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Macclesfield District General Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 15 May 2015

Macclesfield District General Hospital is part of East Cheshire NHS Trust and provides a full range of hospital services, including urgent and emergency care, critical care, general medicine including elderly care, emergency surgery, elective surgery in most specialties, cancer services, paediatrics, maternity care and a range of outpatient services.

East Cheshire NHS Trust serves a population catchment area of approximately 450,000. Inpatient services are provided from two hospital sites – Macclesfield District General Hospital (main site) and Congleton War Memorial Hospital (intermediate care service). Outpatient services are provided in Macclesfield District General Hospital and in community bases in Congleton, Handforth, Knutsford, Wilmslow and Poynton. In total, the trust has 376 beds.

East Cheshire NHS Trust is a non-foundation trust. NHS trusts are run slightly differently to foundation trusts. NHS foundation trusts, first introduced in April 2004, are independent legal entities and have unique governance arrangements. They are free from central government control and are no longer performance-managed by health authorities. As self-standing, self-governing organisations, NHS foundation trusts are free to determine their own future.

We carried out this inspection as part of our comprehensive inspection programme. This report also includes our findings for the minor injuries unit at Congleton War Memorial Hospital.

Overall, we rated Macclesfield District General Hospital as ‘requires improvement’. We have judged the service as ‘good’ for caring. We found that services were provided by dedicated, caring staff. Patients were treated with dignity and respect and were provided with appropriate emotional support. However, improvements were needed to ensure that services were safe, effective, responsive to people’s needs and well led.

Our key findings were as follows:

Cleanliness and infection control

  • Patients received care in a clean, hygienic and suitably maintained environment. Staff were aware of and applied infection prevention and control guidelines.
  • We observed good practices in relation to hand hygiene and ‘bare below the elbow’ guidance and the appropriate use of personal protective equipment, such as gloves and aprons, while delivering care.
  • Policies for managing patients in isolation rooms were not always followed in surgical services.
  • During our inspection we identified serious concerns with the storage of breast milk and the inappropriate storage of decontaminated equipment with clean equipment. We raised our concerns immediately with the trust. We reviewed the action the trust had taken as part of our unannounced inspection and were assured that the trust had taken the necessary steps to address our concerns. However, we identified other concerns in relation to infection control such as the decontamination arrangements for toys in the inpatient and outpatient areas and for cots on the special care baby unit. We also found that staff were unclear about the decontamination arrangements for a breast bump. As a result the matron for the service asked the breastfeeding team to review the process.
  • Some areas of the maternity unit had signs of wear and tear which meant that they could not be cleaned. This included bare and worn wood around sinks and in the sluices. Chipped shelving in the clinical areas, offices and sluices and wooden doors and doorways with bare wood were present. The trust had recognised these areas required improvement as part of their capital improvement programme 2014/15. However, we raised these issues with the service during the inspection and no improvement programme was discussed.
  • During the inspection we raised concerns regarding a damaged wall in the day case theatre. The trust took immediate action to address our concerns. We also found a shower room where the edges of the shower and around the floor were not sealed, allowing water to get between the wall and the floor covering and mould was visible to that area and to the patient call bell cord. An infection control audit report for ward 1 showed that this had been identified in August 2014 but no remedial action had been taken. This was raised with staff and the edges were sealed by the maintenance team during the inspection.

Records

  • The standard of record completion varied across the services. In emergency services, critical care and surgical services we found that medical and nursing notes were structured, legible, complete and up to date.
  • However, we found gaps in the completion of records relating to medication, demographics, growth charts and individualised care plans on the children’s ward. We also found evidence of the retrospective completion of records.
  • There were variations in the completeness of ‘do not attempt cardio-pulmonary resuscitation’ (DNA CPR) forms across the hospital.
  • Records in the outpatients department, occupational therapy, physiotherapy and orthotics department and on the children’s ward were not stored securely in line with requirements.

