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Royal Berkshire Hospital Requires improvement

We are carrying out checks at Royal Berkshire Hospital using our new way of inspecting services. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 25 April 2016

The Royal Berkshire Hospital is the main hospital site of the Royal Berkshire NHS Foundation Trust. The hospital provides maternity and gynaecological services to the population of West Berkshire. Between April 2014 and April 2015 the trust reported there were 5681 births of which 161 were delivered outside the Royal Berkshire Hospital.

We carried out a comprehensive, unannounced inspection of the maternity and gynaecology services on the 11 and 12 November 2015, to check whether improvements had been made since the last comprehensive inspection in March 2014.

Overall we rated the service as requires improvement. We judged effective, caring and well led as good. Improvements were needed to ensure services were safe, and responsive.

Our key findings were as follows:

Safe

  • At the previous inspection in March 2014 we found there were insufficient staffing levels particularly on Rushey ward which had an impact on capacity and associated safety risks. We found improvements had been made in staffing levels across the maternity unit and capacity issues were escalated appropriately.
  • The number of major obstetric haemorrhages reported had significantly exceeded the trust goal of two per month between April to September 2015 with peaks of 13 and 14 in July and September respectively. A review of cases of major obstetric haemorrhage took place and was due to be presented at the maternity unit’s March 2016 academic half day.
  • The trust goal was to have midwife to birth ratio in line with Birthrate Plus of 1:28 by April 2017 and a 1:30 ratio in 2015-16. Between April to September 2015 the service was consistently operating at 1:30 or below and 1:35 in September 2015.
  • Staff work flexibly to consistently ensure women received one to one care in labour redeploying midwives to the delivery suite and on occasions closing Rushey ward, the midwifery led unit. Results were 100% for harm free care from May 2015.

  • Consultant cover remained below the recommended level of 168 hours per week. During the inspection in March 2014 the consultant cover was identified as between 68 to 91 hours per week, the trust had appointed two new consultants and was currently consistently achieving 91 hours a week of cover.
  • In March 2014 the ventilation system on the delivery suite did not meet the expected standards. The ventilation system used to remove used nitrous oxide from the air (produced when using entonox) had been replaced with a unit that met expected standards.
  • All clinical areas were appropriately equipped to provide safe care and were visibly clean. Time to effect equipment and maintenance repairs had improved since the last inspection due to closer monitoring and follow up.
  • Medicines management in the gynaecology service was not robust as there had not been a dedicated pharmacy service on the gynaecology ward since December 2014. For example, a pharmacist did not check prescription charts and medicines management was recognised as a risk on the service risk register. However, all the control measures in place were not strictly adhered to.
  • The gynaecology ward participated in the NHS Safety Thermometer. The NHS Safety Thermometer is a local improvement tool for measuring, monitoring and analysing patient harms and 'harm free' care. Results were 100% since May 2015 except for August 2015 and September 2015 when results were 91% and 94% respectively.

Effective

  • The normal delivery rate was comparable with the England average and the unassisted delivery rate was good when compared with the England average. Caesarean section rates were similar to the England average however instrumental delivery rates were slightly higher than the England average.
  • On the maternity and gynaecology wards care and treatment was delivered in line with current legislation and nationally recognised evidence based guidance. Policies and guidelines were developed to reflect national guidance. On the maternity unit, compliance was monitored and audited to ensure consistency of practice. There were some issues with accessing the policies and procedures on the gynaecology wards as the policies had been removed from the intranet whilst under review.
  • Breast feeding was encouraged and the midwifery services had achieved UNICEF ‘Baby Friendly’ status.
  • Staff had access to training and support to develop and maintain their competencies. New midwives were positive about the support they received through the preceptorship program. However, the supervisor to midwife ratio was 1:21 which was above national recommendation of 1:15, although 95.3% of midwives had a supervisor review in the preceding 12 months
  • When people received care from a range of different staff, teams or services, this was coordinated and staff worked collaboratively.
  • Staff were clear about their roles and responsibilities regarding the Mental Capacity Act (2005). Consent guidelines were followed appropriately.

