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Dorset County Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 16 August 2016

Dorset County Hospital is the single site acute hospital provided by Dorset County Hospital NHS Foundation Trust; it has been a foundation trust since 2007. The trust provides acute and some community services to a population of around 250,000, living within Weymouth and Portland, West Dorset, North Dorset and Purbeck. It also provides renal services for patients throughout Dorset and South Somerset to a total population of 850,000. The geographical spread of the community means the trust also deliver services in Weymouth, Bridport, Sherborne and Blandford Community Hospitals.

Dorset County Hospital has approximately 400 inpatient beds. We inspected the following core services at Dorset County Hospital : Urgent and emergency care, medical care, surgery, critical care, maternity and gynaecology, children and young people, end of life care, outpatient and diagnostic services. We inspected satellite outpatients, day surgery and renal dialysis at two other NHS locations.

We inspected this hospital as part of our planned, comprehensive inspection programme. We carried out an announced inspection visit to the hospital from 8 to 10 March 2016, and additional unannounced inspection visits between 16 and 21 March 2016. During this time we also visited outpatients, day case surgical services and dialysis services provided at two other trust sites.

Overall, we rated this trust as ‘requires improvement’. We rated it ‘requires improvement’ for safe, effective, responsive and well led services, and ‘good’ for caring services.

We rated, medical care, surgical services, critical care, and services for children and young people as good. Urgent and emergency care, maternity and gynaecology, end of life care and outpatient services were rated as requires improvement.

Our key findings were as follows:

Are services safe?

  • The majority of staff understood when to report an incident, these were investigated and lessons learnt shared. However, in outpatients and diagnostic imaging staff felt discouraged from using the system as they did not always receive feedback and lessons learnt were not always shared. Some staff in the surgical specialty were still using were using a supplementary paper-based system which was outside of the trust policy. There was a high level of harm-free care. Staff were aware of the Duty of Candour legislation and the service had a system for tracking incidents that triggered a Duty of Candour response.

  • Systems were in place to enable staff to assess and respond safely to deterioration in patients’ health.

  • Medicines were generally stored and managed appropriately other than the smallamount of emergency medicines stored insecurely in the emergency trolleys. Some Patient Group Directions (PGDs) for medicines held in departments were out of date and not authorised, although updated at trust level. PGDs are instructions that permit authorised to staff to give medicines to patients without the patients having an individual prescription. PGDs need to be accurate and authorised to protect staff and patients,Staff had not followed trust policy for updating PGDs in some departments.

  • The mandatory training target set by the trust at 85% had not been met across all areas of the trust.

  • Safeguarding training compliance had increased to meet the target. Staff were aware of the safeguarding of vulnerable adults and children. Child safeguarding checks were always undertaken, and processes were in place to escalate concerns to the local authority if needed.

  • Regularly serviced and maintained equipment was available for patient’s use in most areas, with a prompt response from the maintenance team when equipment required repair. Some equipment in the emergency department was not clean or fit for use.

  • Patient records were not always secured safely, in lockable storage equipment to ensure confidentiality.

  • There were not always enough nursing, midwifery, therapy and medical staff with the right skill mix to provide safe care. Staffing levels had been reviewed, but changes to staffing levels identified as necessary from the reviews had not been fully implemented at the time of the inspection. The trust had a lower proportion of middle grade doctors than the national average, which put pressure on the medical teams. The trust was working to improve this.

  • Staff adhered to the bare below the elbow policy and maintained safe standards of infection prevention. The trust scored higher than the national average for cleanliness in the patient-led assessments of the care environment (PLACE), scoring 99%. The hospital’s infection control team carried out audits which led to improvements in standards of hygiene. However, the procedure for using the mortuary trolley did not adhere to infection control policies or procedures.

  • Some parts of the environment in emergency department were in need of repair and made cleaning difficult. The critical care unit (CRCU) environment was non-compliant with Department of Health’s Health Building Notes (HBN) 04-02.

  • In the operating departments, staff did not consistently complete the ‘Five Steps to Safer Surgery’ checklist to minimise the risk of patient harm.

Are services effective?

  • Most services followed pathways and protocols based on national guidance, such as the National Institute for Clinical Excellence (NICE) guidelines. Generally, patients’ care was planned and delivered in line with current evidence-based standards. There was monitoring of performance against national targets and the results of audits were used to improve treatment.

  • However on the maternity unit care and treatment did not consistently take account of current guidelines and legislation. For example we found some women did not have ongoing mental health checks throughout pregnancy, the maternal pulse was not consistently recorded on commencing a CTG trace for foetal wellbeing, and CTG traces were not reviewed in line with best practice guidelines.

  • The trust was recently more focused on improving end of life care for patients.But there had been a slow response to best practice guidance and the results of successive national care of the dying audits. The Achieving the Five Priorities for Care of the Dying Person care plan was in the process of being introduced, andits use was yet to be audited.

  • The majority of staff were trained and had the skills and knowledge required to undertake their role. There were educational opportunities available for all grades of medical and nursing staff.There were arrangements in place for the supervision and appraisal of staff. Although not all staff on the CRCU and in diagnostic and imaging had received an annual appraisal.

