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Inspection Summary


Overall summary & rating

Good

Updated 2 February 2016

Wexham Park Hospital is a district general hospital serving a population of around 465,000 people with approximately 3,400 staff and around 700 beds. Since October 2014 it has formed part of Frimley Health NHS Foundation Trust (FT), when Frimley Health NHS FT acquired Heatherwood and Wexham Park Hospital. Wexham Park Hospital was the main acute site of the previous trust.

The previous Heatherwood and Wexham Park NHS FT was inspected by CQC in February 2014. The trust was rated as Inadequate. At that time 3 of the 8 core services at Wexham Park were individually rated as inadequate (Medicine, Surgery and Maternity) with a further 3 core services being rated as Requires Improvement (Urgent and Emergency Care, End of Life Care and Outpatients). Critical Care and Children’s and Young People’s services were the only services to be rated as good at that time. Consequently Heatherwood and Wexham Park NHS FT was placed in special measures.

Following the acquisition by Frimley Park special measures were lifted. This was because Frimley Park NHS FT had been rated as Outstanding in September 2014. This was the first trust in England to be rated as Outstanding with 5 of the 8 core services being individually rated as Outstanding and 3 of the 5 key questions being rated as Outstanding including the key question relating to the trust being Well Led. However, following the acquisition a number of requirement notices related to the Wexham Park location were issued in respect of aspects of care that had been of particular concern.

CQC reinspected the Wexham Park location in October 2015, just over a year after the acquisition and formation of Frimley Health NHS FT. This was a comprehensive inspection of the hospital/location to assess the current quality and safety of care. We did not reinspect the Heatherwood location as this had been rated as Good following the inspection in February 2014.

This report demonstrates that remarkable progress has been made since our previous inspection. Indeed this is undoubtedly the most impressive example of improvement that CQC has observed since our new approach to inspection started in September 2013.

All the external stakeholders we spoke with as part of this inspection were very positive about the progress that has been made over the past year. These included Monitor, NHS England, local CCGs, local HealthWatch and the Health Overview and Scrutiny Committee. We heard from staff working at Wexham Park that the culture in the hospital had improved markedly with a greater degree of openness at all levels. Governance had been completely revised, major improvements had been made with regard to handling of complaints and incident reporting. The number of student nurses who have opted to stay at Wexham Park Hospital following qualification has increased substantially over the past year.

Staff were much more positive about Wexham Park as a place to work than previously and a much higher proportion of staff would now recommend the hospital as a place to be treated. Key measures of performance such as the 4 hour A&E target, cancer waiting times targets and referral to treatment targets have improved markedly.

In relation to individual services, both the Urgent & Emergency Care service and Critical Care have now been rated as Outstanding with all other services being rated as Good. Three services were rated as Outstanding for being well led. This, together with the overall leadership at Wexham Park Hospital has resulted in the Well Led key question being rated as Outstanding for this location. This has been achieved by a team of experienced clinical leaders, mainly but not exclusively from Frimley Park, working with Wexham Park Hospital staff to deliver much better care for patients.

Our key findings were as follows:

Safe

There were effective and robust systems and protocols in place to protect patients from harm, and staff contributed positively to an incident-reporting culture that provided opportunities for continual learning. We found learning from incident investigations was disseminated to staff in a timely fashion and they were able to tell us in detail about improvements in practice that had occurred as a result.

A culture of openness was found in the trust. However, there was room for improvement with the policy and application of policy around Duty of Candour.

Staff contributed to the NHS Safety Thermometer programme. Information was collected on a weekly basis and clear, easy-to-read information was displayed for staff, patients and visitors across the hospital site.

The hospital was clean. However, the auditing of cleaning was not being managed in line with best practice guidance.

Medicines management had improved since our last inspection. Regular medicines audits took place; such as audits of the management of controlled drugs and antibiotic prescribing. Actions were taken where issues were identified such as a change in the antibiotic prescribing policy.

Staff attendance at mandatory training had improved since our last inspection. Mandatory training was monitored and all staff expected to attend on an annual basis. Staff told us that there was less ‘e-learning’ since joining with Frimley Heath NHS Trust and the quality of training had improved. They also told us they now received relevant training specific to their role.

