Robert Francis’ denial and a major failure of the government’s Freedom To Speak Up model at West Suffolk NHS Foundation Trust

 

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By Dr Minh Alexander, NHS whistleblower and consultant psychiatrist, 4 February 2020

Summary: CQC has released detailed supporting evidence from its inspection of West Suffolk NHS Foundation trust which shows stark failure of the Freedom To Speak Up model, with some criticism of the trust’s internal Freedom To Speak Up Guardian as well as the trust senior managers. There are concerns about actual breaches of whistleblower confidentiality in addition to the witch hunt to identify a whistleblower. Alongside this, Robert Francis continues to insist that the Freedom To Speak Up project is progressing well. Having five years ago recommended the voluntary Freedom To Speak Up scheme over substantive whistleblowing law reform, because he claimed the former was a speedier solution, Francis now falls back on claiming that the project “needs time to develop”.  Under pressure, the National Guardian appears to be conceding a little ground on responsibility for remedy of detriment, but it is very early days. She has so far failed to act on the West Suffolk scandal by announcing a case review. The ICO has accepted intelligence about West Suffolk’s processing of biometric (fingerprint) data.

 

A Good Samaritan recently forwarded me a copy of their correspondence with Robert Francis, in which they tried to engage him about the lack of real change for NHS whistleblowers, and the behaviour of lawyers on behalf of the NHS towards whistleblowers. As the person put it, exhorting NHS workers to whistleblow can be like asking someone to volunteer for a Forlorn Hope mission.

As has become his wont, Francis responded by defending his work. He continued to tie himself up in logical knots, stonewalling with counter claims very similar to the daily output by the National Guardian’s Office. Francis maintained that there was safety in numbers and that if many whistleblew, that would solve the problem.

From email by Robert Francis 14 January 2020:

“In my view the best way of ensuring that staff who raise concerns feel safe to do so is to encourage all those who have concerns to do so.  One of the reasons this has been perceived as being risky is the isolation many who have tried to raise issues have experienced.

I fear we are not going to agree about the value of the Freedom to Speak Up National Guardian.  Her office and the network she leads is making a great deal of progress on promoting the freedom to speak up without legislative or regulatory powers.  The concept of guardians in this context is a new one and needs time to develop.   I believe that progress in this field is evidenced in her report, published today showing a dramatic increase in the level of concerns raised with local guardians.”

This is particularly surreal juxtaposed against the months of highly publicised scandal about West Suffolk NHS Foundation’s whistleblower witch hunt, where staff have been pitted against the trust executive. There is no sign there that any whistleblower found safety in numbers or that persecuted staff have declared that all is magically well now.

Doctors at West Suffolk hospital ‘too scared’ to report safety issues

Staff say hospital bosses misled them in hunt for whistleblower

In fact, documents released by the CQC in the last week provided more evidence of the failure of Francis’ useless Freedom To Speak Up model at West Suffolk.

CQC appear to have punished West Suffolk NHS Foundation Trust managers for committing the cardinal sin of claiming that they were following orders from the centre when they hunted a whistleblower, by releasing humiliating details of board failure.

Along with this, CQC have also revealed purported failures by the trust Freedom To Speak Up Guardian.

Alleged central approval for West Suffolk’s whistleblower witch hunt The trust claimed to the Guardian newspaper that its approach was backed by “the NHS national head of whistleblowing”. The National Guardian broke ranks after criticism and denied that it was she. Via social media, her Office fingered NHS Improvement: Alongside this, correspondence with Steve Dunn the trust CEO requesting information about the central backing has been met with evasion. There has also been silence from NHS Improvement to a request for information. Most recently, NHS England press office has issued a slippery denial to BBC journalist Nikki Fox that it did not back the witch hunt. This may be a misleading way to avoid admitting that NHS Improvement was responsible. NHS England tell me their head of whistleblowing did not approve or advise on the fingerprinting of staff at West Suffolk Hospital — Nikki Fox (@nikkijfox) January 30, 2020 A complaint has been made to the ICO about West Suffolk’s flat failure to answer several FOI questions.

 

Notably, a detailed, 396 page CQC evidence appendix, which was the supporting document to the main CQC inspection report, criticised the local trust Freedom To Speak Up Guardian for not focussing on their role to support staff, and criticised the reports produced by the Guardian. CQC also questioned the accuracy of some information provided by the trust Freedom To Speak Up Guardian.

Importantly, the forensic nature of CQC’s dissection on West Suffolk’s whistleblowing governance shows that CQC is perfectly capable of rigour when it pleases.

CQC claimed:

“During interview the FTSU guardian was extremely positive of the support provided by the executive directors. As well as direct support from the executive and non-executive leads for FTSU, they stated they could speak at any time to the CEO and chair and were confident that issues would be dealt with. They were proud of the role and stated they saw it as important and a privilege. They had monthly one-to-one meetings with the interim director of human resources and stated they met the nominated non-executive director (NED) every six months. They recognised that contact out in the community services needed to improve and stated they planned to work with the staff governor in the community to address this.

