Agenda item

To discuss with representatives from the Betsi Cadwaladr University Health Board the findings of the Health and Social Care Advisory Service’s (HASCAS) investigation (and other associated investigations) into the care and treatment provided on the Tawelfan Ward at Ysbyty Glan Clwyd, including the lessons learnt and the Board’s future plans for safeguarding vulnerable individuals and delivering dementia services.

 

Links to the HASCAS report:

Executive Summary:  http://www.wales.nhs.uk/sitesplus/861/opendoc/324119

Full report:  http://www.wales.nhs.uk/sitesplus/861/opendoc/324118

 

 

 

The Chair welcomed the representatives from the Betsi Cadwaladr University Health Board (BCUHB) to the meeting for the discussion.

 

Members’ were reminded of the findings of the Health and Social Care Advisory Service’s (HASCAS) investigation and other associated investigations into the care and treatment provided at the Tawelfan Ward at Ysbyty Glan Clwyd, links to which had been included on the agenda for the meeting.  A copy of the eight main questions which the Committee had prepared at an earlier meeting had been shared with Health Board officials in advance of the meeting to enable them to provide comprehensive replies to them at the meeting.  Earlier on the day of the meeting the Health Board had provided the Committee with links to a number of reports discussed at Health Board meetings relating to the findings of the reviews, these had been public documents for some time and members would most probably be familiar with their contents.

 

Health Board officials confirmed that they would answer members’ questions as comprehensively as possible during the meeting and also undertook to provide written answers to the questions raised.

 

Prior to answering the Committee’s questions BCUHB representatives provided some background and context to the investigations commissioned with respect of Tawelfan.  They confirmed that the process had been protracted due to the number of investigations being undertaken.  There had been two HASCAS investigations, one overarching investigation and one specifically for affected families.  The latter was continuing.  As part of this review 108 individual patient reports had been prepared and reviewed.  This work included working with families, if family members existed and were willing to work with the reviewers.  If evidence of harm to the patient was found set national procedures were followed to investigate those cases.  If required reviewers had met with family members on a number of occasions as part of the review process.  The reviews were undertaken at a pace that was appropriate to the family and included aspects which the family felt were important to them.  In some cases representatives from the Community Health Council (CHC) and/or advocates of the family’s choice had been present.

 

Officers advised that following publication of HASCAS and Ockenden reports it was important that the Health Board responded appropriately to them.  As part of its response the Board had established two high level boards to move things forward and realise improvements.  These were:

 

·         The Improvement Group (chaired by the Director of Nursing); and

·         The Stakeholder Group

 

both of which were overseen by the Health Board, were examining matters such as improving staff recruitment, improvements to buildings and facilities, and raising dementia awareness amongst staff across the Health Board.

 

Responding to the Committee’s questions Health Board officials:

·         advised that costs associated with the closure of the ward were minimal and the building was maintained as part of the hospital’s own maintenance programme.  The major cost associated with the closure of the Tawelfan ward lay with the expenditure incurred in placing some patients on a temporary basis in appropriate care settings outside of the Health Board’s area.  In addition to being costly such placements were not ideal for the patient or their family;

·         confirmed that discussions were currently underway with the Welsh Government’s Estates Team regarding redesigning the former Tawelfan ward building as part of wider proposals to significantly redesign the Ablett Unit.  These plans, which included the provision of a fit for purpose dementia-friendly building, did not propose to use the Tawelfan Ward for clinicial purposes in future.  More information on these proposals should be available by Christmas 2018, with the redesigned accommodation hopefully being completed within three years;

·         advised that all health authorities were presently exploring the best model for delivering dementia services, which included dementia care nursing services, therapeutic services and enhanced care services.  To date BCUHB had invested in dementia trained staff and currently had over 30 dementia support workers in post

·         confirmed that out of area placements for people with mental health problems did peak during 2016/17, at a cost of approximately £3m to the Health Board.  This was £3m which the Health Board did not have in its budget for this purpose, therefore it caused pressures elsewhere in BCUHB.  They were pleased to report that out of area placements had reduced significantly since 2016/17 and where out of area placements were used every effort was made to repatriate them closer to their family as soon as was practically possible.  Nevertheless, the main driver behind out of area placements was the patient’s best interest first and foremost;

