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Poole Hospital Requires improvement

We are carrying out checks at Poole Hospital using our new way of inspecting services. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 25 May 2016

Poole Hospital is the hospital provided by Poole Hospital NHS Foundation Trust. The trust gained foundation status in 2007 and provides services to a local population of around 500,000 people, although this figure rises significantly between May and September each year, as Dorset is a popular holiday destination.

Poole Hospital has approximately 638 inpatient beds. The hospital provides the following services: urgent and emergency care, medical and older people’s care, surgery, critical care, maternity and gynaecology care, care of the young person, end of life care, and outpatient and diagnostic services. We inspected each of these eight core services at the hospital.

Poole Hospital is the trauma unit for East Dorset and the designated Cancer Centre for Dorset, providing medical and oncology services for the whole of the county, serving an approximate population of 750,000.

The Trust has an unusual case-mix, undertaking a very high proportion of non-elective work, with only 15 acute trusts across the country delivering a higher percentage of non-elective activity. Given the distribution of acute services within east Dorset, the Trust does not provide the usual range of elective services, with orthopaedics, urology, ophthalmology and interventional cardiology being largely provided by the neighbouring trust in Bournemouth.

We inspected this hospital as part of our planned, comprehensive inspection programme. We carried out an announced inspection visit to the hospital from 26-28 January 2016, and additional unannounced inspection visits from 8 -10 February 2016. The inspection team included a Chair, a CQC Head of Hospital Inspection, managers, inspectors, planners and analysts. Doctors, nurses, allied healthcare professionals, senior NHS managers and an ‘expert by experience’ were also part of the team.

We inspected the following core services at Poole 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.

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

Our key findings were as follows:

Are services safe?

  • Staff were encouraged to report incidents. The Trust overall had a culture of safety where incidents were mainly appropriately reported and followed up. Learning was shared and changes made as a result of this to improve the safety of services. However, clinical safety incidents were not consistently reported in the maternity service where midwives told us that they were not always able  to report incidents due to staffing pressures. The children and young person’s service had also not always ensured learning from incidents was embedded in practice.
  • The rate of NRLS reported incidents per 100 admissions is 45% higher than the England average: 12.2 per 100 admissions, against an England average of 8.4 per 100 admissions. There was one never event reported in the trust and 88 serious incidents between August 2014 and July 2015.
  • Patients arriving to the emergency department by ambulance were assessed and treated within national standard times. The trust time to treatment had been better than the England average since October 2013.
  • Staff carried out risk assessments and management plans for patients in a timely way although this was not entirely robust within the care of the elderly wards. Some patient risk assessments and fluid charts on these wards were incomplete.
  • The early warning score system needed to be used more reliably for the escalation of patients whose condition might deteriorate.
  • In some operating theatres, staff did not follow the five steps for surgical safety reliably or accurately in order to minimise the risks to patients.
  • The NHS safety thermometer is a monthly snap shot of the prevalence of avoidable harms, in particular new pressure ulcers, catheter-related urinary tract infections, venous thromboembolism (VTE) and falls. At the trust, from July to September 2015, 97% of care was harm free.
  • Medicines were not consistently managed in some areas across the hospital. Medicines were not always kept safe at the correct temperature, or stored securely in line with current legislation, in the ED, critical care and surgery departments.

  • Staff generally adhered to infection control procedures, but systems and processes for monitoring infection control standards in some services were not always reliable or appropriate to keep people safe. Premises and equipment were not always kept clean and cleaning was not always done in line with current legislation and guidance. Most wards and clinical areas were clean. However, areas in the delivery suite and ANDA were visibly dirty.
  • In the Emergency Department, patients were sometimes at risk of harm as they did not always receive name-bands within an appropriate time; this meant they could have had the wrong treatment or care if they were unable to tell staff their name.
  • Equipment was checked and stored appropriately in most clinical areas. However some of the equipment remained unchecked and unsuitable for immediate use in a post maternity clinic. Within the theatre complex, there was an insufficiently robust system for calling for emergency assistance. There were sufficient amounts of specialist equipment on, for example, the stroke unit, where adaptive cutlery and crockery was used.
  • Staff understood their safeguarding responsibilities towards vulnerable adults and children, but in the ED, there was low take up of training for reception staff.
  • Mandatory training compliance was sometimes below the trust target, and this was often as a result of staffing levels, as staff could not always be released to attend.
  • There were not consistent numbers of staff in terms of staffing levels and skill mix as planned by the trust on medical and older people’s wards and in paediatrics. The Trust had tried to mitigate this risk by having on-going nurse recruitment which was successful in some areas. Midwives said they were regularly short-staffed and were not able to consistently provide one to one care to women during labour.
  • Medical staffing levels were mainly appropriate. There were areas where further recruitment was necessary.
  • In diagnostic imaging, staffing was a concern. There were five radiographer vacancies (25% of the workforce) affecting MR and CT scanning. Staff reported heavy workloads and concerns with the demands on the on-call rotas.
  • Senior clinical staff were aware of the Duty of Candour regulation and the importance of being open and transparent with patients and families.

Are services effective?

