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Barnsley Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 13 January 2016

Barnsley NHS Foundation Trust provides a range of acute hospital health services at Barnsley Hospital. The trust serves the Barnsley area which has an estimated population of 236,000. In total the trust had 359 beds. Barnsley is in the 20% most deprived areas in the country.

We inspected Barnsley NHS Foundation Trust as part of our comprehensive inspection programme. We carried out an announced inspection of hospital between 14 -17 and July 2015. In addition, an unannounced inspection was carried out on 26 July 2015. The purpose of the unannounced inspection was to look at the Emergency department and medical wards at the weekend.

Overall, we rated this trust as requires improvement and we noted some outstanding practice and innovation.

However, improvements were needed to ensure that services were safe and well-led.

Our key findings were as follows:

  • Staffing levels were planned and monitored. There were some shortages; most notably there was a shortage of children’s nurses at the trust.
  • There had been no cases of hospital acquired MRSA since 2008. The rate of hospital acquired C.difficile was within the trust’s trajectory.
  • The adjusted mortality rates had reduced significantly in the trust over the past year. Analysis across a range of indicators showed there was no evidence of risk regarding mortality.
  • The trust performed mostly above the 95% standard for percentage of patients waiting to be seen within four hours since May 2014, with the exception of December 2014 and May 2015.
  • Assessments of patient’s nutritional needs were recorded. Across the trust, we found patients were supported to eat and drink.
  • Following transfer to a new IT appointment system, the trust had discovered a backlog of outpatients who potentially needed a follow-up appointment. Work was underway to clinically validate the list and ensure all relevant patients were offered a review appointment by 31 January 2016.
  • Leadership at the trust had been subject to significant change over the last 20 months. Staff spoke positively about the trust leadership.

We saw several areas of outstanding practice including:

  • The uro-gynaecology nurse specialist had introduced “percutaneous tibial nerve stimulation for overactive bladders” following a successful business case to the trust. This improved symptoms for patients and made cost savings for the trust. Audit data from 2014 demonstrated improved outcomes for women.
  • The dermatology service described a tele-dermatology project they were providing in conjunction with the local Clinical Commissioning Group whereby some GP practices could send in pictures of patient problems and receive an electronic treatment plan within three days. The service had also recently been approved to provide private cosmetic procedures (such as Botox) and was seeking to use these as a revenue generator for the trust.
  • We saw that staff in the breast clinic had developed a simple tool for patients to remind them to take their medication. The staff had developed a card, covered in a picture of brightly coloured tablets that could be hung from a door handle at their home such as a kitchen cupboard. This had been shared at an internal nursing conference and staff in other areas of the trust were using for their patients.
  • A midwife had won the prestigious 2015 Royal College of Midwifery’s (RCM) Philips AVENT National Award for Innovation in Midwifery. They created a secure staff social networking site called ‘Ward-book’ which was used by midwifery staff at the hospital to communicate important messages across the department. Each week the Head of Midwifery wrote a departmental update which gave staff the opportunity to feedback in real-time and this was posted on the system. The Ward-book was used as a virtual notice board. It helped communication between managers and staff and helped improve the outcomes for patient care.
  • Pharmacy robots had been introduced at the trust in July 2014. This has reduced errors and increased staff capacity.

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

Importantly, the trust must:

  • ensure all patients attending the emergency department, have an initial assessment undertaken by a suitably qualified healthcare professional in accordance with national guidance.
  • ensure that children attending the hospital are cared for by nursing staff who have the qualifications, competence, skill and experience to do so safely.
  • ensure oxygen is prescribed in line with national guidance.
  • ensure that medicines reconciliation is completed in 24hrs and meets local and NICE guidance.
  • ensure compliance with the five steps for safer surgery.
  • ensure suitable patients are offered laparoscopic colorectal surgery in accordance with NICE guidance.
  • address the backlog of outpatient follow-ups.