Patients were protected from the risks associated with the unsafe use of equipment because staff maintained a reliable and documented programme of checks, including portable appliance testing (PAT).

The trust had identified that improvements in the management of deteriorating patients was a priority. A lead nurse for the management of deteriorating patients had recently been appointed and a work stream was in place to drive improvement across the trust. Actions included ensuring the availability of the resuscitation team, training for newly qualified staff and a review of early warning systems used across the NHS.

At this inspection we found nurse staffing had improved although there were still a number of staff vacancies. Providing safe staffing was an acknowledged risk for the hospital and there were appropriate action plans in place to monitor and address the risk on a daily basis.

Effective

Throughout our inspection we observed patient care carried out in accordance with national guidelines and best practice recommendations.

National clinical audits were completed. Mortality and morbidity trends were monitored monthly through SHIMI (Summary Hospital-level Mortality Indicator) and CRAB (Copeland's Risk Adjusted Barometer) scores. Reviews of mortality and morbidity took place at local, speciality and directorate level within a quality dashboard framework to highlight concerns and actions to resolve issues.

There was a consistent and standardised approach to multidisciplinary meetings and morbidity and mortality meetings trust-wide. The trust told us that attendance was good and learning identified with monthly updates and reports to the Trust’s Quality Committee. The trust had considered the results from national reviews such as the review into mortality and morbidity, and action had been taken to implement the findings and recommendations.

The trust had a range of clinical governance groups who were responsible for reviewing best practice guidelines and changes to legislation. Audits took place against national guidelines with changes to practice shared where appropriate.

The trust identified that not all policies and procedures at Wexham Park Hospital were in date or reflected current best practice. An action plan was in place to prioritise the policies to be updated and the resources required to undertake this. In the meantime the chiefs of service were reviewing policies and procedures to make sure patients were safeguarded. Staff were able to access national and local guidelines through the trust’s intranet, which was readily available to all staff.

Caring

Patients' told us that they were treated with dignity and respect and had their care needs met by caring and compassionate staff. We also received positive feedback from patients who had received care at Wexham Park Hospital over the past few months. This positive feedback was reflected in the Family and Friends feedback and patient survey results.

During our inspection we observed patients being treated in a professional and considerate manner by staff. All staff we were enthusiastic about the service they provided and gave examples of ‘going the extra mile’ to ensure patients received good-quality care that they would want their own families to receive.

Responsive

There had been an improvement in patient flow through all departments of the hospital. The Emergency Department (ED) had re-designed the service to improve patient flow through the department. Wards and departments across all directorates had also made improvements in patient flow through the hospital. Improvements were reflected in data throughout the hospital and the in the ED despite an increased number of people accessing the service the proportion of patients being seen within four hours had improved from 93% to 95% (meeting the national standard) and was being sustained consistently.

At the last inspection, we found complaints were not dealt with in a timely fashion and a backlog had developed. These had now been dealt with and any new complaints were being managed more effectively. Specialist staff were now managing complaints centrally.

We heard of the positive initiatives in place to support patients living with dementia. Dementia Leads were reviewing the care of patients living with dementia across all the trust’s sites against the trust’s Dementia Strategy.

Staff had access to resource folders for patients admitted with special needs such as a learning disability. There was an email ‘in-box’ for staff to raise any queries, referrals or concerns.

Well led

Following the acquisition of Wexham Park Hospital by Frimley Health NHS Foundation Trust in 2014, the trust’s values, vision and strategic plan were reviewed and revised.

At this inspection we spoke with a positive and ambitious workforce. Staff told us that they felt valued and felt able to put excellent patient care and experience at the heart of their work.

Staff across the hospital told us how the trust’s values were now embedded throughout their directorates and were monitored through local work and the appraisal system.

Since the last inspection the executive team had taken action to ensure they were visible on the wards and in the departments and ensured they engaged with front line staff, listening to feedback and acting promptly on any concerns raised. Senior staff walkabouts were undertaken to engage with staff and obtain direct feedback.

