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Queen's Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 2 July 2015

Barking, Havering and Redbridge University Hospitals NHS Trust is a large provider of acute services, serving a population of over 750,000 in outer North East London.  Queen’s Hospital is the trust's main acute hospital.

The private finance initiative (PFI), Queen’s Hospital opened in 2006 and brought together the services previously run at Oldchurch and Harold Wood Hospitals. It is the main hospital for people living in Havering, Dagenham and Brentwood. The Accident and emergency (A&E) department has one of the highest number of attendances in the country. The hospital has 786 beds, including a hyper acute stroke unit and delivers nearly 8,000 babies a year.

The hospital predominantly covers three local authorities; Barking & Dagenham which has very high levels of deprivation, Havering which is closer to the national average but has a relatively elderly population by London standards and Brentwood which is a less deprived area.

We inspected the trust in October 2013, and found there were serious failures in the quality of care and concerns that the management could not make the necessary improvements without support. I recommended to the Trust Development Agency (TDA) that the trust be placed in special measures in December 2013. 

Since the inspection a new executive team has been put into place including a new chair, new members of the board, a chief executive, medical director, deputy chief executive, chief operating officer and a director of planning and governance. The executive team has been supported by an improvement director from the TDA.

The trust developed an improvement plan ('unlocking our potential') that has been monitored and contributed by all stakeholders monthly and published. The purpose of this re-inspection was to check on improvements, apply ratings and to make a recommendation on the status of special measures.

Overall, this hospital requires improvement. The end of life care service was rated as good and all other services were rated as requires improvement. Of the five key questions that CQC asks, we rated the trust as good for caring; safe, effective, and well-led require improvement and responsive was inadequate.

Our key findings were as follows:

  • Improvements had been made in a number of services since our last inspection.
  • The culture had significantly improved. It encouraged pride, responsibility candour, openness and honesty. 

Safe

  • There was a backlog of serious incidents and the quality of investigations into serious incidents lacked detail to ensure failings were understood and lessons were learned.
  • There were insufficient systems, processes and practices to keep patients safe. Lessons were not learned and improvements were not made when things went wrong.
  • Recruitment had been on-going however there was not always enough medical and nursing staff to meet the needs of patients.
  • The management of medicines needed improving to ensure safe administration and a reduction in medication errors.
  • The majority of clinical areas were visibly clean and staff adhered to good infection control practices.
  • Most staff groups achieved completing 85% of mandatory training.

Effective

  • Patients needs were assessed and care and treatment was delivered in line with evidenced-based guidance.
  • Patient outcomes were varied.
  • Some staff were not competent in carrying out their roles.
  • Pain relief and nutrition and hydration needs were assessed and met.
  • Consent, Mental Capacity Act 2005 and Deprivation of Liberty Safeguards were well understood by the majority of staff and part of a patients plan of care. 

Caring

  • Some national surveys have found that staff are not always compassionate. In response, staff had focussed on involving patients, keeping them informed and treating patients with dignity and respect.
  • During our inspection we saw and heard of compassionate, kind care and emotional support being provided.

Responsive

  • There was a focus on understanding the needs of local people and the community the trust served.
  • Urgent and emergency, children and young people and outpatients services were not always responsive to meet patients needs.
  • The emergency department was not meeting the national four-hour waiting time target introduced by the Department of Health.  
  • The hospital was persistently failing to meet the national waiting times target. Some patients were experiencing more than 18 weeks from referral to treatment time (RTT).
  • The access and flow of patients throughout the hospital had improved since our last inspection. The introduction of the Elders Receiving Unit (ERU) met patients needs.

Well-led

  • The new executive team was making improvements. The board was visible and engaging with patients and staff.
  • The leadership and culture were open, transparent and focussed on improving services.
  • At an executive level there was a vision and strategy in development to deliver good care and ensure sustainability. At a service level staff were less clear and many told us they were "fire-fighting".
  • The governance structures did not ensure that responsibilities were clear and that quality, performance and risks were understood or managed.

