Adult Social Care and Health Select Committee Minutes

Tuesday, 16th March, 2021
Microsoft Teams
Please note: all Minutes are subject to approval at the next Meeting

Attendance Details

Cllr Evaline Cunningham (Chair), Cllr Clare Gamble (Vice-Chair), Cllr Jacky Bright, Cllr Kevin Faulks, Cllr Luke Frost, Cllr Lynn Hall, Cllr Paul Weston, Cllr Bill Woodhead MBE
Ann Workman, Emma Champley (A&H); Gareth Aungiers (Xentrall); Nigel Hart, Gary Woods (MD)
In Attendance:
Chris Tulloch, Lesley Wharton, Keith Wheldon (North Tees and Hartlepool NHS Foundation Trust); Mark Graham, Amy Oxley, Fran Toller (South Tees Hospitals NHS Foundation Trust); Peter Smith (Healthwatch Stockton-on-Tees)
Apologies for absence:
Cllr Mohammed Javed
Item Description Decision

AGREED that:

1) the minutes for both the 12th January 2021 and the 9th February 2021 be approved as a correct record and signed by the Chair.

2) further details regarding the queries raised at this meeting in relation to the minutes of previous meetings be provided.
AGREED that:

1) The update on performance and development of the North Tees and Hartlepool NHS Foundation Trust Quality Account be noted, and the requests for further information be submitted by the Trust.

2) A statement of assurance be prepared and submitted to the Trust, with final approval delegated to the Chair and Vice-Chair.
AGREED that:

1) the information provided by South Tees Hospitals NHS Foundation Trust be noted.

2) the requested information around readmissions be provided to the Committee as soon as possible.
AGREED that the minutes of the Health and Wellbeing Board from the meetings in October 2020, November 2020, and December 2020 be noted.
WORK PROGRAMMES 2020-2021 & 2021-2022
AGREED that the Adult Social Care and Health Select Committee Work Programme for 2020-2021 and 2021-2022 be noted.


Councillor Evaline Cunningham declared a personal, non-prejudicial interest in relation to item 5 (Scrutiny Review of Hospital Discharge (Phase 2)) as she was currently a Director of Eastern Ravens.
Consideration was given to the minutes from the Committee meetings held on the 12th January 2021 and the 9th February 2021.

12th January 2021

With reference to item 2 (Scrutiny Review of Hospital Discharge (Phase 2)), Members asked if there were any updates in relation to the comment from Five Lamps that Social Workers sometimes need to be chased following a referral. The Committee was informed that an update would be provided following this meeting.

Under the same item, the issue of personal protective equipment (PPE) was raised, specifically the provision of PPE for carers. It was confirmed that PPE had been made available for carers and that further details around this would again be circulated after the meeting.

9th February 2021

With regards item 2 (Minutes of the meeting held on 17 November 2020 and the meeting held on 15 December 2020), two queries raised following the December 2020 meeting were noted. The first was in relation to who Putting People First Advocacy (a member of the Care Home Protection Group) represented, and it was stated that this organisation involved a paid advocate, not an independent one. The second query was around the use of lateral flow tests in care homes to facilitate visits. A formal response to both elements would be provided following this meeting.

Attention was drawn to item 3 (Overview Report 2021) and the reported data on the COVID-19 vaccination roll-out within care homes. Members asked if there were any updates around the number of care home staff who had now been vaccinated and were informed that up-to-date figures for uptake would be provided after the meeting.