 However, during interview we were not assured that the guardian had full understanding of the role. Their focus was on the support they were receiving from the executive team rather than support they were providing to staff across the organisation. They also stated they caught up fairly frequently with the guardian of safe working hours (GOSW), however this was not confirmed by the GOSW. The GOSW had been in post since March 2019 and informed us that the FTSU guardian had not responded to their initial contact. Despite initial thoughts that contact between the two roles would be important, as time had passed this had lessened, however they confirmed that they knew who the FTSU guardian was.”

“There was no evidence of triangulation to other patient /staff experience data to identify potential emerging issues. There was no trend analysis of numbers, issues, type of worker speaking up or analysis of wider context such as potential risks, barriers and opportunities. Neither FTSU reports mentioned any analysis of the 2018 NHS staff survey results.”

Certainly, a previous review of the data published by the National Guardian showed that the West Suffolk NHS Foundation Trust Freedom To Speak Up Guardian rarely considered that there was any detriment to staff for speaking up.

Given what we now know about the West Suffolk witch hunt and deep staff unhappiness, this raises questions of whether the trust Freedom To Speak Up Guardian was assessing effectively or reporting accurately, or whether staff trusted the Guardian enough to report detriment.

There is an indication in CQC’s evidence appendix about a lack of trust in the local Freedom To Speak Up Guardian due to apparent breaches of confidentiality:

“We heard examples from staff that information they had provided in confidence, to various individuals including the FTSU guardian, had become known”

This is not to say that the Freedom To Speak Up Guardian breached whistleblower confidentiality. Whilst that is clearly a possibility, an alternative is that the trust may have spied electronically on staff by interrogating whistleblower case files. If a trust board are willing to hunt down whistleblowers with fingerprint evidence, why would they stop at other intrusive measures?

These are some other CQC findings about poor culture and whistleblowing governance, as detailed in CQC’s evidence appendix: “Six of the 10 whistle-blower contacts we received between September 2018 and September 2019 raised concerns that there was an apparent reluctance by the senior executive team to hear and accept feedback of a negative nature. Overarching themes included: the trust does not welcome feedback, a lack of robust investigation into employee relation matters and human resource (HR) process, poor support for staff with mental health concerns, poor culture, lack of engagement with FTSU guardian, poor communication, distrust of being able to raise concerns without breach of confidence or fear of repercussion.” “Staff did not feel listened to and saw others that had raised concerns be penalised. There was a focus on the individual raising concerns and response to issues were on occasion disproportionate. The executive leadership team failed to fully recognise the impact that this had on the safety culture within the organisation. “we found that some staff felt the culture did not encourage openness and honesty. Not all staff felt supported, respected or valued and some feared reprisals if they raised concerns. This impacted negatively on the ability of staff to challenge and discuss options for mitigating risk.” “the executive team appeared focused on the who, rather than the why and whether there were effective systems for staff to raise concerns to ensure patient safety.” “There was a level of acceptance, by the executive team, that there were simply two sides of the incident which was not helpful. In one meeting, the medical director described that certain staff were in “separate camps” and alluded to a “them and us” situation. There were wider ripples of impact in that disengagement of the consultant body was a real risk, yet following the concerns raised there had been no separate medical staff survey undertaken to explore the extent of concerns.” “We saw evidence that when staff had raised concerns they were not always taken seriously, appropriately supported or treated with respect. In some cases, responses to those raising concerns, were defensive in nature, individually focused rather than actively collaborating to seek solutions.” “Several of the whistleblowing concerns included factors around poor engagement, communication and leadership. There was a growing disconnect between the executive team and several clinical specialties which had impacted on consultant involvement with the running of services. Communication with some members of medical staff had broken down. We were not assured that the significance of this had been fully acknowledged by the executive directors, or board, or responded to in an effective, timely manner.” “The Pathology team stated they felt the executives had stopped listening and believed the matter resolved.” “During interview it was evident that the board were aware of the areas of concern and there were strong opinions as to the reasons that certain groups were unhappy, however actions to address and repair leadership relationships were less apparent. We discussed with the executive team during feedback, that certain staff felt the executives listened but did not hear.” “There was recognition that the board were aware of a degree of unhappiness among the consultants, and a feeling that concerns were not being recognised. It was noted that the increasing distance felt between the consultant body and the executive team had begun to impact on individuals withdrawing involvement in the running of the trust.” “We reviewed the board meeting minutes for April 2019 and whilst the agenda stated the FTSU report was submitted for the board to accept there was no documented comment in the minutes that this had taken place or evidence of any questions or challenge to the FTSU guardian. Therefore, we were not assured that there was sufficient data or content presented within the reports to provide any assurance to board.”

