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Corbett Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 3 December 2014

We carried out this comprehensive inspection as part of the new hospital inspection programme and as a follow up to the Keogh review which took place in 2013.  Of the 14 trusts inspected under the Keogh review for the quality and safety of their services, The Dudley Group NHS Foundation Trust was one of only three trusts that were not put into special measures.  That review identified concerns regarding:

  • governance arrangements
  • the need to embed a culture of learning from incidents
  • how the trust uses and reviews mortality data
  • the system for bed management and patient flows
  • embedding patient experience in the organisation’s learning and strategy
  • staffing levels and skills mix
  • safety and equipment checks
  • pressure ulcer care.

Before the inspection conducted in March 2014, the Trust was identified in CQC’s intelligent monitoring system as a priority band 4 Trust.  There are six bands within the monitoring system so this Trust had a relatively lower risk.

We noted that the trust’s action plan to address the concerns following the Keogh review had been put into place and signed off.

Our inspection of The Dudley Group NHS Foundation Trust included Russells Hall Hospital, Corbett Outpatient Centre and Dudley Guest Outpatient Centre.  

The announced inspection took place between 26 and 27 March 2014, and unannounced inspection visits took place in the two weeks following this visit.  

Overall, this trust was found to require improvement, although we rated it good in terms of having caring staff, and effective services.

We saw much support for the trust, both from the public and from the local health economy.

We saw a trust that was a considerable way along its improvement journey and saw many areas of strong development. Whilst some of the core service areas within the trust required improvements in leadership, we found the executive team and the trust board had a clear focus on improvement and as such we rated this trust as good for its overall leadership.

The improvements required by the trust were within the grasp of the trust and its leaders. We were confident that these could be achieved quickly.Key findings related to the following:

  • The trust’s staff are seen as highly caring by many of the patients we spoke to and praised the staff for ‘going the extra mile’.
  • The trust’s leadership team is seen as highly effective by the staff; and is recognised to be clearly in touch with the experience of patients and the work of the staff.
  • Staff value the Dudley Group as a place to work and a team spirit is clearly evident.
  • The trust has responded well to the Keogh review in 2013.
  • There are a number of areas of good practice in the trust, which should be encouraged. Staff feel able to develop their own ideas and have confidence that the trust will support them.
  • The emergency department (A&E) is busy and overstretched. There remain challenges in the flow of patients, but much of this relates to flow across the rest of the hospital. Only a small proportion relates to the emergency department itself.
  • The trust does not always follow its own policy in relation to DNACPR (do not attempt resuscitation) notices.
  • The ophthalmology clinics require review to ensure that all patients are followed up as required and that there is capacity for these clinics.
  • The trust must review its capacity in phlebotomy clinics as this is seen as insufficient.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 3 December 2014

Effective

Good

Updated 3 December 2014

Caring

Good

Updated 3 December 2014

Responsive

Requires improvement

Updated 3 December 2014

Well-led

Requires improvement

Updated 3 December 2014

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 3 December 2014

We were concerned with some elements of the service regarding safety; specifically that the arrangements for covering shifts were unsustainable and these were putting pressure on the existing staff. Additionally, we saw that categorisation of incidents and recording of data were at times inaccurate. This prevented the service analysing incidents and learning from these. We also saw the quality of data recorded on the maternity dashboard was variable.

The maternity department had failed to meet some of its indicators on the maternity dashboard, for example, elective caesareans had been higher than expected in recent months. The department was meeting other targets, for example, majority of women booked by 12 weeks of pregnancy – while performance against other indicators varied each month.

We found that staffing levels sometimes fell below the expected numbers and that there had been an increase in the number of staffing-related incidents reported.

We saw that there were processes in place for individual staff members to learn from incidents they had reported or been directly involved with. However, not all incidents were categorised correctly and information did not always flow through accurately to reports and the performance dashboard (an electronic performance reporting and tracking system). Also, the sharing of learning outcomes required improvement.

The women we spoke with were happy with the care they had received. They found the staff to be friendly and helpful and communicated well about their care and treatment.

