Patients sustain broken bones on hospital ward that went ‘unreported’

Inspectors identified ‘significant shortfalls’ at the NHS hospital wards

Care inspectors have raised concerns about “significant shortfalls” in safety at two Cambridgeshire hospital wards. The Care Quality Commission (CQC) carried out an unannounced visit to the Denbigh and Willow wards at Fulbourn Hospital in Cambridge, as well as Maple one and Maple two wards at the Cavell Centre in Peterborough, on January 28 and 29.

The wards are overseen by the Cambridgeshire and Peterborough NHS Foundation Trust (CPFT). The CQC carried out an inspection due to the age rating of the wards, which care for people over 65 years old for various illnesses, as well as “concerns about risk”.

Inspectors rated the trust as requiring improvement overall. The trust was rated as requiring improvement for safe and well-led, but good for effective, caring and responsive.

Stuart Dunn, CQC deputy director of mental health in the East of England said inspectors found that leaders had “missed some concerning gaps in people’s safety”. Mr Dunn added: “The trust had a system for reporting safeguarding incidents but, without a centralised log, staff were not always able to provide these records. This limited leaders’ ability to review or learn from them to protect people in future.

“Additionally, many staff felt there weren’t enough of them to do their jobs properly, and we found they couldn’t provide people one-to-one care regularly. At one point, one of the experts by experience supporting our inspection spent nine minutes speaking to people on a ward without seeing any staff.

“When they sought out staff, they found the nursing office was also unattended.” Mr Dunn recognised that staffing levels resulted in people being able to access limited activities during the week.

He added: “People also told us they didn’t always feel involved in decisions about their own care, and we saw staff didn’t always take all practical steps to support people making their own decisions.

“Most staff were kind, skilled, and respectful. They communicated with people well. When people felt distressed, they de-escalated the situation compassionately.

“However, leaders need to ensure they’re aware of incidents and risks on their wards, so they can guarantee people a consistently safe and high-quality service.” CQC has shared its findings with the trust so they “know where improvements must be made and where there is good care to build on”, added Mr Dunn.

In the report, inspectors identified a number of shortfalls across the wards. In the care section, inspectors said the service didn’t always have a “proactive and positive culture of safety based on openness and honesty”.

The inspector added: “Lessons were not always learnt to continually identify and embed good practice.” The report also said staff “did not always investigate and report safety events”. It was recorded that in the last three months, 2,138 restraints were carried out on the Denbigh ward, as well as 22 restraints on the Maple one ward.

It was also recorded that “two patients on Denbigh ward had sustained broken bones during the night time due to unwitnessed injuries” and these weren’t reported.

The trust’s safeguarding on these wards was rated a lower score of one, with inspectors identifying “significant shortfalls” in this. The report said: “The service did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that.

“They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.”

Staff were also said to “not always treat people with kindness, empathy and compassion” and they didn’t always “respect their privacy and dignity”.

Other concerns found by inspectors were:

• Leaders need to address some alarms going off in error on Willow ward, Fulbourn Hospital, which could wake people up and make them feel unsettled
• Leaders didn’t ensure all staff had enough training in medicines management and weren’t always recording or storing medicines safely
• Inspectors found some breaches of food safety guidelines and staff at the Cavell Centre weren’t always washing cups with soap, which was an infection risk
• Leaders had poor oversight of some risks, including safeguarding, potential ligatures, areas staff could not see, and the use of portable heaters.

While a number of concerns were raised, people in the wards and relatives said staff were helpful and supportive. Staff also told inspectors they felt “supported and respected” and inspectors praised the trust’s work to “deliver high quality care within the budgets available”.

A spokesperson for the CPFT said the trust has taken the findings “seriously” and “immediate actions” have been taken to address concerns. These actions include enhancing safeguarding oversight at a team level, addressing areas of safety and reviewing medicine governance arrangements.

The spokesperson added: “We welcome the CQC’s recognition of the compassionate care delivered by our staff, the positive feedback from relatives and carers, and the services continuing to be rated good for being caring, effective, and responsive.”

The Denbigh ward at Fulbourn Hospital is a 14-bed mixed sex ward for people over 65 years old with cognitive impairment, while the Willow ward is an 18-bed ward for people over 65 years with acute functional illness.

Maple one at the Cavell Centre is an eight-bed mixed sex ward and Maple two is a 14-bed mixed sex ward. Both these wards provide care for people over 65 with cognitive impairment.