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Queen's Hospital, Burton Upon Trent Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 22 October 2015

Queen’s Hospital is part of Burton Hospitals NHS Foundation Trust. The hospital provides a full range of district general hospital services and also has a treatment centre which provides day case ophthalmology, outreach and community-based clinics to the population.

We inspected this hospital in July 2015 as part of the comprehensive inspection programme. We inspected all core services provided by the trust.

We visited the hospital on 7, 8 and 9 July 2015 as part of our announced inspection. We also visited unannounced to the hospital on Friday 24 July 2015.

Overall we have rated this hospital as requires improvement. We saw that services were caring and compassionate. We also saw that people have good outcomes because they receive effective care and treatment that met their needs. We saw a number of areas that required improvement for them to be assessed as safe and responsive. We saw that leadership of services in some areas also required improvement.

Our key findings were as follows:

  • The hospital had made significant progress since our last inspection in April 2014. Improvements in safety and leadership were evident, but there was still more work to be done.
  • Staff were caring and compassionate towards patients and their relatives. Patients’ dignity and privacy was ensured and we saw many examples of good care right across the trust for staff at all levels.
  • There was a strong open culture and staff were encouraged and supported to report incidents. There were clears systems in place to ensure lessons were learnt and services developed as a result.
  • The pathway for patients requiring emergency gynaecology care was ineffective.
  • End of life care services had improved and there were clear plans in place to develop the service further.
  • Nurse staffing was a challenge in some areas of the trust. There was heavy reliance on agency staff to ensure staffing levels were kept safe. The trust was working hard to address this.

We saw several areas of outstanding practice

  • Critical care had developed an organ donation group to improve and promote organ donation within the hospital and the local community.
  • The maternity service was awarded the Excellence in Maternity Care award by CHKS in 2014. The quality of care at Burton Hospitals NHS Foundation Trust was judged to be the best out of 148 NHS maternity providers in England, Wales and Northern Ireland.
  • Innovative practice to increase hand hygiene, using the latest technology monitoring the use of alcohol sanitising gel.

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

Importantly the trust must:

  • The trust must ensure that ward assurance targets, such as hand hygiene practice and recording of patient observations, is achieved at a consistent level in the emergency department.
  • The trust must review the use of agency staff on surgical wards to ensure staffing levels and skills mix are maintain and all staff have access to the relevant records.
  • The trust must develop a clear vision and strategy for critical care services which is shared with staff and clinical leaders and demonstrates how the service will develop in the medium and long term.
  • The trust must ensure that all identified learning points from the investigations into recent Never Events are fully implemented and signed off to ensure that learning and changes to practice have been put in place.
  • The trust must develop a strategy and long term vision for gynaecology services at the trust to ensure that patient services can improve and develop.
  • The trust must ensure that a rapid discharge pathway for end of life patients is formalised to ensure that people can leave hospital in an effective way that meets their wishes.
  • The trust must review policies and procedures for planning and booking outpatient clinics to ensure that waiting times for appointments are minimise and patients are not subject to long delays in waiting for appointments. Waiting times in outpatient clinics should be re routinely monitored.

 

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 22 October 2015

Effective

Good

Updated 22 October 2015

Caring

Good

Updated 22 October 2015

Responsive

Requires improvement

Updated 22 October 2015

Well-led

Requires improvement

Updated 22 October 2015

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 22 October 2015

The pathway for gynaecology patients was inefficient and we saw that the gynaecology ward was shared with other surgical patients and medical outliers. This sometimes prevented women with gynaecological conditions being admitted to the ward. We were told that women experiencing miscarriage could not always access a side room and this affected their privacy and dignity at a difficult time.

Two never events, both retained objects post procedure, were reported in October 2014. We saw that for each of the never events, an investigation had taken place, learning points had been identified and shared and an action plan had been developed.

There was a clear statement of vision and strategy, driven by quality and safety. However, staff we spoke with did not demonstrate awareness or understanding of the vision and strategy.