 

I have raised a concern with the Information Commissioner about West Suffolk NHS Foundation Trust processing staff biometric data without valid consent, and I am now passing on a concern about covert breaches of whistleblower confidentiality.

Biometric data and GDPR The General Data Protection Regulation deems that biometric data used for the purposes of identification constitutes “Special category data”,  which requires more rigorous processing and safeguards. One of the requirements is that employers need to gain explicit consent before processing special category data. This raises issues of lawfulness if West Suffolk covertly processed any fingerprint data or processed fingerprint data through duress and coercion, which may negate valid consent. The ICO has passed the matter to its intelligence team.

 

Breaches of whistleblower confidentiality by the NHS are nothing new. Even regulators have been implicated in such breaches. The CQC has in the past admitted breaching the confidentiality of at least three whistleblowers: Helen Rochester, Shiban Ahmed and a third unnamed person.

In the case of Shiban Ahmed, it very much appeared that CQC outed him to his employer in reprisal for criticising some of CQC’s regulatory failures of child protection.

Thus, CQC’s current scapegoating of the West Suffolk board, which it previously and dubiously elevated to a ‘Outstanding’ rating, looks more like politicised and hypocritical abuse of power than dedication to the public interest.

No honour amongst thieves One particularly hypocritical attack by the CQC on West Suffolk’s leadership deserves special mention. CQC previously told providers that they had to sell themselves as ‘Outstanding’: “Professor Field responded that if a practice was outstanding ‘this is up to the practice to tell us’.” Field: Presentation skills necessary to receive CQC outstanding rating But in its evidence appendix, CQC insinuated that West Suffolk’s leadership should be censured for doing so: “Some staff told us that they felt that the executive team were so focused on maintaining outstanding status this impacted on the response received when concerns were raised and they “only wanted to hear the good”. We explored during the inspection whether there was added pressure on staff internally that was arising from the rating of outstanding. We noted that the theme of outstanding was used in various communications and formats. For example, the summer leadership summit had taken place on 19 June 2019 with outlined objectives and sessions based on creating a more inclusive culture and quality. There was an intense focus on understanding, developing and maintaining outstanding care and 70 staff attended. Session one focused on addressing and responding to priorities for improvement agreed from the 2018 national staff survey results. Session two focused on quality “keep calm and carry on being outstanding.” Minutes from the trust executive group on 2 September 2019 included a section on the CQC inspection and included text “the CQC don’t know we are outstanding, so we need to ensure we tell them”. This message was reiterated by several staff throughout the core service and well led inspections”. The theatrical thoroughness of CQC’s public flogging of West Suffolk’s leadership does emphasise that the centre probably has unsavoury truths from which it wishes to deflect.

 

One of the great concerns about the government’s Freedom To Speak Up scam has been that it spins a false line about progress. This encourages thousands more NHS staff to break cover and make themselves vulnerable to being picked off whenever it suits power. Not unlike Mao’s campaign to “Let a hundred flowers blossom”:

The Silence that Preceded China’s Great Leap into Famine. Mao Zedong encouraged critics of his government—and then betrayed them just when their advice might have prevented a calamity

At present, we wait to see how far up the West Suffolk whistleblower witch hunt went. West Suffolk NHS Foundation Trust staff had the misfortune of whistleblowing in a Secretary of State’s constituency, which increases jeopardy because of the increased political sensitivity.

Matt Hancock Health Secretary initially claimed to the Bury Free Press that he had been told by the NHS that whistleblowing matters at West Suffolk had been handled “entirely appropriately”.

It is essential that this claim is further clarified. I have asked Hancock to disclose from whom he received advice. I expect prolonged resistance by DHSC to my request.

In the meantime the National Guardian has reluctantly, in principle, agreed to stand by a 2017 promise to  help reinstate unfairly sacked NHS whistleblowers. Correspondence continues on whether she will logically help NHS whistleblowers with remedy of other forms of detriment, even though she has tried to date to avoid this. I will report on the outcome of the correspondence in due course.

The National Guardian has so far stood by passively on West Suffolk scandal. Her Office previously even congratulated the trust’s CEO for “commitment” to Freedom To Speak Up.

She should of course proactively review West Suffolk NHS Foundation Trust and help ensure that the detriment suffered by whistleblowers is rectified.

But just as the West Suffolk Freedom To Speak Up Guardian is beholden to their employer, she has no powers and is beholden to the CQC, NHSI/E and DHSC.

The main, damning sections of CQC’s evidence document about the lack of Freedom of To Speak Up at West Suffolk are provided in the appendix. I have formally brought them to Robert Francis’ attention. The letter to Francis is also provided.

 

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RELATED ITEMS

The sham of model of internal whistleblowing champions is spread across UK government departments and satellite bodies, with a policy intention to spread it further. It is wasteful and risky both to the workforce and the public. It is particularly risky now that we have an authoritarian government that has little regard for basic rights or press freedom, and seeks to strengthen its links with other similarly minded governments, such as the pariah administration in Hungary.

