An inspection report of Northampton general Hospital published this morning says the labour ward and A&E were not properly staffed during the audit.
The Care Quality Commission (CQC) report, which rated the hospital as ‘requires improvement’, said: “We found that services at Northampton General Hospital NHS Trust were safe although some improvements were needed. We found that staffing levels were usually appropriate.
But it added: “We found that medical staffing in Accident and Emergency, on the labour ward and for the out-of-hours endoscopy rota was sometimes lower than expected. However we did not see evidence of unsafe care in those departments.
“We found a lack of appropriate testing and maintenance of equipment across the trust during our inspection. However, the trust had started to address this and this work was continuing.”
Although NGH was rated as ‘requires improvement’ in the areas of safety, effectiveness, being well-led and responsiveness, it was awarded a rating of ‘Good’ for standards of care.
A typical example of the issues identified in the report, illustrating both an extremely overloaded hospital, but with very caring and dedicated staff, was an observation in NGH’s emergency department during the inspections in January.
The report said: “We found that the delays in the A&E department meant staff there often looked after patients for a considerable length of time. During our visit, we witnessed one patient in A&E for 11 hours. Patients were found beds and given food and drink by A&E staff and the patients we spoke with felt their needs had been met.”
Elsewhere, the report also says there were “significant delays in serious incident reporting” and the resulting action plans were slow to be completed.
The report noted that, at the time of the inspection, in January this year, the trust had recently begun to use a simulation suite to re-create incidents in order to learn how to deal with them, “so this was expected to improve.”
It added: “We saw examples of learning from incidents at a local level. For example, A&E staff identified a high-risk patient and flagged them on the department’s IT system.
“However, learning from serious incidents was lacking across the trust which meant that improvements to the quality and safety of service provision was not embedded in the serious incident investigation process.”
Siobhan Jordan, the CQC’s head of hospital inspection, said: “The concerns CQC found were unacceptable and we have warned the trust it must improve. CQC will continue to monitor the service closely and our inspectors will be returning unannounced to check on whether improvements have been made and standards are being met.
“I am pleased the trust was open and honest throughout the inspection and I am also grateful to the public who took the time to express their views at the listening event. We believe the report will provide the trust with the opportunity to work with partners to improve services.”
Other issues identified in today’s CQC report included:
- Staff were overall found to be be exceptionally caring and patients were mostly satisfied. The report said: “We found the services in Northampton General Hospital NHS Trust to be caring. We observed caring, compassionate staff in each of the service areas we visited. Patients and their relatives spoke very highly of the caring nature of the staff. Patient dignity was respected and upheld.”
- There was no effective system to identify, assess and manage the risks to the health and welfare of patients who were moved wards at night. The report said: “The inspection team noted that some patients were transferred as late as 3am. Ward transfer records did not note the times or number of patients who were transferred at night.”
- Some middle mangers were perceived as a problem by some staff. The inspectors said: “We listened to staff and recognised an overwhelming sense of dedication and commitment from many employees of the trust. However, this was not the case in all departments, and a common phrase during our inspection was that staff attitudes varied ‘depending on the middle managers’.”
- Members of the dedicated specialist palliative care team [for end-of-life care] “could not confirm the number of patients or identify any of the actual patients who required end-of-life care.
“Therefore, we were not confident about the team’s ability to effectively support the ward staff and manage those patients’ needs.”
- Treatment for children in A&E “was not responsive to their needs.” The CQC report added that: “Northampton General Hospital could not guarantee that a qualified registered sick children’s nurse (RSCN) would be on duty at all times. It continued: ”The A&E service did not have the staffing capacity or space to ensure that patients could be assessed and treated in a timely manner.”
- Hospital monitoring of risks not as good as it should be. The CQC report said: “The trust had identified issues relating to governance, but had not effectively led the management of them. It had recognised the challenges within the emergency care pathway. However, there did not appear to be a co-ordinated process to address this which meant that the risk to patient safety and welfare had not been managed.”
The report added: “During our inspection we revealed a number of risks which had not been identified through the trust’s quality monitoring systems. These related to the supply of medication after patients were discharged, maintenance of equipment, inappropriate completion of the Do Not Attempt Cardio-Pulmonary Resuscitation (DNA CPR) [also known as the do not resuscitate form], the specialist palliative care team’s lack of knowledge of patients in that group and the regular occurrence of multiple patient moves within the trust.”
- Some actions relating to complaints had been outstanding for over three months.
- The door leading into the maternity unit labour ward could be left open and posed a potential risk of unauthorised access to this high risk area.
- Services at Northampton General Hospital ”were not well led”. with the exception of the chief executive [former medical director Dr Sonia Swart, who was appointed late last year]. The report said: “Governance was poor and this had an impact at every level of the organisation. We saw examples of good local leadership in some areas, but this was not consistent.”