  • The treatment and care provided in most services took account of current evidence-based guidelines. However, although evidence-based guidelines for the care and treatment of sepsis patients in the emergency department were followed, although some records had important pre-sepsis checks omitted.
  • Services participated in national and local audits. There was appropriate monitoring of performance against national targets although this needed to improve medical services and for end of life care.
  • Pain relief was given in a timely manner. Pain scores were used as part of the normal observations to record patients’ pain and to ensure that medicines for pain were effective. However, the use of pain tools designed for children were not being used within ED.
  • Patients nutrition and hydration needs were met appropriately. Patients who required intravenous fluids had these prescribed, administered and recorded appropriately.
  • Patients received drinks and food in a timely manner. There were protected mealtimes and staff to support patients who required extra help.
  • Care and treatment for people following a stroke was below the national average and the trust had been slow to implement improvements.
  • Patients were cared for by a multi-disciplinary teams working in a co-ordinated way. Staff reported good working relationships and clear lines of clinical responsibility with specialist teams who were called to review patients.
  • Many services had developed across seven days a week. However, there were reported delays for patients who required mental health assessment out of hours and over the weekends: these services were supplied by a local mental health trust. Stroke inpatients also received significantly less physiotherapy than patients’ nationally.
  • Many staff had access to specific training to ensure they were able to meet the needs of the patients they delivered care to and there were educational opportunities available for all grades of medical and nursing staff.
  • Staff had clinical supervision and appraisal, although appraisal rates for medical staff in the Emergency department were low.
  • Staff had immediate access to patient information. There were robust systems and processes to ensure that information was kept secure, but was available to all clinical staff that needed access to them.
  • Most staff followed consent procedures and had overall good understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards which ensures that decisions are made in patients’ best interests.

Are services caring?

  • All staff made a concerted and sustained effort to ensure that patients, carers and relatives were treated with kindness and support. We observed that staff were consistently kind and compassionate, putting the patient at the centre of care. Receptionists at the front door made a concerted effort to put any visitors or patients at ease, and this level of high support and regard continued throughout the hospital. Staff told us they were encouraged, no matter how busy, to stop to take time to help or reassure anyone in the hospital and this sometimes involved escorting people to unfamiliar areas, rather than just telling them how to get there.
  • However, on the medical and care of the elderly wards, some concerns were expressed about personal care prior to our inspection, and staff understanding of people living with dementia. Further feedback from some patients and relatives on medical wards indicated they did not (always) feel informed or involved in decisions about their care. This inconsistency was also reflected in feedback we received at our listening /public engagement event immediately prior to our inspection.
  • Many other patients, relatives and families told us they were kept informed of plans for on-going care and treatment. They said they had been given personalised support, adapted to their ability to take on complex or emotional information.
  • Patients and their families were supported by staff to reduce anxiety and concern. They felt involved in the decision-making process and had been given clear information about treatment options: they then felt enabled to ask questions of senior medical and nursing staff and be supported to make the decision that was right for them or for their loved one. There was further emotional care from the chaplaincy and bereavement services, and counselling support where required for patients and families.
  • Dignity and respect for patients was maintained at all times during treatment or examination. There were signs on curtains to remind staff and relatives that they needed to ask permission before entering.
  • Overall, the trust consistently scored better than the England average for the Friends and Family test.

Are services responsive?

