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West Cumberland Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 29 March 2017

We carried out a follow up inspection between 6 and 9 December 2016 to confirm whether North Cumbria University Hospitals NHS Trust (NCUH) had made improvements to its services since our previous comprehensive inspection, in April 2015. We also undertook an unannounced inspection on 21 December 2016.

To get to the heart of patients’ experiences of care and treatment we always ask the same five questions of all services: are they safe, effective, caring, responsive to people’s needs, and well-led? Where we have a legal duty to do so, we rate services’ performance against each key question as ‘outstanding’, ‘good’, ‘requires improvement’ or ‘inadequate’.

When we last inspected this trust, in April 2015, we rated services as ‘requires improvement’. We rated safe, effective, responsive, and well-led as ‘requires improvement’. We rated caring as ‘good’.

At this hospital we rated services overall as ‘requires improvement’. We rated surgery, critical care, services for children and young people, and outpatients and diagnostic imaging as ‘good’. All other services, with the exception of medical care, were rated as ‘requires improvement’. Medical care at this hospital was rated as ‘inadequate’.

There were four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations at this hospital. These were in relation to staffing, safe care and treatment, person centred care, and assessing and monitoring the quality of service provision.

The trust sent us an action plan telling us how it would ensure that it had made improvements required in relation to these breaches of regulation. At this inspection, we checked whether these actions had been completed.

We found that the trust had improved in some areas. However, West Cumberland Hospital (WCH) remained rated as ‘requires improvement’ overall, with caring and effective rated as ‘good’ and safe, responsive, and well-led rated as ‘requires improvement’.

Our key findings were as follows:

  • Nursing and medical staffing had improved in some areas since the last inspection. However, there were still a number of nursing and medical staffing vacancies throughout the hospital, especially in medical care and surgical services, and children and young people services, including the special care baby unit.
  • The trust had systems in place to manage staffing shortfall as well as escalation processes to maintain safe patient care. However, a number of registered nurse shifts remained unfilled despite these escalation processes. The ‘floor working’ initiative within medical care should be reviewed in order to support safer nurse staffing.
  • Despite ongoing recruitment campaigns, the trust had struggled to recruit appropriate clinicians in some specialities, particularly in medical care and children and young people services. Medical staffing within these specialities remained reliant upon locum support, and with that, was vulnerable to changes in locum worker preferences or departures.
  • However, within medical care services medical staffing had improved from the previous inspection with additional workforce assurance plans in place. This included securing long-term locum contracts, developing the composite workforce model, improving links with specialist trainees and securing cross-site support from divisional clinician colleagues at CIC.
  • Compliance against mandatory training targets was an issue in some services.
  • Access and flow, across the emergency department, medical care and surgical services, and outpatients remained a significant challenge.
  • For an extended period, the hospital has failed to meet the target to see and treat 95% of emergency patients within four hours of arrival and it was failing to meet consistently a locally agreed trajectory to see and treat emergency patients within four hours of arrival which had been agreed in conjunction with regulators and commissioners.
  • We found patients experienced overnight delays in the emergency department whilst waiting for beds to become available in the hospital.
  • Between 2015 and 2016 the trust cancelled 1,410 elective surgeries. Of these, 12% were not treated within 28 days. For the period November 2015 to November 2016 WCH cancelled 292 elective surgeries for non-clinical reasons.
  • Referral to treatment time (RTT) data varied across specialities, particularly in surgical services.
  • Patient flow initiatives within the medical division were not fully embedded and required improved coordination, ward staff engagement and more timely discharge plans implemented. Medical outliers accounted for a significant proportion of the in-patients beds at this hospital.
  • Delays in obtaining suitable community care placements were causing access and flow difficulties, particularly in medical care services.
  • Within outpatients, there were a number of clinics cancelled within 6 weeks of the clinic across the trust and there were no plans in place to address this issue. Turnaround times for inpatient plain film radiology reporting did not meet Keogh standards, which require inpatient images to be reported on the same day.
  • There had been an improvement in record keeping standards throughout the hospital however, we identified some ongoing areas for improvement around accurate completion of fluid and food charts, risk assessments and completion of DNACPR forms which did not provide evidence of a best interest decision or a mental capacity assessment being undertaken and recorded where appropriate.
  • There was some improvement in strengthening of governance processes across the hospital; however within some services, particularly medical care and maternity, there were gaps in effective capturing of risk issues, and in how outcomes and actions from audit of clinical practice was used to monitor quality.
  • Due to the public consultation taking place at the time of our inspection, it was noted that a preferred option and decision was yet to be taken by Cumbria Clinical Commissioning Group on the future of maternity and children and young people’s services.

    However:

  • Staff knew the process for reporting and investigating incidents using the trusts reporting system. They received feedback from reported incidents and felt supported by managers when considering lessons learned.
  • The policy and activity around critical care patient transfer to other hospitals, including children and babies, when required were good.
  • The hospital had infection prevention and control policies in place, which were accessible, understood and used by staff. Patients received care in a clean, hygienic and suitably maintained environment.
  • There were no cases of Methicillin Resistant Staphylococcus Aureus infection (MRSA) reported between November 2015 and October 2016. Trusts have a target of preventing all MRSA infections, so the hospital met this target within this period. The trust reported nine MSSA infections and 23 C. Difficile infections over the same period.
  • Safeguarding processes were embedded throughout the hospital.
  • We saw that patients were assessed using a nutritional screening tool, had access to a range of dietary options and were supported to eat and drink.
  • Patients were positive about the care they received. Staff were committed to delivering high quality care. Staff interactions with patients were compassionate, kind and thoughtful. Patient privacy and dignity was maintained at all times.
  • Patient feedback was routinely collected using a variety of measures, including real time patient experience.

We saw several areas of outstanding practice including:

  • National Patient safety awards finalist for better outcomes in orthopaedics.
  • The trust had the only surgeon between Leeds and Glasgow doing a meniscal augment in the knee.
  • Honorary Professorship University of Cumbria received by a consultant for work on applying digital technologies in Health Care for elderly population in rural setting, a part of CACHET.
  • Multinational multicentre prospective study in the use of intramedullary nail in varus malalignment of the knee. The trust had the largest international experience of this technology for this application.
  • WCH was one of only 18 Hospitals in England and Wales referred to in the first NELA audit for contributing examples of best practice in care of patients undergoing emergency laparotomy.
  • There was real strength of MDT working and positive patient outcomes in the stroke service;
  • The ‘expert patient programme’ and ‘shared care initiative’ in the renal business unit exhibited real patient integration, empowerment and care partnerships; and,
  • There were a variety of data capture measures in use to monitor ‘real-time’ patient experience and collate patient feedback.