The trust implemented a new governance and committee structure with Board level quality assurance informed by new quality committees. Clinical governance was now embedded at local level with structured standard agendas complete with minutes and action logs. The local groups reported to the quality committee and to the Board via the Trust’s Clinical Governance Committee.

Since the last inspection the trust had established a clear set of values together with the expected standards of behaviour expected from all staff employed by the trust. Direct action had been taken to address the behaviour of individuals who did not demonstrate the professional standards of behaviour expected.

The quarterly Family and Friends Test included additional questions regarding values and leadership. The most recent results (April 2014 to September 2015) showed improvements in staff recommending the Trust as a place to work up 17% to 57% and in staff recommending the trust as a place to have treatment up 25% to 69%.

New central directorates had been established to manage complaints, patient safety and quality assurance.

The Family and Friends Test had been expanded to include questions, which gave a baseline on the patient safety culture within the trust.

A Patient Safety Committee had been established at Wexham Park Hospital and met monthly to share outcomes and take pro-active actions taken to improve safety.

We saw several areas of outstanding practice including:

  • Leadership in the trust had inspired a culture shift since our last inspection that was evident across the hospital in all of the staff groups we spoke with. Staff were proud to work in the hospital, and were committed to delivering care that met with the trusts values and vision.
  • The improvements to patient flow through the ED  meant that patients being seen within four hours had improved from 93% to 95% (meeting the national standard) and was being sustained consistently despite an increased number of people accessing the service.
  • In critical care staff showed considerable innovation in meeting the individual needs of patients under exceptional circumstances.
  • Staff engagement throughout outpatients and diagnostic imaging departments was outstanding. All staff were working towards common values, both clinicians, administrative and support staff, at all levels.
  • The achievement of the radiology department to reduce and maintain their waiting times, in view of reduced staffing levels and equipment issues showed an outstanding commitment to improve patient experience.
  • The improved booking centre processes in outpatients and radiology which involved multidisciplinary team members and ensured patients got the right appointment at the right time.
  • Medical records were available more than 99% of the time, over the past 12 months.
  • The roles of the five practice and development midwives were split between 50% clinical work and 50% administration and teaching workshops. One midwife worked every day in the labour ward to provide on the spot guidance and support to midwives.
  • We observed outstanding prompt, appropriate and sensitive care and treatment provided for a woman in the labour ward who had complex and sensitive needs. Staff adhered to the comprehensive care plan they had developed to ensure the woman did not experience unnecessary distress.
  • The hospital had comprehensive guidelines for staff in regards to female genital mutilation (FGM). The trust’s safeguarding children annual report 2014/15 recorded that the identification of FGM had been an area of development for the trust. The trust had a policy of addressing FGM when booking women for maternity care.
  • The hospital had a Deputy Director for Clinical Education who had developed a comprehensive preceptorship programme for newly qualified nurses. This was a structured period of transition for the newly qualified nurses when they started their employment at the hospital. We viewed comments from newly qualified nurses’ evaluation forms from their learning and found these to be consistently positive.

  • The matron on children and young people’s ward had received a trust recognition award for leadership.
  • A senior nurse in critical care had been seconded into a research post for the year before returning to full time clinical duties. They had contributed to the application of the good clinical practice (GCP) guidance of the NIHR Clinical Research Network, which had been used to prepare a research working book for other nurses to use as a benchmark for research processes, from screening to final data analysis. The research was quality assessed by Monitor through site visits to check that research protocols adhered to gold standard clinical and ethical requirements. The lead research nurse had attended a GCP training course and had successfully been certified against national standards including ethics, legislation and application of the Mental Capacity Act (2005).
  • One of the key research projects, VANISH (Vasopressin versus Noradrenaline as Initial therapy in Septic shock), had resulted in specialised one-to-one training packages for staff and an invitation for staff to present their findings at the European Intensive Care Society Conference in 2015. The study had looked at the avoidance of acute kidney injury through the use of steroids with inotropes and the results were presented to staff in the unit on completion of the study. Other projects included a study of the effectiveness of emergency laparotomies and a study of the translocation of bacteria in abdominal sepsis to consider specific antibiotic therapy. The impact on nurses had been very positive and for three consecutive years, research-active staff had attended the European Intensive Care Society Meeting as recognition of their efforts towards establishing an active programme of testing best practice and treatment.