  • At the time of the inspection the hospital’s services, and those of other acute hospitals in Dorset, were subject to the Dorset Clinical Services Review to redesign and improve quality of care for people in the county.
  • Bed occupancy in the hospital ranged between 86-98%. This was consistently above the England average. It is generally accepted that at 85% level, bed occupancy can start to affect the quality of care provided to patients, and the orderly running of the hospital.
  • Performance in meeting national emergency access target for 95% of patients to be admitted, transferred or discharged from ED within 4 hours had varied through the year. The target was met between May 2015 and August 2015, and again in September 2015. Overall the trust performance had been in line of better than the England average but the average was approximately 91%.
  • The trust reported 72 black breaches between November 2014 and October 2015. This is when ambulances are not able to hand over patients within one hour. A lack of physical capacity in the hospital was the main reported reason for this. The ambulance median time to treatment was around the standard of 60 minutes.
  • The percentage of patients waiting 4 -12 hours in the department for a bed in the hospital had been decreasing since October 2014. However, the trust still remained below the England average.
  • The acute medical admissions ward, rapid assessment consultant evaluation unit (RACE), and medical investigations unit had contributed to the trust’s ability to support older patients and manage the increasing pressures on beds.
  • There were 32 medical outliers at the time of inspection. These patients were appropriately assessed, and there was a robust process to ensure junior and senior medical staff from the relevant speciality reviewed medical outliers regularly.
  • In November 2015, 93% of patients with fractured neck of femur had surgery with 36 hours of being medically fit, 96% within 48 hours and 89% within 24 hours of being medically fit.
  • The trust had identified patient flow through the hospital as a significant concern. In the period October to December 2015, the trust had mixed achievements in meeting the 18 week incomplete pathway for referral to treatment (RTT) standard. National standards detail that 92% of patients should start treatment within 18 weeks of referral for treatment. This data was for patients who were having elective surgical procedures carried out at the hospital. General surgery and trauma and orthopaedic service met this target. However, ENT and oral surgery services did not meet this target, with compliance rates ranging from 87% to 91%.
  • The hospital’s cancellation rate for operations was similar to the England average. The percentage of patients whose operation was cancelled and were not treated within 28 days was lower (better) than the England average.
  • The critical care unit had a low rate of elective surgical operations being cancelled because a critical care bed was not available. However, patients fit for wards were not always transferred out of critical care within 24 hours. Thames-Valley and Wessex networks leads carried out a review in July 2015. The trust was identified as an outlier on the NHSE national dashboard. A further review was planned for January 2016.
  • In critical care, there were 39% of delayed discharges over 12 hours to wards due to lack of bed availability in the rest of the hospital, which meant patients could not be discharged to a ward at the earliest opportunity. This had resulted in patients that should be deemed as mixed sex breaches. There was an action plan in place which included meeting with director of operations to discuss this issue and identify solutions. This would be fed into the Best Practice Organisational Flow Group. The trust had recognised this was an on-going problem and was not meeting the NHS England key performance indicator.
  • Maternity senior managers had not completed an assessment of needs to analyse how the service should be planned and delivered to local people. This meant the managers could not be assured the service provided appropriate care to meet the needs of the local population. The trust wide bed occupancy rates for maternity and gynaecology were higher than the England average and fluctuated between 65% and 83%. For example, from April 2015 to June 2016 the trust reported a bed occupancy rate of 82.8% compared with the England average of just over 60%.
  • Pregnant women had prompt access to maternity services. The national and trust target for booking women for ante natal care by 12 weeks and 6 days gestation was 90%. The hospital consistently exceeded the trust and national targets for April 2015 to September 2015 with an average of 96.2% of women booked within the timeframe.
  • Staff told us the 24 hour paediatric assessment unit improved patient flow. They felt having a facility whereby patients could be observed for longer than four hours allowed the paediatric team to reduce their admission rate to inpatient areas. GPs could refer children to the assessment unit, and following triage children were then admitted or they could return home. There was a system for recording waiting time within the assessment unit.
  • The trust short notice cancellation rate for outpatient appointments was lower (better) than the England average. ‘Did not attend’ rates were also lower (better) than the England average and phone calls and texts were used to remind patients of appointments.
  • The trust was meeting cancer waiting times for patients to see a specialist within 2 weeks and from decision to treat to first definitive treatment within 31 days. The trust also met the waiting times target for from 2 Week Wait referral to first definitive treatment within 62 days (April 2014 to October 2015) in 14 out of the 19 months. Overall performance for this period was 86.6% (target ≥85%).
  • The hospital delivered patient centred end of life assessments in a timely way. The hospital specialist palliative care teams assessed newly referred patients within 24 hours as outlined in the Operational Policy for the Poole Palliative Care Service. The community specialist palliative care nurses assessed patients within three days of the referral.
  • The trust operated a Rapid Discharge Home to Die (RDHD) pathway which served to discharge a dying patient who expressed wanting to die at home within 24 hours.. However, the trust had recognised through audit that patients were not always appropriately highlighted as suitable for fast track Continuing Health Care funding and there was a widespread deficit in knowledge about the CHC funding process.
  • The trust was working in partnership with social care services to effectively support the discharge or patients, particularly patients with complex needs.
  • Clinical staff did not always know how to access information to support them in meeting the needs of patients with a learning disability. There was not a specialist nurse, team or link nurse scheme to support where staff could receive advice and support to enable them to support these patients effectively.
  • There was a clear and comprehensive complaints process. Staff understood how to manage complaints and there was evidence of learning from concerns and complaints. Patient feedback was sought and welcomed across the trust. This feedback was obtained from patient surveys and comment cards. The comments were largely positive.

Are services well led?

  • The trust had published its vision, values, mission statement and objectives, and had taken action to assess and improve staff understanding of these. Staff used “The Poole Approach” (a delivery method of ensuring patients and relatives were at the heart of their care) as a daily strategy for internal and external communications.
  • Staff felt that the executive team provided a strong, visible and supportive presence within the trust. Staff were positive about all the directors in the trust. However, many staff identified that some senior staff who attended bed meetings were viewed as obstructive and unsupportive. They also described difficulties in accessing these staff. For example, some senior nurses described having to wait in a corridor for up to an hour for requests for extra staff to be signed and agreed.
  • The Director of Nursing provides end of life care leadership at trust board level and had good oversight of end of life care issues across both specialist palliative care and the acute medical wards.
  • The trust was part of the on-going Dorset wide clinical service review and the Developing One Dorset vanguard to integrate acute care. Most services had developed interim strategic plans within this context. However, there was not a service-wide strategy or vision for paediatric services or for maternity services. The paediatric service had lacked leadership at a senior nursing level until an acting matron was appointed in January 2016. Senior managers did not consistently demonstrate an understanding of current service risks.
  • Some services had effective clinical governance arrangements to monitor quality, risk and performance, but some local risk registers did not always reflect all of the concerns described to us by staff, or provide sufficient detail on actions being taken. The risk registers did not include key issues such lack of staffing on the paediatric wards or the maternity concerns regarding delays to care and the inability to consistently provide one to one care in labour. A few issues, such as lack of paediatric staffing, had not been formally raised to the executive team.
  • Staff told us they were proud to work for their trust and some had done so for many years.
  • Patient feedback was mainly through surveys and there was less evidence of other engagement opportunities.
  • There was active participation in research and quality improvement projects, and the Outpatient and Diagnostics departments had highlighted much innovative practice.