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

Importantly, the trust must:

In urgent and emergency services

  • Meet the target to see and treat 95% of emergency patients within four hours of arrival linked to meeting the locally agreed trajectory to see and treat emergency patients within the standard agreed with regulators and commissioners.
  • Ensure medical and nursing staff use the computer system fully as intended so that patient real time events are recorded accurately and this is demonstrated through audit.
  • Take further steps to resolve the flow of patients out of the hospital.

In Medicine

  • Ensure systems and processes are established and operated effectively to assess, monitor and improve the quality and safety of the services provided and evaluate and improve practice to meet this requirement. Specifically, improve the management of medical outliers by reducing the number of patients receiving care on a non-designated medical ward, improving repatriation processes and minimising service user moves after 10 pm.

In Surgery

  • Must ensure the peri-operative improvement plan is thoroughly embedded and that all debrief sessions are undertaken as part of the WHO checklist to reduce the risk of Never Events.
  • Improve compliance against 18 week referral to treatment standards for admitted patients for oral surgery, trauma & orthopaedics, urology and ophthalmology.
  • Improve rate of short notice cancellations for non-clinical reasons specifically for orthopaedic surgery.
  • Ensure patients whose operations are cancelled are treated within the 28 days.

In Maternity and Gynaecology

  • Review staffing levels; out-of-hours consultant paediatric cover and surgical cover to ensure they meet the Royal College of Obstetricians and Gynaecologists (RCOG) guidelines (including ‘safe childbirth: minimum standards for the organisation and delivery of care in labour’)
  • Ensure that systems are in place so that governance arrangements, risk management and quality measures are effective.

In Services for Children and Young People

  • The trust must ensure children and young people services meet all Royal College of Paediatrics and Child Health (RCPCH) - Facing the Future: Standards for Acute General Paediatric Services (2015 as amended).

In End of Life Care

  • Ensure that DNACPR forms are fully completed in terms of best interest assessments in line with the Mental Capacity Act.

In Outpatients and Diagnostic Imaging

  • Address the number of cancelled clinics in outpatient services.
  • Ensure that referral to treat indicators (RTTs) are met across outpatient services.

In addition the trust should:

  • Ensure that levels of staff training continue to improve in the hospital so that the hospital meets the trust target by 31st March 2017.

In urgent and emergency services

  • Increase the complement of medical consultant staff as identified in the accident and emergency service review
  • Extend the scope and consistency of staff engagement.

In Medicine

  • Continue to progress patient harm reduction initiatives;
  • Ensure IPC compliance improvement and consistency in standards, in particular regarding catheter and cannula care;
  • Ensure best practice guidelines for medicines related documentation is reinforced to all prescribers;
  • Ensure oxygen prescribing is recorded and signed for accordingly;
  • Ensure medicines management training compliance improves in line with trust target;
  • Ensure all relevant clinical observations are recorded at the required frequent, NEWS scores are accurately calculated and trigger levels are adhered to (or document deviation/individual baseline triggers in the clinical records);
  • Ensure care and treatment of service users is appropriate, meets their needs and reflects their preferences. Specifically, ensure the endoscopy pathway design meets service user preferences and care or treatment needs.
  • Ensure staff are given time to complete all necessary mandatory training modules;
  • Ensure all fields within medical and nurse clerking documentation are completed in full, in line with local policy and best practice guidelines;
  • Ensure all equipment checks are completed in line with local guidance;
  • Progress JAG accreditation application for new endoscopy suite at WCH;
  • Continue to proactively recruit nursing and medical staff, considering alternate ways to attract, such as utilising social media;
  • Ensure measures are put in place to support units where pending staffing departures will temporarily increase vulnerability;
  • Progress the ‘Composite Workforce Model’ and further embed support from substantive medical colleagues at CIC;
  • Ensure food satisfaction standards are maintained and where relevant improved;
  • Work with partnership colleagues to address static diabetes patient outcomes;
  • Evidence improvements in patient outcomes for respiratory patients around time to senior review and oxygen prescribing;
  • Support staff development in line with organisational/staff appraisal objectives protecting/negotiating study time where required;
  • Ensure appraisal rate data recorded at trust level coincides with figures at divisional/ward level;
  • Ensure patients are given sufficient time to converse with staff regarding care related matters;
  • Revisit the patient journey, booking and listing procedures at the endoscopy suite at WCH;
  • Ensure where escalation beds are utilised, they are staffed accordingly with due consideration of existing ward staffing requirements;
  • Consider local leads for patient flow initiatives and reinforce processes with staff;
  • Ensure processes seek to repatriate medical outliers at the earliest opportunity to minimise impact into surgical services;
  • Continue to minimise patient moves after 10 pm;
  • Ensure the ambulatory care suite is utilised as intended;
  • Reinforce the dementia strategy across the division to ensure consistency of practice with support initiatives;
  • Ensure reasonable adjustments available for visually impaired, those with hearing difficulties and those who require translation services are known to all staff;
  • Consider options available to extend ambulatory care services across seven days;
  • Ensure senior divisional staff make every reasonable effort to attend divisional governance meetings regularly;
  • Ensure the risk register is current and reflects actual risks with corresponding accurate risk rating. Ensure all actions and reviews of risk ratings are documented;
  • Ensure progress continues against QIP, realign completion dates and account for deadline breaches;
  • Ensure staff feel involved and integrated into engagement activity for their benefit and ensure all staff are aware of existing provisions available to them;
  • Ensure staff involved in change management projects are fully informed of the aims and objectives of the proposal and these are implemented and concluded in appropriate timeframes;
  • Ensure divisional leads and trust leaders promote their visibility when visiting wards and clinical areas; and,
  • Consider promoting divisional and trust wide success stories to share good news and positive outcomes to improve staff morale.

In Surgery

  • Ensure robust recruitment and retention policies continue to improve staff and skill shortages.
  • Continue to embed the perioperative quality improvement plan.
  • Improve debrief in theatres post-surgery.
  • Improve the proportion of patients having hip fracture surgery on the day or day after admission.
  • Improve the rate of patients receiving a VTE re-assessment within 24 hours of admission.
  • Improve cancellation rates.
  • Ensure all mandatory training is completed by March 2017.
  • Reduce the management of medical patients on surgical wards.
  • Ensure bullying allegations in theatres are addressed.

