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Inspection Summary


Overall summary & rating

Inadequate

Updated 20 June 2017

Worcestershire Acute Hospitals NHS Trust was established on 1 April 2000 to cover all acute services in Worcestershire, with approximately 885 beds spread across various core services. It provides a wide range of services to a population of around 580,000 people in Worcestershire, as well as caring for patients from surrounding counties and further afield.

Worcestershire Acute Hospital NHS Trust provides services from four sites: Worcestershire Royal Hospital, Alexandra Hospital, Redditch, Kidderminster Hospital and Treatment Centre and surgical services at Evesham Community Hospital, which is run by Worcestershire Health and Care NHS Trust.

The trust was rated overall as inadequate and entered the “special measures” regime based on the initial inspection from 14 to 17 July 2015. Special measures apply to NHS trusts and foundation trusts that have serious failures in quality of care and where there are concerns that existing management cannot make the necessary improvements without support. Kidderminster Hospital was rated as requires improvement overall during this period.

As part of a scheduled re-inspection of the trust, we carried out a further comprehensive inspection of Worcestershire Acute Hospitals NHS Trust from 22 to 25 November 2016, as well as an unannounced inspection from 7 to 15 December 2016.

On 27 January 2017 we issued a section 29A warning notice to the trust requiring significant improvements in the trusts governance arrangements for identifying and mitigating risks to patients.

Overall, we rated Alexandra Hospital as inadequate, with two of the five key questions we always ask being judged as inadequate.

Our key findings were as follows:

  • The flow of patients in the emergency department (ED) was often blocked by internal capacity issues, for example, a lack of available beds in the hospital. This resulted in ED becoming over crowded, and with patients waiting on trolleys in a corridor.
  • In November 2016, only 50% of ambulance patients were handed over to ED staff within 15 minutes. There were not enough nurses to ensure that all patients were assessed within 15 minutes of arrival in the department, or to safely care for patients in the major treatment area and resuscitation room.
  • There were not enough consultants to provide 16 hours of consultant cover within the ED each day, in line with national guidance.
  • There was no privacy and little confidentiality for patients waiting on trolleys in the corridor of the ED. Staff did not always have line of sight of these patients.
  • The department could not ensure that there was always as a senior doctor available who was qualified to resuscitate children. Staff had not been trained to use a new system to help staff recognise when a child’s condition was deteriorating. The system had been introduced two days before our inspection.
  • Staff did not complete venous thromboembolism assessments on patients in line with trust policy and national guidance.
  • Appropriate systems were not always in place for the storage, administration and recording of medicines. Intravenous fluids for emergency use were stored unsecured in resuscitation trolleys on corridors in the ward areas. The trolleys were accessible to staff, patients and relatives which meant there was a risk of medicines being tampered with which could cause harm to patients.
  • Safeguarding children training compliance was low throughout the hospital and not in line with national guidance.
  • Staff were unaware of female genital mutilation and child sexual abuse. There was a risk that staff would not recognise when a child was being abused or exploited.
  • There was a lack of radiation protection infrastructure.
  • Medical notes were not always locked away safely.
  • The Hospital Standardised Mortality Ratio (HSMR) and Summary Hospital-level Mortality Indicator (SHMI) results were worse than expected.
  • There was no policy in place regarding the management of medical outliers. Medical outliers are patients who are admitted to a non-medical ward. Doctors and nurses told us these patients were at greater risk because they were not cared for on a designated medical ward.
  • Not all staff had completed mandatory training or received an annual appraisal.
  • Not all staff cleaned their hands before and after contact with patients and some staff did not change their gloves or aprons after each task. This meant that infection prevention and control practices were not in line with trust policy or national guidance throughout the hospital.
  • There was a high number of medical and nursing vacancies and unfilled shifts.
  • The strategy for countywide management of emergency surgery was not fully implemented and some staff were unaware of the surgical plan.
  • There was a culture of incident reporting and most staff said they received feedback and learning from serious incidents.
  • Feedback from patients and those who were close to them was positive about the way staff treated them. We observed patients being treated with dignity, respect and kindness.
  • Relatives of patients in critical care had access to facilities to enhance their stay on the unit; this included overnight accommodation, refreshments and information leaflets.
  • Patients with a mental health condition who attended the ED were cared for by a responsive and effective psychiatric liaison service and specialist alcohol liaison nurse services were available.