We saw areas of outstanding practice including:

  • The trust had developed a set of values called "The Poole Approach". The Poole Approach was established in the early 1990s as a philosophy of care. It pledges that staff at Poole Hospital will strive at all times to provide friendly, professional, patient-centred care with dignity and respect for all. These values were well embedded with staff working in the hospital. Staff were consistently kind and compassionate, putting the patient at the centre of care. Receptionists at the front door made a concerted effort to put any visitors or patients at ease, and this level of high support and regard continued throughout the hospital. Staff told us they were encouraged, no matter how busy, to stop to take time to help or reassure anyone in the hospital.
  • The rapid assessment consultant evaluation (RACE) unit provided a high multi-disciplinary quality of care specifically for older patients, over the age of 80. The unit provided a seven day service and was reducing the number of elderly patient admissions and the length of stay for elderly patients that were admitted.
  • For neonates, children and young people receiving palliative care, the trust had designed a special unit called the Gully’s Place Suite. This was a purpose-designed space which provided privacy and dignity for parents and families of babies, children and young people who required palliative and end-of-life care.
  • Nuclear medicine was an exceptionally well led multidisciplinary service, despite an increasing workload, with no breaches of waiting times. Patients interviewed confirmed an outstanding level of care, information provided to patients, and concerns responded to appropriately. The department has also safely introduced two new radio pharmaceuticals based on scientific evidence. Medical physics have developed a new dental phantom; a commercial product.
  • Non-invasive cardiology in CT and MRI imaging have reduced the need for invasive tests on patients with low and medium risk of coronary disease whilst ensuring high risk patients are transferred quickly to the neighbouring NHS hospital. There is excellent team working between cardiology and radiology to provide this service.

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

Importantly, the trust must ensure:

  • ​Action is taken to improve the cleanliness of clinical areas at St. Marys hospital and this is monitored to ensure good infection control practices.
  • Delivery rooms meet with Department of Health regulations
  • A review of the midwifery staffing to ensure sufficient staff are available to provide one to one care in labour.
  • Medicines are stored at the appropriate fridge temperature and are recorded daily.
  • Medicines are stored safely and securely including intravenous fluids. This should be in line with current legislations, trust’s policies and standard operating procedures.
  • Appropriate dates are placed on medicines once opened.
  • Patient group directions are correctly completed and in-date for staff to use.
  • Flooring is accessible for cleaning purposes and  equipment is clean and protected from dust.
  • There is a robust process for calling for emergency assistance in the theatre complex.
  • There is appropriate support for patients with a learning disability including better flagging and referral for patients to specialist
  • Equipment on the wards is in date and stored in a safe manner.
  • The five steps to safer surgery checklist is appropriately completed.
  • Review the emergency theatre arrangements to ensure patient safety and wellbeing is not adversely affected.
  • The staffing levels and skills mix is assessed in all areas and staffing is delivered as planned.
  • Patient records are secure stored so as not to breech patient confidentiality and to prevent unauthorised access, particularly in medicine and maternity departments.
  • All staff participate in mandatory training.
  • Risk register includes all factors that may adversely affect patient safety.
  • Learning from incidents are embedded in practice.
  • Implement a flagging alert system to identify Looked After Children within the trust
  • Ensure secure access arrangements to the paediatric unit are in place out of hours.
  • Implement policies and protocols for children and young people for absconding or for restraint.
  • Patients and members of the public are informed of the safety thermometer results.
  • Where relevant, DNA CPR forms must be endorsed by a consultant grade doctor.
  • There is a clear and measurable action plan which details how they will improve patient outcomes with regard to the organisational targets and key performance indicators as measured in the National Care of the Dying Audit.
  • Service leads review how they use data to improve patient outcomes.
  • An end-of-life care policy is developed that addresses the withdrawal and withholding of life-sustaining treatment for critical care patients.
  • That end of life care patients are given sufficient opportunity to identify their preferred place of care.
  • There are no mixed sex breaches in critical care.

Action the hospital SHOULD take to improve

  • Consultant presence in the delivery suite meets the Royal College of Gynaecologists and Obstetricians guidelines.
  • Clear guidelines for staff regarding the maximum numbers of women accepted the induction of labour.
  • Conduct a needs analysis to ensure the service is meeting the needs of the local population.
  • Develop clear plans to deliver the maternity service strategy.
  • Encourage improved working relationships between senior midwives and their managers.
  • Patients in the department are correctly identified with name bands in a timely way.
  • Review necessary improvements to achieve referral to treatment time targets.
  • There is a robust process used for monitoring requests for agency and bank nurses and whether they are fulfilled or not.
  • A patient is given the opportunity to wash or clean their hands before meals.
  • Staff check equipment regularly, and equipment is maintained or replaced in line with trust policy.
  • Staff complete risk assessments and actions required to reduce risks to a patient, in a timely way.
  • Appropriate arrangements happen with the local mental health trust to improve patient assessment and out of hours support.
  • Staff are offered regular supervisions and appraisals to promote staff development.
  • Training provision should ensure all staff have an accurate understanding of the trust’s deprivation of liberty safeguards policy.
  • Improvements in the care pathways for stroke and heart failure are embedded and sustained.
  • A decrease in the number of bed moves, and patients moved overnight.
  • An increase in the number of complaints responded to within 25 working days.
  • Delayed discharges from CCU should be improved including out of hours discharges from the unit.
  • Resuscitation trolleys in the critical care unit should be tamper-evident.
  • Mandatory training updates for critical care staff should meet trust targets ensuring staff complete updates in essential and core training.
  • Development of a safety checklist for patients undergoing invasive procedures such as insertion of central venous catheters.
  • Access to a follow-up clinic for patients discharged from the critical care unit should be further developed and to include better access for psychological and other support.
  • The hospital improves the access and flow of patients in order to reduce delays from critical care for patients being discharged to wards.
  • There is dedicated dietetics support for patient in critical care.
  • Policies and procedures should be regularly reviewed to provide up to date guidance for staff including withdrawal of treatment policy.
  • Support and develop the paediatric service so it can deliver service-wide strategy and vision.
  • Outpatient clinics are planned to meet the specific needs of children.
  • Play therapists are used by the outpatient department to help children cope during outpatient procedures.
  • Documents within electronic records for patients are filed appropriately once scanned to enable clinicians to find relevant information effectively.
  • Departmental and team meetings are held at an agreed frequency to enable good communication between managers and staff.
  • Seven day service provision in diagnostic imaging is reviewed and monitored to ensure stability of staffing.
  • Managers in diagnostic imaging provide forums for staff engagement.
  • All staff within outpatients and diagnostic imaging are aware of the department strategy.
  • There is an agreed set of performance indicators for end of life care to measure service quality in a timely manner.
  • There is a process for monitoring whether patients who express a wish to die at home are able to do so and that any delays in discharge are recorded and reviewed.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 25 May 2016