We saw several areas of outstanding practice including:

  • The values of the trust - passion, responsibility, innovative, drive and empowerment (PRIDE) were well known and embedded in the culture of the people working at the trust.
  • The new executive team were visible and engaged.
  • There was lots of involvement from the local community and voluntary organisations. The foyer had lots of people giving information for patients and visitors about services in the local area. For example dementia care, stop smoking and healthy eating.
  • Radiotherapy was one of the top five units in the country.
  • The genitourinary medicine (GUM) clinic had an excellent service with appropriate protocols and processes and support for patients.
  • There had been a number of initiatives to provide a responsive service for general surgery patients. The surgical assessment unit provided a timely service in emergencies and the 'hot clinic' reduced delays for patients.
  • The hospital was a regional centre for upper gastro-intestinal conditions. Outcomes for patients receiving o

    esophago-gastric cancer services were good.

  • There were good outcomes for stroke patients and the stroke service demonstrated good team work.
  • Play specialists had developed a way to distract children awaiting MRI scans which involved joining other children and families on a ‘train journey’ from the outpatient’s clinic down through the hospital corridors, using storytelling and positive reinforcement on the way. This had proved a good distraction for children and reduced their anxiety. We walked with one child and found them to be very engaged in the trail.
  • Consultant paediatricians undertook short notice or ‘HOT clinics’, whereby GPs could make a consultant to consultant referral reach a joint decision on action including if needed early assessment. GP’s reported positively to their commissioners on the success of this system.
  • The consultant led critical care outreach team’s seven day service had improved the outcome for patients through appropriate identification of deterioration and appropriate escalation.
  • The critical care outreach team provided a ‘critical care follow up outpatient clinic’ for patients who required support after leaving hospital. This ensured patients were making progress in the months following their discharge.
  • Neuro-intensive therapy unit encouraged diaries for patients who were staying for longer periods of time in the unit. Patient’s families kept a record of daily activities such as visits, progress and treatments, items of news and the weather. A free newspaper was offered to patients in general critical care to help orientate them.

  • The development of the Elders' Receiving Unit had improved frail, elderly patient care.
  • A dedicated team to support patients living with dementia . Wards could book a dementia trained health care assistant to support one or more patients in a bay on the ward. We were told this was, “A huge improvement” as they were dementia trained. Previously this role was done by a different bank nurse every day.
  • The nurse led oral chemotherapy service was the first in the country.
  • The hospital performed well in the National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme carried out in 2014.
  • The end of life care service was patient focussed and end of life care needs was well understood by the majority of staff from all staff groups.

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

Importantly, the trust must:

  • have clear governance with integrated systems and processes to support staff to provide care and treatment safely.
  • ensure serious incidents are understood, investigated and lessons are learned promptly.
  • review systems for sharing good practice across the divisions and trust wide.
  • ensure compliance with all national guidelines and trust policies for medicines management.
  • improve the service planning and capacity of outpatients by continuing to reduce the 18 week non-admitted backlog of patients as well as ensure no patients waiting for an appointment are coming to harm whilst they are delayed, reduce the did not attend, hospital cancellation and hospital changes rates and improve the 31 day cancer wait target.
  • improve the IT systems so they are up to date and the IT strategy is implemented and supports clinical staff to carry out their duties.
  • ensure all services for neonates, children and young people are responsive to their needs.
  • ensure the radiology is fit for purpose and fulfils its reporting timescales, particularly for CT scans.
  • continuously review staffing levels and act on them at all times of the day.
  • include a dietician as part of the critical care multidisciplinary team in line with the core standards for intensive care guidance.
  • comply with the Duty of Candour legislation.
  • comply with infection control code of practice in respect of hand hygiene audits, training and monitored improvement.
  • ensure locum and agency staff are competent and implement a formal induction process for all locum and agency staff in the relevant areas they care for patients.
  • ensure processes are in place for locum and agency staff in respect of accessing and using IT systems required for their role.
  • ensure patient risk assessments are acted upon.
  • Review the general medicine on-call rota to ensure it meets the needs of patients.
  • meet the Emergency Care standards in the Elder’s Receiving Unit.
  • audit and monitor the patient outcomes from the trust discharge strategies.
  • comply with the National Dementia Strategy.

