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  1. Community Health NHS Trust


    Liverpool Community Health NHS Trust
    Patients suffered “significant harm” because of multiple serious failings by a
    “dysfunctional” NHS trust, an independent inquiry has found. Liverpool Community Health NHS trust (LCH) provided poor, unsafe and ineffective care to patients, including inmates at HMP Liverpool, the scathing report concluded.
    An independent panel, commissioned by the regulator NHS Improvement, also found that the trust had “a climate of fear” as a result of the harassment and bullying of staff who raised concerns.
    The findings of the panel, led by Dr Bill Kirkup, are among the most damning of an NHS trust’s actions since Robert Francis QC’s landmark report into the Mid Staffs care scandal, published five years ago.
    “The trust not only failed in its duty to provide safe and effective services, it concealed this from external bodies. Both patients and staff suffered harm for too long as a result,” said the panel, which investigated LCH’s conduct between 2010 and 2014.
    The trust’s board “became blind to the real concerns that began to arise throughout the organisation” as staff voiced anxiety about plans to reduce its headcount and the impact that would have on patient care.
    “Serious incidents causing patient harm were not reported, not investigated and lessons not learned. The result was unnecessary harm to patients,” the report added.
    The panel highlighted a catalogue of failings by LCH, including that:
    • It sought to achieve unfeasibly ambitious savings targets in a bid to become a semi-independent NHS foundation trust. While 4% is the usual upper limit of annual gains, it tried to save 15% of its budget in one year.
    • The “drastic cost improvement measures” it decided to pursue mainly involved cutting staff, even though it was already understaffed.
    • Staff who raised concerns about those plans suffered harassment, bullying and “extreme action”, including being suspended for months at a time without being told what they had done wrong.
    But mounting problems at LCH went undetected for four years because NHS local and national bodies, including the Care Quality Commission and NHS England, failed to monitor it properly, the inquiry found.
    “Patients put their faith in the NHS, and they should be able to trust that dangerous and dysfunctional services will be dealt with immediately. Sadly, that has not been the case here and it took the help of a local MP to sound the alarm, and many years for the full facts to emerge,” said Jeremy Taylor, chief executive of National Voices, a coalition of more than 150 health and social care charities.
    Ian Dalton, NHS Improvement’s chief executive, said he would not comment on Kirkup’s findings until March, despite their seriousness. The Department of Health and Social Care said: “The leadership failings identified at Liverpool Community Health trust before 2014 were unacceptable and highlight the importance of fundamental reforms to patient safety that the government has made, including the CQC’s independent inspection regime and the special measures programme, which identifies quickly where hospitals have difficulties and puts in place a
    comprehensive package of support to help improve care for patients.” (The
    Guardian 2018)
    Task one:
    Using process mapping as a tool, identify and analyse an aspect of service failure in the above case study. Note that you are expected to undertake wider research on the case study. (50 marks)
    Task two:
    Following your analysis, provide five recommendations for improving the service delivery. (20 marks).
    Task three:
    Devise an implementation plan which could be used to implement two of your above suggested recommendations. (20 marks).
    10 marks will be reserved for the overall quality of the assignment in terms of: appropriate use of referencing, extent and evidence of research, structure of the submission, coverage of issues, presentation and use of appropriate language.

    Task one points to consider
    • Inquiry Findings; focus on only one aspect of service failure
    • Process mapping; failure map versus ideal map
    • Organizational standards and expectations; (mission / vision of the organisation)
    • National Quality Standards; NICE / CQC
    Task two points to consider
    • National & Local quality standards
    • Evidence based practice
    • Benchmarking
    • Your recommendations need to directly address the service failure that you have analysed
    Task three points to consider
    • Stakeholder groups
    • SMART objectives; tabular format

    About this Module -Introduction

    In this era of accessible information, health and social care consumers are more knowledgeable and demand high quality service and products; yesterday’s base-standards are soon not enough, and quality improvement is at the core of health and social care delivery. The Quality Improvement in Health and Social Care module will deepen the quality improvement capability and capacity of the postgraduate MBA students.

