Unsafe, poorly led - and getting worse: Inspectors slam county's flagship hospital
PUBLISHED: 06:59 20 June 2018 | UPDATED: 11:07 20 June 2018
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The county's flagship hospital has been branded unsafe and poorly led in an inspection report which found an "obvious deterioration" in how it was run.
Inspectors from the Care Quality Commission (CQC) said not only had the Norfolk and Norwich University Hospital (NNUH) not improved, but things had actually got worse.
Chief inspector of hospitals, Professor Ted Baker, said: “It is extremely disappointing to see a trust that not only hasn’t improved since our last inspection, but where there has been an obvious deterioration in how the services are run.”
He added: “We received a significant number of reports through whistle blowing following our initial inspection and this showed that a bullying culture remained at the trust, and one of fear of reprisal amongst staff if they should raise concerns.”
It is the first time the NNUH, which has been rated as requires improvement for many years, has been rated inadequate and put into special measures.
The report focussed on specific areas, with most problems being found in urgent care and surgery.
A team of inspectors visited the trust between October 10 last year and March 28 this year. They inspected urgent and emergency care, surgery, end of life care, outpatients and diagnostic imaging services.
They found the hospital was inadequate for both safety and being well-led, it required improvement in effectiveness and responsiveness. And it was found to be good in the caring category, which has been put down to the hard-working nature of the staff..
What did inspectors find?
After a number of inspections starting last year, inspectors found a number of issues including:
• In surgery, there were “significant quantities” of out of date items such as bandages and gauze.
• And theatre staff wore rings and did not always cover their theatre wear when leaving the department, presenting infection risks.
• Patients with suspected infections were not isolated properly.
• Patients waiting in corridors, delays in treatment, delays in admitting patients, and a policy of placing patients on trolleys on wards while they waited for beds.
• A “manipulation of the delays” data by admitting patients who were close to breaching the 12-hour target time to get people into hospital.
• The children’s emergency department “was not suitable for the service provided”.
• The emergency department layout was “not fit for purpose” and was not big enough, with other areas of A&E not being used safely.
• Patient records were not always accurate.
• Significant waits of several hours to move patients from ambulances into A&E.
• The day procedure unit was used as an escalation area, where staff could not cope with the severity of some conditions - including end of life care and dementia patients.
• There was also a lack of medical equipment and medication omissions on this ward.
• Security guards in A&E were “intimidating” and acted in a “highly disrespectful way that was not challenged by staff”.
• There was an “abundance of evidence” of staff raising safety concerns with senior management but “the senior leadership had not taken actions to address the significant concerns in the service until [the CQC] raised them and had failed to address a number of concerns that were highlighted during [a] previous inspection in 2015.”
• The CQC report said: “In our previous report, November 2015, we had raised concerns regarding the bed management and site management processes and culture between the operational and clinical teams and reported the trust should make improvements. We found that no significant changes or improvements had been made. The culture between the site management team and nursing team was not one of mutual respect.”
• It added: “There remained a fear amongst staff, at all levels, that raising concerns could not be safely undertaken without fear of reprisals.”
Prof Baker added: “Although staff at the trust were clearly caring and committed to helping patients, and we found some areas of outstanding practice, we were very concerned by how the trust is being led and with many of its systems and processes.
“Our inspection showed there was much work the trust needs to do. This is why it is now rated as inadequate and why I am recommending it is placed in to special measures, so that it can receive the support it needs to improve and ensure people receive the care they should be able to expect.
“We will continue to monitor the trust’s progress and this will include further inspections.”
Mark Davies, NNUH chief executive, wanted to assure patients the hospital was safe, and said he had witnessed that himself last year.
He said: “I don’t want them to be concerned, I don’t want them to be worried about coming to hospital. About a year ago I had a bad accident while travelling in Asia. I got a significant injury which became infected and life-threatening. I was air lifted back to the UK and I wanted to come here not just because I live in Norwich but because I knew I would get world-class treatment here.”
What happens now?
Mr Davies said already a lot of work had been done, including the redesign of A&E, the children’s A&E and the creation of the older people’s A&E.
