Morecambe Bay: From special measures to outstanding care
How does an NHS trust rocked by a scandal in which patients died turn itself around and earn an outstanding care rating from the Care Quality Commission? By trusting patients and staff to deliver change.
How does an NHS trust rocked by a scandal in which patients died turn itself around and earn an outstanding care rating from the Care Quality Commission? By trusting patients and staff to deliver change
Just under three years ago, things didn’t look great for the University Hospitals of Morecambe Bay NHS Foundation Trust.
Still reeling from a scandal involving the deaths of 11 babies and a mother at one of its hospitals, the trust had been placed into special measures by the Care Quality Commission (CQC) in June 2014. It’s fair to say that its reputation was not good.
Today, however, the trust is celebrating a different CQC verdict. A report published in February rated the care given by its hospitals in Cumbria and Lancashire as ‘outstanding’, while the overall rating was ‘good’.
It’s an astonishing turnaround for the organisation, and nobody could be happier about it than executive chief nurse Sue Smith.
Change of culture
‘I came here in December 2013 and the trust had a bad name that unfortunately was well-deserved,’ she says. ‘There was poor staffing, poor relationships, staff were working in their own little areas, there was poor communication, governance was poor, there was no alignment between board and ward. People died, a mother and babies died.
‘Although the trust had a bad reputation, it also had a lot of good staff, but they were not well-resourced or empowered. It was resonant of what we saw at Mid Staffordshire NHS Foundation Trust - staff would come to work, do the job and go home. There was still lots of good care, but there were pockets of poor care.’
Turning that around has taken a lot of work, and has included obvious steps such as recruiting more staff. But it has also involved changing the culture of the organisation, so that staff are empowered to do what they see needs to be done to improve patient care. This includes a Listening to Action programme that encourages staff to lead on making positive changes, such as improvements to bereavement services (see box).
There has also been a strong focus on patient safety, including weekly patient safety summits involving nurses, doctors and allied health professionals who come together to discuss incidents without blame. ‘Previously incidents were discussed months after they happened. But now if something happens today, we’ll be talking about it on Wednesday,’ says Ms Smith.
Patient engagement has been key to the transformation, and Ms Smith is particularly proud that some family members affected by the maternity scandal have been involved. Two have even joined as staff – something she sees as a huge vote of confidence in the trust’s improvement.
The CQC inspectors were certainly impressed, remarking that considerable progress had been made since previous reports. Ms Smith says staff were enthusiastic, rather than worried about the latest inspection, and were keen to show CQC inspectors what they were doing because they felt confident in their practice.
This confidence is also what is helping the trust to weather the current well-documented pressures across the NHS, with rising demand and tight resources. ‘Staff are allowed to care,’ she says. ‘Yes, these are tough times, but allowing staff to shine is really important.'
Deputy chief nurse Lynne Wyre, who is also lead for inclusion and diversity, has been in her role for nearly three years, but has lived and worked in the area for many more. She has been instrumental in the trust’s recent transformation. ‘There’s a much more supportive culture now,’ she says. ‘It feels like I work in a safe environment, where staff are encouraged to speak up when they have concerns; it’s not a punitive approach. And reflective practice has become part of what we do.’
It’s a very different story to several years ago, she concedes. ‘When you ask the question, ‘‘would you be happy for your family to be cared for in your local hospital’’, at times I might not have been able to answer that positively,’ she says. ‘It’s not that the care was all bad, but it was a command and control situation. You didn’t see the senior managers in the organisation. Today, most of the ward staff would know who the chief executive is, and who the senior nurses are.’
Small, practical changes
Like Ms Smith, she believes that involving and trusting patients and staff has been key to this shift. ‘When you’re put into special measures, the danger is that you go into panic mode and go back to a command and control approach,’ she says. ‘But it’s actually about not losing sight of what we’re here to do, which is to help patients and families.
‘The key to success is the well-being of staff. It’s important that they feel supported and that we listen to the solutions they have for improving care. If I want to know something, I go to where the care is delivered. I certainly don’t have all the answers.’