    Ideas about improvement stem largely from the early days of the quality revolution with the pioneering (Plan, Do, Study, Act (PDSA)) work of W. Edwards Deming, Joseph Juran’s trilogy of quality (control, planning and improvement) and Crosby and Peters four absolutes of quality, and Six Sigma in the post second world war years. This paved the way for the work of Donabedian and Ovretveit in a health care context. It can be argued that Improvement as a set of concepts and principles is a natural successor to notions embodied within Total Quality Management (TQM).

    A key focus for this module is the emphasis on the link between theory and practice, which is aimed at enabling the student to appreciate key concepts surrounding improvement by applying them to real-life health and social care practice contexts. Using scenarios and real-life case studies, students will have the opportunity to develop their abilities and skills to analyse real-life professional practice issues. In concert with such analysis, students will explore the range of achievable plans for quality improvement. Students will also develop skills to critique the implementation of each plan formulated, especially its implementation, in consideration of leveraging any actual or anticipated drivers including change agents, while addressing barriers and resistance; by way of proposing management action to drive quality improvement.

    Reading List/ Resources/ References
    1. Juran J. (1988). On Planning for Quality: Free Press: New York

    2. The Chartered Quality Institute (2017) What is Quality? available at

    3. www.nice.org.uk www.england.nhs.uk

    4. The Kings Fund (2015) Leadership and Leadership Development in Healthcare: The Evidence Base
    London: FMLM

    5. Moon, J (2004). A Handbook of Reflective and Experiential Learning London, Routledge Falmer
    6. Buchanan D & Huczniski A. (2017). Organizational Behaviour (9th edition)

    7, Mullins,L.(2016). Management and Organisational Behaviour (16th edition) Pearson: Edinburgh

    8. Bessant, J. & Tidd, J. (2015) Innovation and Entrepreneurship Sussex: Wiley

    9. Harrison, M. (2004). Implementing Change in Health System London: Sage


Subject Nursing Pages 15 Style APA


Quality Improvement in Health and Social Care


Liverpool Community Hospital NHS Trust was formed with a new Board and senior employees and got insufficient inspection since it was perceived as low-risk, partly because of the nature of the services offered. The outcome was avoidable harm to patients over several years and preventable stress for employees who were, in some instances, bullied and distraught when they attempted to raise concerns regarding worsening inpatient services. These failures were recurrent in the health services LCH offered to HMP Liverpool and added partly to the more significant challenges facing the prison. This paper analyzes the aspect of patient harm as service failure from this case study. This paper also provides recommendations and improvement plans on how LCH can correct the patient harm challenges.

Task 1

In the recent past, substantial investment has been channeled to healthcare service restructuring methods in dealing with the rising problems confronted by the sector, such as the aging population, limited funding, and medical inflation.  Appleby (2015) highlights that as the Health and Social Care Act began in 2012, the UK government spent averagely £1.5 billion in launching prevalent performance development changes to NHS services. Initiatives like process remodel, and health data structures implementation is always pursued togrow the productivity and quality of healthcare supplied while concurrently decreasing waiting times. Pickles et al. (2008, p.5) assert that health service restructuring programs have conventionally concentrated on two areas; performance improvement and supervisory limitations, patient encounter, and less consideration. A competent and conforming procedure does not certainly imply an extraordinary experience will be conveyed (Bate & Robert,2006, p.308). For example, a patient might get an appointment fast, but their broad experience will be miserable if, for instance, the waiting room is congested. The patient encounter should be the primary objective, together with delivering performance enhancement and meeting limitations. 

From the outset, LCH was a dysfunctional organisation that acted inaptly in pursuit of Foundation Trust (FT) status, planning infeasible financial targets that dented patient services. LCH provided services that were ill-equipped to handle mainly prison healthcare in HMP Liverpool. The Board and Senor leadership of LCH failed to acknowledge that LCH was beyond its depth and never considered the outcomes. Employees were overburdened, demotivated, and in some situations, bullied. External NHS bodies failed to realize the challenges for four years as the management team as inexperienced and new (Kirkup, 2018, p.3). LCH Board’s main goal was to become an FT, although frontline employees never shared this viewpoint. This goal dominated the management team’s time and focus, and they and the Board became blind to the real concerns that started arising in the company. 

