Health Department scolded over patient safety concerns

Thursday 04 April 2019

The Health Department has been reprimanded six times in just over a decade for failing to manage “violence and aggression, and ensure a safe environment in a healthcare setting," it has emerged.

The finding came in a critical new report by Comptroller and Auditor General, Karen McConnell, focused on community and social services for adults and older adults - a key provision for looking after some of the island's most vulnerable people, spanning mental health institutions and care homes.

In it, she found that the Health and Safety Inspectorate had issued the department with six improvement notices since 2006 – two of which had come last year alone.

One of the 2018 notices referred to a failure to provide a “suitable and sufficient Personal Alarm System in Orchard House”- the island’s main adult mental health facility. 

Asked by Express, the Government declined to state what the other five notices referred to, saying that the information was restricted under the Health and Safety at Work law and it would need to be released by the States Employment Board (SEB).

Pictured: Orchard House was one of the facilities which was the subject of a Health and Safety Inspectorate improvement notice.

Ms McConnell equally raised the SEB's 2017 conviction relating to the “wholly avoidable and unnecessary” death of a patient in 2016 as a result of “inadequate training, poor procedures and a failure at all levels of management over a long period of time."

Ms McConnell cited these examples in her report as proof that the Health Department had been alerted to “key weaknesses” in the way they operate on numerous occasions in the past decade, but had failed to address these shortcomings.

Although the Department now operates under the new name of 'Health and Community Services', the government watchdog observed lasting habits from the former Health and Social Services’ lack of “a learning culture."

In a table, she catalogued key weaknesses she said she was "disappointed" to see had not been acted on for many years, including "temporary staff not properly trained", "poor record-keeping" and "staff feel vulnerable".

Pictured: The C&AG detailed the issues raised by the HSI improvement notices.

Elsewhere in her report, Ms McConnell charts objectives set out in the Health Department’s 2016 “action plan” which have either not been fully implemented or not met at all.

This isn’t the first time the Health Department has come under fire from the C&AG who conducted a review of the Community and Social Services for Adults and Older Adults in 2015, which prompted an “action plan” from the Department in February 2016.

The watchdog also recently penned a damning report calling for an overhaul of the island’s health system due to its lack of good governance.

The 2016 action plan “made clear that the vast majority of actions were to be delivered by” the end of that year, but, now the C&AG is following up on the department’s progress, she has found that “as at December 2018… none of the recommendations from my 2015 report has been fully implemented for Adult and Older Adult Services.”

“Even where actions have been undertaken and there has been some general progress towards improvement, there has been no mechanism in place to test whether the intended outcomes have been achieved,” Ms McConnell remarks. 

Pictured: The government watchdog outlined the scope of her task when tackling issues to do with Adult Safeguarding.

Bringing her report to a close, the watchdog emphasises the high stakes of the correct management of services to do with adult safeguarding, writing: “the services covered by this review are provided to some of the most vulnerable people in Jersey. My concerns about the way in which those services were managed were significant.” 

Noting the failure to implement “agreed action” and the legacy of a lack of “a learning culture” in the former Health and Social Services Department, the C&AG found that “risk has not been effectively managed, which may have contributed to the repeated Health and Safety failures." 

Ms McConnell did acknowledge that “arrangements have improved” over the last year, but that “more work is required to embed a robust approach to responding to external reviews and agreeing, implementing, monitory and reporting on change".

“Until the States focus on implementation of agreed actions and the outcomes of implementation, opportunities to drive improvements in the services provided and to mitigate the very substantial risk to vulnerable people will not be secured,” the C&AG concludes.

Ms McConnell then makes a series of recommendations to ensure this is achieved.