317429/North Wales Extraordinary/2015 Page 1 of 59

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1 317429/North Wales Extraordinary/2015 Page 1 of 59

2 Extraordinary review of performance in mitigating key risks identified in the NMC Quality assurance framework for nursing and midwifery education Programme provider Bangor University Programmes monitored Registered midwife 36m; Pre-registration nursing - mental health; Pre-registration nursing adult Date of monitoring event July 2015 Managing Reviewer Lay Reviewer Registrant Reviewer(s) Placement partner visits undertaken during the review Peter McAndrew Kate Taylor Hugh O Donnell, Nicola Clark, Gibson D Cruz Betsi Cadwaladr University Health Board (BCUHB): Mental Health Nursing Services Colwyn Bay Hospital: Bryn Hesketh Ward; Bryn Hesketh Mental Health Unit Day Hospital. Glan Clwyd Hospital: Ablett Unit; Dinas Ward; Tegid Ward; Cynnudd Ward; Home Treatment Team. Wrexham Maelor Hospital: Hydref Unit; Heddfan Ward; Helyg Day Hospital; Wrexham Community Mental Health Team; Wrexham Community Rehab Team. Caernarfon: Substance Misuse Service. Ysbyty Gwynedd Hospital Bangor; Hergest Unit; Aneurin Ward; Talesin Ward. Adult Nursing Services Llandudno Hospital: Beuno Ward; Llewelyn Ward; Morfa Ward. Ysbyty Glan Clwyd: Ward 19a. Wrexham Maelor: Accident and Emergency Unit; Cunliffe Ward; Morris Ward; Mason Ward. Chirk Community Hospital. Ysbyty Eryri Caernarfon: Padarn Ward; Peblig Ward /North Wales Extraordinary/2015 Page 2 of 59

3 Midwifery Services: Ysbyty Glan Clwyd: Midwifery Services. Wrexham Maelor Hospital: Midwifery Services. Ysbyty Gwynedd: Maternity Unit. Date of Report 3 August /North Wales Extraordinary/2015 Page 3 of 59

4 Introduction to NMC QA framework The Nursing and Midwifery Council The NMC exists to protect the public. We do this by ensuring that only those who meet our requirements are allowed to practise as a nurse or midwife in the UK. We take action if concerns are raised about whether a nurse or midwife is fit to practise. Standards for pre-registration nursing and midwifery education We set standards and competencies for nursing and midwifery education that must be met by students prior to entering the register. Providers of higher education and training can apply to deliver programmes that enable students to meet these standards. The NMC approves programmes when it judges that the relevant standards have been met. We can withhold or withdraw approval from programmes when standards are not met. Quality assurance (QA) and how standards are met The quality assurance (QA) of education differs significantly from any system regulator inspection. As set out in the NMC QA Framework, updated in 2014, approved education institutions (AEIs) are expected to report risks to the NMC. Review is the process by which the NMC ensures that AEIs continue to meet our education standards. Our risk based approach increases the focus on aspects of education provision where risk is known or anticipated, particularly in practice placement settings. It promotes self-reporting of risks by AEIs and it engages nurses, midwives, students, service users, carers and educators. Our role is to ensure that pre-registration education programmes provide students with the opportunity to meet the standards needed to join our register. We also ensure that programmes for nurses and midwives already registered with us meet standards associated with particular roles and functions. The NMC may conduct an extraordinary review in response to concerns identified regarding nursing or midwifery education in both the AEI and its placement partners. The published QA methodology requires that QA reviewers (who are always independent from the NMC) should make judgments based on evidence provided to them about the quality and effectiveness of the AEI and placement partners in meeting the education standards. QA reviewers will grade the level of risk control on the following basis: Met: Effective risk controls are in place across the AEI: The AEI and its placement partners have all the necessary controls in place to safely control risks to ensure programme providers, placement partners, mentors and sign-off mentors achieve all stated standards. Appropriate risk control systems are in place without need for specific improvements /North Wales Extraordinary/2015 Page 4 of 59

