CQC response to report on paediatric cardiac surgery at John Radcliffe Hospital

The Care Quality Commission said today’s report about paediatric surgery at the John Radcliffe Hospital, raised serious concerns.

Cynthia Bower, CQC’s chief executive, said: “While the report does not say that the failings caused any deaths, I am in no doubt that babies were not receiving care that was as safe as it should be.

“The trust did not handle the safety concerns raised by the surgeon in an effective or transparent way. The delay in notifying the board, strategic health authority and regulator was unacceptable. The clinical governance arrangements to identify and monitor safety risks were not up to scratch. Induction and supervision was clearly poor.”

Ms Bower said CQC was monitoring the trust closely and planned to review standards at the trust as part of its new registration system, which involves ongoing monitoring of quality and safety.

“We will conduct a full review of quality and safety standards across the hospital. This will involve inspections, interviews with patients and staff, and a review of all available data. We won’t hesitate to take action if we find similar problems exist elsewhere in the hospital.”

Background

On 1 April, CQC introduced a tough new licensing system. It registered Oxford Radcliffe NHS Trust without conditions. However, the trust declared concerns relating to:
• insufficient staff on some wards
• poor attendance at staff training
• performance in the cardiac unit (these concerns relate to today’s report)

CQC did not consider that formal conditions were necessary because the trust had good plans in place to address these issues. CQC will check on progress during its upcoming review.

Focused on better care - Care Quality Commission first annual report

Please find below a link to the CQC annual report for 2009/10, we report on our work in CQC’s first year of operation – from 1 April 2009 to 31 March 2010.

Visit our online report to look back on the year’s achievements and challenges and watch videos featuring some of the many people who have worked with us to help make sure that everything we do is focused on better care.

. Visit our online annual report:
http://www.cqc.org.uk/newsandevents/newsstories.cfm?FaArea1=customwidgets.content_view_1&cit_id=36498

Significant improvements found in Mid Staffordshire

Improvements in mortality rates, staffing levels, patient experience and responses to concerns have been found in a review of Mid Staffordshire NHS Foundation Trust.
We have today commended the trust for its progress in the year since a critical report was published while also identifying a number of areas where improvements are still needed.

These include some waiting times in A&E and access for nurses to some equipment.
As a part of the review we carried out both announced and unannounced inspections at the trust, speaking to patients, staff and local groups.
Following the positive findings, we will be lifting five of the six conditions placed upon the trust’s registration in April.

These conditions related to:

• Staffing levels.

• Monitoring of the quality of care.

• Equipment training for staff.

• Managing patients in A&E.

• Maintenance of medical equipment.

The final condition, which relates to supervising and appraising workers, has not yet been reviewed and this will be done in August.

• Read our full press release on the review and the lifting of the conditions
http://www.cqc.org.uk/newsandevents/pressreleases.cfm?cit_id=36495&FAArea1=customWidgets.content_view_1&usecache=false

• Find out more about Mid Staffordshire NHS Trust and the concerns over healthcare http://www.cqc.org.uk/usingcareservices/healthcare/concernsabouthealthcare/midstaffordshirenhsfoundationtrust.cfm

CQC's response to the Dept of Health arm's length bodies review

Cynthia Bower, CQC Chief Executive, has welcomed the publication of the Department of Health’s Arm's Length Bodies review, saying:

“I'm pleased the Department has underlined the importance of integrated health and social care regulation, which we believe can be a real lever to improve the quality of care. The report recognises the hard work CQC has put in to deliver registration of the NHS on time while moving to a more cost effective model.

“In taking on the licensing functions of the HFEA and HTA, we will be looking to preserve the specialist expertise within these bodies. We already regulate a number of sectors where it’s vital to have in-depth knowledge – the rights of people detained under the Mental Health Act, for example – and are confident we can build on what these two bodies have achieved so far.

“We look forward to working with the Department to develop these proposals in more detail, and will be working with Monitor in particular on the single licence for all care providers.”

For the DH's press release and the full report of the Arm's Length Bodies Review, use this link to the DH website:
http://www.dh.gov.uk/en/MediaCentre/Pressreleases/DH_117844

For the DH's consultation paper on expanding Monitor's remit, 'Regulating Healthcare Providers':
http://www.dh.gov.uk/en/MediaCentre/Pressreleases/DH_117848

Registration condition on Surrey and Borders lifted

We have lifted one of two conditions imposed on Surrey and Borders Partnership NHS Foundation Trust.

Two conditions were imposed on the trust earlier this year after we discovered that it was not meeting our essential standards of quality and safety.