In addition the trust should:

  • consider increasing the target rates for mandatory training.
  • review the effectiveness of the rota co-ordination for junior doctors
  • review the accessibility of the radiology services and consider a duty radiographer structure.
  • review the service level agreement for accessing therapies to ensure it meets patients needs promptly.
  • continue to improve patient record availability at outpatient clinics.
  • the culture of staff within radiology and the anti-coagulation to ensure they feel part of the organisation.
  • review the environment in outpatients to improve the waiting and reception areas.
  • review the environment and the staffing levels of the day-care surgery unit.
  • review nurse staffing levels and skill mix on surgical wards, particularly out-of-hours.
  • review the availability and presence of consultant obstetricians and speciality registrar level doctors so that labour ward cover is in line with local and national recommendations.
  • consider an increase in establishment in the dementia team and the pain team.
  • review the audit programme in surgery so that internal audits are completed and implemented.
  • review the theatre electronic recording system to ensure accurate data is available.
  • consider ways to increase multidisciplinary team working within critical care.
  • consider ways to make the overnight accommodation for visitor to patients in general intensive care less austere.
  • consider ways to engage patients in providing feedback specifically related to critical care services.
  • continue to increase the availability of medical records.
  • monitor the impact on patients from the reduction in Coronary Care Unit beds.
  • review the processes for medicines to take away on discharge.
  • consider undertaking a needs analysis in respect of those whose first language is not English.
  • improve engagement between junior doctors and management.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 2 July 2015

Effective

Requires improvement

Updated 2 July 2015

Caring

Good

Updated 2 July 2015

Responsive

Inadequate

Updated 2 July 2015

Well-led

Requires improvement

Updated 2 July 2015

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 2 July 2015

There had been significant improvements to the maternity services since our last inspections. Including improvements in the way women felt about the service, leadership and culture, staff engagement, medicines management and access and flow.  

Governance arrangements were, in the main considered to be sufficiently robust. Dashboards were utilised and offered staff a snap-shot of a range of quality indicators and outcomes to ensure that clinical performance could be assessed. Audits programmes were utilised to underpin the existing governance arrangements.

However, the existing governance arrangements did not always encompass the totality of clinical and maternity services provided to women; those working in foetal medicine and the ante-natal screening service were not always included in, nor received timely feedback from incidents which may have impacted on the management of the woman and her unborn baby and so there was the potential for delays in lessons learnt and service improvements being implemented as a result of clinical incidents.

The service did not employ sufficient numbers of consultant obstetricians to ensure that the labour ward was appropriately supported; the existing establishment was not in-line with national and London based recommendations. A business plan had been submitted to the executive team to increase the number of substantively appointed consultant obstetricians.

Evidenced-based care and treatment was delivered. Outcomes for women were similar to other services when compared. Midwives were competent and kept up to date with their mandatory training. Women received their choice of pain relief and were supported to feed their babies in their preferred method.

Women's needs were met through the way services were organised and delivered. The configuration of maternity services at the hospital meant the service was more responsive. However the gynaecology services were not always responsive.

Medical care (including older people’s care)

Requires improvement

Updated 7 March 2017

There had been an improvement in the reporting of incidents and the sharing of lessons from these across the hospital.

Staff that we spoke to were aware of their responsibilities with regards to duty of candour requirements, confirming there was an expectation of openness when care and treatment did not go according to plan.

The dispensing and administration of medication had improved, with prescription charts being used correctly and processes being correctly followed and audited.

Nursing staff demonstrated an awareness of safeguarding procedures and how to recognise if someone was at risk or had been exposed to abuse. They knew how to escalate concerns and were up-to-date with appropriate levels of training.

Patients were assessed for a variety of risks on admission to the wards, using nationally recognised tools. Magnetic symbols were used on patient information boards to identify those patients at particularly high risk.

Staff had awareness of what actions they would take in the event of a major incident, including a fire. Regular drills were held to ensure staff were trained for emergency situations.

The trust had updated all of their local policies since the last inspection, and these were regularly reviewed.

Nursing and medical staff completed a variety of local audits to monitor compliance and drive improvement. Staff told us that these led to meaningful change across the service.

Pain relief, nutrition and hydration needs were assessed appropriately and patients stated that they were not left in pain.

In the National Diabetes Inpatient Audit (NaDIA) 2015, the hospital scored better than the England average for thirteen indicators out of twenty-one indicators.

For all specialties apart from geriatric medicine, the trust scored above the national average for most measures in relation to first year medical doctors in training (2015 National Training Survey).

The majority of staff received annual appraisals on their performance, which identified further training needs and set achievable goals. Staff were satisfied with the quality of the appraisal process. The trust was supporting nurses with the revalidation process.

Multidisciplinary team working was effective. Most staff said they were supported effectively and felt valued and respected.

The majority of staff had completed Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) training.

Patients were cared for in a caring and compassionate manner by staff throughout their stay. Most medical wards performed in line with the national average in the NHS Friends and Family Test (FFT).