There were areas of poor practice where the trust needs to make improvements:

Action the hospital MUST take to improve

  • Ensure patients privacy, dignity and confidentiality is maintained at all times, particularly during handover.
  • Ensure patients are always assessed and treated in line with the Mental Capacity Act 2005.
  • Ensure that patient documentation, including risk assessments, are completed accurately and routinely to assess the health and safety of patients. This must include pain assessments, venous thromboembolism assessments and fluid balance charts.
  • Ensure that patient weights are recorded on their drug charts.
  • Ensure that there is clear oversight of all deteriorating patients and that the National Early Warning Score chart is completed accurately.
  • Ensure there is an embedded risk assessment process to determine the criteria for patient moves to non-medical wards.
  • Establish a female genital mutilation training programme for all staff working in children and young people’s services.
  • Ensure staff are aware of the Mental Capacity Act 2005.
  • Ensure operating team brief is attended by all required members of staff, as per national guidance.
  • A robust system must be in place to ensure that all electrical equipment has safety checks as recommended by the manufacturer.
  • Ensure that all equipment is checked as per policy, particularly in midwifery services.
  • Ensure that patients are cared for in a safe environment that has the appropriate equipment to facilitate care to a deteriorating patient.
  • Ensure that medicines are stored within the recommended temperature ranges to ensure their efficacy and safety.
  • Review arrangements for the storage of intravenous fluids for emergency use to ensure patient safety.
  • Ensure that medicines are always administered to patients as prescribed.
  • Ensure that there is a system in place in the emergency department to record medicines (including intravenous morphine) administered to patients by ambulance crews.
  • Ensure infection prevention and control procedures are always carried out as per trust policy and national guidelines.
  • Ensure theatres and anaesthetic rooms are compliant with national guidance, Health Technical Memorandum 03-01: Specialised Ventilation for Healthcare Premises.
  • Improve performance against the 18 week referral to treatment time, with the aim of meeting the trust target.
  • Improve performance against the national standard for cancer waiting times. This includes patients with suspected cancer being seen within two weeks and a two-week wait for symptomatic breast patients.
  • Ensure patient harm reviews are carried out on patients who breach the referral to treatment times and cancer waits in order to mitigate any risks.
  • Ensure that incidents are accurately reported and investigated.
  • Ensure all mortality and morbidity meetings are recorded and lessons are learnt.
  • Ensure there are systems and processes established in surgical service to address identified risks, such as cancelled operations, bed capacity and access to emergency theatres.
  • Ensure divisional management teams are aware of patient harm reviews.
  • Ensure divisional management teams have oversight of the patient waiting lists and of initiatives and actions taken to address referral to treatment times and cancer waits.
  • Develop a clear strategy for surgical services which includes a review of arrangements for county wide management of emergency surgery.
  • Ensure children’s and young people’s service carry out clinical audits to identify effectiveness and areas for improvement.
  • Ensure staff are aware of the strategy for diagnostic and imaging services.
  • Ensure patient notes are stored securely and safely.
  • Ensure staff complete the required level of safeguarding training, including safeguarding children.
  • Ensure staff compliance with mandatory training meets the trust target of 90%.
  • Ensure all staff receive an annual appraisal and that there is appropriate supervision for staff.
  • Ensure that there are sufficient registered children’s nurses in post so that the emergency department always has at least one registered children’s nurse on duty per shift in line with national guidelines for safer staffing for children in emergency departments.
  • Ensure only appropriately trained staff members are left in charge of a ward to care for patients.
  • Ensure all patients are clinically assessed by a competent member of staff within fifteen minutes of arrival in the emergency department.

In addition, the trust should:

  • Ensure there are consistent mortality review group meetings in order to review the Hospital Standardised Mortality Ratio (HSMR) and Summary Hospital-level Mortality Indicator (SHMI) across the service.
  • Ensure that clinical audits in the emergency department are reviewed to enable the findings to improve practice. Accurate performance data should be collected and discussed at relevant governance meetings.
  • Ensure robust risk management processes are in place with defined action plans and regular reviews.
  • Ensure governance meetings reflect their terms of reference.
  • Ensure all staff use appropriate personal protective equipment and decontaminate their hands appropriately at all times, especially before and after every patient contact and when moving between clinical areas.
  • Review the arrangements for the storage of intravenous fluids for emergency use.
  • Ensure trust policies are up to date and reflect current national guidance.
  • Develop documents that clearly identify where specific information should be recorded.
  • Ensure record keeping systems are coordinated to enable staff access to all relevant patient information.
  • Ensure there is an effective escalation process when the hospital is approaching full capacity.
  • Ensure there are sufficient consultant emergency medicine doctors to keep patients safe.
  • Ensure all new bank and agency staff receive thorough inductions and ward orientations before starting work.
  • Document and record all meetings where performance in the children’s clinic is discussed.
  • The provision of children’s services should be clarified with external providers to ensure the safe care of children in the emergency department.
  • Ensure all women are asked about domestic violence during their pregnancy in line with national guidance.
  • Share results from national audits and action plans with all levels of staff to improve patient outcomes.
  • The trust should improve its local audit schedule and consider more regular audits in documentation, the environment, equipment, surgical site infections and hand hygiene audits. Audit results should be followed up with improvement action plans where indicated.
  • Ensure staff have knowledge of the key objectives within their service.
  • Ensure all cancelled clinics and outpatient appointments are rescheduled in a timely manner.
  • Review the high levels of unplanned medical admissions onto the surgical wards and implement steps to reduce the number of cancelled operations.
  • Ensure all treatment areas where children and young people are provided with care and treatment, including adult services, are appropriate and child friendly environments.
  • Ensure appropriate waiting areas are available for children and young people when sharing adult services.
  • Take action to address the ‘did not attend’ appointment rate for new children and young people’s services appointments.
  • Ensure patients are discharged from the critical care unit within four hours of the decision to discharge, in order to improve the access and flow of patients within critical care.
  • Investigate complaints within the timescales stated in the trust’s complaints policy.
  • Review the choices offered to patients about where they are discharged to for continuing care.
  • Ensure information from the children’s clinic flows to the board via effective governance processes.
  • Engage and consult with all staff when considering any service reconfiguration and involve staff in the strategic plans to develop the surgical services across the three hospital sites.

Since this inspection in November 2016 CQC has undertaken a further inspection to follow up on the matters set out in the

section

29A Warning Notice mentioned above, where the trust was required to make significant improvement in the quality of the health care provided. I have recommended that the trust remains in special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Inadequate

Updated 20 June 2017

Effective

Requires improvement

Updated 20 June 2017

Caring

Good

Updated 20 June 2017

Responsive

Requires improvement

Updated 20 June 2017

Well-led

Inadequate

Updated 20 June 2017

Checks on specific services

Maternity and gynaecology

Updated 8 August 2017

We carried out a focused inspection to review concerns found during our previous comprehensive inspection on 22 to 25 November 2016. We inspected parts of four of the five key questions but did not rate them. We found significant improvements had not been made in these areas:

  • Despite assurances from the trust, we saw no evidence that obstetrics and gynaecology mortality and morbidity reviews were held. Furthermore, whilst perinatal mortality and morbidity meetings were minuted, we were not assured that action was taken to address any learning identified from case reviews.
  • The trust had monitoring systems in place to ensure medicines were stored within recommended temperature ranges. However, these were not consistently followed across the service.

We also found other areas of concern:

  • Surgical nursing staff, who cared for gynaecology patients on the designated wards, had not received any specific gynaecology training, such as management of surgical miscarriage and bereavement care. However, the gynaecology medical team were available for advice as needed.

However, we found improvements in some areas:

  • All clinical areas we visited were clean and there was good adherence to infection control policies and the use of personal protective equipment.
  • There had been an improvement in compliance with safeguarding children level three training. Staff demonstrated awareness of safeguarding guidance, including female genital mutilation. Staff understood their responsibilities and were confident to raise concerns. However, training compliance was still below the trust target.
  • Equipment was clean, maintained and serviced to ensure it was safe for patient use.
  • Compliance with Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) training had improved. Staff demonstrated awareness of relevant consent and decision making requirements relating to MCA and DoLS, and understood their responsibilities to ensure patients were protected.

Medical care (including older people’s care)

Updated 8 August 2017

We carried out a focused inspection to review concerns found during our previous comprehensive inspection in November 2016. We inspected elements of four of the five key questions but did not rate them. We found significant improvements had not been made in these areas:

  • During this inspection, we still observed that most staff did not generally wash their hands before and after patient contact on ward 12 and the medical assessment unit (MAU).