In relation to the same item, a discussion ensued around the Multi-Agency Support to Care Homes during the COVID-19 Pandemic review that was proposed and supported at the last Committee meeting. Although there was a clear appetite to initiate this work as soon as possible, it was re-iterated that any new topic suggestions had to be approved by the full Executive Scrutiny Committee, and that this proposed review would therefore be considered at the next meeting of that Committee on the 23rd March 2021.
Representatives of North Tees and Hartlepool NHS Foundation Trust (NTHFT) were in attendance to provide their annual presentation to the Committee on the Trust’s Quality Account. Led by the Business Intelligence Manager and supported by the Deputy Medical Director / Consultant Orthopaedic Surgeon and Assistant Director of Nursing and Infection Prevention and Control (IPC), highlights and developments in relation to the Trust’s performance over the course of 2020-2021 were outlined as follows:

• Members were reminded of the three key NHS priorities regarding quality, namely Patient Safety, Effectiveness of Care, and Patient Experience. Within these three main categories, NTHFT had several further Quality Account priorities, all of which would be detailed in the final published document. These included:

Patient Safety

• Mortality: Although the measures for both in-hospital mortalities (Hospital Standardised Mortality Ratio (HSMR)) and in-hospital deaths plus those up to 30 days post-acute Trust discharge (Summary level Hospital Mortality Indicator (SHMI)) had increased in comparison to the same period from the previous year, both values were still below the mean UK average. Much of the rise was attributable to the impact of the ongoing COVID-19 pandemic, though NTHFTs performance in relation to these indicators remained strong when mapped against other regional and national Trusts. Assurance was provided that whilst these measures had increased (particularly in recent times), they had not risen to alarming levels, and NTHFT would be keeping a close eye on the rates over the coming months. The hope was that the data would stabilise post-COVID.

• Dementia: Patients admitted with a diagnosis of dementia / delirium had previously been an increasing trend, but 2019-2020 showed a reduction in cases seen by the Trust. Due to COVID-19, an accurate picture was not available for 2020-2021 due to reduced admissions, nor was it likely to be possible for next year either as the impact of the pandemic continues into 2021-2022.

• Infection Control - C diff: Although the current year (2020-2021) was yet to finish, a year-on-year decrease was reported for both Hospital onset healthcare associated (HOHA) (cases that are detected in the hospital two or more days after admission) and Community onset healthcare associated (COHA) (cases that occur in the community, or within two days of admission, when the patient has been an inpatient in the Trust reporting the case in the previous four weeks) Clostridium difficile (C Difficile) measures. Noted that the decrease for COHA should have read ‘-7’ (not ‘-5’).

2019-2020 and 2020-2021 data for other infection type measures was the same, except for E.coli (which had seen a significant decrease (nearly 50%) in cases), and Klebsiella (a 33% reduction).

• COVID Infections and Deaths: Included to demonstrate the number of COVID-positive patients in hospital since the start of 2020-2021, the peak number (216) was experienced on the 11th January 2021 (during the third (current) lockdown). The stated number as of the 2nd March 2021 (55) has now decreased further, reinforcing the downward-trend since the peak in January 2021. NTHFT had experienced 528 deaths associated to patients with a COVID-19 diagnosis since the start of the pandemic (with a peak of 130 deaths during the third (current) lockdown).

Effectiveness of Care

• Violent Incidents: Added this measure following feedback from partners on last year’s Quality Account, and like-for-like data shows a significant rise in incidents between 2019-2020 (237) and the current 2020-2021 (376). However, there has been a change in the reporting process within the Trust for 2020-2021, and these changes have allowed for the increased reporting of cases that were previously not being logged. The large majority of abuse is by patients against staff, with the most prevalent categories being verbal abuse or disruption (132 incidents), disruptive, aggressive behaviour - other (93), and physical abuse, assault or violence - unintentional (70).

Patient Experience

• Friends and Family Test (FFT): NTHFT continues to seek feedback using both text and paper-based survey methods, though COVID-19 has impacted on response-rates. Of the 12,176 responses received for the current year (April 2020 to end-of-February 2021), 92% rated the service as either ‘very good’ (9,465) or ‘good’ (1,742). The content of feedback continues to be of a very useful quality (particularly via the text method) which is then relayed to relevant areas within hospital and used within the Trust’s ward dashboard data.

