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CQC issues warning over pressures on NHS staff

Poor medicines management and record keeping may be the first signs that staff are overstretched and could warn of more serious care failings, according to the Care Quality Commission.

The regulator’s annual “State of Care” report, published today, presents an analysis of the themes emerging from 13,000 inspections carried out by the CQC during 2011-12. 

Almost a fifth of NHS hospitals inspected by the regulator failed to meet standards on medicines management, as did a quarter of NHS community providers and 17% of mental health trusts.

Common problems included poor storage and incomplete records that medicines had been administered to patients. A further 22% of NHS hospitals, 19% of community services and 17% of mental health services failed standards on record keeping.

The report said CQC inspectors had found poor record keeping was often an early sign of “strain” on an organisation, “for instance, as a consequence of a shortage of staff and the resulting lack of time they have to complete all their tasks”.

CQC chief executive David Behan said: “Our report highlights concerns we have that pressures on some services are leading to problems in the quality of care, keeping people safe, treating people with dignity and respect, and involving people in decisions about their own care.”

However, he said these pressures “cannot be used as an excuse to deliver poor care”.

The report found 16% of hospital trusts inspected were understaffed.  Meanwhile, 23% of nursing homes and 16% of residential care homes were not meeting the CQC standard of having adequate staffing levels.

At the same time the report identified the growing demand for nursing care within social care settings and highlighted the growing pressure on staff from the increasing complexity of patients.

The CQC said 64 new nursing homes had registered with it during 2011-12 and there had been a 3.3% increase in the number of registered nursing beds. However, 15% of inspections of nursing homes found a lack of respectful care.

Crystal Oldman, chief Executive of the Queen’s Nursing Institute, said: “If more care is going to be delivered in the community, including in nursing homes, it is vital that there is more investment in well trained staff who have the time and the expertise to give high quality, compassionate and person-centred care to the most vulnerable members of society.”

In addition, the CQC report said more than 32,000 patients were admitted to hospital from care homes and went on to die there during 2011-12.

It said that, while some of these admissions may have been clinically appropriate, the fact a third of patients died within three days and half within a week suggested they could have been better cared for in their care home.

Most recent figures suggest 29% of people expressed a wish to die in their care home yet only 18% did so.

Jonathan Bruce, managing director of Prestige Nursing and Care, which provides agency staff to nursing and care homes, said it was “incredibly worrying” so many older people were not able to die in a location and surroundings they had chosen themselves.

Peter Carter, chief executive and general secretary of the Royal College of Nursing, said the report “echoed” RCN warnings that not enough hospitals, nursing and care homes were adequately staffed and, when coupled with the wrong mix of skills, was having a real effect on patient care.

“Already too many are failing to meet the CQC’s standards and this will only increase if action is not taken to improve staffing levels,” he said.

Mike Farrar, chief executive of the NHS Confederation, which represents managers, said staff, from the frontline to the board, needed to use the report to “scrutinise” the care they delivered.

He added: “We need to do more to encourage staff to speak out when they are unhappy about the standards of care or support provided on their ward.”

Readers' comments (40)

  • tinkerbell

    when are these issues ever going to be addressed. To keep restating the problem is not a solution just a broken record.

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  • I am happy for the evidence to pile up. I am unhappy that my colleagues (with the exception of Tinkerbell and a few others)continually fail to use ALL the evidence to make their case and take action. Some, on another article, thought it better to blame the people who carried a piece of research rather than use it to their advantage. Nurses will never learn, will never do anything to stand up for themselves and will continue to blame everyone else.

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  • anon 8.33 - nurses do learn very quickly that they frequently find themselves banging their heads against brick walls.

    nurses do try and stand up for themselves, often resulting in being picked on by other staff, you quickly learn that you don't always get the support others promise.

    nurses have to blame others because they are not the ones who have created staff shortages and poor skill mix.

    this research suggests that staffing levels are one of the reasons for poor medicines management, but it is always just the individual nurse who is called to account, it's the nurse who gets disciplined, gets reported to the nmc, has to re-train in medicine management - not the management,not the person who wrote the off-duty, not the person who took one of the trained nurses off the ward to work on an even worse staffed ward, not the employer. How often are 'mitigating' factors such as staff shortages ever taken into account.

    Research is helpful if action is taken, if it's ignored then what was the point of it all. This only confirms what other studies have shown, the RN4CAST study stated staff felt they don't have the staff or time to get all their jobs done, it's all been said before - that is what we find so frustrating.

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  • tinkerbell

    well i have taken this article to my colleagues this morning and we are going to see our management about how stressed some of our staff are feeling as the workload pressure is building up.

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  • the first two articles on this site today are this and the 1,000 staff shortages.

    when is something going to be done to address staffing levels, skill mix, lack of specific training, unregulated care and increasing workloads? how much research needs to be done, how many meetings do we need to have, how many incident forms do we have to submit, how many examples of poor care do we need, how many 'shock' stories need to be televised?

    there is such a thing as overload, too much of the same old, same old, eventually people stop listening.

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  • How dare the CQC say they realise poor record keeping is an early sign of strain and then say that's no excuse - then the link this to poor care. In my my expereince the records can get behind becuase of the massively increased number of patients we are expected to see, to squeeze into each day's work. The concentration is therefore focused of the patients not the record keeping - this does NOT equate to poor care, its simply that the patients come first.

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  • David Behan needs to understand that under staffing & lack of time is a serious issue within the health service & that poor patient care is a symptom of this. Nurses do not want to provide poor patient care but sometimes they just cannot deliver the standard of care expected. Nurses are not super human (I really wish we were) & there are only so many hours in a day. Maybe he should be thinking of some reasonable solutions to the problem instead of critising the one group who strive hard to achieve the highest standards possible.