Staffing levels

  • Overall, medical treatment was delivered by sufficient numbers of skilled and committed medical staff.
  • Consultant cover in critical care services was limited due to only six of the nine consultants being trained in intensive care. This meant that only 80% of patients were assessed by a consultant within 12 hours of admission to the critical care unit and the provision of two daily ward rounds was not achieved at weekends.
  • A shortfall in the number of junior doctors in urgent and emergency services meant that the trust had to employ locum staff from November 2014 to February 2015 to cover shortages. The trust was also having difficulty recruiting to four additional registrar posts. In addition, there were four vacancies for junior doctors’ in critical care services. Shortfalls were covered by locum, bank and agency staff.
  • Care and treatment were delivered by committed and caring staff who worked hard to provide patients with good services.
  • Although we found that staffing levels were adequate at the time of our inspection, there was no flexibility in numbers to cope with increased capacity and demand, or short-notice sickness and absence.
  • The trust was actively recruiting nursing staff from overseas to try to improve staffing levels.
  • The midwife-to-patient ratio averaged at one to 30. This was higher than the recommended number of one to 28. No recognised acuity tool was used to assess the number of midwives required. A staffing acuity guideline was in place based on Birth-rate plus. However this did not allow for the assessment to be done daily.

Mortality rates

  • Our ‘intelligent monitoring’ report of July 2014 showed that there was no evidence of risk for summary hospital mortality level indicators or for hospital standardised mortality ratio indicators.

Incidents

  • Systems were in place for reporting and managing incidents. However, these were not followed consistently across all services.
  • In maternity services, there was poor understanding of the system for deciding the serious nature, or potential outcomes, of an incident or for how it should be investigated. This meant that not all incidents with potential risks of harm were formally investigated or recorded or lessons shared.
  • Incidents were not always reported in line with trust policy in outpatients and diagnostic imaging services or in children’s and young people’s services, which meant that data provided in relation to incidents may not provide a reliable oversight of incidents occurring in these services.

Nutrition and hydration

  • Patients had a choice of nutritious food and an ample supply of drinks during their stay in hospital. Patients with specialist needs in relation to eating and drinking were supported by dieticians and by the speech and language therapy team.
  • The patient records we reviewed included an assessment of patients’ nutritional requirements based on the malnutrition universal screening tool (MUST).
  • Where patients were identified as being at risk, there were fluid and food charts in place and these were reviewed and updated by the staff.
  • Children and young people were offered a choice of meals that were age appropriate and supported individual needs such as gluten-free and sugar-free. Children told us that they enjoyed the food. Parents told us that the food was good quality and there was a lot of choice, including healthy options.

Medicines management

  • The systems in place for the management, storage, administration, disposal and recording of medication, including controlled drugs and oxygen, were not robust and in line with requirements.
  • In urgent and emergency services, controlled drugs registers had not always been signed by two staff members when controlled drugs were dispensed. Also, controlled drugs that were wasted (unused) during a treatment had not been recorded since February 2014. Systems to dispose of controlled drugs were not being followed.
  • In maternity services, the policy for checking stocks of controlled drugs was not followed in practice and we found medication in stock that was past its expiry date stored in an open box with other vials that were in date. This did not comply with the trust’s policy ‘Safe and secure handling of medicines’. We brought this incident to the trust’s attention and it took immediate action to address our concerns.
  • In children’s and young people’s services, the administration and recording of medication did not always occur in a timely manner.
  • Anticipatory prescribing in end of life care was common, in line with best practice. This meant that pain relief and other medication could be started quickly if patients became unwell.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 [now Health and Social Care Act 2008 (Regulated Activities) Regulations 2014] and the trust needs to make improvements in these areas.