Visibility of senior nursing staff is also important, says Ms Wyre. ‘Most ward managers across the NHS work Monday to Friday, leaving the wards with more junior staff at the weekends. We now have a matron rota, with all the matrons and other nurses in senior roles, including the assistant and deputy chief nurses, working on Saturdays and Sundays. We go out and help where help is needed, whether that’s doing the tea round or bed baths. It makes a massive difference to our credibility when we work alongside staff. We also wear uniform, which makes us very visible’ she says.
For her, it’s the relatively small, practical changes that are making a difference, and she points out that many have been staff or patient-led. Examples include working in partnership with other organisations to create dementia hubs in local communities, and establishing a facility where people with learning disabilities or physical disabilities can get changed when they are visiting the hospital. ‘We were told that people were having to lie on toilet floors, which horrified us,’ she says. The new facility has a hoist, changing table and disabled toilet, and there are plans for more in the future. ‘I feel proud that we’re doing this in Furness,’ she says.
As for Ms Smith, she is clear that the credit for the transformation goes all the way from the board to the frontline. ‘Our staff are off and I can’t keep up with them,’ she laughs. ‘I don’t have to be hands-on. I feel I’m standing at the top of the hill watching the snowball gather speed and it’s absolutely fantastic.'
Sascha Wells: Head of midwifery
Sascha Wells says she might not have taken the job at University Hospitals of Morecambe Bay NHS Foundation Trust had she known what was coming.
A positive CQC report on the service the previous year had been reassuring, and she hadn’t thought to Google local media reports, says Ms Wells, pictured.
‘Two months after I joined the trust, there was an unannounced inspection by the CQC and the Nursing and Midwifery Council, following the inquest [into the death of Joshua Titcombe]. What came out of that was harrowing for the family to hear, and it was evident that a huge amount of work needed to be done to address the issues.’
An independent investigation into serious incidents at the maternity unit in Furness General Hospital, part of the Morecambe Bay trust, concluded that 11 babies and one mother had died following a ‘lethal mix’ of failures in the dysfunctional unit between 2004 and 2013. There was clearly a big job ahead – and Ms Wells was in her first director of midwifery post.
‘I’m glad I didn’t know what was to come as I might not have joined,’ she says. ‘I probably wouldn’t have thought I was capable of doing it, but as I was here, I had to get my head down and get on with it – and I wouldn’t change a single day.’
Rebuilding the service, and rebuilding trust within the local community, started with finding out about women’s experiences of services, she says, adding that previously the only feedback came through complaints. ‘We developed a women’s experience survey and started to get a real understanding about what women wanted and expected,’ she says. ‘We realised we were doing what we thought they wanted, but we were imposing our view rather than recognising that no two women are the same.
‘There was no bereavement midwife, no continuity of care, we were giving too much information to women all at once, and they told us they wanted more time with midwives so that they could ask what they wanted to know.’
Since then, there have been many changes at the trust’s maternity units, including involving women in the design of a new maternity unit, developing a partnership with other maternity services in the North West and helping to share and spread good practice and practical improvements such as an improved website.
Inclusive leadership has been key. ‘What I say to staff is that it’s our service, and the women’s service, it’s not about one person making decisions. The CQC report has recognised that.’
Sue Smith: Chief nurse
Nursing staff have been at the heart of transformation of bereavement services at the trust, says chief nurse Sue Smith, pictured.
Steps have included opening ‘death cafes’, where staff, patients and families are encouraged to have conversations about important end-of-life issues, such as where they want to die and whether they want to donate organs.
Bereavement services have been opened up to include people who die in the community, and condolence cards and forget-me-not seeds are sent to family members after the death of a loved one.
The trust has also been using a dragonfly symbol, for example, on canvas bags for people collecting belongings of their loved ones, so that staff know a person has been bereaved.
‘Staff can use their initiative to do what they feel will improve care,’ says Ms Smith, adding that staff who have been bereaved are also supported.
Jennifer Trueland is a freelance health writer