• Is our care good? (Patient Experience Surveys): Like-for-like data shows significant reductions in the number of complaints between this year (2020-2021) and last (2019-2020) across all three complaint stages. The huge decrease (68%) in stage 2 formal meetings was most likely a result of people not wanting to come into the hospital during the pandemic, and the overall fall in complaints could also be attributable to families being more understanding of the overarching COVID-19 situation during the initial wave in the early part of 2020-2021. However, complaints did increase once the first wave subsided and national lockdown restrictions were lifted in mid-2020.

Regarding complaint types, this was dominated (as usual) by issues around communication. The Trust are continually working on this, though incidents are often in relation to interpretation about how certain information is either being given or received.

Comments and questions from the Committee were recorded as follows:

• Reflecting on the data presented, Members felt that a decrease in the number of infections was to be expected in light of fewer outpatient visits to hospital, though were disappointed to see the number of violent incidents recorded during the current year (even if such an increase was as a result of changes to recording processes).

• The screening of patients for COVID-19 was raised, and it was noted that the Orthopaedics department had been very good at identifying infections for many years and had a long-standing practice of taking swabs.

• With reference to the information available around dementia, it was asked if cases could be broken-down into age-profiles so any emerging patterns (particularly around early-onset dementia) could be identified. NTHFT was happy to follow-up on this request and would also see if such data could be included in their final Quality Account document.

• The Committee noted that one of the aims within last year’s Mental Health priority was the intention to embed integrated mind and body care as common practice (so the Trust treats the whole person). Responding to a request for any updates on this, NTHFT stated that a written reply would be provided following this meeting.

• Another concern raised during last year’s consideration of the Trust’s Quality Account was around the high number of catheter-associated urinary tract infections, something which was not addressed during this year’s presentation. Assurance was given that the Trust undertakes ongoing surveillance of these infection types which is reported on a weekly basis as part of staff ‘huddles’. There has been a reduction in such cases this year, though the reasons for this are unclear. The Trust has tried an alternative cleaning agent prior to the insertion of catheters, so this may have had a positive impact.

• As recorded by the Committee in last year’s statement of assurance, Members reiterated their desire to understand the Trust’s plans for addressing those cancer standards that have not been / are not being met. It was stated that whilst many other NHS Trusts will be experiencing similar challenges in hitting targets (particularly in light of COVID-19), this will continue to be a NTHFT priority moving forward, and further details can be circulated in terms of the current position. In the meantime, the Trust was involved in plans to co-ordinate cancer treatment across the whole of the Tees Valley, and that despite doing less surgery now, future service pressures as a result of the pandemic are inevitable (e.g. there had already been evidence of an increase in individuals presenting with the latter stages of bowel cancer due to this not being picked-up earlier).

• Referencing the complaints data, Members drew attention to the prevalence of complaints in relation to ‘attitude of staff’ (101) and queried if any reasons for this were known (i.e. are there similar themes here or does this cover a multitude of issues). The Committee was informed that the Trust’s Patient Experience Team would be contacted following this meeting as they would be better-placed to provide further details.

The Quality Account timeline for 2020-2021 was noted, and Members were informed that the draft document would be circulated in due course. The deadline for publication of the final document (complete with the Committee’s statement of assurance that would be drafted following receipt of the draft Quality Account document and forwarded to Members for comment) is currently the 30th June 2021, though discussions are ongoing around whether this will be shifted due to the ongoing pandemic.

The NTHFT representatives present were thanked for addressing the Committee and Members looked forward to receiving the draft Quality Account document in the very near future.
The Committee continued its evidence-gathering for the second phase of this review (discharge to an individual’s own home) by considering a presentation from South Tees Hospitals NHS Foundation Trust (STHFT). In attendance was the Trust’s Associate Director of Nursing, the Operations Director and the Director of Communications, and key information was outlined as follows:

