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Inspection Summary


Overall summary & rating

Inadequate

Updated 26 January 2016

Walsall Healthcare NHS Trust provides acute hospital and community health services for people living in Walsall and the surrounding areas and the trust serves a population of around 260,000. Acute hospital services are provided from one site, Walsall Manor Hospital which has 606 inpatient beds made up of 536 acute and general beds, 57 maternity beds and 13 critical care adult beds. There is a separate midwifery-led birthing unit and a specialist palliative care centre in the community.

We carried out this announced comprehensive inspection on 8 to 10 September 2015. We held two public listening events in the week preceding the inspection visit and met with individuals and groups of local people and analysed data we already held about the trust to inform our inspection planning. Teams, which included CQC inspectors and clinical experts, visited Walsall Manor Hospital and inspected eight core services: emergency department, medical services, surgery services, critical care services, maternity services, children and young people services, end of life services and outpatients and diagnostic services. We also inspected three out of four community services: adult services, children, young people and families and end of life care services. We did not inspect community inpatient services as this service was registered with the local authority. We also carried out three unannounced inspection visits after the announced visit on 13, 20 and 24 September 2015.

We have rated this trust as ‘inadequate’. We made judgements about eleven services across the trust as well as making judgements about the five key questions we ask. We rated the key questions for safety, effective and well led as ‘inadequate’. We rated the key questions, for caring and responsive as 'requires improvement’.

Our key findings were as follows:

  • Maternity services had multiple issues with staffing, delivery of care and treatment and people were at high risk of avoidable harm. The service had limited capacity and staffing resources which impacted negatively on patient experience and compromised patient safety.

  • The latest MBRRACE report presented results for still births, neonatal mortality and extended perinatal mortality rates for 2013. Standardised results for Walsall were slightly higher than their comparator group. MBRRACE recommended that Walsall should consider a local review to better understand factors that may contribute to these results. In response to this the trust with its partners in the CCG and Public Health had participated in a detailed local study and agreed an action plan both of which have been shared with the Trust Board in public following our inspection.

  • The Emergency Department (ED) triage process was ineffective, there was a shortage of qualified paediatric nurses and no paediatric consultant based in ED. There were regular delays with patient handover from ambulance to ED. The trust had been consistently performing worse (5 to 9 minutes) than the England average (median 3 to 6 minutes) for the time to initial assessment of patients between January 2013 and April 2015.

  • The percentage of patients seen within the national four hour target to see, treat and admit or discharge 95%, was worse than the standard or national average for almost all of the period between April 2014 and May 2015. We saw the percentage of emergency hospital admissions waiting four to twelve hours from the decision to admit until being admitted (18 to 50%) was consistently above the England average of 5 to 15% between April 2014 and April 2015.

  • Incident reporting, particularly feedback to staff was variable across the trust. There was a mixed approach to incident reporting which differed between services. The trust promoted incident feedback to staff through various methods. However, this was dependent upon individual service managers to disseminate lessons learned and staff’s capacity to engage.

  • Previous concerns relating to the trust’s management of duty of candour had improved. We looked at several serious incident records which demonstrated the trust had adopted a more open and rigorous approach to the duty of candour regulation and its process.

  • Staff were caring and compassionate towards patients and their relatives. We did however see that in both ED and Maternity the excessive workload led to the standards of caring falling below that we would expect. Patient’s dignity and privacy was largely ensured and we saw many examples of good care across the trust from staff at all levels.

  • Community services for Adults, Children, Young people and Families and End of Life Care, were rated as good overall. Governance structure and risk management were well embedded and general leadership of community teams was supportive and nurturing.

  • The trust took part in all the national clinical audits they were eligible for, and had a formal clinical audit programme, where national guidance was audited and local priorities for audit were identified.

  • The Summary Hospital-level Mortality Indicator (SHMI) is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die. It was recognised that the SHMI for Walsall Manor Hospital had increased over an extended period of time, March 2015 was 107.41, April 2015 was 110.54 and May was 102.64. This represented a risk to patient safety.

  • The trust was still seeing the effects of implementation of the new electronic patient administration system nearly 18 months previous. Improvements had been made however, the trust was still struggling with simple tasks, (e.g. making patient appointments) as well as experiencing difficulties in gathering accurate information for decision making and performance management.

  • The culture of the trust was described by many staff as poor. Morale was low across many wards and departments and we heard examples of senior managers and in some cases executive members taking a heavy handed approach to problem solving. Despite ‘low morale’ staff demonstrated a positive approach to patient care and a genuine compassion to deliver the best care possible.