Real reform is needed with much better UK whistleblowing law and supporting structure:

Replacing the Public Interest Disclosure Act (PIDA)

In the meantime, we will be stuck for some time with the government’s charade of wholly flawed UK whistleblowing governance, which fails to protect the public.

Prescribed Persons or the Pretence of PIDA. How UK whistleblowers are ignored

The Disinterested National Guardian & Robert Francis’ Unworkable Freedom To Speak Up Project

A portrait of ineffectiveness: Internal whistleblowing champions in their own words

National Guardian reprieves NHS employers, but condemns whistleblowers and patients

 

 

APPENDIX

(1) Letter to Robert Francis:

 

Sir Robert Francis

Chair of Healthwatch England

Care Quality Commission

4 February 2020

Dear Sir Robert,

Further evidence of serious failure of the Freedom To Speak Up model

I am aware from correspondence shared by others that you remain firm in your views that yours and the government’s Freedom To Speak Up model is sound.

I am also mindful that your disclosed correspondence to the National Guardian of 3 February 2017 revealed that you apparently decided not to meet with me as I requested, because you believed you could not change my mind on my concerns about the Freedom To Speak Up project:

“We can have no expectation that Dr A will agree with anything you do or say and I have little doubt that any meeting with me is not going to change that. I do not propose to accede to her request.”

May I posit that it is open to you to change your mind.

To that end, I copy below relevant excerpts from CQC’s evidence appendix for its latest inspection report on the scandal-hit West Suffolk NHS Foundation Trust, where the trust board tried to hunt down a whistleblower with biometric data.

As you will see, the Freedom To Speak Up Guardian is criticised, and staff concerns about the confidentiality of disclosures to the Freedom To Speak Up Guardian are noted.

From the outset, this type of risk to staff and patients was the central and very obvious flaw of the Freedom To Speak Up project.

I would be grateful if you could comment on whether you will act to put right this serious risk and call for better cross sector, UK whistleblowing law and enforcement structure, to drive genuine improvement in culture and practice.

With best wishes,

Minh

Dr Minh Alexander

 

(2) This is the supporting evidence document for CQC’s latest inspection report on West Suffolk NHS Foundation Trust:

West Suffolk NHS Foundation Trust Evidence appendix

Below is the section from this document on the trust’s culture and whistleblowing governance failures. For convenience, I have highlighted the section on the trust Freedom To Speak Up Guardian in bold.

“Culture

Not all staff felt respected, supported and valued or felt that they could raise concerns without fear. Communication and collaboration to seek solutions had not always been effectively undertaken. An open culture was not always demonstrated. However, staff were focused on the needs of patients receiving care. Equality and diversity and opportunities for career development were promoted.

Throughout the core service inspections, we found that the culture was centred on the needs and experience of people who used the service. Staff across the services were proud of the care they provided. Within the divisions staff were positive about the culture and felt supported by their colleagues and immediate line managers.

The trust felt that they promoted an open culture and had policies, procedure and processes in place to support staff, patients and relatives to raise concerns. The trust took assurance from the following mechanisms incident reporting, PALS, freedom to speak up (FTSU) guardian, trusted partners (volunteer members of staff), and guardian of safe working hours. To support staff directly there was an employee assist programme in place and the chaplaincy department was available to all. However, this did not align to the inspection findings. Staff did not feel listened to and saw others that had raised concerns be penalised. There was a focus on the individual raising concerns and response to issues were on occasion disproportionate. The executive leadership team failed to fully recognise the impact that this had on the safety culture within the organisation.

The trust was clear that behaviour inconsistent with the vision and values would be addressed and there were processes in place to manage behaviour and performance. In October 2018 the trust outlined via the green sheet that the trust executive group (TEG) was actively sponsoring action to make sure that anyone who believed they were being / or had been bullied or harassed or discriminated against had the confidence to report it formally and knew how to do this and that access to confidential support was available.

Despite these identified processes we found that some staff felt the culture did not encourage openness and honesty. Not all staff felt supported, respected or valued and some feared reprisals if they raised concerns. This impacted negatively on the ability of staff to challenge and discuss options for mitigating risk. Detail in the provider information request (PIR) was that, between April 2018 and March 2019, the trust had recorded one whistle blowing incidence. Incidences of whistleblowing were recorded in three main categories; patient care and patient safety, fraud, and workforce issues (including bullying culture). Additional PIR narrative then stated there had been six workforce incidents raised, no incidents of fraud and two patient care / patient safety incidents, thus giving a total of eight whistleblowing incidences, not one, within the same timeframe. The trust’s own analysis of theses noted that allegations of bullying and harassment, including lack of consideration and kindness to colleagues were key factors in a number of incidents. Other issues were around professional registration and staffing issues. These correlated to some of the results in the 2018 NHS staff survey and to our findings during inspection.

