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Royal Devon & Exeter Hospital (Wonford) Good

This service was previously managed by a different provider - see old profile

Inspection Summary


Overall summary & rating

Good

Updated 9 February 2016

We inspected Royal Devon and Exeter NHS Foundation Trust as part of our programme of comprehensive inspections of all NHS acute trusts. The trust was identified as a low risk trust according to our Intelligent Monitoring model. This model looks at a wide range of data, including patient and staff surveys, hospital performance information and the views of the public and local partner organisations. Level 6 is the lowest level of risk which the trust had been rated since march 2014.

The inspection took place on 3 – 6 and 10 and 16 November 2015 and included Wonford Hospital and Mardon Neuro-Rehabilitation Centre

We did not inspect the following locations:

Royal Devon & Exeter Hospital (Heavitree)

Honiton Hospital

Okehampton Community Hospital

Tiverton District Hospital

East Devon Satellite Kidney Unit

Exmouth Hospital

Axminster Hospital

South Devon Satellite Kidney Unit

Victoria Hospital Sidmouth

North Devon Satellite Kidney Unit

We rated the Royal Devon and Exeter NHS Foundation Trust as good overall. Wonford Hospital was rated as good overall with two services, urgent and emergency care being rated as outstanding overall. The teams in these areas demonstrated they were very well led clinically and went the extra mile in caring for their patients. The Mardon Neuro –rehabilitation Centre was rated as requires improvement overall. At trust level safety was rated as requires improvement and we rated it as good for effective, responsive and the well-led key questions. As well as the two services – A&E, and critical care, where caring was judged to be outstanding, all other services were rated as good for caring with an overall trust rating of outstanding for this domain..

Our key findings were as follows:

  • The chief executive had been in post for 18 years at the time of the inspection. It appeared that the Chair and Chief Executive had a supportive relationship and worked well together. The board overall had the experience, capacity and capability to lead effectively.
  • The trust culture is strongly focused on quality and safety with patients being the absolute priority. There was tangible evidence of the culture in trust policies and procedures. This was also a consistent theme in the feedback from staff at all levels in the focus groups and drop in sessions held during the inspection.
  • There was an incident review group which reports to the Clinical Governance Committee reviews all incidents that are categorised as amber or red. The culture of reporting incidents was seen to be good with all staff being aware of their responsibilities.
  • Staffing in wards was reviewed on a regular basis with evidence of skill mix changes and additional posts being created in some areas. Other areas were finding it hard to recruit with some reliance on bank or agency staff.
  • There had been no grade 3 or 4 hospital acquired pressure sores for 10 months prior to the inspection. Where increases in pressure ulcers and falls had occurred staff worked together to review practice and implement new ways of working to reduce risk and maintain patient safety. Of note was the emergency department, where staff worked closely with the ambulance service to identify patients at risk of pressure damage prior to arrival. This meant measures to further reduce risk were put in place in a timely way.
  • Survival rates for patients who suffered a cardiac arrest were double the national average. An area in which the trust had worked hard to improve outcomes for patients.

  • Medical records were not always kept secure to prevent unauthorised access. We have raised this in the areas of concern for the trust to take action.

