Agenda item

PLYMOUTH HOSPITALS TRUST - CARE QUALITY COMMISSION UNANNOUNCED INSPECTION

The panel will consider a report on the recent Care Quality Commission unannounced inspection of Derriford Hospital.

Minutes:

The Chief Nurse reported to the panel on the recent unannounced inspection by the Care Quality Commission (CQC) following a number of “never-events” which occurred at the hospital. It was reported that –

 

  1. never events were serious preventable incidents which should not occur when preventable measures had been implemented. Six never events had occurred at the hospital over a ten month period;

 
  1. never events were reported to the PHNT public board meeting on the 28 January 2011 where the board agreed to engage proactively with the CQC;

 
  1. the CQC made an unannounced visit to the Hospital on the 16 February 2011 and found that there was not full and proper compliance with World Health Organisation checklists;

 
  1. since the CQC visit PHNT had published clear guidance on how to complete the checklist. This guidance was displayed in all theatres and anesthetic rooms;

 
  1. before making mitigating changes theatres were reporting compliance rates of between 18 per cent and 80 per cent of patients receiving a complete checklist. Since the guidance had been published weekly compliance rates increased consistently above 95 per cent;

 
  1. further work was being carried out in order to prevent further incidents which included:

 

·        a review processes related to swabs and a standard operating procedure was developed for use in all theatres;

·        a swab ‘bag it’ system was introduced in all theatres to ensure accuracy of swab counts;

·        the throat pack process had been reviewed and a standard operating procedure was developed for use in all theatres;

·        team brief and debrief processes were being reviewed to ensure standard approach across theatre teams;

·        theatre lists scheduling and compilations were being reviewed;

·        all staff were receiving written and verbal communication updates on changes to practice and plans for improvement;

 
  1. theCQC visited again on the 22 March 2011 to check for compliance. Although the CQC had not yet published a report on this visit PHNT did not expect to have to carry out further work.

 

In response to questions from members of the panel it was reported that-

 

  1. PHNT had carried out route cause analysis into each never event and had implemented processes and procedures which were easy to adhere to;

 
  1. it was possible that junior staff felt unable to challenge senior staff members, if there was a case for disciplinary procedures further action would be taken;

 
  1. theatre teams were based around specialities, if there were staff shortages people could be moved around teams. PHNT had started a review around the scheduling of surgery;

 
  1. PHNT had a higher instance of never events than other hospitals in the UK;

 
  1. each ‘never event’ had been subject to a root cause analysis. It was felt that adequate mitigating processes had been put in place. However when a further event occurred in November the problem was found to be rooted in the culture of the work place;

 
  1. no long term harm had been caused to any patient. Patients and their families were offered meetings with the trust following the events and engagement with patients continued;

 
  1. there had been personnel changes, the problem was not based in local teams but was rather a systemic problem.

 

Agreed that the Plymouth Hospitals NHS Trust would provide the panel with an update at a future meeting following the publication of the Care Quality Commission report. The Chair of the Cornwall Health and Social Care Overview and Scrutiny Committee would be invited to the meeting.

Supporting documents: