Adult Services and Health Select Committee Minutes

Tuesday, 12th July, 2016
Jim Cooke Conference Suite, Stockton Central Library
Please note: all Minutes are subject to approval at the next Meeting

Attendance Details

Cllr Mohammed Javed(Chairman), Cllr Lisa Grainge(Vice-Chairman), Cllr Evaline Cunningham, Cllr Kevin Faulks, Cllr Lynn Hall, Cllr Stefan Houghton, Cllr Allan Mitchell,
Liz Hanley, Liz Boal, Natalie Shaw, George Irving(AH), Rachel Down(TEWV), Katie Tucker(CQC), Peter Mennear, Sarah Whaley (DCE),
In Attendance:
Natasha Judge, Jane Hore (Healthwatch)
Apologies for absence:
Cllr Sonia Bailey, Cllr Mrs Sylvia Walmsley
Item Description Decision
1. A letter be sent from the Committee regarding the issues around discharges.
2. the information be noted.
1. The pages 2 results be noted.
2. The on-going utilisation of the QSF as the vehicle through which the Council determines the quality of service provision against the market shaping duty under the Care Act 2014, and as a means of progressing constructive dialogue with the Care Quality Commission (CQC) toward delivering better regulation and outcomes for vulnerable people be approved.
3. The revised 2015/16 QSF inspection programme be noted.
AGREED that the information be noted.
AGREED that the information be noted.
AGREED that the update be noted.


Cllr Allan Mitchell declared a personal non prejudicial interest as he was a registered patient at Thornaby and Barwick Medical Group.
The Committee considered the recently published reports by Healthwatch.

Local Healthwatch was able to undertake Enter and View visits of health and social care services to support their role. This enabled Healthwatch to view how services were being run and gather views from staff, patients/users and carers.

It had previously been agreed by the Committee to consider completed Enter and View reports as and when they were produced.

Healthwatch Stockton-on-Tees had recently undertaken a visit to Thornaby and Barwick Medical Group (TBMG) and the report and comments from Practice were provided. The main information provided could be summarised as follows:-
- Substantial intelligence had been received that there was long waiting time and unable to get an appointment for around 2-3weeks.
- There had been a large growth in patients between 2006 and 2016.
- When trying to make an appointment it was difficult to get through on the phone.
- Recommendations had been made to trial a triage system, promote better use of booking appointments online, opening late some evenings and possible weekends. There was only one phone line therefore making is difficult for those wanting to cancel appointments.
- A response had been received from the Practice to say that the practice manager was leaving and a new manager would be in post soon. Healthwatch were going to attend again in 3 months to see if the recommendations had been addressed.

Members were then given opportunity to make comments/ask questions that could be summarised as follows:-
- Unreasonable for schools requesting children be seen by a doctor before returning. The accuracy of this situation was going to be checked by Healthwatch on a follow up visit.
- Biggest thing highlighted was the issues was the phone system and hopefully with the recommendations in place improvements would be made.
- Issues regarding difficulty in registering at the Practice had not featured in Healthwatch’s work but they would check this on the revisit. It was requested that checks be done on the follow up to see if information was on notice board regarding registering at the practice.

Healthwatch were also able to carry out other reviews into services, and recently completed a report into discharge delays at North Tees and the report was provided. The main information provided could be summarised as follows:-
- A previous piece of work was done in 2014 and the delay in discharge was due to transport. During this visit the main issue delaying discharge was due to medication and discharge letters.
- Patients were very pleased with the staff and how helpful they were.
- Staff had made suggestions for prescriptions to be written the night before if there were no expected changes.
- The discharge lounge had unsuitable seats and there was no television. It was also noted that there was not a toilet in the discharge room for patients although one was available in another area.

- Healthwatch had made some recommendations to address some of the above issues.
- Healthwatch had been invited back to look at some of the changes made to improve the situation though a follow up would still be made.

Members were then given opportunity to make comments/ask questions that could be summarised as follows:-
- Healthwatch identified that staff sometimes leave the Lounge to collect prescriptions. This raised concerns that staffing levels were not always maintained and that staff levels may be lower than advisable potentially posing a risk to patients. Recommendations state that staff should not go to collect the prescriptions but Members felt that the Trust in its reply had not fully addressed these concerns.
- It was clear staff were rushing around at the end of the day before the pharmacy closed to try and ensure patients could be discharged. This could leave the discharge room under staffed and created problems. Healthwatch would work further with the Hospital to try and address these problems.
- Members raised concerns over the waiting time for the discharge for vulnerable older people and including those that had confusion.

