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Addenbrooke's and the Rosie Hospitals Good

Inspection Summary


Overall summary & rating

Good

Updated 18 January 2017

We carried out a full follow up inspection between 20th and 22nd September with an unannounced inspection on 29th September 2016. This inspection was to follow up our comprehensive inspection in April 2015 where the concerns identified by the inspection team had resulted in my recommending the trust for special measures. A smaller focussed inspection in February 2016 followed up our most serious concerns and those areas rated Inadequate.

At this inspection we saw significant improvement across most of the areas we inspected. This included outstanding effectiveness in the critical care units and improvements in safety and leadership in maternity services and outpatients which we have now rated as good. These had been rated inadequate in 2015. There were similar improvements in medical care, surgery and urgent and emergency services with all services now rated as good overall. The improvement was in line with the trusts improvement plan and was assisted by constructive challenge from stakeholders at regular meetings.

Cambridge University Hospitals NHS Foundation Trust is one of the largest in the UK with around 1400 beds. The trust provides a major trauma centre for the east of England and specialist services in immunology, fetal medicine, IVF, neurosurgery, ophthalmology, genetics and metabolic diseases, specialised paediatric, cancer and transplant services.

The trust also provides district general hospital services to patients predominantly coming from Cambridgeshire, Essex, Suffolk and Hertfordshire. The demographics vary during the year due to the large student population of approximately 24,488.

The clinical departments are clustered together into five divisions:

Division A: Musculoskeletal; Digestive Diseases and ICU/ Periops

Division B: Cancer; Laboratory services; Imaging and Clinical support

Division C: Acute Medicine; Inflammation/Infection; Transplant

Division D: Neuroscience; ENT/ Head and neck/ Plastics; Cardiovascular-Metabolic

Division E: Medical Paediatrics; Paediatric Critical Care and Paediatric Surgery; Obstetrics and Gynaecology

During this inspection we inspected all key questions in all of the eight core services. The organisation had been through a significant change in senior leadership in the preceding 12 months which had resulted in a number of governance changes within the organisation. The trust was continuing progress against an overarching improvement plan in response to concerns found at our previous inspections.

Our key findings were as follows:

  • The trust had received support from NHS Improvement since it was placed in special measures in September 2015 and had undertaken a review of governance structures across the organisation. This had included the implementation of the improvement plan and regular oversight of its implementation from regulators, commissioners and stakeholders.
  • There was improvement in the quality and safety of all services with the exception of children and young people’s services which found the demand on the service challenging. This improvement was in line with the trusts improvement plan.
  • There was improved learning from incidents across the divisions. Most staff we spoke with had a good understanding of the duty of candour.
  • There had been an increase in permanent staffing levels resulting in very low levels of agency nurse usage across the trust. There remained use of bank staff and some locum consultants.
  • The trust had developed a system of monitoring patient acuity on several occasions each day. This allowed senior managers and clinical staff to flex staffing levels to meet patient need.
  • There were ongoing capacity issues within the trust resulting in cancelled and delayed surgeries. Children’s services were also under pressure though the imminent opening of additional beds should alleviate some of this pressure.
  • Internal capacity issues were also seen in delayed discharges from the critical care units. There were also delays in transferring some patients from recovery post operatively to a ward for post-operative care.
  • There were ongoing capacity issues within maternity services meaning the unit diverted high risk deliveries on 17 occasions between December 2015 and July 2016.
  • Significant improvement had been made into reducing the numbers of patients waiting for outpatient appointments. However, further work was required to further reduce the waiting lists for appointments and some investigations.
  • The trust failed to achieve the national target for treating, admitting or discharging 95% of patients within four hours. In December 2015, the trust met the target, however performance began to fall in January 2016 and fell to 83% in May 2016
  • The revised governance systems were sufficient to ensure that the senior team had robust information on which to make decisions.
  • There was a large audit programme. However, we saw results in medicine were below the England average and the stroke national audit scored ‘D’ – the second lowest score. There was very limited audit in end of life care though the trust had identified this and were developing an audit plan.
  • The electronic patient record (Epic) had now been in place for some 2 years. Many of the concerns we had identified at previous inspections had been addressed and staff were more familiar with the system though care planning was not always individualised and personalised.
  • Staff were very caring and on some occasions went to great lengths to support and care for patients.
  • There was an open culture. Staff reported incidents and there was increased evidence of learning from incidents.
  • Staff spoke positively of local (divisional) management. Managers in all areas were well sighted on risks as well as developing new pathways and delivering care.
  • Patients spoke highly of the care they received. Friends and Family Test results were generally positive across the trust however, there were very poor response rates in some areas.

