IF you work in a hospital you probably know that healthcare inspectors could turn up out of the blue, but what would your reaction be if they did?
Healthcare Inspectorate Wales (HIW) inspector Claire Foster said she didn’t under-estimate how “utterly terrifying” it might be for some staff, particular agency workers who might not quite have found their feet.
Reaction varied considerably, she said, but generally she and her colleagues were welcomed. “It really does depend on the site – at most places people are really happy to talk to us and don’t run off and hide in cupboards as you might expect,” she said.
HIW inspects NHS services – hospitals, mental health services, doctors’ surgeries, dental practices, among others. It also inspects and regulates independent ones, such as private hospitals, private dental practices, private laser clinics and independent mental health services. Staff and patient feedback is a key part of the inspection process.
Inspectors’ reports regularly make the news and their recommendations for improvement lead to action.
Mrs Foster joined HIW as an inspector 18 months ago after a career in workplace mental health, and was promoted in February. What was the first thing she did when she and her colleagues set foot in a hospital, for example?
“I explain several times what the purpose of the inspection is, what the key points of the inspection are, who’s who (on the HIW team) and what their jobs are,” she said. “I also tend to give them a a list of what documents we need.”
Inspectors are accompanied by clinicians, apart from visits to laser clinics, and don’t need a healthcare background. Mrs Foster inspects a lot of maternity services – a previous role included work with the Nursing and Midwifery Council – and so could be joined by two midwives and an obstetrician as well as a fellow inspector.
She said the intention of inspections was not to trip staff up but ultimately improve patient safety. Conveying that message to staff was important. “They can see we are a conduit for improvement,” she said.
Mrs Foster said she and her colleagues avoided interfering in patient care but looked at how staff interacted with each other, how multi-disciplinary teams functioned, and what happened at handover time when new staff came on shift, among other things. Hospital inspections are mostly unannounced and generally take two days, sometimes including an evening visit.
HIW inspectors look at how a service complies with regulations and meets healthcare and other legal and professional standards. Their reports have three themes: quality of the patient experience, the delivery of safe and effective care, and the quality of management and leadership.
Mrs Foster said if she or her colleagues saw something concerning she would raise it with the person in charge. “It is an open and honest conversation,” she said. In the majority of cases, she said, it would be resolved there and then.
An HIW spokeswoman said if an issue was an immediate risk to patient safety, inspectors can require a response within a week via an “immediate assurance letter” or, in the case of independent healthcare settings, a “non-compliance notice”. They can also designate a service as requiring significant improvement. The spokeswoman said services generally accepted the findings of inspectors and responded well to their reports.
Mrs Foster said she usually gave initial feedback to the healthcare setting at the end of an inspection prior to writing a report. “Senior leaders from the health board generally attend,” she said.
“Then we go back and start looking through our evidence. Often we’ve asked for multiple documents. I need to time to reflect, check and do a lot of ‘triangulation’. Some reports take a lot longer than others.”
Mrs Foster said she aimed for reports to be measured, helpful and not punitive. “I never want to make things worse,” she said. “And it’s never personal.”
Staff and patient feedback, she said, was a “huge part” of a report. “Sometimes the response I get from staff is, ‘I’m pleased to see you – I need to tell you how it is,’” she said. “It can be tricky for patients who are in a hospital bed to share their experience, which is why we do follow-ups (surveys). Equally I’ve had fabulous feedback from patients and staff, and I try to make sure that gets through to leaders.”
Mrs Foster said feedback from black and ethnic minority people using maternity services was particularly pertinent as women from this cohort were more likely to die in childbirth than other groups. “It’s a terrible statistic,” she said.
Asked if she was coming across the same types of challenges in the healthcare sector, she pointed out that she had not been in the role that long, but replied: “Staffing challenges overwhelmingly. Services struggling with demand, capacity and patient flow.”
She said it could be “quite upsetting” to see staff doing their utmost to keep a service going when “they are very nearly on their knees”.
