The Care Quality Commission (CQC) has taken action to keep people safe following an unannounced focused inspection of five acute wards for adults of working age and psychiatric intensive care unit services at Tees, Esk and Wear Valleys NHS Foundation Trust.
The inspection in January was prompted by an incident that had a serious impact on a person using the service. This incident raised concerns about the safety and quality of the service. There was a potential risk of harm to patients if CQC did not inspect.
Inspectors visited five wards - three at Roseberry Park, one at Cross Lane Hospital and one at West Park Hospital and looked at whether the service was safe and well-led. CQC has rated both of these key questions as Inadequate, with an overall rating for the service as Inadequate. At the previous inspection in March 2020 the service was rated Good. The trust’s overall rating of Requires Improvement remains unchanged by this inspection.
The CQC has taken action and served the trust a section 29A warning notice – meaning that it must urgently address these issues to keep people safe to avoid more significant enforcement action and has a timeframe it must do this within.
CQC’s head of hospital inspection for the north (mental health and community health services), Brian Cranna, said:
“During our inspection of Tees, Esk and Wear Valleys NHS Foundation Trust’s acute wards and psychiatric intensive care unit service, we found concerns that urgently needed addressing.
“We found these five wards were providing a service where risks were not assessed effectively or managed well enough to keep people safe from harm. In particular, staff did not fully understand the complex risk assessment process and what was expected of them. The lack of robust documentation put people at direct risk of harm, as staff did not have access to the information they needed to provide safe care.
“It was also concerning that governance systems had not ensured staff understood when and how to observe and engage with people who used the service, and that leaders had not taken action to ensure staff were supported to keep people safe.
“The trust know what improvements must be made and we continue to monitor the service closely and will return to check on their progress.”
CQC findings from the inspection included:
- Staff did not assess and manage risks to patients well or use a system that was robust enough to assess patient risk effectively.
- Inspectors saw three different meetings in place where patient risk was discussed between the multi-disciplinary team and the nursing team. However, inspectors found that the information in handovers and risk documentation did not match for 11 of the 16 patients that were reviewed.
- The trust governance systems failed to ensure that staff understood and complied with the trust’s observation and engagement policy to maintain patient safety. The observation and engagement audit that was in place at the time of the inspection did not ensure that hourly checks were being completed for patients on general observations, or that night-time observation plans were in place for patients.
- The wards did not have a good track record on safety, and the service did not manage patient safety information well. Incidents were not always discussed in order to learn from them and reduce future risks. In particular staff were unable to describe any communication from leaders to alert them to areas of risk following a recent serious incident. Although some staff were aware of the incident, not all staff could describe any changes to practice as a result of learning from this.
- Leaders had failed to ensure that staff knew what was expected of them when assessing and documenting patient risk. Staff told inspectors they didn’t have the training they needed to help them carry out this part of their role.
The trust must make several improvements to comply with the section 29A notice that CQC served, including:
- Ensuring they have systems and processes in place to effectively assess, monitor and mitigate the risks relating to the health, safety and welfare of service users.
- Have an effective procedure and process in place to review and learn from serious incidents.
- Make sure all staff receive the appropriate training to carry out patient risk assessments appropriately and consistently.
- Ensuring staff understand and comply with the trust’s observation and engagement policy required to maintain patient safety.
The lack of robust documentation put people at direct risk of harm, as staff did not have access to the information they needed to provide safe care.
Brian Cranna, Head of Hospital Inspection for the North