We required the trust to take action to ensure that:

· all people who use services have up to date care plans and that staff receive training in the assessment and recording of risk
The trust provided us with evidence to show that it has met the condition before the deadline and applied for the condition to be removed.

Following an inspection in May where we interviewed patients and staff and reviewed documents at six units, we discovered that the trust has:

· put in place monthly record-keeping audits to check on care plans and risk assessments

· designated a nurse to primarily be responsible for auditing the quality of the Care Plan Approach and risk assessments

· organised an audit group to carry out regular inspections of inpatient services including record-keeping, assessments and care plans

· trained all relevant staff in their three-yearly Care Plan Approach and risk training, and will provide them with 10 clinical supervision sessions and an annual appraisal
We will assess whether the trust has met the second condition in the near future.

Find out more

· Download the review of compliance:
http://www.cqc.org.uk/publications.cfm?fde_id=15936

· Read the press release:
http://www.cqc.org.uk/newsandevents/pressreleases.cfm?cit_id=36437&FAArea1=customWidgets.content_view_1&usecache=false

· Read our essential standards of quality and safety:http://www.cqc.org.uk/aboutcqc/whatwedo/monitoringessentialstandardsofqualityandsafety/whataretheessentialstandardsofqualityandsafety.cfm

Comment from Dame Jo Williams in response to Department of Health’s announcement that she is the government's candidate for CQC chair.

Dame Jo Williams said: “I am absolutely delighted to be the government’s candidate for the post of chair for the Care Quality Commission (CQC).

“I have thoroughly enjoyed the last seven months as interim chair at CQC, and am extremely proud of what we have achieved in that time. We have successfully registered the NHS against a new set of standards, and look forward to rolling this out to all health and adult social care providers over the coming months and years. But I don’t underestimate the challenges ahead.

“I am deeply passionate about continuing to drive improvement to ensure everyone has access to safe, quality services across the country.”

-ends-

Department of Health Press release:

http://www.dh.gov.uk/en/MediaCentre/Pressreleases/DH_117655

Dame Jo Williams' reaction to new funding commission appointment

Reacting to Health Secretary Andrew Lansley's announcement today that she has been asked to sit on the new Commission on the Funding of Care and Support, Dame Jo Williams, acting Chair of the Care Quality Commission, said:

"I am very pleased to have this opportunity to help shape a way forward on one of the most significant issues facing society.

"I hope to be able to contribute towards finding an equitable and sustainable solution for future generations."

Dame Jo will serve on the new commission for one day a week while continuing her role as CQC's acting chair.

Care Quality Commission's investigation into GP out-of-hours provider, Take Care Now, reveals serious failings

· Take Care Now (TCN) did not act on previous warnings about the use of diamorphine prior to the death of David Gray, and systemic failings were not addressed
· The five primary care trusts (PCTs) that used TCN had limited understanding of the service and did not monitor performance adequately

The Care Quality Commission (CQC) today (Thursday) published its report into the GP out-of-hours provider, Take Care Now (TCN).

The regulator’s investigation was triggered by the tragic case of Mr David Gray, a patient killed by an overdose of 100mg diamorphine in February 2008. The drug was administered by Dr Ubani, an out-of-hours doctor from Germany employed by TCN.

Dr Ubani has since been struck off the General Medical Council (GMC) register and is no longer permitted to practise in the UK.

CQC looked in-depth at TCN’s out-of-hours service to assess its performance dating back to April 2007. It also assessed whether lessons had been learned and action taken following the death of Mr Gray.

As part of its investigation, CQC considered how the five PCTs that used TCN’s out-of-hours services monitored the quality of the service being provided.

CQC’s report shows that prior to the death of Mr Gray, TCN did not take sufficient action to ensure the safe use of diamorphine. This is despite a senior clinician warning TCN managers that it “was only a matter of time before a patient is killed” due to an overdose of the drug.

The warning followed two non-fatal overdoses of diamorphine, which occurred in Suffolk in the year before Mr Gray’s death (April and August 2007). In both cases the drug was administered by doctors from Germany, where diamorphine is not routinely used. Clinicians suggested changes to prevent future overdoses, but these were not implemented.

Today’s report highlights further systemic failings by TCN. CQC published evidence that:

· staffing levels were potentially unsafe. Unfilled shifts and lack of clinical cover could have compromised the care of patients. There were occasions when one nurse was the only clinical cover for 70 miles.

· TCN failed to investigate, act upon and learn from serious incidents. This included the two previous overdoses of diamorphine.

· reporting of activity to the PCTs was not clear and transparent. “Double counting” of some patients would have given the impression that TCN was treating more patients and could have affected contract negotiations with the PCTs.

