CQC reveal patient safety concern after NHS Trust staff said to be ‘burned out, struggling and broken’

A worker described their team as “struggling and broken” on a mental health ward for young people without enough staff to keep patients safe, a watchdog has said.

The Care Quality Commission (CQC) has taken urgent action over serious concerns over wards at Essex Partnership University NHS Foundation Trust (EPUT).

An unannounced inspection of all three wards of the trust’s children and adolescent health service was carried out in May and June after a “serious incident” on one of the wards.

Their report said: “The service did not have enough nursing and support staff to keep patients safe.”

It went on: “Staff told us because they were short staffed, they felt overworked and stretched.

“One staff member told us the staff team were ‘struggling and broken’.

“Another staff member told us they were ‘burned out’.”

Inspectors found that use of bank and agency staff was “high” and that the “lack of regular and familiar staff impacted on the quality of patient care”.

They said that patient observations were not always carried out at prescribed intervals and “as a result of staff poor observation practice patients had been harmed”.

“This included incidents of patients tying ligatures and self-harming whilst on enhanced observations,” the report said.

“Permanent staff knew about any risks to each patient, not all agency staff did.”

The report added: “Staff missed opportunities to prevent or minimise harm and did not always act to prevent or reduce risks.”

The CQC has lowered the overall rating of the service from outstanding to inadequate and has taken urgent action to keep young people safe by placing conditions on the trust’s registration.

Conditions demand that the trust must not admit any new patients without consent from the CQC.

The trust must also ensure there are adequate staffing levels on all three wards so observations can be carried out safely and patient needs are met.

Stuart Dunn, CQC head of inspection for mental health and community services, said that some young people came to harm as a result of the trust’s failings.

He described under-staffing as a “significant concern made worse by managers not ensuring staff had the appropriate skills and experience to look after the vulnerable patients in their care”.

He said the CQC is “monitoring the trust closely” and will return to check if sufficient improvements have been made.

Inspectors found that staff involved patients in their care plans and discussed these regularly with them on ward rounds to ensure they were aware of any changes or had any feedback.

They were open and transparent and gave patients and families a full explanation if things ever went wrong.

The CQC told the trust to make improvements, including to regularly review staffing numbers and to check the skills and experience of agency staff before they are placed in post.

Chief executive officer of Essex Partnership University NHS Foundation Trust (EPUT), Paul Scott said: “We take the CQC’s findings very seriously, and following their inspection visit in May we took immediate action to make sustainable improvements to our services for children and their families – these include increasing staffing levels, delivering ongoing coaching and mentoring for our staff in observing our patients and engaging with them and strengthening clinical and operational leadership.

“Patient safety is our highest priority, and we continue to work closely with the CQC and our partners to improve standards and ensure every patient has access to the best care possible.”

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