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Worcestershire Royal Hospital Inadequate

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 Worcestershire Royal Hospital as inadequate, with three of the five key questions we always ask being judged as inadequate.

Our key findings were as follows:

  • Crowding and poor flow were having a significant impact on patient care and experience. The flow of patients in the emergency department (ED) was often blocked by internal capacity issues in the hospital. The trust was consistently not achieving the national target to admit or discharge 95% of patients within four hours of arrival.
  • Due to patient care being carried out in corridors and small cubicles in the ED there was a lack of privacy and dignity for patients in these areas.
  • There were not enough consultants to provide 16 hours of consultant cover within the ED each day, in line with national guidance.
  • 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.
  • Staff did not feel valued or listened to by divisional and executive teams. This led to low morale and frustration amongst staff.
  • Robust and appropriate systems were not in place for carrying out and monitoring venous thromboembolism (VTE) assessments, which contravened National Institute for Health and Care Excellence guidance.
  • 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.
  • 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.
  • Assessments for paediatric patients’ requirement of 1:1 care from a mental health nurse were not always undertaken and care was not consistently provided by a member of staff with appropriate training.
  • Not all equipment had been safety tested and the emergency neonatal trolley in the delivery suite was not always checked daily.
  • Medicines management was poor with medicines that required cool storage being stored in fridges which were either below or above the manufacturers recommended temperature. Emergency medicines were not protected from tampering
  • There was inadequate review and document control of protocols for standard x-ray examinations. Some protocols were in a handwritten format with alterations made by various members of staff without apparent ratification.
  • Patient feedback during our inspection was very positive about the nursing and medical staff that provided their care. Patients were treated with compassion and respect by staff
  • There was a positive culture of incident reporting and incidents were reported appropriately and in-line with trust policy. Staff said they received feedback after reporting an incident. However we found in the ED department some senior staff discouraged the reporting of incidents relating to overcrowding.
  • The critical care team were able to ensure safety across the county wide service by transferring skilled staff to assist with the management of patient care according to need.
  • We observed close working between the specialist palliative care team and ED staff to identify patients at the end of life and provide specialist support. The trust was one of ten that had been chosen to participate in a quality improvement partnership with The National Council for Palliative Care and Macmillan Cancer Support.

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. For example, patients staying overnight in the gynaecology assessment unit.
  • Ensure that patient documentation, including risk assessments, are always completed accurately and routinely to assess the health and safety of patients. This should include elderly patient risk assessments, dementia assessments, venous thromboembolism assessments, sepsis bundle assessments and fluid balance charts.
  • Use a standard risk assessment to assess and identify the needs of patients admitted to wards with mental health needs. This must include details of whether the patient requires 1:1 or 2:1 care from a specialist mental health nurse, and the level of care provided.
  • Ensure nursing documentation on high dependency units is contemporaneous with detailed accounts of the day’s activities completed.
  • Ensure that patient weights are recorded on their drug charts.
  • Ensure that there is clear oversight of the deterioration of patients and the National Early Warning Score chart is completed accurately.
  • Ensure that the Paediatric Early Warning Score charts are consistently completed in a timely manner and accurately.
  • Ensure that patients are escalated as a result of the Paediatric Early Warning Score where they trigger a deteriorating patient.
  • Ensure that the eligibility criteria for the clinical decisions unit is followed to ensure appropriate patients are admitted.
  • Ensure there is access to 24-hour interventional radiology services.
  • Ensure staff are aware of ligature points.
  • Establish identification of female genital mutilation training that is to be completed by all staff working in children and young people’s services.
  • Ensure that patients under child and adolescent mental health services receive care from appropriately trained staff at all times.
  • Ensure that staff providing care for children requiring continuous positive air pressure or AIRvlo have appropriate training or up to date competencies to use this equipment safely.
  • Ensure that there is an appropriate mental health room in the emergency department to care for patients presenting with mental health conditions that complies with national guidance.
  • Ensure that flow in the hospital is maintained to prevent patients being treated in the emergency department corridors for extended periods of time.
  • Ensure that children are not left unattended in the emergency department paediatric area.
  • Ensure that there is a robust system in place to make sure that all electrical equipment has safety checks as recommended by the manufacturer.
  • Ensure that 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 always stored within the recommended temperature ranges to ensure their efficacy or safety.
  • Ensure prompt investigation of any medicines which are unaccounted for.
  • Review arrangements around storage of intravenous fluids for emergency use to ensure patient safety.
  • Ensure that medicines are always administered to patients as prescribed.
  • Ensure infection prevention and control procedures are always carried out as per trust policy and national guidelines.
  • 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 they are carrying out patient harm reviews to mitigate risks to patients who breach the referral to treatment times and cancer waits.
  • Ensure safeguarding checks are made consistently.
  • Ensure information relating to the children at risk register is accessible.
  • Ensure that incidents are accurately reported and investigated.
  • Ensure that staff receive appropriate training to enable the correct categorising of incidents.
  • Ensure that staff are not discouraged from reporting incidents relating to capacity and corridor care.
  • Ensure that incidents that need reporting to external authorities are completed.
  • Ensure there is an embedded risk assessment process to determine the criteria for patient moves to non-medical wards.
  • 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 to mitigate risks to patients who breach the referral to treatment times and cancer waits.
  • 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.
  • Develop a clearly defined business plan for paediatrics, which considers the risks to the service and incorporates a vision and plans for service improvement. The plan must have clear objectives and milestones, supported by actions to ensure objectives are realised.