Importantly, the trust must:

  • Ensure medicines including controlled medicines are securely stored at all times.
  • Ensure that end of life care is properly audited (such as preferred place of death and DNACPR) and actions taken in response to those audits.
  • Ensure that complaints are responded to in a timely way wherever possible.
  • Ensure resuscitation decisions are always documented legibly and completed fully in accordance with the trusts own policy and the legal framework of the Mental Capacity Act 2005.

In addition the trust should:

  • Ensure it improves the environment for children in the ED to ensure children’s safety at all times.
  • Review staffing in the emergency department with respect registered nurses (child branch) to ensure children’s needs and national guidance are met.
  • Review staffing of the specialist palliative care team against national guidance.
  • The trust should ensure that all staff complete mandatory training and safeguarding training to ensure it complies with the 90% compliance target.
  • Continue to work to improve delayed discharges and discharges that occur between the hours of 10pm and 7am in the critical care and intensive care units.
  • The trust should ensure the actions from the safeguarding review they have conducted for level three training for staff in adult areas caring for patients under the age of 18 years are implemented.
  • The trust should review the level of children’s safeguarding training healthcare assistants undertake to ensure it is in line with the Intercollegiate Role Framework for Looked After Children and the trusts own Safeguarding Children’s Policy.
  • Review consultant hours in maternity in line with national guidance.
  • Continue to improve referral to treatment time performance including for cancer services and reduce the number of cancelled operations.
  • Consider improvements to the response rate for the Friends and Family Test which are poor across the trust.
  • Ensure that systems are in place to reduce the risk of confidential information leaks.
  • Work to reduce the number of diversions of high risk deliveries in maternity services.
  • Continue to reduce the time for end of life patients to be discharged to their preferred place of care.
  • Ensure that all equipment is appropriately checked and safety tested where required.

We saw areas of outstanding practice including:

  • Ward J2 ran weekly ‘music and movement’ classes to help meet the holistic needs of patients during their long-term recovery. A volunteer specialising in music and movement ran the classes and staff encouraged patients and their relatives to attend. This had received excellent feedback from patients and relatives.
  • The teenage cancer unit provided outstanding facilities for young people diagnosed with cancer and receiving treatment for cancer. The teenage cancer unit provided a welcoming, age appropriate environment for young people to receive treatment, but also meet other young people and relax and socialise.

  • The ED team had developed a mobile phone application called “Choose Well.” The application offered guidance on waiting times and hospital services across Cambridge in order to improve the patient experience and offer choices in health care.
  • The emergency department had secured £100,000 of funding from the Small Business Research Initiative (SBRI) to support the development of a crowd prediction modelling tool to enable the trust to understand and map patient flow through the department.
  • The charitable trust was in the process of setting up a trauma ICU centre in Burma in which a number of the ICU/NCCU staff were involved, as well as the Burma nurse specialist visiting later on in the year.
  • The initiative for ‘Family Facetime’ proposed the purchase of two technology tablets to enable mums on the Obstetric Close Observation Area (OCOA) who are too unwell to visit their baby on the neonatal intensive care unit to receive a video link via Facetime with their baby.
  • The bereavement follow up scheme saw a reduction in complaints of approximately 50%.

On the basis of this inspection I am recommending that Cambridge University Hospitals NHS Foundation Trust is removed from special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 18 January 2017

Effective

Good

Updated 18 January 2017

Caring

Outstanding

Updated 18 January 2017

Responsive

Requires improvement

Updated 18 January 2017

Well-led

Good

Updated 18 January 2017

Checks on specific services

Maternity and gynaecology

Good

Updated 18 January 2017

We rated this service overall as good with findings in the following:

  • The service had robust systems in place to report incidents and the number of serious incidents reported was 16, with no never events reported between January and September 2016.
  • Throughout maternity and gynaecology services we saw the “NHS Safety Thermometer” displayed in public areas. We saw completed essential patient risk assessments including venous thromboembolism (VTE) and early warning score (EWS) assessment outcomes.
  • Staff confirmed to us that the maternity record system was improved with smart text filters in place but there was still a combination of electronic and paper records in place. Smart text is similar to a predictive text with the most used status or treatment descriptors featuring first on the system.
  • All equipment checked was safety tested and was on the pre-planned maintenance programme.
  • Staffing shortages within the delivery suite were seen each day but we were informed of clear plans to fill those vacancies with staff already recruited to start in October 2016.
  • Policies and procedures in place were based on up-to-date evidence-based guidance which had been followed: for example; fetal heart monitoring (FHR) monitoring, vascular thromboembolism (VTE) and early warning score guidelines.
  • All staff were competent and understood the guidelines they were required to follow.
  • Outcomes of women’s care and treatment were robustly collected and monitored. For example, a maternity dashboard was available.
  • Staff also confirmed that electronic hospital (Epic) coordination between electronic and paper-based systems had developed and they were able to show a thorough history for patients including risk factors. Although day case risks were not all completed on our initial review.
  • We observed good practice in terms of audit, effective multidisciplinary team working and that staff consistently had the right skills, qualifications and knowledge for their role.

  • All staff observed were extremely caring and we found that people were treated with dignity, kindness and respect throughout the directorate. There were also exceptionally good support systems in place to meet people’s emotional needs, which included support following bereavement.
  • The service consistently received more compliments than complaints.
  • Women undergoing termination of pregnancy were cared for in a dedicated area that was accessed through a double door into soundproofed side rooms within labour ward but well away from labouring women or crying babies.
  • Information had been provided in ways that the women could understand and which promoted women in being involved in making informed decisions about their own care and the delivery arrangements. Overall maternity and gynaecology services feedback received indicated that staff had a caring and compassionate approach. Women reported being treated with respect and dignity and having their privacy respected and dealt with in a sensitive manner across this service.

  • Women could access and be discharged from the service in a timely way.
  • The gynaecology referral to treatment time (RTT) had maintained at 95% (trust target 92%) from the previous inspection in February 2016. There had been no national standard for RTT since October 2015.
  • Service planning across the directorate was seen with workforce planning addressed. The demand on the service was addressed when patient acuity or staffing could not meet the needs of the women. The maternity unit had 17 diversions between Dec 2015 and July 2016 mainly due to a lack of capacity or insufficient staffing numbers.
  • Senior managers had responded appropriately since the last inspection.
  • Risk registers were up-to-date with clear ownership and actions completed or in progress.
  • Key performance data was collected and analysed which meant that responsibilities were clear and that quality, performance and risk were fully understood and managed.
  • The introduction of electronic hospital (Epic) caused problems with not meeting the needs of the service; for example, with data collection. Four out of six staff confirmed that improvements with the system had been a priority. ” We are still on the journey but have moved forward since last year”.
  • There was an improvement with the completion of the neonatal early warning scores.
  • All staff told us that senior managers were approachable and encouraged them to be open and transparent. Senior managers and staff confirmed their commitment and spoke about “the honour in being able to provide the best care possible to women and their families”. Staff dedication and passion for delivering high-quality care was inspiring and there were numerous examples of outstanding practice in relation to innovation, improvement and sustainability.

Medical care (including older people’s care)

Good

Updated 18 January 2017

We rated medical care as good for safe, caring, responsive, and well led. We rated effective as requires improvement.

  • Staff knew how to report incidents using the trust electronic reporting system. Learning from incidents was consistently shared with staff across the division and formal mortality and morbidity meetings were had been implemented across the service.
  • Staff had a good understanding of safeguarding principles and knew how to make safeguarding referrals.
  • Staff knowledge and understanding of the Duty of candour was good across medical and nursing staff.
  • Equipment was well maintained and regularly checked by staff to ensure it was within its service date.
  • Clinical areas were visibly clean, uncluttered and well organised.
  • Staff provided kind compassionate care to patients and their relatives in all areas we visited.
  • We saw good examples of multidisciplinary team working, especially on the acute stroke and stroke rehabilitation wards.
  • The risk of readmission for non-elective procedures were lower than the England average.
  • The average length of stay for elective patients is lower than the England average.
  • Staff were friendly and approachable and we observed staff treating patients with compassion, dignity and respect on all wards throughout the inspection.
  • Feedback from people who use the service and those close to them was consistently positive about the way staff treated patients.
  • The trust was either in line with or above the England average for referral to treatment times (RTT)
  • There was a learning disabilities specialist nurse who supported staff on the ward in caring for people with additional needs.
  • The trust’s Specialist Advice for the Frail Elderly (SAFE) team saw all patients who were over the age of 75. This multidisciplinary team provided a seven-day service and provided advice to staff at ward level that supported patients over the age of 75 years.
  • The average length of stay at the hospital between March 2015 and February 2016 for elective patients was 2.3 days, which was lower than the England average of 3.9 days.
  • Staff felt well supported by local leaders, peers and by senior management and there was good communication between all staff grades and senior management.
  • The culture with in the hospital was friendly and the trust values were being upheld.