LCH has enough contract revenue to continue with the previous service level when it started. LCH was asked by its commissioners to attain a very substantial cost-saving over the next four years. It seems to have provided no challenges to the viability of achieving this while sustaining current service levels. CCGs and NHSE commissioned LCH services, and it is not apparent that any had a general view on the cumulative effect. This naivety on the LCH part tipped it into a situation of massive cost pressures. Coupled with their acknowledgment of an unsustainable revenue position, LCH undertook to produce an enormous cash surplus in the same period (Kirkup, 2018, p.4). This seems to have been triggered by the desire to show a strong financial position to get the FT application. However, the cumulative effect of this with the revenue reduction was not sufficiently deliberated. To tackle the external and self-imposed cost pressures, the management team began on various radical cost-improvement measures. The suggested cost improvement primarily entailed decreasing staff numbers given the community services nature. Suggestions were subject to quality impact assessment (QIA). This procedure should have recognized the adverse impacts on services and whether they could alleviate. If adverse impacts were deemedinsurmountable, the suggestion would have been abandoned. However, these evaluations were deficient in LCH and failed to recognize the visible adverse impacts of the proposals that were executed. When QIAs are done, they were not actively handled nor thoroughly reviewed. 

The adverse effects of such an ambitious cost improvement program were firstly a demotivated staff. The staff were not involved in the staff reductions plan and felt they were not listened to. Hence sick leave amongst staff rose, which worsened staffing levels further. Secondly, though it was apparent that most staff endeared to compensate for employee reductions, it is equally evident that services started to suffer irrespective of their efforts (Kirkup, 2018, p.4). The frequency of patient harm cases subject to compulsory reporting nationally grew, comprising pressure ulcers and falls. Other occurrences, some grave, should have been reported and investigated. But staff highlighted that reporting was dejected, the investigation was inadequate, events were continually downgraded in significance, andaction planning for improvement was lacking or invisible.

At Liverpool Community Health NHS Trust (LCH), patient experience was not considered in their healthcare delivery.  Prevention of patient harm is foremost to health services quality, comprising their safety, and relies on some vital elements. Firstly, clinical care must be offered based on evidence-based criteria, by adequately experienced and skilled staff working collaboratively. Secondly, there must be an organizational culture that fosters openness and learning through operative professional and managerial leadership and administration (Harrison, 2004, p.20). Thirdly, clinical governance must be useful, to allow timely identification of any deviation from the necessary standards, so that the causes are highlighted, and corrective measures executed speedily. According to the CQC’s report, staff who were confronted with substantial and always overwhelming challenges from the situations they were operating in, reacted to the problems by putting in more time, not taking days off, and training to manage excessive caseloads. Employees were doing their best to uphold patient safety and guarantee that they were treated with empathy and dignity regardless of the problems. Irrespective of these efforts, CQC’s report discovered that the care provided amid the review period was unsafe in noteworthy areas, that employees should not have been put in this situation, and that avoidable harm came to patients (Kirkup, 2018, p.15). The most affected services were community dentistry, intermediate care, and healthcare in HMP Liverpool. LCH staff operated in a reactive environment, and prevention work was not established promptly. LCH lacked appropriate reporting and care planning, which were severe patient safety indicators that should have provoked immediate action and an evaluation of the reporting culture in the Trust.

The process mapping tool below illustrate the barriers the patients experienced when accessing LCH services at the emergency department, and how these barriers were severe patient safety signs that should have triggered prompt action to prevent patient harm.

Task 2


LCH should embrace caring for patients as a team activity. Competent patient care depends on individual staff in a department working in effective collaboration. During complex care management, precise objectives should be written and agreed with patients, which all team members should know and communicate (Langley et al., 2009, p30). As a team, the staff should know their roles in enhancing the patient outcome and for the optimum delivery of care. Hence this calls for constant evaluations, reviews, handovers, briefings, and feedback amongst team members to foster professional relationships and Trust. Also, it encourages seamless care delivery and a transparent environment, mostly to avert care delays. LCH should improve their multi-disciplinary teamwork and communication during handovers and across the management and leadership at all levels. Also, clinicians should be actively involved in decision-making procedures.