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

  • The cleanliness of the hospital must be audited in line with standards set out in the national specifications for cleanliness in the NHS (NSC). This includes the correct classification of high risk and very high risk areas and the frequency of auditing in these areas. Audit processes should include a re-audit where areas are found to be less than 100% compliant. If the hospital chooses not to audit to NSC standards they must provide evidence of an equally robust auditing programme.
  • Ensure their policy around Candour (DoC) includes incidents resulting in ‘psychological harm’. The provider must also ensure the policy is followed when managing incidents that come under this regulation.
  • Continue with its delivery and the risk priorities associated with the backlog program. Fire risks associated with backlog need to be addressed as a priority.
  • Improve Estates governance and ensure that up to date and approved policies and standard operating procedures (SOP’s) are in place.
  • Ensure that monitoring of weekly medicine stock checks in critical care is consistently applied and must ensure that the system in place to make sure out of date medicine is disposed of is audited.
  • Ensure that resuscitation equipment is always checked according to the trust policy. The auditing system must include a visual check of the expiry dates of batteries.
  • Cleaning and storage materials in critical care must be stored in locked facilities and the lock for the cleaning cupboard must be replaced.
  • Recruit to the three vacant consultant posts in ED. Although consultant cover in ED had improved since our last inspection the department still fell short of national standards.

  • Ensure that all oxygen cylinders have an expiry date displayed, and system in place for staff to check that cylinders are within date.

  • Continue to improve staffing recruitment and retention. 

In addition the trust should:

  • Ensure all staff in outpatients have development opportunities and training as agreed in their personal development plans.
  • Ensure that regular and routine checks are made of the temperature of medication fridges.
  • Consider plans for an additional CT scanner and integrated x-ray within the new emergency centre development planned for 2016.

  • Improve pharmacy support for the emergency department and the decision unit (EDDU) in particular.

  • Explore an effective means of explaining to patients why they have to wait to be treated in the ED.

  • Consider testing the major incident plan which had recently been re-written.

  • Consider the size and organisation of paper health records.

  • Ensure the audit trail of medications delivered to wards is completed including the signature of the staff member receiving the medications on the ward

  • Consider the safety of Aria e prescribing system which is not available to staff in the ED and the patient risks associated with this.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 2 February 2016

Effective

Good

Updated 2 February 2016

Caring

Good

Updated 2 February 2016

Responsive

Good

Updated 2 February 2016

Well-led

Outstanding

Updated 2 February 2016

Checks on specific services

Maternity and gynaecology

Good

Updated 2 February 2016

Overall we rated maternity and gynaecology services at Wexham Park Hospital as 'Good'. This was because:

At our last inspection carried out in February 2014 we found the maternity and gynaecology services to be inadequate. This was because of failure to report incidents and reliance on bank and agency staff to maintain the services. Governance arrangements were poor with inadequate systems for monitoring staff performance and dealing with an inappropriate staff culture. We evidenced that the majority of issues identified in the previous report had been identified and addressed.

Patients were protected from the risk of avoidable harm and, when concerns were identified staff had the knowledge and skills to take appropriate action. Incidents were recorded, investigated and, where necessary, actions were taken to prevent recurrences. Medical, midwifery and nursing staff provided safe care; staffing levels were in line with national averages and were regularly reviewed.

Staff delivered evidence-based care and treatment and followed NHS England and the National Institute for Health and Care Excellence (NICE) national guidelines. There was multidisciplinary working that promoted integral care. The audit programme monitored whether staff followed guidelines and good practice standards. The previously high caesarean section rate was now in line with the national average. Staff were caring and thoughtful, and treated women with respect. Patients’ confidentiality and privacy were protected. All patients and relatives we spoke with gave positive feedback about their care and how staff treated them. Women and their partners felt involved with their care and appropriate explanations were given to them.