  • Time critical medicines were not always given when required.
  • Venous thromboembolism (VTE) assessments were not carried out on all patients in line with trust and national guidance. Nine out of 29 patient records reviewed lacked an initial VTE assessment.

We also found other areas of concern:

  • Only twenty-four per cent of staff were up-to-date on medicines’ management training and this was below the trust target of 90%.
  • Patient weights were not routinely recorded on drug charts we looked at.
  • Patients declining to take prescribed medication were not always escalated to or reviewed by medical staff.
  • Doctors prescribed medication but did not always review drug charts to ensure patients were either taking their medication as prescribed or declining to take them. This meant that effective treatment was not provided.
  • Patient’s medical notes were not stored securely as they were left in unlocked trolleys that could be easily accessed by unauthorised individuals. Visitors to wards could see patient identification details on electronic white boards.
  • Staff compliance with Mental Capacity Act 2005 and Deprivation of Liberty Safeguards training was 42%, which was below the trust target of 90%.
  • In response to high capacity demands for medical beds, the hospital had converted a surgical ward to a medical ward: however, nurses said they did not always have the required skills to care for medical patients.
  • The medical service leadership team had not addressed all issues identified as areas for improvement in our last inspection. This meant that there were still potential risks to the safety and quality of care and treatment of patients’ care.

However, we observed improvement for the following:

  • Improvements were noted in completed of NEWS records in the wards visited.
  • Staffing levels in the discharge lounge met patients’ needs.
  • Staff had documented competencies to work in the non-invasive ventilation (NIV) unit. This was identified as an issue during our inspection in November 2016 and had improved during this inspection.
  • The service had taken steps to improve the management of medical patients cared for on non-medical speciality wards with evidence that patients were reviewed regularly by medical doctors.
  • The trust had implemented a new quality dashboard, known as the safety and quality information dashboard. This was used as a drive for improvement and had improved staff’s understanding of safety and quality in the service.

Urgent and emergency services (A&E)

Updated 8 August 2017

We carried out a focused inspection to review concerns found during our previous comprehensive inspection in November 2016. We inspected parts of four of the five key questions but did not rate them. We found significant improvements had not been made in these areas:

  • There was inadequate investigation of, and learning from, serious incidents and inadequate mortality and morbidity reviews in the ED.
  • There was minimal reporting of patient safety incidents relating to patients waiting on trolleys in corridors and when the department was over capacity.
  • There was very little response from the hospital as a whole when the ED safety matrix showed that the department was overwhelmed.
  • This was not sufficient medical cover to provide a consultant presence in the department for 16 hours a day as recommended by the Royal College of Emergency Medicine.
  • The trust had told us that a new full capacity protocol had been developed describing the actions to be taken when the hospital and ED were full. This had not been completed and the trust appeared to take very little action on the many occasions when the ED was full and unable to treat any more patients.
  • There remained long delays for patients at every stage of their assessment and treatment. There had been no improvement in the ability to meet the national standard to admit or discharge 95% of patients within four hours. In February and March 2017, this had been achieved for only 80% of patients which was similar to our previous inspection. We observed six patients who spent between eight and 12 hours in the department.
  • There was very little privacy and confidentiality for patients waiting on trolleys in the corridor.
  • There had been no clinical governance or performance management meetings since our last inspection. High levels of clinical activity in the ED meant there was little time for governance and risk management.
  • There was little understanding of the processes for escalating significant risks to divisional or board level. Doubt remained regarding the degree of oversight of ED risks by senior leaders within the trust.
  • There was significant concern about the lack of effective leadership in the ED and at trust level to tackle the ongoing risks to patient safety.

We also found other areas of concern:

  • There was a lack of advanced training in child safeguarding for doctors and nurses.
  • Safeguarding adults training for doctors and nurses in the ED was inadequate.
  • There was a lack of immediately accessible equipment for the care and treatment for patients being cared for in the corridor area of ED.
  • There was a risk that there would be no appropriately qualified doctors on duty if a child needed resuscitating.
  • Only 78% of patients were assessed by a member of ED staff within 15 minutes of arrival: this had not improved since the last inspection.
  • There were fewer nurses than required for the numbers of patients in the department, particularly at night.

