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St Helier Hospital and Queen Mary's Hospital for Children Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 27 May 2016

St Helier Hospital and Queen Mary's Hospital for Children is part of Epsom and St Helier University Hospitals NHS Trust. The trust provides local acute services for people living in the southwest London and northeast Surrey. St Helier Hospital provides acute hospital services to population of around 420,000.

St Helier Hospital and Queen Mary's Hospital for Children is home to the Southwest Thames Renal and Transplantation unit. There is also a Children's Hospital on this site (Queen’s Mary’s Hospital for Children). All emergency surgery is undertaken at St Helier Hospital and the majority of elective surgery is carried at the trust’s other location, Epsom General Hospital.

Epsom and St Helier University Hospitals NHS Trust employs around 5,024.8 whole time equivalent (WTE) members of staff. Many staff work across both sites, so it is not possible to assign an exact number of staff for each site.

We carried out an announced inspection of St Helier Hospital and Queen Mary's Hospital for Children between 10 and 13 November 2015. We also undertook unannounced visits to the hospital on 21, 23, 25 and 27 November 2015.

Overall, this hospital is rated as requires improvement. We found urgent and emergency care, medical care, critical care, maternity and gynaecology, services for children and young people required improvement. Outpatients and diagnostic services, end of life care and renal services were good, however surgery was inadequate.

Overall, we found the safety, effectiveness, caring, responsiveness and well-led all required improvement.

Our key findings were as follows:

Safe

  • Staff were encouraged to report incidents, but there was inconsistent feedback and learning from incidents.
  • Staff were not always carrying out daily checks of resuscitation equipment in all areas.
  • Staff were aware of their responsibilities to protect vulnerable adults and children. They had access to the trusts safeguarding policy, understood safeguarding procedures and knew how to report concerns. However, the children’s ‘At Risk’ register in the ED had not been updated for three months.
  • Inadequate nurse staffing levels on some surgical wards and inadequate numbers of midwives meant there was a risk to the quality of patient care. There was also a large number of vacant medical staff posts and high use of locums in paediatrics. However, the hospital had recently undergone a recruitment drive which had enabled it to fill some of its nursing and medical vacancies.
  • The environments we inspected were visibly clean. However, the fabric of the St Helier building was reported as difficult to maintain due its age and the trust reported that this was likely to impact on the overall patient experience. This was due to the fact that staff reported difficulties in a range of areas including ensuring the building was hygienically clean; spacing between bed spaces was not in line with nationally recommended standards and a lack of appropriately equipped side rooms and isolation facilities for patients identified as being at risk of acquiring an infection, or whom had developed an healthcare acquired infection.
  • The trust recognised that in relation to infection rates, they were performing worse when compared both nationally and to peer hospitals of a similar size. Again, reasons behind the poor infection rates were partly attributed to the fabric of the buildings. We were concerned that, in light of the fact the physical environment was not always fit for purpose, there had not been sufficient focus on staff consistently applying standard, evidence based practice such as decontaminating hands both before and after patient contact; staff not abiding by bare below the elbow policies; staff not applying isolation protocols in a timely way and staff wearing theatre clothing such as scrubs and theatre shoes in communal areas of the hospital such as the public coffee area located on the ground floor of St Helier hospital. Root cause analysis into incidents associated with patients acquiring healthcare-associated infections included a lack of isolation facilities (side rooms) as a contributing factor to the spread of MRSA in three additional patients during 2014/2015. The NHS estates and facilities dashboard placed the trust in the lower quartile for the percentage of side rooms available and in the lowest (worst) quartile for the amount of functional and suitable space available for the delivery of clinical care.
  • The estates critical maintenance backlog was such that, when considering the negative financial performance of the trust for 2015/2016 and the projected budgeted deficit reported for 2016/2017, it was unlikely the trust was going to be able to deliver any significant impact to the backlog which was reported as a risk adjusted backlog of circa £37 million; this placed the trust as having the 16th highest estates backlog nationally and in 3rd position when compared to peer groups across London of a similar size and activity. The trust was in the highest quartile (worst when compared nationally) for the total reported backlog for maintenance.
  • Following the inspection, the trust shared additional information of concern with us regarding the structural integrity of some parts of the St Helier campus. Concerns were identified regarding the external render of B and C block and the fact that large sections of render had become loose over time posing a potential risk of falling debris to people passing beneath. The trust had commissioned a range of structural assessments to determine the extent of the issue and to determine immediate remedial actions including the fencing off of certain areas of the estate. We have asked the trust to provide the commission with the necessary assurances and have shared the information with a range of partner regulatory bodies so as to ensure sufficient focus is given to the concerns identified. At the time of publication of this report, we are continuing to monitor the situation and will consider any appropriate regulatory action as we consider necessary. 
  • The hospital had a mandatory training programme, however in most instances the completion rate was low. Staff spoke of pressures of work, particularly low staffing numbers that prevented them from attending training days.
  • Staff accessed the service’s clinical guidelines on the Trust’s intranet but were not always reviewed and updated. The service contributed to national audits and undertook local audits.