5 Requires improvement to strengthen the risk control: The AEI and its placement partners have all the necessary controls in place to safely control risks to ensure programme providers, placement partners, mentors and sign-off mentors achieve stated standards. However, improvements are required to address specific weaknesses in AEI and their placement partners risk control processes to enhance assurance for public protection. Not met: The AEI does not meet all the necessary controls in place to safely control risks to enable AEIs, placement partners, mentors and sign-off mentors to achieve the standards. Risk control systems and processes are weak significant and urgent improvements are required in order that public protection can be assured. It is important to note that the grade awarded for each key risk will be determined by the lowest level of control in any component risk indicator. The grade does not reflect a balance of achievement across a key risk. When a standard is not met an action plan must be formally agreed with the AEI directly and when necessary include the relevant placement partner. The action plan must be delivered against an agreed timeline. The extraordinary review in Betsi Cadwaladr Health Board, Wales On 15 May 2015 Bangor University had reported to the NMC indicating that anticipated reconfiguration of maternity services was delayed so plans to reallocate student midwives had not yet occurred. Later on 4 June 2015 the Wales Local Supervising Authority (LSA) notified the NMC about escalating concerns about the supervision of midwifery and the provision of midwifery care within maternity services in Ysbyty Glan Clwyd, Betsi Cadwaladr Health Board. In this exceptional report the LSA had included the impact of those concerns on the support for student learning and assessment in practice and indicated that they were working with Bangor University. On 18 June 2015 Bangor University reported that all student midwives had been removed from Ysbyty Glan Clwyd. On 1 July Bangor University informed the NMC that a mental health student nurse had been removed from their placement at the Maelor Hospital in Wrexham following the escalation of potential risks to vulnerable adults. The NMC discussed the escalating concerns with all relevant organisations including Bangor University, Health Inspectorate Wales in their capacity as the Wales LSA, the Director of Nursing of Betsi Cadwaladr University Health Board (BCUHB) and the Chief Nursing Officer for Wales. Following this meeting the NMC took the decision to conduct an unscheduled extraordinary review, which took place on July The NMC provided the AEI and BCUHB with the terms of reference for the extraordinary review. The extraordinary review s methodology included group presentations, interviews and focus groups. The list of representatives that the review team engaged with together with the documentary evidence can be found at the back of this report /North Wales Extraordinary/2015 Page 5 of 59

6 The review team triangulated what they had been told over the three day period of the extraordinary review (20 22 July 2015) with documentary evidence supplied by the AEI and BCUHB. Registrant and lay reviewers have written their own reports following this triangulation methodology and these have been collated into a single education extraordinary review report by the managing reviewer /North Wales Extraordinary/2015 Page 6 of 59

7 Summary of findings against key risks Resources Admissions & Progression Practice Learning Fitness for Practice Quality Assurance 1.1 Programme providers Registrant teachers have have inadequate resources experience/qualifications to deliver approved commensurate with role programmes to the standards required by the NMC 1.2 Inadequate resources Sufficient appropriately available in practice qualified mentors/sign-off settings to enable students mentors/practice teachers available to achieve learning to support numbers of students outcomes 2.1 Inadequate safeguards are in place to prevent unsuitable students from entering and progressing to qualification 3.1 Inadequate governance of and in practice learning 3.2 Programme providers fail to provide learning opportunities of suitable quality for students 3.3 Assurance and confirmation of student achievement is unreliable or invalid 4.1 Approved programmes fail to address all required learning outcomes that the NMC sets standards for Programme providers procedures address issues of poor performance in both theory and practice Evidence of effective partnerships between education and service providers at all levels, including partnerships with multiple education institutions who use the same practice placement locations (Bangor and Glyndwr AEIs) Practitioners and service users and carers are involved in programme development and delivery Evidence that mentors, sign-off mentors and practice teachers are properly prepared for their role in assessing practice Students achieve NMC learning outcomes, competencies and proficiencies at progression points and for entry to the register for all programmes that the NMC sets standards for 4.2 Audited practice Students achieve NMC placements fail to address practice learning outcomes, all required learning competencies and proficiencies at outcomes in practice that progression points and for entry to the NMC sets standards for the register for all programmes that the NMC sets standards for 5.1 Programme providers' internal QA systems fail to provide assurance against NMC standards Student feedback and evaluation/programme evaluation and improvement systems address weakness and enhance delivery Programme providers procedures are implemented by practice placement providers in addressing issues of poor performance in practice Academic staff support students in practice placement settings Mentors, sign-off mentors and practice teachers are able to attend annual updates sufficient to meet requirements for triennial review and understand the process they have engaged with Concerns and complaints raised in practice learning settings are appropriately dealt with and communicated to relevant partners Records of mentors/practice teachers are accurate and up to date Standard Met Requires Improvement Standard Not met /North Wales Extraordinary/2015 Page 7 of 59

