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Medway Maritime Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 17 March 2017

We inspected Medway Maritime Hospital as part of the Medway NHS Foundation Trust inspection on 29, 30 November 5,8,10 and 17 December 2016. Medway NHS Foundation Trust was identified as a mortality outlier for both the hospital standardised mortality ratio (HSMR) and the summary hospital mortality indicator (SHMI) for 2011 and 2012. Consequently, Professor Sir Bruce Keogh (NHS England National Medical Director) carried out a rapid responsive review of the trust in May 2013 and the findings resulted in the trust being placed into special measures in July 2013. The Care Quality Commission (CQC) then undertook two comprehensive inspections of Medway Maritime Hospital in April 2014 and August 2015. The trust was rated inadequate overall at both of these inspections.

In August 2015 the trust was rated inadequate overall because of concerns relating to patient safety, the organisational culture and governance throughout the trust. Since this inspection the CQC has maintained a heightened programme of engagement and monitoring of data and concerns raised directly with us. The trust was also subject to additional scrutiny and support from the local clinical commissioning groups, NHSE and NHSI through a monthly Quality Oversight Committee which monitored the implementation of action plans to address the shortcomings identified.

This inspection was specifically designed to test the requirement for the continued application of special measures at the trust.

We have now rated Medway Maritime Hospital as 'Requires Improvement' overall. This is based on an aggregation of the ratings for the eight core services we inspected. We were able to see evidence of positive changes taking place across the hospital. However, there were still areas that required improvements so patients received consistently safe care.

The hospital had made improvements to flow through the introduction of a new model for treating medical patients. This was implemented in April 2016 and made significant improvements to the way in which patients’ care was managed.

We found effective systems to assess and respond to patient risk, and significant improvement in this area since our last inspection. These included daily checking for signs of deteriorating health, medical emergencies or challenging behaviour. The hospital had introduced “safety huddles” on the wards and improved staff training in recognising and responding to deteriorating patients. We observed staff recognised and responded appropriately to any deterioration in the condition of patients. Early warning scores were now consistently used across the hospital.

The trust had introduced a new frailty pathway to provide appropriate care for the significant number of patients with complex needs. This enabled staff to treat patients quickly to avoid the need for admission to hospital. The trust had improved their discharge planning and the hospitals delayed transfer of care rate was one of the lowest in England. However, in Surgery the service did not always use the facilities and premises appropriately due to a lack of available beds.

There had been improvements made to the management of patients in the Emergency department (ED). At our previous inspection we found that patients were routinely placed in a corridor where the delivery of safe care had been compromised. At this inspection we found that the corridor was no longer used to treat patients. We also found handovers and safety briefings in ED were effective and ensured staff managed risks to people who used the department. The process of triaging patients had also improved.

The trust had introduced several recruitment strategies. However, staff recruitment continued to be problematic with high levels of bank and agency use in some areas. In some departments staffing did not meet with the recognised standards and guidance. For example, in the emergency department medical staffing did not meet the Royal College of Emergency Medicine minimum requirements for consultant cover, the cardiac care unit (CCU) did not have consistent access to a medical team and in the maternity unit where staffing regularly did not meet its target of ratio of staff to patients, as recommended by Birthrate Plus. In the 2016 staff survey, which included a range of clinical and non-clinical staff, 76% of respondents said there were not enough staff to do their job properly.

There was openness and transparency about safety. Staff understood and fulfilled their responsibilities to report incidents and near misses and were supported when they did. There were effective systems in place to report incidents which were monitored and reviewed. Staff across the hospital gave examples of learning from incidents. Staff understood the principles of Duty of Candour regulations and were confident in applying the practical elements of this legislation.

At our previous inspection , we identified a lack of clinical oversight for patients waiting longer than the targets set for cancer and 18 week pathways. We saw a process of clinical oversight had been introduced and was embedded in the process of monitoring patient pathways. This included weekly patient tracking list meetings, and electronic flags on computer systems to alert staff to patients exceeding their target dates.

Although we saw improvement since our last inspection improvement was still required in relation to staff consistently having appraisals and completing mandatory training in line with trust policy.

We found care and treatment across the hospital was mostly planned and delivered in line with current evidence-based guidance, standards, best practice and legislation. Regular monitoring and audit ensured consistency of practice There were formal systems for collecting comparative data regarding patient outcomes. The hospital routinely monitored and collected information about patient outcomes and used this information to improve care. Benchmarking data showed patient outcomes were mostly similar to national averages. Data supplied demonstrated continuous improvement in some areas since the previous year.