All wards had a performance noticeboard on display which showed the most recent FFT scores.

Patients’ privacy and dignity was maintained throughout their hospital stay.

Psychological support for patients was easily accessible and timely. Patients were routinely assessed for anxiety and depression on admission.

The chaplaincy team offered comprehensive spiritual support to all patients, regardless of religious affiliation.

Diagnostic waiting time indicators were met by the trust every month between May and August 2016, meaning over 99% of patients waited less than six weeks for a diagnostic test.

The average length of stay for all elective and all non-elective patients was below the England average.

People living with dementia received tailored care and treatment. Care of the elderly wards had been designed to be dementia friendly and the hospital used the butterfly scheme to help identify those living with dementia who may require extra help. Patients living with dementia were nursed according to a specially designed care pathway and were offered 1:1 nursing care from healthcare assistants with enhanced training. A specialist dementia team and dementia link nurses were available for support and advice.

Support for people with learning disabilities was available. There was a lead nurse available for support and advice. Staff made reasonable adjustments for patients with learning disabilities and there were easy read information leaflets available to explain treatments and support during their stay in hospital. There was a monthly safeguarding and learning disability operations group.

Catering menus offered many options to cater for those with different nutritional requirements.

Posters for communicating with patients with a hearing impairment were displayed on notice boards and deaf awareness training was also offered to staff on all wards.

The trust had developed a clinical vision and strategy and communicated this to staff of all levels, enabling them to feel involved in the development of the service.

The governance structure had been revised to provide a greater level of accountability and oversight of risk.

Most nursing and medical staff thought that their line managers and the senior team were supportive and approachable. The chief executive and divisional leads held regular meetings to facilitate staff engagement.

Quality improvement and research projects took place that drove innovation and improved the patient experience. Regular audits were undertaken, overseen by a committee. The hospital facilitated a number of forums and listening events to engage patients in the development of the service.

Infection prevention and control audits, as well as hand hygiene audit results, showed consistently poor compliance in some wards and departments.

Although most medication was monitored and stored appropriately, we found a pack of pH indicator strips and an anaesthetic cream on two wards which had expired.

Medical staff were failing to meet trust targets for completion of mandatory training, across all topics.

Staff completion rates in basic life support were below the trust target, due to a lack of external training sessions.

Although nursing staffing levels had improved since the last inspection, some wards still had significant vacancy and turnover rates. On these wards, there was a reliance on bank and agency staff to fill vacant shifts.

There was a reliance on locum doctors across the service.

There was a backlog of National Institute for Health and Care Excellence (NICE) guidance that was awaiting confirmation of compliance across the trust.

The standardised relative risk of readmission for all elective procedures was higher than expected in comparison to the England average. This meant that patients were more likely to require unplanned readmission after non-emergency procedures, suggesting that the hospital’s care and discharge arrangements were inappropriate.

For non-elective admissions, the standardised relative risk of readmission was also higher, particularly for clinical oncology.

The hospital performed worse than the previous year in both the Myocardial Ischaemia National Audit Project (MINAP) 2013/14 and the National Heart Failure Audit (2013/14). In the Lung Cancer Audit 2015, the trust was below expected standards for three key indicators relating to process, imaging and nursing measures.

In the 2015 National Training Survey, junior doctors in geriatric medicine reported lower overall satisfaction than the national average, as well as in measures such as availability of clinical supervision out-of-hours and regional teaching. These results had improved in 2016, but some issues still remained.

The pathways for patients with cancer were not always correctly managed. There was poor communication with tertiary centres, which caused delays with patients requiring tertiary treatment/diagnosis at other specialist hospitals. This issue had been added to their risk register in August 2016 and was currently being monitored by senior staff. Actions were being implemented to improve this.

The pathology service was understaffed and unable to provide effective cover out-of-hours.

The trust performed slightly below the national average in the National Cancer Experience Survey 2015.

Patients were not always able to be located on the specialist ward appropriate for their condition, although management of these patients had improved since the previous inspection.

NHS England suspended endoscopy screening invitations to the trust for eight weeks from July 2016. There was a temporary risk of delayed diagnosis of bowel cancer due to inability to provide a full screening service to the local population.

The risk register highlighted that patients were experiencing extended lengths of stay at the hospital, due to delayed discharge from wards.

Patient information leaflets were not standardly available in languages other than English.