8 Introduction to Bangor University s programmes The College of Health and Behavioural Sciences at Bangor University comprises the following schools and academic centres: the School of Healthcare Sciences; the School of Medical Sciences; the School of Psychology; and the School of Sport, Health and Exercise Sciences. The School of Healthcare Sciences delivers pre-registration nursing and midwifery programmes and has two main campuses at Bangor and Wrexham. The Bangor campus is set within the main university campus and the Wrexham campus is situated adjacent to Wrexham Maelor Hospital. The School was founded at Bangor University in 1990 following the integration into the university sector of NHS education services for healthcare professions. Since its formation the School has continued to maintain close links with BCUHB, which provides practice placements for the majority of the undergraduate pre-registration nursing and midwifery students. BCUHB practitioners make up the major part of the post-registration student body. The School of Healthcare Sciences provides a pre-registration programme for nurses: Bachelor of Nursing (Hons) (three years) in adult nursing; mental health nursing; learning disability nursing and children's nursing. The School also provides a Bachelor of Midwifery (Hons) (three year) programme. The School was approved to deliver the new pre-registration adult nursing programme which meets the NMC standards (2010) in 2012 and the mental health nursing field in The pre-registration programme is influenced by the All Wales initiative which has provided a collaborative approach to the development of the nursing and midwifery curricula since This has enabled NHS Wales and the education and practice placement providers to develop a shared approach to recruitment and selection, educational audit, evaluation mechanisms and the assessment of clinical practice. The School has ensured that this national approach has been complemented by a more localised curriculum development process that has given ownership to stakeholders for the development of the future nursing and midwifery workforce. In 2013 Bangor University successfully won the contract to be the single provider for nursing and midwifery education in North Wales delivering all four fields of preregistration nursing in addition to midwifery education. This has resulted in an increase in student numbers. The extraordinary review is in response to a number of concerns that have been raised over a two-year period about care services in BCUHB. Concerns have been escalated by students in relation to the care of patients in placement areas provided by BCUHB and these concerns have been reported by the university to the NMC. In June 2015 the university removed all midwifery students from Ysbyty Glan Clywd (YGC) maternity services due to concerns about an unsuitable practice learning environment. In June 2013 Health Inspectorate Wales (HIW) conducted an overview of governance arrangements within BCUHB and raised fundamental concerns relating to the effectiveness of the Board and the organisation s management and clinical leadership structures /North Wales Extraordinary/2015 Page 8 of 59

9 A number of HIW unannounced dignity and essential care inspections to care services provided by BCUHB have raised concerns and concluded that improvement plans are required. A HIW report on a review in respect of the provision of mental health care and treatment provided to a specific patient by BCUHB identified a number of serious shortcomings and the need for a development plan. An external investigation into care in an older persons mental health ward after concerns were raised by relatives confirmed that the ward failed to provide the most basic of clinical standards and there was a lack of professional, dignified and compassionate care. The extraordinary monitoring event reviewed the risks associated with the provision of the pre-registration nursing (adult and mental health) and midwifery programmes to provide assurance that there are no risks that are not being managed to ensure effective student learning and that all NMC standards for pre-registration education continue to be met. Students studying the nursing and midwifery pre-registration programmes are positive about the learning support that they receive from the university and its practice placement partners. The commissioners and employers confirm that the programmes prepare registered midwives and registered nurses who are fit for practice. The extraordinary monitoring review took place over three days and involved visits to placement areas to meet a range of stakeholders. Particular consideration was given to visiting placement areas that had concerns escalated by students, adverse reports in relation to HIW inspections and reports and concerns related to practice learning environments. Summary of public protection context and findings We found the following NMC key risks are currently not controlled: resources, practice learning and fitness for practice. Quality assurance requires improvement and the remaining key risk area admissions and progression was met. The university must identify and implement an action plan to address these key risks that are not met and require improvement to ensure the pre-registration midwifery and pre-registration nursing (adult and mental health) programmes meet NMC standards to protect the public. Resources We found the teaching resource for the delivery of the pre-registration midwifery programme is below that which is required to deliver the programme at the level of quality that was specified at the programme approval. The current level of input by teaching staff appears unsustainable. We have serious concerns that the current resources cannot guarantee that knowledgeable, safe and competent practitioners can be achieved at the end of the programme. The role of the Lead Midwife for Education (LME) does not meet the Standards for pre-registration midwifery education (NMC, 2009). The university must take urgent action to provide additional resources and support to give reassurance that the programme is effectively delivered to the standards agreed at approval and that safeguards are put in place which protect the public from /North Wales Extraordinary/2015 Page 9 of 59