In addition the trust should:

  • review processes to enable staff to receive mandatory training on a regular basis.
  • confirm guidance to staff, based on best practice, as to the recording of verbal consent by patients in the clinical record.
  • review sign language interpretation availability for patients whose main or only means of communication is British Sign Language (BSL).
  • monitor the consistent use of the sepsis screening tool and timely completion of the interventions on the sepsis pathway.
  • review the out of hours medical staffing provision within medicine.
  • work with local services to reduce the number of medical outliers and medically fit patients in hospital to improve patient flow and reduce bed occupancy.
  • work with medical consultants to implement a robust system of timely mortality review.
  • work with ward staff to improve the understanding of the specific requirements associate with Duty of Candour.
  • undertake regular infection prevention and control ward audits.
  • improve the quality of medical record keeping and include this in the audit programme.
  • monitor and reduce the number of out of hours bed moves.
  • undertake a review of historic serious incidents and recommendations made to ensure learning is carried forward in to current areas of clinical practice
  • provide appropriate access to IT systems for appropriate staff, including temporary staff.
  • ensure medicines are stored at the correct temperature.
  • review medical note taking including prescription documentation.
  • review infection prevention and control practices within surgical areas including clinical stock rotation, environmental cleanliness and the changing rooms within main theatres environment
  • ensure there are sufficient numbers of staff with suitable qualifications, competence, skill and experience to provide care to patients within trauma and orthopaedics.
  • continue to take action to ensure the urology service meets patient need.
  • improve compliance with national emergency laparotomy audit.
  • undertake a full assessment of the area currently used for lucentis and its environmental and engineering suitability for service provision in the current facility.
  • consider the amount of sessions for ward rounds for surgeons.
  • consider undertaking a review of waiting facilities within theatre reception area.

  • store records in line with data protection requirements.
  • meet the government targets for antenatal screening between 10 and 12 weeks gestation relating to foetal abnormality.

  • consider monitoring of waiting times in the CAU.
  • support incident reporting and ensure timely response to investigations and clear lines of communication to staff in order that lessons are learnt in a transparent manner.
  • consider improving the environment in the POPD waiting area.
  • review the safe storage of patient records in the children’s outpatients department.

  • take action so advanced care planning and preferred place of care are considered by the MDT in a timely way in order that patients wishes at end of life can be met.

  • quality assure radiology reports generated by voice recognition.
  • take action to improve cancellation and DNA rates.
  • take action regarding the visibility of patient information on their electronic check in screens.
  • review the seating arrangements in the phlebotomy department and main outpatients’ areas to provide seating for patients with differing needs.
  • review the facilities and waiting areas for inpatients to improve the maintenance of privacy and dignity.
  • review processes for reporting of x-ray films and CT scans to ensure acceptable and consistent reporting times are achieved.
  • include the quality of record keeping in medical records and the use of WHO checklists in its audit programme.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 13 January 2016

Effective

Good

Updated 13 January 2016

Caring

Good

Updated 13 January 2016

Responsive

Good

Updated 13 January 2016

Well-led

Requires improvement

Updated 13 January 2016

Checks on specific services

Maternity and gynaecology

Good

Updated 13 January 2016

Staff were encouraged to report incidents and systems were in place following investigation to help rapidly disseminate learning. Both nursing and medical staffing levels were in line with national guidelines. The service was 90% compliant for mandatory training overall and this was in line with the trust target. We saw evidence of how they had recently addressed non- compliance in safeguarding supervision training, and although there were some areas which did not meet the trust target, they had identified further training days to address these shortfalls. We found an unlocked cupboard of diaries which contained confidential information. This was brought to the attention of the trust who acted immediately and addressed the situation.

Women received care according to professional best practice clinical guidelines. The unit provided individualised care to people using the service and they were treated with privacy, dignity and respect. The trust had a specialist midwives in bereavement who provided support, compassion and care for women and their families in time of bereavement.

The trust dashboard showed they were not always meeting their key performance indicators (KPI’s) for antenatal bookings for women to be seen before 10 and 12 weeks of pregnancy. The trust target was 90% and the information showed, between April 2014 and February 2015, the bookings for women to be seen before 10 weeks ranged between 53.3% and 81.2%. Women booking before 12 weeks ranged between 72.4% and 96.9%. Trust managers had identified that there were data extraction issues following implementation of the new maternity information system. A manual audit showed the target was met for the 12 week bookings, but not the 10 week antenatal bookings. An action plan had been written to address the issues which included a review and completion dates. A supervisor of midwives was available for all women using the service and feedback/debriefing was offered to patients who had not followed their choice of care pathway.

The service was managed by a cohesive team who understood the challenges of providing good, quality care. They were aware of their shortfalls and had taken steps to address them. Staff were encouraged to drive service improvement and used creative and innovative ways to try to ensure they met the needs of women who used the service and the organisation.