There was a clear care pathway in the maternity unit, according to women’s clinical needs. Women felt that the level of communication from midwives and doctors was good and they felt listened to and well supported.

The layout of the department meant that women and their new-born babies could be cared for in an environment which promoted their privacy during their stay.

We saw that the maternity department had performed well in feedback from patients through the Maternity Survey and that there was a process for handling complaints, although we saw that one complainant had not received an accurate response.

Staff working within the department generally felt well supported by management and thought that they worked in an open and transparent environment.

Medical care (including older people’s care)

Good

Updated 3 December 2014

We found that all of the areas we visited on the medical care directorate were clean and hygienic, which helped to protect patients from hospital-acquired infection. We saw that all areas were well maintained and free of clutter.

We saw that staff had completed mandatory training and received annual appraisals of their performance. All staff received mental health awareness training and de-escalation training had commenced for nursing staff. We found that lead nurses were well informed about de-escalation techniques and challenging behaviour.

We saw that staff received training on how to report incidents, such as falls, and complaints. Staff told us that they received regular feedback on these. We saw that lessons learned from incidents, and actions for any improvements, were discussed in team meetings.

We found that medicines management was safe and patients received timely and appropriate pain medication as needed. We saw that staffing levels had improved and the Trust was in the process of recruiting additional trained nurses and medical staff.

We saw that staff worked in partnership with other colleagues and partners to achieve the right outcomes for patients. Throughout the inspection we observed positive interaction between staff and patients. All of the patients we spoke with said the staff were very good. They told us that they were treated with respect and dignity.

We were concerned about the delays in the flow of patients through the hospital. We saw that some patients had to wait for long periods and were subjected to multiple moves in the directorate. We are aware that this is an ongoing problem and actions have been taken to improve this situation with the introduction of the frail elderly short stay unit. However, this remains an area of improvement for the Trust.

A dementia care bundle – a small set of evidence-based practices and processes to improve care – had been piloted, but this must be implemented across the directorate to provide the best outcomes for people living with dementia.

We found that the service was well-led. Staff told us that senior management were visible and wanted to know about patients’ care. Staff told us that they felt able to raise issues and senior management were approachable and listened to feedback from staff.

Urgent and emergency services (A&E)

Requires improvement

Updated 3 December 2014

The Trust was experiencing an increased number of patients admitted to the ED. This had a negative impact on the Trust meeting the national target of admitting, transferring or discharging patients within four hours of their arrival in the department. We saw  when patients arrived by ambulance they were assessed in a corridor, and at times they were kept in this area until a cubicle was free. Staff told us they were aware the practice was not ideal for patients. Patients were observed until they were placed on a trolley, which was as soon as possible after entering the department.

The ED was struggling to manage the flow of patients through the department. Much of the challenge related to the ability of the ED to identify beds in the hospital for those patients who needed to be admitted. Delays in moving patients from the ED were impacted by general blockages across the system. This in part also related to the lack of capacity outside the hospital to facilitate a prompt discharge for patients.  There were some initiatives in place to avoid unnecessary admissions (where admission isn’t clinically required) and to speed up the discharge of patients but waiting times for patients were not improving.

The Trust told us they were aware of the key risks within the organisation but  there appeared to be no clear communication or action taken between Trust wide managers and the frontline staff within the ED. The reality for the staff of the day-to-day pressure was immense and the staff felt that this was being overlooked. The staff were committed to trying out new initiatives, learning and wanted to improve.  They told us senior leaders were less responsive to supporting them. Although there was some monitoring of quality taking place it was not carried out in a structured or formalised way. 

We found that the ED staff were enthusiastic and caring. Relatives and patients told us they found the staff very kind and caring. Patients told us they felt safe and they had been informed about their treatment. They told us they would recommend the hospital to friends and family. The ED was running at full capacity.

