A damning report by the health watchdog has uncovered “bullying”, “harassment”, a culture of “fear” and staff shortages at a hospital trust which are putting patients at risk of harm.

The Care Quality Commission (CQC) has downgraded the overall rating of University Hospitals Sussex NHS Foundation Trust from outstanding to requires improvement after an inspection between October and December showed a decline in the care being provided to people across several key areas.

At the inspection last autumn, the CQC looked at neurosurgery, children and young people’s urgent and emergency care and as well as management and leadership of the trust. 

This followed other inspections at the trust, which is responsible for seven hospitals inlcuding Brighton's Royal Sussex County, over an 18-month period which highlighted failings in several departments and was in part prompted by whistleblowing concerns from staff.

As well as the decline in its overall rating, how well-led the trust is has declined from outstanding to inadequate. How responsive and safe the trust is has also dropped from outstanding to requires improvement. The criteria of effective and caring remain outstanding.

The report said: “Staff were empathetic towards the challenges the executive team faced in leading a trust of its size in the current healthcare economy. However, from the conversations in our drop-in sessions and contacts from staff, they felt the management style was ‘autocratic’, ‘bureaucratic’ and did not demonstrate commitment and adherence to the trust’s own Patient First Quality Improvement methodology.

“Some staff felt their clinical areas lacked senior leadership and executive oversight and support which left them feeling ‘neglected’ and ‘forgotten’.

“Some staff said they continuously raised concerns but no action was taken to address them and others told us they were afraid to raise concerns because they felt it would be career limiting.

“Some staff felt their experiences of bullying and harassment went unaddressed because of the seniority of the staff allegedly carrying out the bullying and because they saw historical working relationships with senior executives as a deterrent to raising their concerns. 

“Staff felt there was little point raising concerns because no action was taken when they did.

“Although the trust had responded to the cultural concerns in surgery at the Royal Sussex County Hospital, it has had a limited impact. Some consultants continued to display poor behaviours which meant a lot of staff felt undervalued, unsafe and unsupported.

“Staff believed there was a culture of bullying and harassment which pressured them in to making unsafe decisions.

“Minority ethnic staff survey results showed they were more likely to experience poorer outcomes than their white colleagues with regard to pay, autonomy and time pressures, team working and burnout.”

In neurosurgery services inspecctors found: "The environment and availability of equipment did not always support safe and effective care and treatment. For example, there were incidents of surgery being delayed due to a lack of imaging equipment."

This is the first time the trust has been rated in the "well-led" category since the merger in 2021 when it became University Hospitals NHS Foundation Trust. The merger was between Western Sussex Hospitals NHS Foundation Trust and Brighton and Sussex University Hospitals NHS Trust.

The trust said it has already implemented improvements since the CQC’s latest inspection in October last year including a new leadership development programme and a £120 million investment across all hospital sites.

Royal Sussex County Hospital “inadequate”

The overall rating for the Royal Sussex County Hospital has fallen from good to inadequate as has its rating for the safe and well-led categories. Effective remains good, caring remains outstanding and responsive remains requires improvement.

Inspectors said: “The service did not have enough staff to care for patients and keep them safe. Staff did not always complete patient assessments in a timely manner.

“Staff did not always update assessments and there was risk that staff would not identify and quickly act upon patients at risk of deterioration.

“Some areas of the environment did not fully protect people from risk of harm.”

Princess Royal Hospital “requires improvement”

The overall rating for the Princess Royal Hospital in Haywards Heath has dropped from good to requires improvement as have the ratings for safe and well-led. Effective, responsive and caring all retain their good rating.

Worthing Hospital and St Richard’s Hospital still “outstanding”

The "well-led" category at both Worthing Hospital and St Richard’s in Chichester has declined from outstanding to good, although both remain rated outstanding overall. Both hospitals also keep their outstanding ratings for being effective, caring and responsive and their good rating for safety.

Staff concerns

Inspectors spoke to more than 120 staff during the "well-led" inspection. A total of 118 staff raised a concern and two provided positive feedback. The CQC has continued to receive contact from staff on a regular basis.

The report said: “Staff felt leaders were not visible and felt unsupported by senior leaders.