In Critical Care

  • Senior staff should continue to monitor the staffing shortfall an impact in the unit as a result of increased staff sickness. The action plan produced should be reviewed to ensure achievement of the key points. Staff should be able to provide assurance that the staffing ratios for intensive care are protected as per Intensive Care Society guidance.
  • CCOR staff should not be moved to cover ward area staff shortage as part of routine escalation plans. This issue needs to be monitored and CCOR staff should be supported to provide the role across the trust as per practice in line with GPICS (2015), NICE CG50 and against the seven core elements of Comprehensive Critical Care Outreach, (C3O 2011).
  • Take action to improve pharmacy staffing in line with GPICS (2015).
  • The role of the supernumerary clinical coordinator should be protected as per GPICS (2015) standards. Currently this is not the case in the unit and should be in place to support the team in line with the standards.
  • The clinical educator should provide a role in the WCH unit in order to meet GPICS (2015) standards for a unit of this size.

In Maternity and Gynaecology

  • Ensure that processes are in place for midwives to receive safeguarding supervision in line with national recommendations.
  • Continue to improve mandatory training rates to ensure that trust targets are met by the end of March 2017.
  • Ensure that there are processes in place so that record-keeping, medicine management, and checking of equipment are consistent across all areas.
  • Review the culture in obstetrics to ensure there is cohesive working across hospital sites and improved clinical engagement.

In Services for Children and Young People

  • Ensure a registered children’s nurse (RCN) should support healthcare assistants working in the children’s outpatient department with. Royal College of Nursing staffing standards for children in outpatients states a minimum of one RCN must be available at all times to assist, supervise, support and chaperone children. Healthcare assistances should also be trained and competent in weight management and documentation according to their level of responsibility.

In End of Life Care

  • Arrange formal contract meetings with members of the Cumbria Healthcare Alliance to monitor that the service being commissioned and provided is of an appropriate standard in terms of quality and meeting patient need.
  • Ensure that it is aware of the number of referrals to the SPCT within their hospitals.
  • Ensure that it is aware of how many patients are supported to die in their preferred location and there is regular audit of the CDP to demonstrate this.
  • Produce an action plan to address areas in national audits where performance was lower than the England average with key responsibilities and timelines for completion.

In Outpatients and Diagnostic Imaging

  • Continue to ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed in order to meet the needs of the patients. Ensure mandatory training and safeguarding training completion rates and met in line with the trust target.
  • Ensure there are sufficient staffing levels in place and ensure actual levels match planned levels.
  • Ensure that equipment, such as refrigerators in diagnostic imaging, are checked as required.
  • Consider ways of making performance and quality information available for use.

It is apparent that the trust is on a journey of improvement and progress is being made clinically, in the trust's governance structures and in the implementation of a credible clinical strategy. I am therefore happy to recommend that North Cumbria University Hospitals NHS Trust is now taken out of special measures.

Professor Sir Mike RichardsChief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 29 March 2017

Effective

Good

Updated 29 March 2017

Caring

Good

Updated 29 March 2017

Responsive

Requires improvement

Updated 29 March 2017

Well-led

Requires improvement

Updated 29 March 2017

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 29 March 2017

During the last inspection in April 2015 the service was rated as ‘requires improvement’ for being safe, effective and well-led. This was because of a lack of dedicated medical staff cover, no dedicated second theatre, mandatory training levels not being met, ineffective medicines management, insufficient governance and audit processes, staff not following guidelines and lack of cohesive working across hospital sites.

At this inspection although some improvements had been made the service remained as ‘requires improvement’ for being safe and well-led because:

  • Some of the risks identified were still in place and sufficient actions to mitigate the risks had not yet been implemented particularly the lack of senior paediatric medical cover out-of-hours to manage advanced neonatal resuscitation and lack of surgical out-of-hours cover. Although there was no evidence of adverse outcomes this still presented a risk to patients.
  • Due to the public consultation taking place at the time of our inspection, it was noted that a preferred option and decision was yet to be taken by Cumbria Clinical Commissioning Group on the future of maternity and children and young people’s services.

    Although there was some improvement in cross site working the cohesiveness of the two hospital sites for maternity services was not fully embedded. Certain elements of the obstetric team remained dysfunctional with a lack of clinical engagement and support. It was not clear what action was being taken to resolve this.

  • There was some improvement in strengthening of governance processes but there were no indicators to ensure performance and understanding of risk or governance roles. There continued to be gaps in how outcomes and actions from audit of clinical practice were used to monitor quality, and in systems to identify where action should be taken.
  • Not all staff in the service felt engaged in the reconfiguration of maternity services and felt that their opinions were not listened to.

However:

  • Staff understood their responsibilities to raise concerns, to record safety incidents and near misses.
  • Nursing and midwifery staffing levels were similar to the national recommendations for the number of babies delivered on the unit each year. Additional medical staff had been recruited to cover the obstetric rota.
  • Care outcomes were meeting expectations in most areas, and where improvements were required the service had identified action.
  • There were systems to ensure the safe management of medicines. Infection, prevention and control measures were in place.
  • Most women were positive about their treatment by clinical staff and the standard of care they had received. They were treated with dignity and respect.
  • Services were planned, delivered and co-ordinated to take account of women with complex needs, there was access to specialist support and expertise.
  • Midwifery and medical staff worked together ensuring women received care which met their needs.

 

Medical care (including older people’s care)

Requires improvement

Updated 29 March 2017

The service was inspected as part of our comprehensive visit in March 2015. Overall, medical care at WCH was rated ‘inadequate’. A number of areas for improvement were highlighted and the service was told to take action to:

  • Improve medical staffing levels;
  • Increase numbers of trained nurses;
  • Improve the way in which medicines are stored;
  • Provide sufficient infusion pumps so that there are pumps always available for patient use;
  • Ensure the requirements of the Mental Capacity Act 2005 are followed with regard to the application of Deprivation of Liberty Safeguards; and,
  • Improve the routine review of medical patients receiving care and treatment on wards outside their speciality.

 

During this inspection, we found the service had made improvements:

  • While medical staffing was not at full substantive compliment at WCH, there had been recruitment and the division had secured longer term locum contracts. Divisional managers were progressing the ‘composite workforce’ model to bring additional stability to existing provision at WCH.
  • Registered nurse vacancies remained at WCH however all wards reported an improved picture from the 2015 inspection. This was evidenced by improved fill rates across the division. Staffing shortfall escalation procedures were more robust and the division continued to actively recruit.
  • There was no evidence to suggest there were insufficient infusion pumps for patient use as and when required.
  • Staff knowledge of the requirements of the Mental Capacity Act 2005 and the application of Deprivation of Liberty Safeguards was good. Staff completed capacity assessments to evaluate a patient’s ability to make decisions and consent to treatment.
  • Medical patients were cared for on a designated non-medical ward at WCH and were reviewed regularly by the responsible team. Care was progressed accordingly and staff stated there were no difficulties in having this cohort of patients reviewed out-of-hours.