  • Ensure the risk register identifies and mitigates all risks.

  • Ensure there is a review of the paediatric assessment area and subsequent admissions to identify and resolve potential issues with flow and capacity.

  • Ensure the bed management plans for children and young people, devised to deal with escalation issues for staffing shortages or high bed occupancy, is up to date.

  • Ensure there is a strategy is in place for diagnostic and imaging services that staff are aware of.
  • 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.
  • Ensure there are sufficient registered children’s nurses in post to make certain that the emergency department 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 that only an appropriately trained staff member is left in charge of a ward to care for patients.

In addition, the trust should:

  • Ensure lessons learned from incidents are shared.
  • Ensure all equipment is in date and fit for purpose.
  • Ensure that staff follow the policy on the use of the ‘I am clean stickers’, particularly in the emergency department.
  • Ensure that all needles and cleaning chemicals are kept securely.
  • All departmental policies and procedures, including safeguarding policies, should be reviewed and revised to ensure they are reflective of up to date guidance.
  • Ensure that standard operating procedures are in place and are correctly followed, including care of patients within the clinical decisions unit and care of patients within the emergency department corridor.
  • Ensure staff are familiar with the major incident policy and undertake specific training or complete exercises.
  • Ensure that staff are aware of the escalation policies in the trust and were clear on what steps should or be taken during times of increased demand in the emergency department.
  • Ensure that staff are aware of how to use panic buttons or what response would be received.
  • Ensure that the emergency department door which ambulance patients are bought in by is not used as a shortcut for other staff.
  • Ensure there is evidence of mitigating actions taken at trust wide and divisional level to significantly improve the care and environment in the emergency department to ensure patients are safe.
  • Review the agency induction proforma.
  • Ensure NHS Safety Thermometer data is displayed.
  • Ensure that all medical patients have a nominated medical consultant allocated prior to discharge.
  • Review the staffing levels within diagnostic and imagining ensuring adequate cover for the demands for the service, supervision of staff and suitable radiation protection supervisor cover across all sites.
  • Improve the process of review and document control of protocols for standard x-ray examinations.
  • Develop a clinical audit plan that includes local priorities and audits completed on a timely basis. This should include clinical audits that meet the requirements of Ionising Radiation (Medical Exposure) Regulations 2000.
  • Ensure action plans include sufficient detail to address identified concerns.
  • Share results and action plans from national audits with all levels of staff to improve patient outcomes.
  • The maternity service should conduct audits of the care of women with termination of pregnancies and the completion of their maternal early warning score; Worcestershire Obstetric Warning score.
  • Ensure that all cardiotocograph traces have evidence of fresh eye reviews every two hours.
  • Ensure that patients receive pain relief in a timely way.
  • Ensure that patients are appropriately assessed to have a Deprivation of Liberty Safeguard implemented, where required.
  • Ensure that additional steps are taken to maintain patients’ privacy and dignity when nursed in mixed sex areas and during nursing handovers.
  • Provide a follow up service for patients discharged from critical care with access to consultant and nurses.
  • Review the choices offered to patients about where they are discharged to for continuing care.
  • Reduce the number of cancelled of operations in line with the national average of 6%.
  • Review the high levels of unplanned medical admission onto surgical wards, resulting in some cancelled operations.
  • Put arrangements in place to limit the number of gynaecology patients being nursed on general wards.
  • Review the capacity in emergency theatres.
  • Ensure patients receive care and treatment in a timely way to enable the trust to consistently meet key national performance standards for emergency departments.
  • Ensure delays in ambulance handover times are reduced to meet the national targets.
  • Ensure initial patient treatment times are reduced to meet the national target for 95% of patients attending the emergency department to be admitted, discharged or transferred within four hours.