However, we found improvements in some areas:

  • We observed good infection control precautions performed by all staff in clinical areas.
  • There were improved processes for the recording of medication that had been given to patients by ambulance crews.
  • Staff were now confident in the use of paediatric early warning scores.
  • Increased availability of ambulatory emergency care had improved some aspects of patient flow through the department.
  • The lead consultant and matron were highly visible within the department and led clinical activity. The matron had recently implemented new clinical audits.

Surgery

Updated 8 August 2017

We carried out this focused inspection to inspect three of the five key questions but we did not rate them. This was a focused inspection to review concerns found during our previous comprehensive inspection in November 2016 and therefore we did not inspect every aspect of each key question. We found significant improvements had not been made in these areas:

  • Venous thromboembolism risk assessments were not completed in line with national guidance.
  • Medications were not administered as prescribed.
  • Medications were stored in temperatures above manufactures recommended guidelines.
  • Some staff were not compliant with infection control precautions including hand hygiene and appropriate use of personal protective equipment.

We also found other areas of concern:

  • Patient details were visible to all staff and visitors on the ward.
  • All wards displayed the actual number of staff on duty. However, some surgical wards did not display the planned number of staff and therefore patients and visitors could not identify any staff shortages.
  • Less than 20% of nursing and medical staff had received training in Mental Capacity Act 2005 and Deprivation of Liberty.
  • Senior leaders were aware of the trust’s failure to follow national guidance in relation to venous thromboembolism risk assessments and compliance with hand hygiene. However, we saw examples throughout surgery where national guidance had not been followed.
  • When risks had been escalated, there was a lack of follow up and resolution. For example, medications were stored in fridges at higher temperatures than recommended by medicine manufactures and clinical staff had escalated this to managers. However, clinical staff were unable to identify any action taken to reduce the risks of patients receiving medication stored in these fridges.

However, we found improvements in some areas:

  • All staff had ‘arms bare below the elbows’ in clinical areas.
  • Adequate staffing levels were observed on all wards during our inspection. Staff explained their new staffing application (an electronic tool which measured how many staff were on duty against how many should have been on duty), which helped escalate any shortages rapidly.
  • We saw fewer medical outliers on most surgical wards. However, one surgical ward had nine medical outliers at the time of our inspection.
  • Patients undergoing surgery had the correct consent form.
  • Patients who lacked capacity had evidence of a mental capacity assessment.
  • The trust had implemented a new quality dashboard. The dashboard provided monthly quality data for all wards and clinical areas.

Intensive/critical care

Good

Updated 20 June 2017

We rated critical care as good because:

  • There was a positive safety culture. Staff recorded incidents, investigations were completed and staff received feedback. The service had a robust safety briefing in place, which was attended by all staff.
  • Staff maintained and monitored patient safety through local audits which included infection control, patient harms and risks. Action plans were developed to address any issues.
  • Patient records were contemporaneous, legible and stored safely. Evidence based assessment tools were used to monitor risk.
  • Mandatory training was generally in line with trust targets.
  • Medications were stored, prescribed and administered safely. There were systems in place to monitor safe storage and staff took appropriate actions in line with local protocol to address any concerns or anomalies.
  • The service used evidence-based guidelines, policies and protocols to monitor patient outcomes. Results were used to compile service dashboards, which were used to present audit results and monitor trends. Clinical leads reviewed these for compliance and trends and discussed results as part of the divisional and trust wide service meetings.
  • The service had a flexible approach to delivering patient care across both critical care units (Alexandra Hospital and Worcestershire Royal Hospital) to maintain patient safety.
  • Patient outcomes were used to benchmark the service against similar organisations to identify areas for improvement.
  • The service had access to additional specialists such as a pain specialist nurse, dietetics, microbiologists and pharmacy.
  • Staff competence was monitored and maintained through annual appraisal and competency reviews. External training was available for staff.
  • There was evidence that the multidisciplinary team was inclusive and well organised.
  • Patients were treated with dignity and respect, and in line with their individual beliefs and were involved with the care and treatment planning. Patients spoke positively about the care they received.
  • Relatives had access to facilities to enhance their stay on the unit, this included overnight accommodation, refreshments and information leaflets.
  • Patients were assessed appropriately for admission to critical care and received a full review by a consultant within 12 hours of admission to the unit.
  • There were no formal complaints regarding the service.
  • The service was well-led with strong local leadership, a service vision and robust governance systems in place.
  • All staff were positive about their roles, enjoyed working for the service and were dedicated to improving the standards of patient care.

