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Good Hope Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 1 June 2015

Heart of England Foundation Trust is a large NHS provider of acute hospital and community services in Birmingham and Solihull. The hospitals are in the East and North of Birmingham and one smaller site in Solihull West Midlands. There is also the Birmingham Chest Clinic which is in the centre of Birmingham The trust has some community services in Solihull. We did not inspect the community services or the Chest Clinic. The three acute sites are Birmingham Heartlands Hospital, Good Hope Hospital and Solihull Hospital. Along with the community service the trust serves approximately 1.2m people. The Birmingham Heartlands site is where the trust headquarters are located.

We carried out this unannounced responsive inspection because the trust was in breach with regulators Monitor, and we had received intelligence which warranted our response and so we arranged the inspection. The inspection took place between 08 and 11 December 2014. We had inspected the service in November 2013 and the trust was still working through compliance action plans.

This inspection was an unannounced responsive inspection and as such we will not be rating the service. The purpose of the report is to share with the trust and the public the evidence we gathered during that inspection. It is also important to note that at the time the trust was in transition with many changes within the trust executive team, some of whom were in interim posts. This had been precipitated by the previous Chief Executive resigning in November 2014.

Our key findings were as follows:

  • Widespread learning from incidents needed to be improved.
  • Appraisals for staff were not widely undertaken achieving 28% compliance at the time of our inspection.
  • Staffing sickness and attrition rates were impacting negatively on existing staff.
  • The congestion within the hospital was having negative impacts across all the core areas we inspected. For instance the number of patients having to wait in recovery more than 30 minutes was high.
  • Discharge arrangements required improvement; we saw that only 35% of patients were discharged on or before their planned date of discharge.
  • The care of the deteriorating patient was generally managed well.
  • Arrangements for patients with reduced cognitive function were not always effective. This meant that some patients did not receive the level of care and support they required.
  • The leadership was in a transition phase with many in interim posts.
  • The culture within the trust was one of uncertainty due to the number of changes which had occurred.
  • Staff could not communicate the trust vision and strategy.
  • Governance arrangements needed to be strengthened to ensure more effective delivery.
  • IT reporting needed to be improved to ensure reporting was accurate.

We saw several areas of outstanding practice including:

  • The Practice Placement team provided excellent links between the trust and the University in supporting more than 600 student nurses across all three hospital sites.
  • AMU, Ambulatory Care, wards 10, 11 and 24 provided excellent local leadership, services were well organised, responsive to patients individual needs and efficient which resulted in excellent patient outcomes.

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

  • Incident report feedback needs to be improved so that staff are accessing the learning opportunities.
  • Appraisals need to be undertaken for staff and supervision to improve staff development.
  • Arrangements for patients who required mittens were not undertaken to maintain patient’s safeguards.

Importantly, the trust must:

  • The trust must take effective action to address the overcrowding in the majors area of the emergency department and ensure that staff on duty can see and treat patients in a timely way.
  • The trust must review the operation of rapid assessment of patients to improve its consistency and effectiveness.
  • The trust must take effective action to achieve consistent staff compliance of infection control procedures
  • The trust must ensure all patients requiring items of restraint such as hand control padded mittens are supported with a mental capacity assessment, a DoLS and are regularly reviewed by the MDT which is recorded in the patient’s notes and mittens are replaced when soiled. A consistent practice must be adopted across the trust.
  • The trust must provide sufficient staff to operate the second obstetrics theatre at night, and prevent delays occurring.
  • The hospital must improve the information available to outpatients departments to ensure that these are monitored and action taken to improve services through audit, trending and learning.

There were also areas of practice where the trust should take action, and these are identified in the report.

As a result of this, the trust will be subject to regulatory action as requirement notices and a comprehensive inspection will be carried out to confirm this.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 1 June 2015

Effective

Updated 22 May 2014

Many services across the hospital were providing effective care. However, we saw a lack of risk assessment in the A&E department that could affect patients’ care. At our inspection on 27 February 2014, we found that risk assessments were currently in place within the A&E department at Good Hope Hospital. The ward staff knew the pressures on the trust and were aware of the actions taken by it and them in order to resolve these. Training was provided by the trust for staff but ward areas found it difficult to release staff due to the pressures on the ward. This meant that care was not as effective, as staff were not always up to date with their training requirements. An example of this was the lack of uptake on training in dementia care, resulting in staff not fully understanding the needs of patients.