Clinical governance systems, meeting structures and directorate risk registers formed part of the quality assurance and risk management system. Senior staff used the systems effectively to identify and mitigate risk.

At our last inspection we found significant failings in the hospitals estates and facilities management. At this inspection we found there had been improvements, although we still found areas that required attention. The directorate had made some significant changes. These included restructuring the directorate, bringing external contracts in-house (e.g. fire safety and training and a local security management specialist), creating and recruiting a new internal facilities audit team to improve auditing systems, revision of the terms of reference for estates and facilities groups, reviewing policies, and the housekeeping operating plan.

At our last inspection we had significant concerns about fire safety. Fire safety had been significantly improved at this inspection. Kent Fire & Rescue had undertaken a peer to peer review of Fire Safety at the trust. A Fire Action Plan had been created and presented to the trust Board in January 2017 which addressed key fire safety issues. Quarterly fire Safety reports will be provided to the trust Board in future.

Although the hospital was visibly clean, we found instances where clinical environments were not meeting the National Specifications of Cleanliness (NSC). This meant there was inconsistency in the auditing of cleaning standards across the very high risk areas and potentially an increase in the risk of hospital acquired infections.

There were specific areas of the hospital where staff were not feeling the positive impact of changes and where morale was low. This was more evident in theatre staff who were often working beyond the end of their shifts and band five nurses, who were feeling the impact of staff shortages and were often asked to move wards at short notice to cover shortages elsewhere. However, large numbers off staff joined a range of focus groups held at the hospital from different professional groups and we spoke with individual staff as we went around the hospital. The majority of staff we spoke with reported improvements in the organisational culture and were positive about developments at the trust.

We saw several areas of outstanding practice including:

  • The neonatal unit improved their breast-feeding at discharge compliance rates from one of the lowest rates in the country to the highest. A critical care consultant, nurse practitioner, GP lay member and physiotherapist led an innovative programme to improve patient rehabilitation during their ICU admission and after discharge. This included a training and awareness session for all area GPs and a business case to recruit a dedicated rehabilitation coordinator. In addition, a critical care consultant had developed app software to be used on digital tablets to help communication and rehabilitation led by nurses. The consultant was due to present this at a critical care nurses rehabilitation group to gather feedback and plan a national launch.

  • Critical care services had a research portfolio that placed them as the highest recruiter in Kent. Research projects were local, national and international and the service had been recognised as the best performer of the 24 hospitals participating in the national provision of psychological support to people in intensive care (POPPI) study. Research projects for 2016/17 included a study of patients over the age of 80 cared for in intensive care; a review of end of life care practices; a respiratory study and a study on abdominal sepsis.

  • The 'Stop Oasis Morbidity Project’ (STOMP) project had reduced the number of first time mothers suffering third degree perineum tears. The project had been shortlisted for the Royal College of Midwifery Award 2017, Johnson’s Award for Excellence.

  • Team Aurelia was a multidisciplinary team. Women who were identified in the antenatal period as requiring an elective caesarean section would be referred to team Aurelia. Women were seen by an anaesthetist prior to surgery and an enhanced recovery process was followed to minimise women’s hospital stays following surgery.

  • The bereavement suite, Abigail’s Place, provided the “gold standard” in the provision of care for parents and families who experience a still birth. The suite created a realistic home environment for parents to spend time with their child.

  • The frailty and the ambulatory services, which required multidisciplinary working to ensure the needs of this patient group, were met. The individualised care and pathway given to patients attending with broken hips. The care ensured this group of patients’ needs were met on entering the department until admission to a ward. The development and implementation of the associate practitioner role.

Action the hospital MUST take to improve

  • Ensure flooring within services for children and young people is intact, in accordance with Department of Health’s Health Building Note 00-09.

  • Ensure all staff clean their hands at the point of care in accordance with the WHO 'five moments for hand hygiene'.

  • Review the provision for children in the recovery area of theatres and Sunderland Day Unit to ensure compliance with the Royal College of Surgeons, standards for children’s surgery.

  • Ensure staff record medicine fridge temperatures daily to ensure medicines remain safe to use.

  • Ensure compliance with recommendations when isolating patients with healthcare associated infections.

  • Ensure that all staff have appropriate mandatory training, with particular reference to adult safeguarding level two and children safeguarding levels two where compliance was below the hospital target of 80%. Ensure that all staff receive an annual appraisal.

  • Ensure that an appropriate policy is in place ensuring that patients transferred to the diagnostic imaging department from the emergency department are accompanied by an appropriate medical professional.

  • Ensure the intensive care unit meets the minimum staffing requirements of the Intensive Care Society, including in the provision of a supernumerary nurse in charge.