Policies and procedures were available on the hospital’s intranet for all staff to access. Appropriate arrangements were in place for patients who could not make informed decisions about their care. Systems were in place to support patients with a learning disability. Complaints were dealt with effectively and improvements made where necessary. There had been a decrease in the number of complaints made since the previous inspection.

There were established local governance arrangements and risk management identified risks to patients and service delivery through the risk reporting process. This is a process for dealing with risks, actions taken to minimise them and recognising those that required reporting to NHS England. Staff demonstrated a strong desire to develop the services and efforts had been made to gain the views of patients and the public. The widespread poor culture found during the previous inspection had almost gone. Senior managers were working towards eliminating poor practices. Many improvements had been made and staff had an open and motivated attitude that had strengthened the culture throughout. Senior managers had developed a plan to sustain the improvements and continue improving the quality of the services.

Medical care (including older people’s care)

Good

Updated 2 February 2016

Overall we rated medical care (including elderly care) at Wexham Park Hospital 'Good' because:

We found medical care at the hospital was evidenced based and adhered to national and best practice guidance. The trust’s policies and guidance were readily available to staff through the trust’s intranet. The care delivered was routinely measured to ensure quality and adherence to national guidance and to improve quality and patient outcomes. The hospital was able to demonstrate that it mostly met national quality indicators.

Patients' medical outcomes were monitored and reviewed through formal national and local audits. Consultants led on patient care and there were arrangements for supporting the delivery of treatment and care through multidisciplinary teams and specialists. We found that training for staff was good with newly qualified staff being well supported. Staff caring for patients had undertaken training relevant to their roles and completed competence assessments to ensure patient safety.

The hospital was working towards offering a full seven-day service. Although some medical patients were treated in other areas of the hospital when beds were not available, systems had been put in place to ensure the consistent quality of their care. Staff responded to individual patient needs for those living with dementia.

The hospital had systems in place to allow patients to feedback their experience of care on the medical wards. The results of the surveys indicated the department provided excellent, compassionate care by friendly and approachable staff. Patients we spoke with during the inspection confirmed that staff were kind, considerate and respectful. Complaints processes had been improved since our last inspection. Complaints were acknowledged, investigated and responded to appropriately.

However, we found some areas had scope for improvement. We considered that existing mitigating strategies and the expertise of clinical staff meant that risks to patients were minimised.

We found some paper health records to be large in size and documentation was hard to locate in these records.

The electronic prescribing system used for patients requiring chemotherapy could not be accessed by staff working in Emergency Department (ED). Although staff had put in measures to mitigate this risk the trust may wish to reassess the risks associated with these measures.

There was an overdependence on agency staff to support permanent staff to ensure safe staffing levels during the delivery of chemotherapy.

Urgent and emergency services (A&E)

Outstanding

Updated 2 February 2016

Overall we rated the emergency service at Wexham Park hospital as 'Outstanding' because:

Since our last inspection in 2014, a new leadership structure had been developed. Consultant medical staff now provided leadership for some aspects of the service, such as clinical safety and patient experience, clinical governance, education and training. There had also been changes to the senior nursing team with the appointment of matrons who now oversaw the quality of the service being provided in the department on a daily basis, ensuring patients were being well cared for. We found these changes had resulted in sustained improvements in the quality of care patients received.

At our last inspection we were concerned that some patients spent a long time in the ED waiting to be seen. The service had difficulty meeting the national quality standard for 95% of patients being seen in less than four hours. At this inspection, we found the trust had met the four hour quality standard since February 2015. Patients were assessed quickly and the service had met the national quality standard for 95% of patients being seen in less than four hours since February 2015.

Consultant medical staff provided effective leadership of the service such as clinical safety and patient experience, clinical governance, education and training.

Senior nurses took responsibility for the quality of the service being provided in the department on a daily basis, ensuring patients were being well cared for.

The service was well co-ordinated through board rounds held four times a day and clinical practice was audited against the standards set by the College of Emergency Medicine (CEM). Guidelines were accessible and followed by staff.

