Norfolk and Norwich Hospital plunged into special measures
- Credit: NNUH
Norfolk's busiest hospital has been plunged into special measures just months after a challenging winter for the health service.
The Care Quality Commission (CQC) praised staff, but raised concerns about the leadership, along with the hospital's systems and processes.
The CQC also had concerns about the response to whistleblowers, saying a 'bullying culture' remained at the trust, with staff fearing reprisals if they raised concerns.
As a result the trust is now rated as inadequate overall and inadequate for whether its services are well-led.
The trust is also rated as inadequate for whether its services are safe, requires improvement for whether its services are effective and responsive and good for whether its services are caring.
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And inspectors were particularly disappointed that the way the hospital was being run had got worse following its last inspection in April last year, when the trust was rated as requiring improvement overall.
Professor Ted Baker, chief inspector of hospitals, 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.
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'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.
'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.
'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.
'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.'
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.
Norwich South MP, Labour's Clive Lewis said: '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.
'Under the Tories there has been a staggering 234pc rise in patients waiting longer than four hours in A&E and half a million patients are now waiting over 18 weeks for hospital treatment. There are 1,000 fewer family doctors than in 2015 and cancelled operations are at their highest level ever.
'Age Concern says around 400,000 elderly people have lost the chance of free help to live at home since 2011 and under the Tories, £6.3bn has been lost from social care funding since 2010. The Health Foundation calculate the social care funding black hole in 2019-20 will be £2.5bn.
'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 Conservative Norwich North MP Chloe Smith said: 'This is extremely concerning and it;s really important to patients that the hospital is able to service our communities as we all expect. I will want to support the hospital and in particular its really hard-working staff and I'm glad this week we have also seen the prime minister bringing forward a long term funding plan. I hope this will help the hospital.'
The county's other hospitals, the James Paget University Hospital (JPUH) and the Queen Elizabeth Hospital (QEH) are rated as good and requires improvement respectively.
Mark Davies, Chief Executive, Norfolk and Norwich University Hospitals NHS Foundation Trust said:
'We thank the CQC for their report and have accepted its findings. Lack of capacity and sustained high levels of demand over winter put our services under extreme pressure and I would like to apologise to our patients that we were not always able to provide the level of service that we would have wanted.
'The NHS has been through one of the longest, toughest winters on record and I would like to thank staff across all professions and support services at the Trust for everything they have done, and continue to do, for our patients and colleagues. The CQC team also recognised the consistently caring approach by our staff.
'In the nine months or so since the start of the inspection process we have continued to work on many improvements, which, in line with CQC recommendations, have included the significant increase in the capacity of the Emergency Department (ED) and trebling the size of the children's ED. In addition we have over two years increased ED staffing by 38% and introduced the UK's first Older People's Emergency Department (OPED). We are also improving facilities and increasing staffing (alongside Norfolk and Suffolk Foundation Trust) for patients with mental health needs in crisis.
'We are starting to see the positive impact of these and other changes (such as an increase in staffing of 540 – 8%, including an additional 70 consultants – 18% – in the last two years): Across all services the CQC has rated us as 'Good' for Caring, this year the Trust has the fifth most improved staff survey in the country, and NNUH has one of the lowest mortality rates in the East of England (a key indicator for quality in hospitals).
'However, we absolutely recognise there is still much to do and that we have some significant challenges to deal with, particularly in relation to staff feeling able to speak up and raise concerns, and we must improve next winter's escalation plans and improve our systems and processes overall. We are working on our improvement plan with the help and support from NHS Improvement and also the King's Fund (the independent charity and expert think tank on health and care).
'We are pleased that the CQC identified some of our outstanding areas of practice including: Stroke and fractured neck of femur pathways which 'were impressive', the appointment of 15 Advanced Clinical Practitioners in ED, and a forum for outpatient staff which 'provided an opportunity for staff to network and communicate across divisions, grades and specialties' and gold standard 'Mohs' surgery for certain skin cancers.
'Nothing is more important to us than providing the best possible care for our patients and the right culture and environment for our staff.'
What the inspectors said
The Care Quality Commission said there are a number of areas where the trust must make improvements:
Bed management and site management processes need to be reviewed in order to increase capacity and patient flow, and to ensure there are effective processes which ensure patient safety.
The relationship and culture between the site management team and the senior nursing and clinical teams must improve so that patient safety is equally weighted against operational pressure to reduce risk to patients and staff.
Processes for whistleblowing must be reviewed and the trust's leadership must take definitive steps to improve the culture, openness and transparency throughout the organisation.
Mandatory training attendance must improve so that all staff are aware of current practices and the trust must review the knowledge, competency and skills of staff in relation to the Mental Capacity Act and Deprivation of Liberty safeguards.
The completion of staff annual appraisals must improve and there needs to be an effective process for quality improvement and risk management across all departments.
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.