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The Queen Elizabeth Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 30 July 2015

The Care Quality Commission (CQC) carried out a scheduled focused inspection at The Queen Elizabeth Hospital Kings Lynn between the 9 and 11 June 2015. The trust had been placed into special measures in October 2013 due to serious failings and had undergone a full comprehensive inspection in July 2014 where we rated the trust as requires improvement. We carried out the focused inspection in 2015 to review services that had been previously rated as requires improvement or inadequate and to consider the current status of the trust in relation to special measures. Critical care services had been previously rated as good throughout and therefore were not re-inspected.

The trust had two outstanding warning notices in relation to safeguarding (safe and ethical restraint) and medicines management which were reviewed as part of this inspection. We judged that the trust was now meeting the requirements under the regulations and therefore we have removed the warning notices.

Our key findings were as follows:

  • In all areas staff were kind, caring and compassionate towards patients.
  • Overall the trust leadership is strong and cohesive with a clear vision and strategy, the exceptions to this being some local leadership issues within maternity and end of life services.
  • There is good direction and leadership from the chief executive which resonates down through the leadership team.
  • There is good communication throughout the organisation and the morale and culture of the organisation has improved since our comprehensive inspection in 2014.
  • Increased stability of the board has improved the pace of change at the trust and the confidence in the ability to drive improvements throughout the trust.
  • Significant improvements had been made throughout many specialties including the emergency department, medicine and surgery.
  • Evidence was not consistently recorded in the emergency department due to the combined use of paper and electronic systems.
  • Patient assessments and records were not consistent or updated to reflect changes in a patient’s condition within medicine
  • The total number of cancelled operations remained high however a downward trend was beginning to emerge in the number of cancelled operations alongside an improving performance on patients rebooked within 28 days.
  • The previous concerns regarding privacy and dignity for patients within the breast unit remained in place however the service was due to relocate to new premises which would eradicate the issues.
  • Patient outcomes were not being reviewed due to a lack of clinical outcome information within the maternity service.
  • Nurse staffing was insufficient in both the neonatal and paediatric unit.
  • Complaints and significant events were not being appropriately coded for end of life care so information was not being used to improve services
  • The hospital used a prescription and medication administration record chart for patients which facilitated the safe administration of medicines. Medicines interventions by a pharmacist were recorded on the prescription charts to help guide staff in the safe administration of medicines.
  • Management of medicines had improved across the trust with the exception of some storage concerns within outpatients and storage of intravenous fluids within the emergency department

In summary urgent and emergency care, medical care and surgery which had previously been rated as requires improvement have now been rated as good, alongside critical care and children and young people’s services which had been rated as Good in 2014. Maternity and gynaecology services, end of life care services and outpatients services still require improvement.

We saw several areas of outstanding practice including:

  • The waiting area for children within the emergency department, whilst small, was designed in an outstanding way which responsive to all children who visit the service.
  • The commitment of midwifery staff to develop effective midwifery services for women from the King’s Lynn area. Midwifery staff rotated throughout the service to maintain their knowledge and skills.
  • Relatives and staff told us the paediatric team were a well organised and effective team who provided a good service for the children and families of the Kings Lynn area.

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

Importantly, the trust must:

  • Ensure that medicines are stored securely at all times including those within the outpatients department, and IV fluids in the emergency department.
  • Ensure that resuscitation trolleys are checked in accordance with the trust policy and resuscitation council guidelines.
  • Ensure that an accurate record of each patients care is recorded.
  • Ensure that the staffing is in line with national guidance. Examples include but are not exclusive to: registered children’s nurses in the emergency department, patients requiring non-invasive ventilation, paediatric staff on the children’s ward, endoscopy medical staffing, midwives in maternity and staffing on the neonatal intensive care unit.
  • Ensure that there is a robust governance system to assess monitor and improve the quality of services especially in respect of decontamination of flexible cystoscopies, clinical outcome data within maternity services and the management of ASIs (Appointment Slot Issues) within outpatients.

In addition the trust should:

  • Review the clinical pathways especially for fractured neck of femur between the ED and the orthopaedic service and within the maternity and gynaecology services as highlighted in this report.
  • Ensure a system of clinical leadership developed for all areas of the maternity service with clarity about the role, responsibilities and reporting relationships. A strategic vision should be developed.
  • Should ensure that infection control practices are adhered to at all times in the emergency department.
  • The hospital should develop a joint clinical and managerial response to the review carried out by the royal college of obstetricians which provides a clear strategic vision for the service
  • Ensure staff training for patients living with dementia is effective in practice, and that staff can recognise the need and complete the patient passport where necessary.
  • Ensure the operational management structure is established and known to all staff within each service
  • Access to medical staff on call should be improved across obstetrics and gynaecology to ensure patients have timely access to medical advice
  • Develop the role of the PAU in response to the needs of the population
  • Ensure incidents and complaints relating to end of life care are easily identified and a process is in place to ensure learning is identified and used to influence the development of the service.
  • Ensure the cancellation rates and specialty clinic waiting times in the outpatients department are reviewed and improved.