· local GPs were not confident in the service provided by TCN. Fifty per cent of GPs surveyed by CQC said the ability of the organisation to provide clinical care in people’s home was “poor” or “very poor”.

· TCN grew rapidly, taking on more contracts with PCTs, but apparently without the clinical governance in place to ensure the quality of its services.

CQC reviewed the commissioning and monitoring role of the five PCTs that purchased out-of-hours services from TCN: NHS Cambridgeshire, NHS Great Yarmouth and Waveney, NHS South West Essex, NHS Suffolk and NHS Worcestershire.
CQC found that:

· NHS Cambridgeshire took significant steps to monitor TCN's services after the death of Mr Gray.

· Out-of-hours services were a low priority for PCTs, reflecting the national position at the time.

· Those responsible for monitoring the contract with TCN had a limited understanding of the service. They did not fully understand the performance reports or the national quality requirements (NQRs)

· Changes to services that could have had significant implications for patients were often discussed and agreed by non-clinical staff

· None of the PCTs had robust arrangements to share information on poorly performing clinicians.

· Cornwall PCT had admitted Dr Ubani to its performers list without requiring proof of language competency and with limited checking of his references. This meant Dr Ubani could work anywhere in the UK. The trust did not formally review how doctors were admitted to the performers list until March this year.

CQC says the PCTs involved have since taken action to improve commissioning and monitoring of out-of-hours services. But it makes national recommendations to all PCTs and out-of-hours providers across the country to ensure a safe and effective service is delivered.

In relation to the two SHAs, NHS East of England and NHS West Midlands, there is no evidence
that they paid specific attention to out-of-hours care, but have since taken significant action to address issues about these services in their regions.

Dame Jo Williams, CQC chairman, said: "Take Care Now failed on many fronts. Not only did it ignore explicit warnings about the use of diamorphine, it failed to address deep-rooted problems across its entire out-of-hours service. This had tragic consequences for Mr Gray.

"Take Care Now is no longer in operation, but the lessons of its failure must resonate across the health service. Around seven million people contact GP out-of-hours services every year - the provider, the primary care trust and individual clinicians all have a responsibility to ensure services are as safe as possible.

"Since the death of Mr Gray, there is no doubt that out-of-hours care is now a high priority on the NHS agenda, and rightfully so. Primary care trusts in particular are now scrutinising the services they commission in greater detail and demanding assurances about safety.

"We hope the family of Mr Gray will take some comfort in knowing that his tragic death has brought about significant change in the way out-of-hours services are delivered and monitored.
Commenting about potential changes to government policy on out-of-hours services, Dame Jo added: "The Secretary of State has made it clear that there are changes around the corner. Regardless of what these changes may look like, the lessons are clear - the competency of overseas doctors must be properly tested; serious incidents must be properly investigated and quality of care must be monitored closely."

From April 2012, companies providing GP out-of-hours services must be registered with CQC in order to legally provide services. The new registration system brings the NHS, independent healthcare and adult social care under a single set of essential standards of quality and safety.
CQC says it will take the findings of its investigation into TCN, and other external reviews of out-of-hours services, into account when making decisions about how it will regulate out-of-hours providers in line with the new standards.

Find out more

· Full summary of findings http://www.cqc.org.uk/publications.cfm?fde_id=15914

· Briefing notes http://www.cqc.org.uk/publications.cfm?fde_id=15915

· Report 1 http://www.cqc.org.uk/publications.cfm?fde_id=15916

· Report 2 http://www.cqc.org.uk/publications.cfm?fde_id=15917

· Report 3 http://www.cqc.org.uk/publications.cfm?fde_id=15918

· Appendices http://www.cqc.org.uk/publications.cfm?fde_id=15919

CQC lifts registration conditions at Northern Lincolnshire and Goole

· Download the review of compliance http://www.cqc.org.uk/publications.cfm?fde_id=15912

Conditions were imposed on the trust after an inspection of the A&E department at the Diana Princess of Wales Hospital in Grimsby.
Inspectors found that patients who were admitted to the hospital by ambulance were:

· asked to wait in the corridor before triage (the process of assessment based on patients’ need for immediate medical treatment)
· not always properly assessed
We gave the trust a deadline of 1 April to ensure:
· all ambulance patients are seen by a senior clinician as soon as possible
· the quality of services provided by the A&E department are regularly assessed and monitored

During an unannounced visit in May, we found that the trust had improved the arrangements for patients in the A&E department. The trust had:

· ensured a nurse was responsible for ‘triaging’ patients upon arrival
· set up protocols to ensure faster handover of patients from ambulance to A&E staff · secured funding for a new triage area
· arranged for the board to scrutinise the top 10 risks for each department
· given A&E staff more input when it came to clinical governance
· ensured more incidents were reported

Following the new arrangements, approximately 68% of patients brought in by ambulance were triaged within 15 minutes.