Caring

  • Feedback from patients about their care and treatment was consistently positive. Patients were treated with kindness, compassion and dignity.
  • Women felt involved with their care, had their wishes respected and understood.
  • Staff helped people and those close to them to cope emotionally with their care and treatment.

Responsive

  • Between May 2015 to October 2015 the maternity unit was ‘on divert’ (closed) on 29 occasions for between 4 hours and 48 hours. The main reason for closure of the unit to new admissions was due to insufficient midwifery staff to maintain a safe service.
  • Women had access to gynaecological services within the maximum referral to treatment time period set by NHS England of 18 weeks.
  • Translation services were available, and a specialist team of midwives supported women with additional needs such as homelessness and substance abuse through pregnancy and child birth.
  • Complaints and concerns were taken seriously. Improvements were made to the quality of care because of complaints and concerns. For example, additional staff training.

Well Led

  • A new strategy and vision for the maternity service was under development, which included moving the gynaecology service from the planned care directorate to sit with the maternity service in the urgent care directorate.
  • There were comprehensive risk, quality and governance processes in the maternity service.
  • Staff across the maternity service described an open culture and felt well supported by their managers.
  • There was a system in place for the monitoring of quality and the delivery of the gynaecology service as part of the planned care directorate. however, learning from incidents was not robust.

We saw several areas of outstanding practice including:

  • Breast feeding was encouraged and the midwifery services had achieved UNICEF ‘Baby Friendly’ status.
  • A pink patient wrist-band system had recently been introduced for patients who had undergone surgery and had a vaginal pack in situ. This was to ensure the pack was subsequently removed.

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

Importantly, the trust must:

  • Review medicines management practices to ensure medicines are stored at the appropriate temperatures to protect patients from avoidable harm.

The trust should also:

  • Review the consultant obstetric cover to meet national recommendations.
  • Work towards reducing the number of times the midwifery service has to divert women to other centres.
  • Ensure confidential personal information, particularly that held electronically, is maintained securely to prevent unauthorised access.
  • Ensure systems are in place in the gynaecology service to allow staff to share learning from incidents.
  • Ensure staff have access to up to date policies and procedures relating to the gynaecology service.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 24 June 2014

Overall we rated the safety of services in the trust as ‘requires improvement’.

Nursing staffing levels were insufficient on many wards and consequently there was a significant reliance on agency and bank staff. The agency and bank staff were appropriately checked and had an induction checklist carried out. The trust was taking steps to recruit nurses internationally due to the difficulty in recruiting. Midwifery staffing was a concern in the Rushey unit, however, immediately after our inspection the trust closed two beds until further staff were recruited. Consultant presence in obstetrics was not in line with national standards. Medical staffing out of hours was a concern, particularly in medicine. Due to capacity pressures and workload, medical staffing needed improvement in some areas and in particular the critical care unit as consultants regularly needed to stay in overnight when they were on call.

Clinical data was not always easily accessible due to the fragmented structure of the trust’s electronic patient record (EPR) and patient records were not easily accessible or well-maintained with an over-reliance on ‘temporary’ records. This affected patient care as significant information was not available and in some instances patients had more than one test as the initial result was not available. The trust recognised the safety concerns relating to medical records and set up a working group led by the interim medical director to address the issues as a priority.

Medical equipment checks were not consistently completed or recorded and staff reported difficulties in being able to get equipment checked or replaced.

Effective

Good

Updated 24 June 2014

Overall we rated the effectiveness of the services in the trust as ‘good’.

Most patients were treated according to national evidence-based guidelines and clinical audit was used to improve practice. There were good outcomes for patients and mortality rates were within the expected range. Seven-day services were in development and there were good examples of seven-day working. There were good examples of robust ward rounds and multi-disciplinary team working with input from allied health professionals. There were examples of clear documented pathways of care. 

Caring

Good

Updated 24 June 2014

Overall we rated the caring aspects of services in the trust as ‘good’.