  • Ensure staffing levels in the CCU maintain a nurse to patient ration of 1:2 at all times.

  • Ensure that consultant cover in the emergency department meets the minimum requirements of 16 hours per day, as established by the Royal College of Emergency Medicine.

  • Ensure fire safety is a priority. Although the trust has taken steps to make improvements we found some areas where fire safety and staff understanding needed to be improved.

  • The trust must ensure people using services should not have to share sleeping accommodation with others of the opposite sex. All staff to be trained and clear of the regulation regarding same sex accommodation.

  • Ensure clinical areas are maintained in a clean and hygienic state, and the monitoring of cleaning standards falls in line with national guidance.

  • Take action to ensure emergency equipment (including drugs) are appropriately checked and maintained.

Action the hospital SHOULD take to improve

  • Ensure the electronic flagging system for safeguarding children in the children’s emergency department is fully embedded into practice.

  • Review safeguarding paperwork to ensure it can be easily identified in patient’s records.

  • Ensure there is a system in place to identify Looked after Children (LAC) in the children’s emergency department.

  • Enhance play specialist provision in line with national guidance.

  • Ensure children’s names and ages or not visible to the public, in compliance with the trusts ‘Code of conduct for Employees in Respect of Confidentiality’ policy.

  • Ensure compliance with NICE QS94, and ensure children, young people and their parents or carers are able to make an informed choice when choosing meals, by providing them with details about the nutritional content.

  • Identify risks for the outpatient risk register.

  • Begin monitoring the availability of patient records in outpatient clinics.

  • Ensure that referral to treatment times improve in line with the national targets.

  • Monitor the turnaround times for production of clinic letters to GPs following clinic appointments.

  • Ensure there is sufficient resource in allied health professionals teams to meet the rehabilitation needs of patients.

  • Ensure medical cover in the CCU is provided to an extent that nurses are fully supported to provided safe levels of care.

  • Medicines and IV fluids should be stored securely and safely. Intravenous (IV) fluids were stored in a draw on a corridor on pearl ward this was not secure as it did not ensure that IV fluids could not be tampered with. We found ampoules of metoclopramide and ranitidine, drugs commonly used for stomach problems, stored in a box together. This created a risk that patients may have been given the incorrect medicine.

  • Ensure equipment cleaning is thorough, including the undersides of equipment.

  • Ensure complaints are responded to in accordance with the trust’s policy for responding to complaints.

  • Meet the national standards for Referral to treatment times (RTT) for medical care services and continue to reduce the average length of stay of patients.

  • The driving gas for nebulised therapy should be specified in individual prescriptions as can be harmful to the patient.

  • Continue to address issues with flow to improve performance against national standards.

  • Repair/replace the two patient call bells in the majors overflow area.

  • Install a hearing loop in the emergency department reception area.

  • Consider how staff are made aware of internal escalation processes.

  • Take action to ensure patients recover from surgery in appropriate wards where their care needs can be met.

  • The trust should take action to ensure there is sufficient access to equipment. In particular, sufficient sling hoists for patients on Arethusa and Pembroke Wards and sufficient access to computers for staff throughout the surgical directorate.

It is apparent that the trust is on a journey of improvement and significant progress is being made both clinically and in the trust’s governance.

I would therefore recommend that, from a quality perspective, Medway NHS Foundation Trust, is now taken out of special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 17 March 2017

Effective

Good

Updated 17 March 2017

Caring

Good

Updated 17 March 2017

Responsive

Requires improvement

Updated 17 March 2017

Well-led

Requires improvement

Updated 17 March 2017

Checks on specific services

Maternity and gynaecology

Good

Updated 17 March 2017

At our previous inspection in 2015 we rated the service as good. On this inspection we maintained a rating of good as the overall quality of care for patients had been maintained.

At this inspection, overall we rated maternity and gynaecology services as good. This was because:

  • People were being protected from avoidable harm and abuse.

  • Openness and transparency about safety was encouraged. Staff understood their responsibilities in relation to incident reporting. Incidents were investigated appropriately by staff with the necessary clinical knowledge who had received training in leading such investigations. We were given examples of where changes to practice had been made following incidents.

  • Overall, medicines practice met practice guidelines. However, we found two areas where medicines were not stored appropriately.

  • The services, wards and departments were clean and, overall, staff adhered to infection control policies and protocols. However, we found some areas that had not been cleaned appropriately following spillages, and areas which were not cleaned to required standards. We also found that staff were not always washing their hands in line with trust policy.

  • Performance demonstrated a consistent track record and steady improvements in safety. Record keeping was comprehensive and audited on a regular basis.