During our inspection, we found the department staffed with medical and nursing staff in sufficient numbers to meet the needs of patients. We observed patients in the Minors and Majors areas being prioritised or triaged by a ‘triage trained’ nurse. This process ensured that the most appropriate plan of care was organised to meet their needs. Children were triaged in the separate paediatric department from 11am to 11pm. This meant that they were seen by specialist nurses and doctors during those hours.

Surgery

Good

Updated 3 December 2014

We visited six wards, the Pre-operative assessment clinic and the Oral surgery department.  We also visited the day surgery unit and main theatres at Russells Hall Hospital and the day case unit at Corbett Hospital which included the waiting area, ward and theatre. We observed care provided both pre- and post-operatively at both locations. We discussed the never events – mistakes that are so serious they should never happen – that had occurred in the surgical department with staff in the theatres. We also held focus groups and 121 discussions with nurses, junior doctors, consultants and heads of services.

Services in the surgical department were safe for most patients. There were appropriate systems in place to report incidents and concerns and take necessary actions when needed. The Trust had reported two surgical never events, between December 2012 and January 2014. We found that new procedures were in place to minimise further risks as part of lessons learned from these incidents.

The surgical safety checks at Russells Hall Hospital were completed, as per clinical guidance.  The surgical department had good adherence to national and professional infection control and cleanliness guidance.

Patients in all areas of the surgical department complimented staff on their caring approach. Patients’ needs were assessed, and care planned and delivered in line with best practice guidance. Assessments started in the preoperative assessment clinic and continued during the patients’ hospital stay.

Staffing levels had improved and the Trust was continuing to actively recruit staff. Staffing levels were found to reflect patients’ needs. There were arrangements in place to check the competency of staff, their training needs and practice. However there was a need to recommence competency checks for staff who worked in the day case unit at Corbett Hospital to demonstrate that safe and appropriate care continued to be provided in this area.

The Dudley Group NHS Foundation Trust was responsive to patient’s needs to ensure that they had access to timely treatment. Staff were proud of their achievements to reduce pressure ulcers, improve the management for diabetic patients who had surgery, the reduction in the number of patient falls and the management of patients who had a fractured neck of femur.

We found that the surgical department was well led. There were appropriate leadership arrangements at all levels within the surgical department and staff felt supported by their managers. Staff were committed to reviewing and auditing to continually improve the care and treatment that patients received.

Intensive/critical care

Requires improvement

Updated 3 December 2014

Staff we spoke with did not consistently demonstrate that they knew how or when to report incidents using the Trusts electronic incident reporting system.

We looked at risk registers for each of the services in critical care. We did not find that risks had all been identified or recorded. This meant senior managers within the Trust would not have been made aware of these risks.

The HDU was routinely staffed to less than the full capacity for the number of patients they could accommodate. We were informed that the hospital bed managers used this capacity to “flex” up and down to meet the needs of people accessing the hospital. We were concerned that the “flex” staffing arrangements in MHDU could place people at risk of unsafe care. We found that senior nurses were spending unreasonable amounts of time covering shifts with agency staff or the Trust’s own temporary nurses. Greater staffing continuity could have been achieved if the Trust agreed blocks of time the beds would be used for.

Senior nursing staff advised us of the staffing challenge they were currently facing due to delays in recruitment, sickness and maternity leave. We found that efforts had been made to ensure the continuity of staffing wherever possible. Agency nurses we spoke with reported that they had been inducted to the unit and supported to ensure that they were competent and confident to undertake their role.

People in the high dependency units (HDUs) were not cared for in an environment that promoted their dignity or privacy. There was a lack of general space and poor screening around beds in the SHDU and a lack of toilets and bathrooms in both SHDU and MHDU

The latest Intensive Care National Audit & Research Centre (ICNARC) data showed that patients using the ICU services were likely to have better than expected outcomes, as the rates of mortality were fewer than expected when compared with other similar hospital units across the country.

Patients received a good standard of nursing and medical care. Patients benefited from a service that was caring, effective and well-led by an experienced and competent team.

