Insight Bulletin - July 2022

Alun Jones announced as the new Chief Executive of Healthcare Inspectorate Wales (HIW)

Alun Jones has been appointed as the new Chief Executive of Healthcare Inspectorate Wales (HIW), the independent inspectorate and regulator of healthcare in Wales.

Alun joined HIW in April 2014 and has been leading the organisation as Interim Chief Executive since April 2020, during one of the most challenging periods for healthcare in recent history. Alun will be supported by Director of Strategy and Engagement, Abubakar Askira and Katherine Williams, Director of Clinical Advice and Quality Governance .

Alun is from Wales and has over 25 years of experience working in audit, inspection and regulation. He has previously worked for the Audit Commission, the Healthcare Commission and the Care Quality Commission (CQC), where he led CQC’s contribution to the Mid Staffs Public Inquiry.

Operational Plan 2022-2023 Published

On 23 June 2022, we launched our Operational Plan 2022-2023. The plan outlines the actions we aim to take to achieve our new priorities, which were set in our Strategic Plan 2022-2025.

This year, we aim to focus on driving and strengthening engagement, improving, and modernising our ways of working and understanding our communities better in relation to equality, diversity and inclusion.

We have set out a varied work programme for the year and we welcome any feedback, so please get in touch if you have any comments on our work or wish to feedback on healthcare services in Wales.

2022-2023 Assurance and Inspection Programme Update

Our work programme for 2022-2023 is now well underway. We work responsively throughout the year, with an ongoing process for analysing known and emerging risks, feeding the outcome of this analysis into our plans. So far this year we have carried out 42 pieces of assurance work – either onsite inspections, or remote quality checks to a variety of settings. Reports into these pieces of work will be available on our website once ready for publication.

Since the start of April 2022, we have we have published 15 reports from our assurance and inspection work to a range of services from laser clinics to inpatient mental health hospitals and emergency departments.

All published reports can be found on our website - Find an inspection report

Want to find out when HIW reports are due to be published? Take a look at our Publication Schedule.

Service Requiring Significant Improvement – Ysbyty Glan Clwyd Emergency Department Betsi Cadwaladr University Health Board

We introduced The Service of Concern Process for the NHS in November 2021 and we use it when we identify significant service failures, or when there is an accumulation of concerns about a service or setting. The intention of the process is to support improvement and learning, both for the service in question, and across NHS services more broadly.

In March, HIW conducted an offsite quality check of the department in Bodelwyddan which discovered a number of areas for improvement, some of which indicated unacceptable levels of risk to patient safety.

HIW asked the health board to take immediate action to protect patients from the risks identified. HIW subsequently conducted an onsite inspection and as a result of a lack of progress, since the quality check was carried out, HIW has designated Ysbyty Glan Clwyd Emergency Department as a Service Requiring Significant Improvement (SRSI).

Chief Executive of HIW, Alun Jones said: 

‘The Service Requiring Significant Improvement designation enables us to plan and deliver future activities necessary to gain assurance about the quality and safety of care in that service. This designation has been made to strengthen and accelerate the action taken to drive timely improvements within the service. We continue to work with the health board to ensure robust improvements are made in a timely manner. We monitor the progress made and will then consider whether the service can be de-escalated and removed from this process.’

We will be publishing a further report this summer setting out the full findings from our onsite inspection.

Following feedback from stakeholders about our inspection reports, we committed to producing a refreshed reporting style for all our inspection work. Many of you told us that our reports were too long and repetitive. Our task was to find the most effective and efficient way to share our findings, so that they are easy to understand.

We’ve made some improvements and have developed a new reporting style for our onsite inspection reports. Our first inspection report in the new and refreshed style will be published in July 2022.

What will change?

Any onsite inspections that took place after 1st April 2022, we will publish an inspection report and a summary report.

A full inspection report is something we already produce, and you will find on our website for onsite inspections. We have updated the look and feel of the report and we have made the reports more streamlined, eliminated any duplication and refined the content.

Summary reports are brand new and are primarily for the public. A summary report is a concise version of a full inspection report. Our summary reports present our findings in a more user friendly and concise manner.