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  • It is plain that CQC members read the articles discussed here. It's just a shame they aren't capable of assimilating the facts first time around or even acting on the good sense and advice available from staff on the front line.

    Never mind, it makes them feel part of the service to write of potential problems in retrospect....

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  • that good old retrospect-ascope, so often used within the health service and so useful when those responsible don't want to be held responsible.

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  • tinkerbell

    following a discussion with our managers this morning, they came to see us and offered reassurances on the minimum requirements. We then had a lovely get together and shared our food and actually had a proper break. I know on the wards this would be more difficult.

    We need to find ways to destress ourselves and that means supporting each other and we are hoping to have this get together meal every friday.

    Everyone seems abit calmer at the moment.

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  • This will not change things. At best management will come out with a few platitudes and then wiat for the inevitable screw up due to 'Poor medicines management and record keeping' and then simply blame the individual nurse.

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  • michael stone

    I've downloaded the report, but not had time to read it yet. But I heard the Radio 4 'Today' discussion of it, and although it mentions under-staffing, etc, I think it also repeats 'some places seem to do much better with the same resourcing levels'.

    I started on the report (it is very lengthy) and I think it is an improvement on some earlier reports - many current reports look better than those of a few years ago, but they still tend to highlight the (usually already commented on in the past) problems, rather more than they outline mechanisms for genuine improvements.

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  • Here we go again. some do gooders thinking they are telling us something we dont know. More and more patients being cared for in the community (quite rightly) My team are working with less staff than years ago. Staff that are leaving have not been replaced. So much emphasis is on paperwork. ie if you havent documented it you havent done it. I went to occupational health following sickness abscences brought on by being run down and stressed only to be given the advice. "lets get you through the next 2 years when you retire" What sort of solution is that? Wake up CQC and stop blaming nurses and get onto the powers that be to resolve this avoidable problem.

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  • Anonymous | 23-Nov-2012 9:06 am

    Unfortunately, your post only proves my point. It is full of excuses for doing nothing.

    I know hardly any nurse who has ever banged their head against any wall! Oh sure, they can certainly moan. Usually amongst themselves and to no effect. Do you know why? Because they do not take effective action. They blame their apathy and defeatist attitudes on everyone else, but never take their proper breaks, or leave their shift on time, or stand on a picket line, or go on a march or do ANYTHING to help themselves. Instead, they actually contribute to the problems. How many have even written to their MP or Unions? Who are we kidding? They can't even be bothered to vote in a ballot about their pensions, so leaving the unions more toothless than ever.

    Daily, this profession bleats and moans about its lot in life.....but it NEVER LEARNS! We are supposed to be our patients advocates, yet we shuffle around, wringing our hands and mumbling dissent, whilst the NHS collapses around our ears and we are scr*wed for every penny of our pay and pensions. I don't know who you think is going to come along and save us. Unless and until we realise that WE have to take responsibility, unite and take concerted action (there are enough of us), then nothing will change.

    Yes, it is very frustrating indeed.

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  • anon 6.05 - I would be interested to know what action you have or will be taking and what difference your actions have made so far.

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  • Anonymous | 23-Nov-2012 6:19 pm

    For your predictable response, I am happy to enlighten you. I've done the lot and continue to do so. Been on all demos and marches in my region and beyond, union rep, out on strike and (will continue to turn up). I constantly challenge my seniors in my place of work as and when issues arise, as do my colleagues. I lobby my MP, my union, etc to do more.

    What difference has it made at work? We've had some success in improving our immediate work environment, staffing ratios and resources. Plenty of room for improvement, though, which is why we keep up the pressure.

    What difference has it made to the overall situation within nursing and the NHS? Very little, because there are so many apathetic nurses who do nothing, don't appear to see the point and prefer to wait for someone (I don't know who, because that question never seems to get answered) to do it for them.

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  • Anonymous | 23-Nov-2012 6:19 pm

    Meant to ask. What action have taken and what action do you intend to take in the future?

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  • I've done all the things you have done except be an rcn rep, I do volunteer for a different client group two mornings a week.

    I haven't seen any change so far and have been going on marches etc. since the thatcherite years. I presented my first report looking at staffing/ratios/patient need/jobs left undone etc to our nursing officers back in the 90's, things got better for a while but it didn't last.

    What will I do for the future? just bought the staff some new mugs out of my own money and have learnt not to get stressed about work any more.

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  • Anonymous | 24-Nov-2012 8:59 am

    Whilst laudible in themselves, I'm not sure what volunteering for a different client group or buying mugs for staff with your own money, has to do with furthering the causes of nurses pay and conditions and easing government imposed pressure on the NHS.

    I would ask, what are your colleagues doing? Because, to get back my original post, I stated that some nurses take action like you and I, (although it's not clear if you are still active or stopped in the 90s) most do not. So almost anything that we do as individuals has very little effect. And that was my point....the reality remains that nurses don't take action and are adding to the problem. Now that may (and does) seem to hard to accept, but it is nonetheless true.

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  • Doesn't there come a time when nurses have to hand over responsibility to their managers. Not everyone wants to or can spend their precious spare time lobbying their mp, writing letters,going on marches, attending union meetings and thinking constantly about work which can cause an awful lot of stress and can be mentally exhausting.

    Do you think it could be detrimental to our own mental and physical health to constantly worry about work.

    Buying mugs for the staff, working unpaid overtime, covering breaks hopefully shows the staff that I am trying to make things better and that I care about their welfare. Volunteering for a different client group gives me a bit of down-time.

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