Effective

Good

Updated 25 May 2016

Caring

Good

Updated 25 May 2016

Responsive

Requires improvement

Updated 25 May 2016

Well-led

Good

Updated 25 May 2016

Checks on specific services

Maternity and gynaecology

Good

Updated 25 May 2016

Maternity and gynaecology services were rated good for effective, caring, responsive and well led-services However we rated safe as requires improvement.

Clinical safety incidents were not consistently reported. Midwives told us that they were unable to report incidents due to staffing pressures.

Systems and processes for monitoring infection control standards were not always reliable or appropriate to keep people safe. The delivery suite environment was difficult to keep clean. We noted emergency obstetric equipment and equipment required to remedy a tongue tie in the antenatal clinic was dirty and also sterile equipment had expired. There was a risk of a hospital acquired infection if the equipment had been used..

Staffing levels and skill mix were not always planned, implemented and reviewed. Midwives told us the last staffing assessment had taken place in 2012 and this had not been updated to reflect the increase in activity in the service. The midwife to birth ratio did not meet national guidelines. The funded midwife to birth ratio was 1:31. Between April to September 2015 the midwife to birth ratio was 1:32-33. The Royal College of Obstetrics and Gynaecology guidance (Safer Childbirth: Minimum standards for the Organisation and Delivery of Care in Labour, October 2007) states there should on average be a midwife to birth ratio of 1:28. The England average was 1:29. Midwives were unable to consistently provide one to one care for women during labour.

Consultant presence on the ward was 60 hours per week compared to the Royal College of Obstetricians and Gynaecologists good practice recommendation of 98 hours per week. The consultants provided a further 108 hours per week on call.

Overall attendance at mandatory training updates was below the trust’s 95% target. There was a risk that not enough staff had attended updates to ensure they had suitable training to care for women safely.

Midwives followed comprehensive risk assessment processes from the initial booking appointment through to post-natal care. Identified risks were recorded and acted upon across maternity and gynaecology services.

The gynaecology ward participated in the NHS Safety Thermometer. That is a local improvement tool for measuring, monitoring and analysing patient harms and 'harm free' care. The ward conducted monthly audits in respect to patient falls, pressure ulcers, catheters and urinary tract infections. However, information about the audits was not displayed. It is considered to be best practice to display the results of the Safety Thermometer audits to allow staff, patients and their relatives to assess how the ward has performed.

Care and treatment was delivered in line with current legislation and nationally recognised evidence based guidance. Women had access to a variety of methods for pain relief throughout the service. Feedback from women and relatives about their care and treatment was consistently positive. We observed women were treated with kindness, compassion and dignity throughout our visit.

Women had prompt access to gynaecological treatment. For the period January 2015 to December 2015 the hospital exceeded the target of 92% of patients waiting less than 18 weeks for treatment following referral (incomplete pathway).

Translation services were available, and some midwives had undergone further specialist training to support women with additional needs such as learning disabilities and drug and alcohol addictions.

There were comprehensive risk, quality and governance structures and systems to share information and learning. Junior staff across the service described an open culture and felt well supported by their managers.

There was no clear strategy for maternity services. Managers told us they had produced a strategy which had not yet been presented to the board. However, the strategy did not have a plan of how its aims would be met. Senior managers did not consistently demonstrate an understanding of current service risks. The concerns regarding delays to care and the inability to consistently provide one to one care in labour had not been documented on the maternity risk register. Senior midwives described a disconnect between themselves and senior managers. They felt unable to speak freely and said they were not listened to.

There were comprehensive risk, quality and governance structures and systems to share information and learning. Junior staff across the service described an open culture and felt well supported by their managers.

Medical care (including older people’s care)

Good

Updated 25 May 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 ‘required improvement’ for safe.

Processes and procedures were followed to report incidents. Themes from incidents were discussed at ward meetings and staff were able to give examples where practices had changed as a result of incident reporting. Staff adhered to the trust policy of bare below the elbows and the use of personal protective equipment. Nurses and healthcare assistants spoken with had a good knowledge of safeguarding and their responsibilities in raising concerns.

