Agenda item

This item was deferred from the meeting in July 2012 because Care UK were not in attendance and because the report provided focussed on safeguarding issues rather than an explanation of what caused the problems at the UCC and how they have been addressed. A further report now attached, has been provided by NHS Brent and Care UK representatives will be present at the committee meeting on the 9 October for this item.

Ian Winstanley (NHS Brent) introduced the report that provided further details of the findings of the investigation carried out in the wake of the serious incident at the Care UK Urgent Care Centre (UCC) at Central Middlesex Hospital (CMH) identified in March 2012.  The report included the findings of the root cause analysis, the recommendations that followed and subsequent action taken to implement these recommendations and monitoring of their success.  Ian Winstanley advised that NHS Brent was satisfied that Care UK had undertaken all action required following the Governing Body meeting on 3 October.

During discussion, Councillor Hunter sought an explanation as to why sufficient action had not initially been taken despite concerns being raised on five separate occasions that radiology procedures were not being followed.   An update was also requested on the nine patients who had required onward referrals regarding the outcome of their cases.  Councillor Hunter enquired whether the incident had prompted Care UK to look at how they operate nationally and whether they would be subject to any financial penalties if there were any further breaches of contract.  Councillor Gladbaum asked why staff turnover had been high at the UCC and could the incident be partly attributable to an over reliance on agency staff.  She also enquired why there had not been a robust protocol for staff with regard to procedures previously and she emphasised the importance of ensuring high standards for the safeguarding of children.  Councillor Harrison sought assurance that the necessary measures would be in place to ensure that staff had read and understood the protocol.

The Chair enquired if NHS Brent was satisfied to date with the implementation of the recommendations made as a result of the Root Cause Analysis investigation and sought clarification with regard to the issuing of a remedial notice to Care UK under Section 57.

In reply to the issues raised, Dr Titus Bradley (Care UK) acknowledged that the incident should have been noticed and escalated appropriately at an earlier stage.  This had been partly attributable to rapid staff turnover, failure to communicate clearly and insufficient induction of new staff.  Dr Titus Bradley advised that during the time of the incident, there was a significant number of interim staff and the high staff turnover was due to staff changing jobs, doctors taking up post overseas and a number of other reasons.  Since then, there had been much effort to increase the number of permanent staff and the workforce now was considerably more stable and dedicated to CMH.  A number of other measures had also been undertaken following the Root Cause Analysis investigation and all new staff undertook a robust induction that required them to sign a declaration that they understood what they had been told and all staff needed to adhere to the new protocol in place.  Members heard that the previous protocol had been less robust and had not been policed and enforced sufficiently.  Furthermore, managers were available on a 24/7 basis to be contacted if staff were unsure about a particular issue and experienced doctors had been given supervisory responsibilities.  An audit of activities was also being undertaken at the UCC, including scrutinising of X-ray material, and this would enable any inappropriate action to be tracked.

Dr Titus Bradley added that Care UK had learnt from the serious incident at CMH and that the investigation, which he had led, had revealed that upon a review of all patients affected, most did not involve significant abnormalities.  Patients who had been recalled had undergone a thorough process to ensure that the appropriate action was taken.  With regard to the nine outstanding referrals, responses from the patients’ relevant GPs was still awaited and there would be follow-up action to obtain this.

Ian Winstanley confirmed that the serving of a Section 57 notice was a contractual procedure that required Care UK to apply the prescribed remedial action within a certain period.  He advised that at the time of the incident, the contract did not include provision for CMH to impose financial penalties, however since then discussions with the NHS had taken place to standardise all such contracts and to include the right to impose financial penalties where certain conditions had not been adhered to.

Dr Sarah Basham (Brent NHS) commented that Care UK had been very forthcoming in reporting to NHS Brent the mistakes that had been made and of the action they intended to undertake to remedy the situation.  Similarly, NHS Brent had also learnt from the experience and was more aware of where things can go wrong when running a new service like an UCC and they would continue to monitor the actions being taken by Care UK.

The Chair stated that Members expected high standards of care for Brent residents and that it was fortunate that there were not more serious implications arising from the incident in view of the number of patients affected.  She requested that an update on how the recommendations arising from the report were being implemented and details of any additional ones introduced be provided at a committee meeting in around six months’ time.