Overall, patients received compassionate care and were treated with dignity and respect. The Critical Care service provided some excellent caring interventions both for the patients and their families, with positive feedback about their bereavement service. Patients and relatives we spoke with said they felt involved in their care. There were examples of patients not feeling appropriately cared for in A&E and some ward areas where staff were busy. Staff acknowledged that, at times, workload pressures could prevent the level of care and support patients needed. Staff were extremely committed and aimed to put the needs welfare of patients as their priority.

Responsive

Requires improvement

Updated 24 June 2014

Overall we rated the responsiveness of services in the trust as ‘requires improvement’.

The trust faced significant capacity pressures. The A&E department was not consistently meeting the four-hour target for treatment, admission or discharge. The department was designed for 65,000 attendances but had around 100,000 attendances a year at the time of the inspection. This resulted in patients waiting in corridors to be seen and, in some instances, spending longer than 12 hours in A&E.

The flow throughout the trust was not robustly managed, with patients who were clinically fit for discharge not being discharged in a timely manner. There were significant waiting times for radiology diagnostic procedures, which impacted on both inpatients and outpatients. The trust was taking steps to improve the radiology waiting times and looking at other ways of providing diagnostic treatment.

The critical care capacity was not sufficiently meeting the demand and resulted in either patients’ operations being cancelled or patients staying in recovery overnight. The trust did not have clear robust plans to address the capacity and flow issues. However the appointment of the interim chief operating officer was intended to concentrate on addressing them.

Well-led

Requires improvement

Updated 24 June 2014

The trust’s leadership was rated as ‘requires improvement’. Many of the executive team were interim positions and the former chief executive had left in December 2013. The trust had proactively commissioned a review into its leadership and governance processes and we had confidence that they were beginning to take appropriate steps to address some of the trust wide issues found during the inspection. They were aware of the potential risks associated with interim posts and were in the process of appointing a new chief executive. This recent instability in leadership has resulted in front line staff not feeling fully informed about the recent changes and unclear on the overall vision for the trust. Staff did not feel the executive team were visible enough, although many staff told us that the Director of Nursing was more visible and had ‘made a difference’ in the relatively short time she had been in post since June 2012.

Whilst the trust board was aware of the improvements that were required, they were facing a legacy of some areas of governance not being standardised or robust and systems and process being inconsistently applied, which would take some time to address. During the inspection there was some evidence of improvement starting, but it was too soon to establish the impact. There were some areas that needed stronger leadership from the board to the ward to realise the required changes. 

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 25 April 2016

Maternity and gynaecology services were rated good for providing caring, effective and well-led services. However, improvements were required for safe and responsiveness, which were rated as requires improvement.

At the previous inspection in March 2014 we rated safe as inadequate due to insufficient staffing levels particularly on Rushey ward and the impact on capacity and associated safety risks. We also found the ventilation system on the delivery suite did not meet the expected standards. The trust had developed an action plan to address the failings identified. During the inspection in November 2015 we found improvements had been made in staffing levels across the unit and the way in which capacity issues were escalated. However, further improvements were required.

All major obstetric haemorrhages were reported within the maternity governance dashboard and showedthe number of cases had significantly exceeded the trust goal of two per month between April to September 2015, with peaks of 13 and 14 in July and September respectively.Although there had been no corresponding increase in admissions to the intensive care unit or maternal mortality. The trust reported a review of all the cases of major obstetric haemorrhage which had occurred between August to October 2015 had taken place as part of a clinical audit and was due to be presented at the maternity unit’s March 2016 academic half day.

The trust goal was to have a midwife to birth ratio of 1:28 by April 2017 which is the national recommendation. The trust plan for 2015-16 was to have midwife to birth ratio of 1:30. Between April to September 2015 the service was consistently operating at a ratio of 1:30 or above and was 1:35 in September 2015. However, the service had been able to deliver one to one care for women in labour by redeploying midwives to the delivery suite and on occasions closing Rushey ward, the midwifery led unit.