We rated medical care (including older people’s care) as ‘requires improvement’ overall because:

  • Patient harms remained a concern across the division.
  • There was variance in some infection prevention and control practices and medicines related documentation around antibiotic prescribing was not always compliant with recognised standards.
  • Nurse staffing was exposed in some areas and medical staffing remained reliant on locum appointments. The recording of all key clinical observations to support decision making and care escalation needed reinforcement.
  • Medical staffing remained reliant upon locum support, and with that, was vulnerable to changes in locum worker preferences or departures.
  • Patient outcomes in national audits covering diabetes and respiratory care had remained static or fell below national average benchmarking. The division had not fully embedded seven day working across all areas against the NHS Services, Seven Days a Week Four Priority Clinical Standards. Staffing pressures and clinical responsibilities hindered access to non-ward based learning opportunities.
  • Patients considered on occasions staff were often too busy, or did not have the necessary time to engage in meaningful care related dialogue, or did not prioritise this as an essential element of patient care.
  • Staff considered service changes in the booking and list preparation processes in endoscopy did not meet local patient needs.
  • Medical outliers accommodated a significant proportion of designated surgical beds, repatriation of this cohort was problematic and there were a number of patient moves after 10 pm. Patient flow initiatives were not fully embedded across the division at WCH. Reasonable adjustments implemented for vulnerable patient groups were not consistently applied.
  • The divisional risk register did not correlate with top risks identified by divisional leads. Risk ratings were confusing and details of actions taken against the risks were limited. Divisional progress against the Quality Improvement Project objectives was incomplete and slow. Staff morale was variable and they considered engagement initiatives were driven by a management agenda.

However:

  • Staff confidently reported incidents and the division had made considerable efforts to reduce patient harms from falls and pressure ulcers. Ward environments were clean and staff used personal protective equipment appropriately to protect themselves and the patient from infection exposure. Medicines management was good and clinical documentation, in particular, risk assessments and safety bundles, were completed thoroughly. Nurse staffing establishments figures were based on a recognised acuity tool and projects such as the ‘composite workforce model’ sought to bolster medical staffing.
  • The division was actively involved in local and national audit, which provided a strong evidence base for care and treatment. Patient outcomes in the national stroke audit and the renal registry report were good and there had been domain improvements in myocardial infarction and lung cancer audits. Multidisciplinary team working across the divisional wards was cohesive, progressive and inclusive. Staff had an understanding and awareness of consent issues, Mental Capacity Act and Deprivation of Liberty Safeguards.
  • Staff were committed to delivering high quality patient care. Staff interactions with patients were compassionate, kind and thoughtful. Patient privacy and dignity was maintained at all times. Staff welcomed patient and carer partnerships in delivering care. Staff considered all aspects of holistic wellbeing and patient feedback on the care they received was positive.
  • Estate improvements as a result of the new build and upgrading were clear and apparent. The division reported good results against 18-week standards across all specialisms. Divisional managers monitored access and flow through the division and were involved in a number of initiatives to improve flow processes. There had been improvements in the clinical review of patients being cared for on the non-medical ward at WCH and reducing numbers of bed moves. Ambulatory care services and rapid access clinics had been developed. Complaint numbers were low and response times to resolution were good.
  • The division had a clearly defined strategy and vision, which was aligned to organisational aims and wider healthcare economy goals. Divisional leads had an understanding of the pressures and risks the service faced. Governance processes across the division were clinician driven and quality measures were monitored. There were defined leadership structures and staff affirmed there was a strong clinical leadership presence across the division. Cultural improvements had been made in the last 18 months evident by greater openness. Public engagement was good and utilised a variety of mechanisms to capture opinion. The staff engagement agenda had increased in particular, around health and well-being. The division were involved in a number of improvement projects targeting patient safety, patient experience and service efficiency.

 

Urgent and emergency services (A&E)

Good

Updated 29 March 2017

At our previous inspection, in April 2015, we rated this core service as ‘requires improvement’. In December 2016 we rated the service as ‘good’ because:

  • Risks to the delivery of care and treatment for patients were mitigated and a risk register for accident and emergency reflected identified key risks. Safeguarding procedures were in place.
  • Patient care and treatment followed evidence based guidance and recognised best practice standards. Sepsis screening and management and other clinical guidelines were used effectively.
  • Staff provided considerate and compassionate care for patients and treated them with dignity and respect. Staff interacted with patients empathetically and responses to their needs were prompt. Care and treatment was explained to patients in a way they understood. Patients were consulted and involved in decisions about their care and treatment and received emotional support.
  • Patients with a learning disability, patients with dementia, and bariatric patients accessed emergency services appropriately and their needs were supported. Patients with mental health needs could access services in a joined up way.
  • Patient's consent to care and treatment was documented and the requirements of the Mental Capacity Act were followed. Patients’ nutrition and hydration needs were provided for and pain was managed effectively.
  • Incident reporting had increased and serious incidents had reduced. Learning from the investigation of incidents was shared and duty of candour requirements were followed. Emergency preparedness arrangements were in place to respond to major incidents.
  • Public engagement included consultation events about changes to services and although few complaints were received they were investigated and learning was shared with staff.
  • Staffing had improved and staff were deployed in the department effectively so that staffing levels were sufficient to meet patients’ needs. Mandatory training had been completed by most staff. The learning and development of medical and nursing staff was supported and staff received an annual appraisal. Multidisciplinary teams operated effectively. An improved, positive culture was apparent in the emergency department and staff worked well together.
  • The hospital was taking steps to address performance as part of its improvement plan for emergency care. A newly designated emergency floor had recently been opened which brought together acute admissions and ambulatory care patients. Seven day working was operated 24 hours a day throughout the year including some key support services, for example x-ray.
  • Cleanliness, infection control and hygiene procedures were followed and standards were monitored. Equipment and medicines stocks were managed effectively.
  • The department participated in relevant national audits and undertook regular local audits which supported consistent improvements in care and treatment for patients.
  • Governance of the emergency department was more embedded and the vision and strategy for emergency care was understood. The department implemented innovation to benefit patients.

