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Inspection Summary


Overall summary & rating

Good

Updated 10 April 2015

The Care Quality Commission (CQC) carried out a comprehensive inspection between the 6 and 8 January 2015. We also carried out unannounced inspections on 12 and 15 January 2015.  We carried out this comprehensive inspection at Ipswich Hospital as part of our comprehensive inspection programme. Ipswich Hospital is part of Ipswich NHS Trust which was rated as being in band six of our intelligence monitoring tool and was therefore a low risk.

The hospital was first built around 1910, and has been expanded to cover 45 acres. The newest addition is the private finance initiative (PFI) wing, opened in 2007. The hospital serves around 385,000 people from Ipswich and East Suffolk. It has a relatively high deprivation score, being 83rd out of 326 (1 being the worst), and deals with significantly higher levels of depression and people living with dementia than average. There is also a higher than average number of young people with drug and alcohol-related health problems. However, the population that the trust sees has a higher than average life expectancy. We found that the trust had a relatively new executive team, who worked effectively together to highlight issues and address challenges within the hospital. We found the trust management team to be responsive and to act quickly to address issues highlighted to them during our inspection. The trust were aware of the issues of poor leadership faced on Sproughton Ward and highlighted this prior to our site visit. We also identified challenges on this ward, including poor documentation and a differing patient group than had originally been planned for this ward, and the trust took action overnight to ensure that people received safe and effective care in this ward. We returned to this ward during our announced and unannounced inspections, and found that improvements made had been sustained.

The comprehensive inspections result in a trust being assigned a rating of ‘outstanding’, ‘good’, ‘requires improvement’ or ‘inadequate’. Each section of the service receives an individual rating, which, in turn, informs an overall trust rating. The inspection found that overall, the trust has a rating of 'Good.

Our key findings were as follows:

  • 'Never events' that had occurred were actively and imaginatively investigated, including using human factors analysis, and lessons were learnt.

  • Systems in place within the emergency department were assisting to effectively tackle the Winter pressures during our inspection.

  • Staff were caring and compassionate, and treated patients with dignity and respect.

  • The hospital was visibly clean and well maintained. Infection control rates in the hospital were lower when compared with those of other hospitals.

  • The trust performed better than average in a number of national audits, including the national hip fracture audit, the national bowel cancer audit, the national lung cancer audit data, the Sentinel stroke national audit, and the myocardial infarction national programme.

  • Managers and staff responded quickly and took appropriate actions to ensure patient safety where we identified issues on one ward within the medical service.

  • The trust had an ongoing recruitment and retention programme to address staffing shortfalls.
  • The equipment within the diagnostic centre was aged, and whilst it was noted on the vision for the service that equipment was nearing end of its life, there were no plans or timeframe formally in place to upgrade equipment.
  • The critical care pathway for children was not well defined. Improvement was needed with regards to the provision of a children’s high dependency unit (HDU).

We saw several areas of outstanding practice, including:

  • The emergency department trigger tool, which was in place to ensure that the responsiveness of the emergency department was maintained when the department was beginning to see increasing pressures.
  • The chaplaincy service carried a trauma bleep in order to provide emotional support to relatives of trauma victims.
  • Ipswich Hospital was one of only two trusts to participate in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), providing international benchmarking of patient outcomes.
  • There was a comprehensive outreach service in place, providing full 24/7 cover including a 'patient activated' referral for the team.

