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Inspection carried out on 6-8 January 2015

During a routine inspection

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 carried out on 7, 8 January 2014

During an inspection to make sure that the improvements required had been made

This was a follow-up inspection to check two compliance actions around medicine management and pressure sore prevention management practices raised in July 2013 had been addressed. We found that the trust had taken appropriate steps. People we spoke with told us they were happy with the arrangements made for their medication and we could see that people were protected against the risks associated with the management of medicines. We saw that the planning and delivery of pressure ulcer care had improved significantly with the development of the tissue viability team and increased monitoring and staff training systems.

Our experts by experience spoke with a number of people who use the service focussing on support for people with dementia and learning disabilities and most were happy with the care provided and with the nursing staff in particular. We used the Short Observational Framework for Inspection (SOFI) to observe care to help us understand the experience of people who could not talk with us. We found good examples of compassionate effective caring services.

One patient said: “I have a treatment plan and I can give my opinion about the care I receive." A relative said: “The care my relative is receiving is exceptional, the three doctors and consultant have been honest and clear in their explanation of what might happen in the next few days.” Another relative said: "The nurses are very helpful; my relative is assisted with washing and his pressure areas are attended to regularly.”

We had minor concerns that people were not always consulted with regarding the risks, benefits and alternative options available to them regarding resuscitation practices.

Inspection carried out on 4 June 2013

During a routine inspection

We spoke to 27 people who used the service, seven visitors and 28 staff. We also visited eight wards and the accident and emergency department. We looked at 22 sets of records relating to people’s care and treatment.

People told us that they were happy with their care. One person said, “The best in terms of care, the staff are just so kind here. This hospital is so clean, it is spotless, the cleanest one I have been to.” Another person told us, “The care has been fantastic.” A further person said, “I have definitely been well looked after.”

People’s needs had been assessed and risk assessments were in place. However, the management of people’s pressure care did not always meet people’s individual needs and published research evidence and guidance was not always being followed.

People we spoke with told us they were happy with the arrangements made for their medication. One person told us that they were “always well looked after”. However, people were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place for the storage and recording of medicines.

On the day of the inspection, we saw that there were enough qualified and skilled staff to meet people’s needs. Staff told us that they felt supported and had adequate training to perform their role.

Effective systems were in place to assess and monitor the quality of the service provided.

During an inspection to make sure that the improvements required had been made

The people who used the service were not asked about the service on this occasion.

Inspection carried out on 26 July 2012

During a routine inspection

We spoke to 30 people who used the service, four visitors and 35 staff members. We also visited 13 wards and looked at 12 sets of records relating to people’s care and treatment.

Most of the people we spoke with were happy with the care and treatment they received from staff. They and their relatives told us that staff responded to requests for assistance and answered call bells promptly. We saw that call bells were left within the reach of people. One person said “If I press the button someone comes right away.” We saw that on one ward response times to call bells was longer. One person told us “Staff take longer when they are short staffed as they are so busy and it can take a while for them to stop the constant beeping of the machines (Intravenous fluids). Its worse at night as it makes it difficult to sleep through the noise.” Another person told us “Staff are very accommodating and bend over backwards to help even when they are low in numbers.”

We saw that a family had left a written comment on a ward stating “The morale of the team seemed buoyant and cheerful”

People told us they were treated with dignity and respect and described staff as "Kind", "Caring” and "Professional." They said their treatment and support options had been explained to them and they were provided with additional information if required to make informed choices. We saw that when staff provided assistance to people they responded in a calm and reassuring manner. One person told us “Staff look after me well.”

People told us they were offered choices at meal times and there was a varied menu. They said they were provided with enough to eat and drink and staff checked if they needed refreshments. Overall, people using the service were complimentary about the food and said it was appetising. People who said they did not like the food said it was due to personal tastes.

Inspection carried out on 20 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 28 September 2011

During a routine inspection

Over forty five people were spoken with or interviewed over the two days of our visit and most of the people (across six clinical areas) did not identify any privacy and dignity issues. People we spoke with told us that they were well informed regarding their treatment and care. They told us that staff consulted them and that they were involved in decision making about their care needs although most of the people we spoke with did not know how to raise complaints or concerns other than with the ward staff. However, they told us that they had had no reason to raise concerns.

Service user group members we spoke with told us that the hospital were quick to act on concerns and they gave several examples of practice improvements made because people had highlighted these areas as needing improvements.

All the people we spoke with said that the food was acceptable and that they felt the hospital was clean. They were all complimentary about the staff across the hospital. Whilst they said that the staff were busy at times they did not get the impression that they were short staffed.

Overall, the people with whom we spoke told us that the care at Ipswich hospital was satisfactory and in some cases good.

Inspection carried out on 22 March 2011

During a themed inspection looking at Dignity and Nutrition

The people we spoke with who use the service confirmed that they were listened to and were given the opportunity to express their views about their care, support and treatment. Some of the people that we spoke with were very complimentary about the medical staff, saying that they listened and clearly explained issues that related to their care.

Some of the people we spoke with told us that the staff are very respectful, always make time for them and treat them nicely even though they are very busy. However, they told us that some staff are better than others. Some people told us that they have to wait when staff are busy or they don’t come quickly enough or not at all. Some people stated that staff can be a bit rough but this is generally when they are busy or the ward is short of staff. Other people stated that they feel that they are put to bed too early, such as 6pm, making the night feel too long.

People told us that their preferences are not always taken into account, such as having a choice of male or female staff for personal care and not always being referred to by their chosen name.

People we spoke with gave us mixed feedback about the mealtimes, food and nutrition provided during their stay in hospital. Positive comments included that the food is much better than it used to be, there is a good choice and someone said, “If I fancy something not on the menu staff will try to get this for me.” Another comment was, “I enjoyed the food, I am never hungry and there is always enough to eat.” People also told us that if they require assistance to eat this is done kindly. Some of the people told us that the meals look alright but are tasteless, bland and not appetising. Other comments were that there is minimal choice for special dietary needs; the main meal and a hot dessert are given at the same time so the dessert has to be eaten cold.