Quality account 2019 - 2020

London North West University Healthcare

NHS Trust

Quality account 2019/20

Contents Part 1: Quality summary 2019/20

3

Welcome from the Chief Executive

4

Statement of directors’ responsibilities

7

Priorities for improvement and statements of assurance from our board

8

Part 2: Review of our achievements

10

Approach to quality improvement

10

Quality improvement achievements against priorities during 2019/20

11

Part 3: Review of our quality performance

20

The NHS outcomes framework: quality indicators

20

Standardised Hospital Mortality Indicator (SHMI)

21

Patient Reported Outcome Measure (PROM) adjusted average health gain

22

Trust’s responsiveness (patient experience of hospital care)

22

Friends and Family Test for staff

23

VTE risk assessment

24

C. difficile infection rate

24

MRSA bloodstream infection rate

24

Secondary Users Service: quality data

25

Overview of patient safety incidents

25

Patient Safety Alert compliance

28

Patient-led assessments of the care environment (PLACE)

30

Part 4: Statement of assurance

32

Review of services

32

Continuous improvement through research

34

Part 5: Quality Priorities 2020/21

51

Priority 1: Infection prevention and control

52

Priority 2: Staff wellbeing

52

Priority 3: Positive action – BAME focused actions for improvement

53

Annex

55

Statements from our stakeholders

55

2 London North West University Healthcare NHS Trust

Part 1: Quality summary 2019/20 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 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 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 2019/20. It also allows us to focus on our plans that will support continuous care quality improvement throughout 2020/21.

To ensure that we provide a fair assessment of the progress that has been made, the quality account has been reviewed by key stakeholders and by the board including our non-executive directors.

Quality Account 2019/20 3

Welcome from the Chief Executive Our vision, to provide excellent care in the right setting, is underpinned by an ambitious set of goals. These give all staff a common purpose, no matter their role or place of work, to achieve the best we can for those in our care.

I am pleased to present our quality account for 2019/20 which shows how we have performed against our priorities during the year and sets out the main areas of focus for 2020/21.

We are living in extraordinary times. I joined the Trust in March 2020, just as it was hit hard by first wave of the pandemic. Our staff were treating large numbers of COVID-19 patients, many of whom needed to be looked after by our critical care teams.

The organisation adapted quickly to ensure that we could cope with the surge in demand.

At the same time, while some services needed to be paused, others including maternity and stroke, continued to provide care to patients with non-COVID-19 conditions. In addition, hundreds of outpatient appointments were carried out by phone and video call.

I am incredibly proud of how our staff have responded to ensure that patients receive excellent care in the face such exceptional circumstances.

In November 2019, we received the Care Quality Commission’s (CQC) report following a well led and core service inspection. While the Trust continues to be rated as “Requires Improvement” overall inspectors found evidence of improvement across a wide range of services.

The CQC report is a positive and encouraging step forward for the organisation. In looking to the future, we will build on this positive momentum.

CQC inspectors recognised a wide range of improvements across our services. Our emergency departments at Northwick Park and Ealing hospitals performed particularly well, receiving ‘Good’ ratings for providing safe, caring, and well-led care.

Inspectors also improved the Trust’s ratings for its surgical and maternity services, citing a positive safety culture in surgery and the compassion and kindness of staff in maternity.

Overall, the CQC found that there had been a notable improvement to the Trust’s culture across its sites, leading to more cohesive working and improvements to operational performance.

In response to the CQC’s findings, we have reviewed our quality priorities and aims. This will work to improve and strengthen our approach to continuous quality improvement and transformation with staff, patients, regulators, commissioners and stakeholders.

We have also invested in transformation expertise to advance quality and safety and to develop our staff to lead, learn and continuously improve services now and as we move forward.

During the year we continued to improve quality, safety and experience for patients and staff.

We implemented monitoring mechanisms, with input from clinical stakeholders, to ensure ward to board visibility of performance against quality indicators.

4 London North West University Healthcare NHS Trust

As part of this work quality and safety dashboards were developed to support transparency and improvement processes with the development of a template action plan to track improvements for all clinical areas.

To support our focus on improving outcomes for deteriorating adult patients the revised early warning scoring system NEWS2 was introduced.

NEWS2 is a medical assessment tool that supports decision making and escalation of care when a patient’s condition is changing. During 2019, this clinical standard was amended nationally to improve the way patients are monitored for signs of deterioration and ensure that they receive the most appropriate response to any change in their condition.

An education programme was delivered and NEWS2 launched as part of a Trust wide campaign aimed at raising awareness of requirements and ensuring patient safety was adequately maintained.

We have also seen achievements within maternity care where patient safety was prioritised with a focus on reducing perinatal mortality. This was introduced successfully with the implementation of the ‘saving babies lives’ initiative.

During the year, our safety culture continued to build, encouraging high levels of incident reporting, as part of effective incident management. Incident reporting is a fundamental tool of risk management. The aim is to collect information about patient safety incidents to help support learning across the organisation. National Reporting and Learning Service data, published in March 2020, showed Trust to be above average relative to its peer group for reporting of patient safety incidents.

We have consistently seen low rates of mortality and our performance is ‘better than expected‘ when assessed using the Hospital Standardised Mortality Ratio and the Standardised Hospital Mortality Indicator.

Research shows that staff who work within a culture of transparency and openness feel better supported and able to actively contribute to providing high-quality care to patients. During the year we successfully trained staff within transformation work streams. Our focus on quality improvement developed steadily over the year with input from the multidisciplinary teams and patient representatives who were assigned to the transformation board to improve patient involvement.

We are committed to ensuring that patients are at the HEART of everything we do. Our staff actively work to engage patients in decisions about their treatment and care and in developing and improving Trust services. During 2019/20, a “patient database” was created. This includes the details of all users wishing to participate in service reviews and the nature of involvement they are interested in.

The Friends and Family Test allows the patient’s voice to be heard. 76,932 patients completed the survey in 2019/20 with 94.38% saying that they would recommend our services to their friends and families. Overall, the Trust received a rating of 98% for patients being treated with kindness and 97% for feeling safe. One key area in which we need to improve is ensuring that patients feel sufficiently involved in decisions about their care and have more information.

Quality Account 2019/20 5

2019/20 saw significant progress made across the Trust. As we look to the future, we know that the pandemic will continue to cause high levels of uncertainty until an effective vaccine is found. In responding to this challenge, we must ensure that all non-COVID patients have timely and safe access to our full range of healthcare services. Our new Way Forward Delivery Programme describes how we will do this setting out clear objectives for the next 18 months.

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:

Sir Amyas Morse Chairman

Chris Bown Chief Executive

Quality Account 2019/20 7

Priorities for improvement and statements of assurance from our board The impact of the pandemic on the NHS will be long lasting and will require a fundamental shift in how we provide care. This includes the way in which our leaders support our people and teams, and the cultural framework in which we all work.

Our recently published Way Forward Delivery Programme sets out clear objectives for the Trust during the next 18 months. We have also updated our goals and objectives to reflect what we want to achieve.

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.

Three quality priorities have been identified for 2020/21: • Improving and sustaining the safety of our patients and staff with enhanced focus on infection prevention and control • Improving staff wellbeing through a program of focused support • Improving staff experience for members of our BAME 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 NHSI • National policy • Feedback from Healthwatch through partnership working • Feedback from stakeholders, partners, regulators, patients and staff in the development of the quality priorities.

8 London North West University Healthcare NHS Trust

As part of our continuous quality improvement programme and the ‘Change for Patients’ transformation programme, the Trust is working to improve its governance, risk and performance framework. This is to ensure that risks to the safety and quality of patient care are identified, well led and managed.

The achievement of each quality priority will be measured through key performance indicators or metrics. 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 to the Trust board.

Quality Account 2019/20 9

Part 2: Review of our achievements Approach to quality improvement Our approach to quality improvement and transformation is based on proven tools for accelerating improvement that have been widely adopted across the NHS. Based on experience and learning from stakeholders, our continuous quality improvement journey begins by asking these important questions: • What problem are we attempting to solve – what are we trying to achieve?

• What change can we make to bring about transformation and improvement?

• How will we know that making a change delivers an improvement?

These questions ensure that there are clear aims, measures and specific interventions on how changes will be tested, across our clinical settings and services. By engaging and empowering people, implementing changes, evaluating and learning we will continue to improve and learn.

In November 2019, we received the Care Quality Commission’s (CQC) report following a well led and core service inspection in July. While the Trust continues to be rated as ’Requires Improvement’ overall inspectors found evidence of improvement across a wide range of services.

In response, we have reviewed our quality priorities and aims to improve and strengthen our approach to continuous quality improvement and transformation with staff, patients, regulators, commissioners and stakeholders.

We have also invested in transformation expertise to advance quality and safety and to develop our staff to lead, learn and continuously improve services now and as we move forward.

The quality account for 2019/20 is informed by a detailed review of the Trust’s achievements and areas for improvement.

Our goal is to provide outstanding care that is sustainable, high value, high quality and delivered in partnership with health and social care organisations across north west London (NWL).

The driving force behind our Quality Improvement Plan roadmap is the aim to ensure closer integration across the NWL health and social care system to deliver safer, financially sustainable care and services to the population and communities that we serve.

We recognise that it is important to include the voices and views of the public in developing our plans and are working to make it easier for the public to engage.

A robust Patient Experience and Involvement Improvement Plan has been developed which aims to ensure that the public is able to inform, influence, shape, be involved in and influence our plans and services.

10 London North West University Healthcare NHS Trust

In setting out our key quality priorities for 2020/21, we explain the actions that are being taken to ensure the Trust becomes a learning organisation, one that excels.

As per our culture of honesty and transparency we will aim to improve how we enable staff to understand and articulate their roles and promote a positive culture of shared learning aligned to Trust-wide quality improvement and transformation strategies.

Quality improvement achievements against priorities during 2019/20 During 2019 we implemented a quality and safety dashboard to monitor the quality account priorities including a range of local improvement priorities. The following section describes our priorities in detail and the progress that was made. 

Goal achieved

●

Partially achieved

✖

Goal not achieved

Priority 1: Safe for our patients and safe for our staff a) Improved outcomes for deteriorating adult patients – sepsis, acute kidney injury, early recognition using the National Early Warning Score 2 (NEWS2) b) Improved maternity outcomes, through Saving Babies’ Lives.