  • Ensure paediatric patients are directed to the paediatric waiting area in the emergency department.
  • Ensure there are appropriate waiting room and toilet facilities for patients using the gynaecology assessment unit.
  • Ensure there are clear pathways in place to support patients with complex needs, such as a learning disability and patients living with dementia, particularly within the emergency department, gynaecology and maternity.
  • Ensure that staff are aware of how to access full patient information leaflets in an alternate language other than English.
  • Ensure that all complaints are responded to in line with the trust policy.
  • Ensure that health and wellbeing of staff is promoted, including encouragement to take their allocated breaks, particularly in the emergency department.
  • Ensure that staff have an awareness of the trust's strategy.
  • Ensure that senior trust wide leaders have an accurate overview of the care and environment in the emergency department.
  • Ensure there is radiology representation at divisional level.
  • Review the radiation protection governance and infrastructure to ensure compliance with statutory radiation regulations.
  • Consider involving staff in strategic plans and developments within surgical services.
  • Ensure visibility of the executive team.
  • Develop a strategy to monitor the implementation of the gynaecology vision.
  • Undertake a ligature audit in the paediatric department.
  • Improve the process of risk rating and replacement of diagnostic and imaging equipment.
  • Ensure there are consistent mortality review group meetings in order to review the Hospital Standardised Mortality Ratio and Summary Hospital-level Mortality Indicator across the service.

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

Inadequate

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:

  • Although perinatal mortality and morbidity meetings were minuted, there was no evidence that action was taken to address learning from case reviews. We were not assured an effective system was in place to ensure learning from perinatal mortality and morbidity meetings was shared, and actions were taken to improve the safety and quality of patient care.
  • Staff did not consistently follow trust processes for storing medicines at the recommended temperatures, despite there being policies in place.

We also found other areas of concern:

  • There was no system in place to ensure medicines stored in the emergency gynaecology assessment unit were safe for patient use. Immediate action was taken by the trust once we raised this as a concern.
  • Training data showed that 86% of midwifery staff and 53% of medical staff had completed safeguarding children level three training. This was an improvement from our previous inspection. However, compliance was still below the trust target of 90%, particularly with medical staff.
  • The waiting room and toilet facilities for patients attending the emergency gynaecology assessment unit were mixed sex, as these were shared with the respiratory outpatient clinic. Furthermore, this assessment unit did not have appropriate facilities such as bathrooms, to facilitate personal care for patients who had to stay overnight at times of increased bed pressures.

However, we observed improvements for the following:

  • Standards of cleanliness and hygiene were well maintained. Staff adhered to infection control and prevention guidance.
  • Effective systems had been introduced to ensure emergency equipment was checked daily. Equipment was well maintained and had been safety tested to ensure it was fit for purpose.
  • The hospital did not have a dedicated gynaecology inpatient ward. This meant some patients stayed overnight in the outpatient emergency gynaecology assessment unit and were nursed in medical wards. However, the trust had put processes in place to ensure patients were cared for in environments that were suitable for their needs.
  • The number of staff who had completed Mental Capacity Act and Deprivation of Liberty Safeguards training had improved.
  • Daily ward rounds by a gynaecology consultant and nurse were carried out to ensure gynaecology patients were appropriately reviewed and managed, regardless of location within the trust.
  • Staff caring for gynaecology patients on Beech B1 ward had received training on bereavement care, including early pregnancy loss and the management of miscarriage.
  • Risks identified were reviewed regularly with mitigation and assurances in place. Staff were aware of the risks and the trust board had oversight of the main risks within the service.