Six of the 10 whistle-blower contacts we received between September 2018 and September 2019 raised concerns that there was an apparent reluctance by the senior executive team to hear and accept feedback of a negative nature. Overarching themes included: the trust does not welcome feedback, a lack of robust investigation into employee relation matters and human resource (HR) process, poor support for staff with mental health concerns, poor culture, lack of engagement with FTSU guardian, poor communication, distrust of being able to raise concerns without breach of confidence or fear of repercussion. We heard examples from staff that information they had provided in confidence, to various individuals including the FTSU guardian, had become known. Across a number of specialties, including paediatrics, pathology, anaesthetics and vascular services, genuine concerns relating to clinical risk and safety had been raised. Staff directly involved felt communication and collaboration to seek solutions had not been effectively undertaken. Some staff, during interview, stated they felt this had resulted in specific areas and groups of staff being seen, by the executive team, as dysfunctional rather than believing that issues needed to be addressed and worked through with staff to improve services for patients. Some senior staff we spoke with felt that they had not been personally supported by the executive team when they had sought help and advice.

The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 20 Duty of candour, is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that person. When we requested information around a serious incident in the vascular services, we were informed that duty of candour had not been undertaken as the level of harm was still unknown.

Whilst the duty of candour component 20(2) refers to notifiable incidents (death of a service user, severe harm, moderate harm or prolonged psychological harm), component 20(1) states that registered persons must act in an open and transparent way with relevant persons in relation to care and treatment provided to service users in carrying on a regulated activity. Providers must promote culture that encourages candour, openness and honesty at all levels. This should be an integral part of a culture of safety that supports organisational and personal learning. There should also be a commitment to being open and transparent at board level or its equivalent, such as a governing body. We reviewed the trust local policy “Being open – The Duty of Candour” January 2018 where it was stated in the summary that the board set out a commitment to transparency and being open.

We requested copies of communication that were sent to vascular patients that required follow up and received only a draft letter for duty of candour. We were not provided with evidence of what communication had been made with the patients that had been affected by the incident, to be assured that the trust was openly communicating that there had been a failing in internal systems. It was also evident that this had not been acted upon or communicated in a timely manner. Therefore, we were not assured that the trust had acted in line with its own policy or taken reasonable steps to ensure duty of candour had been appropriately applied by being fully open and transparent.

There was a complex serious incident investigation ongoing at the time of inspection that encompassed aspects of alleged patient safety, incident reporting, risk management, breach of confidentiality and both personal and professional conduct. We found that the process of this investigation had far reaching effects across a number of staff, and the executive team, impacting on health and wellbeing, culture and morale of those involved. Whilst internal HR processes were being adhered to, some staff felt that the actions undertaken by the trust were questionable in purpose. Communications sent during the investigation were corporately worded, with direct legal reference, which meant that they lacked any personal element, and were seen by some as quite threatening in nature with a focus for apportioning blame.

On the 10 September 2019 the medical staffing committee (MSC) wrote a collective statement of concern to the chair. This stated that concerns had been raised by multiple departments in regard to the culture and behaviours of the executive body, on multiple occasions, that had not endorsed the trust values of freedom to speak up. The CEO and the chair attended the next meeting of the MSC in October 2019 to discuss and listen to the concerns being raised and reassure the consultant body that the executive directors lived the values. Whilst the meeting itself had been an attempt to address some of the concerns raised, we found that the subsequent response letter to the MSC chair, dated 14 October 2019, could be considered intimidating, and confirmed to us the continued disconnect around communication. The letter outlined that discussions were held around how matters of speaking up were dealt with and how the board sought to ensure balance and objectivity in their decision making. However, it also included a schematic, developed by trust lawyers, to set out the process followed when concerns were made about a professional’s practice and stated that this was “assiduously followed”.

During the well led interviews, we found that the ongoing serious investigation was in the forefront of several of the executive directors’ minds. There was an understandable desire to bring the investigation to a closure as soon as possible however, we were concerned that the route the investigation had taken, and the commitment of the board of non-tolerance to poor behaviour, was potentially limiting their objectivity. CQC have no regulatory remit to investigate or intervene with individual complaints or incidents. Having looked at the process however, we were concerned that the incident focus had potentially impacted on the wider root cause analysis. Irrespective of the incident itself there was learning to be gained from understanding why established channels of raising concerns had not been taken, however the executive team appeared focused on the who, rather than the why and whether there were effective systems for staff to raise concerns to ensure patient safety. There was a level of acceptance, by the executive team, that there were simply two sides of the incident which was not helpful. In one meeting, the medical director described that certain staff were in “separate camps” and alluded to a “them and us” situation. There were wider ripples of impact in that disengagement of the consultant body was a real risk, yet following the concerns raised there had been no separate medical staff survey undertaken to explore the extent of concerns. We fed this back to the executive directors and there was an element of recognition that communication and engagement needed to improve.

