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St Mary's Hospital Requires improvement

This service was previously managed by a different provider - see old profile

Inspection Summary


Overall summary & rating

Requires improvement

Updated 9 September 2014

Isle of Wight NHS Trust is an integrated trust that includes acute, ambulance, community and mental health services. St Mary’s Hospital in Newport is the trust’s main base for delivering acute services for the Island’s population. The hospital has 246 beds and handles 22,685 admissions each year. Services include A&E, the Beacon Centre (providing walk-in access to GP services), emergency medicine and surgery, planned surgery, intensive care, maternity services, services for children and young people, neonatal intensive care unit and outpatient services, including planned care such as chemotherapy.

We carried out this comprehensive inspection because the Isle of Wight NHS Trust is an aspirant foundation trust, prioritised by Monitor. The Care Quality Commission's (CQC) latest intelligent monitoring tool identified the trust as being in band 5 (band 1 is the highest priority for inspection, band 6 is the lowest priority).

The team of 41 included CQC inspectors and analysts, doctors, nurses, patients and public representatives, Experts by Experience and senior NHS managers. The inspection took place from 4 June to 6 June 2014, with an unannounced visit on 21 June between 4pm and 11pm.

We inspected A&E, medical care (including older people’s care), surgery, critical care, maternity and family planning, services for children and young people, end of life care, outpatients and the ambulance service.

Overall, we rated this hospital as ‘requires improvement’. We rated it ‘good’ for providing caring services, but it required improvement for the services to be safe, effective, responsive and well-led.

We rated medical care and end of life care as ‘requires improvement’. A&E, surgery, critical care, maternity and family planning, children and young people’s services, outpatient services and ambulance services were ‘good’.

Our key findings were as follows:

  • Staff were caring and compassionate and treated patients with dignity and respect.
  • Staff followed good infection control practices. The hospital was clean and well maintained and infection control rates in the hospital were within an acceptable range.
  • The hospital monitored harm-free care in all inpatient areas and had taken action to reduce avoidable harms, such as pressure sores and falls.
  • Incidents were reported but staff did not always receive feedback and the lessons learned were not widely shared.
  • Serious incidents were investigated and there was evidence of changes, but these were sometimes not implemented in a timely manner.
  • The trust had considered guidance from the National Institute for Health and Care Excellence (NICE), but these were not consistently implemented, monitored or adhered to.
  • Nurse staffing levels had been reviewed and in some areas the need for a change in staff number and skill mix had been identified. In some areas of the hospital, the right number of staff with the right skills and knowledge to meet patients’ specific needs were not present. For example, there were insufficient numbers of nurses trained to care for sick children in the A&E department and insufficient numbers of medical and nursing staff trained to care for patients who had had a stroke.
  • Some patients were being placed at risk by the hospital’s bed management system. Patients were being moved from wards where staff had the appropriate skills and knowledge to one where staff did not have such skills and knowledge.
  • The hospital had a named consultant for each ward and if a patient moved wards then they were allocated to a new consultant. Patients did not have one named consultant for the duration of their stay and did not necessarily have the specialist they required.
  • There was a palliative care team to support patients who were coming to the end of their life. However, patients were not always being identified as being on an end of life care pathway in a timely manner, and did not always receive the care and support they required.
  • Do not attempt cardio-pulmonary resuscitation (DNA CPR) decisions were not clearly documented, reviewed and were not always discussed with the individual or their family.
  • There were clear processes for taking people’s wishes into account and seeking their consent where they had capacity to do so. People who did not have the capacity to consent did not always have their needs considered in safe and proportionate way, as not all staff were informed about the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.
  • There was a good service for children in the inpatient wards, day care, outpatients and neonatal intensive care unit (NICU) areas. There was, however, a lack of clarity over where sick children should be taken in an emergency when resuscitation might be required, as they could be taken to the ward, A&E, or, if very young babies, to the NICU. This had caused uncertainty and children’s care and treatment had been delayed. At the unannounced visit on we founded the Trust had had changed the pathway for all children to be taken to A&E, but this was without fully considering the opinions and concerns of the paediatric staff. Risks to care were still being identified.
  • The ambulance service provided flexible and responsive services to meet the needs of people on the island.
  • There were good medicine management systems in the hospital, but the system in the ambulance service did not ensure the safe handling, storage and management of medication at all times.  The trust had made improvements during our unannounced inspection.
  • Staff were supported though mandatory training and appraisals.