There was sometimes a shortage of staff on the medical and older people’s wards and safer staffing levels were not always met. The trust set a target of 90% compliance for all staff with mandatory training. This target was not achieved, this meant patients were at risk of being cared for and treated by staff who lacked updated knowledge and skills.

A never event occurred in August 2015 involving the wrong site procedure in the dermatology department. Never events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. When we inspected in January 2016, the trust had not yet agreed and implemented a key action; to implement a new dermatology surgical checklist.

Medical care services used specific pathways and protocols for a range of conditions, based on national guidance such as National Institute for Health and Care Excellence (NICE) guidelines. Hospital standardised mortality ratio was within the expected range. The trust performed above the England average on all three measures of the Myocardial Ischemia National Audit Project (MINAP) audit 2013 t0 2014. Outcomes for people who use services were below expectations in relation to heart failure treatment and care following a stroke. The trust had been slow to implement improvements in stroke care, but action plans were in place to drive improvements.

Multidisciplinary working was widespread and effective. There were arrangements for ensuring patients received timely pain relief. Patients at risk of malnutrition or dehydration were risk assessed by appropriately trained and competent staff. Staff made referrals to dieticians or speech and language therapists as required.

Feedback from patients and their relatives was nearly always positive about the way staff treated them. The culture we observed amongst all staff groups was caring and supportive. Staff encouraged patients and relatives to be partners in their care and make decisions. There was some inconsistency in interactions which caused distress.

Medical services were responsive to patients’ needs. The acute medical admissions ward, the rapid assessment consultant evaluation unit (RACE) for patients over 80 years of age, and the medical investigations unit had contributed to the trust’s ability to support older patients and manage the increasing demands for beds. The trust was working with partners to improve the coordination, safety and timely discharge of patients. However, there was a high number of delayed transfers of care. Staff took complaints seriously and responded in line with trust policy.

There was support for vulnerable people, such as people living with dementia and a learning disability. Staff applied the Mental Capacity Act appropriately, and the associated Deprivation of Liberty Safeguards.

Senior staff outlined the vision and strategy for their department. The leadership was strong and supportive, and staff worked well together. Staff felt valued by their immediate line management and said they were comfortable reporting incidents and raising concerns.

Quality and risk was assessed and monitored through audit. The matrons discussed actions to be taken forward at clinical leads meetings and risk meetings held for general medicine and department of medicine for elderly people. Risks, such as workforce, had been taken to the trust board. The senior team met with the executive team quarterly to present quality reports for medical wards and specialties, and department of medicine for the elderly.

Systems were in place to gain patient feedback and use it to improve services. The trust was involved in the ‘After Francis Research Project’, which involved gathering patients’ experiences. Where required, action plans had been developed to improve patient experiences.

Urgent and emergency services (A&E)

Good

Updated 25 May 2016

We rated the service in the emergency department (ED) as good for safe, effective, caring, responsive and well-led. We saw a high standard of care and treatment delivered by competent, caring and compassionate staff.

The department had a culture of safety where incidents were reported. Learning was shared and changes made as a result of this. The department was visibly clean. Staff adhered to infection control procedures. Equipment was available, fit for purpose and clean. However, medicines were not always 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 suitable trained and skilled nurses in the department. There was a lead nurse for the unit, as well as skill mix of emergency nurse practitioners, advanced nurse practitioners and children’s nurses. There were a low number of nursing vacancies within the department. Agency staff were seldom used as staff worked flexibly to provide appropriate skill mix and staffing levels. Recruitment to a small number of vacancies was ongoing.

The safeguarding requirements for children, young people and vulnerable adults were understood, and there were appropriate checks and monitoring in place. However, there was no flagging system to identify patients with a learning disability.

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, the attitude of the staff. Patients and relatives told us they were treated with compassion, dignity and respect, and staff were observed treating them with kindness and courtesy. Patients’ were kept informed of treatment options and were involved in decisions about their care.

The service had some improvement to make in consistently meeting the 4 hour emergency access target of 95%. 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. However, this target was achieved in 5 months in the last year, and was above 90% for a further 5 months.. Patients were however, assessed and treated within standard times. There was good support provided for patients with a mental health condition and patients living with dementia.

The ED was well led by senior nurses and doctors, and the departmental strategy and vision was recognised by staff. 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, quality and performance by senior staff.

Surgery

Good

Updated 25 May 2016

We rated safe as requires improvement because of shortfalls in areas of medicines management, cleaning, storage of patient records, the environment and equipment and surgical checklist compliance. Staff did not consistently complete the ‘Five steps to safer surgery’ check list to minimise risks of patient harm. In theatres, there was no emergency call system for staff to call for assistance in an emergency. Patient records were stored in unsecured areas, presenting a risk of breaching patient confidentiality.

However, staff were encouraged to report incidents and generally received feedback about reported incidents. A recognised acuity tool was used and was continually developed to determine required nurse staffing levels. There were systems in place to assess and respond to patient risks and records were generally legible and comprehensive.