The Royal College of Obstetricians and Gynaecologists good practice guidelines 2010 states the recommended consultant cover for a maternity unit which delivers more than 5000 births a year should be 168 hours a week. At the previous inspection in March 2014 the consultant cover was identified as between 68 to 91 hours per week, the trust had appointed two new consultants and was currently consistently achieving 91 hours a week of cover. In 2016, further recruitment of consultant obstetricians as well as combined consultant posts with resident commitments will improve hours of consultant presence, working toward the target of 168 hours per week.

At the previous inspection in March 2014 we found the labour ward had an insufficient scavenging system to remove used nitrous oxide from the air (produced when using entonox). This had been addressed and was no longer on the service risk register. This had been replaced with a unit that met expected standards.

All clinical areas were appropriately equipped to provide safe care and were visibly clean. Time to effect equipment and maintenance repairs had improved since the last inspection due to closer monitoring and follow up.

Medicines management in the gynaecology service was not robust as there had not been a dedicated pharmacy service on the gynaecology ward since December 2014. For example, prescription charts were not checked by a pharmacist and medicines management was recognised as a risk on the service risk register. However, all the control measures in place were not strictly adhered to.

At the previous inspection we rated effective as requires improvement. This was due to the way the service performed in comparison to national and local benchmarks. For example, instrumental and caesarean section rates were higher than expected and there were a high number of delayed inductions of labour. During this inspection we found performance had improved and instrumental and caesarean section rates were comparable to the national average.

The gynaecology ward participated in the NHS Safety Thermometer.The NHS Safety Thermometer is a local improvement tool for measuring, monitoring and analysing patient harms and 'harm free' care. Results were 100% since May 2015 except for August 2015 and September 2015 when results were 91% and 94% respectively.

Care and treatment was delivered in line with current legislation and nationally recognised evidence based guidance. Policies and guidelines were developed to reflect national guidance. They were monitored and audited to ensure consistent practice within the maternity service.

Maternity and gynaecology services had performance dashboards which recorded a range of service and patient outcomes. For example, the maternity dashboard showed the numbers and types of births, delivery methods and maternal and neonate morbidity. Between April 2014 to March 2015 the normal delivery rate and caesarean section rate was comparable to the England average. Between April to September 2015 the trust performed slightly below their goal for spontaneous vaginal delivery and the total caesarean section rate was slightly higher than the trust target of 23% at 26.5% but was similar to the England average of 26.7%. Between April to September 2015, the service performed well in relation to the number of patients experiencing third or fourth degree perineal tears, between six to 13, average of nine against a target of 14. However, over the same time period the service consistently failed to meet its target of 80% of patients to have suturing commenced within one hour of delivery, achieving between 44% to 75% and an overall average of 59.5%.

A range of equipment and medicines were available to provide pain relief in labour and for patients on the gynaecological ward. Women received appropriate pain relief and were able to self-administer if required.

Breast feeding was encouraged and the midwifery services had achieved full stage 3 accreditation of UNICEF ‘Baby Friendly’ status.

Staff had access to training and support to develop and maintain their competencies. However, the supervisor to midwife ratio was 1:21 which was above national recommendation of 1:15. The higher ratio increased the workload on the supervisors of midwives.

When women received care from a range of different staff, teams or services, this was coordinated. All relevant staff, teams and services worked together and assessed, planned and delivered peoples care and treatment collaboratively.

Staff were clear about their roles and responsibilities regarding the Mental Capacity Act (2005). Consent guidelines were followed appropriately.

Staff had limited access to the policies and guidelines relating specifically to the gynaecology services. Generic trust-wide nursing guidelines were available on the trust intranet. Specific clinical guidelines relating to gynaecology were not available (other than for colposcopy) as these reference documents had been removed from the trust intranet. The policies were under review and this was recorded as a risk on the service risk register.

Feedback from women about their care and treatment was consistently positive. We observed women were treated with kindness, compassion and dignity. Women told us they felt involved with their care, had their wishes respected and understood. Midwives were trained to provide emotional support, for example, for women who may have suffered bereavement. There were also specialist support and counselling services available.