We saw several areas of outstanding practice including:

  • There was evidence-based care for orthopaedic patients having hip and knee operations.
  • A wide, shared-care network for managing children with the most complex and rare conditions had enabled families to be supported and children treated closer to their homes. It also enabled them to access the best possible advice. For example, the children’s ward was a level 1 paediatric oncology shared-care unit, and the hospital could also offer care to visitors to the island with oncological problems.
  • The pharmacy service was operational seven days a week. The service was innovative and worked effectively within multidisciplinary teams to improve patient care. For example, electronic prescribing had reduced medication errors and was being used when venous thromboembolism risk assessments occurred. The service offered an advice line and was involved in the preadmissions initiation of antibiotics with ambulance services.
  • An integrated call centre (Integrated Care Hub), opened in 2013 and provided access to the 999 emergency calls service, the NHS 111 service, the GP out-of-hours service, district nursing, adult social care, telecare services, non-emergency patient transport services and mental health services. Key services were accessed out of hours through the Hub.
  • Ambulance staff used electronic tablets to enable operational staff to complete their e-learning.
  • The ambulance service was participating in a trial in early intervention in sepsis. The aim was to identify patients who might have sepsis, and to reduce their mortality through early intervention prior to admission to hospital.
  • The Individual Learning Plan (ILP) had been developed and implemented to support the development of staff competency in the ambulance service. This was introduced in 2014 and staff were given learning objectives and were required to demonstrate learning as part of their continuous professional development.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must ensure that:

  • Staff receive training on the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. The principles must then be applied to ensure that where people do not have capacity to consent the correct procedures are followed.
  • The leadership of end of life care services is supported to improve across the trust. A strategy for the service needs to be implemented and the quality and risks to the service need to be appropriately monitored.
  • Staff are competent in being able to recognise a patient who is on an end of life journey, so that decisions are made and their care managed appropriately. The trust must also ensure that staff have received the appropriate training and understand the tools available to them. This includes the use of the ‘AMBER care bundle’ and the use of syringe drivers.
  • DNACPR orders are completed in their entirety, in a timely manner, for all patients where this decision has been made. There must be clear documentation as to how this decision was reached. Discussion with patients and their relatives should happen and be appropriately documented.
  • Risk assessments in relation to patient care are completed and used to inform the patients’ plans of care.
  • All patients have a named consultant for the duration of their stay, with clear referral and an acceptance criteria when there is change in their consultant for clinical need.
  • The provision of care for patients who have had a stroke is reviewed to ensure that the pathway is fully reflective of national guidance.
  • National guidance is reviewed, gap analysis completed, and improvement plans put in place and monitored, where required, to ensure that practices are in line with national recognised guidance.
  • There is a lead nurse qualified in the care of children (RN children) and sufficient registered children’s nurses are employed to provide one per shift in the A&E departments receiving children, as per the Standards for Children and Young People in Emergency Care Settings 2012.
  • There is a single point of access for children in an emergency situation where resuscitation may be required. There should be joint working with the A&E and paediatric teams to ensure that any changes are safely implemented.
  • Nursing staffing levels are reviewed in the A&E department and the stroke ward to ensure that they are staffed to the agreed establishment and skills mix in line with current guidance.
  • There is an effective and safe procedure for the obtaining, recording, handling, using, safe keeping and the dispensing of medicines used by the ambulance service.

In addition, the trust should ensure that:

  • The use of bed rails is risk assessed and the patients’ consent acquired for them to be used. In cases where patients are unable to consent, then there should be clear assessment of their capacity and a clear reason for the use of the bed rails.
  • There is effective working with specialists and expertise in multi-disciplinary teams, particularly where clinical expertise is unavailable or limited in the trust.
  • The environment of the eye clinic is reviewed to ensure that it is fit for purpose and safely meets the need of the patients visiting the department.
  • Consultants have protected time for outpatient clinics so they are not cancelled at short notice when they are called to attend to emergencies.
  • Nursing staff are not disturbed while undertaking a medication round.
  • Patients have protected meal times.
  • All medication and intravenous fluids are stored in line with current guidance in all areas.
  • The number of patient bed moves for non-clinical reasons and out of hours is reviewed and action is taken to minimise this.
  • In all outpatient areas where children are seen, there is a dedicated children’s waiting area.
  • All resuscitation equipment is checked on a daily basis, unless an area is closed.
  • The provision of a separate children’s area in the A&E department is considered in line with current building guidance.
  • The process for implementing change following an investigation into an incident is reviewed to ensure that it occurs in a timely manner.
  • The provision of controlled drugs in the resuscitation area in the A&E department is reviewed.
  • The process for streaming patients in the A&E department is reviewed to ensure the decisions are being made by staff who have the knowledge and skill required to do so.
  • Seven-day services continue to develop, particularly for patients requiring emergency care.
  • Patient information held by the ambulance service is securely stored at all times.
  • There is a clear and current system in place to red flag addresses where there are concerns about safety for ambulance crews to use to make informed choices and manage risk when attending these locations.
  • There is a review of the specialist medical care that is available for patients who have had a stroke.