·         advised that significant capital investment had been made by the Health Board at other sites across the region which accommodated patients with dementia and similar medical conditions e.g. the investment made in the Bryn Hesketh Unit at Colwyn Bay Community Hospital in order to bring it up to national recommended staffing standards for these types of wards;

·         confirmed that, in order to meet the growing demand for services, the Health Board had continually increased the amount it spent on adult mental health services in the region.  During the period between 2012/13 and 2016/17 the amount spent on these service in the Health Board area had increased by 22%.  BCUHB consistently spent above the WG recommended ring-fenced amount (the minimum recommended amount) on primary and secondary mental health services in North Wales.  Officials undertook to provide members with the actual figures relating to these statements;

·         acknowledged that the investigations had taken some considerable time from their commencement to their conclusion, and that this had meant that some staff members had been suspended for a number of years.  Every effort had been made by the Board to try and support these staff members throughout the process as the Board had a duty of care towards them as employees i.e. some staff members had been offered opportunities to retrain etc.  The investigation/disciplinary processes relating to the last of these suspensions were now nearing conclusion;

·         confirmed that mortality reviews had been undertaken in relation to patients who had passed away on the ward during the period in question

·         confirmed that the Health Board had a pathway in place to facilitate opening a dialogue with families immediately an individual was diagnosed with dementia.  This pathway was based on The Alzheimer’s Society Guidance and was highlighted at memory clinics as well at throughout all services, in particular acute services;

·         advised that under the care pathway families could, if they wished, appoint an independent advocate to act on the patient and their behalf;

·         acknowledged that an Accident and Emergency Department setting was not an ideal environment to treat a patient with dementia.  The Board was at present attempting to resolve this by ensuring that a doctor who had dementia specialist training was available to be called upon if required to assist in assessing the patient’s medical needs and balance them with their psychological  needs to ensure that appropriate treatment was administered as soon as possible;

·         confirmed that if a dementia patient required to be transferred to an acute hospital ward, based on the patient’s mental capacity and the need on the mental health service ward at the time, a mental health trained nurse would accompany them.  Some dementia patients had one to one care at times.  Every effort was made when transferring a patient to an emergency or acute hospital setting to inform staff of the patient’s dementia/mental health condition with a view to them minimising upset and disruption to the patient;

·         advised that a number of the HASCAS recommendations had been broken down by the Health Board into ‘sub-recommendations’ to enable them to be allocated to very senior Health Board personnel to action and progress improvements within the services for which they were responsible;

·         confirmed that all patient documentation required to be up to date and accurate in order to mitigate against the risk of their care pathway being disrupted.  The aim eventually would to be have all documentation completed and stored electronically;

·         confirmed that at present approximately 40% of community beds were currently occupied by dementia patients.  With a view to supporting these patients the Health Board had recruited more dementia support workers to work within the community hospitals.  Nevertheless, it was acknowledged under the Board’s Dementia Strategy that individuals suffering with dementia were better managed within the environment of their own home wherever possible;

·         advised that the Health Board was currently undertaking some work on improving patient handover, including handing over procedures in relation to patients suffering with dementia.  They were exploring some useful practices used in the aircraft industry and how they could be modified for use in a healthcare setting;

·         confirmed that the Health Board did not use the ‘Liverpool Care Pathway (LCP) for the Dying Patient’ on the Tawelfan Ward.  Whilst acknowledging that there had been both good and bad examples of end of life care at Tawelfan and that staff had tried their best to get things right at the time, in hindsight this had not always worked.  Since then a clinical risk assessment process had been devised to better identify when end of life care was appropriate and how best to deliver that care.  It was also important for all nursing staff, not only mental health/dementia staff, to be trained on how to deliver dignified end of life and palliative care; 

·         advised that with a view to addressing areas of concern across all of the Health Board’s services a ‘central dashboard’ was being developed which would act as an ‘early warning system’ on areas of risk and concern to enable the Board to intervene and support those services at the earliest opportunity; 

·         advised that the ‘Consultant Dementia Nurse’ post had been created to provide input at a strategic level into the dementia care pathway.  The postholder was charged with delivering the Dementia Strategy, supporting nurse specialists, arranging dementia awareness and skills training to staff across the Health Board and strengthening safeguarding practices for patients suffering with dementia.  Acknowledging the workload associated with this post the Health Board was currently in the process of recruiting a second ‘Dementia Consultant Nurse’;

·         undertook to share the Board’s Dementia Strategy with the Committee;