Quality Account 2019/20 11

1a: Improved outcomes for deteriorating adult patients – sepsis, acute kidney injury, early recognition using NEWS2 What we aimed to achieve in 2019/20

Outcome

Evidence a reduction in cardiac arrest calls on a quarterly basis

●

Evidence appropriate utilisation of calls to the medical emergency team, in accordance with NEWS2 standards



Improve early identification of deteriorating patients to reduce the number of cardiac arrest calls outside of critical care and identify themes and areas for improvement, feeding into deteriorating patient group and divisional governance forums on a quarterly basis



Evidence ongoing compliance with NEWS2 related training via the appropriate eLearning module, including in quarterly divisional governance reports, with exceptions being monitored within the ‘Deteriorating Patient Group (DPG) on a monthly basis

●

Implement monthly audit profile to evidence compliance with national standards and the appropriate escalation of care



Improve patient outcomes with early recognition of signs and symptoms of sepsis, in accordance with NICE guidelines



Improve awareness of acute kidney injury through focused education and development for clinical staff

●

Improved focus on the deteriorating patient to reduce the number of incidents of cardiac arrest This aim was partially achieved. Factors influencing this outcome relate predominantly to the high number of COVID-19 presentations and the rapid deterioration of affected patients in the last quarter of 2019/20.

NEWS2 NEWS2 is a medical assessment tool that supports decision making and escalation of care when a patient’s condition is changing. During 2019, this clinical standard was amended nationally to improve the way patients are monitored for signs of deterioration and ensure that they receive the most appropriate response to any change in their condition.

An education programme was delivered and NEWS2 launched as part of a Trust wide campaign aimed at raising awareness of requirements and ensuring patient safety was adequately maintained. The training model remains face to face education and development within clinical areas. The aim to introduce e-learning has not been fully achieved due to the COVID-19 pandemic.

Safe care provision is dependent upon timely escalation as a response to monitoring of a patient’s deteriorating condition. The medical emergency team (MET) responds to calls for assistance from clinical teams to reassess and stabilise patients whose conditions change. Our aim to enhance the appropriate use of this service has been achieved and is evidenced below.

12 London North West University Healthcare NHS Trust

Improving our response to sepsis The aim to improve patient outcomes in accordance with NICE guidelines and national standards was achieved. 93% of inpatients were appropriately screened and 94% of inpatients received intravenous antibiotics within one hour of presenting symptoms. Emergency care has successfully screened 95% of patients upon presentation with 94% of patients receiving the appropriate antibiotic medication within an hour of presenting to the department.

Improve awareness of acute kidney injury (AKI) through focused education and development for clinical staff This aim was partially achieved with a focus on competency training and continuous monitoring for AKI within clinical areas. Education and focus require further enhancement within inpatient areas. Enhanced focus and monitoring is ongoing via our clinical forums with assurance being provided via the Patient Safety Committee, to ensure ward to board visibility is maintained.

1b: Improving patient outcomes within maternity care with the delivery of the Saving Babies’ Lives care bundle aimed to reduce perinatal mortality in 2019/20 What we aimed to achieve in 2019/20

Outcome

Reducing smoking in pregnancy



Train our staff in continuous improvement as part of our ‘innovation and improvement’ transformation work stream



Increase training of staff who carry out symphysis fundal height (SFH) measurements



Raising awareness of reduced foetal movement during labour (RFM)



Improved risk assessment, prevention and surveillance of pregnancies at risk of foetal growth restriction (FGR)



Quality Account 2019/20 13

Priority 2: Leading from the HEART and enabling our staff to be the best they can be by a) Developing a sustainable workforce that is fit for purpose – creating a culture of continuous and sustainable improvement b) Build a patient focused safety culture enhancing the ‘patient voice and influence’ to improve their experience of care and outcomes.

2a: Developing a sustainable workforce that is fit for purpose – creating a culture of continuous and sustainable improvement.

Research has shown there to be a direct link between staff and patient experience. Staff working within a culture of transparency and openness feel better supported and able to actively contribute to providing high-quality care to patients.

What we aimed to achieve in 2019/20

Outcome

Train our staff in continuous improvement as part of our ‘innovation and improvement’ transformation work streams



Ensure staff are appropriately developed and empowered to advocate for patients with complex needs by improving compliance in development relating to safeguarding, mental health. learning disabilities and the Mental Capacity Act

●

Engage staff in all aspects of care quality improvement work, promoting access to education and development opportunities, to support professional development and career progression



Enhance the positive culture of continuous quality improvement by improving access to support mechanisms which encourage staff to speak up when concerns arise, in accordance with professional standards and learning from the Gosport Inquiry



14 London North West University Healthcare NHS Trust

Continuous improvement and transformation During 2019/20 we successfully trained many staff within ‘Change for patients’ transformation work stream. Our focus on quality improvement built steadily over the year with input from the multidisciplinary teams and patient representatives assigned to the transformation board to improve patient involvement and co-design opportunities.

Empowering staff to advocate for patients with complex needs While staff development remains high on the quality improvement agenda the primary measure to show achievement of this aim is mandatory training compliance in safeguarding, mental capacity and mental health. To date this standard has been partially met. Safeguarding level three and mental health training are outliers in terms of compliance standards and areas for enhanced focus via the workforce quality committee.

Enhancing a positive culture of encouraging staff to speak up when concerns arise The introduction of ‘Freedom to Speak up Guardians’ within the Trust has proved positive. The NHS contract requires all trusts to have local Freedom to Speak up Guardians in place and their role includes: • • • • •

Developing an open culture Ensuring processes are in place to empower and encourage staff to speak up safely Promote learning and development Improve the experience of workers Protect patient safety and the quality of care.

This role has been positively received and to date and an overview of emerging themes can be found below: Theme

Quarter 1 Quarter 2 Quarter 3 Quarter 4

Potential patient safety/quality element

2

7

6

3

Behaviour

1

2

0

2

HR matter

1

1

0

5

Perceived bullying and harassment

0

5

4

15

Other

2

3

1

1

TOTAL

6

18

11

26

Quality Account 2019/20 15

2b: Build a patient focused safety culture enhancing the patient voice and influence to improve their experience of care and outcomes Developing an engaged and motivated workforce, to optimise learning and development opportunities and actively encouraging the formal reporting of risks, concerns, incidents and variances to care quality, is essential in the delivery of safe patient care.

What we aimed to achieve in 2019/20

Outcome

Develop a culture of openness and honesty when things go wrong embedding best practice around the professional duty of candour

●

Reduce harm for those using our services including those with learning disabilities

●

Improved complaint response times Improved performance within incident reporting top 25% of NHS trusts nationally for incident reporting Improved claims responses

●  

Duty of Candour All incidents are subject to ongoing review to validate the level of harm. Those incidents deemed to have caused moderate, severe or catastrophic harm are required to be followed up in line with the Duty of Candour legislation and Trust policy. The clinical divisions receive regular reports highlighting the moderate and greater harm incidents and actions required to confirm compliance with the process. This is reported at local divisional committees and to executive committees with board and non-executive director oversight. Throughout 2019, a dedicated member of the quality and patient safety team focused on supporting divisions with improving duty of candour compliance, chasing evidence and overdue incidents. By the year end in March 2020, we achieved 81% recorded compliance with the verbal stage of the duty of candour on clinical incidents of moderate and greater harm.

Reduce harm for those using our services including those with learning disabilities Patients with a learning disability are supported to access healthcare services and receive a truly integrated and holistic approach to their care and treatment. By taking an individual approach to care provision we aim to promote independence, optimising patient involvement with their care and treatment.

Our learning disability and autism specialist nursing team provides advice, guidance and support to patients, carers and staff. This supports a person-centred approach that promotes collaborative care planning and optimises treatment goals.

From the point of admission into our acute services, we aim to support patients’ safe discharge back into the community where they can continue to progress towards recovery.

16 London North West University Healthcare NHS Trust

Complaints response times The patient relations team work closely with the divisions to improve our response rate times.

Our aim is to respond to 80% of complaints within the specified timeframe and to then sustain this level of performance.

We exceeded the 80% target for the first time in December 2019 by responding, in time, to 84% of complaints that were due during that month. The impact of the COVID-19 pandemic in March 2020 saw us respond to only 47% of complaints due during that month. Overall, in 2019/20 we recorded a response rate of 69% of complaints being responded to in time, an improvement of 4% on the previous year (65%).

The continued commitment to resolve concerns in real time is also evident in the reduction of the number of formal complaints registered during 2019/20. While acknowledging the low number of complaints logged in March 2020, which can be attributed to the pandemic, the numbers suggest that less than 1000 complaints would have been registered in 2019/20, with the final total being 947.

The headline performance figures for last year are: • 947 formal complaints, a 13% reduction on the 1091 complaints in the previous year • 0.09 % of patients made a formal complaint • 69% of complaints were responded to within the agreed timeframe, an improvement on the 65% of the previous year • The Parliamentary and Health Service Ombudsman (PHSO) made 13 enquiries and proceeded to investigate 3 complaints during the year 2019/20 • The PHSO reported on 8 cases, 1 of which was upheld, 5 partially upheld and 2 were not upheld • The number of reopened complaints decreased to 82 from the previous year’s 113 • There were 3,598 Patient Advice and Liaison Service enquiries.

Incident reporting Overview of patient safety incidents Our aim is to provide care that is safe, effective and high quality for all patients and service users. The Trust’s incident reporting and risk management system is designed to support this aim and is based on an open, honest and transparent culture of learning from experience underpinned by a systematic approach to managing patient safety incidents. This cultural approach fully adheres to national guidance from a staff and patient perspective, including the Management of Health and Safety at Work Regulations (1974) and the Sign up to Safety campaign.

Quality Account 2019/20 17

Priority 3: Enhancing the patient journey to optimise safe and timely discharge and improved outcomes (effective safe and caring) Evidence suggests that encouraging patients to maintain independence, within activities of daily living promotes recovery, restores self-confidence and can reduce the amount of time spent in hospital. As an integral component of the multi-disciplinary team, allied health professionals (AHPs) are the biggest clinical workforce in the Trust after nursing and midwifery.

AHP expertise and contribution in the management of patient care is vital to both the patient’s experience and recovery and is essential to safe and effective discharge planning. Improved clinical focus on the patient journey supports patient wellbeing and recovery. This reduces length of stay and improves discharge planning and the patient experience.

As providers of healthcare we must give due regard to the need to eliminate discrimination, harassment and victimisation, to advance equality of opportunity, and to foster good relations between people who share a relevant protected characteristic (as cited under the Equality Act 2010) and those who do not share it.