However:

  • Mandatory training levels were significantly below the trust target and we were not assured that staff had the required skills and competencies within their respective roles.
  • There remained significant vacancies in medical and nurse staffing with a reliance on locum and bank staff in some specialties.
  • Storage of medicines was not always satisfactory.
  • Patient outcomes were mixed and not always in line with the national averages, for example the trust scored below the England average for all in-hospital care indicators in the National Heart Failure Audit in 2014
  • The overall Sentinel Stroke National Audit Programme (SSNAP) score decreased from C to D between January and March 2016 (where band A is the highest and band E the lowest).
  • Participation in the National Diabetes Inpatient Audit (NaDIA) 2015 showed that the trust performed worse than expected on 7 out of 21 questions however it was better than the England average for ten indicators.
  • The risk of readmission at Addenbrooke’s Hospital for all elective procedures is higher than the England average
  • The average length of stay for non-elective patients is higher than the England average.
  • The average response rate for the Friends and Family Test between June 2015 and May 2016 was 10% lower than the England average of 26%. In May 2016, only 83% of patients would recommend ward D10, which was significantly worse than the trust average.
  • We identified concerns from staff that sufficient action was not being taken regarding the movement of staff between wards

Urgent and emergency services (A&E)

Good

Updated 18 January 2017

  

Urgent and emergency care services were rated as good overall. The safe domain has been rated as requires improvement.

  • There were clear procedures for managing and referring safeguarding concerns in relation to children and adults who may be at risk of abuse. Staff we spoke with knew how to make a referral and who to refer their concerns to within the trust.
  • Staff knew how to report incidents and deal with complaints and there was a learning culture within the emergency department (ED).
  • Between May 2015 and April 2016, the median time to initial assessment ranged between one and two minutes. This was consistently better than the England average, which ranged between five and seven minutes for the same period.
  • Medical and nursing staff achieved 100% compliance with their appraisals during 2015/2016, and staff had access to appropriate information and guidance to carry out their roles competently. There were good examples of multidisciplinary team working with internal staff and external agencies for example admission avoidance and safeguarding.

  • The patient escalation procedure and processes were robust and staff used the patient electronic record system effectively to identify and escalate concerns regarding deteriorating patients. We observed staff routinely offering patients pain relief and assessing the level of pain on initial assessment.
  • The percentage of patients in the Friends and Family Test who would recommend the service was consistently above the England average from June 2015 to May 2016. Throughout our inspection, we observed patients treated with compassion, dignity, and respect. Patients we spoke with told us they were well informed regarding their care and treatment. The trust had access to a range of clinical nurse specialists within the department that could provide support to a wide range of staff.
  • The ED had access to translation services for patients whose first language is not English and provided leaflets in a number of formats to support patients who may need further guidance on their condition.
  • No patients waited over four to 12 hours, from the decision to admit until admission, between June 2015 and May 2016. The number of patients leaving the ED without being seen between in May 2015 was 1.8%, rising to 2.4% in July 2015, steadily falling to 2% in December 2015. The percentage rose again to 2% in February 2016 before falling to 1.5% in April 2016. This was consistently better than the England average, which ranged between 2.5% and 3.5% for the same period.
  • The median time to treatment was approximately 20 minutes below the England standard of 60 minutes, between May 2015 and April 2016. The trust performed consistently better than the 60-minute standard between June 2015 and April 2016.
  • The ED used a number of alternative care pathways to alleviate pressure on the department and reduce admissions into hospital flow and employed a full time flow navigator to support patient flow. The trust had a dedicated relatives’ room used by staff at times of bad news or as a rest area for relatives waiting for news of patients.
  • There was good leadership within the ED, staff were clear on roles and responsibilities and understood the departmental development plan and the part they played in achieving its goals. Staff had been involved in planning future service configuration. Departmental risks were identified, mitigated and accountability clearly allocated to staff to ensure risks were monitored and updates shared within the governance structure.
  • Staff we spoke with said that senior staff were approachable and willing to share their knowledge and expertise. Junior doctors told us that the ED was a good place to work, they felt valued by their colleagues, and that they had opportunities to learn and grow in professional confidence.
  • The trust utilised patient focus groups in the community to gain feedback on its provision and plans for the future, for example the development of the ED and redesign of the building. There was a strong focus on innovation and future developments for the department, often with the engagement of departmental staff and external stakeholders in order to improve services for patients.