The senior executive team did reflect and recognise that communication and handling of certain aspects of this incident, and others, could have been better. They also stressed that other incidents had been handled sensitively and had not been brought to the attention of others by those involved. They provided a separate example where wording around a question in relation to pay and annual leave for doctors had caused huge discontent and recognised that often language used can escalate an appropriate question out of proportion, that then takes a long time to repair. The trust had implemented a “lessons learned” process following a grievance or disciplinary to help to ensure any issues identified were not repeated going forward, but we were not provided with evidence that this had been implemented.

There was a better working lives group in place. We reviewed the minutes of the meeting on the 23 September 2019. Under agenda point 7, there was a discussion held in relation to improved support for staff in stressful situations such as coroner’s court, serious incident investigation, a never event, a complaint or after maternity or any long-term sickness absence. Included in this discussion were suggestions from the MSC. Options included ‘opt out’ rather than ‘opt in’ for support required. There was agreement that an exact process for support would be beneficial for all staff, not just doctors. It was noted that this would be a great quality improvement project but would be a huge piece of work. An action was identified that the deputy medical director would arrange a meeting with the head of patient safety and human resources to help take this forward.

Some staff told us that they felt that the executive team were so focused on maintaining outstanding status this impacted on the response received when concerns were raised and they “only wanted to hear the good”. We explored during the inspection whether there was added pressure on staff internally that was arising from the rating of outstanding. We noted that the theme of outstanding was used in various communications and formats. For example, the summer leadership summit had taken place on 19 June 2019 with outlined objectives and sessions based on creating a more inclusive culture and quality. There was an intense focus on understanding, developing and maintaining outstanding care and 70 staff attended. Session one focused on addressing and responding to priorities for improvement agreed from the 2018 national staff survey results. Session two focused on quality “keep calm and carry on being outstanding.” Minutes from the trust executive group on 2 September 2019 included a section on the CQC inspection and included text “the CQC don’t know we are outstanding, so we need to ensure we tell them”. This message was reiterated by several staff throughout the core service and well led inspections.

 

NHS Staff Survey 2018 results – Summary scores

The following illustration shows how this provider compares with other similar providers on ten key themes from the survey. Possible scores range from one to ten – a higher score indicates a better result.

There were no themes where the trust’s scores were significantly higher (better) or significantly lower (worse) when compared to the 2017 staff survey. (Source: NHS Staff Survey 2018) The 2018 NHS staff survey was completed by staff during the period September 2018 to December 2018. A sample of 1250 staff was randomly selected, of which 601 responded. This meant a 48% response rate which was better than the average of 44%. The 2018 national staff survey results showed that staff felt more supported than in the previous year. Ratings improved for staff getting support from their immediate manager (up 2.5%); getting clear feedback on their work (up 2.1%); being asked for their opinion before changes are made (up 2.9%); and for feeling like their manager values their work (up 1.4%). The percentage of staff that felt their role made a difference to patients had decreased from

92.7% in 2017 to 91% but remained above the national average 89%. The percentage of staff satisfied with the quality of care they give was 84% against a national average of 80%, and 78% staff felt enthusiastic about their job (national average 74%). The overview theme results, scored out of 10, for health and wellbeing, morale, safe environment (bullying and harassment) and safe environment (violence) were all above average at 6.4, 6.4, 8.1 and 9.4 respectively. Whilst the trust had a fairly consistent result between 2015 and 2018 in relation to safe environment (bullying and harassment and violence) there had been decline in several of the detailed results: Q13b: In the last 12 months, how many times have you personally experienced bullying and harassment from managers: had increased from 9.1% in 2017 to 11.9% in 2018 (2.8% increase). Q13c: In the last 12 months, how many times have you personally bullying and harassment from other colleagues: had increased from 14.9% in 2017 to 19.3% in 2018 (4.4% increase). Q13d: The last time you experienced harassment, bullying or abuse at work, did you or a colleague report it: reporting had dropped significantly from 51.2% to 37.9% which was in line with the worst rate for acute trusts.

A summary paper on the staff survey results went to board on 1st March 2019 and highlighted reporting, creating a compassionate and inclusive culture, being kind to each other and visible leadership as the top three priorities. We reviewed the trust action plan in response to the 2018 staff survey. Actions to address these results included further analysis to identify any ‘hot spots’ and reasons why staff may not be reporting. Additional actions included communication of the reporting process and importance of reporting via several means (core brief, Green sheet, and medical directors bulletin) alongside the re-promotion of staff support available, alongside setting of agreed behavioural standards and staff training on positive performance management and dealing with unacceptable behaviour. The introduction of an anonymous telephone reporting line had seen two contacts, one of which was to explore what the line was for. The lack of any high immediate response was seen by the executive directors we spoke with is as a positive sign.

