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Warwick Hospital Requires improvement

We are carrying out checks at Warwick 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 28 March 2017

South Warwickshire Foundation NHS Trust provides a range of hospital care services and community health services to a community of approximately 270,000 in South Warwickshire and the surrounding areas. The trust provides a full range of district general hospital services at Warwick Hospital to its local population.

There are 441 inpatient beds within Warwick Hospital.

We carried out an announced comprehensive inspection of the hospital from 15 to 18 March 2016. We undertook an unannounced inspection on 29 March 2016.

The trust obtained foundation trust status in 2010.

We inspected this hospital as part of our programme of comprehensive inspections of acute trusts.

We held focus groups with a range of staff in the hospital, including union representatives, black and minority ethnic staff, governors, nurses, health visitors, trainee doctors, consultants, midwives, healthcare assistants, student nurses, administrative and clerical staff and allied health professionals. We also spoke with staff individually as requested.

The inspection team inspected the following eight core services at Warwick Hospital

• Urgent and emergency services

• Medical care (including older people’s care)

• Surgery

• Critical care

• Maternity and gynaecology

• Services for children’s and young people

• End of life care

• Outpatients and diagnostic imaging

Overall, we rated Warwick Hospital as requires improvement with three of the five questions we ask. Safe, effective and well led were judged as requiring improvement.

We have judged the hospital as good for caring and responsiveness. We found that services were provided by dedicated, caring staff. Patients were treated with kindness, dignity and respect and were provided the appropriate emotional support. The trust was planning and delivering services to meet the needs of patients. The emergency department was rated as outstanding for responsiveness.

Safety

  • Nurse staffing levels and skill mix were planned and reviewed in line with national guidance. Most areas had adequate staff to ensure patients received safe care and treatment.
  • Although the trust had taken a number of actions to promote the Duty of Candour to staff, not all staff had a thorough understanding of this and what this meant within their practice.

  • The trust had reported one never event (wholly preventable incidents, where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level, and should have been implemented by all healthcare providers) in the 12 month period ending February 2016. Although still under investigation at the time of the inspection early lessons had been learnt and shared.

  • The hospitals were seen to be clean and hygienic and most staff followed the trusts infection control policy, were ‘bare below the elbow’ and used personal protection equipment. There were some incidents of poor hand hygiene.
  • All patients admitted to hospital were screened for methicillin resistant staphylococcus (MRSA) to assist with isolation and treatment. There was limited follow up of MRSA screening for patients admitted to the medical wards where we found results of this screening were not routinely recorded in nursing notes.
  • Cases of MRSA were low with the trust reporting zero cases from August 2014 and August 2015, however there were 17 cases of C. difficile reported during the same period.
  • Mandatory training was, across most areas below the trust’s target of 85% and 95% for safeguarding adults and children and information governance.
  • The level of safeguarding children’s training that staff in certain roles undertook was in line with trust policy, but was not compliant with national guidance. Therefore, we could not be sure that staff had the sufficient knowledge and skills to safeguard children.
  • In many wards and departments we saw medicines in unlocked cupboards and drawers. Although some medicines were left unlocked to allow rapid access in an emergency in some areas all medicines were unsecured, not just ones that required emergency access therefore we were not assured that medicines were stored in a way that prevented misuse, tampering or theft.
  • Processes and procedures had been developed for women on the postnatal ward to self-administer some medication if they opted to do so.
  • In the emergency department (ED), children with minor complaints were not seen in a secure paediatric area, they waited with adult patients, which is not in line with national guidance. During our unannounced inspection; we observed changes to the department had been made. A paediatric sub waiting room had been created within the main waiting area for paediatric see and treat patients, although there were no robust procedures in place for children to be observed for rapid deterioration while waiting in this area.
  • Patient records were not always stored securely.
  • Patient risk assessments were not fully completed on admission and generally not reviewed at regular intervals throughout the inpatient stay. This included incomplete risk bed rails risk assessments resulting in the use of bed rails without a completed risk assessment.
  • Management of the deteriorating patient was in place in most areas of the trust through the use of early warning score (EWS) and paediatric early warning score were used (PEWS). However there was no such recognised tool in use in the special care baby unit.