Our focus during 2019/20 We are committed to reducing inequalities for patients in accessing our healthcare services, to ensure improved care outcomes.

What we aimed to achieve in 2019/20 1

Optimise patient independence with a robust approach to initial assessment and early referral to therapies and complex discharge teams, ensuring seamless care provision in accordance with best practice standards

Outcome



2

Improve compliance on response times achieved in 2018/19 for therapy input within 24 hours from time of referral (bedded units) in accordance with clinical risk and best practice standards



3

Improve the approach to proactive discharge planning at the point of initial assessment utilising the appropriate assessment tools, evidencing that both patient and carers, are actively involved in the process



4

Improve discharge planning with early referral to pharmacy for patients with polypharmacy needs, facilitating improved review and communication and limit delays with discharge medications

●

Reducing inequalities in patient experience for people with complex needs and developing improved understanding of where patient experience and involvement could be improved for individuals who may be living with complex needs or disabilities

●

5

18 London North West University Healthcare NHS Trust

The priority has been partially achieved. Working collaboratively within multidisciplinary colleagues our therapy teams have worked to deliver improved response times for our patients. While being consistent throughout the period there was a decrease in the number of referrals in March 2020. This may be explained by the impact of COVID-19 pandemic, which resulted in some therapy colleagues being reassigned to roles within higher acuity areas requiring enhanced expertise.

With over 90% of patients accessing therapy services to optimise safe care, patient independence is being supported and access to timely and appropriate discharge pathways is being facilitated.

Improving patient and carer involvement within the process is yet to be effectively evidenced.

This is largely due to evolving patient expectations and impacts of the pandemic, which has reduced the number of patients within the system and affected our ability to effectively engage patients in detailed feedback around discharge processes and related pharmacy improvements.

Improved discharge planning with early referral to pharmacy for complex patients with polypharmacy needs, facilitating improved review and communication and limit delays with discharge medications. This was partially achieved and will be a continued focus for the multidisciplinary team during 2020/21.

We continue to learn from patient feedback and have worked to improve the relationship with our learning disability (LD) community as part of the patient experience improvement strategy.

Additional work by patient experience teams, working with Harrow MENCAP resulted in the ‘Treat Me Well’ campaign. We have also increased the number of specialist LD nursing roles and incorporated representation into the patient experience collaborative, to enhance the patient voice and involvement with transformation work streams. This work will continue during 2020/2021 with the introduction of a patient engagement manager role. The role will reinforce connections and establish improved relationships with community partners and build upon achievements already made with our LD patients and their carers.

Quality Account 2019/20 19

Part 3: Review of our quality performance This section includes: • Trust performance for 2018/19 and 2019/20 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).

Information governance We provide guidance and assistance with regard to the Data Protection Act 2018 and the General Data Protection Regulation 2016. A detailed privacy policy helps our staff, patients and the general public to understand how their data is being looked after.

We also continue to support the NHS National Data Opt Out system to ensure the rights and views of our patients are listened to and acted upon. The Trust submitted a ‘standards met’ response to the new Data Security and Protection Toolkit (2019/20).

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. They relate to: • Standardised Hospital Mortality Indicator • 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.

20 London North West University Healthcare NHS Trust

Standardised Hospital Mortality Indicator (SHMI) Prescribed information

Trust values Previous period

Current period

Comparators National average

Best performer

Worst performer

The most recent available standardised data for the Trust is supplied by NHS Digital for the period November 2018 to October 2019. The closest previous period for comparison is between October 2017 and September 2018.

Trust SHMI value Trust SHMI bandings The percentage of patient deaths receiving palliative care

0.829

0.836

0.685

1.201

Better than Better than As expected expected expected

Better than expected

Worse than expected

34.0%

58.0%

35.0%

34.2%

1.000

36.0%

The percentage of patient deaths receiving palliative care reduced within 2019/20 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 within the first wave of COVID-19. By way of response at this time, palliative care staff were actively supporting patients within clinical areas including intensive care and high dependency units to optimise patient care and support.

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 Trust has the 10th 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.

We monitor and review mortality rates via the highly level mortality report and within the divisional dashboards that are submitted to the Clinical Effectiveness Committee. Learning is gathered from each patient death and the board receives a report on the learning each quarter. Learning themes are discussed and shared within specialties and then presented to the Learning from Patient Deaths Group, for Trust-wide learning. Mortality reviews are a standard agenda item on the Clinical Effectiveness Committee and each division also has learning from patient deaths as a standard agenda item on their clinical governance meetings. The Trust has also improved its recognition of the deteriorating patient, with the implementation of the new national patient monitoring system NEWS2 that has been built into quality priorities for 2019/20.

Quality Account 2019/20 21

Patient Reported Outcome Measure (PROM) adjusted average health gain Prescribed information

Trust values Previous period

Current period

Comparators National average

Best performer

Worst performer

The most recent available standardised data for the Trust is provisionally supplied by NHS Digital for the period April 2018 to March 2019, published in February 2020 for the adjusted average health gain based on the EQ-5D™ Index. The previous period for comparison is April 2017 to March 2018.

Hip replacement

Knee replacement

0.449 (Not an outlier)

0.447 (Not an outlier)

0.457

0.546

0.348

0.275 (Negative outlier)

0.288 (Negative outlier)

0.337

0.406

0.262

Hip replacement data identifies a slight underperformance for the Trust, though not an outlier when benchmarked nationally. However, there is more of an underperformance within knee replacement, this is likely to be attributed to adjustments of provision within the early phase of the pandemic in the last quarter of 2019/20.

Trust’s responsiveness (patient experience of hospital care) Prescribed information

Trust values Previous period

Current period

Comparators National average

Best performer

Worst 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.

Overall patient experience score

74.6

70.9

76.2

88.4

68.5

During 2019/20 the Trust implemented a robust patient experience improvement plan which prioritised collaborative working, stakeholder engagement and focused on empowering patients and their carers. While we remain below the national average for performance, we will work to increase our focus on enhancing the patient experienced.

22 London North West University Healthcare NHS Trust

The most recent available data for the Friends and Family Test for staff relates to the period July - September 2019. Staff views on the quality of care are also provided via the NHS Staff Survey 2019 results (October - December 2019). To help demonstrate the progress that has been made and to provide a fuller picture of staff views on the care provided by the Trust, data from both surveys is provided below.

Friends and Family Test for staff Prescribed information

Trust values Previous period

Current period

Comparators National average

Best performer

Worst performer

The most recent available data for the Trust has been supplied by NHS England for the period April 2019 to June 2019. The previous period for comparison is the cumulative position for 2018/19.

Staff who would recommend the Trust as a provider of care to family and friends

67.8%

66.6%

80.9%

97.6%

51.4%

The annual NHS Staff Survey also asks for staff feedback on key questions relating to quality of patient care in the organisation. The survey outcomes compare responses with that of similar sized trusts.

Since 2015, staff perception of whether the organisation puts patients as a top priority is in the seventy percentile, higher and consistent with responses relating to ‘whether they would recommend the organisation to friends and family’ (see staff friends and family question).

Delivering excellent patient care is an integral part of our HEART values and since the last report, significant work has been undertaken in building on our values and supporting our staff in the work that they do. This enables them to continue to be the best they can in delivering care to our patients. Initiatives have included clinical skills training, team development, leadership development programmes. Importantly, we have increased staffing and resources to reduce pressure in the frontline. This has resulted in increased recruitment of clinical staff and a reduction in turnover.

We are listening to our staff and better engaging them in making changes that will improve the workplace and patient care. Our ‘Conversations for Action’ engagement events have provided opportunities to implement positive changes that support transformation and help make the Trust a great place to work and receive care.

The most recent available data for the Trust has been supplied by NHS England for the period April 2019 to June 2019. The previous period for comparison is the cumulative position for 2018/19.

We continue to promote our values which put patients at the HEART of everything that we do.

Divisions encourage staff to give Friends and Family Test survey forms to all patients to increase the response rate. Matrons and ward managers work to review and improve results while divisional action plans help to improve performance. These plans are monitored by the Patient Experience Committee.

Quality Account 2019/20 23

VTE risk assessment Prescribed information

Trust values Previous period

Current period

Comparators National average

Best performer

Worst performer

The most recent available data for the Trust has been supplied by NHS Improvement on a quarterly basis for the period April 2019 to December 2019. The previous period for comparison covers the same quarters in 2018/19.

Adult inpatients who have been risk assessed for VTE on admission: 2019/20 Q3

92.1%

96.6%

95.3%

100%

71.6%

2019/20 Q2

86.4%

97.0%

95.5%

100%

71.7%

2019/20 Q1

81.5%

96.3%

95.6%

100%

69.8%

C. difficile infection rate Prescribed information

Trust values Previous period

Current period

Comparators National average

Best performer

Worst performer

The most recent available data for the Trust has been supplied by Public Health England for the period April 2018 to March 2019. The previous period for comparison is April 2017 to March 2018.

Clostridium difficile (C. diff) infection rate per 100,000 bed-days (patients aged 2 or over)

10.8

11.0

12.2

0.0

79.7

MRSA bloodstream infection rate Prescribed information

Trust values Previous period

Current period

Comparators National average

Best performer

Worst performer

The most recent available data for the Trust has been supplied by Public Health England for the period April 2018 to March 2019. The previous period for comparison is April 2017 to March 2018.

MRSA bloodstream infection (BSI) rate per 100,000 bed-days

1.0

24 London North West University Healthcare NHS Trust

1.40

0.78

0.0

6.8

Secondary users service: quality data We submitted records during 2019/20 to the Secondary Uses Service for inclusion in the Hospital Episode Statistics. These are included in the latest published data.

The percentage of records for the period April 2019 to December 2019 which include a valid NHS number was • 98.4% for admitted patient care; • 99.4% for outpatient care; and • 95.4% for accident and emergency care.

The percentage of records in the published data which included the patient’s valid General Medical Practice Code was • 99.9% for admitted patient care; • 99.3% for outpatient care; and • 100% for accident and emergency care.

The Trust is working to improve its clinical coding audit capability with full results for 2019/20 not currently available.

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 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.

Essentials of care quality improvement Clinical areas use several mechanisms to measure the effectiveness of care and monitor patient safety. In addition to patient feedback, risk management and quality indicators, a program of monthly clinical care audits is undertaken within a peer review process. This is enhanced by a quarterly excellence assessment aimed to underpin improvements and benchmark against expectations and national standards.