The freedom to speak up (FTSU) guardian had been in post since 2017 and was directly employed by the trust. Prior to the role they had been a staff governor for nine years and had been approached by the director of HR to consider the role as there had been no expressions of interest. The FTSU guardian stated that they averaged approximately four hours a week but would flex this dependent on need. They could be contacted either directly by telephone or via email. The guardian had received initial training from the National Guardian Office (NGO) and they were involved in the Eastern Counties freedom to speak up network. The trust had hosted the network meeting on site on 26 June 2019.

During interview the FTSU guardian was extremely positive of the support provided by the executive directors. As well as direct support from the executive and non-executive leads for FTSU, they stated they could speak at any time to the CEO and chair and were confident that issues would be dealt with. They were proud of the role and stated they saw it as important and a privilege. They had monthly one-to-one meetings with the interim director of human resources and stated they met the nominated non-executive director (NED) every six months. They recognised that contact out in the community services needed to improve and stated they planned to work with the staff governor in the community to address this.

However, during interview we were not assured that the guardian had full understanding of the role. Their focus was on the support they were receiving from the executive team rather than support they were providing to staff across the organisation. They also stated they caught up fairly frequently with the guardian of safe working hours (GOSW), however this was not confirmed by the GOSW. The GOSW had been in post since March 2019 and informed us that the FTSU guardian had not responded to their initial contact. Despite initial thoughts that contact between the two roles would be important, as time had passed this had lessened, however they confirmed that they knew who the FTSU guardian was.

The FTSU guardian produced two reports a year to board. We reviewed the FTSU reports to board, dated 26 April 2019 and 1 November 2019. We found that these reports lacked substance and were extremely limited in content. Both reports outlined the role of the guardian and ongoing engagement at staff events to promote role. There was no evidence of triangulation to other patient /staff experience data to identify potential emerging issues. There was no trend analysis of numbers, issues, type of worker speaking up or analysis of wider context such as potential risks, barriers and opportunities. Neither FTSU reports mentioned any analysis of the 2018 NHS staff survey results.

Data was submitted quarterly to the NGO as per the “Recording Cases and Reporting Data guidance”, July 2018. Data entry format was the total number of cases, number raised anonymously, number with a patient safety / quality element, number with a bullying or harassment element and number where people report they are suffering detriment. The FTSU report for board categorised the data into behaviour / attitude, trust procedure / practice, capacity / workload and miscellaneous. It was difficult to compare reported data to the NGO with the data reported to the trust board as timeframes and categories differed.

In the data submitted to the NGO for quarter four 2018/19 eight cases were reported, two under the patient safety element and six under bullying and harassment. The same total number overall was reported in the April 2019 board report, with time frame stated as “over the last six months”. Four were recorded under behaviour / attitude, with the status reported as zero resolved and four outstanding. We noted that the additional text did not correlate with the figures presented as it stated “these are two cases where I am either working with staff and HR or where I have been asked to support staff. To date one has been resolved and the other is outstanding with the member of staff awaiting closure”. One was recorded under trust procedure / practice (status outstanding), and three recorded as miscellaneous (all resolved). In the November 2019 report six concerns were documented as being reported in the five months prior to the report. Four as behaviour / attitude (status three resolved, one outstanding), and two as miscellaneous (both resolved). There was no update on any of the previous reports concerns that had remained outstanding in the November report. This limited the board’s ability to track and monitor progress. We reviewed the board meeting minutes for April 2019 and whilst the agenda stated the FTSU report was submitted for the board to accept there was no documented comment in the minutes that this had taken place or evidence of any questions or challenge to the FTSU guardian. Therefore, we were not assured that there was sufficient data or content presented within the reports to provide any assurance to board. We noted that in an additional report to board in November 2019, in response to national FTSU guidance in NHS trusts it was documented that the trust would review the FTSU guardian report to ensure that the board received assurance through this reporting mechanism. In the same document was the commitment to produce a FTSU strategy to be presented to the board in January 2020.”

 

“Is this organisation well-led?

Leadership

The trust had an established, stable executive leadership team. Whilst priorities and issues were known and understood these were not always managed in a consistent way. The style of executive leadership did not represent or demonstrate an open and empowering culture. There was an evident disconnect between the executive team and several consultant specialties. Poor communication and fractured engagement of some of the consultant body had begun to impact on medical managers playing a full and effective role within the organisation.

The trust has an established experienced executive leadership team with only one executive being an interim appointment. The trust board consisted of six executive directors, chair and five nonexecutive directors. The team had remained stable since the previous inspection in 2017, with the only substantive change being the appointment of a new chair on 01 January 2018.

At the time of the inspection, there was an interim executive director of human resources (HR). The previous substantive director of HR, had accepted the interim position on 01 May 2019, on a part time basis following their retirement, until the next appointed director took up the position. Recruitment, and appointment, had taken place and the new director of HR was due to take up position with the trust on 04 November 2019. The chief executive officer (CEO) had been in post since 03 November 2014. The longest established member of the executive team was the director of resources, and deputy CEO, who had been in post since 01 December 2011.

