Investigation Findings Howbeck Healthcare undertook the independent investigation within the following scope: To determine whether the allegations made were wholly or in part correct, If Howbeck Healthcare that any of the allegations were founded we would look to determine whether the ‘harm’ was potential, actual, or neither. Review any actions taken as a result of the internal investigation into the original whistleblowing allegation (Previously received in Summer 2017). We reviewed 156 pieces of information and spoke to 43 staff which gave us a good range of information to assess the whistleblowing allegations and also as agreed with the Chief Executive, how SELDOC is doing with the wider associated management and leadership of the organisation. We recognise that 43 staff members is relatively small, but many staff talked about other staff examples and the points we picked up especially from front line staff, were consistent. We also reviewed the 2017 investigation findings, the allegations of were very similar to the 2018 concern. The 2017 investigation did not uphold any of the allegations that were made. There were some improvement actions identified but it was not easy in this investigation to track the positive impact or learning from the 2017 whistleblowing report. As part of this investigation report we felt it was important to include some of the examples that helped reached the conclusions rather than just share the final decision. The main reason for this is that where we have not upheld the allegation, there is clearly an improvement opportunity for SELDOC that the wider information gathered, especially from staff that can inform SELDOCs improvement journey. We have given narrative examples from our analysis of the information and interviews in section 5.1 to provide rationale for our decisions and recommendations. 5.1 Examples of Findings by Allegation Theme
D Governance 1 The CEO should review the governance processes including responsibilities for policies and Standard Operating Procedures (SOPs). Specifically, this should include: How policies and SOPs are created, approved, communicated and reviewed. Replacement of the Whistleblowing Policy using the NHSE guidance for primary care providers. Update all out of date policies using best practice. (Prioritise Grievance Policy). How access policies. Currently some are on a public facing website and some on the V drive. E.g. Whistleblowing Policy is on the public facing website and Grievance is on V drive. They are policies that staff may wish to easily access at the same time. Both are out of date and need updating. Review within 1 month Replace within 1 month (guidance link already sent) Within 2 months Within 1 month 2 The CEO should ensure that the Medical Director is supported to continue the improvement work on Quality and Safety. Specifically, this should include: Continue to develop and extend the coverage of the GP audits. Review and develop the balanced scorecard with the Operations Director. Continue to develop policies and processes that promote the quality of care and safety of patients and Review of capacity in the clinical governance team within 1 Ongoing support Theme No Recommendations Suggested Timescale
E Improved alignment between Medical /Clinical and operational departments 1 A number of the recommendations in all sections require much closer working between the Medical /Clinical Directorate and the Operations Directorate. Specifically, the CEO should ensure that the focus of this closer working should be to ensure that service priorities, workforce rotas and any operational give primacy to the quality and safety of the patient / family and the workforce. The evidence showed that on too many occasions too many patients waited too long for a service response and that SELDOC could have done more to reduce some of the long waits. To how this will be done within one month and then ongoing oversight by the CEO. 2 The CEO and Executive Team should review all policies and communications to ensure that as many as possible include all staff rather than separating clinical and operational staff communications. Within two months 3 All distribution lists should be reviewed to ensure that All staff on them still work for SELDOC That all emails and contacts for staff are correct That if appropriate, the number of distribution lists are reduced. Within 2 months No Recommendations Suggested Timescale F Workforce, Recruitment and Retention (including leadership, support and skill mix) and safe staffing 1 The Director of Operations and Medical Director should review the recruitment and retention of clinical staff. Specifically: Create a recruitment campaign for medical and possibly wider clinical workforce that shows the wide range of services and flexible working opportunities that SELDOC has available. Review pay rates and overall package for Doctors due to changes in role from October and the need to remain competitive with local pay rates, the current proposed 2019 national offer for indemnity may adversely affect SELDOCs overall package. Review use of Advanced Nurse Practitioners and consider recruiting them as part of either employed or self-employed sessional SELDOC staff. (needs robust governance) Consideration should be given to more home working technology especially for periods of escalation. Within 1 month Within 1 month Within 1 Within 1 making