  • On the maternity unit, most of the consultants performed a limited number of caesarean sections, which had the potential to impact on their competence. Also in maternity consultants did not always give adequate supervision to junior registrars. There was little communication from the consultants to the nurses looking after the gynaecology patients and their attendance was described as “variable”.

  • Patient’s consent for treatment, observation or examination was sought by staff. When people lacked mental capacity to make decisions, staff understood their responsibilities around making best interest decisions.Staff were aware of the impact of the Mental Health Act (2005) and the Deprivation of Liberty Safeguards. However, not all ‘Do not attempt cardiopulmonary resuscitation’ forms were supported by mental capacity assessments when it was stated patients lacked capacity.

  • The trust was still working towards a full 7-day service. There was access to physiotherapy, pharmacy and microbiology seven days a week. The critical care outreach team was only available Monday to Friday 8am -8pm and there was no formal ‘hospital at night’ service. While staff said there was good access to the palliative care team and said they were helpful and supportive, there was not a face-to-face specialist palliative care services, seven days per week. Women who were at risk of miscarriage were only offered scans between Mondays and Fridays. Women were required to attend the emergency department or were referred to a neighbouring trust out of hours.

  • Pain management was variable across the hospital. Patients who had undergone surgery told us their pain levels were regularly assessed and they received adequate pain relief. Pain assessment tools were not used for patients who had difficulty communicating verbally and patient’s pain was not being routinely monitored or managed effectively in CRCU

  • Information was not always provided to the patients GP in a timely manner. There had been a delay in providing discharge letters and clinic letters for cardiology patients, and clinic letters for dermatology and haematology patients.

  • There was effective multidisciplinary working with staff working together to provide patient care in a coordinated way.

Are services caring?

  • Patients and their relatives were positive about the caring attitude of staff and said staff treated them with dignity and respect.

  • Patient surveys showed that staff were caring and protected people’s privacy and dignity. The hospital’s ‘patient-led assessment of the care environment’ (PLACE) audit score for privacy and dignity was 92%, above the national average of 86%. Friends and family test were generally positive with the majority of people happy to recommend the hospital.

  • Patients said they felt involved in their treatment and had been able to make their own decisions.

  • The multi-faith chaplaincy service was available to provide emotional and spiritual support if requested.Patients also said staff helped them emotionally with their care. However, there was no psychology service at this trust so critical care patients with complex emotional needs could not be referred for formal psychological support.

Are services responsive?

  • The hospital often faced challenges with patients flow through the hospital and the number of available beds. The bed occupancy was consistency above the England average. The staff took a flexible approach to managing this situation including opening additional beds when able to do so. Other initiatives to improve the access and flow of patients through the hospital and, to promote shorter lengths of stay included the hospital@home service. Discharge planning was instigated at the time of admission. Ward staff and the discharge team worked with partners to improve the coordination of patient discharges and transfers.

  • Improvements were needed in the responsiveness of critical care, and maternity and gynaecology services. There were delayed transfers from the critical care unit, which was not a suitable environment for patients ready for care on a ward.Mixed sex breaches were not identified and reported in line with national guidance.

  • Services were planned to meet the needs of the local population and in coordination with other health and social care services.These included the services provided in the hospital site and those provided at other locations such as dialysis services in satellite units. Patients with respiratory problems had access to the Dorset adult integrated respiratory service (DAIRS) a small outreach service that coordinated care between the hospital and patients’ own homes.There was a day surgery unit in Weymouth, and a one stop breast clinic for timely and accurate diagnosis for patients awaiting breast cancer diagnosis. Outpatient clinics and diagnostic imaging were available at community clinics.

  • There were translation services available for patients whose first language was not English. Sign language interpreters were also made available. Patient information was available and could be provided in other languages on request.

  • Staff understood how to provide support to vulnerable people, including those living with a dementia or a learning disability or difficulty. There was no specialist liaison nurse for learning disabilities.

  • Staff tried to resolve patients’ concerns before they became complaints. Complaints were taken seriously, and changes made in response to patient feedback. There were improvement plansimproving timeliness of responses, in agreement with complainants

Are services well led?

  • Service leads had identified priorities for improvement, although the strategic vision was in part dependent on the Dorset Clinical Services Review. Strategies were also driven by the recent Vanguard project for more coordinated acute services across Dorset.

  • Service leads had articulated a vision and the priorities for end of life care services, but these had not been implemented. The leadership and governance processes for end of life care services had not been sufficient to ensure that necessary action plans were implemented in a timely way, and that quality, performance and risks were effectively monitored and managed.

  • Staff were aware of the trust’s vision. All staff were passionate about improving services and providing a high quality service. Most staff felt both the trust and local leadership teams were visible and supportive. The exception was the maternity and gynaecology service were consultants did not all work well as a team and working relationships were strained. In some area, managers were put under pressure to work clinically and were then not able to complete all aspects of their role, including quality assurance.

  • There was strong patient and staff engagement including ‘experience based design’ surveys to find out how people felt about their care and treatment. Many of the wards displayed recognition awards for teams and individual staff.