“Some staff did not feel respected, supported and valued. Staff reported low levels of satisfaction and high levels of stress and work overload.

“Not all staff felt they could raise concerns without fear of reprisal. Others experienced ‘concern fatigue’ from raising the same concerns repeatedly with no action taken.

“We found some examples of bullying and harassment.”

The CQC has also recommended to NHS England that the trust should be given the highest level of support via its recovery support programme.

Trust’s response

UHSussex chief executive Dr George Findlay said: “When I took up this role just under a year ago I commissioned an external review to give me a clear picture of where we stood as a newly formed trust – our strengths and our weaknesses. This review and our improvement plans were shared with the CQC at the time of our well-led inspection.

“Everything the CQC is saying now chimes with what we already knew and had committed to addressing right from the start. 

“I’m extremely proud of the huge strides that colleagues have made but we all recognise how much work still lies ahead. The seven months since this inspection have seen rapid progress – now we need to push on again.

“Right from my first day, the focus has been on facing up to our problems and giving our amazing staff the tools and support they need to do their jobs. None of the issues raised in this report are new to us and that is why we were already addressing them.

“Much has changed since the CQC team was here and that progress makes me confident for the future. Delivering NHS care at the moment is really tough, making improvements is tough, but we have the plans and the people in place to do that."

Inspection timeline and series of failings

The CQC carried out seven core service inspections in the past 18 months at University Hospitals Sussex NHS Foundation trust.

These included maternity, surgery (general surgery, upper gastrointestinal (UGI) cancer services, neurosurgery) and urgent and emergency care. In September 2021 inspectors carried out focused inspections of the maternity services at St Richard's Hospital, Worthing Hospital, Princess Royal Hospital and Royal Sussex County Hospital.

These inspections found safety concerns raised by staff to the CQC were valid. The ratings for all four maternity services went down. The CQC took enforcement action by serving a warning notice that asked the trust to make significant improvements.

The CQC inspected the maternity services again in April 2022 and found the trust had complied with the terms of the warning notice. However, it asked the trust to make additional improvements by issuing requirement notices.

It also inspected the surgical core service at the Royal Sussex County Hospital in September 2021 because it had received safety and leadership concerns from whistle-blowers.

This inspection also found the concerns to be valid. The service was rated as inadequate. The CQC took enforcement action and asked the trust to make significant improvement. The CQC carried out another inspection to check on the improvements in April last year.

Its findings showed little improvement had been made and it took additional enforcement action and placed conditions on the trust’s CQC registration.

The CQC carried out an inspection of the elective UGI surgical service last August after it received concerns about the UGI surgical service from staff and other stakeholders.

It found serious safety and leadership concerns.

This resulted in the CQC urgently imposing conditions on the registration of the trust, suspending the UGI elective surgical service to protect patients from the potential risk of harm.

The CQC said it has continued to receive concerns from staff about the safety of the surgical services at the Royal Sussex County Hospital.

It has escalated these concerns to other key stakeholders to ensure there is oversight and support for the trust to make the “necessary improvements at pace”.

The CQC inspected the emergency and urgent care services at the Royal Sussex County Hospital in April 2022. The rating for this service went down from good to requires improvement.

The CQC provided the trust with a list of actions it must and should take to make the changes needed to improve the service. Due to the ongoing safety concerns identified by inspections and the contacts from staff, the trust carried out a well-led inspection.

This was to review its concerns about the quality of the trust’s leadership, organisational culture and the lack of progress against the enforcement action taken in the surgical core service at the Royal Sussex County Hospital. At the same time, in response to concerns, it carried out a focused inspection of the neurosurgical service at Royal Sussex County Hospital.

CQC policy details that when a trust acquires or merges with another service or trust to improve the quality and safety of care it does not aggregate ratings from the previously separate services or providers at trust level for up to two years. However, the CQC can aggregate ratings at any time during that two-year period if it is considered in the best interest of the provider and people using the service.

Following the recent inspection, it has aggregated ratings, including core service rating, location/hospital ratings and the well-led rating to give an overall rating for the trust, resulting in a deterioration in the overall trust rating.