Written evidence from the Care Quality Commission (NEP 01)

Public Administration and Constitutional Affairs Committee

Follow up to PHSO report ‘Missed Opportunities’ inquiry

CQC purpose and role

1. CQC is the independent quality regulator of health and adult social care in England.  Our purpose is to make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage services to improve. CQC has enforcement powers that mean it can take a range of actions against providers who breach fundamental standards of care as set down in regulations.

2. Throughout our work we:

a)      Protect the rights of vulnerable people, including those restricted under the Mental Health Act.

b)     Listen to and act on your experiences.

c)      Involve the public and people who receive care.

d)     Work with other organisations and public groups.

3. CQC does not have a role in investigating individual complaints or incidents but does encourage service users and families to share their experiences.  We do this through a number of channels, including listening events and workshops, CQC’s ‘Share your Experience’ helpline and talking to families as part of inspections. We often use the information from our activity to inform our monitoring and inspection work.

Introduction

4. We welcome the opportunity to submit evidence to the Public Administration and Constitutional Affairs Committee (PACAC), in support of your oral evidence session regarding the development of strong leadership and systemic learning across trusts. We believe these are vital in preventing fatalities and in driving the highest standards of care and patient safety in health and social care.

5. The publication of the June 2019 Parliamentary and Health Service Ombudsman (PHSO) report Missed opportunities: ‘What lessons can be learned from failings at the North Essex Partnership University NHS Foundation Trust’, identified several missed opportunities relating to the death of two young men at the Linden Centre, an acute inpatient service. It followed previous concerns raised by our inspections about the quality of safeguarding procedures and governance structures at the service managed by North Essex Partnership University NHS Foundation Trust (NEP).

6. Our inspectors and Mental Health Act reviewers inspected NEP several times between 2012 and 2017. Each time we identified issues that they needed to address, including the ongoing risk posed by ligature points which led to us taking enforcement action.

7. Due to ongoing legal proceedings, this submission will not discuss the specific circumstances surrounding the deaths at NEP and the associated provisions of care. Rather we will look systemically at the need for providers to facilitate an open, transparent culture in their organisations, where they demonstrate both an accountable approach and willingness to learning from previous failings involving deaths. Evidence obtained from a catalogue of inspections illustrates the importance of trust leaders embedding change through the creation of an environment, where potentially fatal practices are fully explored, and learning encouraged via sufficient resource and staff training.

8. Our submission will focus on the systemic issues which are at the forefront of securing safer practice. This will draw on evidence obtained from our March 2019 ‘Learning from Deaths’ report[1] and supplementary work within our organisation to encourage leadership on post-death action.

Post-death learning and action

9. In December 2016, we published the report, ‘Learning, candour and accountability’. [2] This detailed our concerns about the way NHS trusts investigate and learn from the deaths of people in their care, and the extent to which families and carers are involved in the investigations process. Following the publication of the report, the Department of Health and Social Care established the Learning from Deaths Programme Board, overseen by the National Quality Board, to implement the report’s recommendations.

10. In March 2017, the National Quality Board issued national guidance for NHS trusts on learning from deaths[3]. The purpose of the national guidance was to initiate a standardised approach on learning from deaths in NHS trusts providing acute, mental health and community health services. It included the following points: developing an effective identification process which flags deaths linked to poor care; the appointment of an executive and non-executive director who are responsible for overseeing post-death action and learning processes; a clear policy on engaging bereaved families; the appropriate level of skills and protected time for staff to learn from deaths; and a quarterly review of data collated by trusts on deaths under their care, with associated learning from these incidents.

11. Following the introduction of the national guidance, we assessed NHS trusts' implementation of national guidance on learning from deaths. This forms part of our new well-led inspections. Our analysis was published in our ‘Learning from deaths’ report. In the report, we noted a broad awareness of the guidance across trusts, characterised by some trusts acting to revise policies and establish oversight of learning from deaths.

12. However, we observed that some trusts found it more difficult than others to adopt the changes set out in the guidance. There was some, albeit limited, evidence to suggest that the guidance is better suited to acute trusts rather than mental health or community services. For example, some healthcare representatives noted that it was difficult for a community-based service or mental health service to find out about a death if it occurs in the community in the first place.

Enablers and barriers to good practice

13. Our evidence indicates aspects of a service which can either aid or inhibit a provider’s ability to secure high patient safety standards. These include:

a)      values and behaviours that encourage engagement with families and carers and support for staff

b)     clear and consistent leadership and governance by a specific person who is at a reasonably high level in a trust’s hierarchy

c)      a positive, open and learning culture that encourages staff to speak up about safety issues and has a focus on improving the care of patients

d)     staff with the resources, training and support to carry out reviews and investigations

e)      positive working relationships with other organisations also providing care for the person who has died, to enable the sharing of information and learning from any investigation.

14. These factors are not new and reinforce the findings of our original report findings in ‘Learning, candour and accountability’. Where we found examples of good practice, trusts were able to build on existing strengths, such as having an open and learning culture, that the national guidance could be integrated within. This also echoes the findings of our thematic review of ‘Opening the door to change’[4], which found that the culture of an organisation could affect how well an organisation was able to implement safety guidance.

Meaningful engagement with families and duty of candour obligations

15. Central to an open and accountable culture is the trust’s ability to engage meaningfully with a patient’s family, particularly following a death, encouraging an honest and compassionate conversation around potential failings and steps being taken to ensure vital learning. This line of communication underpins a trust’s duty of candour obligations and allows it to absorb lessons which are crucial for future safety. To meet the duty of candour, the person representing the provider is required to tell the relevant person face-to-face as soon as possible, give an account of the known facts and offer appropriate support to them. They must also notify us as the regulator.