• Current discharge policy and significant changes historically and / or due to COVID-19, learning from people’s feedback regarding discharge to their own home.
• Current communications arrangements in relation to hospital discharge within the Trust (between departments), and between the Trust and Stockton-on-Tees Borough Council’s Adult Social Care department.
• Data on the number of the Borough’s residents discharged from the Trust back to their own home, including seasonal variances in terms of discharge pressures.
• Information given to people prior to discharge from hospital.
• Places within hospital where patients are being discharged from.
• Identification of carers when they require hospital treatment, how people they care for are informed / supported in their absence, and communication that takes place with carers when the people they care for go into hospital.
• How assistance with transport back to an individual’s own home is provided, and how services are picking-up any issues when patients are returned to their homes.
• Communications with GPs following a patients’ discharge from hospital back home.
• Considerations around medication as part of the discharge process.
• Other factors impacted by COVID-19 in relation to discharge of an individual back to their own home (inc. COVID Virtual Ward and vaccination programme, and the Trust’s Diagnostic Virtual Ward).

The Committee was assured that the Trust works closely with all local Council Social Care departments in order to facilitate safe and timely discharges from hospital. Members were reminded that the length of stay within hospital can have a significant impact upon an individual (particularly older people), and the five distinct discharge pathways that the Trust follows at all times were noted, as was the use of the Discharge Lounge if a transfer is delayed (though strict criteria for its use is currently in place):

 Pathway 0: Home without support (home from hospital services)
 Pathway 1: Patients’ needs can be safely met at home with support (assessment, recovery and rehabilitation at home)
 Pathway 2: Unable to return home - patient requires further rehabilitation / reablement (assessment and rehabilitation in a community-based bed setting)
 Pathway 3: Unable to return home - patient has very complex care needs and may need continuing care (nursing / residential bed - long-term)
 Pathway 4: End-of-life (supporting people to die in their preferred place of care)

Headed by the Executive Lead for discharge, the Discharge Team that works with hospital wards seven-days-a-week includes staff from community settings, and daily meetings with Social Care staff take place (through the Integrated Single Point of Access (ISPA)) if an individual requires a care package or placement within the Stockton-on-Tees area.

2020-2021 data on admissions and discharges (both involving home as the discharge destination) for the Borough’s residents was broadly similar, suggesting an encouraging flow of patients through the hospital and few issues around delayed transfers. A large majority of patients are discharged back to their own home.

The Trust approach is to discuss plans for discharge with patients and their families / carers at the earliest opportunity, though the timing must be appropriate. Existing care packages need to be taken into account to ensure relevant Social Care staff are involved in this planning. In terms of where patients are transferred from, a high proportion of discharges take place on the same day as admission, mostly from the Emergency Department and Same Day Emergency Care (SDEC) Unit or the Acute Admission Units.

Assurance was given that carers who require treatment are identified through both planned admissions (via pre-assessment discussions) and unplanned admissions (raised with clinician at earliest appropriate opportunity and
Social Care involved as appropriate). In relation to assistance with transport, most patients return home using their personal / relatives’ vehicles, though the Trust does operate its own transport service in addition to that which is available through the North East Ambulance Service (NEAS). The contact number for the relevant hospital ward is provided so discharged patients can get in touch about any subsequent concerns / issues which the Trust can then look to address / support.

Communication with GPs was outlined, with a discharge letter / e-discharge
summary sent to the GP post-discharge containing an overview of what the patient was admitted to hospital for, a summary of their health status, and details of any medication requirements following transfer. Whilst in hospital, ward-based pharmacists provide patients with medication information and medications are arranged for the patient so they have the supplies they need upon discharge. Again, individuals can use the Discharge Lounge to wait for any required medication to be available.

Reflecting on the impact of the ongoing pandemic, the Trust felt that relationships with Social Care partners had been further strengthened since the emergence of COVID-19 (this was backed-up by the Council’s Director of Adults and Health who was also present at this meeting). The introduction of the highly-successful COVID Virtual Ward (welcomed by the Committee as an innovative initiative which many have benefitted from) and the more recently implemented vaccination programme was highlighted, as was the Diagnostic Virtual Ward which helps facilitate the discharge of clinically-stable patients (who require ongoing investigations and diagnostic tests) within inpatient timescales.