  • There was a governance structure for the services and services participated in audit programmes. A recent trust wide review had demonstrated that the governance processes including the reporting and escalation process needed strengthening.At local level the clinical governance teams had oversight of audit, performance, risks, quality and finance. A newly formatted risk register had been introduced, the completion and use of these registers was variable. Not all risk registers included all the risks and lacked evidence of mitigation and review.

We saw several areas of outstanding practice including:

  • The hospital@home service provided a valuable service supporting medically fit patients to have earlier discharges to their homes. This service was provided 24/7 and helped improve access and flow in the hospital as well improve outcomes for patients.

  • The support for renal dialysis patients was outstanding, with individualised care for patients to receive home dialysis and holiday dialysis when appropriate and safe.

  • The genitourinary medicine service was a well-led, patient focused service that had identified the needs of the patient groups it served, many of whom were vulnerable. There was excellent multi-disciplinary working with external agencies and robust clinical standards in place, which they service, audited themselves against, always looking for how they could improve the service. Outpatient clinics and advice sessions were held, where possible, at venues that encouraged attendance from patients who had the greatest need for the service but could not or found it challenging to attend a hospital.

  • The two bereavement midwives made home visits following a stillbirth or neonatal death. They made follow up visits to tell the parents post-mortem results in person and offered to provide antenatal care for women in any subsequent pregnancy. They also set up the monthly ‘Forget Me Not’ bereavement support group in a local children’s centre. They set up and closely monitored a private social media page for women who had lost a baby during pregnancy or after birth.

  • A gynaecology specialist nurse ran the ‘Go Girls Support Group’ along with a former patient, to provide support for women diagnosed with a gynaecological cancer.

  • Midwives ran specially designed antenatal, breastfeeding and smoking cessation sessions for ‘Young Mums’. They were also offered separate tours of the maternity unit.

  • There were several examples of patient involvement in the codesign and improvement of services and excellent use of experience based design (EBD) methodology.

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

Importantly, the trust must ensure:

  • All equipment is clean and fit for purpose and ready for use in the emergency department. A clear process must be implemented to demonstrate the mortuary trolley has been cleaned, with appropriate dates and times recorded. 

  • The five steps to safer surgery checklist is appropriately completed.

  • The management and administration of medicines always follows trust policy.

  • Patients in the minor operations room (used as a majors cubicle) in the emergency department have a reliable system in place to be able to call for help from staff.

  • There are sufficient therapy staff available to provide effective treatment of patients.

  • The numbers of nursing on duty are based on the numbers planned by the trust all times of the day and night to support safe care.

  • Sufficient palliative care consultant staffing provision in line with national guidance and to improve capacity for clinical leadership of the service

  • The number of midwives is increased according to trust plans and in line with national guidance, to support safe care for women.

  • Staff attend and or complete mandatory training updates.

  • Turnaround times for typing of clinic letters are consistently met, monitored and action taken when targets are not met across all specialities within the trust.

  • All patient records must be stored securely to maintain patient confidentiality.

  • Risk registers at local, directorate and divisional level are kept up-to-date, include all factors that may adversely affect patient safety. And progress with actions is monitored.

  • There is implementation of clear and measurable action plans for improving end of life care for patients. There is monitoring and improvement in service targets and key performance indicators, as measured in the National Care of the Dying Audits.

  • Care and treatment in all services consistently takes account of current guidelines and legislation and that adherence is audited.

  • Consultants supervise junior registrars in line with RCOG guidance.

  • Continue the development of governance processes across all specialties and divisions, with a standardised approach to recording and reporting. Ensure the information is used to develop and improve service quality.

  • Regular monitoring of the environment and equipment within the emergency department, and action taken to reduce risks to patients.

  • Mixed sex breaches in critical care must be reported within national guidance and immediately that the breach occurs.

In addition the trust should ensure :

  • All staff report incidents and feedback is given to the member of staff reporting the incident, and learning from incidents is shared with staff and across teams when relevant.
  • The trust electronic incident reporting system is fully implemented throughout the surgical specialty.

  • Management and specialist staff have the time to undertake their roles

  • Resuscitation trolleys are tamper evident.

  • Staff follow trust procedures when patient group directions are updated, so it is clear they are authorised for use,

  • A recognised pain assessment tool is used in critical care to assist in the monitoring and managing pain for patients.

  • Pain score appropriate tools are used for non-verbal patients across the hospital.

  • Discharge letters are sent to GPs in a timely way and patients are given a copy .

  • Standards of cleanliness are maintained in all outpatient areas.

  • Patient outcome data is recorded and analysed to identify improvements to services for patients.

  • Staff working in outpatients always follow the trust interpretation policy for patients who are non-English speaking.

  • Nurse staffing on the children’s unit is reviewed in line with The Royal College of Nursing (2013) guidelines in terms of numbers or ratios of nurse to healthcare assistants.

  • Review of medical staffing in line with British Association of Perinatal Medicine (2010 Standards) requirements for sufficient medical staff on the neonatal unit at all times, including overnight (9pm to 8am).

