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New Cross Hospital Requires improvement

The provider of this service has requested a review of one or more of the ratings.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 13 December 2016

We undertook this inspection 02 to 05 June 2015. It was an announced comprehensive inspection. This trust had been inspected in the first wave of the comprehensive programme November 2013.

Our rationale for undertaking this inspection was to rate the trust because the initial inspections did not receive a rating due to being in the early wave one pilot programme. In addition to this the trust had taken over some services from the dissolved Mid Staffordshire NHS Trust, which included Cannock Chase Hospital.

The trust had previously stated its intention to become a Foundation trust, but had had to postpone the application a number of times; allowing them to address current matters such as the integration of new services appropriately.

We recognise that we saw this hospital, and the trust is a state of change. Integrating services between New Cross Hospital and Cannock Chase Hospital. We also noted some significant building work on the hospital site, including a new Urgent and Emergency Care unit.

We inspected all core services on the New Cross site; this included Urgent and Emergency Care; Medical Care, Surgical Care, Critical care, Maternity Services, Children’s Services, End of Life care, Outpatients and Diagnostic Imaging.

Overall we rated the New Cross Hospital as Requires Improvement.

We rated Urgent and Emergency Care and Surgical Services as Good, we rates all other services are Requires Improvement.

We rated the hospital as Good for Effective, caring and Responsive; we rated the hospital as Requires Improvement for Safe and well Led.

Our key findings were as follows:

  • Good services were provided by Urgent and Emergency Care. Safe systems were in place and the hospital was responding to the increase in demand by expanding the unit. In the interim; processes and procedures were effective.
  • Good Services were provided by Surgical Services; care was delivered within national guidance and the trust was largely meeting the 18 week referral to treatment target.
  • We saw good compliance with hand hygiene and with the trusts ‘bare below the elbows’ policy. We saw staff in outpatients remind visitors to use hand gel. On the occasions we saw non-compliance, we raised this with the clinical manager and it was immediately dealt with.
  • We saw largely good and compassionate care within the hospital. Staff were focused on patient care.
  • We did see a number of examples in medical care services that did not demonstrate the high standards of patient care set in other parts of the trust. These isolated examples demonstrated poor patient care.

  • We saw nurse staffing levels sufficient for the needs of the service including Urgent and Emergency Care and Critical Care and Children’s Care and Outpatients. However in Medical Care we saw staffing a challenge to meet the requirements of each shift. Staffing in Surgical Care was on the trusts risk register, although we saw the trust had taken action to recruit more staff.
  • There were mainly sufficient medical staff to care for patients. Children’s services and radiology had vacancies and the trust were aware of these.
  • We saw sufficient equipment across the trust to meet the needs of patients, although in medical care services there was a concern about sufficient monitoring equipment.
  • We saw that the trust was meeting cancer access targets and the 18 week referral to treatment times in outpatients and in many of its surgical specialities.

We saw several areas of outstanding practice including:

  • The hospitals SimWard was being utilised to support staff competencies. Staff told us they were in the process of expanding the service externally to provide education and learning to other authorities.
  • Doctors, nurses and therapists were provided with a stamp by the trust with their name and personal identification number. This enabled other staff to easily track who had completed the patient record when required.

  • In surgical services, we saw that the trust recently instituted “In Charge” initiative was welcomed by patients and relatives. This was a badge worn by the person responsible for that shift on the ward.
  • There were arrangements in place with Age Concern that certain patients funded by the local CCG could be called upon to transport suitable patients. There was a checklist in place for the driver who would ensure that the patient had all the necessary comforts in the home for example, food and a suitably heated home. The Age Concern drivers would stay with the patient in their home to ensure they are safe to be on their own.

  • The “panel meeting” concept where senior trust staff provided high challenge and high support to wards managers after investigation of incidents. This meeting enabled staff to take the learnings from such events on board and ensure systems were put in pace to prevent reoccurrence.
  • We saw that the mortuary staff were very passionate about delivering a high standard of care after death.