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

Importantly, the trust must:

  • Review the end of life care paperwork to ensure that it is more individualised and providing a holistic approach in line with National Institute of Health and Care Excellence (NICE) guidelines.
  • Provide training to staff providing end of life care, on how to identify patients approaching the end of life, and on how to use the new care plans.
  • Ensure that discussions with patients and families regarding end of life care, or advanced care planning decisions, are clearly recorded in the person’s medical records.
  • Ensure that prior to undertaking a procedure, or completing an end of life care order, the person’s mental capacity is appropriately assessed in accordance with the Mental Capacity Act 2005.
  • Ensure that all clinical areas in outpatients, including the equipment in rooms, are cleaned regularly, and the cleaning is evidenced.
  • Ensure that the decontamination room in ear, nose and throat (ENT) outpatients is compliant with guidelines on decontamination Hospital Technical Memorandum.
  • Review medicines management in the South Theatre areas to ensure medicines are stored securely.
  • Clearly define a critical care pathway for children and review the provision of services for children requiring high dependency of care, including staffing numbers, competency and provision of registered sick children’s nurses (RSCN).

There are areas where the trust should consider action, including:

  • Review reporting incident mechanisms within the surgery division, including reviewing working arrangements to help facilitate timely reporting.
  • Review monitoring equipment within surgery, with a view to standardising the equipment available.
  • Review service planning and delivery within maternity, to ensure actions for service development are in line with current clinical practices, and consider the requirement of specialist lead roles.
  • Ensure governance procedures and risk registers are active and maintained in children’s services and critical care, and ensure a robust system of audit, including patient outcome monitoring, to improve learning.
  • Review the staffing levels for the palliative care, mortuary and chaplaincy service, to ensure that there are sufficient staffing levels to meet the demand for services.
  • Review the audit tools used for end of life care, including 'do not attempt cardio-pulmonary resuscitation' (DNA CPR) forms, to ensure that they are more dynamic to improve learning.
  • Ensure that a full review of staffing in diagnostic services is undertaken, to ensure that current staffing levels versus service demands is achievable.
  • Develop and agree a reasonably timed plan for the refurbishment and upgrade of diagnostic machines, to ensure that the images meet the NICE guideline requirements.
  • Review working arrangements to share learning and information across the outpatient services between the three divisions.
  • Ensure that waiting times are clearly displayed in the outpatients department, to ensure that people are informed of up-to-date delays to appointments when they attend clinic.
  • The trust should consider ways in which waiting times could be reduced within the outpatient department.
  • Ensure that pain relief is offered to patients in the fracture clinic.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 10 April 2015

Effective

Requires improvement

Updated 10 April 2015

Caring

Good

Updated 10 April 2015

Responsive

Good

Updated 10 April 2015

Well-led

Good

Updated 10 April 2015

Checks on specific services

Medical care (including older people’s care)

Good

Updated 10 April 2015

Medical services protected patients from avoidable harm,  and were effective, caring, responsive and well-led. There were systems in place to report and review incidents, and share learning across teams.

Staffing levels had been reviewed, and nurse staffing had increased in some wards to support the complex needs of frail, elderly patients.

Clinical outcomes for patients were good, with better than national performance on length of stay and readmissions. Services were consultant-led with daily reviews undertaken by the multidisciplinary team to maintain patient progress and facilitate discharge. Written records were, on the whole, good. Patients were treated with dignity, compassion and respect, and were involved in planning their treatment.

There was continual pressure on the availability of beds; however, the hospital responded well to seasonal increases in activity. The trust had created flexibility through the provision of consultant-led escalation wards and appropriate staffing changes.

The trust were aware of areas that required improvement (Sproughton Ward), and managers and staff acted quickly to ensure patient were protected from avoidable harm where we identified issues that were at risk of affecting patient safety or dignity. This included a medical and nursing review of each patient on the ward and a review of the skill mix within the ward.

There were clear governance arrangements in place for all levels of staff. Staff felt supported and valued.

Urgent and emergency services (A&E)

Outstanding

Updated 10 April 2015

Urgent and emergency care services at Ipswich Hospital were good, with some outstanding practice in responsiveness and leadership. There was an open culture for quality improvement, and incidents were reported and learnings shared. Staffing levels and skill mix were planned, implemented and reviewed, and new staff well supported. Staff took the time to listen to patients, and gave explanations of care, to allow for patients informed involvement in decision-making.

