard 5: access to diagnostics • Standard 6: access to consultant directed interventions • Standard 8: ongoing review.

The Trust has now completed five audits with regard to these four standards and is seen as one of the exemplar Trusts nationally. Seven day service audit board assurance The work programme and assurance process for 2019-20 has now changed with providers to report board assurance with regard to the work being undertaken to meet the standard, and reporting of the standards against the target trajectories. This will be reported using the seven day self-assessment template and evidence of the outcomes along with actions or recommendations for improvement. Board assurance for this data is submitted through a direct report to the board or as part of sub-committee processes such as executive review or through an appropriate other sub-committee.

Quality Account 2020-21 65

Breakdown of patients admitted by specialty

• General medicine accounted for 41 (62%) • Emergency care 11 (16.66%) • ITU 3 (4.54%) • Cardiology 2 (3.03%) • Haem 2 (3.03% • Stroke 1 (1.51%)

The planned audit for the 2020 board report was to review standard 8 relating to inpatient ongoing review at ward speciality level. This was due in March 2020. Unfortunately the Trust was at the epicentre of the Covid-19 pandemic at this time and the audit was deferred. Work continued despite of this and seven day consultant cover was initiated across the acute sites to support the management of Covid-19 patients. This was achieved through closing down of out-patient activity and focusing on in-patient care. The benefits of seven day working have been reflected in improved performance for emergency flow and reduction in length of stay. Following recovery from the second wave of Covid-19, and in line with seven day working reporting for 2021, the Trust is reviewing seven day working for standard 8 as part of the improvement of flow group within the discharge improvement programme. We are focusing on embedding seven day working in relation to standard 8 and reviewing diagnostic standard 5 to ensure there is capacity to meet the seven day working standards, given the challenges of meeting increased out-patient referrals due to Covid-19. 66 London North West University Healthcare NHS Trust

What our patients say about us October 2020 saw the national introduction of the new Friends and Family Test question. The core change made was the main question changing from if service users ‘would recommend our services to their friends and family’ to the new phrasing to ask ‘overall, how they rated their experience’. This and the increased focus on inviting free-text feedback through the surveys are to create a more qualitative focus on the feedback collected, and to be able to use it more effectively for improvement. Of the total number of responses, 94% said they would recommend or our services as positive, which mirrors the total for 2020-21, and aligned with our Trust benchmark of 94% set for the recommend rating. We are particularly proud to see that 96.8% said they were treated with dignity and respect, which displays a good indication that staff have taken on board and are living the Trust’s HEART values. Despite the considerably lower number of FFT feedback collected, our results are consistent with 2019-20 pre-pandemic levels. The table below shows the total number of responses received and recommended/ positive score per service: Responses

Recommended/ Positive

A&E

746

91.42%

Outpatient

3,512

94.28%

Inpatient

3,331

95.38%

Maternity

562

92.53%

Community

151

94.04%

Quality Account 2020-21 67

Complaints

The continued commitment to resolve concerns in real time is evident in the number of complaints having reduced from 947 to 739 which represents a 22% reduction. While the pandemic is likely to account for some of this reduction relating do service disruption, it can be noted that with 71 complaints received in The continued commitment to resolve concerns in real time is evident in the number of complaints having reduced from 947 to 739 which represents a 22% reduction. While the pandemic is likely to account for some of this reduction relating do service disruption, it can be noted that with 71 complaints received in The continued commitment to resolve concerns in real time is evident in the number of complaints having reduced from 947 to 739 which represents a 22% reduction. While the pandemic is likely to account for some of this reduction relating do service disruption, it can be noted that with 71 complaints received in January 2021, 50 in February 2021 and 69 in March 2021 is below the average of approximately 80 formal complaints received per month prior to the pandemic.

National surveys Due to changes during Covid-19, the schedules for CQC surveys changed and as a result, no survey results were received for surveys collected during 2020, with the results for urgent and emergency care, maternity care, children and young people and inpatients survey expected to be published in the course of 2021-20.