Medical care (including older people’s care)

Good

Updated 13 January 2016

We rated this service as good.

We saw evidence of learning from incidents locally and across CBU’s. Wards were clean and tidy and equipment was available for staff to use and checked regularly. People’s care and treatment was planned and delivered in line with current evidence based guidance and there was participation in local and national audits.

Feedback from patients, those close to them and stakeholders was positive about the way staff treated people.

There was a clear statement of vision and values driven by quality and safety. Staff in all areas understood the vision and values. The levels of governance within the CBU functioned effectively and financial pressures were managed so that they did not compromise quality of care. The management team promoted staff empowerment and a culture where the benefit of raising concerns was valued. Improvement and innovation was supported.

Services were planned to meet the needs of local people. There was an openness and transparency in how complaints are dealt with. Informal complaints were logged and reported in the CBU. The bed occupancy was higher than the national average. There were a high number of medical outliers in July 2015 and the trust opened additional medical bed capacity during times of operational pressure.

We found evidence of incomplete action plans of serious incident investigations. We saw breaches in infection control practices during our inspection and there was concern about medicines management. We found that some staff groups were unable to access patients’ full clinical record. There was a clinical risk that patients were not fully assessed and treated for sepsis.

Some concerns had been raised prior to our inspection regarding the care of patients with complex needs.

Urgent and emergency services (A&E)

Requires improvement

Updated 13 January 2016

The emergency department operated a triage system to assess patients arriving by ambulance or ‘majors’. However, they did not have a system for triage or initial assessment of patients who did not arrive by ambulance. There were insufficient numbers of children’s nurses to have a children’s nurse on each shift. The trust had not met the 90% target of all staff in the emergency department having received mandatory training, including safeguarding training, in the last year. There was a high usage of bank and agency staff.

The management team had not identified the lack of initial clinical assessment or triage as a risk. Limited audits of nursing care were undertaken. There was a system of governance, risk management and quality measurement, aligned with a senior management leadership structure but this had not identified some key risks. There was limited evidence of engagement with the public.

The nursing leadership in the emergency department and clinical decisions unit was in a period of change. Staff reported an open culture and there were regular meetings. We found that pain scores were not being recorded. There were discrepancies between staff as to whether verbal consent should be recorded in the medical record. Although there was a good system in place for the training of medical staff there was no evidence of regular clinical supervision for trained nursing staff that were not new to the department. The service followed best practice guidelines in the care and treatment of patients and took part in patient outcome audits and reviews. There was good evidence of multidisciplinary working and an effective seven day service.

Patients were cared for in a compassionate and understanding manner and treated with respect. Ninety percent of the patients who completed the “friends and family” test between January and March 2015 recommended the emergency department. The majority of patients we spoke with told us that communication was good and that they were offered emotional support.

The trust performed mostly above the 95% standard for percentage of patients waiting to be seen within four hours since May 2014, with the exception of December 2014 and May 2015. This was an improvement in the previous years. They were also better than other emergency departments with regard to ambulance handover times. The service met people’s individual needs except in the case of the provision of professional sign language support for patients who were profoundly deaf who could not communicate in spoken English.

Surgery

Requires improvement

Updated 13 January 2016

Significant concerns were highlighted with the trust in relation to suitable patients with colorectal cancer not being offered laparoscopic colorectal surgery; the trust was the only trust in the country to report 0% in the data tables for offering laparoscopic surgery to suitable patients. Non-compliance with national emergency laparotomy audit data was also noted and a lack in trained laparoscopic competent medical staff.

There was learning from incidents; however, this wasn’t fully embedded in all investigations. There were concerns about clinical stock being out of date on one ward and drug fridge temperatures were inaccurately recorded on three ward areas. Interim measures were in place due to the condition of some drugs fridges within theatres which were awaiting replacement.

We found evidence of junior and locum medical staff sharing passwords for IT systems. Immediate action was taken to address this. Gaps were found in medical records.

Mandatory training rates were low for surgical medical staff. The World Health Organisation (WHO) five steps for safer surgery process was inconsistently used at Barnsley hospital. Nurse staffing levels in trauma and orthopaedics were lower than the established safe levels; however, staff were taking appropriate action to recruit to vacant posts.

Staffing on the escalation ward during the night raised concerns because of the mixed competence of staff from different areas in the trust.