10 unsafe incompetent practitioners. We found that generally there are sufficient mentors and sign-off mentors available in adult and mental health nursing services for the number of student nurses on placement. In some mental health placements there are adequate sign-off mentors but the numbers are low and can lead to capacity issues which restrict the range of student placements that are available. In some midwifery areas there is a shortage of sign-off mentors and many students reported a lack of continuity of mentorship which created problems when completing their practice documentation. Admissions and Progression We found that procedures to address issues of poor performance in both theory and practice are well understood and implemented effectively in the programmes reviewed. Practice Learning We found that sound partnerships exist with service providers and associated education providers at programme operational level. However, we found that partnership working at a strategic and higher operational level was not as effective and needs to be stronger. We found that there is a need to more effectively coordinate action, to provide a stronger vision, and to fully engage clinical and education staff and service users and carers in the arising development plans. We found that the educational audit must be strengthened to ensure that the quality of the audit process is effectively undertaken, to identify trends and issues, and to ensure action plans are implemented and monitored to ensure completion. We confirmed that the management arrangements for student placements meet the many challenges that exist from the escalation process, clinical governance reporting and service reconfigurations. Effective procedures are in place to protect student learning and to assess if placements need to be withdrawn or rested. This includes a comprehensive joint education and service risk assessment approach. Students report that the policies and procedures for raising and escalating concerns are difficult to understand due to some of the terminology used and that the flow diagrams are complex and unhelpful especially when a student is distressed by the issues that they wish to raise. We recommend that these procedures and diagrams are revised involving students and contained in the students practice portfolio. We found that the mandatory training records of nurses and midwives including mentors and sign-off mentors are at a low level of compliance and do not provide evidence that nurses and midwives are competently using up-to-date knowledge and skills. In relation to safeguarding and the protection of vulnerable adults training, issues that are at the centre of current concerns within some elderly and mental health care settings, compliance is below 40 percent. Midwives compliance with mandatory training is 58 percent. Immediate action must be taken to ensure that all nurses and midwives have undertaken mandatory training to assure that they deliver safe practice, meet the requirements of registration and the NMC Code together with assurance for the Standards to support learning and assessing in practice (NMC, 2008) /North Wales Extraordinary/2015 Page 10 of 59

11 We found that mentors and sign-off mentors are committed to their roles. They are highly supportive to students who are experiencing issues with progression and are prepared to fail students when this is indicated. However mentor status which meets NMC requirements and mentor registers for both nursing and midwifery programmes is not accurate and up to date. We found student midwives are not always allocated a sign-off mentor who meets NMC standards. Our findings conclude that whilst some records are accurate changes must be made to ensure that there is an accessible, robust and up to date mentor register held by BCUHB which ensures students are only allocated to mentors/sign-off mentors who meet NMC requirements. We also found that the mentor register for the private and independent sector, maintained by the university, is inconsistent and inaccurate. Action must be taken to ensure that the register provides a consistent and accurate up-to-date record of mentors who meet NMC requirements. We found that service users and carers are engaged in some aspects of the programme development and delivery and are enthusiastic about increasing their involvement in all aspects of the programme. The service user and carer contribution providing students with feedback on their performance of delivering care at an informal and formal level needs strengthening to meet the NMC standards. Effective coordinated development activity in relation to service user and carer engagement must be taken to ensure that the level of engagement meets the requirements of contemporary practice. We found that academic staff have a visible presence in practice settings and students feel that they are well supported and that their presence enhances the student learning experience. Fitness for Practice We found that students achieve the learning outcomes and competencies for entry to the nursing part of the NMC register. Students emerging from the programme are considered fit for practice by employers and education commissioners. External examiners confirm that the programme meets statutory requirements. We found that in the pre-registration midwifery programme the practice assessment document (PAD) does not provide sufficient information to evidence that European Union and other essential statutory requirements are guaranteed. Urgent action must be taken to ensure that the PAD is robust, meets all NMC requirements and is approved by the NMC. Quality Assurance We found effective processes ensure external examiners engage with both theory and practice elements of the approved programmes. Evaluation systems are in place to enhance programme delivery however the feedback to placement areas is not consistent and requires improvement. We found that policies and procedures are in place to enable students to raise /North Wales Extraordinary/2015 Page 11 of 59

12 complaints. However, we found the procedure needs to be improved so that it provides a suitable avenue for students to raise issues, to ensure that all complaints are fully investigated and the outcomes are reported to all relevant individuals. Summary of areas that require improvement The teaching resource for the delivery of the pre-registration midwifery programme must be strengthened to enable the programme to be effectively delivered to meet the Standards for pre-registration midwifery education (NMC, 2009). Additional resources and support must be put in place to enable the LME to meet the statutory role. At a strategic level there should be stronger partnership working between Bangor University and BCUHB, including effective communication and management of governance issues related to clinical areas and practice learning environments. The educational audit process should be strengthened to ensure that the audit process is effectively undertaken and that action plans are implemented and monitored to ensure completion. The number of nursing students identified for allocation in placement areas needs to be reviewed to ensure all students have an equitable opportunity to gain a wider experience of different patient groups in varying settings. The policies and procedures for raising and escalating concerns should be reviewed to ensure they are clear, comprehensive and understood by students who wish to raise concerns. The mandatory training records of nurses and midwives, including mentors, require immediate action to ensure that all practitioners deliver safe practice, meet the requirements of registration, the NMC Code and mentor/sign-off mentor status. Urgent action must be taken to ensure student midwives are allocated a sign-off mentor who meets NMC standards. Registers of mentors must be more accessible and provide accurate and up-to-date information that all mentors and sign of mentors meet NMC requirements. The mentor register for the private and independent sector must provide a consistent and accurate record. The student nurse (mental health nursing) who is supported by a mentor who does not meet the requirements for triennial review must be allocated a mentor who meets NMC requirements. Effective procedures must be put in place to ensure this issue does not occur again. There needs to be effective coordinated activity developed in relation to service user and carer engagement to ensure their contribution meets the requirements of contemporary practice. In the pre-registration midwifery programme urgent action needs to be taken to /North Wales Extraordinary/2015 Page 12 of 59

