Alistair Campbell CQC way.
The impact of NHS [Un]improvement’s meeting with campaigners on 9 November, including an Open Letter to the Secretary of State, is evident here.
We then received a letter from NHSI’s Anne Eden. She confirms that Southern Health has not fulfilled the Enforcement Undertakings imposed on 30 June 2016. Indeed, Southern Health has not even commissioned a Board Capability Review – one of the undertakings imposed five months ago – all the remarkable in that the Mazars review identified a 4-year failure of leadership and governance.
[Redacted for brevity – but nothing new.]Click here to email Anne Eden
Indeed, in the Minutes of the meeting Healthwatch Hampshire record a bereaved father:
“Since April 2014 you [NHSI] have issued three Enforcement Undertakings for breaches in licence. There is an alarming overlap in the clauses that SH are in breach of. In respect of the latest Enforcement Undertaking issued on the 30th June 2016 there are specific actions required SH to conduct a Joint Governance Review and a Stakeholder Review. There has been no mention of these reviews at any board meetings since July. This was 5 months ago, what has been done? Additional licence clauses get put in place and changes aren’t being made or enforced at all.
“[He] reads out enforcement notices from 2014 and 2016 – similar requests and overlap regarding external reviews of board capability. This shows a lack of follow up and/or the inability of SH to make sustainable changes.
“[He] tore up Enforcement Undertaking to applause, to illustrate the lack of value of them in bringing about improvements.”
Moreover, NHSI were so concerned about what they heard that the Minutes record Anne Eden offering to facilitate a meeting with Dr Paul Lelliott of the CQC as:
“The top man for mental health and LD [learning difficulties)… he is the person that needs to hear your stories [our emphasis]”.
Yet a Care[less] Quality Commission Press Release¹ earlier this week (four weeks after the NHSI meeting) but relating to an inspection in September (over a month before the NHSI meeting), quotes Dr Paul Lelliott:
“Overall, we have concluded that the trust had taken sufficient action to meet the requirements set out in the Warning Notice. The trust has assured us that it will continue to working on the outstanding breaches. We will be monitoring the trust’s progress closely – returning to check that the required improvements have been made and are being sustained.”
So the CQC lifts a Warning Notice before Southern Health has met the requirements of its Enforcement Undertakings … and the media (disappointingly including our friends at the BBC) swallow the Press Release hook, line and sinker despite having evidence that Southern Health is still largely in denial of its failings.
What is even more significant is that the CQC inspection took place on 13 – 15 September 2016 when failed Chief Executive, Katrina ‘Teflon’ Percy (albeit in another capacity) and Interim Chairman Tim ‘Not-so’ Smart still worked for Southern Health.
Moreover, the CQC press release only emphasises what they call improvements. Drill down into (I know more NHS buzz words – meaning “read”) the CQC report itself:
“We [the CQC] remained concerned about the environment at a number of the trust’s locations, where necessary improvements had either not yet been made through the programme of major works or had not been identified and prioritised through the trust’s internal processes. For example, we identified environmental issues at Elmleigh in relation to poor lines of sight, multiple ligature risks, safe management of mixed gender areas, risks from patients absconding and staffing arrangements that were ineffective for the ward’s layout.
“There were potential infection prevention and control issues with shared bathrooms at Forest Lodge. Some of these were in a very poor state of repair and were damp, had peeling ceilings and damaged flooring. Although necessary renovations were part of the planned estates work taking place at the service, we asked the trust to prioritise this aspect of the work.
“We looked specifically at risk assessments and care plans relating to the assessment and management of risks from the environment to individual patients. There was variation in quality and detail. Some were completed to a high standard, and these were verydetailed. Others contained minimum information and no evidence of a person centred care plan.
“The trust had introduced a standardised safety and risk management plan to incorporate an individual’s risks in relation to the specific ward environment. We were told that every patient now had this in place. However, we found that there was no safety and risk management plan relating to the environment in a quarter of the 143 records we reviewed.
“We also raised concerns about risk assessment processes at Ravenswood House medium secure unit.
“Some staff raised their concerns with us about on-going issues on their wards due to low numbers of staff and an over-reliance on agency staff. This was particularly evident at Bluebird House and across the older persons’ mental health wards, where an increase in acuity of individual patients’ mental health problems could have a significant impact on the whole ward.”
So Dr Paul Lelliott lifts the Warning Notice on a Trust that continues to constitute a risk to life inter alia with ligature risks, other serious environmental issues, infection risks and – despite the problem having been regularly exposed in the last five years – no safety and risk management plan in place for 25% of patients. In the latter respect, the CQC noted:
“We were told that every patient now had this in place.”
So someone at Southern Health is telling porkies – what a surprise. As this is a medical issue, I wonder if Dr Lesley ‘Slippery’ Stevens knows where the buck stops on this one.
In short, the CQC is issuing press releases, which give the false impression that Southern Health is safe, and the media are repeating them without checking the facts.
Where are you Dr Lelliott – please come and talk to bereaved families?
Hope runs eternal – there are positive signs that new Interim Chairman, Alan Yates is very keen to meet and learn from bereaved families, carers, ‘rebel’ governors and other campaigners – in distinct contrast to his predecessors.
¹ Curiously, this press release is not available on the CQC press release web page.