  • Compliance with Facing the Future-Standards for acute general paediatric services (RCPCH, Revised 2015) requirements for consultant paediatrician present and readily available during the times of peak activity, seven days a week.

  • Increased compliance with recording of key metrics in outpatient services, such as the time the patient is seen, to enable data analysis to be more meaningful when used to monitor service quality.

  • Daily recording of data on missing notes for outpatient clinics, which is audited and actions taken.

  • Face-to-face specialist palliative care service, 7 days per week, to support the care of dying patients and their families.

  • The critical care unit access is secure to maintain infection prevention and control and the safety of vulnerable patients on the unit.

  • Service leads review how they use data to improve patient outcomes

  • The development of critical care ‘follow up’ clinics, in line with national guidance, in consultation with stakeholders and commissioners.

  • All maternity guidelines are reviewed to ensure they are up to date

  • Pregnant women’s mental health is assessed throughout pregnancy using a tool as recommended by NICE ‘Antenatal and Postnatal Mental Health’ guidance.

  • The use of a NICE recommended CTG evaluation tool which should be entered into the woman’s notes every time the trace is reviewed.

  • The use of a software package, with an individualised growth chart designed to more accurately detect foetal growth problems which are associated with stillbirth.

  • The development of a midwifery led birthing unit, in line with National Maternity review recommendations.

  • The use of the modified ‘Sepsis 6 care bundle’ in the maternity units.

  • The use of the Stillbirth Care Bundle developed by NHS England to ensure that all known measures are taken to reduce the chances of stillbirth.

  • Improved rates of dementia screening to ensure that all emergency admissions over 75yrs are screened and then appropriately assessed.

  • A robust system to support lone workers in the community.

  • Identify and develop a quality dashboard to monitor the quality of the services.

  • Implementation of nursing staffing acuity tool in child health.

  • Supervision for staff involved in children’s safeguarding.

  • The arrangements for children attending appointments in general outpatient clinics are reviewed

  • All staff caring for dying patients undertake mandatory training in end of life care, so that they have the necessary knowledge and skill to deliver end of life care in line with the ‘achieving the five priorities for care of the dying person’.

  • Cleaning between cases in day surgery is sufficient and there are effective arrangements to prevent cross infection.

  • Nursing handover on Day Lewis ward are arranged to respect patients’ privacy and dignity.

  • There are arrangements for more timely discharges earlier in the day (before lunchtime) and more effective use of the discharge lounge by all ward teams.

  • Governance arrangements provide sufficient overview of the quality and risks across outpatient services.

  • The emergency department environment is reviewed to make it more child friendly.

  • There are ongoing risk assessments and improvements in the environment of the critical care unit, taking into account the guidance set out in HBN 04-0.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 16 August 2016

Effective

Requires improvement

Updated 16 August 2016

Caring

Good

Updated 16 August 2016

Responsive

Requires improvement

Updated 16 August 2016

Well-led

Requires improvement

Updated 16 August 2016

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 16 August 2016

Maternity and gynaecology services were rated as requiring improvement for ‘safe’, ‘effective’, ‘responsive’ and ‘well-led’ and rated as good for ‘caring’ .

Consultants did not consistently supervise junior registrars and were not always readily available to assist junior staff in theatre if required.

The midwife to birth ratio did not meet national guidelines. The funded midwife to birth ratio was 1:34. An assessment in July 2015, using a tool to assess how many midwives are required recommended the midwife to birth ratio should be 1:27.

Some women’s maternity records lacked clarity. Within the maternity service, risk assessments were completed at the initial booking and continually evaluated throughout antenatal, perinatal and postnatal care apart from for their mental health. Risk assessments for gynaecology patients were carried out at the pre-operative assessment, around a month before their admission. Risks to patients were not consistently reassessed on admission to the ward. Medical records were not consistently stored securely on Abbotsbury ward. Gynaecology patients were infrequently reviewed by consultants; they were normally reviewed by registrars or junior doctors.

Overall attendance at mandatory training updates was below the trust’s 85% target in some cases as low as 41%. There was a risk that not enough staff had attended updates to ensure they had suitable training to care for women safely.

Harmful cleaning solutions could be easily accessed on the maternity unit and medicines were not consistently stored securely in the maternity unit.

Care and treatment did not consistently take account of current legislation and guidance. Midwives did not use used the ‘Fresh Eyes’ approach which is considered good practice and the maternal pulse was not consistently recorded before commencement of the cardiotocograph (CTG). The maternity service did not use the ‘Sepsis 6’ care bundle or the NHS England ‘Stillbirth Bundle’. There was no current schedule for audits.

Caesarean section rates were higher than England averages and breastfeeding initiation rates were consistently below the trust target, despite the unit achieving UNICEF’s Baby Friendly accreditation.

The trust did not meet its target of 90% of women booked by 12 weeks antenatally.

There was one maternity theatre there was a possibility that elective cases may be delayed if emergency care was required.