  • The trust had not met the cancer referral to treatment targets for some months but had worked to put in place additional urology and endoscopy lists and was anticipating being back on target by December 2015.
  • The overall trust target for mandatory training was 75% which had been achieved for topics such as safeguarding. There were some topics which were above the target and some slightly under the target.
  • Staff reported communication was good in their local teams through use of ‘Comm cells’. These took place regularly with discussions including training, complaints incidents and well as feedback of results of audits.
  • We observed good interactions between staff, children, young people and their families. We saw that these interactions were very caring, respectful and compassionate. Parents were encouraged to provide as much care for their children as they felt able to, whilst young people were encouraged to be as independent as possible.
  • Meeting the needs of people living with dementia was being developed on Kenn and Bovey wards with activities such as knitting, reading and discussion. The staff had recognised the need to relieve patient boredom which may have resulted in patients challenging behaviour.
  • The trust had no never events since 2013. Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. NHS trusts are required to monitor the occurrence of Never Events within the services they commission and publicly report them on an annual basis.
  • The trust performed well on infection rates having had no incidents of MRSA blood stream infection since 2011.
  • Outcomes for patients were good in all services and outstanding in emergency care. All participated in programmes of audit in line with national guidelines and evidence based practice. The trust performed well in a number of these including patient reported outcomes of hip and knee surgery and audits for lung and bowel cancer.
  • In line with national changes to guidelines, the trust and specialist palliative care team had responded to the 2013 review of the Liverpool Care Pathway by putting temporary guidelines in place to ensure appropriate care was maintained. The hospital was one of only three acute hospitals in the UK to have wards recognised to meet the standard of the Gold Standards Framework for the care they provide to patients who are nearing the end of their lives. This was awarded to Yeo and Yarty wards.
  • Leadership in the majority of services was seen to be good and at times outstanding, with governance systems and culture driving improvements in treatment and person centred care.
  • Access and flow was managed and overseen by the bed management team who met three times a day to assess the flow and bed status of the hospital. These daily meetings included a range of senior staff attending. We saw that a cohesive approach to the anticipated number of admissions, discharges and any other operational issues were discussed and plans to maintain flow reviewed at each meeting.

We saw several areas of outstanding practice including:

  • The emergency department had agreed with the ambulance service that crews would radio ahead to tell staff that that they were bringing a patient with a suspected broken hip. This gave nurses time to inflate a pressure relieving mattress for the trolley on which the patient would be treated. In this way, pressure ulcers would be prevented but X-rays could still be carried out without moving the patient.
  • The computer system would alert staff when a child with a long-term illness arrived in the emergency department. Care plans for each child were immediately available so that they received treatment and care that was specific to their condition.
  • The care being provided by staff in the critical care unit went above and beyond the day-to-day expectations. We saw patients’ beds being turned to face windows so they could see outside, staff positively interacting with all patients and visitors and evidence of staff going out of their way to help patients. Patients and visitors gave overwhelmingly positive feedback.
  • A member of staff was on duty at the reception area of the maternity wards to ensure the security and safety of the wards, women and babies. One member of staff employed through an agency to provide security was spoken of highly by patients and staff alike. They commented on their unfailing cheerfulness, politeness and support to them during visiting times and when staying in the hospital.
  • Royal Devon and Exeter NHS FoundationTrust is one of only two trusts in the country with recognition in achieving the Gold Standards Framework for end of life care, with three wards accredited and one deferred. Plans to extend the gold standard to further wards demonstrated an outstanding commitment by ward staff and the specialist palliative care team to end of life care.
  • A significant training programme 'opening the spiritual gate' had been invested in and had been rolled out to medical, nursing and allied health professional staff to offer spiritual care, especially around the end of life.
  • The cancer service was leading a project centred on the ‘Living with and beyond cancer’ programme. This programme was a two year partnership between NHS England and Macmillan Cancer Support aimed at embedding findings and recommendations from the National Cancer Survivorship Initiative into mainstream NHS commissioning and service provision. Patients in the cancer service who were deemed to be at low risk, were discharged and given open access to advice. In the gynaecology clinic, clinicians contacted patients by telephone to follow up treatment and in haematology; this process was done by letter. Results showed that 94% of patients who were participating in the programme rated it as good or excellent.

