Sturdee Community Hospital

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

The provider had addressed most of the concerns identified at the last assessment relating to the well led key question. The exception to this was the risk register, which still needed improvement. Staff had not recorded when each risk had been identified. Risks that we would expect to be present were not. For example, serious incidents, recruitment and retention of appropriately trained staff, staff not having access to all electronic records, and previous enforcement actions taken by CQC . There was no provided guidance on how the grading of risks had been calculated. Leaders were aware of and told us that governance was an area which needed high focus. The registered manager was new in post, having been at the service for approximately 4 weeks. From January 2024, the service had produced a monthly ‘lessons learnt, and actions taken’ log. We noted staff had taken and recorded several actions between January and March. Staff had failed to record actions between April and June 2024, despite there being over 200 incidents reported. We reviewed some governance meeting minutes. Staff had recorded actions from the meetings, but not all actions had been assigned to staff members, nor had target dates for completion. We also noted that during a staff meeting, an issue was raised about agency staff not having access to the electronic incident form, and therefore had to rely upon regular staff to access the system to record incidents accurately. We were concerned that some incidents may not be recorded if staff were busy. We did not find the Freedom to speak (F2SU) arrangements in place were effective. No concerns by staff had been raised through their F2SU process between January and June 2024. Yet CQC had 2 members of staff contact us to raise concerns. A number of patients were on enhanced observations, with lack of plan as how the patient could reduce these. We will require an action plan to address breaches under Regulation 17: Good Governance.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders showed an awareness of the hospital’s challenges following many changes in local leadership positions and were committed to making further improvements to benefit both patients and staff. This included a more collaborative / co-production approach, aiming to ensure the voice of patients and staff was heard. Staff consistently spoke of improved morale and said they felt more supported than they did during our last assessment. Staff said that communication across the hospital, from board to wards was improving.

Following our assessment, we were provided with examples of actions to improve the culture at Sturdee Hospital to include staff surveys, monthly department meetings and improved communication between departments. Other actions included improved senior management visibility including night shifts. We reviewed 6 monthly staff survey results from November 2023. Only 17 out of 94 members of staff responded (18%) so it’s difficult to gauge the accuracy with such a low response rate. Areas to improve included 4 out of 17 staff (23%) did not feel that recognition was meaningful when they received it. The provider had a staff survey action plan in response to the analysis which demonstrated some actions had been taken. What this did not include, was how to increase staff participation in future surveys. Efforts to improve the Integration of overseas staff to the hospital had been considered. Leaders had introduced cultural workshops, and ensured all new staff had an experienced mentor. Staff we spoke with were positive about this.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The freedom to speak up (F2SU) guardian for the hospital was still the deputy chief executive of the company as per last assessment, who visited the service on a weekly basis. Many staff interviewed were unable to tell us who the FTSU guardian was, although told us they would raise concerns if they had them.

No concerns had been raised by staff through their F2SU process between January and June 2024. Yet 2 different staff members had contacted CQC to raise concerns during this period. Many issues were raised to include staff being afraid to speak up for fear of job loss; behaviours of some of the senior leadership team; frequent changes in managers and a lack of direction and stability. This raises a question as to whether the current F2SU arrangements in place are effective. Whilst the provider identified the need for clear channels for staff to voice concerns, there was a lack of evidence of efforts made to improve culture, specifically the introduction of freedom to speak up champions. However, senior staff confirmed this was a work in progress

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Leaders were aware that governance was an area that needed continued focus and acknowledged there had been several changes in senior staff at this hospital, which had not helped consistency with making and sustaining improvements needed. Staff we spoke with talked about changes in ward managers and the registered manager and wanted a stable leadership team to help them deliver the best care they could. Staff spoke positively about the new registered manager, who had been visible across the hospital and took time to talk with staff and patients to aid communication.

The provider had addressed most of the concerns identified at the last assessment relating to the well led key question. The exception to this was the risk register, which still needed improvement. Staff had not recorded when each risk had been identified. Risks that we would expect to be present were not. The providers incident reporting policy states that serious incident action plans and recommendations will be placed on the risk register. These were not present. There was no provided guidance on how the grading of risks had been calculated. Governance needed to be strengthened. We saw gaps, inconsistencies and some minor recording errors in documents seen. We saw a lack of lessons learnt actions following incidents recorded within the monthly ‘lessons learnt, and actions taken’ log between April and June 2024. We would expect this to be more robust due to the number of incidents reported. Similarly, safeguarding analysis seen lacked timely actions and learning from re-occurring themes involving patients harming themselves whilst under enhanced observations. Care records examined failed to consistently demonstrate how patients could reduce their observations and evidence this was the least restrictive option. During governance meetings, staff had recorded actions from the meetings, but not all actions had been assigned to staff members, nor had target dates for completion. During a staff meeting, an issue was raised about agency staff not having access to the electronic incident form, and therefore had to rely upon regular staff to access the system to record incidents accurately. We did not find any actions relating to how to resolve this. The provider needs to improve overall oversight of governance, to ensure data recorded is accurate, reviewed and appropriate actions taken, to effectively monitor the quality of care provided and to mitigate risks effectively.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Leaders told us that conversion to electronic records had made a positive difference in how information was captured. Staff said that awareness of patient risk had been improved by the introduction of handheld devices which held individual information regarding patients risks. Senior staff told us that review of CCTV was an important element of learning from incidents and planned to use this more frequently to aid analysis and learning for staff. Staff did not talk about any other recent developments or research which had been undertaken across the hospital.

The provider ensured staff had regular supervision and had an annual appraisal of work. The appraisal included discussions around training and development. There was some scope for staff promotion within the company, for example the relatively new role of the patient safety officer, which support staff could apply for. We saw evidence of learning and innovation through the provider investing training for some staff in Dialectical Behaviour Therapy (DBT). Additionally, they were exploring trauma informed approaches. Both are pertinent to their patient group. However, we did not see how learning had consistently led to changes to day-to-day practice. We identified that learning from incidents, complaints and safeguarding concerns could be more robust if senior staff maintained good oversight of these areas.