Effective

  • Care was delivered in line with legislation, standards and evidence-based guidance, however some local and trust guidelines needed updating.
  • The mortality rate as indicated by the Summary Hospital-level Mortality Indicator (SHMI) was “as expected” for January to December 2015, at 1.1 against the England figure of 1.0. The trust Hospital Standardised Mortality Ratio (HMSR) (for in hospital deaths only) for January to December 2015 was “within expected range”, at 108.0 against the England figure of 100
  • Data was submitted for all national audits in 2013/2014, with the exception if the Acute Myocardial Infarction and other ACS (MINAP) audit which was not submitted due to staffing issues. Performance in national audits was generally the same or better than the national average. Actions plans were in place to address areas for improvement action.
  • Staff and teams worked well together to deliver effective care and treatment.
  • Not all staff had full understanding of the Mental Capacity Act 2005 and their responsibilities and role in the management of patients with capacity concerns. This includes appropriate formal assessment processes and escalation of concerns
  • The individualised care of the dying patient care plan, which was a replacement for the Liverpool Care Pathway, was designed to be used for patients in hospital and community settings. However, this was found not to be fully embedded in the care of the dying in the hospital and was not used by the community teams.

Caring

  • Feedback we received from patients was consistently positive about the way nursing and therapy staff treated them. Patients felt safe and cared for and staff were respectful of their needs and preferences and took time to understand personal requirements or to explain the care being delivered.
  • The need for emotional support was recognised and provided through a range of support mechanisms including a clinical psychology service.

Responsive

  • The flow of patients into and through the hospital was well managed with all areas of the trust taking responsibility for this.
  • The trust consistently exceeded the Department of Health target for emergency departments of 95% of all patients to be admitted, transferred or discharged within four hours of arrival to the emergency department every month. The percentage of emergency admissions via ED waiting four to 12 hours from the decision to admit until being admitted has been consistently lower than the England average. This meant that patients could access services in a timely way.
  • The percentage of admitted surgical patients that started consultant-led treatment within 18 weeks of referral was consistently below the 90% standard between September 2014 and May 2015. In June 2015 this standard was abolished. Between September 2014 and August 2015 the trust’s performance for this measure was better than the England average in all but two months. However, the trust consistently met the 95% indicator for non-admitted patients’ referral to treatment within 18 weeks and met the incomplete pathways other than for one month February 2015. The percentage of patients waiting more than six weeks for a diagnostic appointment was also consistently better than the national average.
  • The number of cancelled operations was better than the national average with no operation cancelled due to the lack of a critical care bed.
  • There were specific waiting times for patients diagnosed with and suspected of having a cancer. 95% of all patients who receive an urgent referral for suspected cancer and breast symptoms should be seen by a specialist within two weeks. All patients should receive their first definitive treatment 31 days from diagnosis and, all patients should receive their first definitive treatment within 62 days from urgent referral. From October 2013 to March 2015 the service mostly performed the same as the England average which ranged from 93%-96% for patients waiting for two week referrals.
  • Following some challenges in meeting the two week wait for patients referred with suspected cancer and breast symptoms from April to September 2015 this had improved in the three months October to December 2015 and the target was met. From April to September 2015 performance against the 31 day target was mostly the same as the England average and since July 2014 the performance against the 62 day target has been better than the England average.
  • Services were planned, delivered and coordinated to take account of people with complex needs, for example those living with dementia or those with a learning disability, with some innovative practices in the emergency department with the use of computer assisted reminiscence therapy.
  • Overall complaints were well managed with the trust using the issues raised as an opportunity to learn and improve services.

Well led

  • The trust had a clear vision to provide high quality, clinically and cost effective NHS healthcare services that met the needs of patients and the population that they serve. However there was no service specific written strategy for individual core services and specialties did not appear to have a shared vision or aim.
  • There was a governance framework in place which supported the delivery of care although there were some areas of weakness. Whilst the board assurance framework and corporate risk register identified most of the keys risks, there were risks at local level that had not been captured. In addition there were not robust procedures in place to ensure that policies were reviewed in a timely way and reflected national guidance.
  • The executive team was stable and well established and was visible and well regarded by both staff and people in the local community who attended an event to tell us about their care.
  • There was a lack of oversight of the care for neonates, children and young people across the whole trust.
  • The directors identified to provide representation for end of life care services at board level, did not attended of life care meetings and the trust did not have a non-executive director who provided representation of end of life care at board level.
  • There was an extremely positive culture within the trust and staff felt respected and valued. The result sf the 2015 staff survey reflected this positive culture with the trust ranked in the top 20% of all trusts nationally.
  • In line with previous years in 2015/16 the trust had made a small surplus however they clearly recognised the challenges to maintaining such a position.