Quality Account 2019/20 25

Audit outputs and governance reports are shared with the multidisciplinary team at handover.

These are also displayed in staff areas and discussed within service and divisional governance meetings to ensure all staff are aware of areas of good practice and areas requiring improvement.

Action plans generated from audits relating to fundamental aspects of care are designed as a tool to support shared learning and improvement. Areas for improvement are identified through audit outcomes and all action plans are visible and available for access by senior staff for monitoring and ward to board assurance purposes.

Overview of patient safety incidents We continue to build our safety culture, encouraging high levels of incident reporting, as part of effective incident management. Incident reporting is a fundamental tool of risk management. The aim is to collect information about patient safety incidents, including near misses, ill health, accidents and hazards, to help support wider learning across the organisation. The vast majority of incidents do not cause any significant harm. Serious incidents are relatively uncommon but when they do occur we have a responsibility to ensure that there are systemic measures in place for safeguarding people, property, resources, and reputation in the future. This includes learning from patient safety incidents to minimise the risk of them happening again.

Data uploaded to the National Reporting and Learning Service (NRLS) is analysed by NHS Improvement (NHSI) and published every six months in Organisation Patient Safety Incident reports. In addition, monthly statistics for provider organisations is published on the NHSI website.

The chart below is taken from NRLS data report published on 25 March 2020 for the period April 2019 to September 2019 and submitted to NRLS by end November 2019 (data for October 2019 - March 2020 will not be published until October 2020.)

It shows that the Trust is above average relative to its peer group for reporting of patient safety incidents. During this period, the Trust reported 60.5 incidents per 1,000 bed days versus an average of 49.4 incidents across the correct comparator of acute (non-specialist) trusts in the same period.

Patient safety incidents per 1000 admissions April - September 2019

Source: NRLS Organisation Patient Safety Incident Reports (OPSIR): 25 March 2020 26 London North West University Healthcare NHS Trust

We have improved our position significantly during the last 12 months. The corporate clinical governance team carries out detailed screening and quality checks before incident reports are uploaded to the NRLS each month.

We continue to deliver training to frontline staff to raise awareness of the need to report all incidents and near misses. This approach has prompted a steady rise in the number of incidents reported onto the Datix system year on year. In February 2020, reporting began to decline, in all likelihood due to the pandemic which quickly impacted on all aspects of activity from types of care delivered, numbers of patients, numbers of staff at work and staff working in new locations. This translated into reduced levels of incident reporting from an early stage.

To mitigate the decrease alternative means of reporting incidents were introduced. The sudden decline in incidents reported in February-March meant that the previous gradually increasing trend in reporting, as well as absolute higher levels of incident reporting, became a decreasing trend for year as a whole. The board are aware and have expressed concerns around this and receive assurance through the committee supporting the board assurance structure.

Figure 1.2: Patient safety incidents reported onto the Trust’s incident reporting system for the period of 1 April 2018 to 31 March 2020

Our corporate induction programme emphasises the importance of incident reporting; training is provided at bespoke sessions for incident handlers and staff. In addition, relevant training has been targeted at departments and services with lower-than-expected levels of reporting or where there is a downward trend in reporting.

In terms of reporting data, the team prioritises severe and catastrophic incidents for detailed screening. If an incident is reported which appears to have resulted in serious harm or death the Trust will upload this incident to the NRLS ahead of the date of the next batch upload. This supports prompt shared learning and an open and honest management and declaration of incidents and risk issues. Incidents which result in serious harm or death are the subject of a detailed investigation.

A total of 11,977 incidents (increase from 9830 in the previous six-month period) were reported between 1 April 2019 to 30 September 2019 and uploaded to the NRLS between 1 April 2019 and 30 November 2019. Of these, 30 incidents resulted in severe harm (up from 23 in the previous period) and 11 were considered to have contributed in some way to the patient’s death – this is a reduction of 50% compared to 22 in the previous reporting period.

Quality Account 2019/20 27

NRLS data shows that the Trust profile in the category “implementation of care and ongoing monitoring / review category” appears different from the comparator cluster. We attribute the variance to a greater number of pressure ulcers that fall within this category, due to the inclusion of community services in our “acute” organisation categorisation. Trusts are now required to report incidents where patients are admitted into the service with pressure ulcers and moisture lesions acquired outside of the Trust, which further increases the number in the context of the community service.

The Trust has reported higher numbers than the cluster for ‘infrastructure (including staffing, facilities and environment)’ with the largest number of incidents in this category relating to ‘lack of/delayed availability of beds’.

There are ongoing efforts to improve staff awareness of incident reporting procedures, openness of reporting and to increase the number of incidents reported including: • A program of incident and risk management training to enhance awareness and the level of understanding • Work with teams and sub-committee groups to review themes and trends e.g. falls group • Publishing serious incident and never event investigation outcomes on the intranet • Regular updates via internal communications channels • An awareness and engagement for World Patient Safety Day and Patient Safety Awareness Day • Root cause analysis training to help staff understand the causes of incidents and accidents.

Patient safety alert compliance Patient Safety Alerts (PSA) are used to inform the healthcare system of recognised safety risks and offer appropriate guidance for the prevention of incidents that may result in severe harm or death to patients.

These alerts are issued through the NHS’s Central Alerting System (CAS), a web-based cascade tool for issuing alerts, public health messages and useful safety information to the NHS and other healthcare organisations.

Systems and equipment are commonly subject to PSAs where there are recognised errors or faults which would require prompt action to be taken, usually within a specified timeframe, to reduce the risk to patient safety. Coordination of PSAs is carried out by the corporate quality and patient safety team. The team works with departments to facilitate compliance, capture assurance and monitor ongoing work or action plans required to address the issues raised by the alert. The Trust records its compliance with the alerts on the CAS website and through its own bespoke platform created on Datix.

In September 2019 the newly-formed National Patient Safety Alerting Committee (NaPSAC), issued an alert from CAS to introduce a new system of managing National Patient Safety Alerts (NatPSA). A key change to the process is that, going forward, all NatPSAs should be coordinated by an executive leader supported by clinical leaders. The Trust’s process for this is to identify the appropriate executive-level owner for the alert, who nominates a clinical leader.

28 London North West University Healthcare NHS Trust

Details of those trusts who are non-compliant with any PSA are published online by NHS England. The Trust is currently fully compliant with all its actions and obligations under PSAs. Reference

Title

Action status

CHT/2019/001

Alert from the central alerting system helpdesk team

Action completed – The content of the alert brought to the attention of the executive directors.

The introduction of national Patient Safety Alerts NHS/PSA/RE/2019/002

Assessment and management of babies who are accidentally dropped in hospital

Action completed – Resource updated for initial actions to be taken if a baby is accidentally dropped. Brought to the attention of all relevant staff.

NatPSA/2019/001/NHSPS

Depleted batteries in intraosseous injectors

Action completed – Training materials and staff competency frameworks updated.

Update - NHS/ PSA/W/2017/005 (First issued 2017)

Rapid over infusion of parenteral nutrition (neonates)

Action completed – Training materials and staff competency frameworks updated.

Additional measures taken to ensure back-up equipment readily available and staff know the locations of these.

Action completed – Neonatal prescription charts updated to accommodate different types of parenteral nutrition.

NatPSA/2019/002/NHSPS

Risk of death and severe harm from ingesting superabsorbent polymer gel granules

NatPSA/2019/003/NHSPS

Action completed – Risk of harm to babies and September 2020. children from coin/button batteries in hearing aids and Actions to date: Trust policy is to other hearing devices use tamper-proof battery doors on hearing aids for younger children.

Quality Account 2019/20 29

Patient-led assessments of the care environment (PLACE) PLACE are self-assessments of a range of non-clinical services which contribute to the environment in which healthcare is delivered. They are carried out annually between February and June and are overseen by NHS Digital. The assessments are unannounced, and the assessment team make their decisions based entirely on the observations made at the time of the assessment. Patient Assessors make up at least 50% of the assessment team, providing an effective and independent patient voice.

The PLACE programme also offers a non-technical view of the buildings and non-clinical services provided across all NHS Trusts, voluntary, independent and private healthcare providers. It is carried out annually between September and November each year and is entirely based on a visual assessment.

PLACE is undertaken from a patient’s perspective, focusing on what matters to them and only patient areas are assessed. The elements involved in PLACE were extensively reviewed following the completion of the 2018 programme, with a number of changes being applied in 2019. As a consequence of these changes the 2019 results are not comparable to earlier years.

Patient assessors make up 50 per cent of the teams assessing how the environment supports the provision of clinical care, focusing on areas such as: • Privacy and dignity • Food • Cleanliness • General building maintenance • How well the needs of patients with dementia are met • How well the needs of patients with a disability are met.

The 2019 results were published at the end of February 2020 and are available on the NHS Digital website.

Overall, the feedback from the Patient Assessors was positive. They were pleased with the condition of the environment, cleaning standards and the menu choice offered to patients.

There were areas requiring investment in the environment and infrastructure, but it was also noted that there had been a considerable amount of capital investment in patient areas during the preceding year. The one area of concern during the assessments was the lack of compliance with protected mealtimes.

30 London North West University Healthcare NHS Trust

To address the issues identified in the 2019 results the following actions will form part of an overarching improvement plan (COVID-19 may impact on the timings of some actions being completed): • Regular mealtime audits by specialist catering dietician, nursing and catering staff • Mealtime awareness days • Nutrition and hydration workshops and forums • Launch of an e-learning package for nurses and healthcare assistants on mealtimes • Face to face training for all nutrition champions • Joint facilities management audits with a soft facilities management contractor, nursing staff, waste management and estates.

Quality Account 2019/20 31

Part 4: Statement 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 other say about the Trust – Care Quality Commission • Data quality, information governance and clinical coding • Staff survey.

Review of services During 2019/20, the Trust provided: • Emergency department • Admitted patient care for planned and emergency treatment • Critical care • Non-admitted patient care • Maternity services • Integrated community services.

The Trust has reviewed all the data available to them on the quality of care in these relevant NHS services.

A proportion of our income in 2019/20 was conditional on ensuring that reasonable endeavours were made to achieve the quality improvement and innovation goals agreed between the Trust and NWL CCGs through the Commissioning for Quality and Innovation payment framework; 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 NHSI, NHSE, CQC, our commissioners and the STP.