Professor Sir Mike Richards

Chief Inspector of Hospitals

August 2014

Inspection areas

Safe

Requires improvement

Updated 9 September 2014

Effective

Requires improvement

Updated 9 September 2014

Caring

Good

Updated 9 September 2014

Responsive

Requires improvement

Updated 9 September 2014

Well-led

Requires improvement

Updated 9 September 2014

Checks on specific services

Maternity and gynaecology

Good

Updated 9 September 2014

Maternity services at St Mary’s hospital and in the community were well planned and organised. Midwifery staffing levels were below national recommendations but staff were working flexibly to ensure there were adequate numbers. There was recruitment to improve medical staffing level. Safety standards were followed and the environment was clean and the service was fully equipped.

Women’s care and treatment followed national evidenced based guidelines and staff were appropriately trained and worked well in multi-disciplinary teams. Women told us they received compassionate and supportive and supportive care and had choices and were involved in decisions about their care. Governance arrangement and risk management were effective and there was a leadership culture that promoted learning and continuous improvement.

Medical care (including older people’s care)

Inadequate

Updated 12 April 2017

Summary of findings

Overall, we have rated medicine as inadequate because:

  • Ineffective systems of risk identification and management meant that opportunities to prevent or minimise harm were missed.
  • The trust had a system in place for reporting and recording incidents. However, learning and action points were not disseminated to ward staff. Systems and processes were not always reliable and appropriate to keep patients safe.
  • There were a significant number of incidents that required investigation. Without investigating promptly and putting controls in place, the risk of further patient incidents could occur.
  • Governance processes were not effective at assessing or monitoring systems to improve the safety and quality of the services provided.
  • The hospital experienced difficulty meeting the demand for its medical services. Patient moves were tracked by the trust. However, the frequency and reasons were not always appropriately monitored.
  • From April to November 2016 between the hours of 10 pm and 7am, 958 patients were moved around the hospital. Repeated bed moves can be confusing for patients and vital patient care information could be lost.
  • There were medical outliers across the hospital and in temporary wards. Patients stayed overnight in the surgical day care, ambulatory care unit or in the discharge lounge. The placements meant that the single sex requirement was not maintained, however the trust had not declared mixed sex breaches.
  • Staff was discouraged from raising concerns and there was a blame culture.
  • There was a significant shortage of nursing staff across all the medical services.
  • There was insufficient medical cover across medical services, particularly out of hours. There was significant shortage of older people medicine consultants.
  • The trust did not fully comply with infection prevention and control standards.
  • There was a low staff appraisal rate. The trust appraisal rates for November 2016 showed Colwell ward 43% and Appley Ward 91.89%.
  • Completion of mandatory training was low with 40% attending moving and handling training, and 42% trained in basic life support.
  • Staff in the coronary care unit did not have the appropriate training to ensure they had the necessary skills and competence to look after patients.
  • Medicines were not always managed safely or securely.
  • Mental capacity act and deprivation of liberty safeguard training was not part of mandatory training. Staff had limited awareness and a lack of knowledge in managing the process of deprivation of liberty safeguards.
  • Medical records were not always secure and confidential patient information was compromised.
  • The trust did not have a robust system for handling, monitoring complaints and concerns. Response to formal complaints did not meet NHS Complaints Policy July 2016 standards.
  • From April 2015 to March 2016 the average length of stay for medical non elective patients was worse than the England average. The average length of stay for non-elective stroke medicine was more than 70% higher than the national average.

However:

  • The new endoscopy suite was National Joint Advisory Group (JAG) accredited. World Health Organisation WHO checklists briefings took place in endoscopy theatres. Audits took place and results showed 100% compliance. The inadequate rating does not apply to this service.
  • The chemotherapy day unit had processes in place to ensure safe care to patients. The inadequate rating does not apply to this service.
  • The Friends and Family Test (FFT) response rate for medical care at the trust between August 2015 and July 2016 was better than the England average.
  • The trust ran a ‘carers are welcome here campaign’. This meant a carer was welcome to visit the hospital whenever they wanted to.
  • The stroke lead nurse had developed same day access to scanning and Doppler tests to diagnose and treat patients promptly.
  • The trust monitored implementation of policies to ensure they complied with NICE guidance.
  • Mortality review committee meetings were held monthly and were chaired by the executive medical director.