There were strained working relationships between most consultants, despite participation in mediation to improve the situation. Some members of staff felt there was a risk this may impacton the quality of patient care. Consultants did not often review gynaecology surgery patients and did not communicate with nurses looking after them on the ward. They failed to attend two meetings arranged for them to meet the new ward sister. However, we saw evidence that newly appointed consultants were working effectively and improvement to the perinatal mental health service was due to start in May 2016.

Overall feedback from women and relatives about their care and treatment was positive. We observed women were treated with kindness, compassion and dignity throughout our visit.

A range of equipment and medicines were available to provide pain relief in labour and for patients on the gynaecological ward. Women were able to self-administer pain relief if required.

Nursing and midwifery staff were encouraged to report incidents and robust systems were in place to ensure information and learning was disseminated trust wide. Duty of Candour was well-embedded in the maternity services, and praise given to staff, who felt supported by managers. Women had access to sufficient information to support them with their pregnancy options and gynaecological diagnosis. Women had access to telephone translation services and staff told us information could be sourced in other languages if required.

There was a clear strategy, with strong public and staff engagement. We saw evidence of learning from complaints in both the maternity and gynaecology services.

Medical care (including older people’s care)

Good

Updated 16 August 2016

Overall, we rated medical care as ‘good’.

We found that medical care (including older people’s care) was good for effective, caring, responsive and well led and ‘requires improvement’ for safe.

Staff managed most aspects of medicine administration, storage, disposal and recording safely. However, we found that hard copies of Patient Group Directions (PGDs) for medicines on the satelite renal dialysis unit were out of date or not authorised. Staff had not followed trust policy for updating PGDs. Resuscitation trolleys were not tamper evident, creating a risk of incomplete equipment in an emergency.

Patients and relatives told us staff were caring and compassionate, and treated them with respect. They felt involved in their care and recommended the hospital to others based on their own experiences. Staff helped them with pain relief. Medical services sought patient views both routinely on discharge and to help improve treatment pathways. Groups of patients took part in focus groups to share their specific experiences of care.

Staff had a good understanding of how to care for vulnerable patients including those living with a learning disability or difficulty, or with dementia. They used tools to assess patients’ mental capacity and understood the procedures to follow if patients were at risk of a Deprivation of Liberty if they were restricted or restrained.

Staff said their managers provided good support and felt the hospital was a friendly place to work. They had good access to professional development and most staff had completed mandatory training and appraisals. New nursing staff said the induction had been useful, although mentors did not always have time to provide adequate support. Junior doctors were satisfied with their training opportunities.

There was high level of bed occupancy and most wards had additional beds to help manage the increased demand for medical services. There were not always enough nursing staff, medical staff and therapists to support the needs of patients. The trust had carried out a staffing audit but had not completed the review to update staffing levels.

There was a culture of collaborative working and staff said they worked well together in multidisciplinary teams to coordinate patient care. We observed effective handovers between staff, which showed they considered patient’s individual risks and needs. However, we observed a nursing handover on Day Lewis ward, which lacked respect towards patients. Staff assessed patient’s health and welfare risks and agreed plans to support their care and treatment. They monitored changes, including deterioration in health, and took necessary actions.

Patient records were clearly completed and documented patient’s risk assessments and management plans. Staff did not always keep paper records in secure trolleys, to minimise access by unauthorised persons.

The divisional leads had an agreed vision and strategy for services and a clinical governance framework. They had recognised the need to improve their management of risks, and had started to use a new approach to monitoring service risks. Staff reported incidents, and understood how to use the incident reporting system. Staff carried out root cause analysis to investigate incidents and learn from them. The service had a high proportion of harm-free care. The services took part in national and local audits to check they provided care and treatment in line with good practice guidance. They developed action plans and worked with other health and social care providers to improve care pathways. For example, project teams worked to improved discharge arrangements, cancer care pathways and stroke care.

Wards were clean and the infection control team carried out regular audits to identify any areas for improvement. At the time of our inspection, the cardiac catheter laboratory had broken down and required repair by the suppliers. Other items of equipment were maintained safely under contract and staff reported maintenance staff responded promptly when requested. The equipment library also supplied aids and equipment within the agreed timeframe.

Urgent and emergency services (A&E)

Requires improvement

Updated 16 August 2016

We rated the service in the emergency department (ED) as good for effective, caring and responsive but it required improvement for safe and well-led.

The department was visibly clean, but the fabric of the building required some maintenance, which made cleaning difficult. Equipment was available, but was not always clean and fit for purpose. It was not clear who had responsibility for cleaning or checking some equipment. There was no regular monitoring of the environment and equipment to identify risks to patients. Following the inspection, we received a cleaning rota from the trust. There was some monitoring but this was not always effective. Maintenance was slow. There was not a patient call system in all treatment rooms.

The service had identified improvements were needed in the coordination of governance processes. Risks were not always identified or adequately managed. The ED was well led clinically by senior doctors, but nursing leadership was stretched. The matron did not have sufficient time to work clinically and had a dual post as service manager which detracted from the quality assurance role, and led to fragmented nursing leadership and risks within the department not being identified.