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

Importantly, the trust must:

  • The trust must take action to ensure that facilities for children in the emergency department comply with the national Standards for Children and Young People in Emergency Care Settings 2012.
  • Ensure patient information remains confidential through appropriate storage of records to prevent unauthorised people from having access to them in medical, surgical and maternity wards and outpatients departments.
  • Ensure staff have access to current trust approved copies of the Patient Group Directions (PGDs) and that only permitted professional groups of staff, as required under the relevant legislation, work under these documents.
  • The critical care unit must ensure adequate medical staff are deployed at all times. Current overnight levels did not meet the ratio of one doctor to eight patients, as recommended by the Core Standards for Intensive Care Units (2013).
  • Chemicals and substances used for cleaning purposes that are hazardous to health (COSHH) were observed in areas that were not locked and therefore accessible to patients and visitors to the wards. The trust must ensure that cleaning materials including chlorine tablets are stored safely.
  • Ensure that adequate medical physics expert cover is available in the nuclear medicine service.
  • Ensure there are sufficient staff deployed to meet demand in ophthalmology and gastroenterology outpatient clinics
  • Ensure patient privacy in outpatient clinics is maintained.
  • Ensure the steps put in place to reduce the length of time that patients living with cancer must wait for treatment are sustained to deliver services in accordance with the ‘cancer wait’ targets set by NHS England.

In addition the trust should:

  • Ensure that there is sufficient space to treat patients requiring resuscitation and major treatment in the emergency department.
  • Ensure that all patients in the emergency department waiting room can be observed by staff at all times.
  • Ensure that there is band 7 nurse in charge of the emergency department on each shift in line with NICE recommendations.
  • Ensure that accurate, complete and detailed patient records are maintained.
  • Medicines must be stored securely and safely at all times. Intravenous fluids should be stored securely so as not accessible to the public and patients.
  • Ensure that appropriate measures are put in place on admission to the AMU for patients who are at risk from attempting suicide. This should include the appropriate assessments of risk for staff to follow and a suitable and safe environment for patients.
  • Ensure where patients between the ages of 16 and 18 are admitted to the AMU that this is agreed to be the most appropriate environment for them.
  • The maternity service should review and record the staffing levels to ensure all maternity wards are safely staffed at all times including theatre and recovery
  • Ensure that all areas used by children are child friendly and should particularly consider improving the environment for children in the outpatients department and theatre recovery rooms.
  • Ensure staff on the critical care unit are fully aware of their duty to report incidents, including near misses and no-harm incidents.
  • The critical care unit should review compliance against the Department of Health’s building note HBN 04-02
  • Resuscitation trolleys in the critical care unit should be tamper-evident.
  • Staff in the critical care unit should have a thorough understanding of the Deprivation of Liberty Safeguards.
  • Mandatory training updates and annual appraisals for critical care staff should meet trust targets.
  • There should be access to a follow-up clinic for patients discharged from the critical care unit.
  • The hospital should improve the access and flow of patients in order to reduce delays from critical care for patients being discharged to wards and reduce occupancy to recommended levels.
  • Screening of patients who were admitted as an emergency to hospital for gynaecology care and treatment should consistently be screened for MRSA.
  • Action should be taken to address the shortfalls identified in staff hand hygiene audits in the maternity services.
  • The labour ward should ensure that emergency resuscitation equipment was checked regularly and a record maintained to show it was ready to use.
  • Care plans should be consistently completed to provide staff with full detail regarding the patients’ assessed care needs. End of life documentation in patient records is completed consistently.
  • The trust should take action to ensure compliance with national guidelines regarding baby identification labels.
  • The maternity service should provide evidence to demonstrate women received pain relief in labour within appropriate timeframes. Sufficient equipment should be available, for example pumps to self-administer analgesia, for women during labour.
  • Ensure all decisions around ‘do not attempt resuscitation’ status and treatment escalation plans are communicated at nurse-doctor handover
  • Review the leadership and accountability structure of the medical outpatient service
  • The hospital should review the facilities available for children in the outpatient service.
  • Ensure staff in the orthopaedic outpatients department are able to access equipment to take patients height and weight.
  • Ensure that all clinical staff receive adequate clinical supervision to support them in their role

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 9 February 2016

Effective

Good

Updated 9 February 2016

Caring

Outstanding

Updated 9 February 2016

Responsive

Good

Updated 9 February 2016

Well-led

Outstanding

Updated 9 February 2016

Checks on specific services

Maternity and gynaecology

Good

Updated 9 February 2016

We judged the maternity and gynaecology services were effective, responsive and well led. We rated the maternity and gynaecology services as outstanding for caring.