The ED audited clinical practice against the standards set by the College of Emergency Medicine (CEM). The college of emergency medicine is a body which sets national standards for emergency services. The department was also part of the Thames Valley Trauma Network, which aimed to develop high-quality trauma care across all the hospitals in the area. This involves the ED service being reviewed against a set of national quality standards and undergoing a quality review by clinicians providing similar services in other hospitals.

The ED had a system in place for monitoring changes in a patient’s condition. The Detection of Deterioration (EDOD) scoring system was used when patients were first assessed and to monitor their condition during their stay in the ED. Similar systems were in place for both adults and children. Staff monitored each patient’s condition and were able to reduce the risk of unsafe care if they deteriorated.

When we last visited the hospital we found the number of patients waiting between four and 12 hours and longer than 12 hours for admission was much worse than the England average. At this inspection we found that the number of people waiting longer than 12 hours for admission had reduced steadily from 23 in April 2015 to five in June 2015. This reduction may reflect a difference between the seasons with fewer admissions required during the summer months. However, the hospital had also been working on a range of ways of improving the movement of patients from the ED to other departments which had contributed to this reduction.

At our previous inspection we found that patients who were waiting a long time for admission did not have the condition of their skin checked and were not offered anything to eat or drink, both of which are good practice. At this inspection we found staff had improved the care provided and now monitored the condition of patient’s skin and provided food and drink to those waiting.

Staff delivered care based on best practice national guidelines. At our last inspection we found staff had good knowledge about the guidelines and audits in place, but were less clear about how improvements were going to be implemented. At this inspection we found the hospital had strengthened the structures for overseeing the implementation of guidelines and there were effective, clear written information accessible on the computer for all staff working in the department.

Staff spoke positively about the considerable changes that had taken place over the last 12 months and the pace at which this had been achieved. They told us the leadership of the department provided clarity about the vision for the service and senior medical and nursing staff provided support and direction. Consultant medical staff had highly visible leadership responsibilities for improving the quality of service which staff believed was making a positive difference. Staff told us they felt more motivated, supported and energised. They were proud to work in the ED because the leadership and culture had improved.

The ED had worked with other departments to reduce the length of time patients waited to be admitted. Three additional consultants had been appointed, which enabled senior staff to have a greater presence in overseeing the work of the department. Senior nursing staff also spent more time supervising the quality of patient care.

However, we found some areas had scope for improvement. We considered that existing mitigating strategies and the expertise of clinical staff meant that risks to patients were minimised.

The need to improve access to CT scanning. There is currently only one scanner on site. Patients were diverted to another hospital when the CT scanner was out of action. The trust planned to provide a second scanner when the new emergency department is built, however the trust should seek to ensure all patients requiring a CT scan were able to receive one, at the earliest opportunity.

Pharmacy support for the department was limited to 16 hours a week. Patients in emergency department decision unit (EDDU) needed their medicines reviewed before they could return home, the lack of pharmacy support sometimes led to delays in patients being discharged.

A new major incident plan had been developed but not all staff were aware of it. The plan had not yet been rehearsed or tested but a simulation was planned.

Surgery

Good

Updated 2 February 2016

Overall we rated surgical services at Wexham Park Hospital as 'Good'. This was because:

The majority of issues identified in the previous report had been addressed. The trust had action plans for areas of concern that remained, such as staffing. Staff continuously monitored these plans and took appropriate actions in a timely manner.

We found that leadership in all areas had improved. Senior staff were visible, available and supportive to all staff. We foundimprovements throughout the surgical division meant patients experienced safe, effective and appropriate care and treatment that met their individual needs and protected their rights. Staff provided care that was compassionate and all patients were treated with respect and dignity. Patients had their individual risks identified, monitored and managed. There were systems to regularly monitor and review the quality of service provided.

Staff were competent and knowledgeable about their specialties on both the surgical wards and in the theatre units. Mandatory training was generally up to date with further staff training and development available and encouraged.