Caring

Updated 22 May 2014

Most people we spoke to were positive about their care. Much of the care we observed during the inspection was good. However, in November 2013 we had concerns about the A&E department, the medical and the paediatric wards where care was not always as person-centred as it might have been because of shortages of staff and the pressure staff were under.

Patients were full of praise for staff, although expectations about the level of care were low. The staff themselves wanted to provide a good level of care and often made extra effort to ensure that a particular patient had a good experience. This was very evident on the maternity unit where staff often stayed late to ensure that women had a positive experience of the delivery process.

The Friends and Family test however, introduced by the Government this year, shows that the trust is significantly below the national average indicating that people using the hospital would not recommend it to others.

At our inspection on 27 February 2014 we found that intentional rounding had been introduced to the A&E department and patients could be assured that their basic care needs were now being met.

Responsive

Requires improvement

Updated 1 June 2015

Well-led

Requires improvement

Updated 1 June 2015

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 1 June 2015

Incident reporting was good and staff told us they had opportunities to learn from issues raised. There were no safer staffing information on display for staff, women and visitors to the maternity unit. The percentage of women having interventional births was higher (worse) than the England average.

Some good initiatives were observed to facilitate efficient and safe admission and discharge, however support for low risk mothers and assistance with breast feeding was minimal. The caesarean section and induction of Labour rates were significantly higher than the national average.

There was some tension between Labour ward and Maternity Assessment Unit staff, regarding admission criteria for women.

The Maternity department at Good Hope Hospital lacked visible leadership and the staff were unclear about the maternity strategy and felt powerless to affect service development and delivery. Staff worked well in their teams, but there was little inter-department co-operation, and some staff told us they worked in a ‘blame culture’ which lead them to practicing defensively.

Medical care

Requires improvement

Updated 1 June 2015

Medical care (including older people’s care)

Good

Updated 1 August 2017

We rated the service overall as requires improvement:

  • The department breached the Department of Health waiting time target to either admit, transfer, or discharge patients within four hours of arrival and was worse than the national average between August 2015 and July 2016. Performance in meeting the target declined during this time period.
  • Due to a lack of capacity within the ED patients were cared for in corridors approximately 75% of the time.

  • There was an upward trend in the monthly percentage of ambulance journeys with turnaround times over 30 minutes and in July 2016 this had increased to 51%.
  • The department did not meet the trust target of responding to complaints within 30 days. On average, it took 123 days to investigate and close complaints.

  • We saw large quantities of medicines that were out of date still stored in the medicine cupboards and fridges throughout ED.
  • We saw inconsistent checking of controlled drugs and refrigerator temperatures in certain areas of ED.
  • We were concerned about some infection prevention and control procedures; during the announced inspection we saw several old bloodstains on the floor and on equipment within patient areas in the resuscitation area. .

However:

  • Staff were aware of how to report incidents and did so routinely.

  • Awareness of duty of candour was embedded within the department. Duty of candour relates to openness and transparency and requires providers of health and social care services to notify patients, or other relevant persons, of certain notifiable safety incidents and provide support.

  • We saw staff undertake excellent handovers which incorporated additional learning from senior members of staff.
  • Although patients were located within the corridor at the time of our announced visit, we saw staff using a safe placement protocol to ensure all patients were cared for in a safe manner.
  • The department had a plan of audits to undertake in order to measure performance, and took part in national audits.
  • Newly qualified or trainee members of staff were well supported both by colleagues and management. All staff we spoke to commented upon the supportive environment and positive teamwork.
  • We observed excellent examples of care; whereby staff treated patients with dignity, respect and compassion.
  • The trust had recruited a flow co-ordinator to aid the flow of patients throughout the department, and to ensure all patients were treated in as timely a way as possible.

We rated this service as good because:

  • All staff clearly understood the safeguarding policies and processes.
  • Staff reported incidents and received feedback. There was evidence of learning from incidents across the trust taking place.
  • Individual patient risks were identified and managed.
  • Staff planned and delivered patients care and treatment in line with current evidence-based guidance, standards, best practice and legislation. Most patient outcomes were similar or better than national expectations.
  • Staff delivered compassionate and dedicated care.
  • There was an open culture and good team working within the service.
  • .