We have judged safety in the maternity and gynaecology services as requiring improvement. Medicines was not secured at all times which meant it could have been used or abused by visitors or patients on the ward. Cleaning chemicals were not stored securely on the wards and units which meant they were accessible to patients and visitors who may have been at risk from these.

Patient’s confidential and personal information was not stored securely at all times on the wards and in the clinics. This meant it was accessible to others.

The staffing levels on the maternity unit were affected when cover was required in the labour ward to ensure women received 1:1 care. At times this meant other areas were left staffed below the planned establishment level. The midwife to patient ratio was below the recommended levels set by the Royal College of Obstetricians and Gynaecologists (RCOG 2007) Safer Childbirth Minimum Standards for the Organisation and Delivery of Care in Labour. The RCOG states there should be an average midwife to birth ration of 1:28 but at this trust in September 2015 the ratio was 1:34.

Nursing and midwifery staff were encouraged to report incidents and robust systems were in place to ensure lessons information and learning.

The maternity and gynaecology service were responsive to the needs of women living locally and those further away from the hospital. Services were provided in the areas where women lived for example, ante and postnatal clinics. Women had access to maternity and gynaecology emergency clinics seven days a week.

All wards and departments we visited were visibly very clean and hygienic in appearance. We saw staff adhered to the trust policies and procedures regarding infection control. However, audits conducted by the trust showed inconsistencies amongst staff regarding hand hygiene.

Care was delivered in line with the Royal College of Gynaecologists and Obstetricians standards and the National Institute for Health and Care Excellence (NICE) guidelines

It was clear that staff worked well as a cohesive and effective team across the maternity services and gynaecology speciality as well as with other departments of the hospital. The culture of the hospital was inclusive, supportive and staff spoke often as being part of a large family when at work. This cascaded to the patients who spoke of a warm and caring environment.

Women received their care and treatment from trained and competent staff who were supported by their line managers to provide an effective service. Consultant, nursing and midwifery leadership was described as good, with practical examples given by staff to support their experience.

These were overwhelmingly positive and complimentary about the care and service provided with the exception of one comment where the patient felt they had received conflicting information. Patients all said they were treated with respect, their dignity promoted and that staff were kind and helpful.

We observed patients were treated with respect, their dignity promoted and they were involved in discussions about their care and treatment. Patients felt they were listened to and their choices and preferences respected.

The organisation welcomed feedback from staff and there was a culture of listening to staff and learning from incidents. Clear evidence was available to support that the services were well led at a local level. Staff were able to meet with their managers regularly and approach them for support and guidance. Staff all commented they felt proud to work in the trust and felt they were a cohesive dedicated team who were well supported in their roles.

There were comprehensive risk, quality and governance structures and systems in place though some risks had been on the risk register for a considerable length of time.

Medical care (including older people’s care)

Good

Updated 9 February 2016

Safety in the medical directorate was rated as requires improvement.

People were not always protected from the risks relating to the control substances hazardous to health (COSHH) such as cleaning materials stored in unsecured areas that patients and the public could access. Patients with mental illness in the acute medical unit (AMU) were not always well managed. The environment and management of risks was not always possible to keep those vulnerable patients safe.

Management of medicines was not consistently safe and did not meet pharmaceutical guidelines. Cupboards for intravenous fluids were not all lockable with some doors missing. This meant those fluids were not secured.

The management of patient records did not ensure patient’s details were safe and that confidentiality was assured.

Patients received effective care and treatment that was delivered in accordance with evidenced-based guidance, standards and best practice. The trust participated in local and national audits and used the outcomes to improve services.