Participation rates for national audits by financial year 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 32 London North West University Healthcare NHS Trust

to respond locally to the findings. Once all the actions within an action plan are completed, the audit is considered ‘fully completed’. Action plans are correlated against information available in the CQC insight reports for acute NHS trusts, which highlight areas of practice where the Trust needs to focus improvement.

Below is the progress made for each published list by year. Please note that it is not expected that all of these audits will be ‘fully completed’ within a financial year as national audits run across financial years and can take significant time to be published.

National Audits 2019/20 Division

Total

Number applicable

Data collection

Awaiting national reports

106

52

44

Number ready to implement 1

Action plan in place

Fully completed

7

2

The table above shows that of the audits listed for 2019/20 a total of 106 quality account/ national clinical audits were registered, with some sites needing to register separately.

Of these 52 are in the active ‘data collection’ phase, 44 are awaiting the publication of national reports, 8 have ongoing action plans and 2 have been completed.

In addition to the national audits being completed (as above), the following tables give the details of the remaining quality account / national audits from previous financial years that continue to be monitored until completion.

Ongoing National Audits 2018/19 Division

Total

Number applicable

Data collection

Awaiting national reports

103

36

24

Action plan in place

Fully completed

19

18

Action plan in place

Fully completed

19

60

Number ready to implement

Action plan in place

Fully completed

11

86

60

Number ready to implement 6

Ongoing National Audits 2017/18 Division

Total

Number applicable 102

Data collection 3

Awaiting national reports 16

Number ready to implement 4

Ongoing National Audits 2016/17 Division

Total

Number applicable 104

Data collection 2

Awaiting national reports 5

Quality Account 2019/20 33

Summary of completed local audits 2019-20 The following is a summary of local clinical audit activity across the Trust and then by division.

Local clinical audit activity across the Trust is based on evaluating aspects of care that are important for particular services / specialties. The Trust’s expectation is that each service will review its record keeping every 18 months and conduct at least one other clinical audit each financial year, in addition to national clinical audits. Local audits include those that may have been on the clinical audit programme in the previous financial year, which may have continued over a number of years, any areas of high risk or high volume, risk management issues that need further investigation or to confirm that change has taken place.

Division

Registered

Data collection

Reports

33

12

2

19

58%

1

1

N/A

N/A

N/A

Emergency & ambulatory care

40

11

4

25

62%

Integrated clinical services

88

18

4

66

75%

Integrated medicine

41

18

9

14

34%

Surgery

74

45

6

23

31%

Women’s services

37

12

5

20

54%

314

117

30

167

53%

Children’s services Corporate nursing / services

Total

Completed

%

Continuous improvement through research The Trust has developed a process for developing improvement programmes which translate research initiatives and ideas into practice through the development of pilot programmes.

These pilots are evaluated against national best practice, clinical effectiveness, patient and staff satisfaction and cost effectiveness.

National clinical audit reports were published and recommendations were put into action by the Trust during the period. The Trust continues to exceed expectations with both patient recruitment targets and contribution to research in 2019/20.

Research has played a significant role in improving patient care through innovation and new treatments. It is our goal that every willing NHS patient in the north west London can be a research participant. This will significantly improve patient outcomes and the services we provide. We feel that research will help our Trust to make informed decisions for our patients.

34 London North West University Healthcare NHS Trust

Research and development aims to: • Deliver the National Institute for Health Research and Trust research agendas • Identify research priorities for our population • Establish a new supportive network in which our researchers can work • Develop and screen research proposals for scientific rigour and ethics evaluation • Promote and encourage our patients to be an integral part of our research activity During 2019-2020 the Trust continued to expand its research portfolio and increased a number of opportunities for patients and clinicians to take part in high quality and high profile research projects including urgent public health, Chief Medical Officer signed COVID-19 research studies. The research and development department has also increased its portfolio of service evaluations and quality improvement projects. We continue to work with our industry partners and collaborators to ensure increased commercial research activity.

Annual performance: The Trust recruited 2,106 patients into clinical research studies.

Top recruiting speciality areas Specialty

2018/19

2019/20

Gastro-enterology

580

622

Infection

244

465

Cardio-vascular

357

380

Cancer

522

243

Stroke

106

104

Surgery

130

68

Genetics

1,159

65

Children

29

51

Dementia and neuro

1

23

Ophthalmology

7

20

Anaesthesia

52

18

Diabetes

38

14

Musculoskeletal

48

11

There was notable increased participant recruitment in gastroenterology, cardiovascular and infection, dementia / neurodegeneration, children and ophthalmology specialities. Genetics has encountered a decline in recruitment as a result of the closure of the 100k Genome Programme.

Quality Account 2019/20 35

Ealing 18-19

Ealing 19-20

NPH 18-19

NPH 19-20

515

168

41

275

245

Observational

76

49

386

474

Interventional

45

31

132

9

40

60

Large scale study

Commercial

St Marks St Marks 18-19 19-120

CMH 18-19

CMH 19-20

LNWH* 18-19

LNWH* 19-20

124

54

150

1,056

0

296

320

1

10

134

25

157

183

104

99

7

47

1

106

2

30

9

13

0

0

Northwick Park Hospital - Increased participant recruitment across all study types in 2019-20 which was greatly supported by the EVAREST (Cardiovascular) and PREP-IMPACT (HIV/Infection) studies. *LNWH - is recruitment/or a study which is not attributed to one particular site e.g. cross site or centralised recruitment method such a postal surveys. Drop in large scale recruitment due to closing of 100K Genome study.

36 London North West University Healthcare NHS Trust

LNWH top 10 recruiting studies Short title

Disease area

Recruitment 2019/20

EVAREST

Cardiovascular

242

PrEP Impact Trial

Infection

202

Validating Quality of Life Modules in Lymphoma

Cancer

175

Clinical Characterisation Protocol for Severe Emerging Infection

Infection

147

IBD-BOOST: SURVEY

Gastroenterology

135

IBD Bioresource

Gastroenterology

124

Dietary Practices and Beliefs in South Asian Patients with IBD

Gastroenterology

111

HERITAGE

Cardiovascular

100

iGBS feasibility study

Children

62

BRAINS

Stroke

57

Total of top ten recruiting studies

(65% of overall trust recruitment)

1,355

Quality Account 2019/20 37

Figure 1. New principal investigators (PI) by staff type

Figure 2. New studies approved 2019-2020

Figure 3. NIHR portfolio studies open to recruitment 2019-2020 (Total 143)

38 London North West University Healthcare NHS Trust

Commercial research Commercially sponsored studies recruited 185 patients against a target of 59 patients, resulting in 314% increase. Our researchers work collaboratively with commercial partners and continue to attract new and innovative research projects. The Trust was awarded alliance membership with Parexel International as preferred study site provider which opens up valuable opportunities to collaborate and grow the commercial study footprint.

Performance in initiating and delivering clinical research (PID) The Trust reported 5 of the applicable clinical trials were initiated and recruited 1st patient within the 70-day benchmark. For the delivery of commercial clinical research, all four closed commercial trials in year recruited to time and target.

Networking We continue to work with our North West London Clinical Research Network (NWL CRN) to encourage more specialties and researchers including nursing staff and allied health professionals (AHPs) to become research active. The Trust now has an R&D support group that is working closely with the nurses and AHPs to encourage these staff to undertake research and service improvement projects. We continue to collaborate with Imperial College Healthcare Partners (ICHP) on key healthcare impacts such as sepsis and chronic obstructive pulmonary disease with a view to further evolve programmes in the preceding year. We actively contribute to research activity across the whole of UK and have also undertaken international research with our global partners.

R&D IAOCR bronze award 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. R&D is now working towards the silver award. The IAOCR award provides assurance of workforce quality globally. The accreditation aligns people and business strategies to enable organisational excellence in the clinical research sector and allows commercial organisations to engage in large scale commercial research.

R&D excellence awards In 2019 the Ophthalmology Department based at CMH won the annual R&D award for their contribution to setting up an active research multidisciplinary team. In 2017, the Ophthalmology Service at Central Middlesex Hospital (CMH) was research-naïve, with no research sessions for clinicians, no research fellow or team in parallel with the Trust’s tough financial position. Consultations with the patient forum and their views on areas of research helped to define the therapy areas for research in ophthalmology. Ophthalmology is now the busiest outpatient department in the NHS and relies heavily on allied health professionals to deliver care traditionally delivered by doctors. The department has developed a highly skilled multi-disciplinary team conversant with the evidence-base and treatments in the pipeline.

Involvement in research has meant a very highly skilled work-force managing our patients, including patients not participating in a clinical trial.

Quality Account 2019/20 39

Achievements 2019-2020: • 1st NHS Trust in the country to be awarded Bronze IAOCR Accreditation • LNWH exceeded targets for the number of patient’s recruited into NIHR CRN commercial studies by 314%.

• LNWH recruitment to time and target (closed studies) exceeded targets for both commercial (89% against a target of 80%) and non-commercial (92% against a target of 80%) • LNWH continues to be the highest recruiting Trust for gastroenterology across the north west London Sector • LNWH is the 2nd highest recruiting Trust for cardiology, cancer & stroke across the north west London Sector.

• LNWH achieved 105% of its recruitment target into degenerative disease studies.

Challenges for 2020-2021 Our main challenges in the coming financial year are sustainability and further increasing our commercial portfolio. As a large Trust in the north west London, serving a diverse population of over 1.2 million, we are aiming to increase our research capability funding income by focusing on opening studies to more clinical specialties and identifying research studies that will benefit our large population.

Our continued collaboration with our commercial partners will see new partnerships and growth in our commercial activity.

Areas for improvement: • LNWH’s total participant recruitment for 2019-2020 was 2.106 against a target of 2,992.

The decline in participant recruitment largely due to the closure and halt of the large scale recruiting studies.

• The decline in recruitment activity has resulted in a decline in activity based funding (ABF).

Quality improvements agreed with commissioners The Trust continues to monitor and sustain quality improvement programmes linked to best practice, NICE guidelines and national audit outcomes.

These are monitored through the Commissioning for Quality and Innovation (CQUIN) programme, national audit surveys as appropriate and best practice programme review.

This process also links with sustainability and transformation programmes and where possible are viewed from a whole system working perspective

CQUIN Performance 2019/20 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.

40 London North West University Healthcare NHS Trust

A high-level summary of this year’s CQUIN and performance against them is shown in the following table.

