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Bradford Royal Infirmary Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 24 June 2016

Bradford Teaching Hospitals NHS Trust is an integrated trust, which provides acute and community health services. The trust serves a population of around 500,000 people in the Bradford and surrounding area. The trust operates acute services in Bradford Royal Infirmary and St Luke’s Hospital. The trust has three community hospitals; Eccleshill, Westbourne Green and Westwood Park. Eccleshill Hospital was closed at the time of the inspection. In total the trust has around 900 beds and employs approximately 5,500 members of staff.

We carried out a follow up inspection of the trust from 11-13 January 2016. This was in response to a previous inspection conducted as part of our comprehensive inspection programme in October 2014. In addition, an unannounced inspection was carried out on 26 January 2016.

Follow up inspections do not always look at every service the trust provides. They focus on the areas identified as requiring improvement in the previous inspection and any areas of concern identified in the time since the last inspection. In addition, not all of the five domains: safe, effective, caring, responsive and well led were reviewed for each of the core services we inspected.

At the comprehensive inspection in October 2014 we found the trust was in breach of regulations relating to care and welfare of people, assessing and monitoring the quality of the service, cleanliness and infection control, safety, availability and suitability of equipment and premises, respecting and involving service users and staffing. We issued a number of notices which required the trust to develop an action plan for how they would comply with the regulations where breaches had been found. We reviewed the trust’s progress against the action plan during this follow-up inspection.

Overall, we rated Bradford Royal Infirmary as requires improvement at this inspection.

Our key findings were as follows:

  • We found that there had been improvements in some of the services and this had resulted in a positive change in the overall ratings from the previous CQC inspection, notably in critical care and outpatients and diagnostic imaging.
  • However, the ratings remained the same in accident and emergency, surgery, medicine and children’s and young people’s services. This was because we either did not see significant improvement since our previous inspection or because we identified new areas of concern.
  • In relation to outpatient services, the trust had taken the necessary steps to ensure that the backlog of over 250,000 non-referral to treatment patient pathways had been clinically reviewed and actions taken to reduce risks to patients, including prioritising appointments and the assessment of potential harm. An improvement plan had been developed and systems and processes had been changed. The trust had revised executive, clinical and managerial leadership arrangements for outpatients and invested in additional administrative staff and a rolling programme of staff training.
  • However, the new systems and processes had not yet been embedded within the outpatient service and further work was required to establish the new centralised patient booking system. Staff did not feel engaged with the changes and expressed frustration at the new systems and processes. There were still a large number of patients waiting for outpatient appointments and there was a downward trend in referral to treatment times, which could delay access to treatment.
  • The trust had taken action to address the staffing concerns identified in our previous inspection. The trust had introduced integrated patient acuity monitoring systems to assess patient acuity and staffing levels on a daily basis. Staffing levels were assessed in daily matron huddles that were led by the head of nursing and staffing levels were risk rated and monitored by the chief nurse. Nurse staffing levels had been reviewed across the trust and in December 2015 the Board of Directors had approved a £2.5millon spend on staffing.
  • However, we found that there were significant nurse staffing shortages in urgent and emergency services, medicine, surgery, and services for children and young people.
  • Governance and assurance arrangements had been reviewed since the last inspection. However, we found that they were not robust enough to identify issues relating to, for example, medicines storage and reconciliation, issues relating to the availability of portable oxygen cylinders on resuscitation trolleys and gaps in records in urgent and emergency services. This was of particular concern because we identified these issues in the comprehensive inspection in 2014 and the trust had an action plan in place to address them. We wrote to the trust to ask for information about how they would address our concerns. The trust has provided us with assurance that our concerns would be addressed promptly and we have seen evidence that medicines reconciliation rates are now above the trust’s target and that action has been taken to ensure that portable oxygen cylinders are available. The trust has a robust plan to improve the quality of records in the urgent and emergency service.