The five non-executive directors (NED) were appointed between September 2013 and September 2018. There had been two changes of NED since we last inspected in 2017 due to previous individuals reaching the end of their tenure. Of the two most recent appointments, one NED held the responsibility as the audit committee chair, link to director of resources and health and wellbeing programme. The other held responsibilities for safeguarding adults, security and emergency preparedness, resilience and response (EPRR).

We found that the executive leadership team did not always support the delivery of high-quality person-centred care. The style of leadership amongst the executive directors did not represent or demonstrate an open and empowering culture. There was a failure by the executive team to step back from specific clinical safety concerns and consider organisational impact. We saw evidence that when staff had raised concerns they were not always taken seriously, appropriately supported or treated with respect. In some cases, responses to those raising concerns, were defensive in nature, individually focused rather than actively collaborating to seek solutions.

CQC received 10 whistleblowing concerns between September 2018 and September 2019, five of which were received in the three months leading up to inspection. Several of the whistleblowing concerns included factors around poor engagement, communication and leadership. There was a growing disconnect between the executive team and several clinical specialties which had impacted on consultant involvement with the running of services. Communication with some members of medical staff had broken down. We were not assured that the significance of this had been fully acknowledged by the executive directors, or board, or responded to in an effective, timely manner.

The medical staffing committee had been reinvigorated in June 2019, by the consultants, as an opportunity for clinicians to increase engagement collectively with the executive directors. We reviewed the minutes of the first two meetings. In the initial meeting the structure, format and frequency of the MSC were outlined, with the CEO to have a regular 15 minute slot at each meeting. It was agreed that the medical director would attend but that the chair of the MSC could ask the medical director to leave should this be appropriate if discussions directly related to them. Matters arising were minuted, with actions, and it was agreed at that initial meeting the MSC would be held quarterly, with the next meeting set for September 2019.

The 10 September 2019 meeting minutes demonstrated that there had been discussion between the trust chair and the secretary of the MSC, around the morale and concerns of the consultant body. There was recognition that the board were aware of a degree of unhappiness among the consultants, and a feeling that concerns were not being recognised. It was noted that the increasing distance felt between the consultant body and the executive team had begun to impact on individuals withdrawing involvement in the running of the trust. As a result, it was agreed that one of the non-executive directors should be regularly invited to attend the MSC to update the consultants on the issues and concerns that the board was addressing and to gain an understanding of the consultants’ views and concerns. It was agreed at this meeting that the MSC would meet monthly rather than quarterly.

During interview it was evident that the board were aware of the areas of concern and there were strong opinions as to the reasons that certain groups were unhappy, however actions to address and repair leadership relationships were less apparent. We discussed with the executive team during feedback, that certain staff felt the executives listened but did not hear. One example was Paediatrics where the trust and the consultants shared similar concerns but the communication between parties had not identified they were on the same page. Another example was Pathology, where there was an apparent disconnect between the view of the executive team and that of the consultants. The executive view was that staff at the trust were reluctant to work within the North East Essex and Suffolk Pathology Services (NEESPS) network however, we were informed by the consultants, and operations manager, that this was not the case. Their frustrations came from a lack of ability to provide the service they wanted to, due to ageing equipment and no control over the day to day management of the service they provided. Whilst the board had met with the senior team at the lead acute trust that host the NEESPS and received a commitment to deliver the required improvements, the consultants felt that this focused on the longer term and did nothing to address immediate concerns. They remained sceptical about the timeframe for change as NEESPS had been in place for two years with no significant improvement or responses to continued concerns. The Pathology team stated they felt the executives had stopped listening and believed the matter resolved.

There was a process for individual contribution, check and challenge through the internal governance framework, HR processes and various committees. Whilst there was an appropriate level of challenge seen in the various committee meetings we reviewed, we found that there was a potential risk that the board had become so driven behind a united decision there was a reluctance, perceived or actual, to take on board other perspectives and alternatives. For example, there was an ongoing complex, serious incident investigation at the time of inspection. The way this had been managed had impacted on the leadership, governance and culture across the organisation. We reviewed the approach taken by the executive leaders in regard to the investigation process that had occurred, alongside relevant information provided. Actions undertaken were unprecedented and concerning, such as the requirement for fingerprinting and handwriting analysis. These actions had not been disclosed to us until after the trust had undertaken them. Whilst there had been attempts to ensure impartiality, such as external independent reviews and legal advice, we found that certain aspects of the process lent towards individual bias with potentially questionable conclusions and judgements made. We were not assured that, having made the decision to follow the course of action agreed by the board, that any subsequent information had been appropriately considered. We voiced this concern with the CEO and chair during the inspection.”