There were also plans to expand the radiology department and meetings with stakeholders were under way.
But he said he would also now be asking for more money to expand the hospital, which he admitted was too small.
He said: “One of the things I want to ask for is access to capital to expand the hospital. It might have been planned too small.”
He added: “I think there’s enough evidence and I’m getting growing support. The good thing about this is if we’re dealing with 180 ambulances a day we’ve got to be able to cope and we already have run out of space, it’s June and we are full now.”
He said “the idea that some how these patients are not going to come” was wrong and needed to be addressed.
Already a new chief nurse Professor Nancy Fontaine has been appointed as well as John Hennessey as chief finance officer.
But Mr Davies said he did not expect any more change at the top and was remaining at the helm himself.
He said: “I’ve been in the health service for 40 years, I’ve been a chief executive for nearly 30 of those, and when I moved here with my family I did so with my eyes open and I’m in this for the long haul.”
There may also be a chance to access a £500,000 pot of money if improvements are made, but whether or not the NNUH can take advantage of that is decided by an improvement director, who will be parachuted in to oversee the turnaround.
Praise for staff
Mr Davies said he imagined staff would be disappointed with the report, and he was making himself available to discuss it with them.
He said: “I think they will be hugely disappointed which is why I wanted to talk to them and listen to what they want to say.”
He added: “We’re a good hospital with excellent staff.”
Prof Baker added: “I would like to thank all those staff who raised concerns with our inspection team. They have made a major contribution to the recognition of the problems at the trust, which is the essential foundation for any improvement.”
‘Damning’ and ‘catastrophic’
Politicians on all sides of the spectrum have reacted to the result.
Norwich North MP, Conservative Chloe Smith, said the report was “damning” and “catastrophic”. She said: “It’s just not fair on patients and it’s not fair on staff. The leadership has a lack of grip on issues, there are risks and safety concerns they were not even aware of and they are in breach of the law. That means that this report lies at their doorstep.
“The caring rating shows that the hard work of staff but unfortunately it is staff as well as patients who are being let down.”
She added: “There are people who would be opportunistic and make this into a party political matter, but this is more serious than that, the blame for this catastrophic report lies very clearly with the management and it needs to be directed where it belongs. There are mentions of things below the national average, this means other hospitals can manage.
“This is not about anything other than leadership of the trust.”
Labour’s MP for Norwich South, Clive Lewis, added: “Our ambulance service is in trouble, local mental health services have failed twice and we’ve got a Tory county council continually begging their own government for more money for adult social care. And now the N&N has been rated inadequate.
“Make no mistake, we are in the midst of a Norwich NHS and care crisis made in Downing Street.
“The recent announcement of extra funding for the NHS won’t fix our health and care system in Norwich. It’s just a sticking plaster on the wounds caused by eight years of Tory underfunding of health and their savage cuts to social care.”
While Liberal Democrat Norman Lamb, for North Norfolk, said: “Clearly there are serious issues which need to be raised and have to be addressed. But we don’t want people to assume this hospital is not safe or is not in very many respects a good hospital.”
Some outstanding areas
The inspection also found some areas of outstanding practice.
Inspectors found there were impressive pathways for the management of stroke and fractured neck of femur patients. The urgent and emergency service worked with the trust’s specialist teams, even in the ambulance bay, to assess and treat patients quickly and effectively as possible with regard to these conditions.
The cardiology outpatients’ department had a physiotherapy cardiology breathing pattern disorder clinic and, through this, had produced significantly improved the outcomes for patients.
A forum for outpatient staff, established in 2017, provided opportunities for networking and communication across divisions, grades and specialties and, as part of this, staff explored shared issues and set up project groups to resolve those issues. The forum had improved engagement with the executive team, who had attended meetings and taken part in open discussions with staff.
Some outpatient areas were offering innovative treatments. This included the dermatology outpatient area which offered the ‘gold standard’ treatment for basal cell carcinoma (BCC), known as Mohs surgery. This procedure allows for the removal of all cancerous cells for the highest cure rate while sparing healthy tissue and leaving the smallest possible scar.