Patients received their care and treatment from competent staff who were provided with appraisals and training. But staff training to support patients with learning disabilities was limited. Dementia training varied from ward to ward so staff skills varied.

Caring for patients in the medical areas was assessed as good. Patients and their relatives spoke positively about the care they received at the Royal Devon and Exeter Hospital. Patients were treated with respect and dignity and their choices and preferences were taken into account when planning care and treatment. Patients felt included in decisions about them and were clear about their plan of care and what was happening next for them.

However, we saw two occasions when care was not always good and staff did not ensure patient dignity was maintained.

Services were mostly responsive to patient’s needs. The bed management team ensured flow through the hospital. There were some delays in discharge but wards and departments were working to ensure areas of delay were identified and plans put in place to improve discharge.

The medical services were well led. At ward level junior medical and nursing staff were clear about how to ask for help and how to escalate concerns; they had confidence in senior ward staff. Staff were aware of leadership at a divisional level. Some disconnect was noted at this level with staff not sure how information they had provided was used once escalated. Staff were aware of the hospital board staff and felt they were accessible in the hospital.

Staff were aware of the hospitals vision and values and staff spoke of the family atmosphere of working in the hospital.

Urgent and emergency services (A&E)

Outstanding

Updated 9 February 2016

Overall, we rated the emergency department as outstanding. There was a committed team of staff who demonstrated a cohesive, multidisciplinary approach to the care and treatment of their patients. They respected each other’s skills, experience and competencies in a seamless and professional manner that benefitted the people who used the service.

Openness and transparency about safety was encouraged. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. They were fully supported when they did so. When something went wrong, there was an appropriate and thorough investigation that involved all relevant staff. Lessons were learned and communicated widely to support improvement. Facilities for children did not fully comply with national standards. Children’s treatment rooms were not separated from adult areas and the equipment was not always suitable for a children’s environment.

Staffing levels and skill mix were planned, implemented and reviewed. Staff had received up-to-date and relevant training and were encouraged to develop their skills. Risks to people who used the department were assessed, reduced, monitored and managed on a day-to-day basis. All staff were actively engaged in activities to monitor and improve quality and outcomes. Opportunities to participate in benchmarking, peer review, accreditation and research were proactively pursued. High performance was recognised by credible external bodies such as the National Patient Safety Agency.

Feedback from people who used the service and those close to them was continually positive about the way staff treated them. They thought that staff went the extra mile and the care they received exceeded their expectations. There was a strong, visible person-centred culture. Staff were highly motivated to offer care that was kind and promoted people’s dignity. Interaction between patients, those close to them and staff was strong, caring and supportive.

Changes had been made to working practices in order to reduce delays. Waiting times and avoidable delays were minimal and managed appropriately. The department had been meeting the four hour target to admit or discharge patients since June 2015. Performance throughout the year had varied from 93% to 96% which was better than most other hospitals in England. There were very few delays for ambulance patients and people were kept informed of any disruption to their care or treatment. The needs of people with complex needs were well understood and addressed appropriately. People with dementia received care and treatment that was sympathetic and knowledgeable.

It was easy for people to complain or raise a concern and they were treated compassionately when they did so. There was openness and transparency in how complaints were dealt with. Governance and performance were proactively reviewed and reflected best practice. Lessons learned and changes in practice were communicated to staff via monthly governance meetings and newsletters. More immediate feedback was given to staff via thrice weekly “Communication Cells”. Leaders displayed a strong sense of shared purpose, strived to deliver excellent patient care and motivated staff to succeed.

There was strong collaboration and support between all groups of staff and a common focus on improving quality of care and people’s experiences. This led to high levels of staff satisfaction across all groups. Staff were proud to work in the department and spoke highly of the culture.

Surgery

Good

Updated 9 February 2016

We have judged surgery overall as good.

Staff were open and honest about incidents and knew how to report them using the trust system. We saw evidence of learning from incidents and staff were able to tell us about the changes to their practice that had taken place as a result.The trust encouraged an open culture. Staff were aware of the principles of duty of candour and always apologised to patients when things went wrong.