13 ensure that the PAD is robust, meets NMC standards and is approved by the NMC. Feedback from students evaluations should be consistently provided to placement areas. The complaints procedure needs to be improved so that it provides a suitable avenue for students to raise issues; to ensure that all complaints are fully investigated and the outcomes and learning for the future are reported to all relevant individuals. Summary of areas for future monitoring The teaching resource for the delivery of the pre-registration midwifery programme. The LME fulfils all aspects of the statutory role. Strategic partnership working between Bangor University and BCUHB is effective. Monitor the process for educational audits. The allocated numbers of students to placement areas. Students have equitable opportunities to gain a wide experience of different patient groups in varying settings. The policies and procedures for raising and escalating concerns. Mandatory training records of nurses and midwives are compliant and up to date. Mentor and sign-off mentor preparation is compliant. Mentor registers provide accessible, up-to-date, accurate and consistent records. Service user and carer engagement in programme development and delivery and especially in relation to providing students with feedback on care that they have delivered. The PAD for pre-registration midwifery is an appropriate tool which provides evidence that all EU and statutory requirements are met. Feedback from students evaluations is consistently provided to practice placement areas. Confirm that procedures are in place to ensure all complaints are fully investigated and the outcomes and learning from the complaints are reported to relevant parties. Summary of notable practice Resources None identified. Admissions and Progression None identified /North Wales Extraordinary/2015 Page 13 of 59

14 Practice Learning None identified. Fitness for Practice None identified. Quality Assurance None identified. Summary of feedback from groups involved in the review Academic team Pre-registration nursing programme The academic team demonstrates a strong commitment to the learning experience of student nurses. They told us that they have strong and effective working relationships with the staff in the organisations that provide placement experiences for student nurses. They informed us that the curriculum is contemporary and facilitates development of the knowledge and skills to ensure student nurses are able to care for a range of service users. We were told that the university is very supportive in enabling professional and academic development of staff including the completion of higher degrees and doctorates. Some lecturers are also completing a teaching qualification programme, with support from the university. Pre-registration midwifery programme We were informed that the LME and midwifery lecturers were not involved in the discussion regarding concerns raised in Glan Clywd maternity unit, or in the decision to remove student midwives from the maternity unit. The midwifery programme team reported that they were shocked that this decision had been made. The reasons cited for this action was because concerns had been escalated regarding midwives attitudes and behaviours, and that normality was not being promoted. Prior to the students being removed, the LME was not aware of any issues of concern. Positive evaluations had been made by students and no concerns had been raised with the midwifery link lecturers. Mentors/sign-off mentors/practice teachers and employers and education commissioners Pre-registration nursing programme Mentors, sign-off mentors and employers express confidence in the programme and the knowledge and skills of students who successfully complete the programme. Mentors told us that they receive good preparation for their role and additional support is /North Wales Extraordinary/2015 Page 14 of 59

15 available to mentors and sign-off mentors from link lecturers, when it is required. We found all mentors are motivated and willing to support students during all stages of the programme. Mentors clearly understand their important role and the responsibilities they have in supporting student learning and in the assessment of essential skills and NMC competencies. We found that in some areas mentors and sign-off mentors are anxious that their ability to continue to meet NMC standards for learning and assessing in practice may be compromised due to a reduction in students allocated to some practice placements. Managers and employers told us that students are fit for practice and purpose on successful completion of the programme. The perceived quality of new graduate nurses is supported by the high number of students who achieve employment locally on completion of the programme. Pre-registration midwifery programme We found mentors are very supportive of the pre-registration midwifery programme and student midwives. They told us that the programme prepared the students to be competent at the point of registration. Midwifery mentors rotate on either a three or four monthly cycle. The allocation of students to mentors is generally undertaken by the link lecturer. The mentor register database is kept at BCUHB and maintained by an administrator. Triennial review is part of the annual supervisory review completed by supervisors of midwives. We heard that to meet the shortfall, available midwives are being mapped to the mentor/sign-off mentor role on the basis of previous experience which had taken place a number of years previously with no record of recent mentor practice. Mentors told us that they are aware of the plans for the reconfiguration of maternity services at YGC and they know that the plans are currently halted due to a court injunction. The mentors told us that they were unclear of the rationale to remove the midwifery students, and all midwives and mentors based at YGC felt that this was seen as a reflection on their practice and were deeply upset and disappointed. Students Pre-registration nursing programme We found that pre-registration mental health nursing students receive good support in both the university and during practice placements. Personal tutors are perceived by students to be an important learning and support resource which they utilise frequently, as required. We found that students receive good support in practice placements from ward managers, mentors, sign-off mentors and link lecturers. Students have access to appropriate learning resources within the university and in practice placements. We found that students are confident in their personal growth, level of knowledge and competence for the stage of the programme. We were informed that mental health nursing students especially in the early part of the programme wished to be exposed to more focused mental health nursing theory, with a reduction in more generic curriculum content /North Wales Extraordinary/2015 Page 15 of 59