What our staff say about us In 2020, we saw an improvement in our staff engagement index score (EEI), from 6.9 to 7.0 (out of a score of 10). 68 London North West University Healthcare NHS Trust

Over 4,235 employees (52%) of our staff told us they • were more engaged • were more motivation • were more likely to recommend the organisation as a place to work • were more likely to recommend the organisation as a place to receive care Staff survey 2020 engagement questions Theme

Question Statements

Motivation

Involvement

Advocacy

Average NHS

LNWUT

organisations

2020

2019

Often/always look forward to going to work

58%

64%

62%

Often/always enthusiastic about my job

73%

74%

73%

Time often/always passes quickly when I am working

76%

80%

Opportunities to show initiative frequent in my role

70%

71%

70%

Able to make suggestions to improve the work of my team/dept

72%

69%

70%

Able to make improvements happen in my area of work

72%

69%

70%

Care of patients/service users is organisation’s top priority

54%

55%

56%

I would recommend organisation as a place to work

66%

60%

54%

If a friend/relative needed treatment would be happy with standard of care provided by organisation

73%

63%

59%

Despite this improvement, we know there is a lot more to do and we aim to build upon our engagements results. In 2021-22, we aim to increase our staff engagement cores in 2021-22 by 0.2 scale score to 7.6 (best score for trusts in 2020). We will do this by:

• launching an equality diversity and inclusion strategy • implementing of civility and dignity and respect interventions • launching our compassionate leadership framework • making a 2% improvement in mandatory appraisal training for all managers.

Quality Account 2020-21 69

Part 3: Quality priorities 2021/22 During 2019-20, the production of the quality account was deferred until much later in the year. As a result, quality priorities identified for 2021 were defined by our experience of the Covid-19 pandemic as much as prior learning. Due to this, it is of importance to note that many of the priorities identified during 2019-20 were longer term aims, focusing on strengthening our culture of safety and support. In order to ensure achievements were optimised, these priorities and were developed with the intention of rolling over into 2021-22. They have been reviewed and revised and with the approval of the executive team will form our quality priorities for 2021-22. Priorities have therefore been set in accordance with those that have emerged during the Covid-19 pandemic response. Learning from the experience has helped us implement change and steer our focus to what we know to be important to our patients and staff along with those aspects of safety generating most valuable learning. While the account has been produced in accordance with national reporting protocols, ordinarily we would have seen much more collaboration and priority setting involving stakeholder groups and feedback forums. However this has not been possible due to restrictions imposed by the pandemic.

Priority 1: Safe care Improving and sustaining the safety of our patients and staff with enhanced focus on infection prevention and control Infection prevention and control standards continue as a key priority for improving and maintaining safety for all. Additionally this priority goes some way to raising the organisational profile and building confidence within our north west London communities. Aim: Develop a sustainable fit testing program to enable safe practice

A. Develop a long term robust operational model for Respiratory Protective Equipment (RPE) which determines and monitors staff having the correct RPE, evidencing progress with quarterly reporting. B. 100% of staff working in high risk areas have had a fit test by September 2021 C. 90% of staff to be fitted with two different models of RPE by March 2022

70 London North West University Healthcare NHS Trust

Aim: Reduce the transmission of infection by improving hand hygiene during 202

A. To reinvigorate the ‘Glove Awareness Campaign’ with a Trust wide re-launch to promote the correct and appropriate use of gloves within June 2021 B. To improve hand hygiene compliance by 10% C. To reduce nosocomial acquisition by 8% D. To complete peer audits of key performance indicators biannually for all inpatient areas.

Priority 2: Caring Improving staff wellbeing through a program of focused support Staff wellbeing, continues to be an area of enhanced focus for the Trust. Given the challenges that the organisation has faced throughout the pandemic, staff have consistently strived to meet the needs of our patients working flexibly and responsively adapting to requirements to provide high quality, safe care. There is further evidence to strengthen the case for continuing with this priority within the 2020 staff survey, which also outlines opportunities for improvement moving forward. It is therefore essential to continue to prioritise our focus on staff wellbeing during 2021-22. Key priorities Moving forward, caring for the health and wellbeing of our staff and enabling them to become the best they can be remains a top priority for the Trust as we know all too well the far reaching effects of not doing so both for our staff and ultimately patients. This priority will be translated into the following key areas of action: 1. Development of a three year health and wellbeing strategy 2. Recruitment of in-house occupational psychology team 3. Increase the proportion of staff receiving personal risk assessments We will measure the success of these key priorities through our annual staff survey scores 2021:

A. A 3% increase current levels of staff personal self-assessments to 97% of our substantive workforce B. A 0.4 point scale increase in health and wellbeing score from 5.9 to 6.3 score C. A 0.5 point scale increase in number of staff not experiencing bullying and harassment; from colleagues from 7.6 to 8.1 score Quality Account 2020-21 71