  • Decision making about the care and treatment of patients was clearly documented. The service used systems of observation to drive improvement in the timely identification of patients at risk of unexpected deterioration. It had allowed for oversight of patients with elevated risk and concerns were escalated for review by the medical teams.

  • Treatment and care was generally provided in accordance with the National Institute of Health and Care Excellence (NICE) and Royal College of Obstetricians and Gynaecologists (RCOG) evidence-based national guidelines. Maternity and gynaecology had an MDT approach in the care of women and babies.

  • There was a range of national and local audits with action plans. In response to audit results action plans were reviewed and monitored providing evidence of good outcomes for children and young people.

  • Leadership was good and staff told us about being supported and enjoyed being part of a team. There was evidence of multi-disciplinary working with staff working together to problem solve and develop child-centred evidence based services which improved outcomes for children and young people.

  • Development opportunities and clinical training was accessible and there was evidence of staff being supported and developed in order to improve services provided to women.

  • Feedback from women and their families was continually positive about the way staff treated people. We saw staff treated women with dignity, respect and kindness during all interactions. Women and families told us they felt safe, supported and cared for by staff.

  • There was an embedded culture of caring, which was demonstrated by the team winning the Johnson’s Excellence in maternity care award at the annual RCM national awards. Staff listened and responded to women's needs as shown by the introduction of the 'Induction of Labour Team' and the 'Patient Satisfaction Following Emergency Caesarean Section' project.

However:

  • The maternity service was not meeting it ratio of staff to patients every month.

  • There were no guidelines in place in regards to babies’ identification.

  • The maternity unit had closed on seven occasions between April 2015 and July 2016 due to the neonatal unit (NNU) being closed. However, the service had followed trust procedures in regards to unit closures.

Medical care (including older people’s care)

Good

Updated 17 March 2017

At our previous inspection in 2015 we rated medical care services as inadequate. On this inspection we have changed the rating to good because we have identified improvements in the service. We have seen significant changes in key areas to keep people safe and provide effective well led care. The reporting and learning of incidents was embedded in practice, medicines were stored appropriately, the service participated in local and national audits and patient outcomes were monitored. Additionally the service was responsive to patient’s individual needs, discharge planning was evident and a clear leadership strategy was in place.

At this inspection, overall we rated medical care as good because:

  • We found learning from incidents embedded in practice and rates of harm free care had improved. We observed medicines were appropriately stored and confidential patient records were generally stored securely.

  • Clinical environments were visibly clean. Staff in all departments used appropriate hand hygiene techniques and complied with the trust’s policies and guidance on the use of personal protective equipment.

  • Mandatory training was being completed which meant staff had the necessary current skills to do their job. Staff were aware of their responsibilities concerning the protection of people in vulnerable circumstances.

  • Overall we judged there was sufficient medical and nursing staff with the appropriate skill mix to meet the needs of the patients on a day to day basis, although there was a reliance on temporary staff.

  • We found care and treatment reflected current national guidance. There were formal systems for collecting comparative data regarding patient outcomes. Services were generally available seven days a week. There were adequate arrangements to ensure patients received adequate pain relief and had enough to eat and drink.

  • We observed staff interactions and relationships with patients and those close to them were caring and supportive. They responded with compassion to pain, emotional distress and other fundamental needs. Staff treated patients with dignity and respect and people felt supported and cared for as a result.

  • Services were responsive to people’s needs as patients were able to access the care they needed and there was adequate management of demand and patient flow throughout the hospital. Discharge planning had improved since our last inspection with a reduction in levels of delayed transfer of care.

  • The vision and values of the organisation had been developed and were understood by staff. The leadership of the service had been restructured which provided stability for staff. This meant there was a clear focus on achieving objectives. Governance processes were evident at ward, divisional, hospital and corporate level. This allowed for monitoring of the service and learning from incidents, complaints and results of audits. Staff were positive about working for the trust, and spoke with pride about how far the trust had come in such a short time. They told us they now felt valued and that their opinion mattered.

However:

  • Patients were frequently treated in mixed sex wards and there was a lack of understanding by staff of the regulations regarding same sex accommodation. The trust had reduced the average length of stay of medical care patients since the last inspection but this remained worse than the national average. Additionally medical care services were not meeting national standards for referral to treatment times (RTT).

  • Although visibly clean, we found instances where clinical environments were not meeting the National Specifications of Cleanliness (NSC). This meant there was inconsistency of cleaning standards across the very high risk areas and potentially an increase in the risk of hospital acquired infections.

  • We saw the trust was not following national guidelines for the gas used to administer nebulisers. We found individual prescriptions did not clarify this and could be harmful to patients.