However:

  • For an extended period, the hospital has failed to meet the target to see and treat 95% of emergency patients within four hours of arrival and the hospital was failing to meet consistently a locally agreed trajectory to see and treat emergency patients within the standard agreed with regulators and commissioners.
  • Emergency department waiting time data was incorrect. Staff were not fully utilising the computer system as intended so that the times recorded were not accurate.
  • Material issues remained with patient flow in the hospital.
  • Risks related to the transfer of patients needed to be added to the risk register.
  • Changes in the operational nursing structure for the emergency department needed to become embedded.
  • Staff engagement needed to be extended.

Surgery

Requires improvement

Updated 29 March 2017

The overall surgery rating from the 2015 inspection was good. During the December 2016 inspection we rated surgical services as ‘requires improvement’ because:

  • The trust has reported their staffing numbers as of August 2016. These staffing numbers showed that the majority of surgical wards were below the nursing establishment levels. The data shows that ward 1 required 27.93 whole time equivalent (WTE) but had 23.21 WTE nursing staffing in post. Similarly, the day-case unit had 6.48 WTE but required 9.12 WTE.
  • As of September 2016, the trust reported a nurse vacancy rate of 8.2% at WCH. WCH had the higher vacancy rate of the two sites. At WCH, General Theatres had the highest vacancy rate at 19.3%.
  • Between July 2015 and November 2016, the Cumberland Infirmary reported seven incidents which were classified as a Never Event for surgery. There had been six Never Events between June 2015 and February 2016.
  • We saw 26% (November 2016) of patients were re-assessed for venous thromboembolism (VTE) within 24 hours of admission. This is a decrease from October 2016 when 72% of patients were re-assessed with 24 hours of admission. September 2016 figures were 37%. The target is 95%.
  • Surgical debrief as part of the five steps to safer surgery was undertaken 14% of the time. A trust audit had recommended further work on encouraging the team debrief through business unit governance meetings and dissemination of learning by governance leads.
  • We found that training such as fire safety (58%), hygiene for clinical staff (67%), trust doctors patient safety programme (31%), and duty of candour (45%) were below the trust target.
  • The proportion of patients having hip fracture surgery on the day or day after admission was 68.3%, which does not meet the national standard of 85%. The 2015 figure was 75.1%.
  • A last-minute cancellation is a cancellation for non-clinical reasons on the day the patient was due to arrive, after they have arrived in hospital or on the day of their operation. If a patient has not been treated within 28 days of a last-minute cancellation then this is recorded as a breach of the standard and the patient should be offered treatment at the time and hospital of their choice. For the period Q2 2014/15 to Q1 2016/17 the trust cancelled 1,438 surgeries. Of these, 12% were not treated within 28 days. The overall trend is that the trust has a much higher percentage of operations not treated within 28 days compared to the England average. Performance improved from Q1 2015/16 to Q3 2015/16 however performance deteriorated again from Q4 2015/16 and is showing signs of deteriorating further.
  • Cancelled operations as a percentage of elective admissions includes all cancellations rather than just short notice cancellations. Cancelled operations as a percentage of elective admissions for the period Q2 2014/15 to Q1 2016/17 at the trust were consistently greater than the England average. The trust trend has followed a similar pattern to the England average, although the peaks and troughs are far more pronounced, particularly the increase in Q3 2015/16 although it should be noted that junior doctor strikes were planned during this period and may have contributed to the sharp rise.
  • For the period November 2015 to November 2016 WCH cancelled 292 surgeries for non-clinical reasons.
  • Four Surgical specialties were below the England average for admitted RTT (percentage within 18 weeks).
  • An action on the quality improvement plan stated that the division aimed to achieve compliance with 18 week referral to treatment for the incomplete pathway standard by September 2016. The status of this action remained in progress as of December 2016.
  • At trust level, general surgery had a longer average length of stay than the England average for both elective and non-elective admissions.
  • At the time of inspection the perioperative improvement plan was in the early stages of implementation, impacting upon some areas but not yet fully embedded within the division.
  • Staff morale was variable on the wards, theatres and recovery areas. Morale was affected by working in difficult circumstances during the last eighteen months to cover staff and skill shortages.
  • We were advised of ongoing bulling allegations within the theatre departments.

However:

  • The division held regular emergency surgery and elective care business unit meetings where serious incidents were discussed, investigations analysed and changes to practice identified.
  • Senior nursing staff had daily responsibility for safe and effective nurse staffing levels. Staffing guidelines with clear escalation procedures were in place. Site cover was provided out-of-hours 24 hours per day, seven days per week by a team of senior nurses with access to an on-call manager. Numbers of staff on duty were displayed clearly at ward entrances.
  • A ‘red flag’ and safer staffing system had been introduced to identify when lower than optimal staff numbers may impact upon patient care and to initiate mitigation. Escalation processes were in place through the matron, service manager and chief matron. Capacity bed meetings were held twice daily to monitor bed availability, review planned discharges and assess bed availability throughout the trust.
  • All wards participated in the NHS safety thermometer approach to display consistent data to assure people using the service that the ward was improving practice based on experience and information. This tool was used to measure, monitor, and analyse patient ‘harm free’ care.
  • We looked at medical records across wards and saw they were appropriately completed, legible and organised consistently. All documentation checked was signed and dated, clearly stating details of the named nurse and clinician.
  • Patients were treated in accordance with national guidance and enhanced recovery (fast track) pathways were used. Local policies were written in line with national guidelines. A range of standardised, documented pathways and agreed care plans were in place across surgery.
  • During 2015/16, the surgical business unit participated in 12/14 national clinical audits covering a range of specialties, and completed 122 local audits. Outcomes from each audit were reported to Business Unit Governance Board (BUG Board).
  • The perioperative surgical assessment rate was 92.4%, which does not meet the national standard of 100%. However, the 2015 figure was 62.4% showing considerable improvement.
  • WCH was one of only 18 Hospitals in England and Wales referred to in the first NELA audit for contributing examples of best practice in care of patients undergoing emergency laparotomy.
  • Patients admitted with a fractured neck of femur had their pain assessed immediately upon presentation at hospital and within 30 minutes of administering initial analgesia, hourly until settled on the ward and regularly as part of routine nursing observations throughout admission.
  • A dedicated pain team was accessible to support with analgesia as required. The pain team visited patients when baseline pain relief was ineffective. Anaesthetists provided support with pain relief out-of-hours.
  • Between March 2015 and April 2016, patients at WCH had a lower than expected risk of readmission for both elective and non-elective admissions.
  • The Friends and Family Test response rate for surgery at the trust was 38% which was better than the England average of 29% between November 2015 and October 2016. Ward level recommendation rates were variable although recommendation rates were generally high, being between 70-100% for the overall period across all participating wards.
  • We observed the treatment of patients to be compassionate, dignified, and respectful throughout our inspection. Ward managers and matrons were available on the wards so that relatives and patients could speak with them as necessary.
  • The trust was actively working with commissioners to provide an appropriate level of service based on demand, complexity and commissioning requirements.
  • The division had an escalation policy and procedure to deal with busy times and matrons and ward managers held capacity bed meetings to monitor bed availability.
  • Complaints were handled in line with the trust policy, and discussed at all monthly staff meetings. Patients or relatives making an informal complaint were able to speak to individual members of staff or the ward manager. Wherever possible the patient Advice Liaison Service (PALS) would look to resolve at a local level.
  • We met with senior trust and divisional managers who had a clear vision and strategy for the division and identified actions for addressing issues within the division. The divisional leadership team detailed their understanding of the challenges associated with providing good quality care and identified actions needed.
  • The trust had developed a quality improvement plan (QIP) and had identified specific objectives to improve the management of the deteriorating patient, the recognition, and initiation of treatment for patients with sepsis and ongoing development of the Mortality and Morbidity Framework.
  • The division had also developed a perioperative improvement Plan in response to recent issues identified within surgery. This aimed to enhance governance through learning from events and incidents, develop the workforce through a positive learning environment, and initiate external assessment and compliance.
  • There was a systematic programme of clinical and internal audit, which was used to monitor quality and systems to identify where action should be taken. Monthly audits were undertaken and audit outcomes were published quarterly.
  • The division’s risk register was updated following the safety and quality meetings with risks discussed, controls identified, with progress against mitigation, risk grading, assurance sources, and gaps in control documented.