At the previous inspection we rated responsive as requires improvement. This was due to the number of times the midwifery led unit (Rushey ward) was closed due to lack of staff or unit capacity, at least once a month and the number of times the unit was put on divert. This meant that women had to travel to neighbouring organisations in order to deliver their babies. Although the trust had made improvements in the way it managed its capacity to ensure safe delivery of care, we rated responsive as requires improvement for this inspection. Between May 2015 to October 2015 the unit was ‘on divert’ (closed) on 29 occasions for between 4 hours and 48 hours. Mostly due to insufficient midwifery staff. During those times 61 women were diverted to other units. Women had a choice where to receive antenatal care. However, staffing and capacity issues meant the maternity unit was not always able to provide the service to local people.

The majority of women had access to gynaecological services within the maximum referral to treatment period set by the NHS England of 18 weeks.

Patients undergoing investigations in gynaecology were offered appointment times that were suitable to them. There was an early pregnancy assessment unit that provided rapid care for women.

Translation services were available, and a specialist team of midwives supported women with additional needs such as homelessness and substance abuse through pregnancy and child birth.

Complaints and concerns were taken seriously, and listened to. Improvements were made to the quality of care as a result of complaints and concerns

At the previous inspection we rated well-led as requires improvement. This was due to the lack of robust governance and risk management processes. We found improvements had been made in maternity services.

Maternity services were part of the urgent care directorate and gynaecology services were part of planned care group directorate; the governance processes in place were different for the two directorates.

Since the last inspection the maternity service had undergone a service review and an improvement programme was implemented. A new strategy and vision for the maternity service was due to be launched.

There were comprehensive risk, quality and governance processes in the maternity service to ensure issues were reported and escalated for action and learning. Staff across the service described an open culture and felt well supported by their managers.

Medical care (including older people’s care)

Requires improvement

Updated 24 June 2014

Overall the cleanliness and hygiene on the wards was adequate, although some areas fell below expected standards. Nurse staffing levels were at times insufficient with a reliance on bank and agency staff. This was particularly on wards for older people, including wards where elderly patients were not always placed on the most appropriate ward for their needs, due to capacity pressures. Whilst training was available in dementia care, many staff had not attended and some were unaware of the availablity of training.

We were told that a shortage of medical cover out of hours and during weekends, delayed care and discharges. The hospital did have a hospital at night team to improve care out of hours.  Patients were kept on medical wards long after they were assessed as being medically fit for discharge. There were notable lapses in medicines management, with insufficient understanding of drug storage requirements.

Clinical data was not always easily accessible due to the fragmented structure of the trust’s electronic patient record (EPR) and patient records were not well maintained with an over-reliance on ‘temporary’ records. There were standardised care pathways and care plans, but these were not consistently used.

Medical wards were compassionate and caring, with good leadership on the majority of wards.

Urgent and emergency services (A&E)

Good

Updated 24 June 2014

The A&E department was significantly challenged with capacity issues, which directly impacted on its ability to meet the four-hour target for treatment or discharge. This was mainly due to lack of beds available on a ward, delay in A&E and specialty review, or delay in transport. Some patients were staying in the A&E department for over 12 hours.

The department had a process of ‘STATing’ for immediate review of patients arriving by ambulance to assess whether the patient required immediate review and treatment, or could wait in a queue. Patients were observed waiting on trolleys and chairs in the corridor for over two hours waiting to be seen.

An ‘observation ward’, which had space for three beds, with a toilet but no shower, was seen accommodating four patients, which impacted on their privacy and dignity. This area was not subject to the A&E four-hour target. Access to support for mental health patients was variable.

In response to the capacity issues, the team had done work to review the exiting pathways and flow within the department. However, an inconsistent trust-wide systematic approach to discharging patients, to make beds available, was not robust.

Overall A&E was clean. Staff were caring and attentive to patients’ needs, treating them with respect, although there was mixed feedback from patients prior to our inspection. Leaders in the A&E department were open and approachable. The inspection team noted the Children’s A&E to be of a particularly high standard. 