The department had a culture of safety where incidents were reported Learning was shared and changes made as a result of this. Staff adhered to infection control procedures. Medicines were mostly appropriately managed and stored.

The department had appropriate medical staffing levels that included a consultant present for 12 hours a day and senior medical cover for 24 hours per day. There was an appropriate number of suitably trained and skilled nurses in the department; this included a lead nurse for children. There was a matron and service manager in a dual role, a consultant nurse, as well as skill mix of emergency nurse practitioners, advanced nurse practitioners and children’s lead nurse. There were a low number of nursing vacancies within the department. Agency staff were seldom used. However, when agency staff were used, an appropriate induction to the unit was not always provided.

The safeguarding requirements for children, young people and vulnerable adults were understood, and there were appropriate checks and monitoring in place.

The department provided effective care that followed national guidance and this was delivered to a high standard. Pain relief was offered appropriately and the effectiveness of this was checked. Multi-disciplinary work was in evidence and the department ran its services seven days a week.

Patients gave positive comments about the care they received, especially the attitude of the staff. Patients and relatives told us they were treated with compassion, dignity and respect, and staff treated them with kindness and courtesy. Patients were kept informed of treatment options and were involved in decisions about their care.

The hospital was not consistently meeting the national emergency access target of 95% of patients who required hospital admission to be transferred to a ward or discharged from ED within four hours. Patients were however, mostly assessed and treated within standard times. Overall the trust performance had been in line or better than the England average. There was good support provided for patients with a mental health condition and patients living with dementia.

The departmental strategy and vision was not recognised by all staff, although the service had involved senior staff in away days and meetings about developments in the service. The culture within the department was one of accessible leadership with mutual trust and respect, leading to the maintenance of an effective team. There was appropriate monitoring of incidents and performance by senior staff.

Surgery

Good

Updated 16 August 2016

Surgery was rated as good because services were effective, caring, responsive and well led however some aspects of safety required improvement

We rated safe as requires improvement because:

Staff did not consistently complete the ‘Five Steps to Safer Surgery’ checklist to minimise the risk of patient harm. Patient records were not stored securely but in open trolleys, presenting a risk of breaching patient confidentiality. Mandatory training targets had variations of 50-100% compliance against the trust targets.

Staffing levels of registered nurses, particularly overnight left a poor contingency for absence. There was poor availability of therapy staff to support postoperative patients.

However, staff knew how to report incidents, and used the investigation of incidents and never events to share learning with colleagues. They were aware of their responsibilities under the Duty of Candour, adult safeguarding and used the safety thermometer data to inform patients, staff and visitors.

Patients received care and treatment based upon national guidance, standards and best practice recommendations. The surgical services were consultant led and delivered and there was good evidence of multidisciplinary team coordination to support patients. The surgical services participated in a number of national audits such as the Hip Fracture Database, where they had performed well. The trust had robust systems to monitor patient’s nutrition and fluid balance. The patients told us that their pain levels were regularly assessed and they received adequate pain relief.

Staff treated patients with kindness and showed regard to their dignity and privacy. The trust’s results of the Friends and Family Test showed a higher than average response rate. The surgical wards displayed 90-100% of people recommending the ward they had been a patient in. The patients described receiving good care, thoroughly explained and which they had been involved in any decisions relating to them.

The trust had developed services to support the needs of the patients’, the daily single point of access multidisciplinary (MDT) meeting helped to provide a coordinated approach to complex patient discharges. The one stop breast clinic provided timely and accurate diagnosis for patients awaiting breast cancer diagnosis.

The trust had taken steps to improve the Refer to Treatment targets and the majority of the surgical specialties were only just below target. Cancellation of patients’ operations was better than the England average.

Although the trust had a discharge lounge, there was no obvious drive for earlier discharges and poor usage of the discharge lounge by some of the wards caused the holding of post-operative patients in recovery, prolonging theatre lists. The lack of beds could also mean the opening up of the day case unit overnight and the admittance of orthopaedic patients into other surgical wards.

According to the surgical dashboard, surgery had failed to screen all emergency admissions over 75 years for dementia since April 2015 although of those screened 100% of patients were then appropriately assessed.

Staff were aware of the trust’s strategy and vision; there was good engagement from staff that were passionate about improving services and providing a high quality service to patients. Most staff felt the leadership of the trust and within surgical services were visible and supportive. Staff told us they felt proud of their service, the patients’ outcomes and feedback and the response rates for the NHS staff survey was higher than national average Patients were encouraged to be engaged in changes to services, i.e. patient hip and knee pathways.

Intensive/critical care

Good

Updated 16 August 2016

We rated critical care at this trust as good for safe, effective, caring, and well-led care. Responsiveness of the service required improvement.

There was a strong culture of reporting, investigating and learning from incidents. Patients were protected from avoidable harm and abuse and the principles of duty of candour were well understood.

Consultants were notably present on the unit and junior doctors were well supported in developing critical care skills. Nursing staff felt well supported by doctors and there was excellent communication between doctors and nurses during handovers. Physiotherapy assessments happened within 24 hours of an admission and physiotherapists were an integral part of the care team on the unit.