  • There were inconsistencies in the suitable number of staff receiving training at the appropriate level for safeguarding vulnerable adults. Local managers did not always support staff in their development as not all staff received a regular annual appraisal.

Urgent and emergency services (A&E)

Requires improvement

Updated 17 March 2017

At our previous inspection in 2015, overall we rated the ED as inadequate. On this inspection we have changed the rating to requires improvement. This reflects significant improvements in staffing levels, maintaining the dignity and respect of patients, the clinical assessment of patients, monitoring of patients, reporting culture and the medical and nursing leadership.

At this inspection overall we rated urgent and emergency services as requires improvement because:

  • Consultant cover did not meet the minimum requirements of the Royal College of Emergency Medicine and there was a significant shortage of middle grade doctors. The staffing level and was not always appropriate within the resuscitation area.
  • Care provided for patients suffering with sepsis (infection) was not always in accordance with National Institute for Health and Care Excellence. There was mixed compliance with infection control practices during busy times.
  • Staff were unaware of escalation processes used during busy times within the ED.
  • The hospital consistently failed to meet the Department of Health target that 95% of patients be admitted, transferred or discharged within four hours. However, a programme of significant development was underway to improve all aspects of the service times, including triage, assessment and treatment.
  • There was inadequate flow and capacity through the department; however, this was mainly due to a lack of inpatient beds. There were occasions when the number of patients requiring treatment in the majors area and resuscitation areas exceeded the number of cubicles available. Patients experienced significant delays whilst awaiting specialist review or to be placed in a bed on a ward. However, the trust had undertaken a number of initiatives to increase flow and capacity since our last inspection. At the time of inspection there was building work underway, which would significantly improve capacity within the ED in the future.
  • There was no effective system that ensured medicine fridge temperatures were monitored daily. There was no effective system that ensured staff checked the emergency equipment in the minors area daily.
  • Medical staff had not undertaken an appropriate level of safeguarding training.
  • There was no effective system to ensure fire safety checks were undertaken or effective systems to mitigate fire risks.
  • There was no hearing loop in the reception area for patients with hearing difficulties.
  • Mandatory training compliance did not meet the trust’s own targets.

However:

  • Openness and transparency about safety was encouraged. Staff understood their responsibilities in relation to incident reporting. Incidents were investigated appropriately by staff with the necessary clinical knowledge and learning was shared.
  • There was consistent evidence the duty of candour was used in relation to incidents to maintain transparency and communication with patients and relatives.
  • An education programme was available to staff and included practical competency training. Practice development nurses and senior staff supported staff to undertake professional and academic development in line with their specialist interests. This included degree programmes in ED care and preceptorship courses for newly qualified nurses.
  • A range of improvements had been made to quality, safety and training. Staff had undertaken additional training for example in the management of patients with sepsis (infection).
  • Ambulatory care was available to help avoid unnecessary time patients spent within the ED and hospital admissions.
  • A frailty service had been introduced to address the needs of the local population. This service aimed to reduce the need for hospital attendances and admissions and ensure patients had better access to home or community services.
  • There was a clear vision and strategy and staff were positive they were heading in the right direction of continued improvement. The culture of the department had improved, there was a no blame culture and staff morale had improved.
  • There was evidence of multi-disciplinary working with staff working together to problem solve and develop services which improved outcomes for patients’.
  • There was a focus on patient safety and there were systems in place to review patients regularly, which ensured a deteriorating patient was recognised. Record keeping was comprehensive and audited regularly. Decision making about the care and treatment of patients was clearly documented.
  • There had been an effective nurse recruitment programme, and there had been a marked reduction in the use of agency nurses.
  • Feedback from patients was generally positive about the way staff treated patients’. We saw staff treated patients with dignity, respect and kindness during all interactions. Patients told us they felt safe, supported and cared for by staff.
  • The practice of using the corridor to care and treat patients had stopped.
  • The department had improved its waiting time from arrival to initial assessment; this had been highlighted as an area that required improvement at our previous inspections.

Surgery

Requires improvement

Updated 17 March 2017

At our previous inspection in 2015, we rated the surgical services overall as inadequate. Following significant improvements in key areas including incident reporting and learning, assessing and responding to patient risk, complaints, leadership, culture and staff engagement.

At this inspection overall we rated surgical services as requires improvement because:

  • The service did not always use facilities and premises appropriately due to a lack of available beds. There were inappropriate ward placements, patients staying overnight in the recovery areas in main theatres and mixed-sex accommodation breaches. Patients also had bed moves at inappropriate times such as during the night.