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

Action the hospital MUST take to improve

Medicine

  • The trust must improve the attitude and approach of some of its staff to patients in their care.
  • The trust must improve the level of detail in patient care records, reflecting individual preferences.
  • The trust must review the amount of monitoring and supporting equipment on its wards.

Surgery

  • The trust must make sure that the recruitment of additional staff that was being undertaken to resolve the transportation of blood is completed in a timely manner.

Critical Care

  • The trust must ensure that regular checks are recorded regarding the cleaning of equipment.
  • The trust must ensure that locally owned risks are identified and recorded on the risk register and have appropriate actions to mitigate them, with timely reviews and updates.
  • The trust must ensure the medicine room is locked to reduce the risk of unauthorised people accessing medicines.
  • The trust must ensure that intravenous medicines are stored correctly to reduce the risk of the administration of incorrect medicines.
  • The trust must ensure that the microbiologist input is recorded within the patient records to support their care and welfare.

End of Life Care

  • Controlled medication must be labelled, prescribed to a patient and packaging must not be tampered with.

OPD and Diagnostics

  • The trust must ensure that when controlled drugs are removed from the medicines cupboard in radiology, this is clearly documented at the time of administration.
  • The trust must insure that governance systems improve so that safety issues and shortfalls in risk assessments and protocols are highlighted and addressed.
  • The trust must insure that there is clear ownership of responsibilities to ensure the radiology departments is working within best practice professional guidelines and IR(ME)R regulations

Action the hospital SHOULD take to improve

Emergency Services

  • The trust should improve staff understanding of the dementia care pathway for patients in the ED
  • Medicine fridge temperature records in the ED should be recorded daily to ensure medicines were stored safely.
  • Evidence of resuscitation status should be included in patient’s records.
  • ED staff take up of mandatory training should be improved.
  • The trust should be clear about the use of the paediatric facilities in the ED
  • The trust should improve public information about making a complaint in the ED

Medicine

  • The trust should improve the attitude and approach of some of its staff to patients in their care.
  • The trust should improve the level of detail in patient care records, reflecting individual preferences.
  • The trust should review the amount of monitoring and supporting equipment on its wards.
  • The trust should review arrangements for transferring patients to Cannock Chase Hospital late at night.

Surgery

  • The trust should make sure that all staff is up to date with the requirements of the Mental Capacity Act and Deprivation of Liberty safeguards so that patients are not put at unnecessary risk of staff not acting legally in their best interests.
  • The trust should make sure that there are process in place to ensure formal “sign in” takes place in the anaesthetic room.
  • The trust should make sure that a number of required policies and procedures identified from the national emergency laparotomy audit 2014 are put in place.
  • The trust should make sure that patients with bowel cancer can access appropriate clinical nurse specialist.
  • The trust should ensure there are resting seats available for vulnerable patients to avoid them to walk long intervals without resting.

Critical Care

  • The trust should ensure there are procedures in place to record the checking of the resuscitation trolley.
  • The trust should ensure that the trust’s vision and strategy is cascaded to all staff.
  • The trust should ensure that all policies and procedures are up to date and have been reviewed appropriately.

Maternity and Gynaecology

  • The trust should improve the quality of record keeping in maternity.
  • The trust should improve the checking of drugs and fridge temperatures where medicines are stored..
  • The trust should ensure emergency equipment is readily available to use.

End of Life Care

  • The trust might like to review staffing levels in particular on the oncology ward and surgical wards.
  • The trust should develop clear guidance for staff on repositioning spinal cord compression and spinal cancer patients.
  • Spinal cord compression and spinal cancer patients must be repositioned according to their assessment and trust policy. Staff should record incidents where appropriate.
  • The hospital might like to improve on communication with families and better recording of their discussions with staff, ensuring discharge is consistently discussed and they are kept informed of patient’s conditions.