The Committee thanked the STHFT representatives for a detailed presentation and raised the following comments / questions:

• The Trust was asked if data on readmissions was available, whether this be back into a hospital setting or to a care home. Information would be sourced and circulated following this meeting, though it was noted that the Trust would not have data, nor be aware of, an individual who was admitted to another hospital or a care home (though may see some of those who are placed into care as it takes time to put together the required care package).

• Concern was raised around the interface between the Trust and its counterparts at North Tees and Hartlepool NHS Foundation Trust (NTHFT) in relation to awareness of readmissions, as well as the flow of information between the Trust and GPs around medication needs. Regarding the latter, assurance was provided that the e-discharge letter (sent to the GP post-discharge) contains all medication-related details including any changes during a patients’ time in hospital and any medications which have been stopped. As for readmissions, the Committee was informed that a full assessment is undertaken for every new admission, regardless of where a patient has / has not been before. At present, the Trust does not have an Electronic Patient Record (EPR) system (but is working towards this).

• Further to the issue of communication with GPs, it was queried whether GPs had to acknowledge receipt of electronic messages (in keeping with the ‘duty of care’ from both NHS Trust and GP perspectives). Members were informed that GPs who have a registered protected address for receiving such documentation do not have to provide confirmation and that it is their responsibility to regularly check for any correspondence. If the GP does not have a registered protected address, the Trust follows-up on any documentation which has been issued. It was also noted that the Trust checks if a patient is registered with a GP upon admission.

• Members questioned if families / carers are included in the conversations between a patient and the Trust’s ward-based pharmacists as they can often know as much, if not more, about their loved ones’ needs. In response, the Trust confirmed that, with the patient’s consent (if they have capacity - this is assessed too, the result of which will determine the level of interaction with relatives), it always tries to engage with the wider family / carers. It was, however, noted that COVID-19 had prohibited face-to-face contact in this regard.

• Communication with young carers who come into a hospital was discussed, and it was asked if Trust staff make a point of speaking to them or gravitate to the older relatives when a family member is admitted for treatment. The Trust confirmed that it would initiate a conversation to establish who provides care to the individual in question, and that if a young carer is involved, staff would look at things holistically and fully engage with all who cared for the admitted patient. Members noted that young carers often report that they can be side-lined and that all organisations need to focus on ensuring they are sought out and included in discussions. The Trust reported that young carers sometimes do not declare their involvement with an admitted patient, but that the Lead Nurse would be receptive to looking at ways of strengthening identification of, and engagement with, such young people.

• Whilst the second phase of this review was focused on the discharge of individuals to their own home, Members requested assurance around the assistance for those people without family support (e.g. those with a diagnosis of dementia who are transferred into care rather than back to their own home). The Trust stated that anyone being admitted to hospital from home will be discharged back to their home unless they need to be placed into a new facility due to their health condition. Support would be provided by a care home if required, and if an individual had nursing needs, Nursing Services within NTHFT would provide input where necessary. Should a discharged patient have any concerns after returning home, they can contact the hospital ward for advice and guidance (e.g. medication requirements).
Consideration was given to the minutes of the Health and Wellbeing Board from the meetings in October 2020, November 2020, and December 2020.
Consideration was given to the Committee’s current Work Programme, as well as an early outline for the 2021-2022 schedule. This was the final meeting of the current municipal year, and the first meeting of the new municipal year, scheduled for the 20th April 2021, would include the final evidence-gathering for the Scrutiny Review of Hospital Discharge (Phase 2) and a progress update on the agreed Action Plan following the Scrutiny Review of Hospital Discharge (Phase 1) (discharge to care homes during the COVID-19 pandemic). Despite ongoing COVID-related pressures, it was also intended for the ‘health’ element of the Overview Report for Adults and Health (deferred from the February 2020 meeting) to be presented at the April 2020 meeting too.
The Chair had nothing further to report.

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