LCH should adopt a “Just” culture where honesty and transparency are a crucial ingredient to recognize the root cause if care does not meet standards, or when care is not executed as planned. It mandates that staff operate in an open and transparent setting, where employees expose cases and identify near-miss incidences to avert adverse occurrences on care. Likewise, it obliges employees to pursue a duty of forthrightness procedure with patients and families when a patient safety incident happens and impairpublic confidence (Langley et al., 2009, p.20). LCH’s culture of prejudice,distrust, andanxiety, with an apparent absence of care for the employees’ capability to offer services to the standards needed, impaired their compliance to declare incidents and learn from them.

LCH should adhere to Regulation 17 HSCA (RA) on good governance. LCH systems and procedures as per the CQC report were not often operated effectively in ensuring that the risks about the health, safety, and wellbeing of service users and others were evaluated, monitored and mitigated in a timely way. LCH has unacceptable waiting times in some allied health and treatment specialisms. The number of patients reporting to one team leader was excessive, and though this was documented as a danger, steps were not taken to mitigate this risk in a timely way. Operational, clinical governance is a prerequisite for all NHS providers to guarantee that patient safety and clinical efficiency are monitored and enhanced. This was lapses in care standards are recognized and corrected immediately. It relies on useful information, structures to supervise and evaluate, and leadership to guarantee that signals are not only accepted but are likewise acted upon (Langley et al., 2009, p35). Good clinical governance relies on pro-active intervention, mostly to guarantee that risks are acknowledged and that learning from safety occurrences leads to improvement.

To enhance patient safety, LCH should encourage constant staff training to be up to date with compulsory and legal training prerequisites, comprising fundamental life support training, which is of concern in a high-risk environment. 

LCH should use the decision support toolkit authorized by NICE to foster the systematic method of ascertaining the nursing staff necessities. Also, LCH should identify the suitable expertise and nursing aptitude mix needed in the team in meeting the nursing needs of LCH patients. The nursing staff requirement should be based on the staff hours and the activities that can be safelyassigned to trained and skilled staff. This will ease the problem of burdening staff excess workload. LCH should likewise consider hiring more staff because the current staff number they have been overwhelmed.

Task 3

Reducing Medication Management Errors using Root Cause Analysis

Safe care requires healthcare providers to make choices and act when facing dangerous circumstances that imperil patient security and handle possible incidents. Patient safety implies lessening the risk of unwarranted harm to a tolerable minimum. The healthcare providers oversee the risk process evaluation for the resultant decrease and prevention of patient harm. Mostly in inpatient settings, various factors add to incidents happening like patient severity, the usage of sophisticated equipment, amongst other factors. 

From the case study, IG&QC Meeting minutes in December 2014, an incident was identified where a patient was not given the prescribed epilepsy drugs, resulting in the patient having a seizure the next day. Also, there has been a near-miss when another patient was not given their medications for four weeks at HMP Liverpool (Kirkup, 2018, p.32). HMP Liverpool had no secure and suitable processes in place for controlled drugs management. There were no verifying and no double-signatory when drugs were distributed. The staff was not trained, and there was a failure to undertake continuously controlled medicine register inspections and weekly balance assessments when these incidents happened. The team was giving substitute drugs if the prescribed medication were out of stock. The staff was under pressure to administer medicine to many patients in a limited time, leading to teams finding inadequate methods to save time. 

The review further highlighted another medical error case where the patient was given medicine that was not prescribed for that medical condition. The notification registries highlighted that the drug was suspended and not communicated. From the interviews and observations done by the CQC report team, it was revealed that the medical warning is transcribed on an individual’s card for every patient and is used for workforces as a guide for drug administration (Kirkup, 2018, p.33). The cards are not customarily updated during the sift due to time constraints. Following case analysis, these unsafe actions were identified as the staff failure to revise the patient’s card, which is a circumstance that could be avoided if the staff had communicated the change. Hence, insufficient communication amongst the nursing team, poor drug administration, lack of staff training, and competence and policies and procedures not being followed were identified as the contributing factors to the medication management errors at LCH that caused patient harm.



Therefore, to ensure safe care for patients at LCH, LCH must train the multi-disciplinary team on communication with importance given to topics linked to efficient communication when providing patient care (Kim & Bates,2006, p.150). Also, LCH must implement a program for the induction of staff and integrate this program in the Trust. For quality improvement to become an essential and daily practice at LCH, the Trust will establish a Quality Improvement Committee by August 30, 2020. The Committee will be tasked with ensuring that LCH receives zero patient harm cases through monitoring the performance improvement outcomes of staff and helping in key processes when needed.  Also, the Committee will perform monthly performance reviews. The Committee will also ensure that the team is trained on the quality improvement plan annually and other training on improving patient safety.