OPD and Diagnostics

  • The trust should ensure that the renal unit complies with staffing requirements stipulated by the National Institute of Clinical Excellence.
  • The trust should ensure that staff in radiology receives feedback in relation to shared learning and changes in practice resulting from incidents.
  • The trust should ensure that call bells within radiology cubicles are fit for purpose and that there is clear signage outside x-ray rooms alerting patients not to enter and advising women to inform staff if they are pregnant.
  • The trust should ensure that the procedure to check whether women are pregnant prior to receiving radiography tests is improved
  • The trust should ensure that the nuclear medicine (imaging) service issues ‘written instructions’ to females who are breastfeeding and who have undergone a radio nuclide procedure.
  • The trust should ensure that Local Diagnostic Reference Levels are available for the CT scanners (and other diagnostic procedures) and that CT radiographers have a method (or written procedure available to them) of knowing when an overexposure would be much greater than intended and how this should be reported.
  • The trust should ensure that the clinical imaging protocols (operating procedures) are fit for purpose and that basic scan parameters are present that would allow an operator to follow and find operational information to be able to perform a scan safely and to check that recalled electronic settings within the scanning equipment is in concordance with the written protocol.
  • The trust must ensure that the radiation risk assessments are fit for purpose and have enough specific detail for the radiation work undertaken in each area.
  • The trust must ensure that there are Local Rules or systems of work available for mobile radiography units as required by the Ionising Radiation Regulations 1999.
  • The trust should ensure that paediatric reports within radiography are produced promptly.
  • The trust should ensure that appointment letters and patient information leaflets are available in languages other than English.
  • The trust should ensure that there is a method of monitoring whether patients have been present in outpatients or radiology for long periods to ensure they have adequate food and drink.
  • The trust should ensure that patient feedback is received and acted upon in radiology to improve service provision.
  • The trust should ensure that radioactive medicinal products and waste are securely stored and accounted for at all times.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 13 December 2016

Effective

Good

Updated 13 December 2016

Caring

Good

Updated 13 December 2016

Responsive

Good

Updated 13 December 2016

Well-led

Requires improvement

Updated 13 December 2016

Checks on specific services

Maternity and gynaecology

Good

Updated 13 December 2016

Overall we found the service was good although the domain of safe required improvement.

There were many good examples of the maternity unit being safe including incident reporting systems, audits concerning safe practice and compliance with best practice in relation to care and treatment plans. However emergency arrangements needed to improve.

Obstetric consultant cover was not adequate being below the required hours for the number of births undertaken annually.

Policies were based on National Institute of Clinical Excellence (NICE) and Royal College of Obstetrics and Gynaecology (RCOG) guidelines. People received care and treatment that was planned in line with current evidence-based guidance, standards and best practice.

The birth to midwife ratio was 1:30. The named midwife model was in place and women told us they had a named midwife. Midwives provided one to one care in labour.

Patients told us that they felt well informed and were able to ask staff if they were not sure about something. We saw limited patient information leaflets available.

In March 2013 the maternity service at the Royal Wolverhampton NHS Trust achieved compliance with level two requirements of the Clinical Negligence Scheme for Trusts (CNST) Maternity Clinical Risk Management Standards 2012/13, scoring 46 out of 50.

There was an active maternity services liaison committee (MSLC), which met quarterly.

Medical care (including older people’s care)

Requires improvement

Updated 13 December 2016

Nurse recruitment within medical services was a known challenge for the trust. There were initiatives in place to recruit additional nurses but nursing staff shortages especially at night compromised patient safety. The trust policy, not to use agency nurses meant that shifts were frequently unfilled or the skill mix was inappropriate to meet patient’s needs. Cardiology staff had particular concerns about how staffing was adversely affected when the day ward was open overnight which put cardiology patients at risk due to insufficient staff.

Incident reporting was established and was acted upon when needed; although staff felt staffing concerns were always adequately addressed.

