Agenda item

Members to receive a report providing details of the recent Care Quality Commission (CQC) Well-Led inspection at University Hospitals Leicester (UHL).

Members received a report providing details of the recent Care Quality Commission (CQC) Well-Led inspection at University Hospitals Leicester (UHL).

Becky Cassidy, Director of Corporate and Legal Affairs, UHL introduced the report explaining that the well-led inspection took place in September 2022, the outcomes of that inspection were received in December 2022 with the overall rating reduced to “requires improvement”. UHL believed the report was fair and balanced, and as a board UHL were not expecting to have a well-led inspection at that time. It was notable that there were no actions required as “must do’s” but there were eight “should do’s” which were being followed up internally.

Members considered the report and inspection outcomes which included the following comments:

It was felt this was a disappointing report although it was recognised the leadership at UHL was reasonably new. Members queried if inspectors were to come in now whether they would see any difference to September.

In response it was noted that there were a number of fundamental issues, long term that needed to be addressed, some of that related to culture which needed to strengthen and UHL were able to demonstrate some improvements, however at this point in time there was a need to embed new practices and so inspectors might not see a great deal of difference but that would change over time. The inspection report was fully accepted and there would be full reflection of where the organisation was and noting that UHL was still in financial special measures.

Richard Mitchell, CEO UHL, commented that this was an accurate report at a point in time and not necessarily disappointing. The previous CQC well-led inspection had taken place 31 months before this one, in between that time there was considerable change, and an earlier inspection may have seen more deterioration. In context with other university hospitals, the majority had done worse than “requires improvement”. It was suggested that if inspectors came back today then at a high level, not a lot would have changed, however it was hoped the CQC would come back later in the calendar year and would hopefully see improvement in the well-led rating.

Members commented upon the level of operational leadership and accountability and lack of awareness amongst staff of the Trust strategy and how that aligns to their divisions and work.

Richard Mitchell responded that the report was not indicative of a deterioration in the organisation, an awful lot had occurred over the 3 year period since the last well-led inspection visit, when the inspectors came in there was no strategy and the inspectors were told that, the UHL board had subsequently begun the process of determining the direction of travel for UHL for next 5-10 years, and staff and stakeholders views had been sought about that with over 10k interactions received within 2 weeks.

A key engager was the staff survey, as of this year 48% of the staff had engaged and completed that which was a 15% increase on the previous staff survey completion rate.

Members observed that they had not had sight of any action plan or indication of what the organisation was expected to do and by when and suggested that would be helpful for this inspection.

David Sissling, Chair of Integrated Care Board commented from an Integrated Care Partnership (ICP) perspective that the report was fair, and he did not see it as disappointing and that the Trust was taking the right steps to generate a sensible amount of improvement. David suggested that the leadership was effective, there was a culture which was open as well as open to challenge and there was strong focus on delivery. The focus now on strategy was necessary and the ICP very much welcomed the work put in place.

The Chair thanked Richard for bringing the report and responding to members comments.

The Chair indicated that the commission would like to gain more understanding of the process behind how the “should do” actions issued in the report were being addressed as well as the opportunity to examine the Trust’s refreshed strategy and action plan once that was available.

AGREED:

1.    That the contents of the report be noted,

2.    That further details be provided outside the meeting to enable the commission to gain more understanding of the process behind how the “should do” actions issued in the report were being addressed as well as the opportunity to examine the Trust’s refreshed strategy and action plan once that was available.