CQUIN Programme

Indicator or Target

Outcome

Reducing infection and antibiotics in older people

Implementation of catheter care bundle

Implemented with 25.6% reduction in use of catheters

Antibiotic prophylaxis in colorectal surgery

Incomplete due to cessation of colorectal surgery due to COVID-19

Tobacco and alcohol screening and brief advice

90% Of patients screened

90%

High impact actions to reduce falls

Combined indicator of 80% 83% performance against of relevant patients having: combined target Lying and standing BP no hypnotics or anxiolytics mobility assessment within 24 hours of admission

Stroke 6 month review

55%

100%

Same day emergency care for specific conditions

30% of patients with community acquired pneumonia

39%

75% of patients with pulmonary embolus

93%

50 of patients with atrial fibrillation

96%

Quality Account 2019/20 41

Quality improvement The research quality improvement team continue to support the monitoring of care bundles developed to support quality indicators, best practice guidelines and evidencing change following incidents.

Sepsis We continue to meet the quality standard that 90% of patients receive screening and administration of antibiotics within an hour of assessment in both emergency and in-patient areas for 2019/20.

_ 89% _> 90% screened correctly for sepsis <

Sustainability in quality improvement Ealing Heart Failure Lounge The ongoing achievement in best practice tariff led to develop cross site specialist nursing provision, development of multi-disciplinary and multi-agency team meetings with partner organisations and the development of integrated models of care to support admission avoidance. This was evidenced in the partnership programme for patients with decompensated congestive heart failure which was piloted at Ealing Hospital in 2019 and has been successful in reducing non elective care admissions and re-attendances to the emergency department.

The pilot identified the following benefits for patients. â&#x20AC;˘ 176 patients attended the programme 171 patients did not have an admission (97.15%) This programme has received research and Health Service Journal awards and the programme is being followed by the pan London heart failure group.

Following this success, the division identified the need for the same programme to be developed on the Northwick Park Hospital site during 2020/21.

We continue to monitor attendances, admissions, and bed days post lounge interventions as part of the improvement modelling for SDEC services going forward.

42 London North West University Healthcare NHS Trust

What others say about the Trust In 2019 care the Care Quality Commission carried out inspections focusing on the ‘Well led’ domain in addition to core services inspection.

In preparation for the inspection there were over 600 provider information requests (PIR) for information during the months of May to September in addition to use of resources assessments during the month of June.

• The on-site inspection took place from 2 to 4 July 2019 with the following services inspected: • Ealing Hospital – Urgent and emergency services • Central Middlesex Hospital – Medical care, surgery, children and young people • Northwick Park Hospital – Urgent and emergency services, surgery and maternity Well led reviews focusing on organisational leadership, culture, safety and effectiveness took place during the months of August to September.

A draft report was received on the 27 September and was reviewed for factual accuracy, with the full and final report being received on 1 November prior to publication on 6 November 2019.

An overview of the outcome of the inspection is highlighted below Safe

Effective

Caring

Responsive

Well-led

Overall

Ealing Hospital

Requires improvement

Requires improvement

Good

Requires improvement

Requires improvement

Requires improvement

Central Middlesex Hospital

Requires improvement

Good

Good

Requires improvement

Requires improvement

Requires improvement

Northwick Park Hospital

Requires improvement

Requires improvement

Good

Requires improvement

Requires improvement

Requires improvement

Good

Requires improvement

Good

Good

Good

Good

Requires improvement

Requires improvement

Good

Requires improvement

Requires improvement

Requires improvement

Community Services

Overall Trust

Quality Account 2019/20 43

This was a significant improvement on 2018 inspection process where the Trust received: • Five enforcement notices, there were zero in 2019 • Six regulatory notices, there were two in 2019 • 39 required actions in 2018 with none in 2019 • 74 recommended actions in 2018 with 50 in 2019.

Use of resources, was assessed as ‘requires improvement’ in areas such as: • Operational performance, benchmarking of staff utilisation • Medical, nursing and AHP benchmarking higher than the national average for cost – some of it driven by winter capacity and addressing referral to treatment backlogs • Trust had not signed up to its control total • Improvements in the underlying deficit have not been maintained • The key challenge is to maintain operational performance whilst meeting its financial plan.

Well led review was assessed as ‘Requires Improvement’.

With a focus on positive feedback: • The board had the appropriate range of skills, knowledge and experience to perform its role • The board had a clear set of values with quality and sustainability as top priorities.

Aspects identified for improvement in the ‘Well led’ domain: • The Trust had not yet devised a strategy post Shaping a Healthier Future • Staff did not always feel that equality and diversity in their day to day work • Revised governance structure had given ‘clear improvements’ with strong pillars of governance in place needing maturity • Board not sighted on the issues around children and young people at Central Middlesex Hospital • Patients still raised issues about communication, particularly confusing outpatient letters • The board had sight of most of the significant risks, however mitigating actions were not clear and what the board received did not provide assurance relating to controls or gaps.

General themes emerging from the inspection: • Patients were treated with compassion and kindness • Mandatory training – compliance levels for doctors requires improvement • Infection control – hand hygiene and toy cleaning require review • Cross cutting paediatrics – toys, paediatric early warning system, accountability requires definition • Leadership model at Central Middlesex Hospital requires review • Care of complex dementia patients and understanding on mental capacity and deprivation of liberty safeguards requires improved focus • Evidence of improved cross site working particularly at Ealing Hospital 44 London North West University Healthcare NHS Trust

• Greater levels of enthusiasm to address and improve on all areas of performance were evident • Improved operational performance noted • Detailed learning from deaths programme in place • The Trust is an active participant in research • Ongoing focus on culture required in maternity.

Actions After the publication of the CQC report in November 2019, action plans were developed to address the areas for improvement. These comprised of a Trust master action plan and divisional action plans. The areas of improvement related to the 49 actions (recommended actions in the table above). Substantial progress has been made with completion of these actions.

The Trust has made improvements in many areas in response to the CQC recommendations by focusing on its mandatory training programme, workforce planning and staff well-being, patient flow through the hospitals and improving the patient experience.

Progress against the action plan is overseen through the Trust’s governance and monitoring processes. The Trust Board has oversight of the progress made and the Trust Board committees receive assurance on a monthly or bi-monthly basis.

An action plan for the regulatory notices was submitted to the CQC during November 2019 with staff workshops held during December, aimed at celebrating success and to determine opportunities for continuous improvement and organisational transformation. Of the two regulatory notices issued in 2019, one notice remains open and good progress is being made to achieve compliance.

Our focus on improvement to enhance patient care and experience continues. With the emergence of the pandemic, a number of elements were reviewed to ensure the approach is aligned with associated challenges of COVID-19.

The Trust demonstrated its compliance with the relevant key lines of enquiry (KLOEs) through the infection prevention and control (IPC) board assurance framework devised by the CQC in August 2020. The CQC were satisfied that the appropriate IPC measures were in place, especially in relation to the pandemic.

The Trust participated in CQC’s ‘Project reset in emergency medicine - Patient FIRST’ and demonstrated significant achievements and improvements made in the emergency departments since the last inspection.

Focusing on mitigating patient safety, enhanced communication, resilience and recovery as a continuing priority has resulted in a review of priorities and serves to inform quality priorities for 2020/21.

Quality Account 2019/20 45

Data quality, information governance and clinical coding Submission of seven-day self-assessment data 2019/20 This report is based on local data such as consultant job plans and local clinical audits, as outlined in the full seven-day service National Assurance Framework guidance.

The review of standards for seven-day services (7DS) was changed from a formal audit process in February 2019 to an organisational approach through the board Assurance Framework.

This consists of a standard measurement and reporting template, which all providers of acute services complete with self-assessments of their delivery of the 7DS clinical standards.

Background The National programme for seven-day working was implemented in November 2015.

This programme of work was undertaken following the Academy of Medical Royal Colleges 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 s to consultant directed interventions • Standard 8 - Ongoing review.

The Trust has now completed six audits for these four standards and is seen nationally as an exemplar trust.

Evidence of meeting standards for June 2019 submission Audit data seven-day working May 2019. Consultant review within 14 hours of admission.

The sixth audit of 7DS took place in May 2019 and the Trust submitted data at the end of June 2019. The audit included both Ealing Hospital and Northwick Park Hospital (NPH) with specific audit of consultant review within 14 hours for medical patients. This was completed following review of the last audit which showed that medical patients had a longer wait than other specialties to be reviewed. The standard for these patients were just under the 90% target at 89%. Although the Trust met the national standard overall at 97% for weekday review and 95% for weekend review.

As a background to this audit it was identified that there has been a rise in activity as follows: • Growth in type 1 attendances by 11.8% at NPH • Ambulance arrivals grew by 13.3% at NPH and 6.2% at Ealing • Emergency admissions grew by 8.3% at NPH and 5.8% at Ealing • Same day emergency discharges increased by 11.6%.

46 London North West University Healthcare NHS Trust

The findings show that the Trust is continuing to meet the 90% standard for patients admitted to an acute setting being reviewed by a consultant within 14 hours of admission.

The audit has identified that those patients waiting longer than 14 hours were seen within three hours of the standard breach. The standard was breached for two patients across this audit period at across the weekend period at NPH. Clinical standard eight This audits whether patients needing twice daily review are seen by a consultant or are delegated to a designated clinician to support the patient’s management.

Designated clinicians are identified as follows: • Consultant • Specialist registrar • Other doctor • Specialist nurse or advanced practitioner • Other nurse • Other health professional.

This means that a patient seen by an allied health professional, such as an occupational therapy physio therapist, mental health professional or speech & language therapist, is counted as having had a designated clinical review.

The Trust operates an acute medical post take model and surgical post take model which supports consultant review of delegated patients across weekends. High acuity specialties have consultant ward round review daily.

ITU /HDU areas have twice daily ward rounds with consultant responsibility.

Acute medical take at NPH operates three times a day wards round and twice daily at Ealing Hospital.

Surgical take operates a twice daily ward rounds for all emergency patients.

Paediatric take operates a three-times a day ward round for all emergency patients.

At NPH there is also a medical emergency team supporting early detection of deteriorating patients which is supported by critical care out-reach practitioners, this is supported by the medical take at Ealing.

The Trust has implemented a frailty model of care which will review elderly patients with multidisciplinary needs. This is part of the strategic development for care in NHS Long Term Plan and we are working with CCG colleagues to develop a tariff process for this programme.

