A leading children's hospital has been ordered to improve after inspectors found patients were being put at risk by a faulty emergency call alarm system, poor staffing and incidents going unreported.
Alder Hey Children's NHS Foundation Trust hit the headlines last month after an internal review review found significant safety concerns in its theatre departments.
The review, written by the trust's director of nursing, noted "shortcuts being made to safety processes that have created high risk activity".
Today's report from the Care Quality Commission (CQC) found the Liverpool-based trust was failing to meet four out of five national standards on quality and safety. It followed unannounced inspections in early December in response to theatre staff contacting the CQC with concerns.
Inspectors reported satisfactory staffing levels across many wards but "inadequate staffing" in theatre departments and unpredictable numbers of staff due to high staff sickness rates and high demand.
Theatre staff were failing to follow national guidelines on checking equipment and there was poor training, with some theatre staff unaware of what defined an incident or "near miss".
This contributed to the trust having a low level of recording of incidents given its size and staff were clearly not reporting when things went wrong.
The CQC report added: "We found that essential items of equipment such as capnography (airways monitoring equipment) was not in place. Guidance recommendations relating to the availability of emergency call bells had also not been followed.
"Numerous anaesthetic and recovery staff told us that the emergency call alarm system was faulty in the day surgery theatres. We were told that the alarms had become unreliable at the start of recent building works to refurbish one of the theatres and since then the alarms did not function correctly all of the time. This meant that the trust was not compliant with national guidance."
Inspectors found checks had been carried out on some equipment but one anaesthetic machine had medical air and oxygen cylinders that were beyond their expiry dates.
Staffing issues in the theatre department were also having a negative impact on patients, with operations being cancelled. Staffing in the recovery area was also putting patients at risk while morale across the board was low.
The report added: "We found on the days of our visit the staffing levels in the theatres complied with the minimum staffing levels guidance from the Association for Perioperative Practice (AfPP) but they did not comply with the recovery staffing requirement of one practitioner per operating list as per this guidance.
"We felt that this ratio of staff for the recovery area was potentially unsafe and meant that patient welfare and safety was at increased risk."
Managers were also unable to tell inspectors how many immediate life support/paediatric immediate life support qualified staff there were.
"We asked for records to confirm the numbers of staff trained but they were not made available despite our request to theatre managers. We also found that in the theatre department there had been general confusion by staff and managers about whether life support qualifications were current, or had expired."
Inspectors said managers were aware of some of the problems and the trust was taking action to remedy them.
Following the inspection, the CQC contacted regulator Monitor and NHS England to highlight its concerns.
Malcolm Bower-Brown, CQC's regional director for the north said: "Undertaking unannounced inspections in response to information of concern is a vital part of CQC's role and we encourage anyone with concerns about any registered service to contact us immediately.
"The problems we identified at the Alder Hey Hospital are very worrying. We have told the trust where further action must be taken to ensure national standards are met and that patients receive the quality of care they are entitled to expect.
"Inspectors will return to the trust to ensure the necessary improvements have been made."
Louise Shepherd, chief executive of the trust said action had already been taken in many areas, including improving training, staffing and quality processes in theatre.
She added: " I would like to reiterate that there is no evidence that patients have been harmed as a result of these concerns and we remain confident that we are providing a safe service for our children and young people.
"The CQC report does raise some questions about the steps Alder Hey takes to ensure patient safety. I would like to reassure all our families that the safety of patients is our highest priority and there are multiple steps we take to ensure the safety of our patients throughout the duration of their care.
"This means that if one step is ever missed then other steps are always in place to ensure patient safety is upheld.
"The wellbeing of our staff is of paramount importance. Theatres by nature are highly stressful, demanding working environments and we are also facing an increased demand on our services.
"It was regrettable that a small number of theatre staff felt that they had to contact the CQC in November to raise concerns about how they are supported at work. Our director of nursing has provided a personal assurance to them that the Board will do everything possible to ensure their concerns are dealt with and that they feel secure in raising them."