16. An example of these practices being deployed can be found at Sussex Partnership NHS Foundation Trust. The trust was rated as good overall in January 2018. It was one of the first in England to be involved with Making Families Count, an approach developed by the charity 100Families and NHS England.[5]

17. Through this work, the trust was one of the first in the country to implement a team of dedicated family liaison leads, which was introduced in August 2016. This team led on the investigation of serious incidents and worked with bereaved families during the process of investigating the death of their family members. There were three dedicated family liaison leads, with a further 13 staff trained to provide family liaison services. The family liaison leads were part of the serious incident team and provided root cause analysis training to senior staff who carried out reviews, which were based on a strong ethos of enabling strong engagement with families and carers. This included, as part of serious incident reports, details of family meetings and the views of the family, as well as ensuring that duty of candour requirements had been met.

Ensuring trusts are well-led

18. Our comprehensive inspections of NHS trusts have identified the importance of good leadership and governance in providing high-quality care.[6] This includes having a specific lead, at a senior level in the trust, to drive forward work on post-death learning and action. It requires senior management and board support, ensuring serious incidents are considered a priority and that this is filtered across the organisation. In line with this, trust leaders need to take a long-term view by investing and building the necessary capabilities and capacity to robustly investigate adverse circumstances, such as deaths, and to foster staff members’ understanding of how to improve patient care.

19. Our inspections have identified several examples of best practice in this area. Berkshire Healthcare NHS Foundation Trust was rated as good overall and as outstanding for well-led in October 2018.

20. Inspection staff found that the trust had embedded its work on learning from deaths well. The trust had an executive group for learning from deaths, which was attended by the medical director, director of nursing and governance, lead clinical director, deputy director of nursing for patient safety and quality, and the head of clinical effectiveness and audit. This met on a weekly basis to review all deaths reported in the trust incident reporting system. The medical director was the operational trust lead on learning from deaths. A lead non-executive director provided oversight. The level of investigation for deaths was considered in the weekly Executive Mortality Group, and monthly Mortality Group when the death did not meet the threshold for a serious incident. Where the threshold for reporting of a death as a serious incident on the Strategic Executive Information System (StEIS) was met, this followed the usual trust serious incident processes. This committee also reviewed those deaths not reported as an incident to make sure that they were also investigated if needed.

Our well-led inspection criteria

21. Our inspection framework[7] includes a specific question on whether an organisation providing health and/or social care is well-led. This question is used in the context of post-death learning reviews and the specific lines of enquiry in our assessment framework include:

Well-led 8: are there robust systems and processes for learning, continuous improvement and innovation?

Well-led 8.3: How effective is participation in and learning from internal and external reviews, including those related to mortality or the death of a person using the service? Is learning shared effectively and used to make improvements?

22. As part of our own improvement as an organisation, we recognise the need to further support and train our inspection staff in post-death learning. This includes understanding what good reviews and investigations look like, as well as how to engage sensitively with bereaved families and carers to hear the learning from their experiences of care. We are currently doing an internal review of our well-led inspection criteria and are working with NHS England and NHS Improvement to support work their work for the Interim People Plan.[8] Improving leadership and organisational culture and making the NHS the best place to work is a key focus area in the plan.

23. Our internal review will look at how consistently we are applying the well led framework and what is driving our decision making. We will also evaluate the effectiveness of our tools and guidance on evaluating well-led question and ensuring that our inspection teams have the necessary skills and resources to fully explore leadership across trusts.

24. The NHS National Improvement and Leadership and Development Board (NILDB), representing the collective leadership of the national bodies which govern the NHS in England, has also commissioned an independent evaluation of the implementation and impact of the well-led framework. The review will be conducted by the Alliance Manchester Business School in association with consultancy firm Deloitte. The evaluation sets out to study the effectiveness of the well-led framework, both in terms of the outcomes and also in the ways in which it is applied. We look forward to the findings of this review and will be working with NHS Improvement to make updates to the framework in response to the findings.

Working collaboratively to improve patient safety

25. We are working with partners involved in improving safety including NHSI Safety Team, Healthcare Safety Investigation Branch (HSIB), to co-ordinate our approach to how we assess safety in providers.

26. When assessing providers’ reviews of deaths in their service, we use several tools and guidance documents developed by a range of bodies. We assess whether trusts are meeting NHS England national guidance on Learning from Deaths, that sets out what families and carers should expect.[9] This guidance uses a set of good practice principles that have been developed by the NHS Improvement Safety Team and the HSIB. The method has been piloted in the summer 2017 at three NHS trusts, two acute and a mental health provider, and through public comment through our website and electronic community, with around 100 responses which have helped shape the approach.

27. CQC is continuing to have conversations with national bodies working to improve safety including how we can best collaborate and learn from the increasing numbers of national investigations completed by HSIB, the emerging work of medical examiner for NHS trusts, and the development of the new National Patient Strategy. 

Standardising patient safety standards

28. Importantly, a key finding in our December 2018 publication, Opening the door to change, is the challenge of understanding and digesting the varying patient safety standards and guidance. Arm’s-length bodies, including CQC, royal colleges and professional regulators, have a substantial role to play within patient safety, but the current system is confused and complex, with no clear understanding of how it is organised and who is responsible for what. This can make it difficult for trusts to prioritise what needs to be done and when.

29. To address the above, we have called for NHS Improvement to work in partnership with Health Education England and others to make sure that the entire clinical and non-clinical NHS workforce has a common understanding of patient safety. Patient safety should form part of ongoing mandatory training and be included as part of continuing professional development (CPD) requirements and ongoing development. Leaders should release their staff from their substantive duties to carry out this development, not as an optional extra, but as a vital part of every employee’s role.

September 2019