  • Our previous concerns about the safety of children who were cared for in the stabilisation room pending transfer out of the hospital had largely been addressed. There were suitably qualified and trained staff to support critically ill children until the paediatric transfer team arrived. The service had been reviewed by the Royal College of Paediatrics and Child Health in August 2015 and an action plan had been developed to address the recommendations made in this report.
  • Our previous concerns about the care of patients requiring non-invasive ventilation (NIV) had been addressed. Patients requiring NIV were now grouped together in the respiratory unit on ward 23 and the service was compliant with British Thoracic Society Standards.
  • The trust had invested significantly in the estate and the environment. This included building a new hospital wing at the Bradford Royal Infirmary site, which was due to open around November 2016. Paediatric and critical care services would be relocated to the new wing, along with a new care of the elderly ward. The new wing would address many of the issues with the hospital environment identified in the previous inspection and the trust had commenced a full condition survey of the remaining estate. The trust was also in the process of redeveloping the accident and emergency department and gastroenterology.
  • In the interim, the trust had taken action to address some of the issues with the environment, particularly in critical care. However, wards 7, 9 and 15 remained very cramped with limited space around beds. We were concerned that in an emergency situation this would present a challenge.
  • There was a dedicated infection prevention and control team with arrangements in place to prevent the spread of infection. However, we observed staff not following infection prevention and control practices on a number of occasions. The MRSA, MSSA and C-difficile rates for the trust were above the England average for the period August 2014 to August 2015.
  • Policies and procedures were not always up-to-date. We saw policies and procedures that were past their review date and in critical care some of the policies we looked at did not refer to current guidance and standards. Staff in urgent and emergency services were unable to provide us with records to support patient group directives (PGDs), which allowed nurses to administer certain drugs.
  • The trust used the five steps to safer surgery process in the operating theatres to improve patient safety and reduce the risk of clinical incidents. The five steps included the use of the World Health Organisation surgical safety checklist. However, we observed patients receiving surgery when the surgical safety checklist process had not been followed fully. This meant there was a risk that safety issues might not be identified before a procedure took place.
  • Confidential patient information was not always stored securely. In urgent and emergency services, we had concerns about the security of patient identifiable information relating to victims of domestic violence.

We saw several areas of outstanding practice including:

  • The trust was collaborating with another local trust to work towards recruiting and retaining a workforce that reflected the 35% black, Asian and minority ethnic (BAME) population in the Bradford area. Between June 2014 and September 2015, the trust had improved the BAME representation on the trust Board of Directors from 0% to 29%.
  • The trust was leading the “Well North” programme, which was a collaborative programme aimed at improving the health of some of the poorest communities in the most deprived areas in the North of England.
  • The Bradford, Airedale, Wharfedale and Craven Managed Clinical Network for Specialist Palliative Care had won the British Medical Journal “Palliative Care Team of the Year” award in 2015.
  • The trust had performed better than the England average for all indicators in the 2015 Hip Fracture Audit.

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

Importantly, the trust must:

  • Ensure that infection control procedures are followed in relation to hand hygiene, the use of personal protective equipment and the cleaning of equipment.
  • Review and risk assess the environment on ward 24 and put in place actions to mitigate the risk of the spread of infection.
  • Ensure that the use of PGDs in accident and emergency is in-line with trust policy.
  • Ensure that relevant staff working in surgery complies with the five steps to safer surgery process and that the WHO surgical safety checklist is consistently followed.
  • Ensure there are improvements in referral to treatment times and action is taken to reduce the number of patients in the referral to treatment waiting list to ensure that patients are protected from the risks of delayed treatment and care.
  • Ensure that robust arrangements are in place to ensure that policies and procedures (including local rules in diagnostics) are reviewed and updated.
  • Ensure that patient information is held securely and patient confidentiality is maintained in relation to information about victims of domestic abuse in accident and emergency and the storage of property bags for deceased patients.
  • Ensure that there are in operation effective governance, reporting and assurance mechanisms that provide timely information so that risks can be identified assessed and managed.
  • Ensure that there are alert systems in place to identify when actions are not effective and need to be reviewed.
  • Ensure that at all times there are sufficient numbers of suitably skilled, qualified and experienced staff in line with best practice and national guidance, taking into account patients’ dependency levels.
  • Ensure that all staff have completed mandatory training, role specific training and had an annual appraisal.