The Patient Advice and Liaison Service (PALS) did not always respond to complaints in a timely manner.

The NHS staff survey results were variable, with the trust still scoring below the national average in many measures.

Urgent and emergency services (A&E)

Requires improvement

Updated 7 March 2017

There was poor compliance with hand hygiene in the department and the service performed poorly on hand hygiene audits. We observed staff did not wash their hands between patients or when entering and leaving the department.

While we found improvements in the number of senior medical staff since the last inspection, the department still had a heavy reliance on locum medical staff to help fill vacancies. 

However, the trust highlighted that a number of the locum doctors were regular staff members.

Compliance with intermediate life support was 55% against a trust target of 85% which was very low. Lack of resuscitation training was rated as high on the corporate risk register.

Staff accessed evidence based guidelines and protocols via the trust intranet. We found a number of guidelines, such as ambulatory care guidelines, were out of date and agency staff were unable to log into computers to access clinical guidance.

The trust performed worse than the national average in a number of Royal College of Emergency Medicine (RCEM) audits, including sepsis and septic shock.

Staff understanding of consent, capacity and deprivation of liberty safeguards (DoLS) was mixed. Some staff did not know what we meant when we asked about capacity.

The total time in the emergency department for the trust was higher than the national average. Between May 2015 and April 2016 the trust medium time in minutes was between 160 and 210 minutes, compared to a national average of between 130 and just below 160 minutes.

Patients experienced significant delays in initial assessment and treatment.

At the time of the inspection we were told the vision and strategy for the service was still being developed. Staff had a mixed understanding of plans for the department and we received mixed feedback about what had been communicated to staff.

However, there were examples of the department working well with other teams within and outside the hospital.

Interactions between staff and patients were individual and delivered in a caring and compassionate way. Staff treated patients with dignity and respect in most cases, and kept patients well informed.

Since the last inspection improvements had been made to the department’s clinical governance and risk management processes.  

Surgery

Requires improvement

Updated 2 July 2015

There were examples of learning from incidents but there was not a systematic approach to the reporting and investigation of, and learning from, incidents. The standard of investigation of serious incidents was inconsistent and there was a backlog of investigations.

There was a daily assessment of the acuity and dependency of patients on each of the surgical wards. Staff on a ward with patients with complex needs, however, reported there was limited flexibility in providing additional staff. The number and skills-mix of theatre staffing was suitable.

Patients were observed post-operatively and nursing staff had access to medical and surgical staff when needed. Patients were further protected from the risks of surgery by the focus on improving engagement in the ‘five steps to safer surgery’ in theatres, which was resulting in increased consistency in its use.

There had been number of initiatives to promote adherence to national guidelines. Outcomes for patients were similar to national expectations. Many patients had not been receiving services in a timely way because of a backlog in clinic appointments, and it was not yet known if the delays would affect patient outcomes.

Information technology (IT) was underdeveloped, and there was duplication of electronic and manual patient records. The theatre electronic recording system was not fit for purpose and manual verification was necessary in order to access accurate data.

Patients and relatives we spoke with were happy with the care and treatment they had received, and praised the medical and nursing staff. We observed positive and respectful interactions between patients and staff. We found effective teamwork and a focus on the needs of the patient.

There had been developments in surgical specialties to provide an improved and responsive service to patients. However, many patients had not received a timely response following their GP referral. There were challenges in managing the level of demand. Staff worked hard to address these challenges, but some patients were not receiving a responsive service because of delays in access to theatre or, post-operatively to an appropriate bed.

The clinical governance structures were immature. Work was underway to integrate risk management systems. There were concerns about the sustainability of meeting the current, and future, level of demand on the service.

Intensive/critical care

Requires improvement

Updated 2 July 2015

There were insufficient critical care beds available for the population served by the trust in comparison with other London Trusts. Despite four additional beds being made available, capacity has remained high at an average of 95%. It was estimated that critical care bed shortages affect 100-200 patients each month, with cancellation of planned procedures and significant waits in A&E when waiting for a GICU bed.

Incident reporting was variable and staff were unclear about which issues to report. Learning from reported incidents was not always apparent and staff told us there was little change after raising issues. Patient records, including consent and mental capacity assessments, were completed in most cases but we found some gaps in care plans and inconsistency in prescribing resulting in controlled drugs being administered without a valid legal prescription.

