CQC Prosecutions & Enforcement Press Notices

The Care Quality Commission (CQC) took urgent action following an unannounced focused inspection of maternity services at the Jessop Wing. Urgent conditions were imposed on the trust requiring them to take action to ensure the safety of patients using these services and to regularly report to CQC on the progress made. Inspectors found a service that was not providing the standard of care women should be able to expect, leading to the overall rating for maternity services dropping from outstanding to inadequate.

The Care Quality Commission (CQC) issued University Hospitals Plymouth NHS Trust with a warning notice following an inspection of Derriford Hospital's urgent and emergency care department in March. CQC found that the trust must make significant and immediate improvements, outlining areas for improvement including two breaches of legal requirements. Inspectors found a deterioration in the quality of services, with the safety of the urgent and emergency care service now rated inadequate and well-led rated requires improvement.

The Care Quality Commission inspected the medical care services department at Weston General Hospital and found that the leadership team needed to make a number of sustainable improvements. CQC told the trust that it must send an action plan outlining the steps it will take to address concerns and make improvements.

The Care Quality Commission (CQC) took urgent action following a focused inspection of children and young people ext{

The Care Quality Commission (CQC) served Tees, Esk and Wear Valleys NHS Foundation Trust a section 29A warning notice following an unannounced focused inspection in January. Inspectors found concerns that urgently needed addressing, including risks not being assessed effectively or managed well enough to keep people safe from harm. The trust must urgently address these issues to keep people safe and has a timeframe to do so.

The Care Quality Commission (CQC) has told South London and Maudsley NHS Foundation Trust that it must make urgent improvements to the quality of one of its acute wards for adults of working age and psychiatric intensive care units (PICU). Inspectors visited the Jim Birley Unit in December to follow up on concerns about the safety and quality of the service being provided, following three serious incidents relating to the ward. CQC found a number of concerns relating to patient safety, including significant gaps in the recording of physical health checks and issues with medicine administration records.

The Care Quality Commission (CQC) issued a warning notice to Royal Cornwall Hospitals NHS Trust following an announced inspection in December. The inspection assessed actions taken after seven 'never events' occurred within the trust's surgical care group and emergency department. The warning notice required the trust to make significant improvements to the quality of healthcare, including ensuring staff undergo adequate training and improving governance processes to support patient safety.

The Care Quality Commission (CQC) told Greater Manchester Mental Health NHS Foundation Trust that it must improve the quality of care provided to patients in its acute ward for adults of working age and psychiatric intensive care unit (PICU) at Park House, North Manchester General Hospital. Following an unannounced inspection in December, CQC had significant concerns about the ward environment and the risk to patients, and required the trust to take immediate action to address these issues.

The Care Quality Commission (CQC) told Liverpool University Hospitals NHS Foundation Trust to take immediate action to improve the safety of some of its services following two inspections. Inspectors found a lack of effective systems to ensure all patients received adequate nutrition and hydration, and staff did not always follow national infection prevention and control guidelines. The trust leadership team provided a detailed response with immediate actions to mitigate risk and improve the safety and quality of medical care services.

The Care Quality Commission imposed urgent conditions on the registration of Birmingham and Solihull Mental Health NHS Foundation Trust following focused inspections. Inspectors found several concerns, including ligature risks across services and unsafe storage and transport of medicines. The conditions require the trust to address all ligature risks by 18 June 2021 and implement an effective system to improve risk assessments and care planning by 5 February 2021.

The Care Quality Commission (CQC) carried out an unannounced, focused inspection at Queen Elizabeth Hospital in December after receiving information that triggered concerns about the safety and quality of services relating to DNACPR orders. CQC told Lewisham and Greenwich NHS Trust it must ensure DNACPR orders are supported by treatment escalation plans which contain easily accessible and relevant information, checked by senior clinicians, and are in line with trust policies. The trust must also update its policy for treatment escalation plans and send a report to CQC outlining actions to meet these requirements.

The Care Quality Commission (CQC) imposed conditions on the registration of Tavistock and Portman NHS Foundation Trust following an announced, focused inspection in October and November. Inspectors found significant concerns within the Gender Identity Development Services (GIDS), including over 4,600 young people on the waiting list, some waiting over two years, and that staff did not always manage risk well. The conditions require the trust to provide monthly reports detailing actions taken to manage and reduce the GIDS patient waiting list, along with monitoring results and patient figures.