2 The CEO should ensure that there is an improvement action plan for the most recent staff survey in place. If there is already a plan, then ensure that it is reviewed considering this report. Within 1 3 The Medical Director should review the Clinical Training / CPD offer due to poor attendance. Specifically, this could include: Seek views of GPs Review the programme that is offered Review the time of the day / day of the week this is offered especially for GPs who work in the daytime. The location of the training to increase access. Payment for some of the training time. Within 3 months Theme Recommendations Suggested Timescale F Workforce, Recruitment and Retention (including leadership, support and mix) and safe staffing Continued …. 4 4 The Director of Operations should ensure: That all understand how Rotamaster works and how important staff participation in providing availability is to enable the built in fair allocation of work. Contact all non-contracted staff on the rota to confirm if still wish to work for SELDOC and ask for feedback on satisfaction with the amount of work they are allocated. (Noting that many of the workforce will be affected by the 111 integration). Review the criteria and adherence to the criteria for preventing staff doing extra shifts. There is an open and equitable recruitment process in place for all jobs. Within 1 month 5 5 The Director of Operations should: Review the capacity needed overnight especially during periods of high escalation. Review the Business Continuity Plan with a particular focus on managing escalation. Within 1 month Within 2 months
These are a few dates that the provider had been extremely short-staffed. -November 12th, 20th 2017 -December 13th, 22nd, 24th, 25th, 31st 2017 -January 6th, 21st 2018 -February 24th 2018 -March 6th, 9th, 10th and 11th 2018 Please provide: Any incident reports or escalations for the referred to above. Evidence of actual calls and home visits waiting for the dates above. Evidence of the ‘norm’ for the respective days of the week / and bank holidays. Evidence of any escalation and mitigation undertaken on the above dates. Evidence of number of failed calls for the above dates Evidence of what decisions were made for each failed call. 28.05.18 29.05.18 15.6.18 13 - Incidents provided from relevant dates 13 – Word doc explaining spreadsheets etc 13 – Nov 17 April 18 Call Volumes 13 – Contact reports Oct 17- March 13 – Shift SEL Sept - Feb 14 Extract from Whistleblowing Concern 2018): The rotas are routinely filled with names of staff not scheduled to work or names made up by the SELDOC on those days in order for the service to appear well staffed. Please provide evidence and / or names including length of employment to match to rotas. Supplementary Please provide a self-declaration signed by the SEL Rota Manager and signed off by Derek Witt or 17.05.18 28.05.18 21.05.18 12 noon 29.05.18 Not received 29.05.18 No evidence provided. Supplementary question therefore asked. 14 – Self Declaration provided
25 – Response letter zero tolerance policy redacted 25 – Screenshot of re zero tolerance applied 25 – Screenshot to show when incident raised etc 25 – Screenshot to show when SPN added 25 – Screenshot from SPN inc complaint 25 – Email showing weekly bulletin June 2017 26 Documentation in respect of any whistleblowing concerns (with the exception of Summer 2017) from anonymous or named individuals. Supplementary question Have you had staff raise concerns about staff or patient safety, or victimisation via incident forms or verbal escalation to senior team? If yes what, and when, and what action was 17.05.18 28.05.18 21.05.18 12 noon 29.05.18 8.6.18 None 26 – File Note 27 Evidence of action as a result of any other Whistleblowing concerns, and application of the Whistleblowing Policy. 17.05.18 21.05.18 12 noon - None 28 Policy or Standard Operating Procedure for Waking / Sleeping Shifts Supplementary question Is it acceptable and agreed for staff to sleep when on duty? Need a statement to confirm. 17.05.18 28.05.18 21.05.18 12 noon 29.05.18 22.6.18 No policy for this 28 - Statement provided – not acceptable to sleep on duty.
