Fundamental weaknesses in a health board's ability to monitor the safety and quality of care it offers its patients have been uncovered in a damning new report.
Healthcare Inspectorate Wales (HIW) and the Wales Audit Office (WAO) have produced a joint review into the governance arrangements at Cwm Taf Morgannwg University Health Board.
It found that while the health board had a good track record in meeting its financial targets and balancing its books, it was at the detriment of the quality and safety of its services.
It also concluded that leadership at the very top of the organisation needed to be strengthened, with the need to more clearly define the roles of directors and executives to improve accountability.
In addition, there was found to be "insufficient focus and resource" dedicated to gathering, analysing and learning from the poor experiences of patients.
The review team discovered that Cwm Taf staff had become so used to working under high levels of risk that it had become the norm, particularly in its A&E departments.
"Our joint review findings make worrying reading," said Kate Chamberlain, chief executive of HIW.
"What the report shows us is that the health board doesn't have sufficiently robust processes in place to enable it to really understand the quality of care that's being delivered to patients.
"Clearly this hasn't happened overnight. There have been some issues coming through in our work over the past 12-18 months that maybe haven't been getting the visibility and response we might have expected at board level.
"I think it's going to be a very big challenge for the health board to make sure it does take a fundamental look at the arrangements it's got in place for reporting quality, managing quality and responding to quality concerns."
The joint review was carried out following a highly-critical report into maternity services by the Royal College of Obstetricans and Gynaecologists and the Royal College of Midwives last April.
That report unearthed systematic failings in the services, including inadequate support for junior doctors, unacceptable midwife staffing levels and a "punitive culture of blame".
It also found that dozens of serious incidents - including stillbirths and neonatal deaths - went unreported.
This prompted the HIW and WAO to under take a more detailed examination into quality governance arrangements at the health board as a whole, not just isolated to just maternity services.
While the review didn't look specifically at patient-level care, it did conduct a survey of staff working within surgery, theatres and emergency departments across the Royal Glamorgan Hospital in Llantrisant and Prince Charles Hospital in Merthyr Tydfil.
It found a "mixed picture" in relation to staff's confidence in raising concerns.
The report stated: "While some felt sufficiently empowered, other responses pointed to a culture of fear and blame and a reluctance to speak out because they felt nothing would be done.
"This points to a need for senior leadership in the health board to set the right tone for a culture of high-quality, compassionate and continually improving care."
The report added that some staff were discouraged from reporting or "over-using" Datix, a system used for reporting incidents or near misses.
They found that while staff were positive and about the system, it was seen as a role for nurses rather than other medical staff.
"Training in the use of Datix is limited with many staff reporting that they had not received training," the report stated.
"Of those who had received training, this had focused upon the completion of a Datix form rather than in running reports, monitoring progress with incidents or reviewing themes and trends."
While some significant concerns were highlighted, the review concluded that there was cause for optimism due to new leadership being being put in place at the health board. This includes a new chief executive following the resignation of Allison Williams in August.
However, Ms Chamberlain could not rule out the health board being placed under a higher level of Welsh Government control following a meeting of HIW, WAO and Welsh Government in the coming weeks.
The health board is currently receiving "targeted intervention" from the Welsh Government, while its maternity service are in "special measures" - the highest level.
"We have another meeting coming up in the next few weeks, and I would expect our report to be considered as part of that meeting," she added.
"I think one of the clear messages coming through from this report is the importance of any organisation being able to listen to its staff and patients.
"If I was going to give one message back to patients, it's to give positive feedback when you have a positive experience, but also raise concerns when any issues arise, and that way you can be part of the improvement within the organisation you rely on."
The report makes 14 specific recommendations to Cwm Taf Morgannwg University Health Board, including:
- Identifying clear organisational priorities for quality of services, and reflecting these in an updated quality strategy;
- Strengthening identification and management of risk across the breadth of its services;
- Clarifying roles and strengthening leadership in respect of quality and safety, especially in relation to the roles of the medical director and clinical directors;
- A number of actions to help strengthen scrutiny and oversight of quality and safety within the organisation;
- Engagement with staff to help embed a new values and behaviours framework, and broader actions to demonstrate a stronger approach to organisation learning.
Adrian Crompton, the Auditor General for Wales, admitted the scale of the challenge the health board faces is "significant".
He said: "Fundamental aspects of quality governance have been allowed to lapse and work is now urgently needed to rebuild both those internal systems and the external confidence in the Health Board.
"New leadership, who have a clear idea of what needs to change, gives cause for optimism but they will need to act with both resilience and pace to effect the many changes that are necessary."
In response Dr Sharon Hopkins, interim CEO of Cwm Taf Morgannwg University Health Board, said: "We welcome the review by HIW and the WAO and recognise there are very significant findings outlined in their report.
"We accept all of the recommendations and we are committed to listening to our staff, patients and partners and working with them to improve our quality systems and processes to provide the best standard of care to our communities."
She added: "Work is already underway to address the key issues in the report. This includes a major programme to develop our values and behaviours, a new organisational model to improve our structures, increased engagement with staff and partners and strengthening of our quality governance arrangements.
"A number of these plans are already in progress however we know that some improvements will take longer to achieve. We will continue to work hard to put the right systems and processes in place to best support our staff in providing the highest quality services for patients and families."