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 parts of four of the five key questions but did not rate them. We found significant improvements had not been made in these areas:

  • Venous thromboembolism (VTE) assessments were not always carried out for all patients in line with trust and national guidance.
  • We observed that most staff did not generally wash their hands before and after patient contact on the acute stroke unit, Avon 2 ward and the medical assessment unit (MAU) in line with national guidance.
  • Patients declining to take prescribed medication on medical care wards were not always referred to medical staff for a review and were not always reviewed by medical staff.

Areas where improvements had been made were:

  • All 21 records looked at showed NEWS charts were completed fully and patients were escalated for medical review appropriately when required.
  • There had been improvements in the monitoring of medicines’ fridge temperatures.
  • The trust had implemented a new quality dashboard, known as the safety and quality information dashboard (SQuID). This was being used as to drive improvement and had improved staff’s understanding of safety and quality in the service.

Additional areas of concern found on this inspection were:

  • We observed staff handling food on the haematology ward with their hands without the use of gloves, which was not in line with national and trust guidelines.
  • We found that the recording of patients’ weights on drug charts on some medical care wards had not improved.
  • In medical care wards, only 31% of staff were up-to-date on medicines’ management training and this was below the trust target of 90%.
  • We found patient records left unsecured on a number of wards we visited and there was a risk that personal information was available to members of the public. This was raised as a concern during the last inspection in November 2016.
  • Staff compliance with Mental Capacity Act 2005 and Deprivation of Liberty Safeguards training was 45%, which was below the trust target of 90%.
  • Some risk assessment templates were not routinely completed in their entirety, including elderly patient risk assessments and sepsis bundle assessments. We were not assured that inpatient wards were effectively following the trust’s sepsis pathway when required.
  • The medical service leadership team had not addressed all concerns and risks identified as areas for improvement in our last inspection.

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:

  • Staff did not follow good hand hygiene practice at all times.
  • Time critical medications were not always administered to patients who had been assessed as needing them on time.
  • Essential risk assessments were not completed when required to keep patients safe from avoidable harm. There were not effective systems in place to assess and manage risks to patients in the ED.
  • Staff did not always identify and respond appropriately to changing risks to patients, including deteriorating health and wellbeing, including making required safeguarding referrals.
  • There was no appropriate mental health room available within which to safely care for patients.
  • The children’s ED area was not consistently attended by staff except via CCTV surveillance to the nurses/doctors station in the major’s area. Patients and their parents/carers were left alone after assessment and while they waited to see a doctor.
  • There were insufficient numbers of consultants in the ED on duty to meet national guidelines.
  • Staff were not using privacy screens to respect patients’ privacy and dignity whilst being cared for in the ED corridor area. Patients were given meals in their hands by the staff but there was nowhere to rest plates and cups so they could eat their food with dignity.
  • There was no effective plan in place to effectively manage the overcrowding in the ED. The ED’s patient safety matrix showed critical or ‘overwhelmed’ for much of the two days we visited the trust. Patients were being cared for on trollies in the ED corridor had become an institutionalised means of managing the ‘flow’ through the ED, including on occasions when ED cubicles were empty.
  • The number of patients waiting between four and twelve hours to be admitted or discharged was consistently higher than the national average.
  • Adult patients were routinely cared for in the corridor of the department for long periods of time after decision to admit or awaiting therapist assessment for safe discharge. There was no space between the trollies and no screens around them. This happened including during periods when cubicles providing better privacy were vacant within the ED. Routine nursing observations, conversations about care and eating of meals were undertaken in a public space with other patients and relatives passing by.
  • Actions already identified by the trust as necessary to mitigate patient care being compromised from overcrowding in the ED were either yet to be implemented or were not effective in reducing the risk.
  • There was no tangible improvement in performance, caring for patients in the corridors had become institutionalised and we found patient’s privacy, dignity and effective care remained compromised.
  • The trust senior leaders were not effectively addressing these risks through a whole hospital approach.