 

Intensive/critical care

Good

Updated 29 March 2017

During our last inspection of critical care services at WCH, in July 2015, we rated good overall, We have rated the service as good overall after a comprehensive announced and unannounced inspection visit in December 2016, with evidence of ongoing improvement in the unit.

  • There was ongoing progress towards a harm free culture. Staff we spoke with understood the incident reporting system and improvement in reporting culture had been noted by the critical care team. There was a proactive approach to the assessment and management of patient - centred risks and staff had a good understanding of the trust position related to learning from incidents, serious incidents and Never Events. The number of pressure sores recorded in the incident reporting system had shown significant improvement since our last inspection and staff reporting of pressure ulcer grading and level of harm was good.
  • There had been no Never Events in critical care and one reportable serious incident at the WCH site. There had been 27 NRLS reported incidents and themes were monitored closely by grade and seriousness of harm.
  • A 24/7 Critical Care Outreach Team (CCOR) was well established. We observed good practice for recognition and treatment of the deteriorating patient. One hundred percent of patients received follow up once discharged from the unit. Practice was in line with GPICS (2015), NICE CG50 and against the seven core elements of Comprehensive Critical Care Outreach, (C3O 2011) ‘PREPARE’; 1. Patients track and trigger, 2. Rapid response, 3. Education and Training, 4. Patient safety and governance, 5. Audit and evaluation (monitoring patient outcome), 6. Rehabilitation after critical illness and 7. Enhancing service delivery.
  • Medical staff we spoke with discussed good anaesthetic staffing levels and continuity for rotas and out-of-hours cover. Use of locum consultant staff at WCH for anaesthetic cover was lower than CIC (35%) at 9.4% for 2015/16. The demands of the service were very different since the move of major surgery to CIC, and this was reported as having a negative impact on recruiting new anaesthetic staff to the unit.
  • The policy and activity around critical care patient transfer to other hospitals when required were good. The arrangements for the small numbers (seven in 2015/16) of paediatric admission for stabilisation for hours prior to transfer were also good, to include levels of staff training and competence and storage and checking of essential equipment. The unit were part of the ‘North East Children’s Transport and Retrieval’ (NECTAR) new transport service. All senior staff were trained in paediatric life support.
  • The emergency resuscitation equipment and patient transfer bags for both adults and children were checked daily with a good system in place as per trust policy. There was good provision of equipment in critical care, good storage and robust systems for medical device training.
  • The unit was visibly clean, spacious and met Department of Health Building Note HBN-04.02 standards for new build units; standards of infection prevention and control were in line with trust policy. All patient rooms were large single isolation rooms as the unit was modern in design and opened in September 2015 as part of the new hospital build plan since our last inspection.
  • The team in the unit had invested in, and implemented an electronic patient record and prescription system specific to intensive care which we observed to be comprehensive and well understood by staff. All records checked in the system were complete and risk assessment, patient review and prompt systems and processes were good.
  • Patients were at the centre of decisions about care and treatment. We reviewed consistent positive survey feedback and comments which gave evidence of a caring and compassionate team. There was also evidence of well-attended nurse led support groups for patients in the local community. Staff whom we observed and spoke with were positive and motivated and delivered care that was kind, promoted dignity, and focused on the individual needs of people. The improvements made towards the rehabilitation of patients after critical illness since our last inspection were comprehensive.
  • The team in critical care services spoke highly of their local leadership and felt supported by matrons, consultants and senior matrons. A culture of listening, learning and improvement was evident amongst staff we spoke with in the unit. Staff we spoke with across the team were positive about their role. Governance arrangements were clear to the staff especially in view of reporting frequent changes in the senior team over the past five years. Staff expressed that they wanted a period of stability in the senior and executive team.
  • We found that ICNARC data showed that patient outcomes were comparable or better than expected when compared with other units nationally, this included unit mortality. ICNARC data had been collected and submitted consistently at WCH. The data was available to the team and, during inspection, we were able to review consistent annual reports; however we reported to the critical care team that although data had been published on the ICNARC website, that data was only for one unit. Staff we spoke with were not aware of this and could not explain why data had not been published for both units.
  • Plans were in place to provide multidisciplinary follow up clinics across both units for rehabilitation of patients after critical illness, as recommended by NICE CG83 and GPICS (2015). These were for those patients who had experienced a stay in critical care of longer than four days. A small dedicated team was being led by the matron and senior physiotherapist and a health care assistant was recruited to deliver this standard and progress was good. Support groups had been well attended in the local community with staff organising a range of supportive and educational opportunities. The use of patient diaries had been embedded in practice.
  • Patients received timely access to critical care treatment and consultant led care was delivered 24/7. Readmissions to the unit were monitored closely by the Consultant and CCOR team and were below National average. There was good evidence of analysis of reasons for readmission and we reviewed a summary of cases with no significant trends. Minimum numbers of patients were transferred out of the unit for non-clinical reasons. We found that patients were not cared for outside of the critical care unit when Level 2 or 3 care was required, and we did not see examples of critical care outliers in theatre recovery or ward areas.
  • Patients in the critical care unit were discharged to the wards within 8 hours once a decision to discharge was made as per GPICS (2015). ICNARC data indicated a position that was comparable with the national performance against this target. There was good performance for patients discharged within 4 hours of the patient being ready for discharge. There were no incidents of single sex breaches, as the unit had single room provision for patients.
  • We spoke with senior staff about concerns with nurse staffing levels and the actual and potential impact on safety and staff morale created by the increase in long term sickness levels. Senior staff responded to our concerns with evidence of plans to ensure safe staffing levels and escalated recruitment plans for Band 6 and band 5 nurses. This included temporary bed closure and close monitoring of activity. Escalation policies were reissued to staff. This gave assurance that the senior team were supportive and managing the escalation of this short term staffing pressure.