Services for children & young people

Good

Updated 3 December 2014

The paediatric department did not have a system in place to monitor performance against targets beyond the basic nursing principles and other Trust-wide targets. We were told that this was under review and that a performance dashboard (a reporting and tracking system) was in the process of being developed.

We found that staffing sometimes fell below the expected numbers; when this happened, the escalation policy was followed and beds on the unit were suspended.

It was difficult for parents to obtain meals when visiting for long periods of time.

The children and families we spoke with felt staff were caring and supportive. We were told that communication from medical staff was not always consistent, which could cause confusion for patients.

There was a clear care pathway for babies and children according to their clinical need. The unit was modern and nicely laid out which enabled the promotion of people’s privacy and dignity. There was a sensory room on the children’s ward, with toys. Play workers and a teacher were available.

We saw that there were processes in place for individual staff members to learn from incidents they had reported or been directly involved with. However, the sharing of learning outcomes required improvements.

Staff working within the department generally felt well-supported by management and thought that they worked in an open and transparent environment.

End of life care

Good

Updated 3 December 2014

We found that improvements were required to ensure patients were always as safe as possible and received care and treatment that met their needs in relation to do not attempt resuscitation (DNACPR) processes.  A DNACPR policy and procedure was in place, however, we noted a number of concerns in relation to how this had been implemented.

We noted an occasion where there was no evidence that DNACPR decisions had been reviewed and an occasion when a DNACPR decision had not been endorsed by a consultant within the timescale specified within the Trust’s policy, although a discussion with a consultant had previously taken place.

The specialist palliative care team provided support and advice to health professionals working within the hospital and in the community. This ensured a coordinated multidisciplinary approach to end of life care. We found that patients who were receiving end of life care without the need for support from the palliative care team also received a good standard of care.

Patients and their families told us that staff were available at the times they needed them and said that personnel were caring, kind and compassionate. We observed staff treat patients respectfully and with dignity.

The services offered by the chaplaincy, mortuary and bereavement services were considered to be excellent.

Staff we spoke with described strong, supportive leadership at Trust Board level and an organisational culture that empowered staff at all levels of the organisation.

Most people told us that the end of life service was responsive to their needs. From patients’ care notes we found that patients’ healthcare needs were regularly reviewed. Pain relief, symptom management, nutrition and hydration were being provided according to patients’ needs. Most patients and relatives we spoke with told us that they felt involved in decisions made about their care and treatment and care records confirmed this.

Outpatients

Good

Updated 3 December 2014

Most people told us that the services they used were responsive to their needs. However, in some areas of the outpatient department, patients’ needs were not being met. There were problems in ophthalmology with the appointments system, overcrowding in the phlebotomy (blood collection) clinics at Russells Hall and Corbett Hospitals and, issues identified with parking provision at Russells Hall.

Overall, patients received a safe service. They were protected as far as possible from harm or abuse. Staffing levels were good and the Trust demonstrated a commitment to ensuring staff were up to date with mandatory training. Managing risk across the outpatient department had not been consistent; information and good practice in relation to slips, trips and falls had not been widely shared across the department.

Treatment was generally effective. We found that patients were satisfied with outpatient treatment. Difficulties with the transport arrangements to and from outpatient appointments had been identified and the Trust was working towards their key performance indicator of 95% of patients arriving and leaving the outpatient department on time.

Staff at all three sites, including outpatient services for children and young people, told us some clinics used reminder calls and texts and a partial booking service to achieve good rates of appointment attendance.

We observed good collaborative working within the multidisciplinary team. Examples included nurse-led clinics, clinics led by allied health professionals and multidisciplinary clinics.

Patients said that staff were caring, kind and compassionate. We observed that staff treated patients respectfully and with dignity.

We identified some excellent practice that targeted patients’ specific needs in an empathetic manner. This included the Eye Clinic Liaison Officer (ECLO) and the Care of Next Infant (CONI) programme in the outpatient clinic for children and young people.

Most of the staff we spoke with described strong, supportive leadership at board level and an organisational culture that empowered staff at all levels of the organisation.