There was limited space. This resulted in small bed areas and no space for dedicated hand wash facilities or waste bins for each patient space. There was limited available storage for equipment. In most cases, equipment was cleaned in line with the infection control policy but some areas of the unit were not cleaned to the highest standard.

There was little multidisciplinary team working evident on GICU. Physiotherapists attended handovers but access to other professionals was on a referral basis. On NITU, structured MDT meetings were held for long term patients. Pastoral support was available across critical care 24 hours a day.

The leadership team had a strong vision for future expansion of critical care services but this had not been shared with the ward staff. Staff had a mixed understanding of the vision for critical care and the reconfiguration had left some uncertainty about the future expansion plans.

Care and treatment was delivered by trained and experienced nursing staff who worked in dedicated teams. There was suitable medical cover provided by specialist consultants and junior doctors.

Policies and protocols we observed were based on national guidance and international guidelines. The critical care units completed local audits and evidence based work when no national guidance was available. The GICU participated in a national database for adult critical care. Patient outcomes and mortality were within expected ranges when compared to similar services. The outreach team supported ward based staff in the early identification of patients at risk of deteriorating and who may require an HDU or ICU bed. CCOT also provided an outpatient clinic to support previous critical care patients in the months after their admission and to ensure they continue to progress.

Services for children & young people

Good

Updated 7 March 2017

There was clear and sustained improvement from our previous inspection. This included the implementation of an audit programme that led to benchmarking of care standards and improvements in practice.

There was improvement in learning from incidents and how these were communicated with staff, including examples of changes in practice and policy as a result of learning.

Improvements had been made in nurse staffing levels, with an increase in recruitment and a reduction of turnover. Although there was still a vacancy rate of 11% in the nurse team, 15 new staff nurses were due to start and an overseas recruitment programme had been successful in attracting qualified nurses to the hospital.

Medical staffing levels were consistently good and medical care was consultant-led, with support provided by other clinicians with appropriate training and specialist knowledge.

Safeguarding procedures were robust and embedded in clinical practice and a system of meetings, staff training, supervision and audits acted as checks and balances to ensure children were protected from avoidable harm.

Services were benchmarked against the guidance and standards of national health organisations as a measure of good practice. This included audits of the care received by patients with diabetes and epilepsy. The outcomes of audits resulted in improvements to the service.

Practice development nurses provided support in staff development including competency assessments, training sessions and one-to-one support. In addition, staff were provided with the opportunity to develop specialist link roles. This represented part of a broader programme to encourage staff training and development.

A weekly multidisciplinary psychosocial meeting ensured patients with complex needs or those who needed community social support were reviewed by a specialist team. Staff used this meeting to plan complex discharges, review safeguarding alerts and ensure care and treatment met individual needs.

Feedback from patients and their parents was consistently good in the trust’s in-house ‘I want great care’ survey. Staff demonstrated kind, compassionate and friendly care in all of our observations and all of the parents we spoke with told us they were happy with the service.

Services were planned to meet the needs of the local population. This included Saturday outpatient clinics, a daily phlebotomy service and a weekly visit from a peripatetic local authority school teacher.

Two dedicated play specialists and two play workers were available in Tropical Bay and Tropical Lagoon wards and children had access to a range of activities, equipment and toys. This included two indoor play areas and a secure outdoor play area attached to Tropical Lagoon. A sensory room and mobile sensory equipment were also provided.

A dedicated paediatric learning disability nurse had introduced support resources for patients, including a children’s hospital passport and visual communication tools. This helped staff to build a relationship with patients who found it challenging to make themselves understood.

Transition services were in place for when a child moved into adult services. This was a structured approach that provided patients with gradually increasing levels of independence followed by the support of both children’s and adult’s nurses as they moved.

Clinical governance structures enabled staff to monitor risks to the service and involve patients and staff in improvements. This was achieved through various means including a patient safety summit, clinical safety and quality meetings, whole unit team meetings and the use of a risk register to track changes in risk status.

Changes to leadership in children’s services had been well received by staff and as part of the trust’s ongoing improvement programme, a new lead nurse was due to join the hospital in January 2017 with a remit of improving communication between hospital services and the care of young people.

Staff were encouraged to provide feedback on their work and hospital policies and this was acted upon. In addition, staff with an interest in research were supported to participate to help inform innovative practice.

However, environmental safety and waste management standards were not always consistent. This was because access to areas used to store sharps bins and waste was sometimes uncontrolled and there was a lack of compliance with fire safety guidance in some areas.

