Patients were harmed and staff bullied and harassed at a community trust where managers were obsessed with achieving foundation status, according to a damning independent report.
It described Liverpool Community Health NHS Trust as being “dysfunctional” since its creation “from scratch” in 2010 as a large, new organisation.
“Staff were overstretched, demoralised and, in some instances, bullied”
“The trust not only failed in its duty to provide safe and effective services, it concealed this from external bodies. Both patients and staff suffered harm for too long as a result,” it said.
Services provided by the trust included adult care, child and adolescent care, community dentistry and public health. It also provided prison healthcare services at HMP Liverpool and subsequently acquired responsibility for community services in Sefton.
But its managers were “inexperienced” and “inadequate” from the outset, said the report, which covered the period from November 2010 to December 2014 and was published today.
“Senior leadership and the board failed to realise that the trust was out of its depth, and did not take heed of the effects,” said the Liverpool Community Health Services Review Report.
“Staff were overstretched, demoralised and, in some instances, bullied,” it said. “Significant unnecessary harm occurred to patients.”
With echoes of what happened at Mid Staffordshire, managers were found to have acted “inappropriately” in pursuit of foundation trust status, setting “unfeasible financial targets that damaged patient services”.
“We wish to acknowledge the hard work and dedication of staff”
The report highlighted that the “principal objective” of the board – at the time led by chief executive Bernie Cuthel and chair Frances Molloy – was to become a foundation trust, though “frontline staff did not share this view”.
It noted that the objective “dominated the time and attention” of senior managers who became “blind to the real concerns” that began to arise.
Commissioners had asked the trust to make savings while managers were also attempting to generate a surplus, leading them to propose cost improvements mainly via reducing staff numbers.
These were subsequently implemented because of a “confused and conflicted arrangement” where managers who should have had responsibility for clinical quality and risk were also responsible for cost-cutting.
For example, the nursing director, Helen Lockett, was, for at least part of the period, also the chief operating officer, and therefore responsible for achieving the cost improvement programme.
As a result of the staffing cuts, especially to district nursing, and wider leadership failings, the report noted that “adverse consequences were significant”.
“The end result was unnecessary harm to patients over a period of several year”
It said many staff soon became demoralised, sickness absence levels rose, worsening staffing levels further.
“They had not felt involved in planning for the impact of staff reductions, and when they reported difficulty in maintaining safe and effective services, they did not feel listened to,” said the report.
In addition, while it was “clear” that most staff tried hard to compensate for workforce reductions, it was “equally clear that services began to suffer despite their efforts”, said the report.
“When the interim leadership team took over, we were told that the trust was carrying 150 whole time equivalent vacancies, of which 78 were WTE district nurse vacancies,” said the report’s authors.
“We were told repeatedly of the difficulties this created and the major problems faced by frontline staff in relation to recruitment and staff retention,” they said.
“Despite this, frontline staff tried to provide the best services they could, often working long hours in difficult circumstances,” they said. “We wish to acknowledge the hard work and dedication of staff.”
The report noted that, as a consequence, there was a rise in the incidence of patient harm incidents, which were subject to mandatory reporting nationally, including pressure ulcers and falls.
“The report has important lessons for our organisation and the whole of the NHS”
For example, pressure ulcers developed that could have been prevented, and had to be managed reactively, stated the report.
Meanwhile, it was clear, said the report, that the reaction of the trust board to “this gathering crisis in services was based on denial”.
“When some staff attempted to raise concerns, or in some cases grievances as a result of being bullied, the response was seriously deficient,” it said.
“We heard repeated accounts that staff would be suspended without being told why, or what the next steps would be,” it said. “In some cases, these suspensions lasted for many months.”
It added: “We heard specific examples of very poor practice in nursing management and human resources. There were serious shortcomings in the leadership of both departments.”
The report also criticised commissioners and regulators for failing to recognise the risks at the trust. “External overviews failed to identify the service problems for at least four years,” it said.
The report was written by Dr Bill Kirkup, who previously led the inquiry into maternity care failings at University Hospitals of Morecambe Bay NHS Foundation Trust.
Nursing expertise for his Liverpool review team was provided by Susan Marshall, executive chief nurse at Sussex Community NHS Foundation Trust.
In his introduction to the report, Dr Kirkup said his review had uncovered “widespread failings surrounding community health services based in Liverpool”.
He said it showed in “stark terms” what could happen if services were taken for granted and if warning signs were overlooked, combined with an inexperienced board and insufficient scrutiny.
“The end result was unnecessary harm to patients over a period of several years, and unnecessary stress for staff who were, in some cases, bullied and harassed when they tried to raise concerns about deterioration in patient services, stated Dr Kirkup.
He added that “these failures were replicated” in the health services that the trust provided to HM Prison Liverpool.
Dr Kirkup also said he was “grateful to all of the staff” who co-operated with the review, but that he was “disappointed that a small minority of individuals refused to co-operate”.
“It remains the duty of all NHS staff to assist as fully as they are able with investigations and reviews that are directed toward improving future services,” he said.
NHS Improvement said it would respond fully to the review’s findings and recommendations by late March 2018.
Ian Dalton, chief executive of the regulator, said: ”We are grateful to Bill Kirkup for this report which highlights significant failings in patient care.
“The report has important lessons for our organisation and the whole of the NHS,” he said. “We will carefully consider its findings and take appropriate action.”
The review was sparked by a number of events, starting with a Care Quality Commission inspection that was carried out partly in response to whistleblowers and that identified a “range of serious issues”.
Whistleblowers had also raised concerns to Rosie Cooper, Labour MP for West Lancashire, whose father had recently been a patient in one of its intermediate care wards and had witnessed staff under significant pressure trying to provide appropriate levels of patient care.
In February 2014, she raised questions about the management of the trust with the prime minister and the health secretary.
Meanwhile, following publication of the CQC report, NHS Improvement appointed an interim executive management team to turn the failing trust around.
They sought to address issues raised in the CQC report by commissioning a quality, safety and management assurance review, carried out by Capsticks Solicitors and published in March 2016.
However, the Capsticks report “generated a sustained level of concern” and management and safety, leading NHS Improvement to establish the independent review of the trust.
In a statement responding to the new report, Johanna Reilly, the organisation’s current chief operating officer, said: “On behalf of the trust, I apologise for the failings of the past outlined in this review and I am extremely sorry that patients, families and members of staff suffered as a result.
“The trust welcomes the publication of this review and fully accepts all of its findings and recommendations,” said Ms Reilly.
“May I reassure people that significant progress has already been made and we will continue to monitor all our processes, clinical and HR practices to help ensure we deliver the highest standards of care going forward,” she said.
Ms Reilly highlighted that, from the 1 April and subject to approvals, Liverpool Community Health NHS Trust would cease to exist and become part of Mersey Care NHS Foundation Trust.
“We will work tirelessly to pursue and develop a fair and supportive culture that enables all staff to deliver the best care possible for the people we serve,” she added.
Ms Lockett, the trust’s former nursing director, is currently the subject of an interim suspension order from the Nursing and Midwifery Council.
Ms Cuthel was removed from the trust’s board in 2014 and sent on to secondment at Manchester Mental Health and Social Care Trust. She went on to become a director at Betsi Cadwaladr Health Board in Wales, and is now on the governing body of Nugent, a charity back in Liverpool.
Meanwhile, former chair Ms Molloy is now chief executive of another Liverpool-based charity Health at Work.
Community trust’s failures compared to Mid Staffs