However:

  • The dedicated paediatrics area was not secure and had no controlled access or staff reception area. Children arriving at the department had to pass through the main ambulance bay or the main adult waiting areas to access the paediatrics waiting area. Children were not visible from the main paediatrics area meaning that there was no opportunity for staff to monitor or see a child that may deteriorate. Due to staff vacancies, the paediatrics department did not have a registered children’s nurse on duty at all times, which was not in line with the Royal College of Nursing guidance (2003).
  • In August 2016, the department achieved a 64% compliance rate with the sepsis-six bundle, which was worse than the trust target of 95%. Seventy-six percent of patients received antibiotics within an hour, which was worse than the Royal College of Emergency Medicine standard of 100%.
  • Between June 2015 and November 2015, the trust failed to achieve the national target for seeing, treating, admitting or discharging 95% of patients within four hours. In December 2015, the trust met the target; however, performance began to fall in January 2016 and fell to 83% in May 2016.
  • Between May 2015 and December 2015, the average time spent by a patient in the ED ranged between three hours 20 minutes and two hours 20 minutes, which was higher than the England average (two hours and 20 minutes) for the same period.

Surgery

Good

Updated 18 January 2017

Overall we rated surgery at Addenbrooke’s Hospital as good. The safe, effective, caring and well-led domains were all rated as good, with the responsive domain rated as requires improvement.

  • There was a strong incident reporting culture and staff received feedback from incidents to minimise the risk of similar incidents reoccurring.
  • Hand hygiene practices were consistently good in order to minimise the spread of infection. Equipment was in date and stored securely.
  • Medicines were stored appropriately with one exception in plastic surgery, and staff carried out regular checks according to policy.
  • Risk assessment of patients was consistently robust and there was evidence of appropriate escalation by staff in the event of a patient’s condition deteriorating.
  • There was good compliance with the World Health Organisation (WHO) ‘five steps to safer surgery’ checklist, to reduce the risks of mistakes in surgery.
  • Nurse and surgical staffing at the time of inspection was sufficient to safely meet patient acuity and needs.
  • Surgery had a clinical audit programme which assessed compliance with National Institute for Health and Care Excellence (NICE) guidelines and local policy.
  • Staff had the required skills and competencies to care for patients effectively and received robust training and induction to support them with this.
  • There was good evidence of multidisciplinary team (MDT) working in all surgical areas to help maximise patient outcomes. Patient outcomes were monitored and reviewed through formal national and local audits.
  • Staff were familiar with the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (2009) and there was evidence of obtaining appropriate consent.
  • All observations of interactions between staff and patients and relatives were compassionate.
  • Patients and relatives spoke highly of the care received and Friends and Family Test (FFT) results for surgery were consistently high.
  • Clinical, divisional and ward leads showed good awareness of the risks within their service and had robust action plans to address them.
  • Leads engaged with staff at all levels and responded to their concerns. The service was focused on continuous improvement to address the issues around responsiveness.
  • Clinical governance was robust, and risks were highlighted on the risk register and appropriately mitigated as far as possible.
  • There was a positive working culture amongst all levels of staff in all the areas we inspected, and staff took great pride in their work. Surgical services had several ongoing innovative initiatives to develop services and maximise patients’ experience.