34 – Dr A Telephone Audit Nov 2017 35 Evidence of ‘reprimands’ of staff for referrals to A&E 17.05.18 21.05.18 12 noon 23.5.18 35 – Cover email and letter re patient being sent to A&E (supplied in PDF and word) 35 – and attachment re UHL ED Handbook 35 – SELDOC Weekly Bulletin 35 – re A&E incident and discussion re learning of referrals 35 – email re dissemination of guidelines following incident 35 – email acknowledging incident re appendicitis and agreeing to investigate. For 111 calls, the clinical decision support software is ‘NHS Pathways’ 36 Confirmation and information of any clinical decision support software in place 17.05.18 21.05.18 12 noon 29.05.18 36 - Call Handler Tool kit 37 Evidence of any review of compliance with any algorithms within clinical system or agreed care pathways. 17.05.18 21.05.18 12 noon 29.05.18 37 - SELDOC do not use algorithms – Pathways updated regularly to latest version in 111 38 Organisational structure and governance structure for the period June – July 2017 17.05.18 21.05.18 12 noon 26.5.18 38 – Organisational structure before 1 November 2017 39 Organisational structure and governance structure for the period March – May 2018 Supplementary question Re governance – do you have any board sub committees? Supplementary 3.6.18 The SI policy refers to an “Operations & Strategy Subcommittee” is this in place? 17.05.18 28.05.18 3.6.18 21.05.18 12 noon 29.05.18 4.6.18 26.5.18 29.05.18 8.6.18 39 – Organisational structure after 1 November 2017 39 – File Note re organisational structure 39 – File Note re organisational structure
40 Any specific recommendations or action plan in relation to Whistleblowing concern (summer 2017). (Or confirmation that there is no action plan / further documentation). 17.05.18 21.05.18 12 noon 26.5.18 40 – Whistleblowing concern summer July 2017 response 41 Provide confirmation as to whether the Whistleblowing concern (summer 2017) was shared with the CCG and any evidence to support any discussion / outcome to show whether the CCG was happy with the investigation. Supplementary question Did the CCG give any feedback re the investigation and / or agree with findings? We are seeking to establish CCG role (if any) in this. 17.05.18 28.05.18 21.05.18 12 noon 29.05.18 26.5.18 29.05.18 41 – Whistleblowing concern summer July 2017 response (reference to sharing the findings with the CCG) 41 – from CCG to SELDOC (D Witt) (see also no 48) 42 Removed (reference investigation 2) 43 Copy of Whistleblowing Policy 28.05.18 29.05.18 29.05.18 43 – Whistleblowing / Protected Disclosure Policy (Jan 2015) 44 SELDOC Way Booklet and Training Programme 31.05.18 01.06.18 5.6.18 44 – SELDOC Way (June 16) 45 Grievance Policy 31.05.18 01.06.18 31.05.18 45 – Grievance and Disputes Policy (Jan 15 – expired Aug 17) 46 Access to On-line Induction Programme / System 31.05.18 01.06.18 01.16.18 Access given. 47 Checklist that is given to Agency when requesting: Locum GPs Locum Nurses 31.05.18 01.06.18 31.05.18 5.6.18 5.6.18 47 – Checklist for GP Locums 47 – Duty Doctor Checklist 47 – Duty Doctor SWL 47 – Nurse Checklist (dated 26.4.18) 48 Attachments and recommendations to SELDOC Response / Report in respect of the Whistleblowing Concern – Summer 2017 31.05.18 01.06.18 31.05.18 48 – Attachments 1-19 of SELDOC Response to Whistleblowing Concern – Summer 2017 48 -1 Failed Contact Process May 2017 48 – 2 Weekly Broadcast June 2017
48 – 3 Addition to weekly bulletin 48 – 4 Email and reply to GP re SD tone / style of email 48 – 5 Weekly Broadcast 48 – 6 email response re urgent site visit following summer 2017 concern 48 – 7 Zero Tolerance Policy 15 – April 17) 48 – 8 Redacted zero tolerance letter re repeat prescribing etc 48 – 9 SEL Patient Experience Qtr 4 48 – 10 Blue Bag 48 – 11 Blue Bag Sheet 1 48 – 12 GP Criteria 48 – 13 SEL Performance Report 48 – 14 SWL Performance Report 48 – 15 Balanced Scorecard Update 48 – 16 Repeat Prescribing Policy (July 16 – July 17) 48 – 17 Letter to patient re repeat prescribing 48 – 18 SPN for zero tolerance case 48 – 19 High Risk Medicines Prescribing Policy (July 16 – July 17) Further attachments following queries from CCG (see 48a11 for context) 48a1 – Call Handlers Log 17 48a2 – Call Handlers Log May 17 48a3 – Example GP1 48a4 – Example of quarterly email to GPs re performance data 48a5 – Failed contact process 2014
48a6 – Failed contact process July 2017 48a7 – GP 2 Quarterly Performance 48a8 – GP Audit Criteria May 2017 48a9 – Performance Policy for Duty Doctors (May17-May 19) 48a10 – Redacted email to GP1 re quarterly performance below standard 48a11 – SELDOC Whistleblowing response with CCG questions and SELDOC responses tracked 49 Minutes of the Contract Monitoring Meeting in 2017 where the response to the Whistleblowing Concern – Summer 2017 was discussed. 31.05.18 01.06.18 12.6.18 49 – Contract monitoring minutes Sept 2017 (reference section 4) 50 of Reference for the Quality Committee 31.05.18 01.06.18 31.05.18 50 – Terms of Reference Board and Clinical Governance Committee (2015) 51 Minutes of the last three Contracting Monitoring Meetings (in particular, looking for concerns raised by LMC at meeting re GPs being referred to GMC, and Sarah Donald’s response). 31.05.18 01.06.18 8.6.18 51 – Minutes of Meeting March 2018 (Provided by Jean Young, CCG) Minutes not as clear as conversation with JY suggested re challenge about Doctor performance and RO referrals 52 Balanced Scorecard 31.05.18 01.06.18 01.06.18 52 – Balanced Scorecard (Contains PID) 53 Details of HR Structure / Arrangements 31.05.18 01.06.18 12.6.18 Tel Call with Sandra Ketter 12.6.18 54 GP Performance Policy 31.05.18 01.06.18 12.6.18 54 - Duty Doctor Performance Policy (next review May 2019) 55 Further examples of Weekly Bulletins from Clinical Governance Team 31.05.18 01.06.18 24.6.18 55 – Weekly Bulletin 2.2.18 55 – Weekly Bulletin 27.4.18 55 – Weekly Bulletin (no date) 55 – Newsletter broadcast snapshot