  • Problems with access and flow meant operating lists rarely ran on time.

  • Medicines storage and management arrangements were not always sufficiently robust. We found out-of-date emergency drugs in main theatres and an unlocked drugs cupboard containing medicines to take out on Phoenix Ward. We also saw evidence of intravenous drug administration on Phoenix Ward that was not in line with Nursing and Midwifery Council (NMC) Standards for Medicines Management.

  • The shortage of permanent nursing staff may have left the service vulnerable to spells of understaffing. However, in most areas, we saw the service used agency staff appropriately to fill the gaps.

  • Staff did not receive mandatory training in identifying and reporting female genital mutilation (FGM). As a result, some clinical staff lacked awareness of FGM and their legal duty to report it.

  • The trust failed to meet the national specifications for cleanliness in the NHS (NSC) regarding the frequency of audits in theatres. Infection prevention and control measures were not effective in some areas. For example, there were repeated infections on Phoenix Ward.

  • Bedside handovers on the surgical wards did not always maintain patients’ privacy and confidentiality.

  • Not all leaders had the necessary experience, knowledge, capacity or capability to lead effectively. However, the trust recognised this and had introduced training to support and develop leaders, such as matron development days.

However:

  • The service encouraged openness and transparency about safety. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. We saw evidence of learning from incidents and a positive culture of incident reporting and learning.

  • The service assessed, monitored and managed risks to patients. This included daily checking of signs of deteriorating health, medical emergencies or behaviour that challenged.

  • The service planned and delivered care and treatment in line with current evidence-based guidance, standards, best practice and legislation. Regular monitoring and audit ensured consistency of practice.

  • The service routinely monitored and collected information about patient outcomes. The service used this information to improve care. Benchmarking data showed patient outcomes were similar to national averages. The trust’s performance had improved in some areas since the previous year.

  • Staff helped patients and those close to them to cope emotionally with their care and treatment.

  • The trust had cleared its backlog of complaints and complaint response times were beginning to meet trust targets. We also saw evidence of learning from complaints.

  • The service made reasonable adjustments and took action to remove barriers for patients who found it hard to use or access services. This included translation services, services for patients living with dementia and facilities for bariatric patients.

  • Staff in all areas knew and understood the trust’s vision and values.

Intensive/critical care

Requires improvement

Updated 17 March 2017

At our previous inspection in 2015 we rated the critical care service overall as requires improvement. This reflected insufficient medical staffing and cramped conditions on the MHDU, delayed flow of patients through critical care due to insufficient ward capacity and no strategy to direct improvements in the service. At this inspection we also rated the service as requires improvement. However, we found improvements had been made in a number of areas. This included improvements in leadership and governance structures, safety equipment and processes and a significant improvement in patient mortality.

At this inspection overall we rated critical care services as requires improvement because:

  • Nurse staffing cover did not always meet the minimum requirements of the Intensive Care Society (ICS) core standards for intensive care medicine. This included the ratio of nurses to patients and the availability of a supernumerary nurse in charge.

  • The cardiac care unit (CCU) did not have consistent presence from the medical team and at times nurses struggled to cope with the acuity of patients combined with their lack of resources. An informal agreement existed that enabled them to ask doctors in the adjacent intensive care unit for help and although an operational policy was in place for the CCU, we did not see this used or have a positive impact on how the unit operated.

  • There were gaps in fire safety and evacuation planning, including a lack of control and oversight of fire risks in the environment and a significant proportion of staff without up to date fire safety training.

  • Due to short staffing in the allied health professionals (AHP) team, patients in the intensive care unit (ICU) did not receive the minimum amount of physiotherapy per day as recommended by the ICS and there were often delays in initial assessments such as swallowing and choking risk. This also meant there was not routine AHP presence at ward rounds, handovers or in multidisciplinary meetings.

  • Between November 2015 and October 2016, bed occupancy was higher than the national average in every month and at 100% of capacity in four months.

  • Between September 2015 and August 2016, 31% of patients experienced a discharge delay of over 24 hours. In the same period, 17% of discharges took place out of hours between 10pm and 6.59am.

However:

  • There was evidence of tangible and sustained improvement in leadership and governance. For example, a new critical care programme had established a clinical director post and a more multidisciplinary triumvirate model of leadership to link clinical and non-clinical staff.

  • A range of improvements had been made to quality, safety and training. This included training in sepsis and shock for foundation-level doctors and the delivery of a regional intensive care course.

  • Patient mortality rates had significantly improved in the medical high dependency unit following improved consultant availability and discharge planning.