During the inspection there was no clinical lead for surgery in post. Recommendations made in serious incident reports were reviewed in historic serious incidents these had not been consistently acted upon and the similar incidents had occurred since. The lack of offering laparoscopic colorectal surgery to patients at Barnsley hospital had not been addressed. Public engagement was limited.

Departmental policies were based on nationally recognised best practice guidance. Enhanced recovery pathways for patients undergoing hip and knee replacement procedures were implemented to improve the patient experience and outcomes. Protected mealtimes and a duty “snack monitor” had been implemented to improve nutrition on wards and departments.

Throughout the inspection we saw positive, kind and caring interactions on the wards between patients and staff. Patients spoke positively about the standards of care they had received.

There was access to a specialised dementia nurse and learning disability nurse. We saw examples where lessons had been learned and actions taken following complaints.

There were effective systems in place to deep clean equipment regularly. The wards and departments had systems in place to safeguard vulnerable adults. Mortality rates within orthopaedics were below the national average.

Surgical elective and non-elective length of stay data was better in the trust than the England average. The number of patients not treated within 28 days was good and only one patient since 2011 had not been treated within 28 days from cancellation day. During the reporting period April 2013 to November 2014, the trust performed better than the standard and the England average for the 18 weeks from referral to treatment target. The percentage of patients (with all cancers) waiting less than 31 days and 62 days from urgent GP referral to first definitive treatment was better than the England averages. Breaches of national waiting time targets including the cancer waits were occurring in some specialties. Increases in non-elective surgical activity and medical admissions have led to an increasing number of medical and surgical outliers.

A clear vision and strategy for surgical services and clear governance structures within the business units was apparent. Nursing leadership at ward level was good, with positive interactions between staff, ward managers and matrons noted. Some good areas of innovation, improvement and sustainability were noted.

Intensive/critical care

Good

Updated 13 January 2016

We rated the care delivered by the intensive therapy (ITU) and the surgical high dependency (SHDU) units as good.

Staff used the trust policies and procedures when reporting incidents. Details of incidents and the lessons learnt were shared among staff and action was taken to prevent or minimise the occurrence of similar incidents. There was a multidisciplinary team (MDT) approach to reviews of incidents, morbidity and mortality. Staff attended organisational inductions, mandatory training which included safeguarding and infection prevention and control.

The Safety Thermometer results between April and June 2015 showed the unit had performed better than the nationally expected targets. The units had sufficient supplies of equipment and cleaning products to maintain safety. Equipment was cleaned in line with the department of health infection control policy. Staff we spoke with were aware of the major incident policy and their role in managing it.

An outreach team made up of a consultant, a nurse, a physiotherapist and a healthcare assistant supported patients when they were transferred from ITU or SHDU to wards. They also assessed deteriorating patients within the hospital and decided whether patients would be appropriately cared for in either SHDU or ITU.An outreach team supported patients when they were transferred from ITU or SHDU to wards. They also assessed deteriorating patients within the hospital and decided whether patients would be appropriately cared for in either SHDU or ITU. A multidisciplinary team approach meant care was delivered in a more co-ordinated and consistent way which had a positive impact on patient progress and the length of time spent on the unit.

The computerised system used by nursing staff was seen as onerous, time consuming and unreliable. Access to information for bank and agency professionals was available after appropriate training. Management told us that there was a system in place to provide agency nurses with their own unique access login. However to maintain safety this automatically expired after 30 days.There was good understanding of the Mental Capacity Act and its application.

Patients and relatives we spoke with told us that they would recommend this service to others. We observed examples of good compassionate care and treatment practices by staff. Staff had implemented the use of ‘patient’s diaries’ on ITU. Relatives had access to a bereavement service and enquiries about organ donation were attended to by a specialist nurse.

The ITU and SHDU services worked collaboratively with the surrounding NHS providers to meet the needs of the local population. Patients discharged from ITU and SHDU had access to a follow-up clinic. Staff were proud to work at the Barnsley hospital and they understood the priorities.

There was a clear structure within the unit for doctors, nurses and the multidisciplinary staff. They demonstrated their roles and their specific responsibilities during our inspection so that patients received consistent care.

We found that 24 hour intensivist cover was not provided for ITU in accordance with Core Standards for Intensive Care Units guidance (2013), however plans were in place to address this. On six occasions over two weeks the lead nurse and the clinical educator were counted in the numbers to ensure safe staffing levels. The fill rate of shifts for registered nurses was 80-85% during days and 93 -97% at nights over the previous three months.

