Learning from investigations from the Healthcare Commisson highlights the following issues that have been consistently highlighted as a result of their investigations.

• Leadership and management: Poor leadership was a problem in nearly all of the investigations carried out by the Commission.

  Some boards had been focused on mergers or targets at the expense of their broader activities.

  Lack of continuity in leadership was a problem in some trusts, where frequent changes in management were a factor in poor care. Bullying and harassment by managers was a factor in two cases investigated. The Commission found there was a fine line between promoting change vigorously and bullying.

  Investigations often uncovered a breakdown in leadership and management, with a lack of clarity on responsibilities from board to ward. Poor teamwork, either between management and clinicians or between clinicians themselves was another common factor in failings.

• Use of information: The Commission was surprised that most of the trusts investigated did not have adequate systems in place to routinely inform the board of trends or potential problems. Board members must assure themselves about the quality of services for which they are responsible and need data to do this professionally.
• Mergers and restructures: Seven of the trusts investigated had recently undergone mergers or significant organisational change. The message from the Commission’s investigations is that where significant change is taking place, the management task should not be underestimated.
• Safeguarding vulnerable adults: Poor understanding of adult protection procedures and responsibilities was a serious problem in the two investigations into learning disability services and also a number of interventions in trusts. The Commission said staff need good training to understand their crucial role in protecting vulnerable adults.
• Poor care on general wards: When its investigations looked at acute hospital care, the Commission noted that care on general wards fell well below the care provided on specialist wards. Older patients were most at risk as they were often most dependent on good nursing care. The Commission will monitor this aspect in future investigations to identify whether this is an emerging common theme.