Effective

  • National audits that the trust took part in indicated that they adhered to best practice standards as well as or better than the England average, however there was a limited range of evidence for local audits.
  • There was a lack of agreed guidelines specific to the critical care unit and multidisciplinary working was not well embedded.
  • The hospital took part in national audits in the maternity service but we saw trust wide and not unit-specific data. The use of merged data from both maternity units was unhelpful in terms of monitoring unit performance, because of the difference between the two units in terms of size, culture, activity, staffing and demographics.
  • Pain scores were not routinely recorded and patients were not always administered timely pain relief. There was inconsistency in the pain scoring tools staff used to assess patients whilst in the ED.
  • Staff we spoke with were clear about their responsibilities in obtaining consent from people, however we saw no evidence of documentation of a ‘best interest’ decision making process for patients who did not have capacity to consent in some areas.
  • We found staff appraisal completion rates were low.
  • There was a lack of clarity amongst some staff with regard to how the Deprivation of Liberty Safeguards should be used.

Caring

  • Staff treated patients with compassion, dignity and respect. Interactions between staff and patients were professional kind and friendly. Patients were positive about the care and treatment they received.
  • Whilst Family and Friend Test feedback was positive, the response rate was notably low.
  • In critical care, patients were not always given the opportunity to be involved in their care.
  • In most cases, staff involved patients, their carers and family members in decisions about their care.
  • Bereaved mothers were sensitively supported by staff in maternity.

Responsive

  • The ED consistently performed at a rate better than the England average in meeting national standard of a doctor seeing 95% of patients within four hours of their arrival for the 12 month period November 2014 to October 2015.
  • Patient information and advice leaflets were only available in English.
  • Patients living with a learning disability were ‘flagged’ on the records system. However the department did not use a system for identifying patients living with dementia and there were no care arrangements for meeting their specific needs.
  • In surgery, the trust had fallen below the standard for the referral to treatment times (RTT).
  • Flow through the maternity wards was poorly organised, and women were not always in the most appropriate wards.
  • In outpatients, there was limited audit of patient waiting times for clinics.
  • Staff were aware of the complaints policy and told us how most complaints and concerns were resolved locally.
  • There was inconsistent feedback and learning from and complaints.