Urgent and emergency services (A&E)

Requires improvement

Updated 12 April 2017

Medical consultant cover in the emergency department was below 16 hours per day and therefore not in line with recommendations from the Royal College of Emergency Medicine. This impacted on the care and expertise available to the patients.

Consultant staff did not have sufficient time to supervise the education of junior medical staff.

The department did not use a safer nursing care tool for accident and emergency units. It was evident that the emergency department did not meet minimum registered nursing levels for safe care. There was insufficient nursing staff at night and in the emergency resuscitation department which meant that the safety and care of seriously ill patients attending the department was compromised.

The emergency department had 16 hours children nursing allocation per week. This did not meet the recommendations in “Standards for Children and Young People in Emergency Care Settings” developed by the Intercollegiate Committee for Standards for Children and Young People in Emergency Care Settings. (The recommendation is for one registered nurse [children] per shift to be available in emergency departments receiving children)

The responsibility for children, and the pathway for the care of children attending the emergency department, was not undertaken in a way that ensured safe and appropriate care as registered nurses (child branch) were not overseeing their care. We observed the paediatric team refused to accept children onto the ward or to come to the emergency department to see them. The children’s waiting room was not fit for purpose. The room was also used as a mental health assessment room but did not provide a safe environment for this purpose either.

Staff did not always follow safe infection prevention standards or medicines management.

There was no drug dispensing machine in minors which often caused delays due to staff queueing in the medicines room.

No data on mandatory training rates was made available to us prior to the inspection, during the inspection or post inspection. Therefore we were not assured regarding what training was provided or when staff attended. There was insufficient medical staff in the emergency department with child safeguarding level 3 training.

The Department did not participate in all national audits, but had performed poorly in a number of those it did participate in. There was no robust local clinical audit plan in place to drive improvements to quality and performance. Patient flow was poor through the department due to poor access to medical beds.

The governance structure did not provide a clear route to escalate issues of concern and there was no evidence that senior trust managers took account of the views of frontline staff.

However we observed staff provided compassionate care and the department received many messages of thanks from patients for the care they received. Staff felt supported and displayed resilience through team working and support from their leaders. Staff worked closely with the medical assessment unit to try and improve patient flow through the department.

Surgery

Good

Updated 9 September 2014

Overall, surgical services were good. The use of the ‘five steps to safer surgery’ – the NHS Patient Safety First campaign adaptation of the World Health Organization (WHO) surgical safety checklist – was monitored and the way staff were completing this checklist was improving across all specialties, except ophthalmology, and actions were being taken to address this. Information about the quality of care was displayed on the wards.

Staff provided compassionate care to patients. Patients and relatives told us nursing care was good. Patients who needed help in eating were provided with the necessary support. Patients who were seen by a GP in the A&E department were, if they required surgery, referred for appropriate clinical colleagues. Data from national audits and databases showed surgical outcomes were at, or close to, the national average. There was support available for patients living with dementia and patients with learning disabilities.

The trust vision was well recognised by staff. However, concerns raised by clinical staff were not always heard, or acted upon, by the trust leadership team. The surgical services team had a ‘can do’ culture. There was a sense of energy and purpose in the divisional leadership team that they could improve the service and make a positive impact on the patient experience.

Intensive/critical care

Good

Updated 9 September 2014

The service followed procedures that ensured patients received safe and effective care. Clinical outcomes were monitored and this showed good outcomes for patients. Patients and relatives expressed a high degree of satisfaction about the care they received. Care was provided in a caring, dignified and compassionate way. The departments were well led and demonstrated positive leadership and culture. A business plan had been submitted to the trust board and this included a review of ICU and CCU and a proposal to include dedicated high dependency beds in order to improve care. This would also improve the responsiveness for pre-planned admissions following surgery, and effective use of ICU beds.

Services for children & young people

Good

Updated 9 September 2014

Services for children and young people were good throughout. Most parents told us the staff were caring, and we saw that children and their parents and carers were treated with dignity, respect and compassion. Ward areas and equipment were clean. There were enough trained staff on duty to ensure that safe care could be delivered. There were thorough nursing and medical handovers that took place between shifts to ensure continuity of care and knowledge of patient needs.