Medical records were appropriately completed although nursing care records lacked detail and were not individualised. The safe hands system identified patients and staff location and was an excellent initiative to promote patient safety. The availability of appropriate equipment used to monitor patient’s observations was insufficient and caused staff concern and put patients at potential risk.

Care was provided in accordance with evidence-based and best practice guidelines. Care was monitored to show compliance with standards and there were good outcomes for patients. Seven days working was established for the majority of staff and multidisciplinary working was evident to coordinate effective patient care. Staff had access to training and had received annual appraisals.

Patients said that staff were caring and friendly and felt that their dignity and privacy were respected. We observed mostly kind and compassionate care although found not all staff appeared caring or compassionate.

The trust worked together with partners and commissioners at a strategic level to respond to the needs of the patients. We saw patient focussed approaches to care and treatment.

Staff were positive about the standard of care they provided and the support they received from their managers. There was a culture of audit and improvement within the medical services.

There were suitable arrangements to identify and manage risks, and to monitor the quality of the service provided. However despite efforts to employ sufficient nursing staff this risk had not been fully addressed and this had not been appropriately addressed by senior managers.

Urgent and emergency services (A&E)

Good

Updated 13 December 2016

We found services provided by the ED overall were good.

Safety systems were in place that supported incident reporting and learning from incidents, safeguarding children and adults and providing sufficient numbers of staff with the right skills to assess, treat and care for patients.

Patient’s care was planned and delivered in line with up to date guidelines and protocols. The ED checked its own performance regularly and took steps to improve on it if it was below standard or as a result of learning from incidents. There were good professional relationships between nurses and doctors and other specialist health and social care workers to support patients’ needs and safe discharge.

Staff were caring and responded compassionately to patients when they were in pain and were kind and warm towards patients and their relatives when they were upset and worried. Staff supported patient’s dignity and privacy.

The trust was responding to the increased need for emergency and urgent care services and working with local commissioners. The ED had not met national targets around seeing, treating and discharging patients within four hours but a new system had been put in place to help managers to improve the flow of patients through the ED and the wider hospital and avoid it becoming blocked at busy times. There were arrangements to make sure patients with particular needs were looked after such as children and people with mental poor health.

Complaints were taken seriously, investigated and reported up to trust leaders. Staff learned from them. However, the complaints procedure was not readily available to patients in the ED.

The ED was well supported by the rest of the trust, had strong local leadership and staff at all levels and roles worked as part of a team and enjoyed their jobs. There was an openness and willingness to learn from mistakes. Safety and quality was regularly reviewed and risk was managed. Staff and managers were also involved in planning the new emergency and urgent care centre.

Surgery

Good

Updated 13 December 2016

Patient safety was monitored on a daily basis and incidents were investigated to assist learning and improve care. Patients received care in safe, clean and suitably maintained premises. Medicines were stored safely and given to patients in a timely manner. Patient records were completed appropriately. The staffing levels and skills mix was sufficient to meet patients’ needs and staff assessed and responded to patients’ risks. Staff received mandatory training in order to provide safe and effective care.

The surgical services provided care and treatment that followed national clinical guidelines and staff used care pathways effectively. Surgical services performed in line with similar sized hospitals and with the England average for most safety and clinical performance measures. The results of the national emergency laparotomy audit 2014 identified a number of required policies and procedures were not yet in place. The National Bowel Cancer Audit 2014 showed overall good results in all areas. The exception was the number of patients seen by a clinical nurse specialist.

Patients received care and treatment by trained, competent staff that worked well as part of a multidisciplinary team. Patients spoke positively about their care and treatment. They were treated with dignity and compassion.

The majority of patients were admitted, transferred or discharged in timely manner. The surgical services achieved the 18 week referral to treatment standards for most specialties. The majority of patients whose operation was cancelled for non-medical reasons were treated within 28 days.