We observed good use of five steps to safer surgery that included the surgical safety checklist and briefing sessions, which all staff were aware of their roles and responsibilities.All the wards and units we visited were clean and staff followed infection prevention and control protocols. We heard high praise from patients for the domestic staff.The trust had no reported cases of hospital associated methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia since September 2011.

The hospital performed well in a number of national audits, including the Patient Reported Outcome Measures (PROMs) for April 2014 to March 2015 which is based on patients reporting to the hospital on their outcome following surgery for groin hernias, hip replacements, knee replacements, and varicose veins. The trust also performed well in national cancer audits, including those for lung and bowel cancer. A number of the surgical specialties were involved in national audits and were introducing new initiatives including a remotely led clinic for monitoring patients with prostate cancer.

There was a varied result in the standardised risk of readmissions to elective and non-elective patients (readmission rates after surgery for corrective measures or infections). There was a slightly higher risk of readmission for elective patients compared with the England average, and a slightly lower risk for non-elective patients. The average length of stay (LOS) for surgical patients within the hospital was the same as the England average.

All the feedback we received from patients and their relatives about their treatment by staff was positive. Patients gave us individual examples of where they felt staff ‘went the extra mile’ and exceeded expectations with the care they gave. Patients felt staff maintained their privacy and dignity at all times and provided them with compassionate care.

Between April 2013 and February 2015, the trust performed better than the England average for the percentage of admitted patients seen within the 18-week target time following referral. The number of operations cancelled at the hospital was below (better than) the England average until the months of October to December 2014. The percentage of patients not treated within 28 days of a cancelled operation was above (worse than) the England average for January to June 2015. This improved and, at the time of our inspection, the number of patients not rebooked in the 28-day time scale was below the England average.

Staff supported people with a learning disability and those living with dementia to improve their experience of hospital. Staff were kind and patient with people living with dementia and we observed one-to-one care taking place. A specialist team of nurses in the hospital provided support to patients living with a learning disability and staff caring for them.

The service leadership was good, and a cohesive clinical governance structure showed learning, change and improvement took place. Managers regularly reviewed the approach to risk management in the departments. A number of specialty meetings fed into the overall clinical governance and provided board assurance.

The trust used patient feedback to make changes to its services.

We found patient records were not being stored securely on the wards so that unauthorised people had access to them.

We found Patient Group Directions (PGDs), (written directions that allow the supply and / or administration of a specific medicine by a named authorised health professional to a well-defined group of patients for a specific condition) were being used without the correct trust authorisation and this potentially breaches the Human Medicines Regulations and this potentially placed both patients and staff in the West of England Eye Unit at risk.

Intensive/critical care

Outstanding

Updated 9 February 2016

We have judged the overall critical care service as outstanding. Caring and leadership was outstanding. The safety, effectiveness and responsiveness of the service were good, with some elements of outstanding.

Treatment by all staff was delivered in accordance with best practice and recognised national guidelines. There was a holistic and multidisciplinary approach to assessing and planning care and treatment for patients. Patients were at the centre of the service and the overarching priority for staff. Innovation, high performance and the highest quality care were encouraged and acknowledged. All staff were engaged in monitoring and improving outcomes for patients. They achieved consistently good results with patients who were critically ill and with complex problems and multiple needs. The whole service had a collaborative approach with a multidisciplinary attitude to patient care.

Patients were truly respected and valued as individuals. Feedback from people who had used the service had been overwhelmingly positive. Staff went above and beyond their usual duties to ensure patients experienced compassionate care and that care promoted dignity. People’s cultural and religious, social and personal needs were respected. Innovative support for patients, such as the development of patient diaries, was encouraged and valued. Staff took the time to ensure patients and their families understood and were involved with care plans.