·         confirmed that the Health Board was currently working towards making dementia awareness training mandatory for all staff; 

·         confirmed that the Board was confident that it had sufficient funding to deliver specialist dementia care, the problem currently was being able to recruit sufficient numbers of qualified staff to deliver the care required.  To improve the care provided and ensure continuity for the future the Board needed to be able to recruit permanent specialist staff and be less reliant on expensive locum and agency staff;

·         acknowledged that recruiting and retaining health service staff was a national problem and not confined to the North Wales area.  Highly skilled individuals were attracted to working as locums or working abroad due to the salaries paid.  In addition there were not sufficient numbers of young people entering the higher education system to train in medicine or related professions and those who did train in these disciplines were enticed to remain in the vicinity of their medical school once they qualified.  Hospitals close to long established medical schools rarely encountered recruitment problems.  However, BCUHB’s area had a lot to offer newly qualified medical practitioners and the area’s amenities did attract some health practitioners.  The Health Board was currently working with the both Bangor and Glyndŵr universities in a bid to have more specialist training available in the area;

·         advised that with a view to addressing staff shortages in certain skill areas the Health Board was running an upskilling and development programme.  Training was delivered in a number of different formats e.g. in groups, face to face, e-learning etc., the possibilities of working with partners to deliver some training was also currently being explored.  The Board also sent representatives to job fairs etc. with a view to attracting young people into healthcare careers; 

·         advised that currently some considerable training was being undertaken in relation to the Mental Health Act and the Mental Capacity Act, including the differences between both acts and the requirements of both acts;

·         confirmed that the Health Board was currently funding, supporting and monitoring some dementia patients residing in highly specialist dementia nursing homes.  This practice released hospital beds for patients with medical needs.  However, there was a shortage of highly specialist homes for dementia nursing care in the area;

·         gave assurances that every effort had been made to close the ‘gap between the Board and the ward’ and vice-versa.  Leadership in mental health services had been significantly strengthened.  Weekly ‘Putting Things Right’ meetings were held, any incidents which occurred were discussed at these meetings.  The Director of Mental Health and Learning Disabilities spent a minimum of half a day a week on a mental health ward for the purpose of escalating any concerns drawn to his attention to a higher level.  At the time Tawelfan closed no Director with responsibility for mental health services served on the Board.  This had since changed with the Director of Mental Health and Learning Disabilities reporting to the Board on matters within his services on a weekly basis;

·         advised that the latest staff survey results indicated that Health Service personnel felt that the Board’s interaction with staff had improved significantly within the last four years.  However, the Board would not be complacent in this respect and was aiming for further improvement in this area;

·         advised that with a view to reducing the amount of paperwork involved in healthcare and addressing the perception that senior nurses were in offices completing administrative processes and not on the wards, the Board was currently piloting some technological devices in a bid to release nurses to undertake more operational work.  Latest policies and procedures would be available on these devices and it was therefore anticipated that up to 20% of nurses’ time could be released to undertake more ‘ward’ based work.  A similar pilot undertaken in the Wirral area had proved extremely successful; and

·         advised that the plans for the proposed new ‘North Denbighshire Community Healthcare Facility’, in Rhyl, did not include specialist dementia care beds.  The 28 beds proposed in the plans were for a broader elderly care pathway.  There would be an older people’s mental health care clinic on site along with other clinics and patients would have access to community mental health care services.  The facility itself would be purposely designed to be dementia friendly.  Work was currently underway on the revised business case for the project and on evidencing why the proposed model was fit for purpose. 

 

Prior to the conclusion of the discussion the Committee thanked Health Board representatives for their honesty and candour when answering members’ questions.  Members enquired if the Health Board was satisfied with its working relationship with Denbighshire County Council in relation to health and social care services and the interface between them.  The Board’s Chief Executive Officer confirmed that a good working relationship existed between both organisations, a view which was echoed by the Lead Member for Well-being and Independence and the Head of Community Support Services.  Both organisations wanted to get things done more effectively and efficiently for their patients and service-users in order to improve their well-being and support their families.

 

Committee members acknowledged that no one was in a position to change what had happened in the past, but sincerely hoped that the lessons learnt would safeguard against a similar situation arising in future.

 

The Committee:

 

Agreed: - to note the information provided and thanked Health Board officials for attending the meeting to discuss the issues raised and answering members’ questions.

 

Meeting concluded at 4.15pm