-Members were pleased to see the use of volunteer drivers and would encourage them to be utilised wherever possible.

It was agreed that a letter be sent from the Committee echoing their concerns regarding the discharge issues and everything possible be done to improve the situation, but to also commend staff who worked over to accompany patients waiting to be discharged, and encourage further use of volunteer drivers.
Members considered a report that summarised and provided the final report on Phase 2 of the Council’s Quality Standards Framework (QSF) for Older Peoples care homes without nursing. The report identified the performance of specific homes and reviews general findings and good practice.

The QSF provided a framework for consistently assessing and evaluating the quality, efficiency and overall performance of the providers the Council contract with.

The QSF provided an in-depth evaluation of the regulated services that the Council commissions and included reviews of the following areas:
Leadership & Management
Staff Competence
Residents Finances
Care Planning
Service Users experience of their Care & Support
Medication management
Quality of the environment

The activity gave the Council further assurance that the statutory Care Act 2014 duties to shape the market for care and deliver relevant quality services were proactively driven forward.

Members were provided with details of the phase 2 outcomes. There were 17 care homes involved, 4 homes declined to participate, QSF was voluntary although it was hoping that it would become compulsory in the future. Details of the concerns that the officers had were provided and action plans were in place to address these.

Members were given opportunity to ask questions/make comments that could be summarised as follows:-
- There was some discrepancy between what the Council rated homes as in their QSF inspection against the CQC inspection rating. It was explained that although the time between the inspections may be short, changes could have happened within the home and it a very fluid situation, particularly with regard to management. It was also noted there were two different but complementary frameworks; one focussed on care standards and one focussed on the commissioning specification. It was also important to note that CQC inspection rating stayed online until they were re-inspected, whereas the Council would take action as soon as concerns were identified.

- How long does a care home get to improve their situation if they were requiring improvement or inadequate. The representative from the CQC outlined the process in such cases. Management Team meetings would determine the course of action in such cases, and it was explained that varying levels of action could be taken including stopping admissions. There was a validation stage for report, and providers would usually be given the opportunity to make representations should they disagree with a report before it was published, ultimately to a tribunal. This process took time and could give the impression that no action was being taken between the inspection and the publication of the final report. The CQC was working with the Government to see if reports could be made public more quickly.

- Members requested that if possible a way be found to show a trend for each care home to inform the Committee better of how that homes has performed over a period of time. It was explained that a different way of reporting was being looked at as key issues change over time and this affected comparability. This may include some core standards that should not change, and more variable indicators that address particular issues at points in time.

- Members queried the reasons why some homes did not take part. It was noted that although the Council aimed to co-produce the QSF, some home still felt it was an administrative burden. The Council still undertook quality checks for those homes.

Members were informed that as well as the QSF reports, commissioned services were constantly monitored against a dashboard of key indicators.
The Committee received information on how DoLS were applied from TEWV and CQC.

The main information provided from TEWV was:-
-Workload around DoLS hasn't impacted on the workload of TEWV but what they had seen being a mental health trust was an increase in the Mental Health Act assessments.
- Within the trust there has been 60 -70 DoLS assessments mainly in community and respite settings.
- Occasionally DoLS may apply in inpatient settings, and this was if a patient was awaiting discharge and DoLS had been used instead of the Mental Health Act to arrange the treatment.
- The staff had been kept up to date with relevant information and training. Staff used the national referral form.
- There hadn't been any significant issues with the DoLS apart from ensuring staff applied the acid test appropriately.
- TEWV were focussing on the way they demonstrate compliance with DoLS and Mental Capacity Act and how they capture evidence that staff were doing what they should be.
- TEWV were members of the regionalDoLS Implementation Network Group.