The Care Quality Commission (CQC) carried out unannounced focused inspections of Finchingfield Ward in October and November 2020 due to concerning information regarding safety incidents. Inspectors found that some staff did not follow required actions to maintain patient safety, including inadequate observation practices and issues with record-keeping. CQC served warning notices to the trust to ensure improvements are made around safe care and treatment, staffing, and good governance.

The Care Quality Commission (CQC) served Oxleas NHS Foundation Trust with a warning notice, requiring immediate improvements to its mental health wards for older people. An inspection found out-of-date ligature risk assessments, a lack of clear mitigation for high-risk ligature points, and staff not implementing actions from serious incident investigations. Essential information and action plans were not shared at ward level, impacting patient safety.

The Care Quality Commission (CQC) told Croydon Health Services NHS Trust that it must improve the quality of care provided to patients in mental health crisis in its urgent and emergency services at Croydon University Hospital. Following an unannounced, focused inspection in October, CQC took enforcement action and imposed conditions against the trust registration. These conditions require the trust to commission an external review of the quality and safety of care for mental health patients at Croydon University Hospital and provide CQC with a report and fortnightly updates on actions taken.

Following inspections on 14 and 15 October 2020, CQC imposed conditions on the registration of maternity and midwifery services at Nottingham City Hospital and Queen’s Medical Centre under Section 31 of the Health and Social Care Act 2008. This urgent action was undertaken to prevent patients being exposed to the risk of harm. The conditions require the trust to comply with instructions to drive improvements.

The Care Quality Commission (CQC) told North Cumbria Integrated Care NHS Foundation Trust that it must make immediate improvements to keep people safe following inspections in August and September. CQC issued the trust with a warning notice for Cumberland Infirmary and West Cumberland Hospital, requiring rapid improvements to protect people from the risk of harm. The warning notice requires the trust to take action to minimise the risk of patients being exposed to harm due to issues such as untimely care, delayed transfers, insufficient staffing, and ineffective systems to mitigate risks.

The Care Quality Commission issued an urgent notice of decision under Section 31 of the Health and Social Care Act 2008, placing conditions on Mid and South Essex NHS Foundation Trust's registration. This action followed an inspection of maternity services at Basildon University Hospital on 18 September 2020. Inspectors identified several serious concerns including insufficient staff, inadequate identification and escalation of safety concerns, and dysfunctional multidisciplinary team working.

The Care Quality Commission (CQC) told Devon Partnership NHS Trust that it must make urgent improvements to the quality of its medium forensic inpatient or secure wards. Following an urgent inspection in August 2020, CQC found concerns relating to patient safety and staffing levels at Ashcombe and Holcombe wards at the Dewnans Centre, Langdon Hospital. The trust was instructed to ensure sufficient qualified staff, a safe environment, and robust methods for patient observation.

The Care Quality Commission (CQC) issued a fixed penalty notice to Shrewsbury and Telford Hospitals NHS Trust, fining it £4,000. This was for not triaging patients within 15 minutes of attending the emergency department and not ensuring follow-ups for children who left without being seen. The trust had not fully adhered to conditions previously imposed on its registration following inspections in 2019.

The Care Quality Commission announced it is prosecuting East Kent Hospitals University NHS Foundation Trust. This action follows complications which led to the death of a baby in its care. The trust is charged with exposing Harry Richford and his mother Sarah Richford to significant risk of avoidable harm.

The Care Quality Commission (CQC) used its enforcement powers at the East of England Ambulance Service NHS Trust, requiring it to overhaul its safeguarding processes and report back to CQC on issues it must address. This action followed an inspection that found poor leadership had fostered bullying and abuse, with staff being undervalued and treated disrespectfully when raising concerns. Leaders also did not act decisively when staff faced allegations of predatory sexual behaviour towards patients.

The Care Quality Commission (CQC) prosecuted University Hospitals Plymouth NHS Trust for breaching the duty of candour regulation. The trust admitted it did not disclose details relating to a surgical procedure or apologise following the death of a 91-year-old woman. The trust was ordered to pay a total of A 12,565 in fines and court costs.

The Care Quality Commission (CQC) used its urgent enforcement powers by placing conditions on The Hillingdon Hospital NHS Foundation Trust's registration. This action was taken in response to safety concerns following an inspection on 4 and 5 August 2020, which looked at how the trust was dealing with COVID-19. CQC found concerns relating to infection control practices and told the trust it must make immediate improvements to protect the safety of patients and staff.

The Care Quality Commission told Surrey and Borders NHS Foundation Trust it must make improvements to its acute wards for adults of working age and psychiatric intensive care units to keep patients safe. CQC highlighted serious concerns surrounding patient safety on The Abraham Cowley Unit following an inspection in June 2020, requiring the trust to submit information explaining how it would make immediate improvements.