Services for children & young people

Requires improvement

Updated 13 January 2016

Overall we rated the service as requires improvement. We rated safety and well-led as requiring improvement. We rated effectiveness, responsive and caring as good.

There were significant gaps in medical and nursing staffing which had led to high usage of locum staff and the regular movement of nursing staff across all the areas attended by children and young people to attempt to meet the service needs. In the POPD, the CCN team records were not stored in secure cupboards which presented an information governance risk.

The service had a system for reporting incidents; however, there did not appear to be a culture of reporting incidents and complaints. Data provided by the trust identified incidents which had passed the date by which they should have been investigated and reported on. Senior management staff we spoke with told us there had been challenges feeding back from incident reporting and were looking at improving feedback mechanisms.

There were outstanding follow up outpatient appointments following a change to record keeping. These records were being assessed for follow up appointments. Waiting times on the CAU were long for some children.

There was a board level Executive Director for Children’s Services, as required by the National Service Framework for Children.

The service had processes in place to implement NICE guidelines and other best practice guidelines, and the service participated in national audits. The service implemented local audits and had developed a local safety thermometer tool for paediatric services. The service had care pathways in place, but some policies were out of date. There was evidence of multidisciplinary working across all the children’s services; children and families were provided with timely and appropriate advice.

The children’s services worked together to promote early discharge and reduce readmissions. The children’s service had responded to feedback with a ‘you said – we did’ project which is displayed on the wards. The play team work across the trust providing support to children in any department of the hospital, the sensory equipment was mobile which enabled them to also meet the needs of children with special needs. There was a pathway to promote a safe transition to adult services for children.

Throughout our inspection we saw children and their families were treated with dignity, respect and compassion. We heard staff using language that was appropriate to children’s age and level of understanding. All the children and their families we spoke with were happy with the care and support provided by the staff. Parents felt confident when leaving their child on the wards that their child would be safe and well cared for.

End of life care

Good

Updated 13 January 2016

We rated end of life care services at Barnsley hospital as good. There were some outstanding examples of compassionate care. There were areas where there was potential for improvement and these had been identified by the trust. We saw evidence that work was in progress to further improve the service.

The end of life service was led by committed leaders. There was good visibility of senior staff and end of life care was high on the agenda of the trust. The trust’s end of life steering group, which was responsible for providing clinical leadership and implementation of the service, told us they provided assurance to the trust. Procedures had been developed to support a smooth transition of care from hospital to the community. There were strong links with community teams.

There had been 550 referrals to the specialist palliative care team from April 2014 to March 2015. This had increased from 480 referrals the year before. We saw 100% of the referrals made to the team from April to June 2015 were seen within 24 hours. Most of the referrals (85%) were for cancer related diagnosis and the palliative care team were aiming to address the imbalance by working with other services to reach end stage heart and respiratory failure patients. The AMBER care bundle had been implemented using a rolling programme across medical wards at Barnsley hospital since May 2013. There was a dedicated AMBER care pathway facilitator. The AMBER care bundle is an approach used in hospitals when clinicians are uncertain whether a patient may recover and are concerned that they may only have a few months left to live.

We saw outstanding compassion for patients at the end of life and their families, particularly from the porters, mortuary staff and bereavement officers. Porters told us they looked after deceased patients as if they were their own parents and were committed to caring for them in a dignified manner. The mortuary team provided training to a wide range of staff from inside and outside the trust. There were comfortable, sensitively decorated areas for bereaved families; we found that a number of staff in a variety of roles supported them.

During our inspection we found that oxygen was rarely prescribed. The National Patient Safety Agency (NPSA) indicates oxygen should always be prescribed except in emergencies, as there is a potential for serious harm if it is not administered and managed appropriately. We pointed this out to senior managers at the time and immediate action was taken to address this.

We found that advance care planning was rare. If patients brought in a preferred place of care folder into hospital from the community, hospital staff thought it was not relevant, as it was a ‘community document’. Senior nurses and doctors told us they did not understand the concept of advance care planning; they thought this could only be done in the community. Some staff told us it was often too late to have care planning discussion with patients by the time it was recognised they were dying. This was reflected when we found three patients on the respiratory ward had become too poorly to be transferred. We found that advance care planning would have prevented these situations and enabled patients to achieve their preferred place of care at the end of life.