Importantly, the trust must:

  • Ensure that there are robust systems in place for the management, storage, administration, disposal and recording of medication, including controlled drugs and oxygen, in line with requirements.
  • Ensure that records contain accurate information in respect of each patient and include appropriate information in relation to the treatment and care provided, particularly with regard to children’s and young people’s services, pain relief documentation in the emergency department and ‘do not attempt cardio-pulmonary resuscitation’ (DNACPR) forms.
  • Ensure that records in children’s and young people’s services are stored securely in line with regulatory requirements.
  • Ensure that there are effective processes in place for the decontamination and storage of clean and contaminated equipment and for the monitoring of this, particularly in relation to children’s and young people’s services.
  • Ensure that the environment within medical wards, surgical wards and maternity services is well maintained and fit for purpose so that appropriate standards of cleanliness can be maintained.
  • Ensure that there are effective systems in place to identify, assess and monitor risks relating to the health, safety and welfare of people who use services and staff. This includes incident-reporting systems and risk-management processes for the maintenance of equipment.

In addition, the trust should:

  • Consider improving arrangements for clinical supervision to ensure that they are appropriate and support staff to carry out their responsibilities effectively, offer relevant development opportunities and enable staff to deliver care safely and to an appropriate standard.

In urgent and emergency services

  • Ensure that the four-hour target data is recorded accurately at the minor injuries unit (MIU) at Congleton War Memorial Hospital.
  • Assess all patients for pain relief as they enter the emergency department and ensure that the pain score and any administered pain relief are recorded accurately.
  • Review the timeliness of access to interpreter services.
  • Review the process to manage bariatric patients.
  • Consider implementing a pain audit for paediatrics.

In surgical services

  • Take appropriate action to ensure that there is adequate provision of suitable showering facilities for patients within the orthopaedic wards.
  • Take appropriate action to ensure that all staff receive clinical mandatory training.
  • Take appropriate action to improve performance relating to length of stay for general surgery patients in the hospital.
  • Take appropriate action to improve compliance with national targets for 18-week referral-to-treatment time (RTT) standards.
  • Consider taking action to ensure that there are appropriate management arrangements in the theatres department.

In medical care services

  • The trust should ensure that mental capacity assessments are recorded appropriately and that all staff understand the requirements of the Mental Capacity Act and deprivation of liberty safeguards.
  • The trust should take steps to ensure that all staff are included in lessons learned from incidents and near misses and have a full understanding of the trust’s governance processes.
  • Action should be taken to ensure that any chemicals are stored appropriately and that ‘out of bounds’ areas are secured appropriately.

In critical care

  • Consider a review of services to manage patients safely over a 24-hour period.
  • Consider reviewing the level of cover provided by consultants to ensure that there are twice daily rounds and that the assessment of admissions to the CCU can be achieved within the recommended 12-hour period.

In maternity and gynaecology services

  • Ensure the safe storage of medical gases, disposable medical equipment and other items on the ward.
  • Ensure that risks associated with the use of the birthing pool are assessed and appropriate emergency evacuation equipment is provided.
  • Ensure that all staff are up to date with mandatory training.
  • Ensure that there are systems for the safe management of patients during operations and in the event of emergencies. This should include joint working with the theatre staff and assurance that midwives who may be requested to assist in theatre are competent to do so.
  • Take action to reduce the number of gynaecology operations cancelled at short notice.
  • Ensure that the facilities for patients undergoing a termination of pregnancy provide privacy and dignity.

In children’s and young people’s services

  • Ensure that there are robust monitoring arrangements in place to make sure that areas are appropriately locked in children’s and young people’s services.
  • Ensure that all staff are aware of arrangements for recording and accessing information relating to safeguarding in children’s and young people’s services. This includes obtaining assurance that consultant assent arrangements are followed in line with trust policy.
  • Ensure that staff receive relevant training to support children and young people with mental health needs.
  • Ensure that staff are competent and confident in the use of continuous positive airway pressure (CPAP) equipment.
  • Ensure that there are monitoring and escalation procedures in place to make sure that there are enough staff with the appropriate skills in order to meet the needs of children and young people.