In addition the trust should:

  • Review use of the public address system in accident and emergency to ensure that patients are aware that they are being called and where they should go.
  • Review the signage to the accident and emergency department within the hospital grounds to ensure that the department is clearly signposted.
  • Improve assessment facilities for patients admitted into accident and emergency with mental health concerns.
  • Review the arrival to initial assessment times in accident and emergency to ensure that patients are reviewed in a timely manner.
  • Risk assess the isolation facilities in accident and emergency to ensure that they meet current infection control standards.
  • Ensure cramped single rooms on wards 7, 9 and 15 are risk assessed to inform staff of the procedure in an emergency situation.
  • Review and monitor the demand for the outreach service to ensure the needs of deteriorating patients out of hours are met.
  • Review pharmacy cover against the Core Standards for Intensive Care Units (2013) (Pharmacy cover guidelines) which states that there should be at least 0.1 whole time equivalent specialist pharmacist for each single Level 3 bed and for every two Level 2 beds.
  • Complete a review of unmet demand for beds which was identified as an action from the previous inspection and quality key indicators reports.
  • Ensure that the amount of epidural waste destroyed is recorded, in-line with best practice.
  • In maternity, the trust should ensure that PAT testing of electrical equipment takes place and is recorded.
  • Consider having a policy regarding the use, monitoring and security of the baby milk refrigerators.
  • Address the environmental issues on ward 2 to ensure patients and families have privacy and their dignity is respected.
  • Review the practice of transferring patients from theatre to recovery with endotracheal tubes in place without any monitoring to ensure that any risks to patients are minimised.
  • Ensure that staff in surgery and theatres understand the definition of a serious incident and a never event.
  • Review ward 12 to ensure that patients are cared for by staff with appropriate skills and experience.
  • Review the availability of play facilities for children.
  • Review nurse staffing levels in services for children and young people to increase the availability of a senior staff member to provide clinical support and leadership to junior staff.
  • Review the use of interpreters in outpatients and diagnostics to ensure that patients’ privacy is maintained.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 24 June 2016

Effective

Good

Updated 24 June 2016

Caring

Good

Updated 24 June 2016

Responsive

Requires improvement

Updated 24 June 2016

Well-led

Requires improvement

Updated 24 June 2016

Checks on specific services

Maternity and gynaecology

Good

Updated 24 June 2016

We rated this service as good overall. We rated safety as requires improvement. Staffing levels and skill mix had improved since our previous inspection in October 2014. However, further planned recruitment was to take place and staff had not yet experienced the full benefit of the recruitment made towards the end of last year. Nurse staffing shortfalls continued for the labour ward, theatres and staff continued to cover shortages on the labour ward.

At the previous inspection, the morning staff handover consisted of four separate staff handovers, followed by a ward round. The arrangements were not always effectively managed, which at times resulted in overlap between teams and some delays. Since that inspection, the handover process had been reviewed. The changes were to reduce the lengthy process and improve the handover period.

We found staff had not always checked the resuscitation equipment daily to ensure it was available in an emergency. This was also identified at the previous inspection.

Daily checks of medicines and infant milk storage refrigerators were not taking place. This meant staff would not know if the medication or milk products had been stored within the correct temperature range and remained safe to use.

Although the overall figures for completion of mandatory training had improved, the individual figures for basic life support and movement and handling training were below the trust target of 95%.

There were effective systems for reporting, investigating and acting on adverse events and there was an up to date incident reporting and investigation policy. Staff were able to give examples of feedback received from incidents, lessons learnt and action taken where appropriate, to prevent a similar situation occurring.

The consultant obstetricians cover for the labour ward had increased, from 60 to 98 hours per week since the last inspection. This complied with the Royal College of Obstetricians and Gynaecologists (RCOG) best practice standard for consultant labour ward cover.

Women’s services were clean, well maintained and there were effective systems in place to monitor infection control.

Records relating to women’s care were of a good standard and stored securely in line with the data protection policy.

