CQC: Not enough staff across Manx Care to 'ensure safe care'

Inspections highlight ongoing issues with recruiting staff

The latest reports from the Care Quality Commission (CQC) have been published, alongside a programme overview report and an Action Plan from Manx Care.

The four final baseline reports looked at Acute and Community Services, the Manx Emergency Doctor Service (MEDS), the Manx Care Leadership and Governance ‘Well-led report’, and Integrated Mental Health services.

Whilst the CQC emphasised that Manx Care staff 'treated people with compassion and kindness', it also identified several system-wide recommendations and areas for improvement.

These included concerns around safeguarding; staff training, recruitment, medicine management, data sharing, patient outcomes and the maintenance of both premises and equipment.

In summary, the CQC found that the Isle of Man 'being an offshore island resulted in a strain on the system because of problems in recruiting sufficient staff to deliver services'.

Staff were concerned about these pressures and inspectors found that, 'at times, the shortages could affect the types of services that could be delivered and the safety of these services'.

Safeguarding:

Work has already started on improving the approach to safeguarding on the island. 

Whilst the island’s initial priority has been children, now that the approach is more developed, the team has capacity to move forward with the adults safeguarding strategy and policies. 

The CQC found:

• Safeguarding needs to be further co-ordinated between services. 
• A lack of data sharing arrangements appears to be a significant barrier that prevents services discussing and sharing safeguarding concerns. 
• Multi-agency safeguarding meetings are still being established, and GPs have reported not being invited to child protection meetings. 
• At the moment, there are no formalised transitional safeguarding arrangements in place to support the safety of children and adolescents who transitioned to adult services

Staff training: 

Completion levels for mandatory training were low across services.

Mandatory training does not currently include all continual professional development in line with requirements of professional regulators, such as infection prevention and control, sepsis awareness, or mental health.

Recruitment:

Recruitment is an arm’s length process on the island. 

Problems with recruitment have caused issues across Manx Care services, although it is trying to address this by aligning the position of recruitment director to the Board structure. 

• It is difficult to recruit to positions across health and social care because of complexities in the recruitment process and advertising outside of the Isle of Man. 
• Nurse training had previously been suspended and, although this was re-established, there is a now a potential gap in nursing staff if off-island recruitment was not successful.
• Across Manx Care services, there were not always enough staff to ensure safe care and manage patients effectively. At the time of the CQC assessments, the vacancy rate was 22%.
• Pre-employment recruitment checks were not consistent between services, and information was often held on separate systems that did not communicate with each other, making it difficult for services to have effective oversight. 
• Checks did not always include all points, such as checks of the qualifications, professional registration and medical indemnity status of clinical staff, or the vaccination history for patient-facing staff.

Medicine management:

Where the CQC raised concerns about medicines management and security during their assessment, Manx Care took immediate action to mitigate the risk. 

• Across services, medicines were not consistently or effectively managed safely or stored securely. 
• In several services, medicines were found that had passed their expiry date and had not been identified or removed, including in hospital operating theatres and resuscitation trolleys. 
• Temperature checks in medicine fridges and rooms were not always taken in line with guidance, and medical oxygen canisters were not always stored appropriately. 
• Other medicines, such as contrast media (used to improve the visibility of internal organs and structures in X-ray based imaging) were not stored safely which could be a danger to staff and the public. 
• Appropriate emergency medicines and equipment were not always available, stored appropriately, or regularly checked (for example, in primary care, there was a particular tendency for emergency medicines to be stored in locked cupboards or rooms, which could cause a delay in patient care) 
• In dental locations, emergency drugs were provided in a sealed box, which prevented staff from opening or handling the equipment. However, this facility was withdrawn during the CQC's assessment phase.

Data sharing and patient records:

During the CQC assessments, they found there were several different IT systems in place across the island, with little or no sharing of patient information between services - there were 8 different patient record-keeping systems. 

Staff reported they could not always access the patient care records they needed as the different IT systems often ‘did not talk to each other’. 

Having multiple IT systems may lead to patients having to tell their story multiple times, gaps in the patient journey and frustration for busy staff.

The quality of patient records was variable across different types of services. Some services maintained comprehensive and contemporaneous records of care, but some did not maintain records to required standards.

The communication between different services was reported as a common challenge, particularly between primary and secondary care. 

Common themes reported included:

• Delays receiving discharge summaries and clinic letters
• Letters being sent both electronically and by post, causing additional administrative work
• Illegible handwritten medication orders. 

Patient outcomes:

Out-of-hours GP services reported having no access to clinical outcome data, so were unable to accurately assess the clinical effectiveness of their service. 

There was a lack of psychological neurological specialist support in both the acute and community services. A waiting list of approximately 4 years was negatively affecting the rehabilitation of stroke patients.

GP practices reported they did not have access to their practice's prescribing data, which meant they were unable to compare their prescribing performance with that of other services.

Premises, equipment and maintenance:

All but three GP practice buildings are owned by the Isle of Man Government and leased to each service. 

Some services reported significant challenges with the upkeep and maintenance of their building, with some defects affecting their ability to meet infection prevention and control standards. 

Examples included:

• Carpeted clinical areas with no arrangements for deep cleaning
• Damaged wall and floor coverings
• Damaged toilets and sinks.

There were inconsistent processes regarding the cleaning, maintenance, and calibration of equipment:

• There was limited evidence of regular and effective checks of pressure vessels used in oral health services, and portable appliance testing was completed inconsistently. 
• In other services, such as the hospice, staff did not use separate cleaning equipment for different areas of the hospice, which increased cross-contamination risks. 
• Services did not have consistent effective systems to manage the potential risk of legionella, and there was confusion over who was responsible for carrying out legionella testing. 
• Hazardous waste such as amalgam (a mercury-based alloy used in dental fillings) could not be disposed of safely. The CQC noted there was no provision for waste amalgam, gypsum and X-ray development chemicals to be removed from the Isle of Man. 

Some facilities were not currently fit for purpose having implications for the safety of patients and staff:

• The children’s ward at the hospital did not have any dedicated cubicles for children who presented with mental health needs. 

There was an inconsistent approach to fire risk management:

• Although some services had comprehensive fire risk assessments in place and undertook regular fire evacuation drills, other services did not. 
• Fire extinguishers at some services, such as dental services, were not stored appropriately or checked regularly, with some tamper-proof tags missing that had not been either identified or rectified by the service

You can find a link to the reports here.