There is no doubt that leadership of the trust is much stronger than in the past. This has helped to drive very considerable improvements in the quality and safety of patient care in a relatively short period of time. Importantly more of the core services are now rated as ‘good’ than when we inspected in 2014. I am therefore recommending that the trust should now come out of special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 30 July 2015

Effective

Good

Updated 30 July 2015

Caring

Good

Updated 30 July 2015

Responsive

Requires improvement

Updated 30 July 2015

Well-led

Requires improvement

Updated 30 July 2015

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 30 July 2015

Responsive and well led in maternity services required improvement. Many of the issues we identified in maternity services during our last inspection in 2014 report had not improved. Staffing both medical and nursing was a concern, specifically senior medical staffing, and midwifery staffing levels meant staff had to be transferred from other areas of the service to support the central delivery suite (CDS). At times the unit had to close due to insufficient numbers of staff with patients being diverted to other units.

Women were not offered the choice between a home birth or a birth in a midwifery led unit. The Trust had developed plans for a midwifery led unit and aimed to have the service in place by September 2015.

Planned elective caesarean sections were delayed on occasions because of theatre and medical staff availability. Patient assessments were not consistently recorded which meant there was a risk that a woman’s deteriorating condition may not be escalated appropriately. There were privacy and dignity concerns for women experiencing a miscarriage as they were seen in the main emergency department or the surgical assessment unit before being admitted to a surgical ward.

The trust had commissioned a review by the Royal College of Obstetricians to look at the leadership and management of the service. The review highlighted the lack of clinical outcome information and the absence of outcome reviews. There was a lack of clinical ownership for clinics, inpatients and theatre lists. The report had been submitted to the trust in April 2015 but it was not clear what the trust’s plan was for responding to the recommendations.

There had been a change in leadership within the service and a maternity transformation project was in the early stages of development but it was not clear whether consultant medical staff were fully engaged in the work. A strategy for quality improvement across the trust had been developed and strategic objectives had been identified at specialty level however a strategy for maternity services had not been developed.

Medical care

Good

Updated 30 July 2015

Medical care (including older people’s care)

Updated 30 July 2015

Medical services required improvement in safe because records and risk assessments were not consistently completed and updated in response to a patients changing condition. Nurse staffing had improved but did not always meet national guidance in relation to specialist respiratory care. There remained ongoing challenges in relation to medical staffing.

Care and treatment was evidence based. We saw that patient pathways and care bundles were underpinned by national and local guidance. Nutrition and hydration was adequately managed and we saw patients had bottled water within reach during our inspection.

Services were planned to meet the needs of local people. Referral to treatment times met national targets and there had been innovative work to reduce length of stays. Admission to the stroke unit (within four hours) was failing to meet the 90% benchmark and audit data for stroke services showed the trust to be performing poorly but we were told this was a data collection issue.

There was effective discharge planning and services were responsive to people’s needs including named consultants and availability of specialist equipment. Complaints were properly investigated and learning disseminated to staff.

The medicine directorate had a clear vision for the service as well as detailed strategic plans for the development of services. There was a robust ward to board governance structure and senior managers had a clear idea of the risks within the directorate. Staff stated there had been a positive shift in culture under the new leadership, staff felt supported and able to raise concerns.

Urgent and emergency services (A&E)

Good

Updated 30 July 2015

Significant improvements have been made to the urgent and emergency services provided at the Queen Elizabeth Hospital in Kings Lynn since our last inspection 2014. Services were now effective, caring responsive and well led however still required some improvement in safety. Care bundles were in place and the care provided was in line with national guidelines and staff were being developed to become specialised in emergency care. Whilst the service was not always delivering against the four hour target or ambulance handover times they were one of the top performers in the East of England and recovered well from times of peak capacity and demand. The new emergency department for children was very responsive and was built in a way that met the needs of all children including those with complex needs. The board and senior management were engaged in the service and incorporated the ED as part of the trust so the department now felt integrated rather than isolated from other services. The culture of the service had changed significantly since our last inspection with the culture being open and transparent with good working relationships with most services now apparent.