Outcomes for patients were good and the surgical departments followed national guidelines. The clinical environments, including the equipment available, were clean and well maintained. Departments undertook frequent audits such as environmental, theatre checklist, infection control and hand hygiene. Clinical governance teams analysed the audits and fed the results back to staff. Where risks were identified there were action plans to resolve or manage them in a timely fashion.

Incidents and complaints were investigated and handled in line with trust policy. There were systems to feedback to staff any learning from incidents and complaints.

The trust had recognised that improvements were needed to address the culture within the surgical division and had taken robust action to address the bullying issues. Staff were enthusiastic about the initiatives taken to address the concerns raised at the last inspection and were passionate about the quality of care they delivered.

However, we found some areas had scope for improvement. We considered that existing mitigating strategies and the expertise of clinical staff meant that risks to patients were minimised.

There was a degree of underreporting of incidents. The trust was aware of this issue and had strengthened governance systems and improved training and development in reporting and managing incidents and complaints.

Although we noted an improvement in medicine management, there were still some practices that did not meet current best practice or comply with national guidelines. Issues included insufficient monitoring of temperatures and security.

Intensive/critical care

Outstanding

Updated 2 February 2016

Overall we rated the critical care unit (CCU) at Wexham Park Hospital as 'Outstanding' this was because:

We found significant areas of good practice through our review of clinical audits, staff training, patient notes, clinical outcomes and other indicators such as an exemplary programme to promote independence and person-centred care. Leadership in the unit was coherent, robust and respected by staff. This leadership contributed to a team that continually challenged existing practice to identify new and improved ways of working. Innovation was very much part of the culture in the unit and staff spoke positively about the development opportunities available to them as a result.

Clinical practice was benchmarked against national guidance from organisations such as the National Institute for Health and Care Excellence (NICE), the Royal College of Physicians and the Intensive Care Society (ICS). Such guidance was embedded into the work culture and staff used it to evaluate and improve their practice. For example, an extensive programme of audits was used to update policies and procedures. Staff contributed to national audits compiled by the Intensive Care National Audit and Research Centre (ICNARC). They then used the national audit results alongside local studies to inform the planning of staff study days. The CCU team had access to multidisciplinary specialists who contributed to decision-making and ward rounds to ensure best care for patients. An established critical care outreach team supported patients across the hospital and provided bereavement and emotional support.

The CCU appeared clean, hygienic and well maintained. Staff demonstrated good infection control practices but there was room for improvement in some areas of housekeeping. Equipment was serviced regularly and staff were competent in its use with regular training updates. We found one area of non-compliance with the trust’s medication management policy but there were safeguards in place to ensure that this would not affect patient safety.

A robust incident reporting system was in place that staff confidently used to investigate incidents and errors. There was evidence that learning from investigations had taken place consistently with an effective system in place to ensure all staff were aware of updates to practice. These measures contributed to an environment in which safety was prioritised and patients received individualised care.

We observed numerous instances of significant commitment to personalised care. Staff were competent, passionate and driven, and their efforts included supporting a patient to return home safely to their garden during an extended CCU stay and a programme to promote independence in patients' in the middle of their recovery. Staff were active in clinical research and were supported in this by a senior team of nurses and doctors who understood the need for continued innovation in care and treatment. One relative told us, “I am overwhelmed by the attention of all of the people looking after [relative].”

Staffing levels were reviewed continually using an established nursing acuity tool and there were enough staff to provide care and treatment in accordance with Royal College of Nursing (RCN) guidance. The use of agency staff was consistently below the maximum acceptable level set by the trust and temporary staff underwent stringent induction and background checks before working on the unit. Without exception staff told us they were supported and valued by the senior team and they felt proud to work in the unit.

At our last inspection of Wexham Park Hospital, we found critical care services for responsiveness to require improvement. This was because admissions and discharges were often delayed and patients were sometimes transferred out of hours because of a lack of capacity elsewhere in the hospital. At this inspection we found a significant and sustained improvement in these areas, with an acute commitment from the senior team to improve the unit's responsiveness to patient needs that had been highly successful. In areas we previously found to be good, staff had worked hard to build on their existing practice and explore innovation in patient care and treatment.