- Lack of take-up of staff training. The report said: “Throughout the hospital there was varied and, overall, poor compliance with both mandatory training (which had remained on the trust’s risk register for three years with evidence of limited improvement) and completion of annual completion of personal development plans (PDPs). This meant that patients may have been at risk from staff who were not up to date with their training and / or had not had any performance concerns addressed.”
-Many of the executive post holders are either new to post or in interim positions, which had an impact on the trust’s leadership, the CQC said.The report added: “Staff reported that senior leaders, with the exception of the chief executive, were rarely visible on wards and were unaware of the positions and responsibilities of most executive post holders.”
However, it continued: “There have been significant changes at the executive level of the trust for some time, and the chief executive was aware of the need for stability among this group in order to address the leadership concerns across the trust.”
- Inspectors also noted that staffing levels were low in some areas, although clear signs of improvement could be seen. It said: “The trust had a recent history of poor staffing levels on some wards. During our inspection, we saw that action had begun taken to address staffing issues. Staff told us that improvements in staffing levels were already having a positive impact on services.”
Meanwhile, the report author said that NGH appeared to be very clean throughout, adding that a national survey noted the trust was “performing well in relation to infection prevention and control.”
NGH bosses had also “responded to recent concerns around staffing and care on two medical wards” and had taken action, including “increasing the staffing establishment to address those concerns.”
The hospital emphasised this morning that, as well as identifying areas for improvement, there are a number of positive findings within the report.
It pointed out that NGH was judged as ‘Good’; across all services for ‘caring’ and inspectors found that ”in the main, the safety and effectiveness of services has been maintained, despite the overriding urgent care pressures. This reflects the work already done and still underway in these areas.”
Dr Sonia Swart, chief executive, said: “I am proud to say the inspectors found our staff to be caring, that the hospital was clean and that infection control was good.
“The CQC’s report highlights issues we knew we faced and were already working to address. Where there are problems we have recognised them. We know we have the capability to turn this round. I still think this is fundamentally a good hospital and is doing well to cope with the pressures that we have. “We are a hospital that can improve and we accept the importance of some key threads running through the report, which reflect many of the issues we know we need to address. Most fall under the categories of urgent care performance, governance and leadership.
“We also accept that some of the key important actions mandated as compliance actions or as actions the Trust must take, are issues we must tackle as a priority.”
Following the inspectors’ announced visit in January, the Trust was required to take three immediate actions, all of which were implemented before the CQC returned for their unannounced visit towards the end of January.
- The DNAR (do not attempt resuscitation) forms were replaced overnight with a more simple form and, within one week new, clearer forms were introduced on all wards, with immediate explanations to staff. Audits and further training are now in place.
- Testing of medical equipment began immediately the need to take action was identified. In the space of a week more than 900 items were tested in high-risk areas. Over 95 per cent of the equipment had records evidencing appropriate testing and none required any intervention. Of the 22,000 items of equipment that underwent electrical safety testing during 2012-13 only 12 were found to have defects and no harm related to equipment had been recorded.
- The sending medication to patients’ homes by taxi was stopped immediately. This was an issue that had already been raised within the Trust and the policies were under review.
An NGH spokesman said: “All the actions from the CQC report will be pulled together into a comprehensive improvement plan for the hospital. Presentations to staff have been arranged to explain the outcome of the inspection and invite them to join relevant improvement groups. Progress will be monitored by the executive team and trust board.
Dr Swart added: “We are committed to improving the safety and quality of the services we provide. I am pleased the inspectors recognised the commitment of our staff and their caring approach, as well as the open and transparent way in which NGH operates.”
Dr Swart, said: “I am proud to say the inspectors found our staff to be caring, that the hospital was clean and that infection control was good.
“The CQC’s report highlights issues we knew we faced and were already working to address.
“Where there are problems we have recognised them. We know we have the capability to turn this round. I still think this is fundamentally a good hospital and is doing well to cope with the pressures that we have.
“We are a hospital that can improve and we accept the importance of some key threads running through the report, which reflect many of the issues we know we need to address.
“Most fall under the categories of urgent care performance, governance and leadership. We also accept that some of the key important actions mandated as compliance actions, or as actions the Trust must take, are issues we must tackle as a priority.”
Following the inspectors’ visit in January the Trust was required to take three immediate actions, all of which were implemented before the CQC returned for their unannounced visit towards the end of January.
The Chief Inspector of Hospitals for CQC, Professor Sir Mike Richards, said: “Whenever we inspect we will always ask the following five questions of every service: Is it safe? Is it effective? Is it caring? Is it responsive to people’s needs? Is it well-led?
“While some services were delivered effectively at the trust, the issues at the A&E department, poor management, staff training, and equipment maintenance must be improved.
“The trust appeared to have hard working staff but there were concerns surrounding the lack of mandatory training being completed which could affect the way care is delivered. It is essential that staff are being adequately supported and developed in their roles.
“Despite this shortfall we observed caring and compassionate staff in each of the service areas. Patients and their relatives spoke very highly of the caring nature of the staff.”