The emergency department had an escalation policy and utilised a demand trigger tool, developed by the management team, which monitored and linked patient demand to whole trust demand. This enabled a pro-active response to clinical demands. The tool triggered when the department was experiencing high demand and set in motion a series of actions to reduce the pressure on the department. This was outstanding as it maintained flow through the department and ensured admission of patients in a timely manner.

The emergency department was led by operational and clinical managers, who were experienced, and strived to deliver and motivate staff to succeed.

Surgery

Good

Updated 10 April 2015

Surgery services at Ipswich Hospital were good; however, staff in East Theatre felt unable to report incidents due to time constraints, and believed the process to be too time consuming. Therefore, an open culture for raising safety concerns was not embedded throughout the division. This area require improvement.

Patients were monitored and reviewed promptly. Care and treatment given was evidence-based, and followed NICE guidelines. The surgical division had taken a robust approach to audit, and was benchmarking patient outcomes internationally by participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Best practice learnings was shared across the trust.

Surgical services were planned, and surgery cancellation rates were low. The service was responsive to the needs of patients; patients were treated with compassion, kindness, dignity and respect.

The arrangement of surgical services across the site made for logistical problems and management challenges, resulting in varying leadership across the division.

Intensive/critical care

Good

Updated 10 April 2015

Critical care services were safe, effective, caring and responsive to meet the needs of patients and relatives, and the service was well-led. Staff cared for patients with compassion, dignity and respect. Good quality outcomes were evident, and patients received treatment that was based on national guidelines. The overall capacity was adequate, and patients received timely care and admission to the unit; however, delayed transfers out of hours were high due to the unavailability of step down beds on the wards.

Medical and nursing staffing levels were planned, implemented and reviewed depending on patient acuity and turnover, and adhered to national guidance.

Staff competency and training arrangements were embedded, resulting in a supportive environment, and staff morale was good.

Service provision for children was primarily stabilisation prior to transfer; however, the unit treated approximately 20 children a year. There was no written policy for paediatrics in place, and no registered sick children’s nurse (RSCN) employed on the intensive care unit (ICU).

The management at service level on the nursing side were clear about their roles and vision for the service; however, this was not as embedded within the medical team. The governance and risk management within critical care was not embedded. During our inspection we identified a number of aspects of care where risks had been identified; however, there were no current risks on the risk register. An example of this was the paediatric patients on the ITU. Therefore, there was no assurance that timely actions were being taken to protect people from avoidable harm.

Maternity and gynaecology

Good

Updated 10 April 2015

Maternity and gynaecology services provided to women and babies by Ipswich Hospital overall was good, with some improvements required in respect of the responsiveness of the service. There was a strong focus on patient safety and risk management practices. Mandatory training, including safeguarding measures, were in place, and staff recognised and responded appropriately to changes in risks to people who use services.

Staff were appropriately qualified and competent, and safe staffing levels and skill mix encouraged proactive teamwork, to support a safe environment. Individual care and treatment was planned and delivered in line with current evidence-based guidance.

Patient outcomes for maternity and gynaecology were good, as was the counselling support for women undergoing termination of pregnancy and those women suffering a miscarriage. Care provided was good, and patients were treated with dignity, respect and kindness.

Service planning and delivery required improvement, as actions for service development in line with current clinical practices were not always in place or proactive, as there was a lack of specialist lead roles.

 The midwifery leadership model encouraged co-operative, supportive relationships among staff, and compassion towards people who use the service. An open, honest and transparent culture was evident, with staff confident in the support of their managers and the senior executive team.

Services for children & young people

Requires improvement

Updated 10 April 2015

The children and younger people’s service was caring and compassionate. We received positive feedback from the majority of children and parents that we spoke with. We were told that staff demonstrated a caring attitude. The service had a good incident reporting culture; however, more work was needed to embed and demonstrate a learning culture. Staff were clear in relation to their responsibilities with regards to safeguarding. We saw safe medicine practices being adhered to, and equipment was safety checked.