However:

  • During our inspection we found that the team were finding it difficult to maintain nurse staffing levels in the unit due to a recent significant increase in long term sickness levels in the unit. We observed that there had been occasions were there had not been sufficient numbers of staff to provide 1:1 nursing for a long term level 3 patients, in line with intensive care standards. We escalated concern to senior staff during the inspection around the impact of a recent spike of 12% in staff sickness, which increased potential risk to patient safety. We also highlighted the lack of supernumerary coordinator in line with GPICS (2015), and the limitations and pressure on nursing staff to be able to observe patients in single rooms. A comprehensive action plan was produced by the trust after an unannounced visit which provided further assurance that these issues were being closely monitored and managed. Nurse staffing had been good prior to September 2016 with sufficient staffing levels for provision of critical care standards.
  • The CCOR team had been moved frequently to support shortfalls in staffing in other wards and departments. We spoke with staff who felt that this had presented a risk to patient safety across the trust when they were unable to provide a CCOR service. It had affected the morale of team however we did not see evidence or incident at the time of inspection that patient care or safety had been compromised i.e.; increased readmission rates or late admissions to critical care. Staff we spoke with told us that more recently senior support had changed and improved. Protection of the CCOR cover had been prioritised since September 2015 and since the unit restructure under the Surgical and Anaesthetic directorate.
  • There was no supernumerary clinical educator in the unit, in line with GPICS (2015). Staff provided support for training however it was recognised that the sickness in the senior, experienced team may impact on the team’s ability to provide training and support to junior staff.
  • The critical care pharmacist provision was well below GPICS (2015) standards. We spoke with staff in the unit who did not report any issues with management of medicines and pharmacy support, however pharmacists were not able to fulfil the critical care role, join ward rounds or deliver improvements in practice with only 0.2 WTE dedicated hours.
  • Discharges out-of-hours, between 22.00hrs and 06.59hrs have been proven to have a negative effect on patient outcome and recovery. Critical care discharges out-of-hours were reported as 2.8% in 2015/16, against a national average of 2.0% as reported by ICNARC for 2015/16.

 

Services for children & young people

Good

Updated 29 March 2017

We rated this service as ‘good’ because:

  • The leadership, governance, and culture promoted the delivery of high quality person-centred care. Staff were competent and had the skills they needed to carry out their role effectively and in line with best practice. Managers were visible and there was a real strength, passion, and resilience across medical and nursing teams to deliver high quality care to children, young people and their families.
  • Staff told us they were proud to work for the trust and promoted a patient-centred culture. Children, young people, and parents felt that medical staff communicated with them effectively, kept them involved and informed about care and treatment, promoted the values of dignity and respect, and were kind and compassionate.
  • Staff protected children and young people from harm and abuse. Medical and nursing staff understood and fulfilled their responsibilities to raise concerns and report incidents, and managers took appropriate action to investigate and share learning.
  • Medical and nursing staff followed appropriate processes and procedures to safeguard children and young people. The trust was represented at local safeguarding children board meetings and other sub-groups. Clinicians shared learning from serious case reviews and care records showed staff provided very good standards of care.
  • Children and young people received effective care and treatment, planned and delivered in line with current evidence-based practice and legislation. Children’s services participated in national and local audits, and other monitoring activities including service reviews and accreditation schemes. Managers shared the outcomes from audits and actions plans were developed to address areas of concern.
  • Children’s services were organised to meet the needs of children and young people. Managers and healthcare professionals from the team worked collaboratively with partner organisations and other agencies to ensure services provided choice, flexibility and continuity of care.
  • Nurse staffing on the children’s ward and in the special care baby unit was compliant with recommendations from the Royal College of Nursing and the British Association of Perinatal Medicine.

 

However:

  • The unit did not meet all Royal College of Paediatric and Child Health (RCPCH) – Facing the Future: Standards for Acute General Paediatric Services (2015 as amended) within contracted hours. Despite ongoing recruitment campaigns, the trust had struggled to recruit appropriate clinicians. The current paediatric consultant team voluntarily worked in excess of their programmed activities to ensure children and young people were safe, however staffing constraints meant this was done in their own time. In a letter to CQC, the trust formally acknowledged our concerns and outlined the actions taken to address the current shortfall, which included robust handovers and ward rounds, plus on-site consultant presence and out-of-hours support. The trust had also secured long-term contracts for consultant locums.
  • Healthcare assistants worked within the children’s outpatient department without support from a registered children’s nurse. This was in breach of Royal College of Nursing staffing standards for children in outpatients as, most of the time; a healthcare assistant was the only member of the nursing team in the unit. In addition, staff did not have documented competencies and had not received additional training.