Well-led

  • Many staff had worked in the departments for many years. However, some were unaware of the trust’s vision of ‘Put the Patient First’.
  • Governance arrangements in the medical directorate were adequate, and staff commented on very good multidisciplinary teamwork; collaborative care and line management support although a number of staff commented on the disjointed cross site working.
  • Positive comments were received from many staff regarding the new senior management.
  • The hospital had a number of innovative projects underway, including those relating to patients living with dementia.
  • Risks for the service had been identified in various governance meetings and from a series of incidents but there lacked cohesiveness and a trust board understanding of how to address these issues in a timely manner.
  • In critical care, the leadership team had struggled to achieve good team dynamics because of behavioural issues from certain staff members and have not been successful in their attempts to manage this. The service had been unable to agree a strategy and an external advisor had been appointed by the trust to assist the critical care workforce in achieving this. The culture on the unit was very hierarchical and challenges were not always welcome.
  • In maternity, risks for the service were poorly identified and not managed in a timely way. There was little challenge in governance meetings. The culture was hierarchical and did not involve staff in developing systems. There was a lack of strong leadership or vision and there was not an effective communication route from ward to board.
  • In renal, the service was well led with a clear vision and strategy and effective governance and risk management processes. Managers in the service were aware of shortfalls and took steps to addressed them. Staff spoke positively of the leaders and culture within the service.

We saw areas of outstanding practice including:

  • The leadership of the outpatients and diagnostic imaging teams was very good with staff inspired to provide an excellent service, with the patient at the centre.
  • The diagnostic imaging department worked hard to reduce the patient radiation doses and had presented this work at national and international conferences.
  • The OPAL team had clearly had a positive impact in increasing the quality care of the elderly, particularly those living with dementia.

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

Importantly, the trust must:

  • Ensure child protection notifications are always up to date.
  • Ensure there are adequate numbers of nurses and midwives to deliver safe and quality care.
  • Implement agreed guidelines specific to the critical care units.
  • Ensure the management, governance and culture in the critical care units, supports the delivery of high quality care.
  • Obtain feedback from patients/relatives in the critical care units, so as to improve the quality of the service.
  • Make sure the 'Five steps to safer surgery' checklist is always fully completed for each surgical patient.
  • Identify, analyse and manage all risks of harm to women in maternity services
  • Ensure identified risks in maternity services are always reflected on the risk register and timely action is taken to manage these risks.
  • Improve the care and compassion shown to patients in the medicine, surgical and critical care areas.

In addition the trust should:

  • Ensure that the consultant hours in the emergency department meet the RCEM recommendation.
  • Ensure staff were not always carry out daily checks of resuscitation equipment in all areas.
  • Ensure the children’s ‘At Risk’ register in the ED is kept up to date.
  • Ensure that the trust's infection control procedures are complied and theatre staff do not wear theatre gear such a gowns and head covers in public areas.
  • Improve staff attendance at mandatory training
  • Ensure clinical guidelines on the trust’s intranet are always reviewed and updated.
  • Ensure there are agreed guidelines specific to the critical care unit and that multidisciplinary working is well embedded.
  • In maternity, ensure monitoring data is separated by location.
  • Ensure ‘best interest’ decisions are documented for patients who did not have capacity to consent.
  • Ensure staff appraisals are completed as required.
  • Ensure all relevant staff are clear about how the Deprivation of Liberty Safeguards should be used.
  • In critical care, ensure patients are always given the opportunity to be involved in their care, where appropriate.
  • Improve the referral to treatment times in surgery.
  • Improve the 31 day cancer waiting times for people waiting from diagnosis to first definitive treatment and the 62 day waiting time for people waiting from urgent GP referral to first definitive treatment.
  • Improve the flow of women through the maternity wards and ensure women are cared for in the most appropriate wards.
  • Ensure there are appropriate processes and monitoring arrangements to reduce the number of cancelled outpatient appointments, the auditing of patient waiting times and the timely and appropriate follow up appointments.
  • Improve the cohesiveness of risk management and address them in a timely manner.
  • In critical care, ensure good team dynamics and better working relationships amongst staff; an agreed strategy for the unit that includes the critical care workforce across the two sites and that all risks are identified and on the risk register.
  • In maternity, ensure risks are properly identified and managed in a timely way, leadership
  • Review arrangements for admission of women to maternity wards so that a member of staff can greet women and prevent unauthorised access.
  • Ensure policies reflecting national evidence-based guidance are communicated to all staff.
  • Ensure staff were able to use the structured communication tool, SBAR (Situation, Background, Assessment, Recommendation), effectively.
  • Review the skill mix on the maternity wards.
  • Increase the number of sonographers in radiology.
  • Ensure that the paediatric emergency department comply with Royal College of Paediatric and Child Health guidelines.
  • Ensure the servicing of equipment is undertaken on a regular basis and that broken equipment is removed from clinical areas.
  • Ensure pain scores are routinely recorded in the emergency department.
  • Improve the response times to complaints in the medical directorate.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 27 May 2016

