The Care Quality Commission (CQC) has told Nottingham University Hospital NHS Trust it must improve the quality of its leadership and urgent and emergency services.
CQC carried out an inspection in June and July at urgent and emergency services and surgery at the Queen’s Medical Centre and surgery at City Hospital, as part of CQC’s continual checks on the safety and quality of healthcare services. An inspection of the well-led domain of the trust overall was also carried out.
Following the inspection, the trust was issued with a warning notice requiring them to make improvements around leadership, risk management, governance and culture due to concerns found.
As a result of the inspection, the overall rating of the trust has moved down from good to requires improvement. The trust was rated outstanding for being caring, requires improvement for being safe, effective and responsive and inadequate for being well-led. The overall rating for surgery remained as good and the overall rating for urgent and emergency services remained as requires improvement.
Sarah Dunnett, CQC’s head of hospital inspection, said:
“Our inspection of Nottingham University Hospital NHS Trust found a number of areas where improvements were needed, particularly around leadership regarding the trust board and executive team, culture and risk management, to ensure patients receive safe and timely care and staff are fully supported.
“We were concerned about the culture of bullying across the trust with many staff being too frightened to speak up. We were told of bullying incidents occurring that hadn’t been addressed quickly and staff hadn’t been adequately supported. We were told several bullying cases were directly attributable to racial discrimination which is not acceptable.
“There was a high level of anxiety among staff in the emergency department about the overall lack of capacity and space to meet the needs of people using the service. Although staffing was reviewed frequently, it was often challenging to resource the department when it was over capacity which resulted in patients being nursed in areas where staff were not always present which placed them at risk.
“However, we also saw examples of good practice across the trust. For example, surgery services at both sites were managed effectively with high quality patient care deemed a priority. Staff were caring, supportive and respectful and worked hard to achieve the best outcomes for patients.
“Despite the pandemic impacting waiting times for surgical treatment, managers monitored these and ensured patients could still access emergency treatment. The service had a dedicated flow matron who had oversight of these pressures and worked to ensure patients were not impacted.
“The trust knows where we expect to see improvements. We will continue to monitor the service closely to ensure the necessary improvements are made.”
The board was not working effectively together to achieve its full potential. Whistleblowing information described executive directors having poor relationships and often working in silo. Some staff did not know who their leaders were, and many said they were not visible or approachable.
Some board and executive team leaders lacked integrity, focusing on the trust’s external reputation rather than addressing challenges. For example, the maternity service was experiencing significant challenges that resulted in needing support from a nearby NHS trust. At this time, there was limited executive oversight of the service with the challenges being addressed locally outside of the executive team.
Following the inspection, CQC told the trust it must make several improvements, including:
- The disconnect between the board and the wider organisation must be addressed.
- Measurable action must be taken to address bullying across the organisation.
- Safety and safeguarding incidents must be reviewed and investigated, and lessons must be learned when things go wrong.
- All levels of governance and management must function effectively and interact with each other appropriately.
- All staff, including those with protected characteristics under the Equality Act, must be treated equally.
In urgent and emergency services:
- Patients must be assessed, and their care must be prioritised in a timely way.
- There must be enough competent staff employed and deployed to meet the needs of patients.
- Risks must be considered and sufficiently mitigated against, with appropriate oversight from the trust board.
- Patients who require admission must be transferred without unnecessary delay.
- All patients must receive a mental capacity assessment when concerns about capacity to consent are identified.