 

End of life care

Good

Updated 29 March 2017

During our last inspection of End of Life Care Services at Cumberland Infirmary in April 2015 we rated the service as ‘requires improvement’ overall. During this inspection there was evidence of ongoing improvement. We have rated the service as ‘good’ overall, with effective as ‘requires improvement’ because:

  • The trust had developed a care of the dying patient (CDP) care plan that provided prompts and guidance for ward based staff when caring for someone at the end of life. We observed the use of these and saw that information was recorded and shared appropriately and that the plans were completed.
  • Records within the mortuary were comprehensive and included processes for appropriate checking.
  • The palliative care end of life communication training (Sage and Thyme) is part of the mandatory training for all staff at WCH.
  • An early warning scoring system was in use throughout the trust to alert staff to deteriorations in a patient’s condition. Patient’s recognised as being at the end of life had their care plan transferred to the care of the dying patient framework when they were expected to die within a few days.
  • The Trust had an organ donation policy, which adhered to national guidelines. The framework process made reference to specialist nurses, clinicians and nursing staff supporting the family throughout the process.
  • Porters had face to face mortuary training that included the transfer of the deceased including promoting dignity and respect and an understanding of bereavement.
  • Care plans for patients at the end of life included an assessment of nutritional needs and aspects of nutrition and hydration specifically relating to end of life care.
  • The trust ensured that there was timely identification of patients requiring end of life care on admission. Systems were in place where a patient admitted who was known to the palliative care team would generate an alert to the team.
  • We observed staff caring for patients in a way that respected their individual choices and beliefs and we saw that records included sections to record patient choices and beliefs so that these were widely communicated between the teams.
  • The chaplaincy team worked with ward staff and other professionals for patients receiving end of life care.
  • An Integrated End of Life and Bereavement group was now in operation. This was headed by the Deputy Director of nursing the members of the group the SPCT, chaplaincy, the bereavement lead, education and training and consultant medical staff.
  • Referrals to the SPCT could be made any time during a patient’s treatment. This allowed early involvement of the SPCT and time to facilitate the most appropriate care and treatment. The SPCT encouraged referrals from nursing, medical and allied health professional staff from across the trust.
  • The trust had developed “Welcome to Hospice at Home – West Cumbria” initiative. All services provided are free of charge This service included the provision daytime and night nursing care, Respite Care - day, evening or night and also volunteer support in the home They can also refer patients to other services within the organisation including complementary therapies for patients, carers and those bereaved, one to one or group support, bereavement support and Lymphoedema support. All services provided are free of charge
  • The specialist palliative care team developed a care pathway tool for patients in all areas of the hospital. This was to ensure that patients who required end of life care. Patients were identified at the earliest opportunity and to facilitate the most appropriate care in the most appropriate place for each patient.
  • A clear vision had been established where ‘All people who die in Cumbria are treated with dignity, respect and compassion at the end of their lives and that regardless of age, gender, disease or care setting they will have access to integrated, person-centred, needs based services to minimise pain and suffering and optimise quality of life
  • The Lead Bereavement Nurse and the chaplain had leadership roles in terms of end of life care and raising awareness of aspects of their service across the trust. This involved attending meetings and working collaboratively across services and departments to raise awareness of end of life care issues.
  • Staff were consistently positive about delivering quality care for patients at the end of life.
  • There was a commitment at all levels within the trust to raise the profile of death and dying and end of life care. This included improving ways in which conversations about dying were held and engaging with patients and their families to ensure their choices and wishes were achieved.
  • Discharge coordinators were available to support the process of rapid discharge at the end of life and the trust had recently implemented a community service where patients could be supported by trust staff in their own homes where care packages were difficult to access in the community.

However:

  • For patients who did not have mental capacity, DNACPR forms we viewed at this inspection were inconsistently completed. We saw DNACPR forms that did not provide evidence of a best interest decision or a mental capacity assessment being undertaken and recorded. In a letter to CQC, the trust formally acknowledged our concerns and outlined the actions to be taken to address this issue.
  • The trust had not achieved two clinical indicators and three organisational indicators in the End of life care Audit: Dying in Hospital in 2016
  • The trust had not produced an action plan with key responsibilities and timelines for achievement, to address areas where performance was lower than the England average.
  • The trust could not provide the number of referrals to the SPCT.
  • Both the SPCT and on general wards supported patient’s to die in their preferred location. However the trust did not collate or hold the data that would demonstrate the percentage of patients who died in their preferred location. This information was held by the Clinical Commissioning Group; however the trust could not provide this information.
  • There was no regular audit of the CDP to demonstrate that the trust supports patient’s to die in their preferred location.
  • Specialist palliative care was not provided across a seven day service.
  • The trust did not have formal contract meetings with members of the Cumbria Healthcare Alliance to monitor that the service being commissioned and provided is of an appropriate standard in terms of quality and meeting patient need.

 

Outpatients

Good

Updated 29 March 2017

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We rated this service as good overall, with responsive as requires improvement, because:

  • There was an electronic system to report incidents in the services. Staff were aware of how to report incidents.
  • The environment of the services were visited were found to be clean and tidy and hygiene standards were good. Equipment was mostly available, except for bariatric wheelchairs and a recliner chair in the phlebotomy clinic.
  • Medicines were found to be securely stores and medicines checked were in date. Data for medical records showed the improvement made previously had been generally maintained, however a recent change in the storage of the medical records had led to some challenges such as notes arriving late for clinics. Data provided by the trust showed that in September 2016, 94.38% of notes were available at the start of clinic
  • Outpatient and Diagnostic services were delivered by caring, committed and compassionate staff. Patients were positive about the way staff looked after them and the care received.
  • Care was planned and delivered in a way that took account of patients’ needs and wishes. Patients attending the outpatient and diagnostic imaging departments received effective care and treatment. Care and treatment was evidence based and followed national guidance.
  • Staff had attended courses and further training to enhance competence in their services. Staff had access to the required information and systems, for example the electronic incident reporting system.
  • Staff provided compassionate care and took into account the privacy and dignity of patients.
  • The services had been responsive to the increasing demand for clinics by putting on addition clinics on a weekend where required. There had previously been issues with diagnostic six week waiting times; however there had been a steady trend of improvement at this inspection.
  • There services had received a low number of complaints in the last 12 months.
  • Outpatient managers were able to describe the risks to the services and what they action they were taking to mitigate the risks, however not all identified risks such as staffing levels were on the risk register.
  • Staff were mostly positive about local leadership in the service. Staff we spoke with enjoyed their role and overall felt respected and valued by the trust. Staff described good team work and supportive teams.

However:

  • Safeguarding mandatory training completion rates were below the trust target. Mandatory training completion rates were generally below the trust targets.
  • The imaging department quality assurance system had been suspended when new equipment was installed and not re-introduced until eight months later. Diagnostic imaging did not carry out daily refrigerator temperature checks.
  • Orthopaedic practitioner staffing levels were not at the planned levels.
  • Referral to treatment time (RTT) data varied across the specialities. The service did have patients which the see by date had been breached.
  • There were a number of clinics cancelled within 6 weeks of the planned clinic date across the trust, and there was no current action plan in place to address cancelled clinics in outpatients. The trust did not measure how many patients waited over 30 minutes to see a clinician in outpatient departments.
  • Turnaround times for inpatient plain film radiology reporting did not meet Keogh standards, which require inpatient images to be reported on the same day.