Conclusion Although the Trust continues to meet the standards required to support 7DS this has been achieved under considerable pressure caused by higher attendances and admissions and the requirement to meet other clinical standards such as cancer screening and treatment.

Quality Account 2019/20 47

The focus on maintaining these standards will require action to reduce this pressure through the development of whole system approaches to reduce the number of patients attending hospital unnecessarily and improving same day emergency pathways.

Friends and Family Test 2019/20 The Friends and Family Test allows the patient’s voice to be heard promptly and at volume: 76,932 patients completed the survey in 2019/20 with 94.38% saying that they would recommend our services to their friends and families. It is important to understand the reasons for the ratings and the patient’s perspective of their experience. This valuable data is analysed and reported monthly to the divisions to inform and improve learning and enact changes to the care and services we provide. Overall, the Trust received a rating of 98% for patients being treated with kindness and 97% for feeling safe. Less positively, patients reported that they would like to feel more involved in decisions about their care and have more information.

Patient involvement and engagement strategy The Trust remains committed to ensuring that patients are at the HEART of everything we do and to engage them in decisions about their treatment and care but also to developing and improving Trust services. During 2019/20, a “patient database” was created. This includes the details of all users wishing to participate in service review and development and the nature of involvement they are interested in. This is in line with the 4Pi National Involvement Standards.

The Trust has actively engaged with the public, as well as other key stakeholders and patient groups, to better understand what matters to them and how this can be delivered through the Patient Involvement Engagement Improvement Strategy, which prioritises: • Communication – promoting ‘patient voice’ • The patient journey – access and discharge standards • Patient engagement and involvement • Staff Survey 2019: Summary of results.

In our 2019 survey, more staff (45%) than in the previous year told us what it is like to work in the organisation. Over the last five years, we have seen incremental improvements in our performance in most of the survey indicators. We have also seen improvements when compared to other NHS trusts.

What did the survey tell us?

When compared with similar organisations: • We continue to score highly on the impact of performance appraisals on the quality of care and productivity; agreeing objectives and discussions around organisational values • Fewer staff said they put themselves under pressure to come to work when not feeling well enough • More of our staff said that their training and development needs were identified during appraisal.

48 London North West University Healthcare NHS Trust

We also improved in the following areas when compared with the last survey: • Making adequate adjustments to enable disabled staff carry out their work • The numbers of staff who said they were reporting physical violence • Availability of more people resources to enable staff do their jobs properly • Fewer staff said they had to work additional unpaid hours above contracted hours.

Our staff also told us that there were areas for improvement and when compared with other Trusts: • More of our staff said they were planning to leave the organisation in the next 12 months • Fewer staff were happy with the standard of care provided by the Trust • Fewer staff believed the organisation acted fairly on career progression.

We compared our performance with response in 2018 survey and know we need to do more around: • Staff satisfaction with opportunities for flexible working • Numbers of staff having appraisals • Greater autonomy in staff decisions on how they work and in making suggestions to improve the work in their service/department.

Key themes from the survey include: Staff engagement and Staff Friends and Family questions In 2019 our engagement scores were low, staff told us they needed more involvement in service improvement and more autonomy in making decisions about their work. This low engagement level was also reflected in responses to Staff Friends and Family Test questions where only 54% of respondents said they would recommend the Trust as a place to work against an NHS average of 62%. In terms of quality of care, only 69% of respondents said they would be happy with the standard of care provided by the Trust against an NHS average of 69%. Although this is an increase of 11% when compared with responses in 2018, there is significantly more work for the Trust to do in this area.

Staff appraisal When compared with other trusts, more of our staff reported a positive experience of their appraisals. Where appraisals took place, staff said clear objectives were set and training and development needs were identified. Staff said this helped them improve how they did their job. Our data also indicates that this is a strong recruitment vehicle and research indicates a mark of quality of care.

Reporting of physical violence and bullying and harassment More staff said they reported physical violence when compared with the 2018 survey.

Although the changes in this indicator were not statistically significant, it represents Quality Account 2019/20 49

incremental improvement and a step in the right direction. This is an indicator that it is further embedding its behavioural and culture change programme. This will continue during 2020 as we will continue roll out of our HEART values programme.

Staff health, wellbeing and safety at work Responses to questions on health wellbeing and safety in the workplace showed improvements as more staff said they feel cared for and valued. This has been achieved through targeted work by our occupational teams, in particular investment in the Employee Assistance Programme and psychological support for teams and individuals. In response to the pandemic we have invested significantly in supporting the physical and mental wellbeing of our staff and maintaining safe and risk free workplaces.

Perceptions around career progression A breakdown of staff responses by ethnicity reveals (as in previous years) a marked difference in the experiences of staff from Black Asian and Minority Ethnic (BAME) backgrounds of the workplace when compared with that of their white counterparts. The survey indicated that only 67% (65% in 2018) of BAME staff believed the Trust acted fairly on career progression (and promotion). This compares with responses from white respondents where 82% (81% in 2018) believed this was the case. The Trust needs to do more in managing these perceptions and provide better support to BAME employees.

Leaving the organisation More of our staff said they were either planning or looking for a job at a new organisation.

We know that we need to continue to do more to improve retention however report that staff retention has improved when compared with previous years. Nevertheless, the Trust acknowledges the value of this feedback in ensuring it is more competitive and better understands the reasons for staff leaving.

Flexible working Our staff told us they want us to do more about flexible working. Over second half of the year significant investment in technology has introduced new opportunities for flexible and remote working. This has improved the quality of life of our staff, their health and wellbeing and how we care and treat our patients. In a recent pulse survey, the Trust scored highly in this area.

Ongoing actions for improvement The staff survey remains a valuable mechanism for informing the organisation on how it can continue to improve the working lives of its workforce. We are listening to staff and data indicates that ongoing changes are making a positive difference to the working lives of our workforce. However, we know there is always more to do. We shared the survey findings with staff who have told us areas of priority for their divisions. This will ensure that interventions are owned by staff and are having the right impact.

50 London North West University Healthcare NHS Trust

Part 5: Quality Priorities 2020/21 This year’s setting of priorities has been different from previous years; this is primarily due to the emergence of the COVID-19 pandemic and deferral of the publication of the quality account by NHSE earlier in the year.

Whilst 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.

Priorities have therefore been set in accordance with those that have emerged during the COVID-19 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.

Having undertaken a retrospective review of performance against quality and safety standards for 2019/20 and following the guiding principles of safety, effectiveness and experience, quality priorities proposed for 2020/21 are as follows: • Priority 1: Improving 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 BAME community with positive action initiatives focused on professional development, career progression and learning from experience.

Quality Account 2019/20 51

Outlined below is a detailed breakdown of areas of focus within each priority, highlighting why these aspects of quality are important and what our primary aims will be:

Priority 1: Infection prevention and control Infection prevention and control – minimising risk and ensuring the safety of our patients and healthcare workers has never been more important following our experiences in the COVID-19 pandemic.

Our healthcare workers need to have a good understanding and working knowledge of the use of personal protective equipment. When it needs to be used; what needs to be used; when to change it and how to decontaminate areas.

It is important that staff are always aware of the COVID-19 status of patients they are caring for. They should communicate this information to colleagues when patients move from one healthcare setting to another. Staff also need to feel comfortable challenging peers and colleagues to minimise risk and protect others.

We should also not to lose sight of other significant organisms, apart from COVID-19, that may pose a threat to our patients if appropriate control measures are not in place.

Maintaining capacity and the operational bed base is important to ensure patients receive the right treatment at the right time.

To ensure all the required actions are embedded across the organisation the following priorities are agreed: 1. Fit testing – We aim to achieve fit testing of 90% of trust staff working in accordance with national standard 2. Hand hygiene – we aim to complete quarterly audits evidencing an improvement in compliance with hand hygiene standards 3. 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.

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. COVID-19 psychological support sessions, staff wellbeing meetings and more recently the People Plan 2020/2021, created opportunities for the following priorities to emerge: - COVID-19 specific support and advice - Staff psychological and emotional wellbeing, in particular stress and anxiety - Physical health needs; change in alcohol consumption, smoking levels, diet habits, exercise, sleep support and spaces for staff to rest and unwind.

52 London North West University Healthcare NHS Trust

In January 2020, LNWH employed a health & wellbeing lead, a new role to the Trust.

Since March 2020, the needs of staff have changed and developed. A COVID-helpline was developed in March and has been running successfully to support staff. COVID-19 PCR testing, antibody testing, asymptomatic testing and risk assessments are continuing to run daily.

Psychological and emotional wellbeing resources such as our ‘EAP’ and the ‘Keeping Well’ service are available for staff, these are promoted via our internal communication channels and on our H&W intranet pages. Business cases have been submitted for specific staff psychological support, based in occupational health.

A H&W MOT for staff is awaiting approval. These individual appointments will screen and signpost staff based on their biopsychosocial needs – ensuring a holistic support is provided.

The MOTs will provide the Trust with data on what additional support our staff really need.

Key priorities for improvement 1. Develop a robust process to determine staff supports required evidencing progress and responsiveness, with quarterly reporting.

2. To 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.

3. 5-8% of staff will have had an MOT by the end of 2021 4. Increase usage of the employee assistance program by 2% to ensure that psychological wellbeing is prioritised.

How will we measure success?

Success will be measured by how many staff use the available support. Staff sickness numbers and staff MOT objective measurements, such as blood pressure values can indicate positive changes.

Priority 3: Positive action – BAME focused actions for improvement 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 2020/2021, we plan to develop an equality diversity and inclusion strategy and 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 services it has worked to strengthen the experience and working lives of BAME employees.

Quality Account 2019/20 53

The Trust has been bold and ambitious in implementing initiatives at pace, changes that will improve the working lives of BAME employees over the next 18 months.

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 • Senior leadership enablement • Establish 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 BAME talent pipeline through the launch of dedicated skills and career development programmes • Launched the associate leadership programme to fuel the BAME leadership talent pipeline and increase BAME representation in senior leadership roles • Strengthened BAME leadership networks and representation in senior roles through a dedicated executive mentoring and executive 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.

Key priorities identified for improvement: 1. We will evidence a 6% increase in the number of BAME staff who believe that the trust provides equal opportunities 2. 1% reduction of BAME staff going through disciplinary process 3. Launch ‘management charter’ outlining good leadership and management behaviour by January 2021 4. Launch executive mentoring and ‘reverse mentoring’ program by from December 2020.