We saw several areas of outstanding practice including:

  • The use of reminiscence therapy within the emergency department (ED) for patients with a learning disability, dementia and mental health conditions.
  • A smartphone application for medical staff containing relevant trust information, policies, clinical guidance and teaching availability.
  • The ED staff worked with external agencies to provide services, including substance misuse liaison specialist support for patients.

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

Importantly, the trust must:

  • Ensure that regular risk assessments are completed appropriately on admission to medical wards and repeated regularly to identify any changes in patient’s risk of harm. This includes bed rail and mobility assessments and nutritional assessments for patients receiving end of life care.
  • Ensure that all staff receive safeguarding children training in line with national guidance.
  • Ensure that staff have full understanding of the Mental Capacity Act 2005 and their responsibilities and role in the management of patients with capacity concerns. This includes appropriate formal assessment processes and escalation of concerns.

In addition the trust should:

  • Ensure that staff in the outpatients department record all incidents.
  • Review staff have a clear understanding of the Duty of Candour.
  • Ensure that defined cleaning schedules and standards are in place to comply with the Department of Health 2014 document ‘Specification for the planning application, measurement and review cleanliness services in hospitals’.
  • Ensure that infection control and prevention policies are embedded into practice, particularly on the medical wards.
  • Ensure medicine fridge temperatures are recorded accurately and any deviation from temperature controls acted upon.
  • Ensure all medicines are stored safely in locked cupboards.
  • Ensure that facilities in the emergency department are suitable for caring for patients with mental health needs.
  • Ensure that all mandatory training is completed in line with the trust target.
  • Ensure that all staff have completed the relevant safeguarding adult training to ensure staff are aware of their roles and responsibilities in the identification of safeguarding needs and how to escalate concerns.
  • Establish formal cover arrangements for acute palliative care consultant post when they were on leave.
  • Continue to implement and monitor use of the swipe card access of the corridor and clean utility room in critical care to ensure safe storage of medicines, records and equipment on critical care.
  • Investigate and share learning from the controlled drugs incident on critical care and ensure any corrective actions are completed.
  • Ensure that all staff working in critical care receive training and guidance regarding their responsibilities outlined in the major incident plan.
  • Ensure that staffing levels meet patient demand, enable adequate care of children by a qualified paediatric nurse and allow monitoring of all patients within the department at all times of day.
  • Ensure that patient records are stored securely and completed in line with legislation.
  • Review the high number of caesarean sections developing an action plan to reduce these.
  • Ensure that there is an early warning score tool for babies on SCBU to ensure that any deterioration of a patient’s condition is recognised.
  • Ensure all trust policies are up to date and relevant.
  • Ensure there are appropriate polices and operating procedures to support processes within the emergency department.
  • Monitor pain scores in a consistent manner in the emergency department and ensure that there are formal pain tools used across SCBU and Macgregor ward.
  • Ensure that advance care plans (a plan that documents patients’ views, preferences and wishes about their future care) are in place for patients receiving end of life care.
  • Ensure the annual audit plan for maternity is formally approved, that recommendations address the issues identified and action plans for improvement are developed.
  • Develop, approve and implement an annual audit plan for gynaecology.
  • Ensure that outcomes for gynaecology patients are clearly presented and reviewed.
  • Ensure that nurses on the gynaecology ward receive training relevant to the specialism and acuity of patients admitted to the Beaumont ward.
  • Ensure privacy of in patients attending radiology department is maintained.
  • Ensure that the use of the individual plan for the dying person is embedded.
  • Audit the effectiveness of the end of life care service, including collecting information on the number of patients who have been discharged to their preferred place of care, collecting information on those patients who died in their preferred place of death and audit the effectiveness of the rapid discharge process.
  • Ensure arrangements are in place to monitor how quickly women attending midwifery assessment unit are seen and treated.
  • Ensure specialist palliative care team referral guidelines are place, and circulated to all wards and departments.
  • Reduce the delays for patients being discharged from critical care to the wards.
  • Ensure that leaflets and interpreters are available and used for non- English speaking patients.
  • Ensure that all complaints are reported to ensure themes are identified and lessons learnt cascaded to staff.
  • Ensure that there is clear leadership and overall oversight of care for neonates, children and young people.
  • Ensure that the arrangements for governance and performance management operate effectively in the services for children and young people.
  • Ensure that all risks are identified on the risk register and appropriate mitigating actions taken.
  • Ensure there is a clear process for the documentation and review of risks within the gynaecology service.
  • Ensure that each service has a local vision and strategy which is disseminated and understood by all staff so that it is embedded within the service.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 28 March 2017

