Inspectors were forced to intervene when they witnessed a patient choking and staff failed to help, according to a highly critical report on the quality of care at Portsmouth’s Queen Alexandra Hospital.
It was just one of a series of distressing examples of poor care documented by the Care Quality Commission, which has told Portsmouth Hospitals NHS Trust it must make urgent improvements to protect the welfare and dignity of some of its most vulnerable patients.
“Our inspection team intervened in order to ensure the safety of the patient”
But the regulator suggested the serious failings were underpinned by a range of other issues including staff shortages, suggestions of bullying and previous failings at management level.
Following inspections in February and May this year, both the medical and urgent and emergency care departments at the hospital were rated “inadequate” for safety.
The CQC’s report on the trust described how members of the inspection team had to step in on a number of occasions to ensure the safety of patients, including one incident in the acute medical unit (AMU) where they saw someone choking.
“We observed a patient choking on their meal; two members of staff were in close proximity but did not attempt to help the patient,” said the CQC in its report. “Our inspection team intervened in order to ensure the safety of the patient.”
In another incident in the AMU, inspectors observed a patient with dementia calling out for help but not getting it.
“A member of staff stood next to the patient did not respond to these calls and, as a result, the patient was incontinent,” said the report. “The patient’s care plan clearly stated they required assistance with toileting.”
“The board appeared to have no real understanding of what was happening on the wards”
In addition, inspectors found the quality of emergency medical care was “very poor” and gave medical care services an overall rating of “inadequate”.
“There was a culture of poor care and behaviour which had become normalised for staff within the AMU and some medical services,” said the report, published today.
However, inspectors also highlighted pressures on staff with some “frustrated and demoralised” and higher than average staff sickness and turnover rates.
“Nursing shifts were not always filled, which meant unwell or vulnerable patients did not receive the appropriate level of care and supervision,” said the report. “Staffing was not always adjusted according to acuity and demand at any given time.”
Meanwhile, “staff did not feel listened to or connected to senior management”, said the report which also reveals allegations of bullying and harassment.
Other incidents described in the document included staff failing to preserve the dignity of frail and confused patients.
“I am convinced that we have the skills, dedication and ambition to address all the issues raised by the CQC”
Inspectors had to intervene once again when they witnessed a female patient with dementia wandering around a medical ward in “a short nightdress, which did not preserve their dignity”.
“The patient walked past two members of staff who were sitting at the nurses’ station and did not attempt to help the patient,” said the report. “The inspection team intervened and asked staff to assist the patient to ensure their safety, privacy and dignity.”
In the AMU inspectors saw a patient left without a blanket or clothing on the lower half of their body, because “nursing staff did not help them to remain covered”.
Another patient was sat in a chair in mesh underwear “with their incontinence pad exposed”.
Other key concerns included a failure to always complete vital assessments to identify patients at risk of falls, pressure ulcers and nutrition. Meanwhile, some patients at risk of malnutrition did not get help at mealtimes.
When it came to emergency care services, which were rated “requires improvement” overall, inspectors noted some positive steps had been made, including the introduction of a “navigator nurse” in October 2016.
Based in the emergency department waiting room, this senior qualified nurse carries out a brief clinical assessment of patients as soon as they arrive, aided by a healthcare support worker.
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The nurse is able to stream patients direct to the major treatment area, if necessary, and also to the minor treatment area and minor illness service.
“We observed the navigator nurse triaging a walk-in patient with suspected sepsis to majors for urgent medical assessment,” said the report. “Patients we spoke with told us they felt the navigator role ensured they were able to discuss their reason for attending with a nurse immediately when they arrived.”
A second report on wider performance issues at the trust found most staff were “committed to providing the best care they could” with the resources and training available to them.
However, it highlighted failings in leadership and managements that made this task harder.
Inspectors noted the trust’s mortality rate had increased steadily over the past year, but said they “were not assured this was being addressed”.
They found the quality of incident investigations was “very poor” and there was “limited evidence or assurance that lessons learned from incidents were implemented”.
This report also highlighted bullying claims and the fact staff felt unable to raise concerns.
“Many staff perceived there was bullying and didn’t feel able to speak out about concerns. This was expressed by different staff groups who raised concerns to CQC before, during and after the inspection,” said the report.
“We were not assured that the processes for raising concerns internally were open and free from blame. This discouraged staff from feeling free to speak about concerns,” said the inspectors.
At the time of inspection, the senior team was mainly made up of interim leaders, noted the CQC.
“The board appeared to have no real understanding of what was happening on the wards: we concluded that the trust leaders were not giving sufficient attention to many of the concerns we identified or the concerns of their own staff,” said CQC chief inspector of hospitals Professor Ted Baker.
The CQC has issued a warning notice and placed six conditions on the trust’s registration, including the fact it must take immediate action to ensure patients are safe.
That includes ensuring enough, suitably qualified staff, robust risk assessments and that care plans for those with mental health issues are followed.
Trust chief executive Mark Cubbon, who has been in post for a month, admitted the report “makes for difficult reading”.
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“We have fallen short in some key areas; but I am confident that we can and will do better,” he said.
“In the four weeks since I have been here, I am convinced that we have the skills, dedication and ambition to address all the issues raised by the CQC and ensure we give the best possible care we can to every patient,” he said.
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Mr Cubbon, who has a nursing background, said the trust had made some “significant and important changes” since the CQC inspections took place in February and May.
This included “strengthening the joint working of our doctors and nurses in the emergency department, urgent and medical services”.
“We have also seen very significant improvements for vulnerable patients, including those who have mental health issues, we have active, early risk assessments in our ED, a mental health liaison team, working much more closely together and much stronger cross organisation working with colleagues from partnership organisations,” said Mr Cubbon.
“I will be publishing our action plan, so patients, staff and our key partners can see how the trust is going to deliver better, improved care for patients who use our emergency department, and urgent and medical services here at Queen Alexandra Hospital,” he added.
The trust has recently appointed Dr John Knighton as it new medical director, with other permanent director appointments due to be announced in coming weeks, according to Mr Cubbon.
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Nicola Ryley is currently interim chief nurse, having joined the trust in May from her post as executive director of nursing at Devon Healthcare NHS Trust.
According to the trust’s website, she has been brought in on a temporary basis “to provide professional leadership to nursing and to promote the delivery of safe, effective, patient-centred care to all who use our services”.
Earlier this week, it was revealed that the trust had launched a review of its patient records, following a warning from external advisers that thousands of patients may have been put at risk of harm due to missed follow-up appointments.