  • Divisional and corporate risk registers did not accurately reflect identified risks trust wide.

  • The trust had failed to implement the new checks and tests necessary to fulfil the requirement for all directors to be ‘fit and proper’ persons. This statutory requirement came into effect in November 2014. We saw no checks had been carried out for any directors within the trust and there was no Fit and Proper Person Policy in place. Following the announced inspection, the trust had taken remedial action to satisfy statutory requirements which demonstrated compliance with the Fit and Proper Person Regulation before the inspection period ended.

  • The Trust Board was aware that the organisation faced significant quality and performance challenges and had launched an Improvement Plan in June 2015 to seek to address these.

  • The Trust described to us a “perfect storm” in 2014 as a result of significant increases in emergency and obstetric activity and problems following the replacement of the patient administration system. The Trust Board recognised that the organisation faced significant quality and performance challenges in 2015 and had launched an Improvement Plan (“Improving for Patients; Improving for Colleagues; Improving for the Long-Term”). The plan included a programme of work to develop the two to five year strategy for the Trust and its services. The plan had been launched in June and as in its early stages at the time of our inspection in September 2015.

Importantly, the trust must:

  • Improve the governance of incident reporting systems to ensure that processes are embedded across the trust.
  • Improve duty of candour training to ensure staff have a clear understanding of the process.

  • Implement systematic training for complaints investigation, improve the RCA process and dissemination of lessons learned to front line staff and their managers.

  • Ensure there are adequate numbers of qualified staff across all services, particularly in: maternity services, emergency department and medical services to meet the needs of patients to protect them from abuse and avoidable harm.

  • The trust must ensure there is an adequate supply of equipment in good working order and fit for purpose across all services. Any mitigation to replace equipment must have clear reasons, regular review and an up –to-date action plan clearly demonstrating alternative options and timescales to support actions.

  • The trust must ensure equipment is stored appropriately; all fire exits must be kept free without compromising patient and staff safety and staff can access equipment when required.

  • Mental Capacity Assessments (MCA), Deprivation of Liberty Safeguards (DoLS) and Do Not Attempt CPR (DNACPR) assessments to be carried out in a timely manner and supported by appropriate documentation.

  • Review the patient administration system to minimise problems associated with missed patient appointments. Ensure data is accurate and the system is a reliable resource for staff to use which meets the need of patients using the service.

  • Ensure health records are completed appropriately and patient data is confidentially managed. Patient confidentiality is maintained at all times across all service.

After the inspection period ended, the Care Quality Commission issued the trust with a Section 29a warning notice outlining there was significant improvement required. This set out the points of concern and timescales to address this. The trust has responded to this with a detailed plan for remedial action.

Importantly, the trust must:

  • ensure there are adequately qualified staff across all services to meet the needs of patients and protect them from abuse and avoidable harm.

  • improve the embedding of governance of incident reporting systems trust wide.

  • ensure medication is stored, administered and recorded appropriately across all services.

  • ensure patient confidentiality is maintained at all times across all services.

  • ensure all fire exits are kept clear.

  • ensure the birthing pool in maternity services is always accessible and available for use and the birthing pool room is free from clutter and non- essential equipment.

  • ensure there is an adequate supply of equipment in good working order and fit for purpose across all services. Any decision not to replace equipment must have clear reasons, regular review and an up to date action plan clearly demonstrating alternative options and timescales to support actions.

  • ensure equipment is stored appropriately without compromising patient and staff safety and that staff can access equipment when required.

In addition the trust should:

The Emergency department SHOULD:

  • consider redesigning the seating arrangement in the ED general waiting area to provide some personal space between the seats.
  • improve staff annual appraisal rates within the ED.
  • ensure all staff can be easily identified by patients and visitors at all times when on duty.
  • better inform patients and their relatives/carers about the streaming systems in operation in the ED and how patients are going to be seen.
  • review the purpose and use of the ED log sheets.
  • consider setting out its overarching vision for the ED.