Medical care (including older people’s care)

Requires improvement

Updated 24 June 2016

Overall we rated medical services as requires improvement, as we still identified areas of concern in safe, effective and well-led. Whilst we did find improvements within medical services we were not sufficiently assured and the evidence did not support a change in rating because:

  • We observed infection control practice not in line with policy.
  • The ward environment in some areas was still a concern, notably ward 7, 9, 15 and 24.
  • Fridge temperatures were not always within acceptable limits so we were not assured medicines were being stored at the appropriate temperature.
  • Mandatory training figures remained below the trust target.
  • We were not assured the hyper acute stoke unit had sufficient staff to care for five patients.
  • Some policies and clinical guidelines were past the date for review and lacked version control and an author.
  • The risk register had a number of risks past the review date.

However:

  • The management of patients requiring non-invasive ventilation had significantly improved.
  • There was an improved culture in relation to reporting and sharing learning from incidents.
  • We saw evidence of good multi-disciplinary working within the areas we visited.
  • Staff demonstrated a good knowledge of safeguarding.
  • The nutrition and hydration needs of patients were recognised and well managed and documented.
  • The management team had become more cohesive and demonstrated an understanding of the challenges to providing quality care to their patients.

There had been a focus on staff engagement and this was noted from the staff we spoke with.

Urgent and emergency services (A&E)

Requires improvement

Updated 24 June 2016

  

We rated this service as requires improvement because we found that although there had been some improvements since the comprehensive inspection in October 2014, sufficient progress had not been made or sustained to change this rating. Specific concerns raised in 2014 had on the whole been addressed. However, in a number of areas changes had not led to sustained improvement and we found checking systems had not been embedded to alert staff to risk, such as inconsistent checks on equipment. Areas still in need of improvement included infection prevention and control and waiting times for patients. There was a plan in place for a new emergency department to open in autumn 2016, which was expected to address some of the concerns raised at the previous inspection.

During this inspection we had significant concerns about record keeping and the management and storage of medicines. We brought this to the attention of the trust who took immediate action to address safety concerns raised. A lack of specialist cubicles for infectious patients and mental health patients continued to put patients at risk. Some patients were still experiencing long waiting times for assessment and treatment. Privacy and dignity of patients was not adequately protected at all times.

Surgery

Good

Updated 24 June 2016

We rated this service as good overall. There were arrangements in place for reporting incidents which might affect the quality and safety of patient care. Most staff we spoke with knew how to report incidents. But we found inconsistencies in theatres about reporting and learning from incidents. Some staff were unaware of national definitions of serious incidents including never events despite the trust’s investigation into two never events which had occurred recently.

Staff in this service were below the trust’s target for completion of mandatory training. 48% of staff requiring Level 3 children’s safeguarding had completed the necessary training and 68% of eligible staff had completed Level 2 children’s safeguarding training. Mandatory training for some groups of staff in medicines administration, adult basic life support and blood transfusion were below the targets set by the trust.

The number of hours worked by nursing staff were below planned levels on nine surgical wards.

A small number of surgical procedures were carried out under general anaesthetic in a theatre at the end of ward 14. The theatre was located on the floor below the main nucleus theatre complex. We were concerned about the remoteness of this theatre suite. The trust had developed a policy to ensure surgery could be performed safely in this theatre, including emergencies. However, neither staff in nucleus theatres or on ward 14 were aware of the procedures which should be followed. Staff in theatres and on the ward were unaware of who was responsible for the theatre.

There was wide variation between surgical specialties and theatre suites for the levels of mandatory training completed.

The trust used the five steps to safer surgery process in the operating theatres to improve patient safety and reduce the risk of clinical incidents. The five steps included the use of the World Health Organisation (WHO) surgical safety checklist. The process requires that a checklist is completed for every patient undergoing a surgical procedure. However, we observed patients receiving surgery where the sign in process did not take place. This meant there was a risk that safety issues might not be identified before a procedure took place.

Patient records were well maintained. Information was clear and patients’ needs were well documented. Records were audited to check the early warning system for deteriorating patients was carried out correctly and information about patients’ medicines was accurately recorded.

Intensive/critical care

Good

Updated 24 June 2016

We rated this service as good overall.

We found the relationships within the unit had improved. Senior managers now attended team meetings and were more visible on the wards. Governance structures were still not embedded and clinical leads had only recently come into post.