There was clearly visible leadership within the surgical services. Staff were positive about the culture and support available. The management team understood the key risks and challenges to the service and how to resolve these.

Intensive/critical care

Requires improvement

Updated 13 December 2016

Critical care services required improvement to support safe care. There were significant risks posed by the infrastructure and environment of the integrated critical care unit (ICCU). Medical staffing was appropriate and there was good emergency cover. The storage of medicines in the integrated critical care unit (ICCU) required improvement to ensure secure storage facilities to reduce the possibility of misappropriation of medicines. We found intravenous medicines were mixed within the storage room visited which could lead to the misadministration of medicines to patients.

Staff told us they were encouraged to report any incidents which were discussed at weekly meetings. There was consistent feedback and learning from incidents reported. The service had procedures for the reporting of all new pressure ulcers and slips, trips and falls. The environment was visibly clean and most staff followed the trust policy on infection control.

The critical care service demonstrated good effective care. Patients received care and treatment according to national guidelines and there was good multidisciplinary team working to support patients. The service participated and provided data for the Intensive Care National Audit & Research Centre (ICNARC). This ensured that the practice was benchmarked against similar services. Policies and procedures were accessible to staff. However, we saw that some hard copies of policies were dated 2007 to 2014 with no evidence of review. Staff told us they were able to access up to date policies on the trust’s intranet system.

Patient’s pain was appropriately managed as was the nutrition and hydration of patients. Staff had access to training and had received annual appraisal. The critical care service had a consultant-led, seven-day service. Staff had awareness of the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DoLS).

We observed good care within the ICCU. Staff cared for patients in a compassionate manner, with dignity and respect. They involved patients and, where appropriate, their relatives in the care. Emotional and spiritual support was also provided.

The critical care services were responsive to the needs of patients. Patients were admitted to and discharged from the unit at appropriate times. Patients had follow-up support from the outreach team.

Patients with a learning disability were provided with the necessary support. Staff also had access to translation services. Complaints were handled appropriately.

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We found that critical care services required improvement to be well-led. Most staff were not aware of the vision or strategy for the critical care service.

The ICCU held monthly clinical governance meetings where quality issues such as complaints, incidents and audits were discussed. However, there was a disconnect between the risks identified at unit level and those identified and understood by senior management. There were concerns about the impact on patient care and safety which were not identified on the risk register.

There was a culture of support and respect for each other, with staff willing to help each other. Staff told us they were able to speak openly about issues and incidents, and felt this was positive for making improvements to the service.

Patients were engaged through survey feedback. The survey questionnaires showed that patients were happy with the care and treatment they had received.

Innovative ideas and approaches to care were encouraged and supported. There was positive awareness among staff of the expectations for patient care.

Services for children & young people

Good

Updated 13 December 2016

Overall we found the service to be good.

We found that there was a reactive culture in the service which responded well after events had happened. They shared learning to prevent an event re-occurring and responded to issues which had been brought to their attention.

Similarly the Trust Development Agency (TDA) had completed a review of the paediatric ward earlier in the year, they identified 77 minor issues. We saw evidence during our inspection that all the issues had been dealt with and interventions put in place to prevent them re-occurring, but again the issues were such that proper governance and supervision should have identified.

We found that services were caring and staff were dedicated and knowledgeable.

Services were based on recognised clinical pathways which meant patients received treatment based on the latest information and best practice guidance.

Patient care was individualised and designed to meet the physical and mental needs of each patient. The service responded to people’s needs.

The service needed to improve to identify failings and prevent issues occurring in the first place.

We saw instances of unsafe practice in relation to services provided to children and young people both in the paediatric day-case unit and the fracture clinic. These were escalated and dealt with immediately, but the service failed to identify the risks themselves.

 

End of life care

Good

Updated 13 December 2016

Out of the 94 incidents reported to the palliative team, we saw eight were in relation to low staffing levels. We noted some resulted in palliative patients not being attended to or observed as often as they required and “Care was compromised”. Staff on surgical wards told us they would struggle to ensure end of life patients received the care that they needed. However, they told us that the palliative team were aware of their pressures and were very supportive.