Medical services SHOULD:

  • provide a protected, suitable environment for physiotherapy.
  • review its stock of equipment including, but not limited to syringe pumps and weighing scales.
  • ensure that feedback is given on all reported incidents.
  • ensure that the patient safety dashboards on display in medical wards are maintained with up-to-date and accurate information.
  • inspect its physiotherapy equipment to ensure that it complies with infection prevention and control guidelines.
  • arrange for a patient group directive to be written for the administration of saline flushes.
  • ensure that fluid balance front sheets are consistently completed for any patient having their fluid intake and output monitored.
  • review the contents and layout of its nursing assessment documentation booklet.
  • reinstate a programme of acute illness management training for nurses working on medical wards.
  • review its major incident training and the method of its delivery to improve understanding among staff.
  • take action to improve staff understanding of the meaning of the butterfly symbol to indicate patients living with dementia and the purpose of butterfly bays on wards.
  • ensure that it consistently reports on its performance against the NHS 18-week referral-to-treatment target.
  • ensure that robust translation services are used to communicate with patients who do not understand English.

Surgery services SHOULD:

  • review the low uptake of medical devices training across the trust.

  • review the environment in recovery for children post-surgery to promote a child safety area.

  • ensure operating theatres are deep cleaned on a regular basis and should review how equipment is stored in the theatre environment

  • ensure equipment used specifically for children in the operating theatres is up to date

  • ensure intravenous fluids are stored in secure environments

  • ensure easier access to translation services.
  • review the provision of physiotherapy services to ensure initiatives such as the ‘joint school’ can be re-established.

Critical care Services SHOULD:

  • review its morbidity and mortality review process to ensure all deaths are reviewed.

  • review its checking system for fridge temperatures so that if temperatures are out of range, they are rechecked to ensure medicines are stored at the correct temperature.

  • review infection control procedures to ensure staff wash their hands after removing gloves and aprons rather than just using sanitising gel.

  • review junior medical cover to ensure doctors are available to attend consultant ward rounds in critical care and document contemporaneous patient plans in notes.

  • review multidisciplinary team working in critical care to enable multidisciplinary team ward rounds and effective multidisciplinary team working.

  • review systems to improve flow throughout the hospital to reduce the number of delayed discharges in critical care.

  • ensure patients have access to patient information leaflets in languages other than English.

Maternity and gynaecology services SHOULD:

  • ensure fridges used for the storage of medicines are kept locked and secure from unauthorised access.

  • ensure that medicines that look similar are not stored next to each other.

  • consider how it enables staff to attend required training and supports staff to gain additional qualifications to support the service.

  • consider how it can improve care records to ensure that risk assessment and safeguarding issues are easy to locate.

  • consider the use of specialist midwives to improve the experience of families including :bereavement, teenage pregnancy and diabetes,

  • consider ways to support and improve active birth.

  • consider ways to reduce the induction of labour and caesarean section rates.

  • consider ways of improving the sharing of information and improving engagement with midwifery staff, so they are aware of and involved in future developments.

  • consider ways to improve breastfeeding support to new mothers.

  • consider involving patients fully in care decisions by developing a ward round on delivery suite to incorporate every woman present.

  • consider ways to improve relationships between maternity and gynaecology to allow the joint use of the gynaecology theatre.

  • evaluate the management of outliers on the gynaecology ward.

  • consider NICE and best practise recommendations and ensure guidelines reflect up-to-date guidance.

  • consider individual feedback to staff reporting incidents.

  • consider the ways to inform patients of the role of Supervisors of Midwives.

  • consider the use of an assessment tool for the prevention of pressure ulcers for all maternity patients.

  • consider the use of the maternity safety thermometer tool.

  • consider a way to identify when a piece of equipment is clean and ready for use.

  • improve the cleanliness of the delivery suite and delivery suite theatres.

  • consider the use of disposable straps for the CTG machines.

  • consider the use of wireless CTG monitoring.

  • consider trialling the child abduction policy.

  • consider increasing audits to improve practice such as the audit of one to one care in labour.

  • consider the use of a debrief for patients following a caesarean section to discuss suitable mode of birth if they choose to have more children

  • consider the need for a policy for transferring women to a tertiary unit.

  • consider the need for a transition care ward for babies needing extra care.

  • consider a pool evacuation policy and suitable equipment to evacuate patients in all areas where pools are used.

  • improve the consistency of checking resuscitation equipment on the delivery suite.

  • consider a strategy for capping bookings for the service as the number of births increases.

Children and young people services SHOULD:

  • take steps to further improve the safety of, and reduce risks to CAMHS (patients receiving care on the children’s ward.

  • ensure the neonatal unit is suitable for the service provided and is large enough to accommodate the number of babies using the service at any one time.

  • review the scope of root cause analysis investigations and the process used to review mortality and morbidity to ensure all possible contributory factors are considered.

  • take action to maintain the standards of hygiene and cleanliness within the Starfish suite along with equipment within the suite, and ensure it is appropriate for the purpose for which it is used.