In end of life care

  • Ensure that there are robust arrangements in place for out-of-hours consultant cover and that these arrangements are communicated clearly to all staff, particularly the specialist palliative care team (SPCT).
  • Ensure that all staff receive appropriate end of life training.

In outpatients and diagnostic imaging services

  • Ensure that equipment is maintained in line with the manufacturers’ recommendations.
  • Take action to reduce the number of clinic cancellations.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 15 May 2015

Effective

Requires improvement

Updated 15 May 2015

Caring

Good

Updated 15 May 2015

Responsive

Requires improvement

Updated 15 May 2015

Well-led

Requires improvement

Updated 15 May 2015

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 15 May 2015

There had been an emphasis on completing the necessary audits and training to obtain and maintain level three in the Clinical Negligence Scheme for Trusts (CNST). This recognises a high standard of training and care. However, the standard of some of the more basic day-to-day practices and procedures, which were not included in this work, had not been maintained. Staff did not always follow procedures correctly for the management of controlled drugs or for the completion of some records. There was no formal system for deciding the serious nature, or potential outcomes, of an incident or for how it should be investigated. This meant that not all incidents with potential risks of harm were formally investigated or recorded or lessons shared. Some of the facilities, such as those for parents of babies in the neonatal unit and to facilitate infant feeding, were not fit for purpose.

 

There were no inpatient beds used specifically for patients undergoing a gynaecology operation or termination of pregnancy. Such patients could be accommodated in a mixed ward but this did not protect their dignity or the potentially sensitive nature of the support they would need. A high number of gynaecology operations were cancelled at short notice. There was no clear vision or strategy to improve or develop gynaecology services within the hospital. The trust provided information regarding the strategy for gynaecology services but staff within the service were unaware of both the strategy and any of the development plans in place. There was a lack of monitoring of day-to-day procedures and this had led to poor practice not being identified or rectified. Not all areas of risk had appropriate assessments in place or actions to reduce those risks. The trust had identified the need to plan to sustain maternity services and had identified several actions. However, senior midwifery staff did not identify these plans when we spoke with them.

 

The maternity services used local and national data and good practice guidance to develop policies and procedures. The working procedures and outcomes were audited to monitor the effectiveness of the service. Action plans were in place to improve outcomes in the areas identified as being below either national standards or the trust’s own targets, including for the number of normal deliveries and third and fourth degree tears. There was a multidisciplinary approach to the care and support of patients, with the inclusion of specialists from other medical areas such as diabetes management and mental health services. However, there was a lack of joint working with theatre staff. The competence of staff was monitored and midwives received the necessary supervision and support. Staff were caring and treated people with respect and dignity. People spoke highly of the care they had received and the attitude of staff. There were opportunities for staff to develop personally and professionally, with clear lines of leadership and accountability in the service.

Medical care (including older people’s care)

Requires improvement

Updated 15 May 2015

Some concerns were identified with unsecured environments and storage facilities. Although there were generally good practices with regard to infection control, some communal areas and equipment were unclean at the time of our inspection. Staff were committed and passionate about providing good care. All of the patients we spoke with were positive about their experience. The interactions we observed between staff and patients were varied, although they were mostly positive in nature. However, in some areas staff were task oriented and did not always provide a person-centred care approach.

 

The quality of records varied. Some essential care documentation, including observational records, was completed poorly. Evidence-based practice was used. However, some people’s care plans were not effective in providing guidance to staff on how to safely provide care and treatment to meet patients’ assessed needs. Care plans for people living with dementia were not effective. Pain relief and nutrition and hydration needs were assessed appropriately and patients stated that they were not left in pain. There were some measures of patient outcomes, but not all staff were fully aware of these.

