Care Quality Commission
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CQC investigation identifies serious failings and demands further action to protect patients
CQC yesterday publishes its full investigation report into Barking, Havering and Redbridge University Hospitals NHS Trust (BHRT).
The investigation into quality of care at the King George and Queen’s Hospital sites, which began in early July, identifies serious problems and places requirements on the trust to deliver fundamental and wide-ranging improvements.
Action has already been taken, ahead of the publication of this report, to address CQC’s immediate concerns about maternity services provided by BHRT.
During the course of the investigation, an unannounced inspection of maternity services found that the risk of poor care was unacceptably high. CQC urgently raised these concerns with the Department of Health, NHS London and the trust and demanded immediate improvements.
NHS London responded by putting in place a package of emergency measures, including significantly enhanced professional leadership, a reduction in capacity and an increase in experienced staff leading to an improved skill mix.
CQC inspectors revisited the trust’s maternity services a week later to assess the impact of these emergency measures. They found that as a result of these actions, the service had been made safer in the short term. However, CQC has been very clear that these improvements need to be sustainable in the longer term, and has made strategic recommendations for BHRT and its commissioners to this effect.
The investigation found that despite some signs of improvement in recent months, patients remain at risk of poor care in this trust. While the most immediate concerns were around maternity services, failings were also identified in emergency care and in radiology. Widespread improvement is needed in patient flows, the management of complaints, staff recruitment and governance in order to improve patient experience.
The trust does not have the right systems and processes in place to identify and mitigate risk to patients; it addresses issues on a short term basis, under instruction, rather than proactively looking for longer term solutions to delivering better patient care.
Key findings of the report include:
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Problems identified in maternity services included poor clinical care, a service operating in isolation, verbally abusive and unprofessional behaviour by some staff to patients and to their colleagues, a lack of learning from maternal deaths and incidents, and a lack of leadership from senior management. The attitudes of some midwives continue to cause concern among both patients and staff. The most significant problems were identified at Queen’s Hospital, although elements of poor care were present across both sites.
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A&E services at Queen’s Hospital have struggled to meet the four-hour target for admission. A crisis point was reached last winter when the quality of services suffered. There have been some improvements in 2011 but the trust needs to consolidate these to reduce the risk of poor care occurring again this winter.
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Staff vacancies have been filled by agency, locum or bank staff with an impact on the quality of care. The trust has recently taken positive action to recruit more permanent staff, particularly midwives and nursing staff in the emergency department – but concerns remain regarding the number of medical vacancies.
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Concerns were identified in other clinical areas, including in the day case surgical unit and interventional radiology, with delays having an impact on treatment and care.
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Trust governance systems and corporate governance are weak. Governance systems have recently changed, but lines of communication in the new structure are unclear and there is a risk of issues being missed. Performance information is not used to drive change and there is a lack of learning from serious incidents.
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The trust’s response to complaints is poor, with a high number received each year and frequent issues with timing and quality of response. The level of distress caused by poor complaint handling was, in some cases, reported to be as bad as the poor care experienced in the first place.
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There is past and current evidence of poor leadership from some managers and a culture among some staff of poor attitude and a lack of care for patients, especially in maternity. However, there is recent evidence that this is beginning to change due to the efforts of the new chief executive, the director of nursing and medical director.
There is recent evidence that this is beginning to change due to the efforts of the new Chief Executive, the director of nursing and medical director.
The report makes it clear that the significant changes that are needed, in particular on capacity, are likely to challenge both clinical flows and trust finances. To achieve the necessary improvements, BHRT will need the support of partners in the local health economy, including NHS London and commissioners.
CQC makes a number of recommendations which the trust must fulfil in order to ensure that care delivered across all sites meets the essential standards of quality and safety required by law.
Three of these are strategic recommendations which require longer-term planning from BHRT in conjunction with NHS London and commissioners. These recommendations – which include a reduction in activity at Queen’s Hospital - cannot be delivered by the trust in isolation, and will be followed up via NHS London and commissioners.
A further 16 are ‘key’ recommendations – with the greatest impact on patient care - which the CQC will monitor through unannounced inspections.
CQC will then review evidence at the end of March to determine whether the response from the trust and from NHS London and commissioners is delivering improvements in patient care.
Cynthia Bower, Chief Executive of the CQC, said: “We launched this investigation in order to understand and address what was behind this trust’s history of poor care - and why it was struggling to meet essential standards of quality and safety.
“In maternity, where we had the most acute concerns, we’ve already triggered urgent action by demanding that the trust and NHS London make immediate improvements to protect women. As a result, a package of emergency measures has been put in place to make the service safer. However, these measures are a ‘quick fix’ - what is needed is genuine and sustainable improvement to ensure that women are safe.
“The report also identifies a number of concerns across other services, including emergency care. We have been forcing the trust to address issues on a short term basis - but we have real concerns about safety in the mid-to longer term. This organisation needs to stop relying on others to tell it what’s wrong and put in place the systems and processes that will ensure care is safe – so that no one else is failed or harmed by poor care.
“There have been some recent improvements due to the efforts of the new Chief Executive, the director of nursing and medical director, but there is still a huge task ahead. The trust, NHS London and commissioners must now take responsibility for tackling the significant problems we have identified on a longer term basis.”
When CQC registered BHRT in April 2010, the trust had among the highest number of ‘conditions’ in the NHS. CQC has since made a number of unannounced inspections which have identified concerns and has taken enforcement action in the form of warning notices.
While the trust made some localised improvements, questions emerged about its overall capacity to respond to the extent and level of CQC’s concerns. As a result, CQC took the decision to launch a formal investigation under the Health and Social Care Act 2008in order to better understand deep-seated issues about quality of care at BHRT.
For further information please contact the CQC press office on 0207 448 9401 or out of hours on 07917 232 143.
Notes for editors
About the Care Quality Commission
The Care Quality Commission (CQC) is the independent regulator of health and social care in England. We make sure that care in hospitals, dental practices, ambulances, care homes, in people’s own homes, and elsewhere, meets government standards of quality and safety - the standards anyone should expect whenever or wherever they receive care. We also protect the interests of vulnerable people, including those whose rights are restricted under the Mental Health Act.
We register services if they meet government standards, we make unannounced inspections of services, both on a regular basis and in response to concerns, and we carry out investigations into why care fails to improve. We continually monitor information from our inspections, from information we collect nationally and locally, and from the public, local groups, care workers and whistleblowers. We put the views, experiences, health and wellbeing of people who use services at the centre of our work and we have a range of powers we can use to take action if people are getting poor care.