Whilst the safety of the service had improved further improvements were still required. The service was not able to evidence all the care that was provided to patients because the records system, which was a combination of electronic and paper records, was difficult to navigate and disorganised and meant that completion of records was not good. The resuscitation trolleys had not been checked daily in line with trust policy, IV fluids were not securely stored throughout the department and the hand hygiene of medical staff in the department was noted to be poor.

Surgery

Good

Updated 30 July 2015

In 2014 surgical services were rated as good for safe, effective and caring and inadequate for responsiveness and requires improvement for well led.

During the inspection in 2015 we reviewed responsiveness and well led aspects of patient care within surgery. There had been considerable improvements, the responsiveness of the service was good and the service was well led. There had been a dedicated focus on improving the efficiency of the service. Whilst cancelled operation total numbers remained high there was a downward trend emerging and an improving performance on patient booked within 28 days

Identified specialties for further improvement were trauma and orthopaedics and urology. Timely admission for patients with fractured neck of femur was not consistent and there was no robust system to ensure patients were seen in a timely manner for urology. Feltwell ward (Urology) had no ward manager in position with clinical specialists undertaking dual roles. Staff had raised concerns that this situation was not sustainable and that there was limited risk management and oversight which could become detrimental to patient safety. There was no tracking system in place to record the decontamination of flexible cystoscopes used with urology. The on call consultant cover for Endoscopy required review as there was no formal medical consultant on call rota to cover for emergency gastric bleeds.

Intensive/critical care

Good

Updated 19 September 2014

Patients and their families said that staff were attentive and caring. Staff treated people with kindness, dignity, respect, compassion and empathy, while providing good care and evidence-based treatment. Staff worked well as a team, felt supported by their line managers, and were highly motivated to provide patients with the best care possible.

 

The service had a clear vision and credible strategy to deliver high-quality care and promote good outcomes. The service was actively involved in national and local research and audit projects, and demonstrated innovation through involvement in equipment design. The trust engaged with patients and visitors, and acted on their feedback.

 

The trust’s track record on safety was good. There were reliable systems, processes and practices in place to keep people safe and safeguarded from abuse. The trust learned when things went wrong, and improved safety standards as a result. We were concerned that there were no side room facilities for coronary care patients; however, we were reassured that this was already on the service risk register, and that senior managers were taking appropriate action by looking at ways to resolve this issue.

Some outcomes for people using the service were good compared to other services. There were periods in the past year where bed occupancy levels were above the England average. These capacity issues meant that patients were not always cared for in the most appropriate setting for their needs, and elective surgery got cancelled.

Services for children & young people

Good

Updated 30 July 2015

The safety of the children and young people service had improved since our last inspection and despite further improvement required we have rated this service as being good as action had been taken to mitigate the risks we identified. Nurse staffing levels remained an issue and did not comply with national guidelines. The number of beds had been reduced from 23 to 18 on Rudham children’s ward to ensure there was adequate staff for the number of beds. The trust planned to increase the beds flexibly in response to demand and there being sufficient staff available.

There was only one member of staff available to care for children attending the PAU. A business case had been developed to fund additional staff and opening hours but at the time of our inspection this had not been presented to the board and therefore approval and funding were not definite.

End of life care

Requires improvement

Updated 30 July 2015

At our previous inspection in 2014 end of life care services were rated as requiring improvement for responsive and well led. In 2015 we found that whilst there had been some improvements there were specific areas where further improvements were still required. These included the development of a plan for specialist consultant input in the event of continued recruitment difficulties. Complaints and significant events were not being appropriately coded for end of life care so information was not being used to improve services. Other areas where information was not being used to improve services included mortality meetings that were not focusing on the end of life care journey, the trust was not routinely surveying patients or relatives regarding end of life care and audits to evaluate the quality of care provided were not routinely being carried out.

Outpatients

Requires improvement

Updated 30 July 2015

Safety and responsiveness in the outpatient service required improvement. Infection prevention and control had greatly improved since our last inspection in 2014 with a clear audit process in place to ensure that care and treatment was delivered in line with current national standards and legislation.

However there were concerns around the safe storage of medicines which was not consistently in line with trust policy and national guidelines. Patient records were not always stored securely. Access to services was inconsistent with significant delays in some specialties with a large number of patients waiting too long for their appointments. Staff demonstrated a commitment to patient–centred care. Patients were treated with dignity and respect and spoke highly of the staff. The staff were friendly, helpful and approachable. There were good links with other community services.