Effective

Requires improvement

Updated 28 March 2017

Caring

Good

Updated 28 March 2017

Responsive

Good

Updated 28 March 2017

Well-led

Requires improvement

Updated 28 March 2017

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 28 March 2017

1:1 care in labour not always achieved and the number of caesarean sections and normal vaginal births were worse than the trusts targets.

The trust did not provide evidence that any registered clinical staff within the maternity service had completed their level 3 safeguarding children training, which was a national requirement for their role. This meant we could not be sure that all staff have the sufficient knowledge and skills to safeguard children.

Records were not always stored securely.

Termination of pregnancy records were not consistently completed in line with legislation.

There were processes in place for maternity staff to learn from incidents, however, these were not working effectively in practice.

Governance arrangements for gynaecology services were not robust and there was no clear vision or strategy for the service.

There was a five year strategic plan in place for maternity, although this did not include a review of achievements against previous objectives.

Recommendations to ensure that lessons were learned when things went wrong were not always completed within appropriate timescales.

Intravenous fluids were not always stored in a safe environment meaning there was a risk they could be stolen or tampered with.

The trusts mandatory training target of 85% had not been achieved in either the maternity or gynaecology service.

The maternity annual audit plan had not been formally approved. The audit plan did not record the justification for audits. Recommendations did not always fully address the issues identified and action plans were not always completed.

The audit plan for gynaecology consisted of five audits over a five year period, one of which had been withdrawn. Two audits had been completed within the last 12 months; the other two audits dated back to 2011 and 2013. Limited information on completed audits was provided.

Data on patient outcomes for gynaecology patients were not reported and monitored in a central dashboard.

There was a good track record on safety with low rates of infection.

Patients reported that they received good care and that staff were friendly and helpful.

Patient records were completed and observations recorded.

A high number of staff had received their annual appraisal.

Multidisciplinary arrangements worked well.

Safeguarding arrangements were in place and the staff we spoke with had a good understanding what to look out for as well as the reporting process.

When women asked for help, they were responded to in a timely manner or told that they would be helped as soon as possible.

Patients told us that staff were helpful and that they explained things to them in a manner they could understand.

Recent friends and family surveys had reported positive feedback from patients.

The maternity service was proactive in considering a midwifery led unit (MLU) to ensure women’s choice was at the forefront of the service.

Medical care (including older people’s care)

Requires improvement

Updated 28 March 2017

Patient risk assessments were not fully completed on admission and generally not reviewed at regular intervals throughout the inpatient stay. This included incomplete risk bed rails risk assessments resulting in the use of bed rails without a completed risk assessment.

Infection control practices were not embedded with isolated poor practice relating to hand hygiene and the use of personal protective equipment.

All patients admitted to hospital were screened for MRSA to assist with early identification and treatment; however we found results of screening were not routinely recorded in nursing notes. This meant it was unclear whether the patient had a negative MRSA result, or the result had not been reported.

Nursing and medical records were not routinely stored in secure areas, leaving them accessible to unauthorised persons.

Medications were not always stored securely, with doors unlocked or missing and cupboards unsecure.

Patients on a different specialty ward were not reviewed daily by their speciality consultant or medic. However, care of the elderly patients reviewed daily by a medical nurse practitioner.

Staff showed varied understanding of the Mental Capacity Act 2005 and their roles and responsibilities in the management of patients with reduced capacity. There was no evidence in practice of a clear system to ensure these patients were cared for safely and effectively. A few patients had entries in their notes that stated they did not have capacity but there was no record of any formal assessments of their capacity having taken place.