Thank you for taking the time to read the Trust quality account for 2019/20, which provides a fair reflection of our current position at this time. We look forward to working with all stakeholders to ensure that we meet and build upon the priorities outlined to further enhance the experience of our patients, carers and staff.

54 London North West University Healthcare NHS Trust

Annex Statements on the content of the Quality Account from our stakeholders The Trust would like to thank all stakeholders for their comments on the 2019/20 Quality Account. We are pleased that the statements from our stakeholders demonstrate the collaborative commitment we share in improving the quality of services we provide and the outcomes for our patients.

(See next page for statements)

Quality Account 2019/20 55

Mr Chris Bown London North West University Healthcare NHS Trust Northwick Park Hospital Watford Road Harrow HA1 3UJ

15 Marylebone Road London NW1 5JD Tel: 020 3350 4798 www.healthiernorthwestlondon.nhs.uk 7 December 2020

Dear Chris Re: 2019/20 Quality Account for London North West University Healthcare NHS Trust The North West London Collaboration of eight CCGs has welcomed the opportunity to review your Quality Account Report for 2019/20. We confirm that we have reviewed the information contained within the Account and it is compliant with the Quality Account guidance for NHS Trusts as set out by the Department of Health and Social Care and NHS Improvement.

This has been reflected in the Q4 data in your Quality Account and will require new ways of working that we anticipate will be reflected in due course in your 2020/21 Quality Account.

We note that the CCG and other key stakeholders were not considered to contribute to the development of this Quality Account, but do appreciate the extenuating circumstances in which the NHS has been operating this year in the pandemic. We would very much welcome supporting the development of the Quality Account for 2021/22.

We acknowledge the work that the Trust has completed over the previous year arising from the priorities identified in last year’s Quality Account.

In the CCG response to your organisation’s Quality Account for 2018/19 the CCG made reference to a number of themes that we had hoped would be included in the Quality Account for 2019/20. Unfortunately the account for 2019/20 has not picked up on these previously identified themes. As such, we are unable to see if the Trust has sustained improvement in these areas over time.

We were disappointed in the “requires improvement” rating given to the Trust by the Care Quality Commission (CQC) following the initial inspection of June 2018 and the subsequent inspection in November 2019. We noted the significant steps, actions and improvements taken by the organisation in line with your overarching organisational “Way Forward Delivery Programme”. We believe that the Trust is on a trajectory for improvements to be sustained and evidenced for all partners in the health economy. It is recognised however that this improvement journey is currently impacted to some degree by the COVID-19 pandemic. We acknowledge the on-going challenges to implement sustainable change to improve the quality and care provided to our patients and for the Trust to achieve its ambitious goal to be rated outstanding in 2021 by the CQC. In the 2018/19 Quality Account you made reference to the improved performance within Accident and Emergency, which the CCG noted and commended the organisation on. The 2019/20 Quality Account however makes no reference to this important standard and how the Trust has performed. We believe this is a significant gap within the Account and will require inclusion within the 2020/21 Account.

NHS North West London Collaborative of Clinical Commissioning Groups is a collaboration of NHS Brent CCG, NHS Central London CCG, NHS Ealing CCG, NHS Hammersmith & Fulham CCG, NHS Harrow CCG, NHS Hillingdon CCG, NHS Hounslow CCG, and NHS West London CCG.

56 London North West University Healthcare NHS Trust

2 In the 2018/19 Quality Account we made reference to cancer pathways: “We look forward to seeing the impact of quality improvements and how these are reported in the 2019/20 Quality Account.” This Account however does not reflect whether the achievements in 2018/19 have been sustained into 2019/20.

We are disappointed in relation to Pressure Ulcers (PU) that the 2019/20 Quality Account makes minimal reference to ulcers and the system changes that the Trust stated in the previous year they would implement to drive improvement. It is therefore not possible for the CCG to comment on whether changes have driven improvement in this area in the care of patients.

We are pleased to see the improvements in completing the verbal requirements of Duty of Candour (DoC), however the Account makes no mention of the written aspect of DoC and whether improvements have been made across the complete pathway for DoC. We are pleased with the Trust’s performance on the “Saving babies lives care bundle” and the comments from the CQC noting that maternity services are “compassionate and kind”.

We are pleased to note the improvements that the Trust has made in complaint response times preCOVID-19. We hope that the Trust will maintain and further improve against this measure.

It is disappointing that the concerns about child safeguarding assurance, specifically relating to the training of staff in level 3 safeguarding and mental health that were noted in 2018/19, remain an issue for the Trust.

Furthermore the Trust is an outlier in this important key performance indicator and consequently it will be subject to enhanced focus by your Workforce Quality Committee in 2020/21.

We have noted that you have not met the Quality Premium for 2019/20 and we would wish to be assured that you have systems and processes to track how the organisation will meet these in 2020/21.

We are pleased to note that the freedom to speak initiative is taking shape within the organisation and that these are to be embedded and actively encouraged in coming years.

The NWL CCGs support the above quality priorities and the Trust's plan over the coming years to ensure that they sustain improvements in these important areas. We believe that these quality priorities will improve the safety and the quality of care for our patients.

We are looking forward to continued work with the Trust to monitor progress against the set priorities for 2020/21 through the System Oversight Meetings. This will help the NWL CCGs and the system gain assurance regarding the continuous quality improvement of services provided to the North West London population.

Yours sincerely

Diane Jones Chief Nurse and Director of Quality cc: Jo Ohlson, Accountable Officer, NHS NWL CCGs Sheik Auladin, Chief Operating Officer for Brent, Harrow and Hillingdon CCGs Dr M C Patel, Chair Brent CCG NHS North West London Collaborative of Clinical Commissioning Groups is a collaboration of NHS Brent CCG, NHS Central London CCG, NHS Ealing CCG, NHS Hammersmith & Fulham CCG, NHS Harrow CCG, NHS Hillingdon CCG, NHS Hounslow CCG, and NHS West London CCG.

Quality Account 2019/20 57

Chris Brown Chief Executive Officer London North West University Healthcare NHS Trust Trust Offices Northwick Park Hospital Watford Road Harrow, HA1 3UJ 9th December 2020 Comments on Draft Quality Report, 2019 â&#x20AC;&#x201C; 2020 Dear Chris Healthwatch Harrow welcomes the opportunity to comment on the London North West University Healthcare NHS Trust (LNWHT) Quality Accounts 2019/20.

We are pleased to continue our regular engagement with the trust. Our comments reflect feedback gathered by our team from local communities and stakeholders.

It has been a challenging year for all, so it is positive to see from our quarterly intelligence reports that when comparing 2019/20 with 2018/19, we find that whilst there are some concerns around maternity in which satisfaction levels have dropped by 9%. Complaints about administration are down by 50% (26 versus 72) and on telephone access down by 63% (21 versus 56). So, I would like to compliment you on a substantial and sustained improvement, in a key area in which we have previously raised concerns.

In our view, the Quality Accounts capture the spread of priorities that are important for our local communities and patients in a clear way. They are a fair reflection of the equally wide range and quality of services provided by the Trust.

It is clear to see that your work strives to live your HEART values and is about putting the patient at the heart of everything you do. Which is particularly important when adapting quickly to the first wave of the COVID 19 pandemic. As an organisation you adapted quickly, and you proudly recognise how well your staff responded.

Whilst the CQC report identified areas requiring improvement, the evidence of improvement across a wide range of services is clear to see, and particularly encouraging to see that this had fed into your quality priorities and aims for the coming year. We particularly support the priority of improving the staff experience for members of our BAME community, as evidence shows COVID has had the biggest impact on this community.

58 London North West University Healthcare NHS Trust

We look forward to understanding more around the Patient Experience & Involvement Improvement Plan and how the public are able to inform, influence, shape, be involved in and influence plans and services. This engagement is crucial and Healthwatch have a key role to play in this and in working with the trust.

Yours sincerely,

Marie Pate Operations Manager, Healthwatch Harrow/ Enterprise Wellness Ltd Healthwatch Harrow, 3 Jardine House, Harrovian Business Village, Bessborough Road, Harrow, HA1 3EX

Your Voice, Your Harrow - have your say on local health and social care services, click https://www.surveymonkey.co.uk/r/FSDJ8D5

Quality Account 2019/20 59

To Donna Adcock,

In response to London North West University Healthcare NHS Trust Quality Account 2019/20:

The Quality Account is well written and the improvements that this document outlines are very welcome. In particular, Healthwatch Ealingâ&#x20AC;&#x2122;s own findings from our Patient Experience Reports on the quality of staff, their suitability and their overall attitudes coincides with the proactive approach that the Trust has taken to improving these areas, during the period. It is also good to see that the Trust is making a concerted effort to include and involve patients in their treatment progress more, as this was a key concern that we found in our COVID-19 report more communication between patients and providers, particularly outpatients and further support for how individuals who leave the Trustâ&#x20AC;&#x2122;s care should continue to self-manage their condition.

Of course, there are still concerns regarding the efficiency of dealing with patient complaints during this period. However, it is noted that the pandemic may have impacted any significant improvements in this area. Another area of concern is the notion that the board was not sighted on issues around children and young people at Central Middlesex. I trust that this has been addressed.

The overall framework for continuing to improve in 20/21 looks both efficient and viable and given the wealth of research the trust is looking to continue it would be interesting to hear any thoughts on whether Healthwatch Ealing could support any of this work.

With thanks,

Matt Van Mol-Jones, Operations Manager, Healthwatch Ealing

0203 8860 830 | đ&#x;&#x2013;&#x201A;đ&#x;&#x2013;&#x201A; info@healthwatchealing.org.uk | ď&#x192;ž www.healthwatchealing.org.uk 45 St Maryâ&#x20AC;&#x2122;s Road, Ealing, W5 5RG | Healthwatch Ealing is provided by YVHSC | Registered Charity 1154672

60 London North West University Healthcare NHS Trust

Quality Account 2019/20 61

Our Trust covers:

Contact and follow us at:

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Trust HQ London North West University Healthcare NHS Trust Northwick Park Hospital Watford Road Harrow, HA1 3UJ

Ealing Hospital Northwick Park Hospital St. Markâ&#x20AC;&#x2122;s Hospital Community services across Brent, Meadow House Hospice and the Willesden Community Rehabilitation Hospital

T. 020 8864 3232 E. lnwh-tr.trust@nhs.net (general enquiries)

@LNWH_NHS London North West University Healthcare NHS Trust www.lnwh.nhs.uk

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