16 Students report that they have the opportunity to achieve practice learning objectives in a wide range of clinical and community settings throughout the programme. They can self-select spoke placements which are of particular interest and will be placed in these areas for short periods, if the student s mentor determines the spoke placement to be relevant to the placement speciality. We found that students have good opportunities to meet and share learning opportunities with other health and social care professionals. Students in the final year of the programme informed us that they have achieved the necessary knowledge, skills and competence required to progress to registration. We found the adult nursing students are confident and objective. They spoke positively about the university and practice placement providers. They value their teaching and placement experiences and find them to be instrumental in their learning. They felt that they are acquiring the knowledge, skills and attributes to become competent registered nurses. Students told us that they are aware of the negative reports of standards of care in some healthcare organisations, however their experience of care is very different. They had not witnessed any incidents of concern and had not had their placement patterns altered as a result of adverse reports. The students did tell us that the negative reports in the press had made them more vigilant and they strived to ensure that their professionalism and practice was always to the highest standard. Pre-registration midwifery programme We were informed that there are currently 62 students studying the three-year midwifery programme at the university and 19 students were based at YGC maternity services. All students in years one and two at YGC were moved to either Bangor or Wrexham maternity hospitals depending on their residential address, and year three students were moved to community placements. Students are very supportive of their programme but are all unclear of the reasons for the extraordinary monitoring visit. The students based at YGC were upset at being moved and reported that some of the midwives displayed negative attitudes towards them following notification of the move that they found challenging and upsetting. The students told us that there was no communication from the university explaining why students had been relocated from YGC and when, or if, they would be returning. Students told us that the programme prepared them to undertake the role of the midwife and nearly all were in the process of applying to BCUHB for a midwife post in the local area. Students informed us that they felt supported although this largely appeared to be by one permanent member of the academic team and some cited a lack of continuity due to the rate of tutor turnover during their programme. Students told us that they have recently formed a midwifery society and are extremely enthusiastic regarding events and study days held by the society for students, including the focus on normality in childbirth. Service users and carers Pre-registration nursing programme /North Wales Extraordinary/2015 Page 16 of 59

17 Service users told us that they are involved in the pre-registration nursing programme and are positive about their participation and expressed a wish to be more involved in the future. The service user group is currently involved in developing terms of reference related to the creation of an expert patient panel. Service users are involved in activities within the pre-registration nursing programme, including student selection activities and providing feedback to students following seminar presentations. Teaching staff provide service users with feedback following episodes of curriculum participation. Service users are involved within research teams and receive research training to support their participation. We spoke to a number of service users during practice placement visits, and they expressed satisfaction with the quality of care which they had experienced from students. We observed service users participating in a range of therapeutic activities during placement visits and witnessed a range of resources to help promote therapeutic activities for service users. The potential exists for service user feedback regarding student performance to be included within the student portfolio and service users would welcome this development. However, there has been limited implementation of this initiative. Pre-registration midwifery programme We heard service users involvement has been improved with the inclusion of their feedback from continuity cases (case loading experience) which is then placed in the student s practice portfolio. However, this could be expanded to include recruitment /North Wales Extraordinary/2015 Page 17 of 59

18 Relevant issues from external quality assurance reports These external quality assurance reports provide the reviewing team with context and background and attribute to the reasons that informed the extraordinary review. NMC monitoring review of Bangor University January 2014 The NMC standards were met in all key risk areas. The monitoring review focused on the pre-registration nursing programme, in particular the adult and child nursing fields. The monitoring visit took place over two days and involved visits to practice placements to meet a range of stakeholders. Particular consideration was given to the student experiences in the placements which had been subject to adverse concerns. The monitoring visit to YGC identified effective infection control practices and a collegiate approach which included students in maintaining effective practices. Areas for future monitoring: One area identified for enhancement and further development is the activity already in place to manage escalating concerns. All contributors have their own processes in place but to date these processes have yet to ensure transparency for all stakeholders. Discussion with NHS Wales, BCUHB personnel and Bangor University identified a need to better share information that will enhance the transparency of concerns raised and share best practice (1). HIW is responsible for inspecting NHS and independent healthcare organisations in Wales against a range of standards, policies, guidance and regulations. They focus on how well those who may be in vulnerable situations are safeguarded and identify where services are doing well, as well as highlight areas where services need to be improved. Previous quality reports on midwifery services undertaken in Wales by HIW are over five years old and were not considered relevant to this extraordinary review. A number of external reviews have however been undertaken in relation to escalated concerns in elderly mental health care settings and maternity services. These settings have also been used as practice placement settings for nursing and midwifery students. External investigation into concerns raised with regards to the care and treatment of patients in Tawel Fan Ward, Ablett Acute Mental Health Unit, YGC September 2014 Tawel Fan Ward provided care for the older person with a mental health problem. In February 2014 concerns were raised by family members of patients regarding the quality of care provided on the ward, many of which were very serious. BCUHB agreed to commission an independent external investigation. In September 2014, the external investigator (Ockenden) provided a summary of the ten key themes of her findings from the external investigation: Lack of professional, dignified compassionate care /North Wales Extraordinary/2015 Page 18 of 59