We also found other areas of concern:

  • There was an inconsistent approach to following both the ED’s child and adult safeguarding processes. Staff training compliance for both adult and children’s safeguarding was significantly worse than the trust target.
  • Pain relief given to children was not evaluated for its effectiveness for all patients.
  • There was no significant change in streaming for self-presenting patients with an operating model based on urgent care GP streaming.

However, we observed improvements for the following:

  • Staff felt supported to report incidents including occasions when they judged patients to be unsafe because the ED was ‘overwhelmed’.
  • An electronic patient safety matrix and ED occupancy tool was in place showing real time data about ED capacity, which gave oversight of the pressures in ED.
  • Most patients were assessed within 15 minutes of arriving by senior nurses.
  • Nurse breaks in the clinical decision unit were now covered by other nurses.
  • Most staff were attentive, discrete as possible and considerate to patients.
  • There was a senior initial assessment nursing system in place for patients arriving by ambulance. Staff told us the flow had improved since two ‘ambulance access’ cubicles were specifically allocated in the department.
  • There was a patient co-ordinator on duty at senior sister level responsible for managing the flow of patients. The ED matron reported two hourly the ED status to a capacity hub meeting that overviewed the situation across the trust throughout the day and night.
  • Health care assistants were undertaking comfort rounds for patients’ cared for in the corridor area of ED, completing documentation and giving patients a leaflet explaining why they were waiting in a corridor.
  • The ED was managed locally by the matron and senior ED consultant. Staff were very committed to their work and doing the best they could for their patients even under regular and consistent heavy pressure.
  • The trust had put in place an electronic safety and capacity matrix that reported data about the ED flow in real time: this enabled the executive team to have a clear line of sight to the risks at any and all times.
  • The trust had implemented a ‘Full Capacity Protocol’ that was activated when the emergency department safety matrix status showed critical or overwhelmed status.

Surgery

Updated 8 August 2017

We carried out this focused I and inspected four 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 (VTE) and 24 hour reassessments were not completed in line with national guidance.
  • Some staff did not clean their hands before or after patient contact and some staff wore personal protective equipment inappropriately.
  • Fridge temperatures for the storage of medicines exceeded recommended ranges in two areas visited
  • Anticoagulation medicines had not always been administered as prescribed.

We also found other areas of concern on this inspection :

  • Some patients were prescribed inappropriate doses of anticoagulation medication without regard to their weight.
  • Some wards did not display their planned staff on duty only their actual staff on duty.
  • Visitors to wards could see patient identification details on electronic white boards.
  • Senior leaders were aware of the trust’s failure to follow national guidance in relation to venous thromboembolism risk assessments (VTE) and hand hygiene. However, we saw examples throughout the service where compliance with trust and national guidance had not significantly improved.
  • When risks had been escalated, there was a lack of follow up and resolution. Effective action following the reporting of high fridge temperatures for storage of medicines was not evident.

However, we observed improvements for the following:

  • All staff we saw in clinical areas had ‘arms bare below elbows’.
  • There were fewer reported staff shortages and shortfalls were escalated and risk assessed so patients’ needs were met.
  • The hospital had implemented a new quality dashboard. The dashboard provided monthly quality data for all wards and clinical areas.