Improvement was needed with regards to the provision of a service for children with more complex needs. We found that although not commissioned to provide a high dependency care for extremely sick children, there was a local need for this service. This meant that the children’s department was providing this type of care without sufficient numbers of trained staff. The critical care pathway for children was not well defined, and there was a lack of consistency in explanations with regards to roles and responsibilities. The critical care operational policy highlights 'paediatrics as a very small part of admissions, but as such represents significant risks'. Provision for critically ill children was primarily stabilisation prior to transfer.

Processes were in place to determine best practice guidance, which related to the children and younger people's service. There was a lack of local initiatives and auditing to monitor and measure patient outcomes. Data provided by the trust showed that training in paediatric intermediate life support (PILS) had been completed by 90% of the staff who required it. Children and younger people’s individual needs were taken into account, and there was a good approach to multidisciplinary working when delivering care and treatment.

There were many initiatives in place which demonstrated that this was a responsive and sustainable service. For example, we heard examples of how the service had been redeveloped, based on feedback from patients, and initiatives to grow and expand areas of the service. Every member of staff that we spoke with was passionate about providing the best care possible, and were keen to input into improvement. There was an open culture, and staff felt valued and well supported from the leaders within this department.

However, despite staff telling us that capacity was one of the biggest risks within the service, we were not provided with information which demonstrated that the department was safely managing increases in service demand.

Governance systems required developing which meant that the risk management system was not effective; we found risks on the register which had been present for nine years. There was a lack of evidence to support continuous monitoring and improvement over time, and a poorly developed audit programme. Senior members of staff within this unit however agreed, and had already identified that this was an area in which improvements were needed.

End of life care

Good

Updated 10 April 2015

Services for end of life care were good, with some improvements required in effectiveness. We found that whilst the new end of life care programme was in its infancy, patients were receiving safe care however improvements were required to embed this programme of care. Staffing levels for the palliative care service required review due to the number of referrals outweighing the number of staff available.

We found that the new end of life care tools that had been implemented trust-wide had been done so without formalised education of staff. The tools required improvements to ensure that all elements of care, including holistic, spiritual and emotional needs, were considered in line with NICE guidelines. We also found that these new tools required further information to ensure that they were individualised to the patient. We also found that staff required further training to ensure that they could identify patients at the end of their life who would benefit from the specialist service.

Staff at Ipswich Hospital provided very compassionate care to patients leading up to the time of their death. Locally, staff spoke highly of the care offered by the palliative care, mortuary, chaplaincy and bereavement teams.

The end of life care and palliative care team supported the provision of rapid discharge, and rates of discharge within 24 hours were in line with the England average. Relatives were being invited to share their experience, to learn and improve the delivery of end of life care. Locally, those providing end of life care within departments led the provision of this well.

Outpatients

Good

Updated 10 April 2015

Outpatient and diagnostic imaging services required some improvement. Not all areas of the outpatient services were visibly clean. The outpatient ENT department decontamination room was not fully Hospital Technical Memorandum compliant. The equipment within the diagnostic centre was aged, and whilst it was noted on the vision for the service that equipment was aged, the plans for replacement had only recently been signed off by the trust board. Due to the age of the equipment, NICE guidelines were not being met due to out-of-date software and hardware. This meant that whilst they were safe they could not deliver treatment and diagnosis in line with current guidance. Seven day working did not take place in outpatients or in diagnostic imaging. The care provided by staff to patients in the outpatient and diagnostic imaging services was good. The service was responsive, and patients were able to access their outpatient and diagnostic appointments in a timely way, with the trust performing well on the outpatient and cancer pathways. The service was well-led locally, although the structure of the outpatients department meant that there was no overarching outpatients lead, and there was a disconnect between how each outpatient service was run, because it was run by each division. Staff were proud to work at Ipswich Hospital.