The trust had processes in place to keep people safe and staff were aware of their roles and responsibilities in reporting incidents.

The trust had reviewed medical admission processes, which resulted in an improved patients experience and pathway. The admission area facilitated the flexible use of beds to meet the demands of the service at any one point. This meant that when activity increased, additional beds could be used to relieve pressures within the emergency department (ED).

The admission area facilitated a review by senior clinician within four hours of arrival with an early decision to admit to hospital or not. Where possible patients were managed through daily attendance at the clinical decisions unit for treatment.

The cardiology and respiratory specialities had introduced a speciality “pull” from admission areas to ensure that any patient admitted with that speciality would be reviewed as soon as possible after admission and transferred to the most appropriate area to manage treatment.

The flow of patients through the hospital was effectively managed and a policy was in place. Bed management meetings were held three times a day to discuss and prioritise bed capacity and patient flow issues. Discharge coordinators and the complex discharge team helped to facilitate appropriate patient discharge. A high percentage of patients had less than two ward moves per admission to hospital.

Wards were visibly clean.

Referral to treatment performance was in line with national targets.

Although there was a high level of nursing staffing vacancies within some teams, staffing levels did generally meet patient needs at the time of our inspection. Medical staffing was in line with national guidance.

Overall, mandatory training in nursing staff did meet the trust target of 85%.

There was some evidence of provision of seven day a week services.

The medical care service was generally well led at a ward level, with evidence of effective communication within ward teams. The leadership and culture promoted the delivery of high quality person-centred care as governance and risk management systems were in place in the service.

The trust performed ‘as expected’ and ‘within expected range’ in the two mortality indicators (SHMI and HMSR respectively) and the service had systems in place to review mortality rates. Monthly mortality meetings included reviews of any patient deaths to identify learning and individual development.

Care was provided in line with national best practice guidelines.

The trust participated in some national clinical audits.

Pain relief was assessed appropriately and patients said that they received pain relief medication when they required it.

Generally, patients received compassionate care and their privacy and dignity were maintained. We saw staff interactions with patients were person-centred and unhurried. Patients told us the staff were caring, kind and respected their wishes. Most patients felt involved in planning their care, making choices and made informed decisions about their care and treatment.

The trust worked closely with community services to enable an established ‘discharge to assess programme’, which had been used as a reference centre for other trusts and the reinstatement of care packages up to 14 days after admission to hospital.

There were additional facilities for patients living with dementia and those with learning disabilities. Including activities for patients, the use of “this is me” document and extended visiting hours for families and carers.

The service had good governance processes in place with an audit calendar and evidence of learning. Staff reported receiving feedback regarding incidents that they had reported.

The trust had implemented an application (app) that could be downloaded onto mobile phones, which contained all policies, and procedures, which could be used for advice or direction.

Haematology services had developed a standard of practice for all patients admitted with suspected neutropenic sepsis enabling early intervention and treatment.

Urgent and emergency services (A&E)

Good

Updated 28 March 2017

  

Evidence based guidance was used within the department and was relevant and up to date.

Multidisciplinary working was a strength of the department and relationships with internal and external services helped to avoid unnecessary attendances and facilitated early discharges.

The department took part in local and national audits and showed learning from audit outcomes.

Patient’s feedback was positive about the care they received and we saw good examples of compassionate care within the department.

The department was consistently meeting the four hour target, with escalation processes implemented at the earliest opportunity to allow proactive plans to be put in place to assist flow.

All staff were passionate about providing high quality patient care.

The department did not fully comply with guidance relating to both paediatric and mental health facilities.

Safeguarding children training was not in line with national intercollegiate guidance.

Leaders showed a full understanding and drive to improve flow within the department but lacked understanding of safety in relation to care of children.

There was a lack of governance to support staff to follow procedures within the ED, including policies in relation to see and treat and triage.

Staffing at night time did not always meet demand we observed staff sometimes caring for over twice the number of patients recommended by national guidance. Nursing staffing numbers were increased following our inspection and as a result of an on-going review.

Initial assessments were not always carried out in a timely way and escalation of this was inconsistent due to lack of operating procedures to advise staff.