Surgery

Requires improvement

Updated 24 June 2014

Nurse staffing levels were insufficient due to vacancies with a consequent reliance on bank and agency staff. Checking and maintenance of equipment was inconsistent across the service. Capacity pressures across the trust resulted in patients’ operations being cancelled or delays in patients being admitted to a ward post-operatively, with some patients being cared for in the recovery area overnight.

The 18 weeks from referral to treatment (RTT) targets were not consistently being met. A variation in practice for pre-operative assessments led to operating lists being changed on the day, or patients’ treatments being cancelled. Completion of the WHO surgical checklist was consistently embedded in practice.

Patients were treated with respect, dignity and compassion. Whilst there was positive feedback about managers and matrons, there was a reliance on goodwill and staff felt there was no cohesion over the directorate, as areas worked independently without a clear vision or robust forward planning.

Intensive/critical care

Requires improvement

Updated 24 June 2014

Medical staffing levels were not sufficient to meet the needs of ICU and HDU, particularly when HDU had ventilated patients due to capacity pressures in ICU. These pressures also resulted in patients being cared for in the recovery area.

The unit contributed to the Intensive Care National Audit and Research Centre (ICNARC) Case Mix Programme, and outcomes were within expectations for the size of the unit. Staffing pressures prevented proactive review of performance data.

Feedback from patients and relatives was overwhelmingly positive with excellent caring interventions and patients and families always being involved and informed of care. The bereavement service was well established and there were twice yearly memorial services in memory of patients.

Services for children & young people

Good

Updated 24 June 2014

Babies, children and young people were cared for in wards and departments that were clean. Infection control practices were adhered to. There were sufficient nursing and medical staff across all areas. Staff used recognised early warning systems for both neonates and paediatric patients. Staff reported incidents, and learning was shared across the area to prevent the likelihood of a reoccurrence. Security for patients and staff in the neonatal and paediatric areas was good. Access to mandatory and additional training was available to staff, to allow them to develop additional skills.

Care and treatment was delivered in line with national guidelines. Outcomes were reviewed, and there was active participation in research and audit. Care plans and pathways were in use. Multidisciplinary team working was good in all areas.

Staff provided care in a kind and compassionate manner. Parents were involved in both decision-making and the delivery of care and were given appropriate emotional support. There was a highly visible leadership team and an open and supportive culture.

End of life care

Good

Updated 24 June 2014

The palliative care team was available seven days a week, with the hospice providing out-of-hours cover. Medicines were provided in line with guidelines for end of life care. DNACPR forms were not consistently completed in accordance with policy and there were no standardised processes for completing mental capacity assessments.

Training relating to end of life care was provided at induction and study days were arranged for palliative care link nurses from wards. Leadership of the palliative care team was good and quality and patient experience was seen as a priority.

All patients requiring end of life care could access the palliative care team. Viewing times in the mortuary were limited, which impacted on patients’ families being able to view their relative. There was a multidisciplinary team (MDT) approach to facilitate the rapid discharge of patients to their preferred place of care.

Relatives of patients receiving end of life care were provided with meal vouchers and free car parking. Patients were cared for with dignity and respect and received compassionate care. The ‘End of Life Care Plan’ was the pathway patients were placed on in the last few days of life.

Outpatients

Requires improvement

Updated 24 June 2014

Patients received kind and compassionate care and were treated with dignity and repsect, and their privacy maintained. Patients told us that staff were kind and they felt involved in their care. One-stop clinics and specialist clinics were provided.

Medical records were not consistently available at all clinics for each patient because of ‘missing’ notes. Shortages of staff in clinics and administration resulted in long waiting times for patients. In addition, delays in radiology significantly affected the efficiency of the outpatient service. There was a singificant variation in the time between an outpatient consultation and the GP receiving the outcome letter of within one week to six weeks.

There was also a lack of information in any alternative language or format other than in English. The outpatient department staff felt supported and learning was communicated from incidents and complaints.