Outpatients

Good

Updated 13 January 2016

Barnsley Hospital NHS Foundation Trust outpatients and imaging departments was judged as good overall. The safe, caring and well-led domains were rated as good with the responsiveness domain found to be requiring improvement. We are currently not confident that we are collecting sufficient evidence to rate effectiveness for outpatients and diagnostic imaging.

Within the departments, patients received safe care and staff were aware of the actions they should take in case of a major incident. Incidents were reported, investigated appropriately and lessons learned were shared with all staff. The cleanliness and hygiene in the departments was within acceptable standards, however, there were some areas in need of re-decoration and a lack of appropriate seating for patients with different needs in some areas.

Staff were aware of the various policies designed to protect vulnerable adults and children and we saw good examples of actions taken to address identified concerns.Patients were protected from receiving unsafe treatment as medical records were available 99% of the time and electronic records of diagnostic results, x-ray images and reports and correspondence were also available. The records we looked at were in good order and entries were legible; however, some areas of record keeping practice required improvement.

Workload within outpatients was predictable due to the scheduling of clinics and availability of clinic lists in advance and nurse staffing levels were based on the number of clinics and expected number of patients. There were some vacant radiologist and radiographer posts; however, there were mitigations in place to ensure gaps in service were covered.

Care and treatment in outpatients and diagnostic imaging was evidence-based and performance targets consistently met. The staff working in outpatients and diagnostic imaging departments were competent, received an annual appraisal and there was evidence of multidisciplinary working across teams and local networks. Nursing, imaging, and medical staff understood their roles and responsibility regarding consent and the application of the Mental Capacity Act.

Staff undertook regular audits in imaging and pathology departments regarding quality assurance to check practice against national standards and action plans were put in place to make improvements when necessary. We found that some imaging reports contained mistakes due to the voice recognition system that generated the reports. We were told that no formal audit was in place to monitor these errors, but that clinicians highlighted errors in reports within their discrepancy audits.Outpatient clinics ran every weekday, occasionally at weekends and on Thursday evenings. Imaging services for inpatients were available seven days a week.

During the inspection, we saw and were told by patients that staff working in the outpatient and diagnostic imaging departments were kind, caring and compassionate at every stage of their journey. Patients told us they were given all of the information they needed, were given sufficient time and were encouraged to ask questions to ensure understanding. Patients were able to make informed decisions about the treatment they received and there were services in place to emotionally support patients and their families.

Confidentiality was maintained in all of the areas we visited.

Areas of good practice included mechanisms to ensure that services were able to meet the individual needs of patients such as for people living with dementia, a learning disability or physical disability, or those whose first language was not English. There were also systems in place to record concerns and complaints, review these and take action to improve patients’ experience.

Staff were focussed on delivering the best possible experience for all of their patients.

Staff and managers had a vision for the future of the departments and were aware of the risks and challenges. Managers at all levels were active, available and approachable to staff. Staff felt supported and were able to develop to improve their practice. Regular meetings took place where all staff participated and were confident to talk about ideas and sharing of good news as well as anticipated problems. There was an open and supportive culture where lessons were learnt and practice changes resulting from incidents and complaints were discussed.

The department was supportive of staff who wanted to work more efficiently, be innovative and try new services and treatments. Staff were centred on delivering a good patient experience, they said that they felt proud to work for the trust and that they provided a good service to patients.

After moving to the new electronic patient record system in October 2014, the trust had identified in June 2015 that 23,557 patients were being held on a review list and who may not have been provided with follow up appointments. Immediate validation of the list reduced this to 7,980 patients overdue an appointment to end August 2015. Due to the change in processing the trust was carrying a backlog of about 2,000 outpatient outcomes per month; these were all reconciled by the end of each month. A further 9,613 patients appeared to have an open patient pathway, however these patients were discovered to have multiple pathways opened in error and the duplicates were removed from the system early into the validation process. Work was underway to ensure all relevant patients were offered a review appointment by 30th November with all patients seen by 31 January 2016; however, this was rated as a red risk by the trust, which indicated the potential patient safety risk associated with missed appointments. It was unknown at the time of inspection whether any harm had occurred to patients as a result of this situation, however, there was a risk that there may have been delayed treatment or diagnosis.

There were relatively high rates of cancelled clinic appointments and patients who did not attend their appointments.