Find out more

· Read the press release http://www.cqc.org.uk/newsandevents/pressreleases.cfm?cit_id=36427&FAArea1=customWidgets.content_view_1&usecache=false

· Read about our essential standards of quality and safety http://www.cqc.org.uk/aboutcqc/whatwedo/monitoringessentialstandardsofqualityandsafety/whataretheessentialstandardsofqualityandsafety.cfm

Conditions lifted on Mid Essex Services NHS Trust

· Download the review of compliance at Mid Essex Services NHS Trust: http://www.cqc.org.uk/publications.cfm?fde_id=15911

We imposed a condition on the trust’s registration following an inspection in February 2010 which revealed a lack of:

· cleanliness
· staff training into infection control

We required the trust to take urgent action to ensure cleanliness and safety for all its patients and staff.

In May we made an unannounced visit where we interviewed staff and inspected wards. The inspection revealed significant progress in following appropriate infection control policies.
However, minor improvements can still be made in areas concerning the:

· cleanliness of patients’ rooms
· logging and recording of decontaminated medical equipment such as pillows, mattresses and disposable items

Find out more

· Read the press release:

http://www.cqc.org.uk/newsandevents/pressreleases.cfm?cit_id=36422&FAArea1=customWidgets.content_view_1&usecache=false

· Find out how we monitor essential standards of quality and safety:
http://www.cqc.org.uk/aboutcqc/whatwedo/monitoringessentialstandardsofqualityandsafety.cfm

Care Quality Commission response to the government's health white paper

CQC said the white paper confirmed its continued role as the quality regulator for health and adult social care. Under the proposals, the current risk-based regulatory regime will remain largely unchanged.

However, the white paper does set out a number of important changes for CQC.

- HealthWatch England will be established as a new independent consumer champion within CQC
- Providers will have a joint licence overseen by both Monitor and CQC

-The NHS Board will take over assesssment of commissioning

In relation to 'HealthWatch', Ms Bower said: "Anything that gives people more say in how care services are monitored is a good thing. We already work closely with local groups and this will formalise and strengthen that collaboration. There is enormous potential here to share information and get local people even more involved in inspections and assessments. But we want to be clear that HealthWatch should be a separate arm of the regulator. It must be close enough to CQC to influence regulation and share information, but retain enough independence to be a strong voice, constantly challenging on behalf of local people."

Ms Bower added that CQC would begin discussions with Monitor over the joint licensing system.

Ms Bower said: "This year we introduced a tough new licensing system for essential standards of quality and safety. We look forward to working with Monitor to develop a joint licensing regime."
In relation to assessment of commissioning, Ms Bower said: "It's right for the responsibility of assessing commissioning to sit elsewhere, however no doubt we will still contribute a lot of important information. CQC's role is now clearly focussed on getting standards of quality and safety in place across the whole sector."

Reduced risks to patients at West London Mental Health NHS Trust

Our new report reveals significant improvements at West London Mental Health NHS Trust (WLMHT) to protect patient safety.

Download the follow-up report:
· http://www.cqc.org.uk/publications.cfm?fde_id=15896

Nine recommendations were implemented on WLMHT in July 2009 after a year-long investigation of the Trust. The original report highlighted delays in investigating incidents and a failure to learn from common themes documented in action plans.
This was followed up by an inspection completed in March of this year, involving interviews with people who used services, staff and board members, and a review of documented evidence.

This inspection found that the trust had made improvements in:

· the assessment of physical health care
· the reporting, investigating and communication of risks
· the provision of primary care services
· cleanliness of wards

However, the trust must continue to make progress in:

· care planning
· improving communication between staff and people who use services
· demonstrating that lessons learnt are shared across the whole trust
CQC will continue to monitor the trust to ensure that recommendations are met. It will carry out a review of commissioning services later this year.
Find out more:

Read the original report
· http://www.cqc.org.uk/_db/_documents/Investigation_into_West_London_Mental_Health_NHS_Trust_FINAL_200907171608.pdf
Find out how we monitor the use of the Mental Health Act
· http://www.cqc.org.uk/usingcareservices/mentalhealthact.cfm

Read the press release
· http://www.cqc.org.uk/newsandevents/pressreleases.cfm?cit_id=36395&FAArea1=customWidgets.content_view_1&usecache=false