People received care and treatment that was planned in line with current evidence-based guidance, standards and best practice. For example, we observed that policies were carried out in accordance with The National Institute of Health and Care Excellence (NICE) and the Royal College of Obstetricians and Gynaecologists (RCOG) guidelines.

Women told us they had a named midwife. The ratio of clinical midwives to births was 1 midwife to 29 women. We saw documentary evidence that 99% of women received one to one care in labour. Women told us that they felt well informed and were able to ask staff if they were not sure about something.

There was an active maternity services liaison committee (MSLC) which met quarterly and provided input into service developments

The governance arrangements facilitated discussion and review of quality and safety matters, with dissemination of learning. There was oversight of quality and safety at the trust board meetings.

The maternity service was awarded the Excellence in Maternity Care award by CHKS in 2014. The quality of care at Burton Hospitals NHS Foundation Trust was

Medical care (including older people’s care)

Good

Updated 22 October 2015

Staff within the medical care services were caring. Patient care was monitored to show acceptable standards were maintained with good outcomes.

All areas we visited were clean, tidy and well maintained. We saw that patients were risk assessed on admission and on an on-going basis; they were protected from harm. We found that medical care services were effective using evidence-based national guidelines and trust policies and procedures.

Staff felt they were well managed at ward level but the disconnect between them and the senior executive team was improving and not fully resolved. It was acknowledged that staff shortages had impeded some initiatives such as dementia care. Medical staff shortages had also caused workforce issues including lack of training time. Staff understood their role and responsibility to report concerns and safety incidents.

Discharge facilities had improved with the opening of the discharge lounge in July 2015; however the amount of medical patients in the hospital exceeded the bed spaces which caused medical patients to be nursed in other speciality beds. Some patients had experienced a number of bed moves including at night which was unsatisfactory.

We identified that patients on ward 44 lacked rehabilitation support due to reduced involvement of the physiotherapy service. The ward lacked service planning for staff that were not available to work and service input was less that that expected at the main site, for example physiotherapy sessions and MDT review.

Urgent and emergency services (A&E)

Good

Updated 22 October 2015

The Emergency Department (ED) checked its own safety performance monthly, some systems were consistently safe but others varied. Updates on training such as safeguarding were patchy for staff. The ED was working on improving the time it took to assess and to treat patients but it still struggled to consistently achieve some safety targets. The layout of the ED was not as safe for patients with mental ill health as it could be. Staffing levels had been improved and all nursing vacancies were being filled but the ED was struggling to replace the locums with permanent staff.

Staff reported incidents and local leaders ensured there was a system in place to learn from incidents and improve practice including regular safety briefings for staff. We found some changes had not been completely followed through. Staff treated patients with kindness and took care of their dignity throughout their treatment.

The trust had taken some new action to help the ED to respond to increasing numbers of patients but had more work to do with other organisations in the wider community to contribute to this. Managers were making sure the whole hospital system was working more efficiently to help the ED especially at busy times. The trust experienced delays in getting patients with poor mental health reviewed and moved on to other services to help them.

The ED was struggling to regularly meet some of the government targets for the time taken to see and discharge or admit patients but it had a system for prioritising patients according to the seriousness of their condition and into different areas so they could be seen as quickly as possible. We found the ED service was well led at the hospital.

Surgery

Good

Updated 22 October 2015

We saw large number of vacancies for registered nurses and heavy reliance on agency nursing hours in some areas. The service had successfully filled some nursing vacancies with overseas nurses. The managers described their reliance on agency staff for nursing and medical staffing as a major challenge for the service.

We noted a high number of medical outliers on the surgical wards. Staff shared their concerns that they lacked the skills and experience to care for these patients. However, we saw staff were skilled and competent to care for surgical patients.

Staff knew how to report an incident. The service was compliant the World Health Organisation (WHO) safer surgery checklist. Overall we saw good evidence of staff responding to patient risks.

We observed patients being treated with compassion, dignity and respect. The Friends and Family Test (FFT) showed expected results which were similar to the England average, with the exception of ward 30 which was better. Patients were involved in their care, treatment and discharge.