However:

  • Patients were not always safely discharged in a timely manner.
  • Staff were not following The Sepsis 6 (Deteriorating Patient Screen pathway) for the patients with sepsis whose notes we reviewed.

  • The service was not compliant with recommendations for the safer management of controlled drugs and waste regulations

Urgent and emergency services (A&E)

Requires improvement

Updated 1 August 2017

  

We rated the service overall as requires improvement:

  • The department breached the Department of Health waiting time target to either admit, transfer, or discharge patients within four hours of arrival and was worse than the national average between August 2015 and July 2016. Performance in meeting the target

  • Staff within ED reported that due to a lack of capacity within the ED, some patients were cared for outside of cubicles around the nurses stations repeatedly. 

  • There was an upward trend in the monthly percentage of ambulance journeys with turnaround times over 30 minutes and in July 2016 this had increased to 51%.

  • The department did not meet the trust target of responding to complaints within 30 days. On average, it took 123 days to investigate and close complaints.

  • We saw large quantities of medicines that were out of date still stored in the medicine cupboards and fridges throughout ED.

  • We saw inconsistent checking of controlled drugs and refrigerator temperatures in certain areas of ED.

  • We were concerned about some infection prevention and control procedures; during the announced inspection we saw several old bloodstains on the floor and on equipment within patient areas in the resuscitation area. .

However:

  • Staff were aware of how to report incidents and did so routinely.

  • Awareness of duty of candour was embedded within the department. Duty of candour relates to openness and transparency and requires providers of health and social care services to notify patients, or other relevant persons, of certain notifiable safety incidents and provide support.

  • We saw staff undertake excellent handovers which incorporated additional learning from senior members of staff.

  • Although patients were located within the corridor at the time of our announced visit, we saw staff using a safe placement protocol to ensure all patients were cared for in a safe manner.

  • The department had a plan of audits to undertake in order to measure performance, and took part in national audits.

  • Newly qualified or trainee members of staff were well supported both by colleagues and management. All staff we spoke to commented upon the supportive environment and positive teamwork.

  • We observed excellent examples of care; whereby staff treated patients with dignity, respect and compassion.

  • The trust had recruited a flow co-ordinator to aid the flow of patients throughout the department, and to ensure all patients were treated in as timely a way as possible.

Surgery

Requires improvement

Updated 1 August 2017

We rated this service as requires improvement because:

  • Improvements were required in adherence to infection prevention and control practices and medicines management.

  • Although staff were aware of the focus on reducing pressure ulcers and falls there was a lack of awareness of other incidents, or any learning which had been identified as a result of incidents.The identification of incidents and risk and the management of risks on the risk register was not always robust.

  • The service had below average performance in relation to a range of national measures to assess the effectiveness and responsiveness of care.The effectiveness of care, as measured in national clinical audits, indicated performance below the national average in a number of areas. The risk of an unplanned re-admission following discharge was also higher than the England average for all specialties other than urology. The average length of stay for elective surgery was higher than the England average

  • Patients experienced delays at all stages of the patient journey through surgical services. This included delays in scheduling unplanned surgery and delays in returning from recovery to the surgical wards.

  • Care provided did not always take account of patients’ individual needs, in relation to those living with dementia and those with a learning disability.Access to independent translation services was not promoted. Records of mental capacity assessments and the best interest decision making process was not well completed.

However:

  • There was a good awareness and escalation when patients’ condition deteriorated and a good awareness of sepsis.

  • Initial medical assessments and nursing risk assessments were completed and reviewed appropriately; there was a multi-disciplinary approach to care and clear plans of care for patients. Care pathways were used for routine procedures to ensure a consistent approach to care. Patients’ pain was regularly assessed and effectively managed. Patients were aware of the plans for their care and felt involved in decision making.

  • Good clinical leadership was in place at ward level. Staff had access to training and development and completion of mandatory training was generally good. They had attended adult safeguarding training and there was good awareness of safeguarding policies and procedures.Staff worked well together; they were supportive of each other and were committed to improving the quality of patient care.