However:

  • There were a small number of delayed discharges from critical care, which affected patient flow and experience.

Services for children & young people

Requires improvement

Updated 20 June 2017

We rated services for children and young people as requiring improvement because:

  • Staff were not aware of any guidance to support them in identifying what incidents should be reported. This created a risk that some incidents might not be recorded and therefore any learning from these would be missed.
  • Incidents were not always graded. In addition, learning from incidents was not identified. This meant there was a risk in the service that staff would not learn from incidents.
  • Recording templates for patient information were not always clear and did not contain columns on documents that clearly identified where height and weight should be recorded. This meant they were difficult to read and information could be lost.
  • Staff were unaware of female genital mutilation (FGM) and child sexual abuse (CSE). There was a risk that staff would not recognise when a child was being abused or exploited.
  • Level 3 safeguarding children’s training was not always face to face and was not updated annually; this was not compliant with the guidance on safeguarding training.
  • There were some policies relating to safeguarding children that were not available on the trust intranet. This included the ‘no allegations’ policy, and the ‘managing celebrity visits’ policy. The ‘safeguarding supervision’ policy also stated that it was in development on the intranet safeguarding pages.
  • There was no clinical audit plan for the children’s clinic. There was little evidence that continual improvement of the service and compliance with best practice was identified or actions taken to address any shortfalls.
  • The women and children’s division had introduced a performance dashboard to monitor patient outcomes. There was little evidence that performance in the children’s clinic was discussed.
  • There was no formal clinical supervision for nursing staff. Supervision was provided by the outpatient’s manager over the telephone. However, the manager also worked in WRH as an advanced nurse practitioner and could only offer staff telephone support when there were quiet periods at WRH.
  • Multidisciplinary working between all the trust’s hospital sites was not effective at all times.
  • The ‘did not attend’ appointment rate for new children and young people’s services appointments was regularly above the trust’s target of 7%.
  • From September 2015 to August 2016 there had been three complaints about children’s services at Alexandra Hospital. The hospital took an average of 31 days to investigate and close complaints. This was more than their complaints policy, which requires complaints to be closed within 25 days.
  • As a result of the emergency service reconfiguration, the children’s service did not have a clear vision and did not have a long-term strategy for children’s services. Staff were unaware of the vision and values in the children’s outpatient service as these had not been defined.
  • The governance framework was not effective. There was no evidence that information flowed between the directorate and divisional governance or quality meetings.
  • Monthly divisional governance meetings were not consistently adhering to their terms of reference. This included, not focusing on themes and trends from incidents and safeguarding training performance. Compliance to level 3 safeguarding training was not recorded separately and therefore the service was unaware which staff had completed level 3 safeguarding training.
  • The divisional risk register, focused on the number of risks recorded, rather than how they were being managed. The hospital had recently closed to paediatric inpatients and there had been little discussion around how the transitional period was managed.
  • The outpatients manager had not been allocated any contracted hours for service leadership, which they had to fit around their other role at WRH. This meant it was unlikely that staff would receive timely supervision and advice.
  • Some staff did not feel fully consulted about the service reconfiguration.

However:

  • The environment in the children’s clinic was visibly clean and staff followed correct cleaning protocols.
  • Overall, care records were generally written and managed well.
  • Staff had achieved the trust’s mandatory training target of 90%.
  • There was no paediatric resuscitation ‘bleep’ in use at Alexandra Hospital. However, there were clear protocols describing how children should be transferred to WRH if they needed to be treated by a specialist paediatric doctor.
  • Medical and nursing staffing levels were planned and reviewed in advance based on an agreed number of staff per shift.
  • The trust had a major incident plan in place although some staff were unaware of the business continuity plan to deal with adverse weather.
  • Staff who worked in the children’s clinic took time to interact with patients and their parents in a manner which was respectful and supportive.
  • The patients and parents we spoke with told us that staff were kind and caring and that they felt well looked after.
  • Feedback from the CQC’s children and young people’s survey 2014 was largely similar to other trusts including privacy, care and treatment and staff friendliness.
  • Staff communicated with children and young people and their families in a way that they could understand.
  • Children and young people and their families said they could be involved in their own care and treatment if they wished.
  • There was a range of patient information available in the children’s clinic.
  • Staff understood the impact that a patient’s care, treatment and condition had on them and those close to them.
  • Services in the children’s clinic took into account the needs of different children and young people. Consideration had been given their age, gender and any disability.
  • Transition arrangements were in place for patients approaching adulthood to ensure children and young people had access to the appropriate support.
  • The trust regularly met its 95% target for referral to treatment time for non-admitted children and young people and most received an appointment within 18 weeks.
  • Managers told us service reconfiguration was made with the objective of making improvements for patients and staff. However, at the time of our visit it was too early in the reconfiguration process to measure whether this would result in sustainable improvements to children and young people’s care.