19 Lack of 1:1 care to maintain patient safety. Unsupervised patients. Lack of nurses to adequately care for patients. Lack of fundamentals of care. Concerns regarding standards of operational safety briefings/quality nursing handover. Professional concerns breaching duty of care. Patients nursed on the floor. Patients distressed and not supported in an environment which does not promote independence and resulting restraint. Regimes/routines/practice on the ward which may violate individual patient s human rights. The external report provided additional information as follows: All the concerns raised by the families were upheld. It is possible that there have been serious, long-term and consistent breaches of standards (GMC and NMC). The ward failed to provide the most basic of clinical standards and there was a lack of professional, dignified and compassionate care. Almost all the families were deeply dissatisfied with the care of their loved ones The majority of staff interviewed maintained that the ward was a centre of excellence, despite evidence of degrading practice. Numerous Protection of Vulnerable Adults (POVA) issues had been raised, along with formal and informal concerns by families. Complete lack of effectiveness in capturing and acting upon informal and formal concerns or for assuring the quality and safety (9). Strategic review of Older People s Mental Health (OPMH) Services in BCUHB undertaken by Flynn and Eley Associates Ltd December 2014 The review identified the following seven areas for improvement: Involving older people and their carers in service planning and design. Developing a strategic vision for OPMH in North Wales. Post-diagnostic support for people with dementia and their carers. Clinical networks to support people with dementia and their carers. In-patient services. Stronger partnerships with primary care. Information Technology internal and external communications /North Wales Extraordinary/2015 Page 19 of 59

20 In receiving this report the BCUHB confirmed its intention to work closely with the authors of the review to implement the priorities outlined within a new strategic direction for OPMH services (10). HIW Inspection (unannounced) BCUHB Ablett Unit, YGC June 2014 The Ablett Unit has four wards, consisting of: Cynnydd, a 10 bedded locked adult rehabilitation ward; Dinas, a 20 bedded ward split into a male (10 beds) and female (10 beds) area; Tegid, a 10 bedded older persons ward; and Tawel Fan, a 17 bedded older persons ward which is currently closed. The inspection raised a number of serious concerns relating to: the lack of nurse call systems in some ward areas; some essential bathing facilities and equipment were not effectively operational; unsafe practices in relation to the storage and administration of medications (including controlled medicines) were identified; serious omissions in patients care plans; serious inadequacies in the checks that should have been undertaken to ensure staff were of good health and character prior to commencing employment; and a serious lack of mandatory training (11). BCUHB HIW action plan in response to a visit to the Ablett Unit, YGC on June 2014 July 2014 A detailed action plan was submitted to address the issues raised (14). HIW Dignity and essential care inspection (unannounced) BCUHB: Wrexham Maelor Hospital, Accident and Emergency Department 30 September 1 October 2014 The unit was managing high volumes of patients requiring treatment on the days visited. Physical and environmental resources were not sufficient to manage the intensity of the work. As a result, delivery of the fundamentals of care was compromised and a number of patients were waiting in ambulances for long lengths of time on inappropriate trolleys intended for transfer only and with reduced access to food, drink and toilets. The report highlighted many negative findings and challenges faced by the Accident and Emergency (A&E) staff relating to the way in which the fundamentals of care are delivered in the A&E. However, the team of staff were excellent at prioritising patients clinical needs and emergency/urgent care needs. Patients needing urgent care consistently received it promptly, including those patients arriving in ambulances. In using their skills and abilities of clinical prioritisation, the staff team were excellent at ensuring patients received urgent care when their condition was most unstable. For those patients who had a more stable condition, yet required to be seen by a doctor or nurse, delays were experienced due to the total volume of patients in the department and a team of very busy staff. An improvement plan was required within two weeks of the inspection to address the issues raised (6). HIW Dignity and essential care inspection (unannounced) BCUHB, Ysbyty Eryri /North Wales Extraordinary/2015 Page 20 of 59