The services were responsive to the needs of children and young people and their families and carers. The ward managers communicated well with staff and staff were positive about the service and quality. Children’s experiences were seen as the main priority. Staff felt supported by their managers and were encouraged to be involved in discussing their ideas for improvements.

End of life care

Requires improvement

Updated 12 April 2017

There was limited learning from end of life care incidents across the organisation. Not all patients had end of life risks assessed and managed. There was no monitoring mechanism in place to ensure risks to patients were assessed. Medical staffing levels did not meet national guidance.

It was not clear whether staff had completed mandatory training on end of life care and mandatory training data was not provided by the trust for all specialities.

A significant number of Do Not Attempt Cardio Pulmonary Resuscitation’ (DNACPR) forms were not completed according to national guidelines.

Care did not consistently take account of evidence based practice and guidance, for example, priorities of care plans were not routinely completed for patients nearing the end of their life. The AMBER care bundle was not embedded in practice.

EOLC training was not mandatory for consultants.

A specialist palliative care service was not available seven days a week, telephone advice was available.

The trust performed worse that England average in the End of Life Care – Dying in Hospital Audit (2016) key performance indicator on health professionals’ communication and discussion with relatives and friends, and consideration of their needs.

End of life care patients did not always receive care in a side room as these were prioritised for treating patients with infections. Staff did not take extra care to ensure continued levels of privacy, dignity and compassionate care for the patients and families and friends when this happened.

End of life care patients were moved from one ward to another or from one ward area to another for non-clinical reasons. This resulted in lack of continuity of care for patients and was not monitored. There were not robust processes to facilitate rapid discharge of patients and staff were not trained to use the rapid discharge forms. The trust was not monitoring the number of end of life patients who were discharged with fast track rapid discharge in place. Most patients were not transferred to their preferred place of death. There were complaints relating to end of life care but the learning was not shared across the organisation.

Staff were not aware of how the trust was implementing the action plan as a result of the End of Life Care - Dying in Hospital Audit 2016 or how the end of life care strategy was to be implemented. Staff did not feel engaged with and described the culture in the organisation did not lead to integrated working. The governance structure was not efficient. Meetings took place but outcomes and action plans were not joined up. The quality, risks and performance issues within end of life care were not monitored through the executive governance framework

However the trust had a protocol for the prescribing of anticipatory medicine. Patients had access to pain relief. The trust had implemented the ward accreditation programme across all wards.

Staff treated people with compassion, kindness, dignity and respect. Feedback from patients and their families was positive. We saw good examples of staff providing care that maintained respect and dignity for individuals. There was good care for the relatives of dying patients, and staff showed sensitivity to their needs.

Outpatients

Good

Updated 9 September 2014

There were effective procedures to support a safe service for patients. Staff were caring and treated patients with dignity and respect. Patients were seen within national waiting times and told us they were happy with the care they had received while attending their appointments within the outpatient department.

Most of the patients we spoke with felt they were seen promptly and were kept informed if clinics were running late. Each clinic had a board that displayed the length of time patients might expect to wait to be seen. The service was undertaking a review to improve its efficiency and responsiveness to the needs of the local population. The leadership of the service was good and there were examples of innovative practice to support people and improve treatment and diagnosis on the island.

Ambulance services

Good

Updated 9 September 2014

The ambulance service had a very low occurrence of untoward incidents and clear ownership of risk. The ambulance station and vehicles were clean, and equipment was well stocked and maintained. Medicines management was not appropriate, as there was poor stock control and storage arrangements for medicines although this had improved during our inspection process.   Staff were well trained and supported by some examples of innovative practice. Planning for major incidents was fully in place in conjunction with partner organisations.

The service used evidence-based guidelines for treatment and was innovative in developments to support best practice. The early intervention in sepsis trial was an example of innovations and initiatives, which were used to support evidence-based care and treatment. The Individual Learning Plan was used to support the development of staff competency. The Hub, which coordinated access to care for the Island, was a good example of multidisciplinary working.

Patient satisfaction comments were consistently positive in surveys. Patients were treated with compassion, dignity and respect by ambulance staff. Ambulance crews listened carefully to patients and involved and supported them in understanding their care and treatment. Staff provided emotional support for patients and their relatives throughout their contact with the service.

The ambulance service had clear operational and clinical leadership. Ambulance staff told us that the level of integration of the ambulance service and being part of the trust allowed them to respond quickly for the benefit of patients. The ambulance service monitored the operation of the service against key performance indicators and consistently met its response time standards.

Other CQC inspections of services

Community & mental health inspection reports for St Mary's Hospital can be found at Isle of Wight NHS Trust.