Effective

Requires improvement

Updated 27 May 2016

Caring

Requires improvement

Updated 27 May 2016

Responsive

Requires improvement

Updated 27 May 2016

Well-led

Requires improvement

Updated 27 May 2016

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 27 May 2016

We judged maternity as requiring improvement. Poor deployment of staff combined with inadequate numbers of midwives meant there was a risk to women's care. Processes for addressing staffing shortages were not well planned and did not take account of skill mix. There was inconsistent cascade of learning from incidents and complaints and the service was slow to implement change.

The hospital took part in national audits using trust wide and not unit-specific data.The use of merged data from both maternity units was unhelpful in terms of reflecting unit performance, because of the difference between the two units in terms of size,culture, activity, staffing and demographics. St Helier performed better on normal birth because it had a well-established birth centre, and had fewer instrumental births, but the hospital had much higher caesarean section rates and numbers of mothers smoking during pregnancy.

St Helier carried out a narrow range of audits and did not collect data on all standard indicators and some data was misleadingly reported, such as midwife to birth ratio which was reported on the basis of establishment rather than actual numbers of midwives to care for women.

The majority of patients told us staff were caring.Bereaved women were sensitively supported.

Flow through the maternity wards was poorly organised, and women were not always in the most appropriate wards.Little work had been done to find out what women wanted in their antenatal and postnatal care, and to design the service around their needs. There was no dedicated telephone line or triage for women in labour.

Not all high level risks were reflected on the risk register and action to manage risks was slow. There was little evidence of challenge in governance meetings. The culture was hierarchical and did not involve staff in developing the service.

There was a lack of strong leadership or vision. The communication route from ward to board was not effective.There was a lack of good quality data on many aspects of performance, and audits were not used to drive improvement or monitor change.

The gynaecology service had weaknesses in incident reporting, and a high level of agency staffing leading to poor completion of patient observations and a past record of poor hygiene. Referral to treatment times were not always met.

Medical care (including older people’s care)

Requires improvement

Updated 27 May 2016

We rated medicine as good for being effective and well led; but as requiring improvement for being safe, caring and responsive. We foundmandatory training and staff appraisal completion rates were low; not all patient records were accurate; some wards repeatedly fell below the trust's infection control thresholds' and patients were able to access areas of wards that might compromise their safety. We also found staff were not always carrying out daily checks of resuscitation equipment.

The medical directorate’s use of locum staff, both medical and nursing, had consistently been above the trust average. The hospital had recently undergone a recruitment drive which had enabled it to fill some of its nursing and medical vacancies.

There was a lack of clarity amongst staff with regard to how the Deprivation of Liberty safeguards should be used. Staff generally provided care in a compassionate and kind way that preserved patients’ dignity, and said they felt supported by their line managers to provide high quality care. Patients’ feedback was largely positive however relatives’ comments were less so.

In all but neurology and dermatology, the medical directorate achieved the 18 week referral to treatment thresholds. The average length of stay trust wide was similar to the England average, but longer at St Helier for non-elective geriatric medicine.

Urgent and emergency services (A&E)

Requires improvement

Updated 27 May 2016

We have rated the ED as requires improvement.

The department was not meeting the Royal College of Emergency medicine (RCEM) recommendation that consultants should provide 16 hours emergency cover seven days per week. The ED was reliant on using bank and agency staff, for the 12 month period April 2014 to March 2015 the ED used an average 29% of bank and agency staff. In the children’s ED for the same period an average 25% of bank and agency staff were used. At the time of our inspection, the nursing vacancy rate in the department was 19%.

