Community health services for children at Birmingham Community Healthcare NHS Foundation Trust have been downgraded from “good” to “inadequate” by inspectors who raised concerns about staffing levels and heavy caseloads.
The latest report by the Care Quality Commission comes after union officials recently warned the health visiting service in Birmingham was “in meltdown” with staff morale at rock bottom.
The CQC report, published on Monday, shows health visitors have not been meeting the requirements of the mandatory healthy child programme, with some families missing out on key antenatal visits.
Inspectors also raised serious concerns about “inadequate” staffing levels and “unmanageable” workloads, with health visitors struggling to cope with caseloads of up to 500 – double the recommended figure for safe practice.
The trust’s overall rating slipped from “good” to “requires improvement”, after the CQC inspection carried out in May and June this year.
A raft of safety concerns prompted inspectors to issue an official warning notice – as reported by Nursing Times last month – setting out 18 urgent steps the trust must take to avoid regulatory action.
“Concerns raised by staff about their colleagues were not always investigated or acted on”
The report shows the safety of community health services for children and young people was rated “inadequate” by inspectors, who said systems to learn from mistakes were not effective and identified “a lack of a learning culture”.
“Learning from lessons was not always shared to ensure action was taken to improve safety,” stated the report.
It said: “Following a serious incident within the health visiting service, which occurred in April 2017, learning appeared to have been identified but there was no evidence it had been shared with staff within the trust.”
In addition, inspectors from the regulator found concerns raised by staff were not always acted upon.
“Concerns raised by staff about their colleagues were not always investigated or acted on which impacted on the care delivered to children. Some staff felt fearful of raising concerns with their managers,” said the report.
Other key safety concerns included the fact staff did not adhere to infection prevention and control standards and that care planning was inconsistent.
Meanwhile, many children were waiting longer than the 18-week referral to treatment target for therapy and child development services and the trust “could not provide assurance that child health was not deteriorating as a result”.
“Mothers were not monitored or contact made to ensure their safety and wellbeing”
There were particular concerns about lack of capacity in the health visiting service and the fact vulnerable mothers and children could be slipping through the net
“When health visitors did not have capacity to take on additional mothers for antenatal visits, these mothers were not monitored or contact made to ensure their safety and wellbeing,” said the report.
“There was no data available on the number of referrals which had not been allocated or the reasons why the visits were not carried out. This meant the trust could not be sure risk was being safely managed,” it said.
Inspectors also found health visitors did not consistently record the advice given to families in records.
Overall, they found “ineffective systems in place to assess and respond to patient risk in the health visiting service”.
Inspectors identified area of good practice in children’s community services, including in school nursing – a service that has been under threat due to drastic funding cuts.
“The complex care team and the special school nurses supported children with additional needs and also those with multiple disabilities and compromising health conditions to participate in school,” said the report.
Meanwhile, school nurses delivered important public health education messages in mainstream schools and supported children with health issues to continue attending school.
“We know that our children’s teams are doing a difficult job in challenging circumstances”
Other services provided by the trust were rated good including community health services for adults, community inpatient services, end of life care and learning disability services.
Overall the trust was rated “good” for being caring, effective and responsive but “requires improvement” for safety and leadership.
Trust chief executive Richard Kirby said it was naturally disappointing to drop down to an overall rating of “requires improvement” but acknowledged improvements needed to be made in children’s services.
“We know that our children’s teams are doing a difficult job in challenging circumstances and we have already begun to make the necessary improvements to ensure we provide better support to our staff and better care to our patients,” he said.
Key areas that needed work included risk management and ensuring freedom for staff to speak up, he said.
“Our community children’s services face significant challenges and there is much to do to support these teams going forward,” he said.
“I am confident that we are now working with those involved in a way that will enable us to make the improvement that is needed,” he added.