However:

  • There were issues with access to surgery and flow through the hospital. The service was performing worse than the national average for cancellation rates and the number of patients not treated within 28 days of last minute elective cancellation.
  • Data provided by the trust prior to inspection showed that the service was performing significantly worse than the national average on meeting targets for referral to treatment times (RTT).
  • Recovery was regularly used to accommodate patients; from July to September 2016 there were 68 occasions where patients remained in recovery for non-clinical reasons.
  • Between June and August 2016, there were 1,176 patients recorded as outliers on surgical wards. However, cancellations, out-of-hours discharges and RTT were showing gradual improvement since our previous comprehensive inspection and there was evidence of actions to address the main areas of concern.

Intensive/critical care

Good

Updated 18 January 2017

We rated the critical care services provided at Addenbrooke’s hospital as good overall, with caring and effective as outstanding.

  • There was a good reporting and learning ethos throughout the unit. Staff told us that there was a “no blame culture”. Duty of candour was understood and discharged appropriately by staff. Morbidity and Mortality meetings were open to all staff which contributed to a positive learning and open culture across all disciplines of staff.
  • Since the previous inspection in 2014, there had been significant improvements made in relation to nurse staffing levels, meaning that nurse staffing levels were sufficient to meet with the Faculty of Intensive Medicine Standards.
  • There had been a dedicated supervisor introduced. Staffing levels, as well as patient acuity and dependency were reviewed five times per day to ensure that staffing levels remained safe and that patients were receiving high quality care.
  • The previous inspection in 2014 had identified that data collection and upload to the Intensive Care National Audit and Research Centre (ICNARC) had been stopped, meaning that data had not been submitted for two years.
  • However we found on this inspection that there was a dedicated team for ICNARC data collection, consultant engagement for review and accuracy check, mid-month review of any trends and themes, and training provided to staff, which included other staff being able to input data. Data had been submitted since quarter four 2015.
  • There were numerous examples of outstanding team work across medical, nursing and allied health professionals. Staff worked collaboratively to provide the highest possible care for patients. Feedback from patients and relatives during our inspection was very positive. We saw examples of innovations from the focus groups, which were recorded and logged onto an action plan.
  • The critical care Rapid Response Team (RRT), provided outreach services into wards, proactively identifying patients who would benefit from closer monitoring. The team also ran bed side teaching as well as delivered on a number of internal courses, providing support and education to ward teams.
  • There was a strong culture of service improvements and research. There were a number of research studies ran by the National Institute of Heath Research (NIHR) studies, which the critical care unit were involved in. We saw poster presentation that had been presented at National conferences in 2016.

However:

  • Data from the East of England critical care network showed that between April 2015 and March 2016 there were 776 delayed discharges (discharges delayed between 4-24 hours).It was recognized that the critical care unit was working hard to improve this by early identification of patients that could be discharged and escalating to the control and command centre. Bed capacity throughout the hospital contributed to these delays.
  • The result of these delays meant that 32 patients in September 2015 across critical care, were transferred between 10pm and 7am.However, it was noted that numbers had been declining since the early months of 2015 to the latter months. This was due to actions, such as early identification of patients ready for discharge in the day and escalation to the control room.
  • During August 2016, seven patients had been identified as requiring level one care, but remained on the unit. We were not assured that mixed sex breaches were being robustly reported, as we were told that only those delayed “overnight” were reported internally but not declared externally.

Services for children & young people

Good

Updated 18 January 2017

We rated this service as good because:

  • The service managed safety well. Staff knew how to report patient safety incidents and what should be reported as an incident. Managers investigated when things went wrong and shared lessons to be learnt with all staff to help prevent further similar incidents.
  • Medical and nursing staff knew that when things went wrong with care and treatment they needed to inform patients honestly, give them support and apologise to them verbally and in writing. This process is known as duty of candour.
  • Duty of candour training and knowledge was good across medical and nursing staff.
  • Equipment servicing was up to date and equipment checked was safety tested.
  • Clinical areas were visibly clean.
  • The service had enough staff to keep patients safe and to provide the care they needed. Staffing levels for senior doctors, nurses and healthcare assistants consistently met demand.
  • We found good transitional care services at Addenbrooke’s Hospital for patients transferring from children’s services to adult services.
  • The hospital had good systems in place to continually improve the quality of their services and protect high standards of care.
  • The divisional leadership team were knowledgeable about the service and understood the constraints within which the service was working.
  • There was a strong culture of openness and transparency within children and young people’s services.
  • Staff provided kind compassionate care to patients and families in all areas we visited.
  • Patients and relatives felt informed and included in the decisions being made about their care.