Some of the servicing on equipment was out of date (thermometers) or not working for example ophthalmoscope/otoscope which would be vital to use when assessing head injuries. On resuscitation trolleys daily checks were not being regularly completed, and some of the water used for injections had expired

Staff we spoke with were aware of their responsibilities to protect vulnerable adults and children. They had access to the trusts safeguarding policy, understood safeguarding procedures and knew how to report concerns.However, the children’s ‘At Risk’ register had not been updated for three months. This meant that staff were unable to check if children attending the ED in the last 3 months had previously been entered on to the ‘At Risk’ register.

Pain scores were not routinely recorded and patients were not always administered timely pain relief. There was inconsistency in the pain scoring tools staff used to assess patients whilst in the ED.

Multi-disciplinary working was in evident in the ED. Staff we spoke with were clear about their responsibilities in obtaining consent from people, however we saw no evidence of documentation of a ‘best interest’ decision making process for patients who did not have capacity to consent.

The ED consistently performed at a rate better than the England average in meeting national standard of a doctor seeing 95% of patients within four hours of their arrival for the 12 month period November 2014 to October 2015.During the same period, the number of patients waiting for between four and 12 hours to be admitted to a hospital ward was better than the English average. However, initial assessments of patients did not occur in a timely way. For the 12 month period November 2014 to October 2015 the average time patients waited for an initial assessment was 25 minutes. In the children’s ED for the same 12 month period the average waiting time was one hour and 31 minutes for an initial assessment.

Patient information and advice leaflets were only available in English.Patients living with a learning disability were ‘flagged’ on the records system. However the department did not use a system for identifying patients living with dementia and there were no care arrangements for meeting their specific needs.

Some staff we spoke with had worked in the department for many years. However, staff we spoke with were unaware of the trust vision of ‘Put the Patient First’.

Staff treated patients with dignity and respect. Interactions between staff and patients were professional kind and friendly. Patients were positive about the care and treatment they received. They told us that they felt involved in their care. In the A&E survey 2014, the trust scored about the same as other trusts for treating patients with dignity and respect whilst they were in the ED.

Surgery

Inadequate

Updated 27 May 2016

We have judged surgery services overall as inadequate. Low nurse staffing levels on some wards meant there was a risk to the quality of patient care. The shortage of staff had led to harm for some patients. There was no escalation plan to address staffing shortages as they arose. There was inconsistent feedback and learning from incidents and complaints. Processes to ensure people’s safety were not robust or consistent across the service. Not all staff had received the training they required or had their annual appraisal which meant we could not be assured that staff were competent in their roles.

National audits that the trust took part in indicated that they adhered to best practice standards as well as or better than the England average, however there was a limited range of evidence for local audits.

The majority of patients told us staff were caring, the patient experience survey for April 2015 to April 2015 had an equal amount of positive and negative comments about the care patients had received on surgical wards.

The trust had fallen below the standard for the referral to treatment times (RTT). Bed management meetings did not discuss the patient’s needs and staff told us that patients experienced moves to different wards at night.

Risks for the service had been identified in various governance meetings and from a series of incidents but significant issues identified were not addressed and action had not been taken. There lacked cohesiveness and a trust board understanding of how to address these issues in a timely manner.

Intensive/critical care

Requires improvement

Updated 27 May 2016

We rated the critical care unit as ‘requires improvement’ overall. Although staff were reporting incidents, there was no system in place to ensure that all staff were learning from incidents. We identified gaps in record keeping and found that intravenous (IV) fluids were not being stored securely. The unit was small and cramped and staff told us this made it difficult to have all the equipment required around the patient bedspace.

There was a lack of agreed guidelines specific to the critical care unit and multidisciplinary working was not well embedded. The unit had a larger number of delayed discharges and out of hours discharges compared to similar units and staff in other parts of the hospital reported delays in accessing critical care.