Multidisciplinary staff did not attend nurse and medical handovers or ward rounds and short staffing in therapies teams meant there was inconsistent input from physiotherapy and dietetics and no occupational therapy service. This was evident in the inconsistent standards of nutrition risk assessments in patient records.

Local audits identified documentation of consent to treatment as an area for improvement. Nursing staff were aware of this and handovers included a discussion of which patients had consent forms completed.

End of life care

Good

Updated 2 July 2015

Patient’s do not attempt cardio-pulmonary resuscitation’ (DNA CPR) forms were accurately completed in all cases. Patients had a clear care plan which specified their wishes regarding end of life care, staff were aware of their wishes in regards to the preferred place of death. There was good coordination across all divisions to ensure consistency of approach in end of life care. Staff knew how to report concerns. Staff were respectful and maintained patients’ dignity, there was a person centred culture. Patients told us staff were caring and compassionate. They also said they had appropriate access to pain relief and were happy with the food and drink offered. Specialist palliative care team members were competent and knowledgeable. There were examples of good multidisciplinary team working.

Outpatients

Good

Updated 7 March 2017

There was evidence of significant improvements in outpatient, diagnostic and imaging services. There had been an 88% reduction in the overall backlog of patients waiting over 52 weeks since May 2016.

Staff were aware of how to report incidents and could clearly demonstrate how and when incidents had been reported. Lessons were learnt from incidents and shared across the trust.

The trust had changed their patient records system and introduced the electronic patient record (EPR).

There were appropriate protocols in place for safeguarding vulnerable adults and children. Staff were aware of the requirements of their roles and responsibilities in relation to safeguarding.

Patients’ and staff views were actively sought and there was evidence of improvement and development of staff and services. Staffing levels and skill mix were planned to ensure the delivery of outpatient, diagnostic and imaging services at all times. All new staff completed a corporate and local induction. Staff were competent to perform their roles and took part in benchmarking and accreditation schemes.

Medicines were found to be in date and stored securely in locked cupboards. Staff were able to describe the procedure if a patient became unwell in their department and knew how to locate the major incident policy on the intranet.

All the patients, relatives and carers we spoke with were positive about the way staff treated people. There was a visible person-centred culture in most departments. Patients and relatives told us they were involved in decision making about their care and treatment. People’s individual preferences and needs were reflected in how care was delivered.

Work was in progress to conduct a demand and capacity analysis to enable the service to develop a model whereby the hospital could assess and effectively manage the demands on the service. The hospital was using a range of private providers to assist in clearing the backlog of appointments.

Patients attending outpatients and diagnostic imaging departments received care and treatment that was evidence based. The service was monitoring the care and treatment outcomes of patients who were receiving outsourced care from providers in the private sector.

Outpatients, diagnostic and imaging services had introduced extended clinics seven days a week to clear patient waiting list backlogs.

There was a formal complaints process for people to use. Complaints information, as well as patient experience information was fed into the trust governance processes and trust board with formal reporting mechanisms.

Most local managers demonstrated good leadership within their department. Managers had knowledge of performance in their areas of responsibility and understood the risks and challenges to the service. There was a system of governance and risk management meetings at both departmental and divisional levels.

However , we also found:

Outpatients and diagnostic imaging services were in transition. The strategy for these services was in development. There were a number of new senior managers who had introduced new quality assurance and risk measurement systems. However, these were not fully embedded.

We found alcohol hand sanitising gel dispensers in the ground floor outpatients waiting area and diagnostic and imaging department entrance were empty. Staff in the diagnostic and imaging department did not observe best practice guidance on hand washing or using sanitising gel between patients. The first floor outpatients’ department corridor was being used as a waiting area and this created a risk due to patients waiting in the corridor.

Privacy curtains were not being drawn in the main diagnostic and imaging department, and the emergency room in ophthalmology had bays that did not promote patients’ privacy and dignity. Phlebotomy waiting rooms were full and there appeared to be limited space for the phlebotomy service’s footprint to expand.

The percentage of patients who did not attend (DNA) their appointment was above the England average. Staff told us they were not confident of meeting the standard for patients waiting less than 18 weeks by their target date of March 2017. The trust’s performance for the 62 day cancer waiting time was consistently below the England average. Appointments cancelled by the hospital were also higher than the England average.

Some staff in the diagnostics and imaging team said there was a lack of clarity around their roles and responsibilities.