The unit aimed to have a senior nurse shift coordinator who was supernumerary on at all times in line with national guidance. This was not always achieved when there was unscheduled staff absence. However, we saw that during these times there was a clear escalation process and patient safety remained the priority.

Medicines, including controlled drugs, were stored and managed safely with the exception of a small number of emergency medicines, which were located in the emergency trolleys. The emergency trolleys in non visible areas were not tamper-evident. This was corrected during the inspection, medicines were put in sealed boxes on the trolleys.

The unit was submitting on-going data to the Intensive Care National Audit Centre (ICNARC). Patients’ predicted mortality outcomes at this critical care service were in line with, or better, than similar units, with the exception of patients admitted with pneumonia whose predicted mortality was below similar units. There were consistently low rates of unit acquired infection and audits showed consistent compliance with best practice hand hygiene standards.

Treatment and care followed current evidence based guidelines with the exceptions of the critical care outreach services which was not available 24 hours a day seven days a week and did not have follow up provision for critical care patients. The trust was working towards having a 24 hour critical care outreach team.

Staff were sufficiently skilled in delivering critical care and 59% of the nursing staff held a post-registration award in critical care in line with national standards. The clinical nurse educator oversaw the education and training development of the nursing team though was frequently required to cover routine clinical work, which distracted from this. Appraisal compliance was low on the unit at 79% of the overall staff team in December 2015. However, the critical care outreach team staff had all been appraised within the last 12 months.

Equipment was clean and well maintained but the layout of the unit was not optimal for the delivery of critical care. The unit was not compliant with Department of Health’s Health Building Notes (04-02), Risk assessments had been undertaken and there was ongoing review. The unit was not secure as there was a second entrance via another ward. There was not clear signage or mechanisms to stop visitors and staff from other wards walking on and off the unit.

Patients were not routinely discharged in a timely manner and delays occurred in over 40% of all discharges. Delays led to patients staying in mixed sex and sub optimal accommodation for significant length of time. Mixed sex breaches were not being reported immediately as they occurred which was not in line with national guidance.

Patients and their relatives were involved, where possible, in decisions made about their care and treatment. Staff were sensitive when required to deliver bad news and ensured that suitably skilled and experienced staff were available to support patients and relatives at these times.

Staff were responsive and worked collaboratively to meet patients’ health needs including those unrelated to their critical illness or condition. Staff made reasonable adjustments and used tools to support patients from vulnerable groups such as individuals with a learning disability.

Services for children & young people

Good

Updated 16 August 2016

We found that the services for children were good for safe, effective, caring, responsive and well led.

There was openness and transparency about safety, and continual learning was encouraged. Staff were supported to report incidents, including near misses. Access to the children’s ward and neonatal unit was secure. Staff were clear about their responsibilities if there were concerns about a child’s safety. Safeguarding procedures were understood and followed, and staff had completed the appropriate level of training in safeguarding and other mandatory training.

The trust did not follow the Royal College of Nursing guidance on safe staffing levels for the paediatric wards. Whilst the trust did mitigate the impact of this overnight through effective rostering of competent staff, the system may not be sustainable. The unit was relatively small and not fully compliant with British Association of Perinatal Medicine (2010 Standards) requirements for a local neonatal unit as there was not a totally separate tier 1 rota, and the rota covered the children’s unit as well. However, there was no evidence of any negative impact of this arrangement. There were good levels of low and middle grade doctors and they were positive about the trust as a learning environment. The unit was also non compliant with the Royal College of Paediatric and Child Health Facing the Future: Standards for Acute General Paediatric Services (2015) as the unit did not have a consultant paediatrician available during the times of peak activity, seven days a week. Although a consultant was resident overnight

Care and treatment was planned and delivered in line with evidence-based guidance, standards and best practice. The individual needs of children and young people were assessed and care and treatment was planned to meet those needs. Care pathways and multidisciplinary records were used to support practice. Staff assessed patients’ pain effectively and obtained consent to treatment appropriately and in line with legal guidance. A paediatric early warning system was used for early detection of any deterioration in a child’s condition and an early warning system for neonates was used in the NNU.

Staff were trained and had the skills and knowledge required to undertake their role. Staff completed appropriate competence assessments. Appraisals and supervision took place and this helped staff to maintain and further develop their skills and experience. Services, including access to consultant paediatricians, were provided seven days a week.

Feedback from children, young people and parents about the care and kindness received from staff was positive. All the children and families we spoke with were happy with the care and support provided by staff. Staff worked in partnership with parents, children and young people in their care.

Inpatient services were tailored to meet the needs of individual children and young people. There were suitable facilities on wards for babies, children and young people and their families. A paediatric assessment unit, open 13 hours a day, improved patient access and flow through the hospital. There were no barriers for those making a complaint. Staff listened to the feedback given to them by parents. Play therapy staff ensured children were supported during their hospital stay.

There was a clear governance structure to manage quality and risk. There was strong visible clinical leadership that had brought about positive developments. Staff at all levels of the organisation were proud to work in this department. The unit had also involved a child inspector from social services in making improvements to the service.