Mrs Foster said it was motivating when services improved following an inspection, or simply remained good having been good to start with. “The people using those services, and the staff, are probably happier,” she said.
The 47-year-old, of the Vale of Glamorgan, said she loved her job and was in awe of the clinicians and others whose expertise she could draw from. “Our work is vast,” she said. “No two days are the same, and I’m never bored.”
Haydn Bradley-Davies began working as an HIW inspector in March this year after working in different Welsh Government roles. He also continues to volunteer as a Dyfed-Powys Police special constable a minimum of 16 hours a month and said the investigative skills he has picked up transferred to his HIW job.
“I remember my first unannounced inspection – a busy A&E department in a hospital in South Wales at about 8pm on a Monday night,” he said. “When we spoke to reception staff, with our lanyards and badges, they were probably a bit taken aback.
“But staff were supportive and very welcoming,” he said. “We understand that we don’t take priority. Patients take priority.”
He added: “The patients I have spoken to have been complimentary about staff. They understand the pressures.”
Mr Bradley-Davies said unannounced inspections allowed the HIW team to see a service how a patient saw it. He also inspects GP surgeries and dentist’s and on these occasions prior notice is given to avoid patient disruption.
He explained that discussions with managers of a service happened throughout an inspection. “You don’t want to reel off a list of things at the end of the day,” he said.
The 27-year-old, of Aberystwyth, said he keenly awaited patient and staff feedback, and the more he received the better. He understood the demands faced by healthcare services. “Staff are passionate and invested in their work – giving negative feedback is never easy,” he said.
Michelle-Louise Walters used to work in general and palliative care, then in the community screening for cardiovascular disease, before various Welsh Government roles led to her current HIW job three years ago.
She said it was important that health workers felt they could provide a safe level care and that they were listened to.
“I think staff morale is still quite low, although it does vary,” she said when asked. “Everyone is rushed off their feet. They are trying to do their best. It’s clear to me that staff work really hard in often really challenging environments. Low staffing levels always come up.”
Mrs Walters said it was good to see positive changes when re-inspecting a service, for example greater visibility among senior management and staff feeling more able to raise concerns.
“It can be really challenging addressing areas for improvement when staff are under pressure,” she said. “I empathise with them. But I know it’s for the greater good – ultimately we all want the same thing.”
She said the element of surprise of unannounced inspections could be daunting for staff. “Once they’ve passed that initial shock, we are generally welcomed,” she said. “Managers are usually happy to see us and have usually been through the process before.”
She revealed there was one occasion when she had a suspicion the setting had been tipped off as she and her colleagues were staying in the only hotel in the area for miles around.
Mrs Walters said she would, following arrival, request a tour of the facility and, if an evening inspection, check things like medicine storage, resuscitation equipment, general cleanliness, and that staffing levels were safe.
She said access to mental health services and timeliness of treatment was a recurring theme, plus general levels of demand, service capacity and staff resourcing. The “big issue”, she said, was patient flow – the movement of patients through a hospital and back out into the community.
Mrs Walters said the independent sector was not immune, with recruitment pressures of its own. “They are reliant on agency staff quite a lot,” she said.
Asked about the most concerning thing she had seen on an inspection, she said it was the sight of bodily fluids on a hospital bed and other pieces of equipment which had been signed off as clean and sterile.
“They posed significant risks for the next patient, and were immediately dealt with,” she said. “It was easy to tell them (staff). They were appalled at the prospect that these items were due to be used by the next patient.”
HIW has just under 90 employees in total. This includes 26 inspectors – although at the time of writing there were four vacancies – working in four different teams. Where they inspect, and how often, is guided by an “intelligence team” which identifies key national and health board-specific risk areas. The inspection of independent health services is also shaped by information about risk, and the nature or complexity of the service.
Mrs Walters, 38, of Aberdare, loves her job. “When I came off the (hospital) wards due to illness, I said to myself I would like to influence things from the top down rather then the bottom up if I could,” she said. “I believe we do make a real difference.”