Intensive/critical care

Requires improvement

Updated 20 June 2017

We rated critical care as requiring improvement because:

  • We found that clinical incidents were not always categorised accurately or reported externally. We saw evidence that staff remained confused as to what constituted a near miss incident and reported incidents as a near miss when patients were placed at risk.
  • Outside of critical care, staff felt pressurised and unsupported. Nursing staff felt that patient care was not a priority to the trust.
  • The executive team were not visible across the organisation and staff felt that the lack of a permanent executive team affected progress.
  • Nursing records within the high dependency units were not always contemporaneous, with data entries being completed at the end of clinical shifts and not when events occurred.
  • The clinical environment for the critical care and high dependency units did not meet all the recommendations set out in the Health Building Note 04-02 Critical care units’ standards. This included limited washing and toileting facilities for mobile patients on the critical care and high dependency units.
  • Staff did not always adhere to infection control and prevention practices.
  • Consultants were responsible for the management of children admitted as an emergency until transfer to a children’s specialist hospital was arranged.
  • Patients on the high dependency units who were categorised as level two due to arterial line being in situ were not provided with additional screens or privacy when placed in beds opposite a member of the opposite sex.
  • We saw that venous thromboembolism assessments were not always completed in line with recommendations, with the repeat assessment after 24 hours of admission missing.
  • Mandatory training compliance did not always meet the trust target. High dependency staff had not completed critical care handbooks at the time of inspection, although these were in progress.
  • Medical consultants were not always allocated to the care of patients following discharge from critical care, which affected patient follow up after discharge.
  • There was a limited follow up service for patients discharged from critical care with no provision of a formal medical lead clinic.

However:

  • Critical care staff completed a daily safety brief where they discussed any incidents or complaints and identified learning. Learning was also shared across the service at team meetings.
  • Appropriate staff regularly reviewed patients. Medical teams reviewed patients a minimum of twice daily. The critical care outreach service assisted with the monitoring and treatment planning of sick patients across the trust, providing local support for teaching and monitoring of compliance in trust wide deteriorating patient audits.
  • Critical care were able to ensure safety across the county wide service by transferring skilled staff to assist with the management of patient care according to need.
  • The service had implemented a weekly multidisciplinary team meeting to review patient’s rehabilitation needs.
  • Critical care used evidence based patient pathways, policies and protocols to provide care.
  • Trust data published by the Intensive Care National Audit and Research Centre detailed that the service performed in line with similar sized organisations and as expected.
  • The service provided a seven-day service with access to specialists, such as dietetics and pain specialists, for additional treatments or advice. Specialist were involved with the planning of treatments and participated in multidisciplinary team meetings.
  • The service had a robust training programme for staff that included the use of a competency handbook, local training support from the practice development nurses and scenario based training.
  • Patients and their relatives were treated in a compassionate, respectful manner. Staff provided privacy for relatives and patients. Patients and their relatives were supported during their stay within critical care with staff offering opportunities to discuss care and treatment.
  • There were additional facilities within the critical care unit, which enabled patient’s relatives or loved ones to stay on site. There were also facilities for those requiring additional support for aspects such as learning disabilities, translation services.
  • Staff and relatives used patient diaries to record events. These helped patients understand what had happened whilst they were sedated.
  • There were systems in place to address formal and non-formal complaints. The most relevant persons completed investigations and responses and learning shared amongst the team though open discussion and team meetings.
  • Critical care had a vision of the service, which reflected the trust core values. This included the plans to centralise critical care services and build a high dependency unit.
  • The service had a robust governance structure and cascaded service performance data to the trust board and to staff on the units.
  • Local leaders were reported as being supportive, accessible and approachable.

Services for children & young people

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 (safe, effective, responsive, well-led) but did not rate them. We did not inspect the caring key question. We found significant improvements had not been made in these areas:

  • Whilst perinatal mortality and morbidity meetings were minuted and well attended, which was an improvement since the previous inspection, there was no evidence that action was taken to address learning from patient case reviews.
  • Paediatric mortality and morbidity meetings were not multidisciplinary and only attended by medical staff.
  • Whilst some improvements were observed in completion of Patient Early Warning Scores charts, not all charts had been completed in accordance with trust policy. We also found there was not always evidence of appropriate escalation for medical review when required.
  • One to one care for patients with mental health needs was not consistently provided by a member of staff with appropriate training and reliance was, on occasion, placed on parents or carers.