  • ensure patient records and referral documents are available in a timely way for children’s outpatient attendances.

  • ensure action plans are in place to improve practice in relation to national quality audits and monitor progress against these.

End of Life Care services SHOULD:

  • take action to ensure that there are sufficient mortuary fridges in working order.

  • ensure that all patients approaching end of life have their spiritual and religious needs assessed and are offered support.

  • ensure both amber care bundles and advance care planning are being used consistently.

  • consider how the trust provides dedicated bereavement care.

  • consistently identify a patient’s preferred place of death and support them to achieve this.

  • ensure there are appropriate areas for patients in the last days and hours of life that provide privacy and dignity for them and their relatives.

Outpatient and diagnostic imaging services SHOULD:

  • have a clear plan to replace ageing equipment in the radiology unit.

  • consider improving the post-operative procedure facilities for patients attending the day surgery unit and the endoscopy unit.

  • ensure all staff have access to trust policies and procedures.

  • ensure receptionists are available to meet and book in patients when they are attending for appointments and procedures.

  • ensure staff handling food for patients have attended basic food hygiene training.

  • ensure resuscitation trolleys are checked daily as recommended by the Royal College of Anaesthetists.

In response to these concerns, the Care Quality Commission issues Walsall Healthcare NHS Trust with a section 29a warning notice on 26 October 2015 setting out concerns and significant improvement required.

Since issuing the section 29a warning notice we have seen the trust take significant action to address these issues.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Inadequate

Updated 26 January 2016

Effective

Inadequate

Updated 26 January 2016

Caring

Requires improvement

Updated 26 January 2016

Responsive

Requires improvement

Updated 26 January 2016

Well-led

Inadequate

Updated 26 January 2016

Checks on specific services

Maternity and gynaecology

Inadequate

Updated 26 January 2016

Reporting of incidents was not a fixed part of the routine and it depended on how much time staff had whether an incident was reported or not. The service frequently experienced staff shortages, which had an adverse impact on patient safety. Women assessed as high-risk and requiring one-to-one care did not always receive it. There was no system in place to easily identify a woman at high-risk. Midwife to birth ratio was one to 37 at the time of our inspection, which far exceeded the national recommendations of one to 28. Further work was required with infection prevention and control. Cleaning checklists were in place but there were no cleaning regimes for t

he delivery suite, the antenatal, postnatal or gynaecology wards. Concerns were raised with the use of the second theatre, which had been converted from a high-dependency room and was not fit for purpose. There was a shortage of equipment such as birthing stools and CTGs and the birthing pool area was not used for its purpose but, instead, to store beds. Medication was not always stored appropriately and further work was required to improve the standard of documentation and tighten up patient confidentiality.

Staff were caring and compassionate and went above and beyond what was required to deliver care, often by working more than their contracted hours, including their days off. Feedback was generally positive from people who used the service. The service took part in national and local audits but results were not always shared with staff. There were good clinical multidisciplinary working relationships across maternity and gynaecology services. Middle management was visible and approachable. Senior management and the executive team were not supportive or visible and their management style was described as ‘dictatorial’. Maternity staff were unaware of the trust’s vision and values and were focused on ‘getting through the day’ with little innovation evident.

Medical care (including older people’s care)

Requires improvement

Updated 26 January 2016

Incident reporting across medical wards was variable, as many staff had little confidence that feedback from incidents would be shared and so staff were reluctant to report. There were staff shortages across several wards including the acute medical unit (AMU), wards 1, 16 and 29. The environment and availability of equipment were not sufficient to keep patients safe. For example, the design of ward 29 made it challenging for staff to observe people living with dementia and staff response time to meet patients’ basic needs needed to be improved. Some medical wards did not have an adequate supply of intravenous pumps and weighing scales. There was minimal protected time for staff training and clinical progression was not available, leading to staff leaving and moving to other NHS trusts in pursuit of development opportunities. National data was not always reported and some data within the hospital could not be verified. Nursing staff across medical wards did not feel supported or valued. Staff often worked longer than their designated shift time. Staff told us they felt ignored by senior management and ‘put on’ and felt the executive team did not have a good grip of risks and challenges across medical wards. Despite staff shortages, patients and relatives told us that they were treated with dignity and respect, and that the hospital staff provided genuine, compassionate care.