The Care Quality Commission (CQC) told Devon Partnership NHS Trust it must make urgent improvements on Delderfield ward and complete its ligature minimisation work across its acute wards and psychiatric intensive care units. This directive followed an inspection in June 2020 which identified serious concerns regarding patient safety, including risks of self-harm and patient deaths. CQC required the trust to provide information detailing how it would implement immediate improvements.

CQC issued a warning notice requiring Mid and South Essex NHS Foundation Trust to make urgent improvements to ensure mothers and babies are safe in its maternity services at Basildon University Hospital. Inspectors found several concerns, including high-risk women giving birth in low-risk areas, insufficient staffing with relevant skills, and dysfunctional multidisciplinary team working. The warning notice identified specific areas where improvements must be made, with a compliance date for 14 August 2020.

The Care Quality Commission (CQC) undertook focused inspections of the emergency departments at Pilgrim Hospital and Lincoln County Hospital on 6 and 7 January 2020, prompted by patient safety concerns. Following these inspections, CQC imposed conditions on United Lincolnshire Hospitals NHS Trust at Pilgrim Hospital. These conditions require the trust to ensure patients are seen within a specified timeframe, appropriate systems are in place for deteriorating patients, enough skilled staff are on duty, and patients are treated with dignity and respect.

The Care Quality Commission imposed conditions on Tees, Esk and Wear Valleys NHS Foundation Trust's registration in August 2019. This action followed an inspection of the trust’s child and adolescent mental health wards (CAMHS) in June 2019, which were rated Inadequate. Following the imposition of these conditions, West Lane Hospital closed.

The Care Quality Commission issued a fixed penalty notice to Bradford Teaching Hospitals NHS Foundation Trust, fining them £1,250. This action was taken because the trust did not comply with the Duty of Candour, a regulation requiring providers to be open and honest with patients or their families following incidents where harm occurred.

The Care Quality Commission imposed urgent conditions on Shrewsbury and Telford Hospital NHS Trust's registration following inspections of its maternity and emergency departments. Inspections highlighted concerns regarding reduced foetal movements guidelines in maternity services and the treatment and recognition of sepsis in urgent and emergency care. The conditions require the trust to report weekly to CQC on actions taken to ensure effective clinical management in midwifery services and management of deteriorating patients and sepsis in urgent and emergency services.

Section 29A warning notice served on maternity services at Newham University Hospital. A CQC inspection in September 2018 rated the hospital's maternity service inadequate overall, with concerns that the systems to assess, monitor and mitigate risks to patients and the service's governance systems and processes were not operating effectively. The notice required the trust to make significant improvements by 16 November 2018. A follow-up inspection on 14 and 15 January 2019 found evidence of improvement to the safety and governance of the service.

The Care Quality Commission varied conditions on The Dudley Group NHS Foundation Trust's registration following an inspection at Russells Hall Hospital. Inspectors found concerns regarding the triage, assessment, and tracking of patients in the emergency department, especially concerning suspected sepsis. Care records were not consistently managed to ensure patient safety.

The Care Quality Commission issued a warning notice to Kent and Medway NHS and Social Care Partnership Trust, requiring significant improvements to its community-based mental health services for adults of working age. This followed an inspection where CQC found that community mental health teams lacked systems for effective caseload management and did not always have sufficient staff to assess new patients effectively in some areas.

The Care Quality Commission issued a Warning Notice to Royal Cornwall Hospitals NHS Trust. This notice requires the trust to make significant improvements in the care of patients at the Royal Cornwall Hospital. Inspectors found issues including insufficient staffing, increasing waiting lists, high levels of delayed discharges, and ineffective systems for maintaining confidentiality.

The Care Quality Commission issued a Warning Notice to Portsmouth Hospitals NHS Trust, requiring improvements in safety, patient consent, dignity and respect, safeguarding, and overall leadership. Concurrently, CQC placed six conditions on the trust's registration, mandating specific actions to ensure patient safety. These actions followed inspections that identified concerns in medical care services, particularly for frail older people or patients living with dementia, leading to an 'Inadequate' rating for medical care and safety.

Following a focused inspection in April 2017, CQC issued a Warning Notice to Worcestershire Acute Hospitals NHS Trust. The notice requires the trust to take action to address concerns regarding governance systems and the mitigation of risks. Inspectors found no tangible improvement in performance since the previous inspection, noting issues such as patients being cared for in corridors in the emergency department.