Plan, Do, Study, and Act Approach to Reduce Patient Harm Through Staff Training


By December 2020, LCH intends to improve on service delivery at HMP Liverpool caused by poor organizational culture, lack of systematic clinical governance, and clinical competence from 10% to 60%.



Individual responsible

When to be done

Where to be done


Focus on patient care and safety will be done and implemented by the Quality Improvement Committee.

Quality Improvement Committee.

7/7/2020 to 30/12/2020

HMP Liverpool



Activities to be done to effect the change.


Individual responsible

When to be done

Where to be done


1.      Bi-monthly team meetings to report on progress and challenges.

2.      Record and report every incident

3.      Develop materials for training HMP Liverpool staff.

4.      Patient safety will be included in the monthly employee appraisal form.

5.      The patient safety report will be included in the feedback loop report for the Trust.

Senior Management Team and the Board

7/7/2020 to 30/12/2020

HMP Liverpool



Predict what will occur when the activity is done

Predicted Outcome

Measures to ascertain if prediction succeeds

Ten consecutive staff will have training sessions scheduled before the appraisals begin.

A chart audit will be done to determine if training is scheduled.


Do: Describe what occurred when the activity was done.

During the week, the senior management team and the Board scheduled the staff training. For training on weekends, appointments were not planned. 


Study: Describe the measured outcomes and how they compared to the predictions

Interviews, case reviews, and chart audits found that for training amid the week, the procedure functioned well, and the number of cases of patient harm reduced. For weekend class training, the senior management did not see the order used for organizing training classes or forgot to record in the chart that training was done. 


Act: Describe what modification to the plan will be made for the next cycle from what you learned

The senior management team will review the procedure for staff attending training on weekends. When the training coordinator is not available during the weekends, then the assistant trainer that sometimes helps conduct 72 hours post-discharge follow-up calls for patients can book training appointments for the staff on Monday morning.


In conclusion, this paper has adequately discussed the patient harm aspect of service failure in the case study. Also, this paper has provided recommendations for improvement, and devised an implementation plan for avoiding medical management errors and staff training.







Appleby, J., 2015. The Cost of Reform. Retrieved from http://www. kingsfund. org. uk/blog/2015/02/cost-reform.

Bate, P., and Robert, G., 2006. Experience-based design: from redesigning the system around the patient to co-designing services with the patient. BMJ quality & safety15(5), pp.307-310.

Bate, P., and Robert, G., 2006. Experience-based design: from redesigning the system around the patient to co-designing services with the patient. BMJ quality & safety15(5), pp.307-310.

Campbell, D. February 8, 2018. Liverpool NHS Trust ‘Dysfunctional’ and Unsafe, The Guardian. Retrieved from https://www.theguardian.com/society/2018/feb/08/liverpool-nhs-trust-dysfunctional-and-unsafe-report-finds

Harrison, M.I., 2004. Implementing change in health systems: market reforms in the United Kingdom, Sweden, and the Netherlands. Sage.

Kim, J., and Bates, D.W., 2006. Results of a survey on medical error reporting systems in Korean hospitals. International journal of medical informatics75(2), pp.148-155.

Kirkup, B., 2018. Report of the Liverpool Community Health independent review. NHS Improvement. retrieved from https://improvement.nhs.uk/documents/2403/LiverpoolCommunityHealth_IndependentReviewReport_V2.pdf

Langley, G.J., Moen, R.D., Nolan, K.M., Nolan, T.W., Norman, C.L., and Provost, L.P., 2009. The improvement guide: a practical approach to enhancing organizational performance. John Wiley & Sons.

Rogers, H., Pickles, J., Hide, E., and Maher, L., 2008. Experience-based design: a practical method of working with patients to redesign services. Clinical Governance: An International Journal.













Appendix A:

Communication Plan for an Inpatient Unit to Evaluate the Impact of Transformational Leadership Style Compared to Other Leader Styles such as Bureaucratic and Laissez-Faire Leadership in Nurse Engagement, Retention, and Team Member Satisfaction Over the Course of One Year

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