We also found other areas of concern:

  • Safeguarding children’s level three training was below the trust’s target of 85% and future training sessions had been cancelled. Compliance rates for this essential training were no better or worse in April 2017 in some staff teams compared to November 2016.
  • The department became busy at times and staff said activity had increased since the service reconfiguration. However, there was limited monitoring of assessment and admission to inpatient areas.
  • The risk register had been updated to include two additional risks identified during the November 2016 inspection, but not all risks found on this inspection had been identified, assessed and recorded. For example, the increased activity in the service following the transformation process.
  • There was limited oversight and planning with regards to the increased activity in the service. This meant that service leaders were not in a position to understand current and future performance and to be able to drive improvements for better patient outcomes.

However, we observed improvements for the following:

  • Paediatric mortality and morbidity meetings for paediatrics were now held and minuted.
  • Infection control protocols were followed.
  • There were appropriate arrangements in place for management of medicines, which included their safe storage.
  • All patients admitted to the ward because of an episode of self-harm or attempted suicide had a risk assessment on file.
  • The majority of staff had been competency assessed in medical devices used to help patients breathe more easily.

End of life care

Good

Updated 20 June 2017

We rated end of life care 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.
  • There was good identification of patients at risk of deterioration and identification of patients in the last days of life.
  • The trust had taken action to improve the facilities in the mortuary since a previous inspection. This included replacing fridges, flooring and improving the hot water facilities.
  • There was clear evidence of the trust using national guidance to influence the care of patients at the end of life. A comprehensive programme of end of life care training was available for the full range of staff within 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.
  • People were supported, treated with dignity and respect and told us they felt involved in their care. We observed staff communicating with patients and relatives in a manner than demonstrated compassion, dignity and respect.
  • Patients and relatives told us that the staff were caring, kind and respected their wishes. People we spoke with were complimentary about the staff and told us they felt appropriately supported.
  • The specialist palliative care team responded quickly to referrals and typically 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 and non-cancer referrals.
  • The specialist palliative care team worked proactively with the emergency department to identify patients who may benefit from palliative care input.
  • The trust had begun to record and audit preferred place of care at the end of life and there were clear systems in place to make improvements in this area.
  • The specialist palliative care team had audited complaints that had an end of life care component, identified trends and had taken action to address improvements.
  • 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.
  • There was consistent promotion of the delivery of high quality person centred care and strong leadership for end of life care. Staff were consistently passionate about end of life care, positive about their roles and consistent in their belief that the quality of end of life care was good.
  • Innovations included close working between the specialist palliative care team and emergency department staff to identify patients at the end of life and provide specialist support. The trust was one of ten that had been chosen to participate in a quality improvement partnership with The National Council for Palliative Care and Macmillan Cancer Support.

However:

  • Discussions around DNACPR (do not attempt cardiopulmonary resuscitation) decisions were not always sufficiently recorded within patient’s medical records.
  • Feedback from relatives and staff showed there had been some delays in obtaining death certificates, although we saw that this had been discussed at the meeting of the bereavement group and we were told the lead nurse was taking the lead on addressing this issue.

Outpatients

Inadequate

Updated 20 June 2017

We rated the outpatients and diagnostic imaging services as inadequate because:

  • There was a lack of radiation protection infrastructure.
  • There was inadequate review and document control of protocols for standard x-ray examinations. Some protocols were in a handwritten format with alterations made by various members of staff without apparent ratification.
  • Aging and unsafe equipment across the trust that was being inadequately risk rated with a lack of capital rolling replacement programmes in place.
  • There have been two patient safety incidents in the trust whereby patients had been physically injured by unsafe x-ray equipment.
  • Whilst staff were aware of their roles and responsibilities with regards to reporting patient safety incidents, incident reporting in outpatients was low and where incidents had been reported, the dissemination of lessons learnt was insufficiently robust.
  • The trust was failing to meet a range of benchmarked standards with regards to the time with which patients could expect to access care.

However:

  • Staff were dedicated and caring.
  • Patients were treated with kindness, dignity and respect and were provided the appropriate emotional support.
  • The premises were visibly clean.
  • The process for keeping patients informed when clinics overran was established and well managed.
  • Leadership within the outpatient’s team was visible however, the management of risk was insufficiently robust and further improvements were necessary.