Services for children & young people

Good

Updated 2 February 2016

Overall we rated services for children and young people at Wexham Park Hospital 'Good' because:

The treatment and care needs of children and infants were assessed and planned from referral to discharge, taking into account their individual needs. The health and wellbeing of children, young people and infants was monitored using recognised assessment tools. Arrangements were in place for looking after vulnerable children. Staff responded compassionately when children and young people needed help and supported them to meet their basic personal needs as and when required.

Children said that the staff were kind and caring and that they received information that helped them understand what treatment and care they were receiving. Staff helped children and young people and those close to them to cope emotionally with their care and treatment. Comprehensive safeguarding policies and procedures were in place. This included referral pathways for children’s safeguarding. The service had systems in place to ensure that incidents were reported and investigated appropriately.

Children and young people’s services were well-led by a very enthusiastic and committed staff team. The leadership, governance and culture promoted the delivery of high quality child-centred care. There was a clear statement of vision and values, driven by quality and safety, with defined objectives. Staff were aware of best practice guidance for the safe and effective care of children and infants. The service had experienced nursing staff shortages, but were actively recruiting nurses by advertising the vacancies.

End of life care

Good

Updated 2 February 2016

Overall we rated the EOLC services at Wexham Park Hospital as 'Good' this was because:

National guidance determines precisely what end of life care (EOLC) should look like for adults diagnosed with a life limiting condition in all care settings. EOLC is defined as a patient with less than 12 months to live no matter what the diagnosis.

Overall we found the EOLC service provided by Wexham Park Hospital was good. The duty of the inspection was to determine if the hospital had policies, guidelines and training in place to ensure that all staff delivered suitable care and treatment for a patient in the last year of their life. The hospital provided mandatory EOLC training for staff which was attended, a current End of Life Care Policy was evident and a steering group met regularly to ensure that a multidisciplinary approach was maintained.

Staff at Wexham Park Hospital provided focused care for dying and deceased patients and their relatives. Facilities were provided for relatives of patients and patient's cultural, religious and spiritual needs were respected. Further supplies of syringe drivers were purchased to enable a dying patient to receive prompt, adequate and appropriate medication.

The palliative care team had a high level of evidence based specialist knowledge. They worked well with the local hospice and other departments involved in providing EOLC. The team were well thought of throughout the hospital. They supported, trained and gave advice to other staff.

There was evidence that systems were in place for the referral of patients to the palliative care team for assessment and review to ensure patients received appropriate care and support. Through education and acknowledgement of national guidance the number of referrals to the palliative care team had increased since the last inspection and these referrals were seen and acted upon within 24 hours.

At our last inspection of Wexham Park Hospital we found the EOLC service to require improvement. This was because the service relied on the drive and vision of the EOLC team and not through any trust wide strategy. EOLC did not appear to be a priority for the trust.

Since the hospital's acquisition by Frimley Health  NHS Foundation Trust the service had board representation and a dedicated clinical lead. This had resulted in a well led trust wide service that had a clear vision and strategy.

Outpatients

Good

Updated 2 February 2016

Overall we rated the outpatients and diagnostic imaging departments at Wexham Park Hospital as 'Good' this was because:

The hospital consistently met waiting and treatment times in line with national standards. Professional staff treated patients with kindness, dignity and respect. The outpatient and radiology departments followed best practise guidelines and there were regular audits taking place to maintain quality.

The booking centres had processes to ensure patients received appointments within the appropriate timeframe. There were fail-safes in place and medical staff assisted management if required. Medical record management enabled clinicians in outpatients to have access to patients’ records more than 99% of the time. The radiology department had worked to reduce waiting times in the past year.

Staff were competent , professional and treated patients with dignity and respect. The outpatient and diagnostic imaging department appeared clean and well maintained. Staff demonstrated good infection control practices . Equipment was serviced and maintained regularly.

Every member of every team contributed positively to patient care. All staff shared the vision and values of the hospital and good leadership was visible at all levels. Staff worked hard to deliver improvements in their departments. They were proud of their achievements and had the vision and energy to continue with improvements and develop services further.