  • Patients gave mostly positive feedback on the care and compassion shown by staff and the timeliness of staff responses when they required assistance. Results from the Friends and Family Test (FFT) were above the national average. We observed patients’ privacy and dignity being maintained and a professional and sensitive approach by staff when providing care.

Intensive/critical care

Good

Updated 22 May 2014

We found that services within the critical care area were safe. Staffing was at the level required by national guidance and staff were found to be caring and compassionate. Communication flows of information from other areas of the hospital were good and lessons learnt shared with all staff. The support of the critical care outreach team was valued by other staff in the hospital; however, bed capacity in this unit was sufficient for the hospital’s needs.

Services for children & young people

Requires improvement

Updated 22 May 2014

None of the parents or patients raised any concerns with us about safety at the hospital. Children’s safeguarding procedures were robust and were improved in response to findings from a serious case review. Assessments were done of patients’ needs on admission by both nursing and medical staff, and care and treatment were delivered effectively. Parents spoken to were mostly pleased with the care and treatment that the hospital had provided, and positive about the staff.

There was a lack of appropriate response to the management of children with mental health needs and a lack of an effective response to the shortage of permanent senior paediatric doctors (registrar, middle grade), which had an overall impact on the delivery of care. At times there was a shortage of nursing staff with the appropriate skills, knowledge and experience to care for patients. A lack of clarity on the function of the redesigned inpatient service meant that pathways in place were not always followed and the service was not responding to the needs of patients who were admitted.

There was a strong management presence in the form of the head of nursing, matron and supervisory ward sisters. We saw evidence of regular senior meetings and completion of audits to monitor the quality of service provided. There was evidence of learning and improving as a result of incidents that had occurred. Arrangements were in place for the management of high-risk issues that affected the hospital. For example, the hospital had proactively responded to concerns about staff shortages and bed occupancy of the inpatient assessment unit. However staff felt that the focus was on the Heartlands site and that they were marginalised by this. 

End of life care

Good

Updated 22 May 2014

Patients received safe end of life care. They had support to make decisions about their care and staff working in the service were experienced, knowledgeable and passionate about providing good care outcomes for patients. Patients and their families had positive views about the end of life service. The hospital had worked hard to meet the needs of its local ethnic population and to ensure that the religious and cultural needs of people at the end of their life were met in a timely and sensitive way.

Outpatients

Good

Updated 1 August 2017

We rated this service as good because:

  • We saw staff washing their hands and using the gel provided.
  • Incidents were investigated; we reviewed incident reports and root cause analysis documents from outpatients and diagnostic imaging and found these to contained details of concerns, findings from investigations, recommendations and arrangements for shared learning.
  • Outpatients and diagnostic imaging departments were tidy, clean, and uncluttered. Equipment had I am clean stickers applied, this showed equipment had been cleaned. In diagnostic imaging, we saw evidence of the cleaning of ultrasound probes before and after use.
  • Equipment was maintained and tested in line with trust policy. We saw that labels were applied which identified when equipment had last been checked. Service reports were available to view in diagnostic imaging. There were plans in place to replace or purchase additional pieces of equipment in diagnostic imaging.
  • Hospital staff kept medications locked and secure in cupboards. Prescriptions were stored securely.
  • Records reviewed were legible, accurate and up to date.
  • Staff were aware of their roles and responsibilities in relation to safeguarding and knew how to raise matters of concern.
  • Nursing, medical and dental staff received mandatory training. The training consisted of 17 modules including infection control, information governance and manual handling.
  • Staff in diagnostic imaging adhered to diagnostic imaging policies and procedures. These were written in line with the Ionising Radiation (Medical Exposure) 2000 regulations IR(ME)R.
  • Procedures were in place to ensure that the probability and magnitude of accidental or unintended doses to patients from radiological practices were reduced as far as reasonably practicable.

However:

  • Service records for lasers were unavailable to inspection staff at the time of the inspection; staff were unable to locate these. Local rules for YAG and KTP (types of lasers) were displayed, however they were not dated. Local rules should be signed and dated by the laser protection advisor.

  • Feedback to staff on individual incidents was limited.

  • There was a lack of hand hygiene  audits for the main outpatient department.