Both reports will be published at the same time to the healthcare settings page on our website. In line with our publication policy, onsite inspection reports are published three months following the last day of inspection. If there is a need to delay the publication, we will communicate this via our publication schedule.

We are always striving to improve the way we share our findings and communicate with you. If you have any feedback please get in touch.

National Review of Patient Flow - Stroke Pathway

Our National review of patient flow is still ongoing. If you work in NHS healthcare services across Wales you may have encountered one of our teams as they have been out onsite undertaking the fieldwork part of this review. Thank you to staff at all sites visited so far for the professionalism shown to HIW teams.

The aim of this review is to assess the impact on patients of any delay in assessment or treatment. We are using the stroke pathway to assess the quality of a patient’s journey. We want to understand what is being done to mitigate any harm to those awaiting care and how the quality and safety of care is being maintained throughout the stroke pathway. You still have time to help shape this work by providing your views.

If you work in stroke care, or in services related to patient discharge from hospital we would love to hear your views. 

If you, a family member or friend have suffered a stroke within the last few years, please complete our short survey.

Local Review of the Quality Governance Arrangements in place within Swansea Bay University Health Board, for the delivery of Healthcare Services to Her Majesty’s Prison Swansea

We have now published our report into the governance by Swansea Bay University Health Board of healthcare services provided at Her Majesty’s Prison Swansea.

HIW explored the experiences of people who access care and treatment, to understand how services help them to manage their mental health conditions and prevent crisis. The review also considered how GPs and other NHS services across Wales provide safe and effective care to help prevent mental health crisis, and what third sector organisations do to support this.

Some of the key findings from the report:

• Inefficiencies in process – HIW’s review found that referral processes can be complex, leading to potentially lengthy waiting times, during which individuals lack sufficient support.
• Committed staff - Those working within healthcare, emergency and third sector services and across Wales are committed and dedicated to providing support and care to people with mental health needs.

Have you ever wondered what it is like to work with us as a peer reviewer? Read on to find out what Melanie Webber-Maybank thinks of her experience working with us.

Career background:

Melanie has worked in NHS for 25 years across major hospitals in South Wales, specialising in trauma and leadership. Melanie left the NHS eight years ago to take up the position as Head of Clinical Services in the independent sector, at which time she joined HIW as peer reviewer. Melanie’s current position is interim hospital director for two hospitals in Cardiff. Melanie is also currently studying for her MBA.

What made you decide to become a peer reviewer?

I made the decision following a recommendation from a senior leader in HIW, as they felt I had the right skillset. I was happy to apply and to allow my skills to benefit other organisations and ultimately improve patient safety. Personally, I really enjoy the inspections as I have met a diverse range of people from the inspection team to patients and the clinical staff on the ground. It allows me to feel that I am contributing to improving healthcare in Wales.

Can you describe to us the work you do as a peer reviewer?

As a peer reviewer we support the HIW inspection team to inspect healthcare establishments across Wales. The role is varied, and you can be allocated to work in any clinical area that is within your skillset and experience. HIW contact you to ask if you are available on certain dates and your availability, there is no pressure to accept if you are not available. I work full-time in my current role so often I have other commitments, but that has never been an issue. There is a meeting before the inspection starts and you are allocated a role as part of the team where you could be inspecting infection prevention, medicines management, or reviewing patients notes, you also speak to patients and staff to record their experiences. There are workbooks to work through during the inspection that guide you regarding standards and areas you need to be observing or reviewing. You see so much good work that goes on and identify areas of improvement that can improve patient experience, safety and working conditions for staff.

How rewarding is the role? And how does this position contribute to HIW’s priorities?

The role is really rewarding as you are working with professional teams who support you as a peer reviewer during the inspection process. You also feel you are contributing to keeping patients and staff safe. You contribute towards HIW priorities as you inspect against the recommended framework and standards for patient care. HIW also asks for feedback on the inspection process, so as a peer reviewer you can also help shape the future of inspections.

What do you enjoy the most about the role?

Speaking to the staff and patients about their experience is the most enjoyable part. As the staff work so hard often in challenging environments, the inspection process can really help support them in the future. Also, the patients are often very complimentary about their care, but if there are issues identified they are often able to be addressed and improved.