The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care. All the senior staff were committed to their patients, their staff and their unit with an inspiring shared purpose. There was strong evidence and data to base decisions upon and drive the service forwards from a clear programme of audits and national evaluative studies. Staff, patients and their families were actively engaged with to identify areas of good practice, as well as areas that could be improved. There was a high level of staff satisfaction, with staff saying they were proud of the unit as a place in which to work. They spoke highly of the culture and consistently high levels of constructive engagement. The leadership drove continuous improvement and staff were accountable for delivering change. Innovation and improvement were celebrated and encouraged, with a proactive approach to achieving best practice and sustainable models of care.

There was a good track record on safety, and lessons were learned and improvements made when things went wrong. This was supported by staff working in an open and honest culture and by a desire to get things right. There were reliable systems and staff received training to keep people safe from abuse. The environment did not meet all the requirements for modern critical care units, being an older unit, and this was recognised by the trust. The unit was generally clean and well organised. Staff adhered to infection prevention and control policies and protocols. There were good levels of nursing staff meeting the Core Standards for Intensive Care Units (2013) to keep patients safe. However, overnight medical cover did not meet the core standards and there were times when a doctor was not available on the unit because they were attending a medical emergency call elsewhere in the hospital.

The critical care service responded well to patients’ needs. Communication aids, including translation services, were available for patients who could not otherwise communicate easily or effectively. There were bed pressures in the rest of the hospital that meant about 50% of patients were delayed in their discharge from the unit, but the numbers of these incidences were below the NHS national average. Very few patients were discharged onto wards at night and there was a very low rate of elective surgical operations being cancelled because a critical care bed was not available. The facilities for patients, visitors and staff in critical care were good. There was quick input from consultants and nurses when new patients were admitted. Patients were treated as individuals, and link nurse roles were used to support specific aspects of patient need.

Services for children & young people

Good

Updated 9 February 2016

Services for children and young people were judged to be good. We found that services were safe, effective, caring, responsive and well-led.

Risk was managed and incidents were reported and acted upon with feedback and learning provided to most staff. Staff adhered to infection prevention and control policies and protocols. The units were clean and well organised and suitable for children and young people.

Treatment and care were effective and delivered in accordance with best practice and recognised national guidelines. There was excellent multidisciplinary team working within the service and with other agencies.

Children and young people were at the centre of the service and the priority for staff. Innovation, high performance and the highest quality of care were encouraged and acknowledged.

Care and treatment of children and support for their families was delivered in a compassionate, responsive and caring manner. Parents spoke highly of the approach and commitment of the staff who provided a service to their families. Children, young people and their families were respected and valued as individuals. Feedback from those who used the service was consistently positive. Children received excellent care from dedicated, caring and well trained staff who were skilled in working and communicating with children, young people and their families.

Staff understood the individual needs of children, young people and their families and designed and delivered services to meet them.

There were clear lines of local management in place and structures for managing governance and measuring quality. The leadership and culture of the service drove improvement and the delivery of high-quality individual care.

All staff were committed to children, young people and their families and to their colleagues. There were high levels of staff satisfaction with staff saying they were proud of the units as a place to work. They spoke highly of the culture and levels of engagement.

There was a good track record of lessons learnt and improvements when things went wrong. This was supported by staff working in an open and honest culture with a desire to get things right.

End of life care

Good

Updated 9 February 2016

End of life care was judged to be good overall. The service had enough staff with the appropriate skills to provide care. Although the trust had identified vacancies across nursing and medical staff posts this had not affected end of life care. Trust staff and the end of life team followed systems, processes and practices to keep patients safe. Staff kept adequate patient records, which were audited, and we found evidence of continuous improvement in record-keeping.

The service learned lessons from incidents and complaints, and made improvements when things went wrong and had followed duty of candour process.

