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CQC warns Bristol Royal Children’s Hospital that it must improve staffing levels on cardiac ward to protect patients
31 October 2012
The Care Quality Commission has issued a formal warning to University Hospitals Bristol NHS Foundation Trust in relation to staffing levels on a cardiac ward at Bristol Royal Children’s Hospital.
Inspectors found that the trust had been failing to meet three essential standards of quality and safety covering staffing levels, staff training and support, and the overall care and welfare of patients. Providers have a legal responsibility to make sure they are meeting all the essential standards.
CQC warned the trust that it was facing further enforcement action unless it made improvements to staffing levels on Ward 32. The trust has also been told that it must provide a report within seven days setting out how it will meet the other standards.
The unannounced inspection on 5 September followed concerns which had been raised by two families whose children had been patients at the children’s hospital. Ward 32 is a 16-bedded unit which admits babies and children up to the age of 18 for investigation, assessment and treatment of cardiac conditions or for management of other related conditions.
Inspectors, joined by a professional clinical advisor, spoke to parents, nurses, healthcare assistants and doctors during the inspection. The inspectors met the trust shortly afterwards to pass on their preliminary findings.
Since receiving the warning notice, the hospital has reduced the number of beds on the ward to 12, creating two cardiac high dependency beds in the paediatric intensive care unit. The trust has also decided to reduce its programme of cardiac surgery in line with the new bed capacity, and to continue to restrict the ward to cardiac patients only.
This week the Care Quality Commission attended a meeting, convened by NHS South of England, along with the trust, Monitor and NHS commissioners to consider the actions taken by the hospital to ensure that the safety issues are being addressed. The actions were considered to be appropriate and their impact would be closely monitored.
A full report on all four standards which were reviewed by the inspection team has been published on the CQC website.
Inspectors found that there were not enough qualified, skilled and experienced staff to meet patients’ needs.
At the time of the inspection, the hospital did not have a designated high dependency unit, designed to provide care to children who may require closer observation and monitoring than is usually available on an ordinary children's ward.
Ward 32 admitted children from the paediatric intensive care unit who were recovering from cardiac surgery and were in need of high dependency care. Staffing levels were set in line with those found on a paediatric general ward, (one nurse for every four children over the age of two during the day time) even though guidelines from the Royal College of Nursing require more registered nurses to provide high dependency care (one nurse to every two children). At times, some shifts went unfilled. All clinical staff who spoke to the inspectors said that they were concerned at the low staffing
Care and welfare of patients
Inspectors concluded that patients were generally safe, but there were inherent risks to their health and wellbeing which the trust had been aware of for some time, but had not effectively addressed.
The trust was not reducing the risk of people receiving unsafe or inappropriate care, treatment and support, because high dependency care was being delivered on Ward 32 without adequate staffing levels over a sustained period of time.
Support to staff
The report concludes that staff were not supported to deliver care and treatment safely and to an appropriate standard. Several members of staff expressed their concerns about the lack of specialist training for doctors, registered nurses and health care assistants in children’s cardiac care or high dependency care. Some of the nurses had attended high dependency care training, and others were booked on the course in May 2013. Sometimes the workload meant that they were not able to attend teaching sessions or study days.
Respecting and involving people who use services
Inspectors found that people's privacy, dignity and independence were respected. The trust was meeting this standard.
Ian Biggs, deputy director of CQC in the South said:
“Everyone seems to agree that there should have been more staff on duty looking after some very frail children.
“All the parents we spoke with on Ward 32 told us that their child had received good treatment, support and care, even if the staff were very busy.
“Doctors and nurses told us that the current staffing levels were having an impact on the care and service being provided, with checks missed or reduced at times, and not enough time to communicate with families.
“The trust themselves have acknowledged that their system of providing high dependency care was not sustainable. But having identified the risks of providing high dependency care on a general ward, they had not taken effective steps to ensure they reduced the risks to patients.
“We found that on a number of shifts, staffing levels on Ward 32 fell below these inadequate levels, and to make matters worse, some staff did not have the appropriate experience to care for patients with high dependency needs.
“Since our inspection, University Hospitals Bristol NHS Foundation Trust has taken steps to reduce the number of cardiac beds and ensure a higher ratio of nurses to children.
“While the immediate effect may be fewer heart operations in Bristol, I am sure that the trust will work with commissioners to plan for the long term how it provides a safe service which fully meets its role as the regional centre for children’s heart surgery.
“We will continue to monitor the trust’s progress and at some time in the near future we will return to satisfy ourselves that the improvements we required have been made. If not we will consider further action to support the families who depend on this service.”
For further information please contact the CQC press office on 0207 448 9401 or out of hours on 07917 232 143.
Notes to editors
According to the warning notice, University Hospitals Bristol NHS Foundation Trust is in breach of:
- Regulation 22 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 - Staffing,
Regulation 22 states: In order to safeguard the health, safety and welfare of service users, the registered person must take appropriate steps to ensure that, at all times, there are sufficient numbers of suitably registered, skilled and experienced persons employed for the purposes of carrying on the regulated activity.
If the required improvements are not made within a set timescale, CQC has a range of enforcement powers which include restricting the services that a provider can offer, or, in the most serious cases, suspending or cancelling a service. CQC can also issue financial penalty notices and cautions or prosecute the provider for failing to meet essential standards. Any regulatory decision that CQC takes is open to challenge by a registered person through a variety of internal and external appeal processes.