 

Staffing levels met the needs of the patients at the time of our inspection. The service was addressing concerns regarding staffing levels and staff skill mix. Staff recruitment was in progress to fill staff vacancies. Staff uptake of mandatory training was meeting the trust’s target. Multidisciplinary team working was well established. Staff understanding and awareness of assessing people’s capacity to make decisions about their care and treatment was variable. Staff generally felt supported and valued. Staff views on the trust’s leadership and vision were varied. Services were well led at a local level in some areas but not all staff had a clear understanding of the trust's vision. In some areas, staff felt they were not engaged in decision making about their service and that there were no effective two-way communication streams.

Urgent and emergency services (A&E)

Good

Updated 15 May 2015

Systems were in place for reporting and managing incidents. Patients received care in safe, clean and suitably maintained environments with the appropriate equipment. Medicines were not managed consistently in line with requirements. This was because the controlled drugs registers had not always been signed by two staff members when controlled drugs were dispensed and controlled drugs that were wasted (unused) during a treatment had not been recorded since February 2014. Systems to dispose of controlled drugs were not being followed.

 

Patients were assessed for pain relief; however, the pain score had not always been recorded and, when a score was indicated, appropriate and regular pain relief was not always recorded as being given. Staffing levels were sufficient to meet patients’ needs and processes were in place to ensure that resource and capacity risks were managed. The ratio of junior doctors was worse than the England average and the trust was having difficulty recruiting to four additional registrar posts. Shortfalls were covered by locum, bank and agency staff. Security arrangements were in place at the emergency department at Macclesfield but there was no on-site security at the MIU.

 

Overall, the trust had met the national Department of Health target to admit or discharge 95% of patients within four hours of arrival at accident and emergency (A&E) between 5 January 2014 and 28 September 2014. However, we found discrepancies in the recording of waiting times at the MIU. Waiting times were recorded only from when the nurse actually saw and treated the patient to when the patient was discharged. This meant that data did not provide an accurate picture of the waiting times for this service. Overall however, this had limited impact on the trust’s waiting time targets.

 

Care and treatment provided were evidence-based and adhered to national guidance. We saw effective collaboration and communication among all members of the multidisciplinary team and services were geared to run seven days a week. Staff treated patients with dignity, compassion and respect, even while working under pressure.

 

The trust’s vision and strategy had been cascaded to all staff, and staff were proud of the work they did. Key risks and performance data were monitored. There was clearly defined and visible leadership and staff felt able to challenge any staff members who were seen to be unsupportive or inappropriate in carrying out their duties. The emergency department faced challenges such as patient flow and local changing needs, including an increased elderly population, but it had initiatives in place to tackle these.

Surgery

Requires improvement

Updated 15 May 2015

Older equipment, such as operating tables used in theatres, was not replaced in line with manufacturers’ recommendations. During our inspection we raised this issue with the trust. We reviewed what action the trust had taken during our unannounced visit and found that it had taken action to address our concerns. The general environment within the day case and main operating theatres was not maintained suitably. We raised concerns regarding specific environmental issues during the inspection. The trust took immediate action to address our concerns. Staff received mandatory training. However, clinical mandatory training compliance was below the hospital’s target of 80%. Medicines were stored safely and given to patients in a timely manner. Where patients received oxygen treatment, the use of oxygen was not always recorded on medication charts. The majority of staff followed infection prevention and control guidelines but policies for managing patients in isolation rooms were not always followed.

 

Patients experienced delayed transfers of care to other providers, such as community intermediate care. The surgical services had clear plans in place for how they would reduce delayed transfers of care. The hip fracture audit for 2013 showed that the hospital’s performance was worse than the England average for the percentage of patients undergoing hip surgery within 36 hours and within 48 hours. The clinical director for orthopaedics told us that they had increased the number of patients with hip fractures who underwent surgery within 36 hours over the past year and the improved performance would be reflected in the hip fracture audit data for 2014. The surgical services met the national targets for 18-week referral-to-treatment times (RTT) for patients admitted for general surgery but following a national amnesty agreed by NHS England and the Trust Development Authority, failed to meet the national targets for all other specialties. The theatres department did not always meet its own performance targets, which meant that theatre lists did not always start or finish at the required times. All patients whose operation was cancelled were treated within 28 days. The average length of stay for elective and non-elective patients across all specialties was longer than the England average. The surgical services had taken action to improve the length of stay for patients undergoing elective hip and knee surgery by using rapid recovery care pathways.