Surgery

Good

Updated 28 March 2017

There was a culture of incident reporting and staff said they received feedback and learning from serious incidents. However, some staff did not always receive feedback on all clinical incidents. Staff were able to speak openly about issues and serious incidents.

The environment was visibly clean and generally staff followed the trust policy on infection control, although, we saw no evidence of domestic staff using cleaning checklists.

Medical staffing was appropriate and there were good emergency cover arrangements. Consultant-led, seven-day services had been developed and were embedded into the service.

Staffing levels were planned and reviewed to ensure that patients received safe care and treatment. Agency and bank staff were used and sometimes staff worked additional hours to cover shifts but this was well managed and patients’ needs were met at the time of the inspection.

Treatment and care were provided in accordance with evidence-based national guidelines. There was good practice, for example, assessments of patient needs, monitoring of nutrition and falls risk assessments. Multidisciplinary working was effective.

Patients outcomes were generally good but not all staff were aware of patients’ outcomes relating to national audits or performance measures.

Most staff had received annual appraisals and support systems for staff development were effective, however there were areas of poor compliance with mandatory training.

Staff had awareness of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) procedures to keep people safe.

The consent process commenced in outpatients, there were specific consent clinics and consent was reconfirmed at the time of admission.

Patients told us that staff treated them in a caring way, and they were kept informed and involved in the treatment received. We saw patients being treated with dignity and respect.

Patient care records were appropriately completed with sufficient detail and kept securely.

The service had an effective complaints system in place and learning was evident.

There was support for people with a learning disability and reasonable adjustments were made to the service. However information leaflets and consent forms were not available in other languages. An interpreting service was available and used.

Surgical services were well-led. Senior staff were visible on the wards and theatre areas and staff appreciated this support. There was generally a good awareness amongst staff of the trust’s values.

Intensive/critical care

Good

Updated 28 March 2017

The service demonstrated a good track record on safety with low rates of infection and avoidable harm to patients.

Patient outcomes reported within ICNARC showed the service performed as expected, or better than expected for most outcomes when compared to other similar critical care services.

Staff understood and spoke positively about the safety reporting system in place, and felt that openness and transparency about safety was encouraged.

Staffing levels were compliant with Guidelines for the provision of intensive care services, 2015 ( (the core standards) with staffing levels and skill mix planned, implemented and reviewed to keep people safe at all times.

There were clear policies, procedures and training in place to enable staff to keep people safe and safeguarded from abuse.

The environment was clean and well organised, and we saw good compliance with infection prevention and control practices.

Risks to people who used the service were assessed, monitored and managed on a day-to day basis.

Care and treatment was delivered in accordance with best practice and recognised guidance and standards.

There was collaborative working amongst the multi-disciplinary team, and with other services and providers.

Staff had the right qualifications, skills, knowledge and experience to do their job and were supported through appraisal, supervision, training and revalidation.

Patients and those close to them spoke positively about their care and treatment, and felt supported and cared for by staff.

There were clear processes in place for people to raise concerns or complain; these were low in number and managed in a timely manner.

The nursing leadership team were knowledgeable about quality issues and priorities, and took action to address the challenges; there was alignment between the recorded risks and concerns raised by staff.

Staff satisfaction was high and staff felt engaged with the service leaders.

Services for children & young people

Good

Updated 28 March 2017

Children and young people were treated with dignity, respect and kindness. Feedback from parents and children were positive. Parents felt supported and told us staff cared about them and their children.

Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. We found evidence sharing learning and changing practice as a result of incidents.

Services were clean and staff adhered to infection control policies and protocols. Equipment was checked daily, cleaned and documented.

The service used a comprehensive prescription and medication administration record card which facilitated the safe administration of medicine.

Patient records we looked at were comprehensive.

Medical ward rounds and nursing handovers took place three times a day across the service and were well attended.

The risks associated with anticipated events and emergency situations were recognised, assessed and managed.

Staff received training on the duty of candour.

Staff understood their roles and responsibilities for safeguarding children. Although mandatory training was generally well attended, safeguarding children training at level three was not in accordance with the intercollegiate guidance 2014 document published by the Royal College of Paediatrics and Child Health (RCPCH), ‘safeguarding children and young people roles and competences for health care staff, 2014’. This meant there was a risk that staff may not have the level of competence to respond appropriately to safeguarding concerns.