Staffing was adequate to meet patient needs and medical staff now worked one week in seven on ICU, in-line with national standards. Nursing staff had access to critical care training at the local university. Following the previous inspection we found that the service had reviewed the ward area and redesigned access to the sinks to improve infection control. The service planned to move the four HDU beds from a bay on a ward to a larger area which would allow patients to be cared for in a more suitable environment.

The capacity of the service to meet demand remained an issue. The bed occupancy for the unit was about 92% and patients were sometimes being cared for in recovery in the nucleus theatre because there was not a bed available on ICU. It was unclear if the new unit would be sufficient to reduce the occupancy rates because the number of ICU beds was not being increased. There had been no review of unmet demand for beds, which was identified as an action from the previous inspection and quality key indicators reports. The service was still not seeing all patients within 12 hours of admission although improvements had been made and processes put in place to mitigate the risk.

Patient outcomes information was not always completed and audits from patient outcomes were not always available. However the service did complete Intensive Care National Audit and Research Centre (ICNARC) data and it was used to benchmark against similar organisations. The service had not reviewed policies and procedures to ensure they adhered to professional standards and guidelines.

Delayed discharges of over four hours still occurred. However, the number of delayed discharges of over four hours had reduced since the last inspection and delayed discharges were better than similar units. Quicker discharges were facilitated by staff attending bed meetings to discuss discharges from ICU.

Services for children & young people

Requires improvement

Updated 24 June 2016

We rated this service as requires improvement. There had been recent increases in staffing to account for winter pressures and the need for staff to attend the paediatric stabilisation unit. However, nurse staffing was below recommended levels. However, there were still frequent staff shortages for shifts across the service. At times staff levels did not achieve 85% of shifts filled.

The trust was progressing in the development of a new building which would address the concerns about the environment in which children were cared for.

The trust had addressed the safety concerns raised about the paediatric stabilisation unit during the comprehensive inspection in October 2014. There were suitably qualified and trained staff to support critically ill children until the paediatric transfer team arrived.

The service had undergone a change to leadership and management structure. The trust had established a children’s board and there were clear governance structures to report to the Trust Board. The trust had engaged with staff and the public to contribute to the design of the building to create an environment which was reflective of the needs of local children and families.

End of life care

Good

Updated 24 June 2016

We rated this service as good because people at the end of their life were cared for within the hospital by ward staff, who were supported by a hospital specialist palliative care team. This team worked closely to the national Gold Standards Framework to ensure that patients experienced a good quality of care at the end of their life. The team was supported by a consultant in palliative care medicine ensuring that appropriate and timely advice was available to staff across the wards and district. In addition, patients and their relatives had access to support through the ‘Gold Line’ a telephone service, available 24 hours a day, seven days a week.

Care was arranged to meet the needs of the individual and to ensure where possible that people were able to spend the end of their life in their preferred place of death. There were systems and arrangements in place to ensure that people’s diverse needs were respected and supported. There was collaborative working across multi-disciplinary teams and other agencies to ensure that patients with cultural, religious and special needs such as a learning disability were incorporated into their individual care packages.

Outpatients

Requires improvement

Updated 24 June 2016

We rated the service as requires improvement. We found that a great deal of work had been undertaken to improve the arrangements for booking appointments, addressing concerns over the identified backlog with outpatient appointments and develop assurance mechanisms. However, the new systems and processes had not yet been embedded within the outpatient service and further work was required to establish the new centralised patient booking system. Staff did not feel engaged with the changes and expressed frustration at the new systems and processes. A programme of training and development had been introduced as part of the improvement plan to establish the centralised patient booking service. This was work in progress at the time of this inspection.

We found that there were systems and processes in place for incident reporting and learning from incidents.

There were staff shortages across outpatients and diagnostic and imaging services, with some specialities particularly impacted at times such as dermatology clinics. There were arrangements in place to assess whether staffing levels were safe, access support through agency or locums and from colleagues in other clinics.

There had been a reduction in the number of patients waiting on the total RTT waiting lists and in particular the backlogs identified in August 2014 and April 2015. However, there were still a large number of patients waiting for appointments, which could delay access to treatment.

There were times when there were delays in accessing interpreting services and on occasion patients’ relatives were translating questions, which may not have been appropriate or protecting patient privacy.