'I won't be happy until there is no avoidable harm'
Sue Smith is relentlessly positive about improvements at Morecambe Bay. She tells Jo Stephenson about taking the helm after recent tragedies led to severe criticisms.
The news that University Hospitals of Morecambe Bay Foundation Trust had been placed in special measures at the end of last month may come as little surprise to observers.
“We have been kicked a lot and rightly so, but… I want people to see how far we have moved on and how quickly”
Yet behind the headlines, the trusts’ new executive chief nurse Sue Smith is adamant things are improving at a rapid pace.
In recent years, Morecambe Bay has been the focus of safety and quality concerns, including an ongoing investigation into the deaths of mothers and babies at Furness General Hospital.
Meanwhile, the Care Quality Commission’s latest inspection report published at the end of June rated the trust “inadequate”, with ongoing concerns about patient safety and staffing levels in several areas.
But while past failings cannot be ignored, it’s time for the organisation to “shake off this bad reputation” and look to the future, Ms Smith told Nursing Times.
“We have been kicked a lot and rightly so, with fair criticism of a number of issues in the past, but we are a different organisation [now] with a very different philosophy,” she said. “I want people to see how far we have moved on and how quickly.”
Even in the few months since the CQC’s visit, she maintained much had changed and the regulator’s blanket rating of “inadequate” did not reflect the progress it had made.
“We do feel inadequate overall was harsh, because none of our individual hospitals was deemed inadequate,” she said. Furness General and the Royal Lancaster Infirmary were labelled as “requiring improvement” but Westmorland General Hospital was judged “good”.
“That said, we would definitely acknowledge we have been on an improvement journey and continue to be,” she added.
Ms Smith said the decision to place the trust in special measures, which will involve the appointment of an “improvement director, is “an opportunity”.
“It’s not about turnaround, it’s about improvement – that was made very clear to us – so we very much welcome the opportunity for support,” she said.
Developments in the trust’s recent history include a complete change in senior leadership, though this is still seemingly ongoing. Both the trust’s chair and interim medical director resigned recently.
One criticism in the CQC report was that the executive team and boards members – with the exception of Ms Smith – “were not visible and communication with frontline staff was poor”.
“A few weeks ago the board was doing ‘speed dating’ with our ward managers to try and get to know each other better”, said Ms Smith, highlighting one example of culture change. In addition, ward managers are now fully involved in setting budgets for their wards.
The trust has made a concerted effort to get to grips with staffing and has recruited 130 new nurses reducing its vacancy rate to 4% – below the national and North West regional average of around 10%.
Taking into account people arriving and leaving, the net increase in nursing staff from April 2013 to May this year was just over 100 full-time equivalents, explained Ms Smith.
In December the trust introduced “red rules” for minimum staffing levels and the Safer Nursing Care tool is now in use in 20-30% of wards and in the process of being rolled out.
Like many other trusts, the recruitment drive has included recruiting internationally.
Overall staffing data for February showed a funded establishment of 1,407.83 on the wards with 1,327.72 on contract and 1,423.46 actually working.
The figures are indicative of a new policy of over-recruitment, with the trust starting to recruit in cohorts.
“The aim is that we will save more money than we invest through reducing our bank and agency staff and overtime so we look at it as better for patients, better for the team and good business,” said Ms Smith.
She explained that recruitment now starts as soon as managers are alerted to a vacancy with the trust committed to covering maternity leave.
Other initiatives include an emphasis on recruiting and training high quality healthcare support workers.
Building on a successful Cadet Programme, the trust will start offering apprenticeships early next year, with apprentices employed as healthcare assistants for two years. Those that pass can either take up a permanent job or progress into further training to become a nurse with guaranteed employment once qualified.
In line with new NHS England rules on displaying staffing data, the trust now has information boards on each ward, which also show a range of “nurse sensitive outcomes”, including pressure ulcers, hand hygiene scores and patient comments.
In 2013 intentional rounding was introduced on all adult inpatient wards. An audit in March found a 31% reduction in complaints relating to nursing and a 58% drop in falls where patients were harmed. “I won’t be happy until we get no incidents of avoidable harm,” said Ms Smith.
She stressed there had been real improvements in areas where particular problems were identified, such as the 50-bed medical ward 39 at the Royal Lancaster Infirmary – the subject of an official CQC warning notice about staffing levels in October.
“The trust in fairness had already recognised this and was recruiting,” said Ms Smith. “But the morale on the ward was poor. People were working very hard and winter was about to hit us.”
The ward has now been fully staffed for several months with the stats from February showing a funded establishment of 57.21 and actual staffing of 60.04.
It also has a “superb” new ward manager and matron in place, said Ms Smith. “My main issue on 39 was getting the right staffing and I believe we are there,” she says.
“Friends and family [score] returns were very low but have improved significantly this year and show there is a good level of patient experience. Overall the majority of comments we get on that ward are very positive.”
“When babies and mothers die there is nothing you can do to make that better, but the learning from this midwifery team has been significant and they are now frontrunners in a number of national pilots”
Nevertheless, only the other day the matron had to reassure a couple of families nervous about relatives being cared for on the ward as a direct result of recent negative media coverage.
“It has a big impact on staff because they’re actually doing a blooming good job on that ward,” said Smith, who cannot hide her frustration.
In the maternity unit at Furness, which was the focus of much high profile publicity surrounding infant deaths from 2004-13, Ms Smith said there have been many changes. Staff there are “being brilliant”, despite the strain of an ongoing investigation into the deaths, she said.
“I don’t want to undermine the history. When babies and mothers die there is nothing you can do to make that better, but the learning from this midwifery team has been significant and they are now frontrunners in a number of national pilots,” she said.
The unit is taking part in the I Want Great Care initiative and is one of just a handful around the country publishing data on harm events, as part of NHS England’s Open and Honest Care project.
Staff are also involved in the Fresh Eyes scheme, which involves routine double checking of each other’s cardiotocographs, which measure an unborn child’s heart rate.
Finally, the trust is currently seeking another trust to act as a “corporate stability partner” and provide objective feedback and support to help the midwifery department keep improving.
Survey data from the Furness labour ward in May showed patients scored it an average of 4.81 out of 5, with the majority “extremely likely” to recommend it to friends and family.
However, there is no getting away from the devastating impact of recent tragedies on everyone concerned.
“Until I came here I didn’t understand just how widely those ripples go and how many people are affected,” said Ms Smith, noting that staff had received “emotional resilience” training and other support.
“We’re making great progress and the nurses on the frontline are doing a cracking job. It would be really nice for them to be recognised for that instead of continually criticised”
She believes the trust – one of the first to sign up to Nursing Times’ Speak Out Safely campaign – has created a new atmosphere where staff are encouraged and helped to raise concerns.
“I don’t want us to ever get to the point where we have whistleblowing because, if something is going wrong, we need to escalate it early and that is the clear message to staff,” she said.
“We have still got a long way to go, but probably not as far as a lot of people think,” she said. “We’re making great progress and the nurses on the frontline are doing a cracking job.
“It would be really nice for them to be recognised for that instead of continually criticised,” she added.
As for Ms Smith herself, who came into post towards the end of last year, she told Nursing Times she had “never been happier” in a job, despite its challenges.
As well as talking and listening to nursing staff, she has been known to don uniform and work alongside them “doing a bed bath here or there”.
“I absolutely love my job,” she said. “I love working here with this team and feel I am appreciated by my board but, more importantly, by the frontline staff.
“I came into this job knowing it would a challenge but it has been easier than I thought because actually people just wanted a bit of leadership.”