 

There were action plans in place to address identified risks. However, we found that when issues were identified, timely action was not always taken to address those risks. The theatres department had not had a theatre manager since December 2013. The theatres were managed by two theatre leads who were band 7 nurses. The theatre leads reported to the head of service for surgical specialties and were responsible for the day-to-day management of the theatres department.

 

The majority of staff were positive about the culture and support available across the surgical services. Patient safety was monitored and incidents were investigated to assist learning and to improve care. The surgical services provided care and treatment that followed national clinical guidelines and staff used care pathways effectively. The services participated in national and local clinical audits. Patients received care and treatment by trained, competent staff who worked well as part of a multidisciplinary team (MDT). Patients spoke positively about their care and treatment. Patients were treated with dignity and received compassionate care.

Intensive/critical care

Good

Updated 15 May 2015

The introduction of the National Early Warning Score (NEWS), a system used to determine whether or not a patient’s condition was deteriorating, had been effective and audits had shown a marked improvement in the recording and use of observations. However, the outreach service that provided support for the management of deteriorating patients on the wards was limited to weekdays only with no out-of-hours or weekend support provided. Consultant cover was limited due to only six of the nine consultants being trained in intensive care. Also, there was a reliance on locum cover for junior doctors’ vacancies. Only 80% of patients were assessed by a consultant within 12 hours of admission to the CCU and the provision of two daily ward rounds was not achieved at weekends.

 

Care was delivered in the CCU by a well-led team of competent nursing staff and in accordance with national and best practice guidance, for example National Institute for Health and Care Excellence (NICE) guidance. The service was effective at monitoring, managing and improving patient outcomes. Patients and relatives spoke positively about the care they had received and the kindness and efficiency of the staff. Staff were responsive to patient feedback and used information to improve the quality of the service.

 

There were reliable and effective systems in place, including for reporting and learning from incidents. Infection prevention and control measures, including hand washing and the use of personal protective equipment, were practised well and the unit was found to be clean and well maintained. There were reliable planned maintenance systems in place to ensure that equipment was available for use and fit for purpose.

Services for children & young people

Requires improvement

Updated 15 May 2015

During our inspection we identified serious concerns with the storage of breast milk and the inappropriate storage of contaminated equipment with clean equipment. We raised our concerns immediately with the trust. We reviewed the action the trust had taken as part of our unannounced inspection and were assured that the trust had taken the necessary steps to address our concerns. However, we identified other concerns in relation to infection control; these included the decontamination arrangements for toys in the inpatient and outpatient areas and cots on the special care baby unit. We also found that staff were unclear about the decontamination arrangements for a breast bump. As a result the matron for the service asked the breastfeeding team to review the process. We found that patient notes were not stored appropriately in the outpatient setting. We also found gaps in clinical records relating to medication, demographics, growth charts and individualised care plans.

 

The environment and layout in the children’s ward were such that some parts of the unit were unobservable. There was no evidence of risk assessment when placing children and young people in these areas. We were also not satisfied that monitoring arrangements relating to escalation processes, staffing levels and patient acuity were robust. We raised our concerns with the trust at the time of the inspection. We returned to the ward as part of our unannounced visit and were satisfied that new procedures had been put in place to address our concerns.

 

We found that, while there were ongoing discussions regarding healthcare provision, there was no clear vision or strategy in place for children’s and young people’s services. Staff were passionate about continually improving children’s and young people’s services.

 

Audits and monitoring of areas such as medical records and infection control had not identified the concerns we raised during our inspection. Staff knew how to report incidents but some staff told us they did not always report incidents using the electronic reporting system. For example, when levels of care changed on the ward.