Patients were not always given the opportunity to be involved in their care. There was a poor response to patient feedback surveys and the unit did not offer a follow up clinic for patients post discharge.

The leadership team had struggled to achieve good team dynamics because of behavioural issues from certain staff members and had not been successful in their attempts to manage this. The service had been unable to agree a strategy and an external advisor had been appointed by the trust to assist the critical care workforce in achieving this. The culture on the unit was very hierarchical and challenges were not always welcome.

The unit had good outcomes for patient when compared to similar units and staffing was in line with national guidelines, although agency nurses were used frequently. Staff, including agency, received a good induction and competency based assessment prior to caring for patients independently. Doctors in training received good teaching and support from consultants and patients we spoke with spoke highly of the staff and the care they received on the unit.

Services for children & young people

Requires improvement

Updated 27 May 2016

We had concerns about staffing levels and the dependency levels of children. Throughout the inspection managers and staff told us they had concerns about staffing levels. We were told the trust had implemented the ‘Safer Staffing’ model for ensuring there were sufficient staff on duty to meet children’s needs and the service met nationally recommended staffing ratios but we found examples of staffing ratios falling below these levels. There was also a large number of vacant medical staff posts and high use of locums to cover for medical staff who were off sick, posts were unfilled or on maternity leave.

There was a system in place for reviewing staffing levels if the dependency levels of children increased but it was not clear if additional staff were always provided when dependency levels increased. Staff recorded observations about children every two hours to monitor their condition. Records showed these observations were being carried out but we also found examples where the system for escalating concerns about a deteriorating child were not being followed.

Child protection notifications from the trust were not up to date. There was a three month backlog in notifying safeguarding concerns. Staff on the ward were unaware of this and there was a risk that staff were not aware that a child was on the child protection register. We did not find any interim processes in place to reduce the risk of a child being treated and discharged without staff realising there were any safeguarding issues.

Uncertainty about the future structure of the trust had contributed to difficulties recruiting and retaining staff resulting in staffing pressures on the ward. Developing a strategy for the service had also been problematic without clarity about the organisation’s future. Managers had responded to the uncertainty by developing a five-year business and service strategy.

An executive director provided board level leadership for children’s services.

End of life care

Good

Updated 27 May 2016

The Specialist Palliative Care (SPCT) team provided end of life care and support six days a week, with on call rota covering out-of-hours. There was visible clinical leadership resulting in a well-developed, motivated team.

Patients told us the ward based staff and the palliative care clinical nurse specialists were caring and compassionate and we saw the service was responsive to patients’ needs. The SPCT responded promptly to referrals. There was fast track discharge for patients at the end of life wishing to be at home or their preferred place of death.

Staff throughout the hospital knew how to make referrals to the SPCT and referred people appropriately. The team assessed patients promptly, to meet patient needs. The chaplaincy and bereavement service supported patients’ and families’ emotional and spiritual needs when people were at the end of life.

Most hospital staff were complimentary about the support they received from the SPCT. Junior doctors particularly appreciated their support and advice, and said they could access the SPCT at any time during the day. They recognised that the SPCT worked hard to ensure that end of life care was well embedded in the trust.

The director of nursing had taken the executive lead role for end of life care, along with a non-executive director (NED), to ensure issues and concerns were raised and highlighted at board level. The trust's board received EOLC reports, outlining progress against key priorities within the EOLC strategy, including audit findings, themes from complaints and incidents, evidence of learning and compliance with end of life training requirements.

The SPCT provided a rapid response to referrals, assessed most patients within one working day. Their services included symptom control and support for patients and families, advise on spiritual and religious needs and fast-track discharge for patients wanting to die at home.

The National Care of the Dying Audit 2013/2014 (NCDAH) demonstrated that the trust had not achieved three out of seven organisational key performance indicators. At the time of the inspection, the trust had not fully rolled out the replacement of the LCP, and this delay meant that staff were not fully supported to deliver best practice care to patients who were dying. The leadership failed to apply enough urgency to have an individual plan of care in place.