Patients’ care, treatment and support achieved good outcomes, promoted a good quality of end of life and was based on the best available evidence. Staff assessed patients’ needs and provided care and treatment in line with legislation, standards and evidence-based guidance including well managed pain and nutrition and hydration. The service monitored patients’ care and treatment outcomes through audit, which compared well with other similar services. Specialist staff had the skills, knowledge and experience to provide effective end of life care. Training rates in relation to end of life could be improved across the trust. End of life care documentation (for instance, treatment escalation plans) and recording in patients’ notes had improved but use of some forms and sharing of information needed improvement which had been noted in audit outcomes.

Staff treated patients and those close to them with kindness, dignity, respect and compassion. Hospital staff demonstrated an understanding of patients personal, cultural, social and religious and spiritual needs. Patients and bereaved relatives were involved as partners in their care contributing to patient records and engaging in bereavement groups set up by the trust. Support was available to enable patients and those close to them to have the support they needed to cope emotionally with their care, treatment or condition with the provision of support from volunteers and chaplaincy services.

Services were planned and provided to meet the needs of patients and those close to them, taking account of the needs of patients including those with learning disabilities and those with dementia,. Patients could access care and treatment in a timely way with a few exceptions such as occasional delays in discharge. There were excellent communication links between specialist palliative care team members, palliative discharge team and community nursing staff and others. Patients and those close to them who raised concerns and complaints were listened and responded to, and staff used the experience and information shared to improve the quality of care.

The leadership of end of life care was evident from all staff. The service had a clear vision and strategy to provide good quality end of life care, and leaders recognised that progress was still needed. The governance framework ensured that responsibilities were clear and lead roles within the trust and specialist palliative care team had a detailed service level agreement.

The trust encouraged openness and transparency and promoted good quality care. Patients and others who used the service, the public and staff were engaged and involved in the delivery and development of it.

Outpatients

Requires improvement

Updated 9 February 2016

We judged the outpatients and diagnostic imaging services as requiring improvement overall. Safety was rated as requires improvement. In some clinics, patient records were not always stored securely and this meant that the confidentiality of patient information could not be guaranteed. We saw that staffing was a challenge for some teams. In particular, there was insufficient medical physics cover to provide consultation on patient dosimetry, quality assurance, and advice regarding radiation protection concerning medical exposures. Staff were aware of their responsibility to raise safeguarding concerns and they understood their responsibility to report incidents.

We saw that some aspects of care in the outpatients service were not effective. Clinical supervision was not offered to nursing staff. This impacted upon patient care because it meant that staff were not regularly reflecting on their performance in terms of the quality of care given to patients. However, outpatient teams were utilising a quality assessment tool to peer review the quality of care received by patients in the clinics. There was some evidence of best practice within radiology. Referrers to the radiology department were encouraged to use an evidence based referral system and the radiology service held accreditation with the Imaging Services Accreditation Scheme. However local diagnostic reference levels had not been adopted in radiology.

We rated caring as good Staff in all departments including those in managerial and clerical roles demonstrated a compassionate understanding of the needs of patients. Patients told us they were able to understand their condition because the nurses had taken time to explain it to them

We rated responsiveness as requires improvement. There were long waits for people who needed treatment for cancer. During 2014/2015, 115 patients had waited more than 62 days for their cancer treatment. There were also delays for treatment in ophthalmology, orthopaedics, and cardiology. Rapid access clinics had been introduced where needed and the teams had used creative ways to reduce the requirement for face to face consultations In some clinics, the privacy and the safety of patients was not well accommodated by the environment, for example there was insufficient room in the ophthalmology department to fit adequately curtained vision aisles.

We rated well led as good. There was a vision for the remodelling of the outpatients service as a whole, and the challenges regarding lack of capacity within the ophthalmology service were being addressed by the planned relocation of the service in January 2016. There was clear governance process around the risks associated with delays to treatment for patients living with cancer. The trust had a clear and focussed plan to reduce the time that patients had to wait for treatment for cancer and for other conditions. Key aspects of the plan were already in place with additional capacity fully commencing in December 2015. Leaders in the trust were well respected and staff told us they felt proud to work for the trust