The palliative team were not solely responsible for end of life patients but they supported the medical and nursing teams in providing specialist advice.

We reviewed 20 medication administration records across the wards and units inspected and found these were consistently well completed. Although improvement was needed to ensure that controlled medicines were safely and appropriately administered.

We reviewed medical and nursing paper care records and Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) records and saw these were well completed.

The palliative team worked across both New Cross Hospital and Cannock Chase Hospital so we found similarities across both sites. On both sites we found staff were well engaged with education and training programs around end of life care and it has taken a priority to ensure the care of patients and families is enhanced.

The palliative care team had introduced a staff survey, the results identified how approachable, supportive and informative members of the team were.

The palliative team were in the process of implementing the Swan Project at both hospital sites as a care planning tool and guidance for patients in the last few days of life. Staff adopted practices of the Salford Royal NHS Foundation Trust such as: the Swan logo being placed on the curtains or the door of the side room to alert staff to be mindful, relatives were given canvas bags with the Swan logo with their relative’s belongings as oppose to a plastic bag, staff offered families of end of life patients keepsakes such as photographs (of hands) and handprints, locks of hair (taken discreetly from behind the ear and presented in an organza bag not as previously in a brown envelope) , staff returned jewellery in a small box, they were given the choice of the deceased being clothed in their own clothes rather than a disposable paper shroud and the hospital renamed the mortuary the Swan Suite for discrete communication in public areas. Literature on both hospital sites had been updated and rebranded such as: the advanced care plan, the ‘practical information leaflet’ and the feedback survey was redesigned to have the Swan logo.

The rationale for the Swan logo was to trigger a compassionate response and kind communication. All staff at New Cross Hospital and Cannock Chase Hospital were aware of the project and had recently started the project for the past few patients. During the inspection we found the scheme to be in its infancy stages although all staff were fully aware of the project, what to do and how to implement it should they be caring for a dying patient.

We noted there was easy access to the palliative care team and they were responsive in supporting ward staff.

On both hospital sites the staff developed a ‘Rapid Home to Die Care Bundle’ which facilitated a rapid discharge. Staff told us they had used this bundle several times and were able to discharge a patient with a complex package of care within 24 hours.

For both hospital sites the palliative team had a clear vision for their service. The leadership, governance and culture promoted the delivery of high quality person centred care. The team displayed good engagement and attendance at national/international conferences and the West Midlands expert advisory group for palliative care.

The palliative team felt the trust were engaged with topics around end of life care and were supportive in their efforts to improve the service. They told us the board staff members were visible and were engaged in best practice.

We saw the culture was a positive energetic one.

Outpatients

Requires improvement

Updated 13 December 2016

Overall the services within outpatients and diagnostic imaging services required improvement. Most of our concerns related to imaging within safety, effective, responsive and well led. Outpatients was broadly satisfactory.

Within radiology there were concerns with the safety of signage, out of date clinical items and the management of controlled drugs. Clinical imaging protocols and risk assessments were not fit for purpose.

Staffing levels within the renal unit did not comply with NHS England and British Renal Society guidelines. Appointment letters and patient leaflets were only available in English. There was no method of monitoring the length of stay of patients within outpatients to ensure they were provided with food and drink.

There was not a clear vision and strategy within the outpatients and radiology departments. There were clear governance structures and defined reporting systems in place in both departments. However, the governance systems within radiography had not highlighted the many safety concerns and shortfalls with protocols and risk assessments specified within this report. There was no ownership of who was responsible for ensuring the department worked within best practice professional guidelines and IR(ME)R regulations.

Patients spoke highly of the staff in both outpatients and radiography. Patients described caring staff that were supportive and treated them with dignity and respect. We observed that staff were courteous, polite and friendly when responding to individual patient needs.