Urgent and emergency services (A&E)

Inadequate

Updated 26 January 2016

The incident reporting system was not a firmly fixed part of the routine and patients’ records were not always completed. Staff were aware of child protection but further training was required for safeguarding adults from abuse. Triage systems were in place but not always followed by staff when ED became busy, which was often. Patient comfort rounds did not have a structured process however, nursing and medical handovers were well organised and thorough. Nearly 25% of admissions were children and young people, but no paediatric consultant worked in ED, and qualified paediatric nurses were not available 24 hours a day. The ED took part in some local and national audits, but action plans to support audits were not robust. Staff were generally caring but at very busy times patients did not always receive effective pain relief and their hydration and nutritional needs were not always met. There was a strong internal and external multidisciplinary team (MDT) working to discharge patients home. The rights of patients being held under the Mental Health Act were respected by the ED staff. Patient confidentiality was not maintained at all times, as patients and visitors could see people’s private information on the large tracker screen that was located where staff could use it easily. Communication between staff and patients needed improvement as some senior staff did not wear name badges and not all patients knew who they were waiting to see or approximate waiting times. The ED was not fit for purpose; twice the number of patients now attended ED, the environment was cramped and some patients had to share a single cubicle with another patient when the ED was busy. It was trust policy to keep patients waiting in ambulances rather than on trolleys in the ED. This meant that people waited longer than the government targets for admission, treatment and discharge. The service risk register did not reflect all risks identified in ED, for example, poor performance relating to pain relief and lack of paediatric-qualified nurses. Patients were encouraged to feed back to improve service delivery. The hospital did not have a strategic plan for how ED would develop and improve in the future. Staff were encouraged to attend team meetings but were often too busy to do so and frequently went without breaks. Doctors were more positive about working in the ED. Some new improvements had been introduced, for example, the dementia and learning disability champions and the quick assessment of people by a consultant after they arrived by ambulance. However, they were not a fixed part of the routine at the time of our inspection.

Surgery

Requires improvement

Updated 26 January 2016

There were good systems to report and investigate safety incidents. However, there was poor incident feedback to staff. Concerns were identified with lack of training with medical devices, for example, intravenous pumps. Medical and nursing staffing levels were adequate to meet patients’ needs across surgery wards and theatres. Medicines management and management of confidential records worked well. Infection prevention and control practice was a firmly fixed part of the routine however, there were concerns relating to the lack of regular night deep clean of theatres, which could compromise infection control processes. We found there was excessive storage of equipment and out-of-date equipment, specifically in children’s surgery. Mental capacity assessments, Deprivation of Liberty Safeguards and consent were well managed and understood by staff. Staff were aware of the safeguarding policies and procedures and had received training. Most staff understood their responsibilities under the duty of candour. Surgery services used national guidance to underpin care delivery. Services took part in local and national audits, showing non-compliance, with some local audits being deferred to the 2015/16 programme. Staff competencies were assessed and signed off appropriately and patients were cared for by an MDT multidisciplinary team working in a co-ordinated way with access to some services seven days a week. Patients’ hydration and nutritional needs were met and patients and relatives were very complimentary about staff across all services. There was insufficient bed capacity to meet the needs of patients. This resulted in medical patients being placed on surgical wards, which affected the service. The environment in the recovery area in theatres was not child friendly and had not been furnished with children in mind. Arrangements were in place to support people with disabilities and cognitive impairments, such as dementia. However, translation services were  not well used by staff and there was a reliance on patients’ relatives to translate. Staff felt supported and listened to by line managers. There was a surgery divisional risk register in place, however it did not accurately reflect all risks identified across the division and was not regularly reviewed.

Intensive/critical care

Requires improvement

Updated 26 January 2016

Staff were aware of how to report incidents and an open culture encouraged this. There was no structured, systematic process to review all deaths and the morbidity and mortality meeting did not include MDT members. Medicines management needed improvement, for example, fridge checks and recording of temperatures to store medication were inconsistent and staff did not document the administering of bolus intravenous sedatives. Only one member of staff signed the prescription chart when the guidelines clearly stated that two were required to sign. There was no effective multidisciplinary team-working, with individual members working independently rather than as a cohesive team. The majority of staff demonstrated a kind and compassionate approach to patient care. However, there were a few occasions when staff worked in silence and provided minimal engagement with patients. This showed a task-orientated care delivery. Delayed discharges were worse than the England average in comparison with other similar sized units, resulting in 53 single sex breaches since June 2015. There was a lack of patient information leaflets in languages other than English. The trust had recognised the need to build a new critical care unit due to lack of facilities within the high dependency unit (HDU) and a business case for a new integrated 18-bedded critical care unit was awaiting approval by the Department of Health. Some governance arrangements were in place in critical care, including a risk register. However, the register did not accurately reflect all risks, for example, the lack of isolation rooms and shower and toilet facilities. The service took part in local audits, but there was no action plan, review date or responsible person to ensure actions were completed to drive improvements in care. Medical and nursing leadership was evident and staff felt supported.