Outpatients

Good

Updated 27 May 2016

Overall, we found that outpatients and diagnostic imaging were good. The service was rated as good for safety, caring, responsive and well-led. The effective domain was inspected but not rated. Some aspects of the delivery of safe patient care in relation to radiation safety were excellent.

Patients, visitors and staff were kept safe as systems were in place to monitor risk. Staff were encouraged to report incidents and we saw evidence of learning being shared with the staff to improve services. There was a robust process in place to report ionising radiation medical exposure (IR(ME)R) incidents and the correct procedures were followed. The pathology department had a comprehensive quality management system in place with compliance targets set at higher than the national average to improve safety and quality. There was evidence of excellent practice for the monitoring and administering of patient radiation doses to be as low as possible.

The environments we inspected were visibly clean and staff followed infection control procedures. Records were almost always available for clinics and if not, a temporary file was made using available electronic records of the patient. Staff were aware of their responsibilities within adult and children safeguarding practices and good support was available within the hospital.

Nurse staffing levels were appropriate and there were few vacancies. The diagnostic imaging vacancies were higher, particularly ultra sonographers. There was an ongoing recruitment and retention plan in place.

There was evidence of service planning to meet patient need such as the emergency eye service offered Monday to Friday 8.30am to 4.30pm for patients with sight threatening eye conditions, requiring urgent specialist ophthalmic treatment. National waiting times were met for outpatient appointments and access to diagnostic imaging. A higher percentage of patients were seen within two weeks for all cancers than the national average, but the cancer waiting times for people waiting less than 31 days from diagnosis to first definitive treatment and the proportion of people waiting less than 62 days from urgent GP referral to first definitive treatment were both below the national average.

Staff had good access to evidence based protocols and pathways. There was limited audit of patient waiting times for clinics, but patients received good communication and support during their time in the outpatients and diagnostics departments. Staff followed consent procedures and had a good understanding of the Mental Capacity Act 2005.

We observed and were told that the staff were caring and involved patients, their carers and family members in decisions about their care. There was good support for patients with a learning disability or living with dementia.

Staff were aware of the complaints policy and told us how most complaints and concerns were resolved locally.

The outpatients and diagnostic imaging departments had a local strategy plan in place to improve services and the estates facilities. From December 2015, the current outpatient services that are in Clinical Services Directorate will move to a new Outpatients and Medical Records Division. Staff expressed some concern over these changes.

Governance processes were embedded across outpatients and diagnostics. The directorate was commended on its risk register in a recent review of risk registers in the trust. Senior managers told us the newly appointed quality manager had made significant improvements in making sure priorities, challenges and risks were well understood. Good progress was evident for improving services for patients.

We found good evidence of strong, local leadership and a positive culture of support, teamwork and innovation.

Renal

Good

Updated 27 May 2016

Overall, we found renal services were good. Reviews of care through incident investigation and morbidity and mortality were completed throughout the service and opportunities for learning were shared with staff. Infection control practices were robust in all areas. Staffing levels and skill mix were appropriate in all areas across the service with low agency staff usage.

Patient outcomes were in line or exceeded with national standards and effectiveness was regularly assessed and benchmarked. There was effective multidisciplinary working, with specialist nurses and allied health professionals and joint clinics were held with relevant specialties including diabetes. However we noted that standards for vascular access for haemodialysis were not met.

Most patients’ spoke positively of the care they received within the hospital, and individual patient needs were met. Delays in transport were noted as a particular concern by patients’ and their carers.

The environments in the dialysis units were cramped and in some areas, including at St Helier, facilities for patients were limited.

The service was well led with a clear vision and strategy and effective governance and risk management processes. Managers in the service were aware of shortfalls and took steps to address them. Staff spoke positively of the leaders and culture within the service