  • Consultant intensivist cover met the requirements of the Intensive Care Society core standards for intensive care medicine in the time to initial review, ratio of consultants to patients and the accreditation of consultants with the Faculty of Intensive Care Medicine.

  • Practice development nurses and senior staff supported clinicians to undertake professional and academic development in line with their specialist interests. This included degree programmes in the CCU and post-registration qualifications in the ICU.

  • Clinical staff benchmarked care and treatment against national guidance and used local audits to identify areas for improvement. For example, improved interprofessional understanding between dieticians, speech and language therapists and the catering contractor led to improved nutrition for patients.

  • Staff provided consistently compassionate and kind care, treatment and involved patients and relatives in care planning where possible. This included in discussions around decision-making in line with National Institute of Health and Care Excellence (NICE) guidance.

  • Overall numbers of complaints were very low; with only two formal complaints receive between all critical care services between August 2015 and July 2016.

  • Feedback from staff about the culture of the service was variable but most of the individuals we spoke with agreed bullying and harassment had decreased and was no longer tolerated.

Services for children & young people

Good

Updated 17 March 2017

At our previous inspection in 2015, we rated the services for children and young people overall as good. On this inspection, we have maintained the overall rating as good, as the overall standard and quality of care has been maintained.

At this inspection overall we rated services for children and young people as good because:

  • Risk was managed and incidents were reported and acted upon with feedback and learning provided to staff.

  • There were effective systems in place to report incidents. Incidents were monitored and reviewed and staff gave examples of learning from incidents. Staff understood the principles of Duty of Candour regulations, were confident in applying the practical elements of the legislation.

  • Treatment and care were effective and delivered in accordance with National Institute of Health and Care Excellence (NICE) guidelines and other best practice guidelines. There was effective multidisciplinary team working within the service and with other agencies. The service also participated in national audits and implemented local audits such as infection control audits.

  • Staffing levels and skill mix were planned, implemented, and reviewed to keep children and young people safe at all times.

  • We found all clinical areas visibly clean and the equipment was fit for purpose and well maintained.

  • We saw that parents were fully informed prior to consent being obtained and that nursing and medical records had been completed appropriately and in line with each individual child’s needs.

  • Staff skills and competence were examined and staff were supported to obtain new skills and share best practice.

  • We observed good team working both within the services for children and young people and externally with other wards and departments that children had contact with.

  • All parents and young people spoke highly of the approach and commitment of the staff that provided a service to their children. We saw good interactions between staff and children, young people and their families. The caring attitude of all staff was obvious in every department we visited. Staff had expertise in caring and communicating with children and young people. Support and equipment was also provided for mothers on the neonatal unit to assist with breast-feeding.

  • There were clear governance arrangements in place that monitored the outcome of audits, complaints, incidents, and lessons learned throughout the service. Staff were positive about the culture in children’s and young people’s services and felt supported by senior managers in the trust.

However:

  • A recommendation from the previous report was there should be an electronic flagging system for safeguarding arrangements in the children’s emergency department. On this inspection, an electronic flagging system had been implemented but was not yet fully embedded into practice.

  • There was no flagging system to identify Looked after Children (LAC) in the children’s emergency department, as staff in children’s emergency department told us they relied on children or their parents/carers to inform them.

  • A recommendation from the previous report was children’s services should enhance play specialist provision in line with national guidance. The play specialist provision had not been enhanced since the previous inspection.

    Safeguarding documentation was on yellow paper along with other documents including consent forms and day care unit documentation for paediatric surgery; this made it difficult to distinguish safeguarding documentation in children and young people’s notes.

  • The service was not complying with National Institute for Health and Care Excellence (NICE) Quality Standard (QS) 94, as children were not given a menu to read, and we told the meal choices. This did not allow children and young people or their parents and carers to make informed choice when choosing meals, as they are not provided with the details about the nutritional content. Children and parents we spoke with told us they had a low opinion of the quality of meals provided.

  • There was no dedicated paediatrics recovery area in theatres. There was no segregation of children from adults in the recovery areas of the theatres. This meant children were directly opposite adult post-operation patients, other than a drawn curtain. In addition, parents were not always able to be with their children in the recovery room due to adult post-operative patients being present. This was not in accordance with The Royal College of Surgeons, standards for children’s surgery.

  • We saw children’s names and ages on a white board, which was visible to the public. This did not comply with the trusts ‘Code of conduct for Employees in Respect of Confidentiality’ policy.

  • Fridge temperatures on medicine fridges were not consistently recorded.

End of life care

Requires improvement

Updated 17 March 2017

At our previous inspection in 2015, we rated end of life care (EoLC) overall as requires improvement and said the trust had to improve compliance with anticipatory medication, provide EoLC training to hospital staff and full seven-day services.