End of life care

Good

Updated 20 June 2017

We rated the end of life care service as good because:

  • Staff understood their responsibilities to raise concerns and to record safety incidents. Incidents relating to end of life care were reviewed by the lead nurse for specialist palliative care. DNACPR (do not attempt cardiopulmonary resuscitation) records were generally completed well and the trust were making use of audits and learning from incidents to drive improvements.
  • There was good identification of patients at risk of deterioration and those in the last days of life. There was clear evidence of the trust using national guidance to influence the care of patients at the end of life. There was consistent promotion of the delivery of high quality person centred care. Several audits had been undertaken to evaluate the service with associated action plans to address improvements identified.
  • A comprehensive programme of end of life care training was available for the full range of staff within the trust. However, we were not able to establish compliance with mandatory training (including safeguarding adults training) for specialist palliative care staff, including their annual appraisals rates. Evidence for this was requested but not provided by the trust.
  • There was good evidence of multidisciplinary working and involvement of the specialist palliative care team throughout the hospital including allied healthcare professionals as well as medical and nursing members. The specialist palliative care team provided a seven day face to face assessment service across the trust.
  • The trust had taken action to improve the service since the previous inspection. This included the replacement of fridges, flooring and improving the hot water facilities within the mortuary. Issues relating to obtaining syringe drivers had been addressed and appropriate anticipatory prescribing was used at the end of life.
  • There was clear evidence of the trust using national guidance to influence the care of patients at the end of life. The trust had begun to record and audit preferred place of care and there were clear systems in place to make improvements in this area.
  • The specialist palliative care team responded quickly to referrals and would see patients within a few hours if the need was urgent. The majority (92%) of patients were seen within 24 hours and there was a good balance between cancer patient and non-cancer patient referrals.
  • Patients and relatives told us that the staff were caring, kind and respected their wishes. We observed staff communicating with patients and relatives in a manner than demonstrated compassion, dignity and respect.
  • There was a clear vision for the service and a draft strategy was in place, highlighting the key areas the trust were focusing on in relation to end of life care.

Outpatients

Inadequate

Updated 20 June 2017

We rated outpatients and diagnostic imaging as inadequate because:

  • There were long waiting lists for the majority of specialities and the trust had not met all cancer targets for referral to treatment times. The trust was failing to meet a range of benchmarked standards with regards to the time with which patients could expect to access care.
  • Mandatory and safeguarding training levels did not always meet the trust’s target and not all staff had received an annual personal development review.
  • Incidents were not always categorised appropriately in terms of the level of harm caused. Incidents were not always reviewed in a timely manner and we were not assured that learning from incidents was cascaded to all staff.
  • Complaints were not always responded to in a timely manner.
  • There was a lack of radiation protection infrastructure.
  • Old and unsafe equipment across the trust was inadequately risk rated and there was a lack of capital set aside to fund replacement items.
  • There had been two patient safety incidents in the trust involving unsafe x-ray equipment and which had resulted in patient injury.
  • We were not assured the service had a robust, realistic strategy for achieving its priorities and delivering good quality care.
  • Governance arrangements and the management of risk was insufficiently robust and further improvements were needed.

However:

  • Patient records were stored securely and effective systems were in place to ensure clinicians had access to appropriate and up-to-date patient information.
  • Patients were treated with kindness, dignity and respect and spoke positively about the care they had received.
  • Care and treatment was delivered in line with national guidance.
  • Some departments had developed services, such as one-stop clinics, in order to better meet the needs of patients and improve service provision.
  • There was effective multidisciplinary working across the outpatient and diagnostic imaging service.
  • Local leadership was strong, supportive and approachable. However, staff did not feel directorate and divisional leads were visible.
  • Staff were proud to work at the hospital and were passionate about the care they provided.