What skills or characteristics would you say best suit the role?

You need to be able to work as part of a team, have a flexible approach and be able to organise yourself within the areas you are inspecting. Good communication and a friendly open approach is helpful, so that patients and staff feel confident and comfortable to speak to you about their experiences.

What are some of the challenges you face as a peer reviewer?

The challenges can be addressing areas for improvement, as that can be difficult when staff are under pressure. In general, I do not find there are many challenges as a peer reviewer, as you are supported by HIW inspection team, and I have always been welcomed by the staff in the areas I am inspecting.

What advice would you give to someone considering this role?

I would advise anyone who is able to dedicate time to the role to apply, as it is so rewarding and offers fantastic experience.

If you could sum up the role in three words, what would they be?

Rewarding, enjoyable, responsible

Medicines Management

Over the past five years HIW has repeatedly reported a variety of issues with medicines management in our individual inspection reports and annual reports. Whilst a variety of issues were reported, a number of key themes have emerged through a retrospective review by our clinical team. We feel that it is important that we highlight these common themes and also areas of good practice we have identified. We hope this helpful for you and your staff in thinking about how we can all contribute to making medicines management safer and more effective.

The areas of concern we have found during our review were:

• Safe storage and checking of medicines
• Omissions and documentation relating to omissions
• Oxygen prescription
• Allergy recording
• Time critical medicines

1. Safe storage and checking of medicines

In a number of reports it was highlighted that medicines were consistently not stored securely and at the right temperature. Areas of concern included:

• Medicines being left in areas where members of the public or patients could access them
• Intravenous fluids being stored in unsecure cupboards
• Medicines requiring refrigeration not being refrigerated
• Medicines being left at a patients bedside unsecured

Some areas of good practice we noted which you may want to adopt included:

• Swipe access to all medication preparation and intravenous fluids storage areas. This ensured that if medicines were left out they were still secure from unauthorised access. It also meant staff could access these areas easily without the need for a key.
• Regular spot check audits to assess medicine security and storage on an ongoing basis.
• Policy and reminders in place to ensure staff watched patients take their medicines before leaving their bedsides.

2. Omissions and documentation relating to omissions

Omissions of medicines were also noted in a large number of inspection reports. This included the reasons for omissions not being recorded and left blank and patients not receiving medicines they required.

Some areas of good practice we noted which you may want to adopt included:

• Regular prescription chart audits and checks to highlight any issues and work with staff to resolve them.
• Reporting of any omissions on handovers and safety briefings, to ensure that they are rectified as soon as possible.
• Incident reporting any omissions.
• Training from pharmacy staff or pharmacies to help staff understand how to avoid omissions and ensure alternative routes are available if needed.

3. Oxygen prescription

The prescribing of oxygen remains a concern for HIW in acute health care settings. Although the NHS has adopted a prescribing protocol which is printed on prescription charts, we found this was often not filled in. In many cases patients were receiving oxygen therapy without this being prescribed on their prescription chart.

Some areas of good practice we noted which you may want to adopt included:

• Oxygen prescription added to safety briefings and handovers to remind staff of importance of this issue.

4. Allergy recording

Allergy information was blank in a number of records. This could be a risk to a patient if they do have allergies which have not been recorded.

5. Time critical medicines

In a number of inspections it was noted that patients did not always receive their time critical medicines on time. This included medicines such as insulin and medicines for Parkinson’s disease. It is important these medicines are given on time to ensure patients do not suffer any unwanted side effects as a result of delays.

Some areas of good practice we noted which you may want to adopt included:

• Flagging system for patients taking time critical medicines. Such as symbols on their prescription charts or by their bedside.
• Allocated ‘time critical nurse’ in ward settings. This nurse would ensure that all patients on time critical medicines received them on time by prompting the nurse looking after them or assisting by administering themselves.
• Alarm clocks situated by patients which were set to go off at the time the medicine was required.

We carry out surveys when we want your views on particular topics.

We have a range of staff and patient surveys now open and we welcome your views on any of the topics.

All open surveys can now be found on our surveys page on our website.