 

Parents and young people told us that they felt safe, informed and supported by trust staff. Throughout our inspection we saw children and young people being treated with dignity and respect. We observed staff providing compassionate care.

End of life care

Requires improvement

Updated 15 May 2015

Consultant and specialist palliative care services were available but lacked clear lines of communication between them. There was a committed specialist palliative care team but end of life care services lacked organisational structure and leadership. The palliative care service was limited to weekdays only with only informal consultant cover provided during periods of absence. Staff had not received any training for end of life care in the past six months due to staff shortages. There were variations in the completeness of DNA CPR forms across the hospital. Forms were supposed to be reviewed daily but evidence suggested that this did not happen consistently. Action plans had been developed in response to the National Care of the Dying Audit of Hospitals (NCDAH) but their implementation was only partially completed at the time of the inspection. There was evidence of good multidisciplinary team working on the wards and that pain relief was managed effectively. In the main, medicines were managed safely and administered by competent staff. However, some ‘when required’ (PRN) medicine such as pain relief did not have a maximum dose prescribed that could be administered within a 24-hour period. This meant that patients could potentially receive more than the recommended dose.

 

Most staff were aware of how to report and respond to incidents and they received feedback to ensure that they learned from incidents. Safeguarding systems were well embedded in the service. In the NCDAH for 2012/13, the trust had performed in line with or better than the England average for 14 of the 17 key performance indicators. The end of life care plan introduced in July 2014 had been developed to replace the Liverpool Care Pathway. The plan included guidance for the care team about recognising and responding to deteriorating patients to ensure that their care was timely and managed effectively and that patients’ preferred priorities for care were met.

 

The fast-track system worked well and requests were usually fulfilled within a day. There was evidence to show that most people managed to die in their preferred place of care. Consultants commented on the timely response they received to requests for support from the palliative care consultant. Patients and relatives had confidence in the medical and nursing staff and felt that they had been involved in planning their end of life care. Staff were observed to listen and respond appropriately to patients’ requests in a kind and caring manner. Patients and relatives told us that they found the staff to be kind and understanding and they spoke highly of the care and support provided.

Outpatients

Requires improvement

Updated 15 May 2015

Incidents were not always reported in line with trust policy, which meant that data provided in relation to incidents may not provide a reliable oversight of incidents occurring in outpatients and diagnostic imaging services. Records in the outpatients department and the occupational therapy, physiotherapy and orthotics department were not stored securely, which meant that there was a risk of people’s records and personal details being seen or removed by people in the department. Records were not always available in time for clinics; on occasion this led to the cancellation of clinics.

The organisation of the outpatients departments was not always responsive to patients’ needs. The trust recognised that the layout and size of the department was insufficient to provide a safe environment for the number of people using the unit. However, there were no action plans or procedures that had been put in place to mitigate risk or to change the environment. Equipment had not been maintained in line with manufacturers’ recommendations. Nearly a third of clinics were cancelled and patients experienced delays when waiting for their appointments. The vision and strategy for outpatients and diagnostic imaging services were not clear. Risk management and quality measurement systems were reactive and not proactive. Outpatients and diagnostic imaging services had not identified all risks to service users, and those identified were not being managed effectively.

 

Cancer waiting times were consistently better than the England average for 31-day and 62-day targets. Since September 2013, RTT for patients with incomplete pathways were better than the England average. RTT for non-admitted patients had been inconsistent between April 2013 and May 2014 but were better than the England average from June 2014. Diagnostic waiting times had been better than the England average since November 2013.

 

There was evidence of good multidisciplinary working in the outpatients and diagnostic imaging departments. Doctors, nurses and allied health professionals worked well together. We found that staff were approachable, welcoming and friendly. Staff were discreet and kind when they saw that a person was upset, and we saw them take extra time to communicate with people if they deemed it necessary.