Patients received care and treatment that followed national clinical guidelines and staff used care pathways based on evidence-based research. Staff audited patient treatment and care, and used the findings to improve outcomes for patients. Patients commented positively about the skills of staff, the quality of food and the provision of pain relief. Staff completed training relevant to their roles. Most staff had a good understanding about their responsibilities towards the Mental Capacity Act and associated Deprivation of Liberty Safeguards

There was effective team working within and across different staff groups. This included multi-disciplinary working to provide person centred care. Staff commented that local leadership within the service was good and there were opportunities for personal and professional development.

Patients told us that staff provided care in a kind and compassionate manner and they were involved in decisions about their care. Results of patient feedback, as well as quality and safety data, were displayed for patients and visitors to view on ward areas.

Performance data showed, with the exception of trauma and orthopaedic surgery, the hospital was not achieving the referral to treatment times for 92% of patients to be on a waiting list for less than 18 weeks for surgery. Cancellation rate for operations was similar to the England national average. The percentage of patients whose operation was cancelled and were not treated within 28 days was lower (better) than the England average. Trauma and orthopaedic patients were frequently allocated beds on general surgical and medical wards. The trust mitigated risks to these patients with a trauma and orthopaedic outlier medical team that provided the medical care and treatment for trauma and orthopaedic patients on non-speciality wards.

There was an effective governance structure to review performance and there was evidence of formal reviews of risks, incidents, deaths, complaints and audits.

Intensive/critical care

Requires improvement

Updated 25 May 2016

We rated critical care services as requires improvement overall with elements of innovative and outstanding care. We rated safety and responsiveness as requires improvement. Caring is rated as outstanding, effective and well led are ‘good’.

There were generally safe systems for the management of infection control, medical records and equipment. Infection control procedures were followed for the prevention and control of infection. Equipment in CCU was standardised to minimise the risks of errors as all staff were familiar with these.

However, not all medicines were consistently stored safely and securely which may impact on patients’ health and safety.

Patients received care and treatment in line with national guidance and best practice. There was a process for assessing risks such as pressure ulcers falls and venous thromboembolism (VTE) and care plans were developed to help manage these effectively. However the unit was not fully compliant with two National Institute for Health and Care Excellence (NICE) guidelines which pertained to critical care patients.

There was a holistic and multidisciplinary approach to assessing and planning care and treatment for patients. The CCU was using critical care bundles to ensure compliance with national best practice. Care bundles ensure key aspects in the general care of a critically ill patient were regularly identified and checked.

They used recognised critical care pathway for assessments and treatment of patients. All staff were engaged in monitoring and improving outcomes for patients.

The multi- disciplinary team worked collaboratively and provided care tailored to patients’ individual needs. Patients and their families were involved in their care as much as possible.

There were adequate numbers of skilled nursing and medical staff to provide safe and effective care. The unit was consultant led and medical staffing met the recommended standards and consultants were available at all times for advice and support.

Feedback from patients and their relatives was overwhelmingly positive. Staff ensured patients experienced compassionate care which promoted privacy and dignity. People’s cultural, religious and personal needs were respected. Although support and links for patients with a learning difficulty were not well developed.

The vision and strategy for the service was known by staff. There was monitoring of performance and quality which fed into the trust wide dashboard.

Innovative support for patients, such as the development of patients’ diaries, was encouraged and valued.

There was evidence of strong local leadership in the unit. Leadership, governance and culture within the service were used to drive and improve patients’ care.

Services for children & young people

Requires improvement

Updated 25 May 2016

We rated the services for children and young people as requires improvement for safety and well led We rated effective, caring and responsive as good.

Our key findings are:

There were not sufficient number of nurses on the paediatric ward based on the Royal College of Nursing guidance. There was not a flagging alert system to identify Looked After Children within the trust. The trust did not have policies such as an absconding protocol and a restraint policy for children and young people. Learning from incidents was not always embedded in practice.

However, there was openness and transparency about safety, and continual learning was encouraged. Staff were supported to report incidents, including near misses. There were secure access systems in place, however these were not consistently robust on the paediatric wards at night.

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. A paediatric early warning system was used for early detection of any deterioration in a child’s condition.

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.

Staff were trained and had the skills and knowledge required to undertake their role. Staff undertook 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. However, concerns were raised regarding attendance for training for junior doctors.

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 treated children, young people and their families with compassion, kindness, dignity and respect. 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 good facilities on wards for babies, children and young people and their families. A 24 hour paediatric assessment unit 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. Parents told us how they provided a much needed break sometime for them. Play therapists were not engaged by the outpatient department to help children cope during outpatient procedures. There was a risk children would be distressed in the outpatients clinics, as they were treated with adult patients who were treated at the fracture clinic.

There was not a service-wide strategy and vision for paediatric services. The paediatric service had lacked effective leadership until the recent appointment of an acting new matron. This had an impact on nursing staffing as the lack of nurses was not formally highlighted neither on the risk register nor on the quality reports submitted to the executive team.

Staff at all levels of the organisation were proud to work in this department and were familiar with the Poole approach of being compassionate, open, respectful, accountable and safe.

End of life care

Good

Updated 25 May 2016

End of life care at this hospital was rated as ‘good’. We rated the service as requiring improvement for responsive care. We rated the service good for safe, effective, caring and well-led care.

The trust had taken part in the National Care of the Dying Audit (NCDA) between 2013 - 2014 and at that time had not achieved six out of the seven key organisational targets and scored below the national average for six of the ten clinical key performance indicators. In the 2014 – 2015 NCDA the trust performed better than the national average in 10 out 12 measured indicators of performance. The data could not be directly compared as it did not measure against exactly the same performance indicators. However, it did suggest improvement when compared nationally with other end of life services.