On this inspection we have rated EoLC as requires improvement, because:

  • While there had been considerable work done to improve the service, we found the governance structure was not well established. It remained unclear that EoLC governance could be fully demonstrated at this stage and we concluded it was too soon to tell if the measures being implemented translated to established systems that effectively monitored and managed clinical quality and performance.

  • Senior managers readily and transparently acknowledged this and stated EoLC was on an improvement 'journey', which was consistent with our own observations and comments made to us by staff and patients.
  • Side rooms and interview rooms were not always available for patients at the end of their lives or their families. Facilities were not available for relatives to stay by the bedside and the hospital did not always provide the appropriate surrounding and privacy relatives required.
  • Patients did not have face-to-face palliative care services seven days a week.
  • It was unclear if actions and discussions from the EoLC steering group were shared widely across teams.
  • Death certificates were not always issued in a timely way.

However:

  • We found that the EoLC team had significantly increased in size and demonstrated a high level of specialist knowledge. There was a newly implemented leadership structure that had resulted in improved policy, procedures and a daily presence on the wards.
  • There were sufficient staff with the right skills and staff had been provided with mandatory and additional training for their roles. Completion rates for mandatory training were better than trust targets.
  • There was openness and transparency about safety. Staff understood and fulfilled their responsibilities to report incidents and near misses and were supported when they did.
  • The departments we visited were visibly clean and there were appropriate systems to prevent and control healthcare associated infections. There was sufficient equipment available to meet patients’ needs.
  • Mortuary services had received investment that resulted in increased capacity and improved facilities.
  • In the majority of patients’ medical records, we found ‘Do Not Attempt Cardio-Pulmonary Resuscitation’ (DNACPR) orders prominently presented at the front of the record folder.
  • Medicines were managed safely in accordance with legal requirements and anticipatory prescribing was utilised effectively.
  • EoLC staff were sensitive, caring, and professional. Patients’ complex symptoms were controlled and patients and those close to them were supported.
  • Spiritual and religious support was available through the interfaith spiritual care team. The chapel, recuperation rooms and viewing suite in the mortuary were suitable to meet the needs of service users and their families.

Outpatients

Requires improvement

Updated 17 March 2017

At our previous inspection in 2015, we rated outpatients and diagnostic imaging services as inadequate. On this inspection we have changed the rating to requires improvement because we have seen improvements in key areas such as assessing and responding to patient risk and learning from incidents, but improvements are still required in key areas such as access and risk management.

Overall we rated outpatient and diagnostic imaging departments as requires improvement. This was because:

  • The vacancy, turnover and sickness rates for the departments were worse than the hospital’s target. Nurse staffing levels for outpatients and diagnostic imaging were regularly below the planned levels.

  • The patient led assessment of the care environment (PLACE) scores for condition, appearance and maintenance were worse than the national average.

  • Environmental audits fell below the hospital target of 90%.

  • The trust referral to treatment times (RTT) fell consistently below the 92% standard.

  • The trust was performing worse than the operational standards set for cancer patients on two week, 62 day and 31 day treatment targets.

  • Patients had been consistently waiting longer than the national average for diagnostic tests.

  • Whilst the overall mandatory training target of 80% had been met by both departments, there were areas of poor compliance in safeguarding vulnerable adults and children, adult life support and infection control level two training.

  • The hospital did not audit whether patient records were available for their consultations.

  • Staff appraisal rates were worse than the hospital target for both outpatient and diagnostic imaging staff.

  • There were no risks identified for the outpatient department on the programme risk register.

  • There was no strategy in place for the service, and although these were under development, staff we spoke with were unaware of these.

However:

  • Since our last inspection, clinical oversight of patients waiting over 52 weeks had been instigated and embedded into the service.

  • The departments had systems and processes in place to keep patients free from harm. All staff we spoke with understood the incident reporting process and there was evidence of learning from incidents.

  • We observed good radiation compliance as per national policy and guidelines during our visit. A radiation protection supervisor was on site for each test and a radiation protection advisor was contactable if required. This was in line with ionising regulations, 1999 and radiation (medical exposure) regulations ( IR(ME)R), 2000.

  • The diagnostic imaging department had recently been re-accredited by Imaging Services Accreditation Scheme (ISAS).

  • Staff interacted with patients in a caring and considerate manner, and respected their dignity. Patients told us they felt the staff cared for them and this was reflected in the department friends and family test results.

  • Staff felt their line mangers were visible and approachable and staff spoke of improvement in the overall culture at the hospital.