Following an inspection in November and December 2016, the Care Quality Commission issued a warning notice to Worcestershire Acute Hospitals NHS Trust. This action was taken because significant improvements were required in relation to staffing levels, governance, investigation of clinical incidents, and culture.

Immediately after an inspection, CQC placed conditions on the registration of the trust to minimise the risk of patients being exposed to harm. The trust was required to operate an effective system to prioritise patients needing access to community mental health services. Additionally, an urgent assessment of the physical environment on mental health wards at St Mary’s Hospital was mandated, including a comprehensive assessment of ligature points and a plan to address risks.

The Care Quality Commission imposed conditions on the registration of Isle of Wight NHS Trust following an inspection of its community mental health and mental health inpatient services. CQC found that some people needing access to community mental health services were at risk of harm due to long waits for assessment or treatment. The trust must implement an effective escalation system, assess the physical environment on mental health wards at St Mary’s Hospital for ligature points, and develop an action plan to mitigate risks.

The Care Quality Commission issued a Warning Notice to West London Mental Health NHS Trust, requiring significant improvements in the care of patients at Broadmoor Hospital. Inspectors found the trust did not have enough suitably qualified staff to meet patient needs, with a 30% vacancy rate for qualified nurses. This affected the provision of social and therapeutic activities and opportunities for patients in long-term segregation.

Immediately after an inspection in June and July 2016, CQC issued a Warning Notice to St George’s University Hospitals NHS Foundation Trust. This notice highlighted breaches in regulations concerning safe and fit premises at St George’s Hospital, obtaining consent under the Mental Capacity Act 2005, good governance, and the fit and proper person requirement. Inspectors found several trust buildings were in disrepair and not fit for purpose, with poor fire detection systems and a heightened risk of water contamination.

The Care Quality Commission told South Tyneside NHS Foundation Trust that it must make further improvements to protect children and young people who may be at risk of harm. A focused inspection found limitations within the patient recording system in the emergency department and limited oversight of safeguarding at management level, which the trust must address.

CQC issued a Warning Notice to Brighton and Sussex University Hospitals NHS Trust requiring significant improvements by 30 August in three areas. Inspectors found that the trust's systems to assess, monitor, and minimise risks to people receiving care and treatment were not operating effectively. There were also ineffective systems to ensure the care, privacy and dignity of patients, and the trust was not ensuring patients were seen in line with national timescales for diagnosis and treatment.

The Care Quality Commission issued a Warning Notice to South East Coast Ambulance Service NHS Foundation Trust, requiring significant improvements in the quality of its services. This action followed a comprehensive inspection in May, which identified six main areas of concern. These included ineffective systems for staff deployment, untimely responses to NHS 111 calls, inadequate equipment maintenance, and ineffective safeguarding and medicines management processes.

Following an unannounced inspection in April, CQC inspectors issued a Warning Notice to North Middlesex University Hospital NHS Trust. This required the trust to significantly improve the treatment of patients attending the emergency department. Inspectors found significant delays in patient assessment and movement to specialist wards, and insufficient middle grade doctors and consultants on duty.

The Care Quality Commission (CQC) placed four conditions on Portsmouth Hospitals NHS Trust's registration following an inspection of its urgent and emergency department. Inspectors found the emergency department at the Queen Alexandra Hospital was over-crowded with patients not being assessed or treated in a timely way. The trust was rated Inadequate for Urgent and Emergency services.

The Care Quality Commission issued a warning notice to Southern Health NHS Foundation Trust following an inspection in January 2016. The inspection found the Trust had not put in place robust governance arrangements to investigate incidents, including deaths, and had not addressed known risks from the physical environment. The warning notice required immediate action to ensure the safety of patients at Evenlode, Oxfordshire and Kingsley ward at Melbury Lodge.

The Care Quality Commission (CQC) placed four conditions on the registration of Portsmouth Hospitals NHS Trust following an inspection of emergency services at Queen Alexandra Hospital. CQC found that too many people were waiting too long for attention in the Emergency Department, leading to overcrowding and delayed treatment. The conditions require the trust to make immediate improvements to ensure patients are assessed, treated, and seen by specialists in a timely manner, and to ensure effective leadership within the department.

The Care Quality Commission (CQC) issued a warning notice to Southern Health NHS Foundation Trust, requiring significant improvements to protect patients in its mental health and learning disability services. CQC found that the Trust did not operate effective governance arrangements to ensure robust investigation of incidents, including deaths, and did not adequately ensure it learned from incidents to reduce future risks to patients.