Information from the DoLS Manager included:

- The Council currently had a backlog of around 140 applications but a Managed Approach was being taken to reducing this on a risk assessed basis.
- TEWV agreed that Stockton Council appeared to have proper procedures in place to manage the process. DoLS were also included in the QSF framework.
- Stockton Council provided quarterly information sessions for providers to attend

The main information provided by CQC could be summarised as follows:-
- CQC had a legal function for monitoring the application of the Mental Capacity Act and Mental Health Act. It was quite right that you won't see many DoLS in place in mental health inpatient care as primarily patients would be treated under the Mental Health Act.
- It was also noted that Care Homes needed to be up to date of the regulations and also apply the acid test to ensure assessments are only made when necessary. CQC also had regulations to ensure this was being done properly.
- The CQC recognised the backlog in client assessments and this was a national issue. The key issue it looked at was whether care home and health staff were monitoring such cases effectively.
- The CQC wanted to make sure they people were aware of the right to challenge DoLS decisions, and that legal aid was available for this.
- It also checked whether any conditions attached to a DoLS were being implemented correctly, and that clients were being reviewed as required.
-Enforcement action could be taken if there was a failure to check client capacity and compliance, and a failure to apply DoLS correctly.

Members were then given opportunity to ask questions/make comments that could be summarised as follow:-
- How has the backlog progressed? After the court judgement in 2014 there was over 900 waiting and now it around 140, it hadn't progressed as fast as wanted but there wasn't the resource to carry out the assessments as well as section 12 doctors, while there was this number the team were still receiving urgent assessment and urgent changes to those that already had a DoLS. It was hoped to have the backlog processed by December 2016.
- When someone was coming to the end of the maximum 12 month how was the process triggered again? It was explained that it was the duty of the managing authority. The managing authority would need to submit a form 3 to 4 weeks before the current DoLS expired. It was noted them hospital Trust had developed a database for this purpose and would advise care homes of how they could use one. Larger care homes have sometimes struggled to keep track of the necessary requirements.
- Managing Authorities would normally initiate the process, but social workers and family members could also apply for a DoLS authorisation. The CQC could also insist that an application be made if it picks up issues during an inspection.
The Committee received an update from the CQC on its strategy for 2016-2021. The information provided included:-
- CQC role, values and statutory objectives
- New models of care
- Registrations
- Plans for hospitals
- Plans for primary medical services
- Plans for Adult Social Care
- Enforcement

The new strategy aimed to ensure regulation kept pace with market innovation and addressed the reduced funding to CQC.

There would be a more targeted and responsive approach, and the volume of inspectors may change for future inspections. There would be an increased use of intelligence and the CQC was developing a central intelligence source for adult social care, as there was a gap at national level, unlike for the NHS. This would be more detailed and include things such as Coroners ‘reports.

CQC was still seeing variations in care. Theme work would continue, and for inspections of providers, the CQC would expect to see evidence of continuous improvement. There would be a continued focus on rights and equalities.

Registration to become a provider would be more stringent. At least one director per organisation would need to demonstrate an understanding of the sector. The CQC would also take on the responsibilities of the HSE in relation to incidents that occur on provider premises. There had been the first prosecution in relation to this recently.

The Tees Valley Team had completed all but one of its inspections for the current year.

Member were then given opportunity to ask questions/make comments that could be summarised as follows:-
- Do CQC give notification when going into care settings? Not in relation to care homes, and it is a range of times and days.
- Those requiring improvements in hospitals could be visited anytime with progress quite quickly? Yes the special measures process for hospitals is different to social care in that hospitals could have the Boards removed and a new system put in.
- Communication with the local authority after inspections of adult care? It was noted that any safeguarding concerns would be raised immediately. The report would be compiled and all evidence considered, if people were not unsafe, the provider would be given the chance to respond, and if any warning notices or actions were to be taken these would be shared with the Local Authority.
Members considered an update on the work of the Tees Valley and Regional Joint Health Scrutiny Committee.

Middlesbrough Council chair and support the Joint Committee during 2016-17. Dates for the meetings had been set as follows:

- 28 July
- 21 October
- 26 January 2017
- 27 April

Papers relating to the above would be circulated to the Committee for each time for information.

Hartlepool BC was currently supporting the North East Regional Health Scrutiny Committee. The Committee met on 2 June to discuss Neonatal Intensive Care Transport, the national Congenital Heart Disease review, and the Vascular Surgery Review. a copy of the presentation was provided.
The minutes of the Health and Wellbeing Board were noted.
The Committee noted it work programme.

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