D. An 11% point increase in disabled staff saying they have received reasonable adjustments E. A 3.5% point increase in staff saying the organisation takes positive action on health and wellbeing

Priority 3: Responsive Improving staff experience for members of our Black, Asian and Minority Ethnic community with positive action initiatives focused on professional development, career progression and learning from experience. Positive action on working to improve the experience of our Black, Asian and Minority Ethnic colleagues has been a key area of focus throughout 2020. Evidence suggests a distinct correlation between staff wellbeing and positive culture being one of the key drivers for improving patient experience and outcomes. To be truly effective the culture change required will need to be embedded throughout the organisation, interwoven within our values, with fundamental aims and ambitions of the strategy being met. This can only be achieved with moderate to longer term focus as an organisational priority. Our data tells us that despite successes, there is still much to work to do. The organisation has therefore set itself an ambitious plan for transformative change through its new equality diversity and inclusion strategy. This vision for the future will be developed with the involvement of staff at all levels of the organisation. We have also made a commitment to accelerating diverse representation in senior roles through:

1. Launching an inclusive compassionate leadership programme 2. Developing ethnic minority talent to non-executive positions 3. Creating of new positive action initiatives which will see appointments of ethnic minority colleagues to senior development roles to support talent development and create leaders that represent the communities we serve 4. Launching civility and dignity and respect interventions

How will we measure success? The Workforce Race Equality and Disability Standards remain strong measures for identifying improvement on equality and diversity. These standards not only measure areas of improvement but compare our performance with those of other NHS organisations. In 72 London North West University Healthcare NHS Trust

terms of the key commitment areas outlined above, our measure will be against improvements in staff survey 2021 responses on questions relating to leadership, bullying and harassment and HEART values questions. Overall, our ambition is to aim for an 11% point increase in staff survey 2021 score on the ‘equality and diversity’ indicator.

Summary Thank you for taking the time to read the LNWH NHS Trust quality account. We take great pride in being able to showcase our achievements in 2020-21 and look forward to embracing the opportunities for improvement in 2021-22. In acknowledgement of the achievements of our team during the reporting period, it has been essential to highlight some of the challenges which have emerged during the Covid-19 pandemic within this this document. We would like to express our gratitude for the continued commitment, professionalism and energy our team have provided caring for our patients during this difficult time. Additionally we would like to express our appreciation for the massive support we have received, from our patients and communities. We have truly lived our values and our achievements are credit to all concerned.

Quality Account 2020-21 73

Annex – Stakeholder feedback

74 London North West University Healthcare NHS Trust

Quality Account 2020-21 75

76 London North West University Healthcare NHS Trust

Quality Account 2020-21 77

78 London North West University Healthcare NHS Trust

Quality Account 2020-21 79

Healthwatch Ealing response to London North West University Healthcare NHS Trust Quality Account 2020/21

Healthwatch Ealing would like to first congratulate the Chief Executive and the rest of the Trust for producing the Quality Account during what has been a trying year for us all, due to the COVID-19 pandemic. The Quality Account for 2020/21 provides a clear and comprehensive account of the Trust’s achievements as well as the areas that have posed a challenge during this year of adapted working and has been written in a very clear and understandable manner. Healthwatch Ealing would like to highlight: •

The effectiveness of the Improvement Fellow projects in delivering real practical improvements driven by the Fellows themselves seems to be particularly impressive;

•

The quality improvement achievements against the Trust’s priorities set out in the report are commendable, given the challenges the Trust has faced during the year;

•

Performance against the NHS Outcomes Framework was solid, but clearly the Trust will want to identify ways to drive performance towards that of the best national performers;

•

The clear and comprehensive plan to address the incidence of patient safety incidents is very welcome;

•

The CQCs assessment of the Trust indicates that there are still more ‘areas for improvement’ and we are hopeful that the Trust can address these areas as we continue to move out of the national lockdown;

•

Finally, it was especially encouraging to see the positive feedback from the Trust’s patients. Healthwatch Ealing are very pleased with the concerted effort that the Trust made to hear from patients and their relatives during this time. We also welcomed the consistent opportunities during the pandemic to provide the Trust with our own Patient Experience programme intelligence to provide a robust picture of how hospital patients were being cared for.

The progress and achievements that the Trust made during this time are testament to the efforts of the staff and we look forward to working even more closely with the Trust in this coming year.

Matthew Van Mol-Jones Operations Manager, Healthwatch Ealing

80 London North West University Healthcare NHS Trust

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Quality Account 2020-21 81