Patients were protected from avoidable harm and abuse. There were reliable systems and processes in place to ensure that safe care was being delivered. Staffing levels were sufficient to provide safe care.

Staff at this hospital delivered person-centred care and treated people with compassion, dignity, kindness and respect. Feedback from patients and relatives was consistently positive.

There was good multidisciplinary working and staff were effectively trained. End of life care formed part of the mandatory training and staff induction programme at this trust. Staff received training in advanced communication which equipped them well when having sensitive discussions with patients and their relatives.

Staff across the trust reported timely access to advice and support from the specialist palliative care team and who were able to meet response times as outlined in the Operational Policy for Poole Palliative Care Service. The end of life care facilitator supported the care of dying patients across the hospital.

Patients were offered a range of pain relief interventions including medication and complementary therapies and pain was assessed, monitored and managed effectively. Staff had good working knowledge of end of life pain medicines to include anticipatory prescribing.

The leadership for end of life care was good. Service leads have produced a five year strategy which includes seven day working for the specialist palliative care team. The overalls aims and vision for end of life care were well understood by staff working in specialist palliative care and the trust had an awareness of the need to embed the strategy with staff working across the whole hospital. The Director of Nursing provided end of life care leadership at trust board level and had good oversight of end of life care issues across both the hospice and the main hospital.

The trust were undertaking regular audits to assess some patient outcomes in specific areas. However, the trust did not have an agreed set of performance indicators in order to measure the quality of the service on a continuous basis. The trust were collecting a variety of patient data at a local and national level but were not effectively using the data to improve patient outcomes.

DNA CPR orders were not always recorded by, or endorsed, by a consultant which meant decisions being made a patients resuscitation status may not have been shared by the consultant in charge of the person’s care.

The trust operated a Rapid Discharge Home to Die (RDHD) pathway which served to discharge patients who were diagnosed as dying with 24-48 hours if they expressed a wish to die at home. Local audit results from March to April 2015 showed that patients were not being discharged within 24 – 48 hours and the trust could not demonstrate improvement following this audit. Patients who were dying and had expressed a wish to die at home were not routinely discharged in a timely way. The trust were not routinely monitoring discharge delays for patients on the RDHD.

Outpatients

Good

Updated 25 May 2016

We found the outpatients and diagnostic departments at Poole Hospital were good for safe, caring, responsive and well-led services.

Staff were encouraged to report incidents and the learning was shared to improve services.

Staff compliance with mandatory training was good in outpatients and diagnostic imaging.

Two radiographers worked overnight and were responsible for plain film X-rays for the main hospital and the emergency department. One on-call radiographer carried out computerised tomography (CT) scans and worked alone if called in. Radiographers reported a heavy workload and raised issues regarding manual handling. Between 10.00pm and 8am, radiology was supported by an overnight, outsourced radiologist service. Staff confirmed that this service worked well and did not compromise patient care.

In diagnostic imaging, staff were confident in reporting ionised radiation medical exposure (IR(ME)R) incidents. Staff followed procedures to report incidents to the radiation protection team and the care quality commission.

The environments were visibly clean and staff followed infection control procedures. There were monthly environmental audits carried out by the infection prevention team. There was appropriate management and storage of medicines. Records were available for clinics using an electronic document management system. Patients were assessed and observations were performed, where appropriate. However, there was not a tool in use to help identify a deteriorating patient.

Nurse staffing levels in the department were appropriate to patient needs, and there were few vacancies (approximately 8% at November 2015). Radiographer staffing levels were five vacancies (25%) across the service. Staff reported this affected the on-call rota and was placing a strain on their workloads. However, there was an ongoing recruitment plan for nurses and radiographers.

There was evidence that care was being provided according to National Institute for Health and Care Excellence (NICE) guidelines.

Staff had access to training and had annual appraisal but did not have formal clinical supervision.

Staff provided compassionate care, and ensured patients and relatives were well supported whilst in the department. Patients were well informed and routinely involved in the planning of their care and treatment. Staff recognised when a patient required extra support to be able to be included in understanding their treatment plans. Patients and relatives we spoke with gave us positive feedback about the department.

There was evidence of service planning to meet people’s needs. For example, with there had been changes to seven day working in radiology, and a re-design of the therapies directorate. National waiting times were consistently met for outpatient appointments, cancer referrals and treatment and diagnostic imaging. There was good support provided for patients with a mental health condition and patients living with dementia.

Patients whose first language was not English had access an interpreter although some staff were not aware of how to access this service. The self-service checking in system, located in outpatients, presented multiple languages on screen. The service received very few complaints that were upheld and, where possible, concerns were resolved locally.

Governance processes to monitor risks and quality required further development in the outpatient and diagnostic department.

Staff were not clear about the overall vision and values of the trust but told us that the departmental patient experience and the provision of high quality care was their main concern. All staff spoke of the ‘Poole Approach’, which is a culture, embedded across the whole trust.

Nursing staff in the outpatient department felt well supported by their immediate line managers. They told us that they felt well supported and valued. However, some staff in diagnostic imaging did not identify a strong leadership presence and did not feel well supported. All staff said they enjoyed working for the trust due to the strong team support from colleagues.

Public and patient engagement occurred through feedback such as surveys and comment cards.