However:

  • Staff on adult wards caring for young people aged 16 and 17 did not undertake children’s safeguarding level three training in line with the Intercollegiate Role Framework.
  • Staff management of controlled drugs in children’s intensive care was a concern. Staff left controlled drugs keys unattended and hung on portable workstations.
  • Senior management raised concerns about the lack of acute paediatric beds available across children’s services.
  • The children’s divisional management team told us that 250 scheduled admissions were cancelled between January 2016 and August 2016 due to a lack of beds.
  • Between September 2015 and August 2016, the trust cancelled 132 procedures for children and young people. Of these 121 were rebooked within 28 days of the procedure being cancelled and 11 patients waited longer than 28 days to be rebooked.
  • Staff did not receive training in how to take patient’s consent for treatment. Staff delegated the task of consent should have completed a consent competency package according to the trust consent to examination, treatment and post mortem policy. However, the trust provided no detail on completion of this.

End of life care

Good

Updated 18 January 2017

We rated end of life services as good because:

  • Patients were well cared for and kept safe from avoidable harm. Staff worked to clear guidelines and policies, and were all up to date with mandatory training, including on how to manage risk and safeguard patients from abuse.
  • Staff used good infection control techniques, such as use of personal protective equipment and disposal of waste.
  • Staff provided care personalised to each patient and in line with national guidance. , That was reflected in care records that were well organised and accessible.
  • The service was responsive to patients’ needs. Patients referred to the service were seen promptly and the team was responsive to their individual needs throughout their care, including managing their pain and symptoms with anticipatory medication. The team tried hard to improve discharge times so that patients at the end of their lives could be in the place of their choice.
  • Staff were exceptionally caring and compassionate. They treated patients with dignity and respect, and were responsive to the needs of patients and visitors. We saw outstanding examples of how staff had fulfilled patients’ dying wishes, including by arranging a wedding in the hospital, moving a patient’s wife of 65 years into the bed next to him so they could hold hands, and tracking down a patient’s daughter so she could be with him before he died.
  • The service had good governance arrangements for continually improving the quality of their services and safeguarding high standards of care.

However:

  • There were inconsistencies in the types of care plan used, with no specific replacement of the Liverpool care pathway, a care pathway covering palliative care options for patients in the final days or hours of life.
  • The hospital did not meet the staffing levels within the palliative care team, as recommended by the Association for Palliative Medicine in Great Britain and Ireland, and the National Council of Palliative Care.
  • Half of DNACPR forms reviewed were completed incorrectly.
  • Patient wishing to die at home could go on a fast track discharge. The average time for this was 3.84 days. Although there had been recent improvements this did not meet the recommended time of 2 days.

Outpatients

Good

Updated 18 January 2017

Overall, we rated the outpatient and diagnostic imaging service as good. We rated outpatient and diagnostic imaging as good for safe, caring and well led. We rated responsiveness as requires improvement and although effectiveness of the service was inspected, we did not rate it. We found:

  • The trust had taken action to ensure that patients awaiting appointments were being risk assessed to enable appointments to be booked in order of clinical priority.
  • There had been improvements with appointment slot issues (ASIs) and did not attend (DNA) rates since our inspection in February 2016.
  • Staff received feedback about incidents that happened in their area and there was evidence of learning.
  • Staff received appraisals and there was effective multidisciplinary working within the department.
  • Staff were caring and patients and carers spoke positively about the care and compassion shown by all clinic staff. Friends and family test (FFT) data showed 93.8% of patients would recommend the service although this was based on a low response rate.
  • Medical staff planned and delivered patient care and treatment in line with current evidence-based guidance, standards, best practice and legislation.
  • The board and other levels of governance within the trust worked effectively together and interacted with each other regularly. Structures, processes and systems of accountability were clearly set out, understood and effective.

  • Staff gave us numerous examples of innovations and improvements which had been introduced across OPD and DI as well as plans to improve sustainability.

However, we found:

  • There were still appointment backlogs in some specialties.
  • The trust was failing to meet referral to treatment time in six of the 18 specialties. However, this was an improving performance since our last inspection.
  • There were waits of longer than six weeks for some diagnostic tests.
  • FFT response rates were low.