There was a clear vision and strategy for the service supported by an up to date business plan. Managers had a vision of key areas for development and were aware of their strengths weaknesses. We saw the culture throughout the division was very was positive and there was a good level of engagement with staff.

Sound governance and quality measures were in place. We saw strong leadership from the board to divisional managers to local managers. Much work had been done to review the sustainability of the service and much improvement had taken place since last year.

Intensive/critical care

Good

Updated 22 October 2015

There were effective processes in place to learn from incidents. The environment was clean and staff followed infection control procedures. Medicines, including controlled drugs, were safely and securely stored.

Patients received treatment and care according to national guidelines. Critical care was obtaining good quality outcomes as evidenced by its ICNARC data. We found there was good multidisciplinary team working across the unit.

Staff cared for patients in a kind, compassionate and professional manner. Patients spoke very highly of staff and said they were always treated with dignity and respect. Patients and relatives were kept fully informed and staff treated them with kindness and understanding. Staff were supportive and responsive to patients' individual needs.

Critical care was responsive to patient’s needs. The overall capacity in the critical care unit meant that patients received timely care. The outreach team had developed and implemented a rehabilitation pathway which used a structured, team approach to monitoring events both during and following step down from critical care, to ward based care and through to follow up post discharge from hospital.

There was strong medical and nursing leadership within critical care. Staff felt well supported within an open, positive culture. There was a clear governance structure with on-going monitoring of the quality of care delivered. Innovative practice within critical care included their rehabilitation pathway, a new system for monitoring mortality and their organ donation system.

Services for children & young people

Good

Updated 22 October 2015

Incidents were reported and investigated appropriately with learning from incidents shared with staff. Staff were open and honest with patients when things went wrong and when errors were made. Staff had appropriate paediatric life support training relevant to their role and there was equipment and facilities available to respond to patients who became seriously unwell.

The service conducted local and national audits to measure performance against national and local guidance. There was learning and action taken to improve services. Transitional arrangements were in place for young people moving into adult services. Staff were caring.

There were clear discharge pathways and procedures to ensure patients received the appropriate care and treatment after their stay in hospital.

The service was responsive to patient’s needs. There were resources in place to communicate with patients and their families. There was a clear vision and strategy for the service with both staff and managers aware of key priorities. Staff felt engaged and involved in improving and developing services.

End of life care

Good

Updated 22 October 2015

Overall we judged end of life care services at Burton Hospitals NHS FT as good.

Patients and relatives were treated with dignity, respect and compassion in the time leading up to the end of patients’ lives and after their death.

The service was supported by proactive, dedicated and passionate members of the specialist palliative care team who were working to improve the structure of end of life care services and to embed the key areas of end of life care into the hospitals’ culture.

Medical and nursing staff on hospital wards told us they were well supported in decisions about the care of dying patients and that they knew when and where to find specialist advice.

Partnership arrangements with local hospices were well-managed and effective.

Managers of the service were aware that work was needed to further develop the quality of end of life care and plans were in place to progress further.

During our inspection we spoke to seven patients, three patients’ relatives and 45 staff. We visited twenty wards, three specialist teams and the hospital mortuary.

Outpatients

Requires improvement

Updated 22 October 2015

Whilst we found that the service was responsive to the local community we identified issues with the appointments system. Overbooking of appointments had become common practice which led to clinics over running and frustration for patients who experienced long waits. Five percent of patients failed to attend appointments. The hospital cancelled 10% of appointments and patients cancelled 11% of appointments.

Formal complaints processes were embedded however we did not see evidence that informal complaints were being recorded in line with the trust complaints policy.

Local leadership was good. Managers understood their staff and provided an environment where they could develop.

Patients, visitors and staff were kept safe as systems were in place to reduce and monitor risk. Services followed recognised pathways of care and were completed by trained and skilled staff. Patient outcomes were audited and benchmarked against national standards. Staff were caring and involved patients, their carers and family members in decisions about their care.