Although nursing staffing levels did not always meet RCN and Toolkit for High Quality Neonatal Services 2009 recommendations; and the service did not comply with RCPCH standards for having 10 consultants to cover, we found mitigating actions were in place and there was no evidence of a negative impact on the care and treatment children and young children received.

Children and young people’s care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation. This was monitored to ensure consistency of practice.

Staff were proactively supported to acquire new skills and share best practice and staff were competent to carry out the care of children and young people.

Services were planned and delivered in a way that was meeting the needs of the local population. The individual needs of children and young people were generally met.

Waiting times, delays and cancellations were minimal and managed appropriately.

The service was part of the integrated paediatric strategy (2014-2019) that included both acute and community provision of services. The vision, values and strategy had been developed through a structured planning process with regular engagement from internal and external stakeholders, commissioners and others.

Staff in all areas knew and understood the vision and values. Staff felt well supported and felt they were well managed.

The arrangements for governance and performance management did not always operate effectively. Governance arrangements were fragmented with no one person responsible for children and young people’s services.

Not all risks we identified on the risk register.

It was unclear who had the overall oversight of care for neonates, children and young people. After the inspection the trust told us that the Head of Midwifery had oversight of the service in the hospital.

We found limited evidence of public engagement.

Mandatory training compliance levels did not always meet the trust target. This meant that there was a risk that staff did not have the necessary skills to carry out their role.

There was no recognised early warning score tool for babies on SCBU and no audit for the use of a local tracker and trigger system on Macgregor ward within the last 12 months. This meant that there was a risk that any deterioration of a child’s condition may not always be recognised. However, we saw no evidence of this in practice.

There were no formal pain tools used on SCBU.

End of life care

Requires improvement

Updated 28 March 2017

The trust did not have a clear vision or a strategy for end of life care services; however they had recently appointed a full time consultant with the remit of developing a strategy.

The end of life care service did not have effective processes in place to measure their effectiveness and outcomes.

There were no formal arrangements to cover the acute palliative care consultant post when they were on leave.

Mental capacity assessments around decisions about do not attempt cardio-pulmonary resuscitation (DNACPR) in was only evident in 66% of patients’ records.

The acute SPCT had not completed an audit of patients who had been discharged to their preferred place of dying. This meant, because it was not recorded, this information could not be used to improve or develop services.

The acute SPCT trust did not collect information of the percentage of patients that had been discharged to their preferred place of death within 24 hours. Without this information, they were unable to monitor if they were meeting patients’ wishes and how they could make improvements.

The trust had in place a replacement for the Liverpool Care Pathway (LCP) called the Individual Plan of Care for the Dying Person. However, its use was not firmly embedded in the trust’s culture.

The directors identified to provide representation for end of life care services at board level, did not attend end of life care meetings.

The trust did not have a non-executive director who provided representation of end of life care at board level, which is a recommendation of the National Care of the Dying Audit of Hospitals.

The leadership team was not able to evidence that they were knowledgeable about quality issues therefore were unable to take actions to address them.

Relatives and patients spoke positively about end of life care. Staff provided compassionate care for patients.

There were arrangements to minimise risks to patients with measures in place to safeguard adults from abuse, prevent falls, malnutrition and pressure ulcers and the early identification of a deteriorating patient through the use of an early warning system.

Patients received good information regarding their treatment and care. The service took account of individual needs and wishes and patients’ spiritual needs.

The bereavement support staff provided good support to relatives after the death of a patient.

The hospital had a rapid discharge service so that patients could be discharged to their preferred place of care.

Outpatients

Good

Updated 28 March 2017

Performance data showed a good track record in safety.

Clinical areas were generally clean and well-organised. Medical records were maintained accurately and securely, and there was an effective records tracking and location system.

Infection control procedures were followed and the service conducted regular audits.

There were robust systems in place to ensure that patients and staff were protected by adherence to national guidelines relating to ionising radiation and diagnostic imaging.

The service had a system in place to recognise and respond to changes in patient’s health.

There was evidence that patients were told when things went wrong and offered an apology.

There were systems in place to ensure the right patient received the correct diagnostic procedure.

Staff were recognising, resolving and discussing incidents but not always recording them in line with trust policy, this meant that learning from incidents was not always shared.

Not all staff had the appropriate level of training for safeguarding children.