Services for children & young people

Requires improvement

Updated 26 January 2016

There was an open culture of incident reporting but investigations of incidents were not robust and we were not assured lessons were learnt. Staff shortages were evident and the trust had employed overseas nurses to fill vacancies. Cramped conditions in the neonatal unit posed a potential safety risk when the capacity was increased above 15 patients. Bed occupancy on the neonatal unit was 100% and, on occasions, capacity had increased to 21 babies. Plans were in place to expand the unit and work was expected to start within the financial year. Ward 21, the children’s ward, was spacious and well equipped. There was good multidisciplinary team-working and some examples of development of services across the hospital and community services. There were transition clinics in place for children with long-term conditions such as diabetes and asthma. However, we had concerns about the trust’s ability to access specialist child and adolescent mental health services (CAMHS) in a timely way and the management of patients requiring these services in the interim. Without exception, parents and children spoke highly of the dedication and care of staff. Children, parents and carers were involved in care planning. Children’s and young people’s services had strong leadership at unit and ward level but there was no overall vision and strategy for the service. Senior managers and the executive team were not visible or supportive and some governance processes required improvement.

End of life care

Requires improvement

Updated 26 January 2016

Incident reporting was a fixed part of the routine and lessons learnt were shared. DNACPR forms were not completed appropriately, mental capacity assessments (MCA) were not completed for patients deemed not to have capacity and Deprivation of Liberty Safeguarding (DoLS) assessments were delayed due to the unavailability of medics to complete them in a timely manner. End of life care followed national guidance however, there was no documentation to replace the Liverpool care pathway (a national pathway previously in place for care of the dying patient). The trust had a policy for advanced care planning (a structured discussion with patients and their families or carers about their wishes and thoughts for the future) and had started to implement amber care bundles (a systematic approach to manage the

care

of hospital patients who are facing an uncertain recovery and who are at risk of dying in the next one to two months) but these were not used consistently across wards. Patients requiring end-of-life care did not always achieve their preferred place of care. Side rooms were not always available for patients in their last days and hours of life and there were limited facilities to allow relatives to stay. Spiritual needs of patients were not always addressed and anticipatory medicines for the five key symptoms in the dying phase were not consistently prescribed. There was no bereavement service in place and no bereavement lead person. Patients’ pain, nutrition and hydration needs were met. The service took part in local and national audits to assess the effectiveness of end-of-life care. The specialist palliative care team (SPCT) demonstrated good multidisciplinary working and provided a seven-day service. There was strong and committed leadership within the SPCT and the team were well respected in the trust. Patients who were referred to the SPCT were seen quickly and the team provided care to a high percentage of non-cancer patients. End-of-life services at this trust were caring. Patients and relatives spoke highly about the care they received and patients were treated with compassion, supported and involved in their care. Risks had been identified by service managers, however little action was taken to resolve them. For example,

the mortuary fridges were on the mortuary risk register since May 2014 due to repeated breakdowns. This had been reviewed in September 2015, but the only action taken had been to monitor the frequency of the breakdowns. SPCT felt supported by senior management but felt executive team members were not visible.

Outpatients

Requires improvement

Updated 26 January 2016

Incident reporting across OPD and diagnostic services was generally good and managers shared feedback from incidents to staff across both departments. Staff shortages were experienced across OPD and diagnostics, and a specific shortage of radiologists resulted in a reporting backlog currently at two weeks for routine x-rays. Introduction of a new electronic records system had caused major backlogs with the appointment system and caused loss of data. Clinics had been overbooked and appointments had been cancelled by mistake. Staff were kind and caring and involved patients and their carers in decisions about their care. Many devices were overdue for replacement and required regular attendance to maintain their functionality. This included a gamma camera, which regularly broke down and disrupted care delivery and delayed patients’ diagnosis. This had been on the risk register since April 2014 with no firm action plans in place. Local leadership was good in outpatients and imaging. Managers understood their staff and provided an environment where they could develop. OPD and diagnostic staff did not feel supported by senior managers and stated some members of the executive team were poor role models with a ‘bullish’ approach to management and leadership.