21 Hospital, Padarn And Peblig Ward December 2014 Padarn Ward, providing care for up to 20 female patients and Peblig Ward for up to 14 patients, including eight male patients and up to six male/female palliative care patients who were nursed in single en-suite rooms. At the time of the inspection two beds were not being utilised on Padarn Ward due to staff shortages, which BCUHB were attempting to address through staff recruitment drives. At the time of the inspection work was in progress to review the overall management structure for Eryri Hospital and HIW will be notified of the outcome in due course. Staff were kind and caring with patients and the delivery of care was good. The staffing levels were not always adequate to provide the level of rehabilitation care required for the patients. HIW issued an immediate assurance letter to BCUHB immediately after the inspection. This was in relation to staffing levels and staff training. BCUHB s response to address these matters is to be followed up by HIW. There was evidence that regular audits were being undertaken at ward level and the audit results were displayed within the ward for patients and staff to see. An improvement plan was required within two weeks of the inspection to address the issues raised (5). HIW Dignity and essential care inspection (unannounced) BCUHB: Chirk Community Hospital Ceiriog Ward January 2015 Chirk Community Hospital was newly built and reopened in Ceiriog Ward comprises of 31 inpatient care beds primarily for care of the elderly, rehabilitation and palliative care. A range of other services are provided at Chirk Community Hospital, including inpatient and outpatient physiotherapy, occupational therapy and speech and language therapy services, outpatient clinics and community healthcare support groups. Various assessments had been completed regarding patients needs and individualised, person centred care being delivered. This practice was not reflected in the care planning documentation and therefore recommendations were made for improvements. It was also recommended that additional assessments and care planning tools be considered for people who have dementia or a cognitive impairment. BCUHB was advised to consider confidentiality when storing patient records in ward areas and it was recommended that the ring binders used to file patient records were generally improved. At various points during the inspection it was observed that some of the doors to storage rooms, including the medication room, had been left open when unattended. Recommendations were made that these rooms are closed and locked when not in use. An improvement plan was required within two weeks of the inspection to address the issues raised (12). HIW Dignity and essential care inspection (unannounced) BCUHB: Llandudno General Hospital, Beuno Ward 2 3 September 2014 Llandudno General Hospital has two rehabilitation wards and two step down wards for /North Wales Extraordinary/2015 Page 21 of 59

22 patients from the District General Hospital including medicine, trauma and orthopaedic, surgery and gynaecology. As part of HIW s annual inspection programme Beuno Ward, which is a medical ward, was visited. The inspection team concluded that the fundamentals of care were being delivered at a basic level. However, there were staffing issues on the ward in terms of numbers, resilience and skill mix. The team of staff on the ward were very busy and experienced significant challenges as a result of these issues. Documentation to support the delivery of safe and effective care and treatment was considered to be generally poor in terms of its quality and completeness. The staffing issues, identified above, were considered to be a contributing factor. There was a lack of effective management and leadership to help and support staff to deal with the day-to-day challenges and pressures they were experiencing. There was a lack of multi-professional rehabilitation being provided on the ward. Additionally, concerns were also identified regarding the extent of medical input into multi-disciplinary team meetings. Overall, the inspection team concluded that given the number of concerns they identified during this inspection, patients could not be assured that they would routinely receive a safe and effective service. This was because despite the dedication and hard work of the ward team, staffing issues (numbers, resilience and skill mix) and the lack of effective management and leadership were contributing to the day-to-day challenges and pressures being experienced by staff. An improvement plan was required within two weeks of the inspection to address the issues raised (13). HIW Dignity and essential care inspection (unannounced) BCUHB: YGC ward 19a (Gynaecology and breast care) January 2015 The acute hospital service at YGC provides a wide range of inpatient and outpatient services for adults and children. Ward 19a (gynaecology and breast care) had 12 inpatient beds, eight of which were designated for women receiving obstetrics or gynaecology treatment and up to four beds for women receiving breast care treatment. Ward 19a also runs outpatient services, from a separate day unit, for colposcopy, hysteroscopy, pre-operative assessment, urogynaecology and early pregnancy assessment. As a result of the inspection BCUHB approved the temporary transfer (12 18 months) of gynaecology inpatient services to Wrexham and Bangor. Ward 19a will therefore become a breast care ward for this period. However BCUHB was advised to apply the recommendations made in this report when implementing the service change/provision on ward 19a. Staffing levels on ward 19a were generally sufficient to meet patients needs. However staff stated that on some occasions they did not have the full complement of healthcare assistants required due to regular staff members leave arrangements. The inspection advised that staffing availability during these absences is reviewed. Staff informed that they were supported by the ward sister and junior ward sister /North Wales Extraordinary/2015 Page 22 of 59