There was a strategic plan for paediatric services 2016/17 and the service was part of the ongoing Dorset wide Clinical Services Review, and the acute services Vanguard project.

End of life care

Requires improvement

Updated 16 August 2016

Overall this core service was rated as ‘requires improvement.’ We rated end of life service as ‘requires improvement’ for safe and effective and ‘inadequate’ for well-led, We rated caring and responsive as good.

Leadership and governance of end of life care services needed to improve to ensure that necessary action plans were implemented, and that quality, performance and risks were effectively monitored and managed. The palliative care consultant clinical lead worked part time therefore had limited time or capacity for strategic planning or leadership of the service, within the restricted hours available to them.

The trust was developing end of life care in line with national guidelines, but progress had been slow. The results of the National Care of the Dying Audit undertaken May 2014 highlighted several areas for improvement. An action plan had been written in November 2014 prior to the receipt of the results of the audit. The results of the National Care of the Dying Audit undertaken in 2015, showed there continued to be areas for improvement. During the inspection we saw that the end of life facilitator, appointed in August 2015, was driving improvements however there had not been audit to demonstrate this.

The trust had introduced an “end of life care for the dying patient individual care plan” to replace the Liverpool Care Pathway after its national withdrawal in July 2014, and to meet the requirement for individualised care plan. In January 2016 the trust commenced a rolling programme to implement a new end of life care plan called Achieving the Five Priorities for Care of the Dying Person. This was not yet embedded in practice across all areas of the hospital.

End of life care training was provided during induction but there was no mandatory ongoing end of life care training.

There was investigation of incidents but there was a lack of detail and recording to demonstrate how end of life issues had been comprehensively investigated or how action plans would be used to drive improvements. It was not possible to extract end of life themes or issues that had arisen through the incident reporting process and there had been limited learning from incidents that related to end of life care.

Most but not all DNACPR forms we inspected were completed according to national guidelines. The trust audits had also identified areas for further improvement, to ensure that forms showed discussions with patients and families and mental capacity decisions were documented.

Patients’ needs were mostly met through the way end of life care was organised and delivered. There was rapid discharge of those patients expressing a wish to die at home most of the time, there were sometimes delays, due to difficulties in accessing community care services

Patients had appropriate access to pain relief. Anticipatory end of life care medicines were correctly prescribed and patients were provided with pain management support.

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

Outpatients

Requires improvement

Updated 16 August 2016

We rated outpatients and diagnostic imaging as requires improvement. We found the service to be good for caring and responsive but requires improvement for safe and well-led.

There were significant delays in the typing of clinic letters for cardiology, haematology and dermatology, with a risk that GPs were not kept informed of any changes to medicines or the results from diagnostic tests. The trust put in place an action plan for haematology after our inspection, with work already taking place in cardiology and dermatology. Patients’ records were not stored securely in the oncology department and the records store for the genitourinary medicines clinic had a leaking roof.

We had concerns that some staff did not always report incidents as sometimes they did not receive feedback or learning was not shared at team meetings. Governance processes across the four divisions and the different specialties lacked standardisation, particularly for monitoring and reporting on service quality. Risk registers were not always complete. Two patient records policies were out of date and audits to monitor compliance to these policies did not take place.

Staff followed national guidance to ensure patient care followed an evidence-based approach. Some departments used clinical audit to monitor the standard of care provided, although this was not consistently used across all departments.

The service overall met referral to treatment time targets (RTT) but did not consistently achieve the two-week wait for urgent cancer referrals. Work had been completed in a number of specialities, including ophthalmology, to help them achieve the RTT targets. The trust offered a number of one-stop clinics to reduce patient visits.

Staff working in outpatients and diagnostic imaging told us they enjoyed coming to work at the trust, they were well supported by managers and felt they provided a good standard of care to patients. Overall, there were sufficient staff to run clinics and we observed good multidisciplinary working. Staff were up-to-date with their mandatory training and felt confident in their role. Access to additional training was sometimes affected by demand for services. The majority of staff had recently completed an appraisal but staffing shortages had impacted on this for diagnostic imaging.

Staff felt involved and able to make suggestions on how the service improvements although examples of good practice were not always shared within or across divisions, Staff found the weekly newsletter from the chief executive kept them informed of changes across the trust, however, outpatient staff at Weymouth Community Hospital did not feel engaged with the trust as a whole.

Patients commented on the cleanliness of the departments they visited and we observed staff adhering to the trust’s infection control policies and procedures. However, the waiting room environment at Weymouth Community Hospital required review by the trust and owner of this hospital. Medicines and exposure risks to radiation for patients and staff were safely managed in diagnostic imaging. However, some patient group directions (PGDs) for the supply or administration of medicines held in departments were not authorised or in date for use. Staff were not following trust procedures for updating of PGDs.

All patient feedback was positive for the care and treatment they received from staff. Patients told us staff treated them with kindness, understanding and staff took the time to listen to their concerns and explain their condition in a way they could understand. Services were planned to meet the needs of local people, including those with additional needs or who were vulnerable due to their condition or personal situation. Patients were involved in developing services through experience based design projects.