Agenda item

Care Quality Commission (CQC) Inspection Report and Recovery Support Programme

To consider a report by the University Hospitals of Morecambe Bay NHS Foundation Trust (copy enclosed).



The Committee received a report that provided the outcome of the CQC inspection that took place in April 2021 and a subsequent unannounced inspection in August 2021 to medical services at Royal Lancaster Infirmary. The outcome of the inspection was that the Trust remained at a rating of requires improvement. The paper described the must and should do’s the Trust was required to undertake.  The importance of system wide working with partners on such issues as discharge pathways and information sharing on discharge, ED pathways and direct referrals/direct access was recognised.  The paper also described the NHS England/Improvement (NHSEI) Recovery Support Programme (RSP) that had been established to ensure the delivery of sustainable quality improvements across the Trust.


The Chief Executive, introduced the report by thanking system partners for their hard work and commitment, working in a very pressurised environment, over the last 18 months.  The Chief Executive introduced the Interim Chief Nurse who outlined the key findings from the CQC Inspection Report.  Members were informed that there were a total of 90 recommendations, 57 Must Dos and 33 Should Dos.  It had been recognised that a number of the recommendations were duplicated and had therefore been incorporated into one recommendation for the purpose of the Improvement Plan.  The Interim Chief Nurse informed the Committee of the Section 31 Notice issued to the Trust, the license for Stroke Services and a Notice of Proposal to impose conditions for regulated activities in relation to Maternity and Midwifery Services on all three sites.


Members were informed that since the receipt of the CQC Inspection Report, the Compliance and Assurance Team had worked with partners to develop the Improvement Plan.  The Plan had been submitted to the CQC on 1 October 2021.  The Trust representatives outlined action that had and was being taken to address the recommendations.  Members noted that all the recommendations had been assigned to a responsible Executive Director and Assurance Committee and progress of them would be reported to the relevant Committee and then onto the Trust Board on a monthly basis.  The need for sustainability was reiterated throughout the report.


The Intensive Support Director outlined the National Policy Context – System Oversight Framework (SOF) and Recovery Support Programme (RSP).  Organisations in SOF 4 would be provided with a new Recovery Support Programme (RSP) which also required local system partners to play a key role in addressing system related challenges and develop supporting system solutions to the challenge(s). The NHSEI North West Region established the Morecambe Bay System Improvement Board in April 2021.  The Intensive Support Director outlined the development of the exit criteria from the RSP and the recovery support proposal.  The themes from the recommendations overlapped with themes identified as areas of focus in the Trust’s Forward Improvement Plan and were included in the Recovery Support Programme. 


To conclude the report, the Chief Executive, endorsed the new approach and expressed confidence in the sustainability of the changes in the long term.


Members, in discussion, requested sight of the monthly RAG rated action plan and the Chief Executive agreed to provide this.  The Chief Executive gave an update on the work that was taking place in Stroke Services.   In answer to members’ questions, the Trust’s representatives outlined the Trust’s financial position, the commitment of the Executive Board and the changes that were taking place to the membership of that Board.   Members were assured of the Board’s engagement in the process and were informed of the significant changes that were taking place in their reporting processes.  It was noted that the Board was reintroducing visibility at ground level following the lifting of restrictions.


Recruitment and retention of staff was discussed and the Trust’s staff vacancy and sickness levels.  Members noted that the overall turnover of staff was currently at 9% and sickness levels were between 8 and 9% compared to a normal level of 4.5%.  The impact of the high sickness level, the ability to cope and the measures to address these were discussed.  Following a question on staff morale and motivation, the Trust representatives confirmed staff commitment to improvement and change.


Members questioned the impact on patient treatment and ‘No Right to Reside’ formerly referred to as ‘delayed transfers of care’ (DTOC).  The Interim Chief Nurse reported that surgical operations had been impacted and highlighted the difficulties faced by the hospitals currently running at 98/100% occupancy.  Partnership work was taking place to address the ‘No right to reside’ figures ensuring the right package of care was in place and patient safety remained the key priority.  The impact of changes needed in social care were recognised and a member asked what could be done at a local and national level to assist this.  The Trust representatives confirmed the mechanics of the process were correct at a local level, but more placements were needed, and more consistency would be desirable at national level.


The Director of Communications outlined a range of engagement events taking place for Executive Teams of Local Councils, local MPs and interested parties.


To conclude members requested an update report.  It was therefore:-




(1)  the Trust’s Action Plan be circulated to the Committee on a monthly basis;


(2)  a further meeting be arranged to receive an update report on the CQC Action Plan and the outcome of the Community Beds Consultation.



Supporting documents: