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Inspection Summary


Overall summary & rating

Good

Updated 8 March 2016

Nottingham University Hospitals NHS Trust is the fourth largest acute trust in England and provides services to more than 2.5 million residents of Nottingham and its surrounding communities. It also provides specialist services to between three and four million people from neighbouring counties. The trust is based in the heart of Nottingham on three separate sites around the city: Queen’s Medical Centre, Nottingham City Hospital and Ropewalk House. Queen’s Medical Centre is the emergency care site, where the emergency department, major trauma centre and the Nottingham Children’s Hospital are located.

Nottingham University Hospital NHS Trust were inspected as one of 18 CQC new wave pilot inspections in November 2013 but the trust was not rated at this inspection. The purpose of this comprehensive inspection was to award a rating to the trust for the services it provided. We carried out an announced inspection to the three hospital locations between 15 and 18 September 2015. Unannounced visits were carried out on 28 September to medical wards and Haywood House.

Overall Nottingham City Hospital was rated as good with some aspects of outstanding. End of Life services however, required improvement.

Our key findings were as follows:

  • Overall patients we spoke with expressed a high level of satisfaction with the care and treatment provided to them. Pain relief was given to patients in a timely manner. Staff treated patients with kindness, dignity and respect.

  • There was good incident reporting culture in the trust and systems were in place to report incidents and largely there was effective learning from incidents. The exception to this was a backlog of radiology and maternity incidents where a lack of timely review may affect the ability to quickly implement any learning.

  • Cleaning services were contracted out to a private provider. There had been some concerns about the standard of cleanliness and this was reflected in some ward audits. On-going monitoring and performance management of the cleaning services, delivered by the private provider was planned. During the inspection the wards appeared visibly clean.

  • Hand cleansing facilities were available in all areas and mostly good practices were seen. However, we saw that some staff on Hogarth Ward did not always wash or cleanse their hands when going in and out of ward or bay areas. There were 31 cases of Clostridium Difficile (C. Diff) infections at the hospital between May 2014 and April 2015. C. Diff is an infection which causes diarrhoea. There were no cases of Methicillin Resistant Staphylococcus Aureus (MRSA) bacteraemia at the hospital in the same time period. MRSA is an infection that is sometimes very difficult to treat.

  • The systems for ensuring equipment was safe and fit for use was not robust. We found that some equipment was not checked or serviced as frequently as it should be.

  • In most areas staffing levels were sufficient and there were escalation systems in place to identify and address shortfalls in staffing levels. At Haywood House we found that some shifts had been short of staff which had affected the care patients received.

  • For end of life services we found that there was strong leadership for specialist palliative care services but this was not extended to end of life care provided on other wards.

  • There was an open culture throughout the trust and staff were generally positive and proud to work there. Across different disciplines staff worked well together. The trust board members were visible and positively regarded by staff.

  • The trust introduced shared governance in 2012. Shared governance gave staff the opportunity to create councils for each ward or department and any level of staff could join the council. It was a ‘bottom up’ model of management which aimed to empower frontline staff to make decisions about patient care at the point of care delivery.

We saw several areas of outstanding practice including:

Medical care (including older people’s care)

  • We saw examples of innovative practice in order to reduce risks to patients. On Southwell Ward we saw patients wore a coloured wrist band when they required oxygen to ensure they received the correct rate. This ensured staff could easily identify the patient’s required rate and dangerous levels of oxygen would not be administered.

  • Patients receiving oxygen through a nasal cannula were at risk of developing pressure ulcers where plastic tubing went over the tops of their ears. Sponge covers were placed over the tubing to prevent this from happening. (A nasal cannula is a lightweight tube which splits into two prongs placed in the nostrils and from which a mixture of air and oxygen flows).

Surgery

  • Theatres benchmarked activities against their own standards and compared their practices with external organisations. For example, they had compared some of their processes with neighbouring hospitals and as a result asked a trained band six nurse to do a specific eye procedure instead of a consultant.

Critical Care

  • A critical care consultant at the trust was developing a tool to support the complex decision making process for critically ill patients. The tool was based on an ethical and balanced approach to selecting a suitable treatment plan for patients and act as a base for further clinical decisions. The tool would then be used as a tracking system so that clinicians understood previous treatment choices and clinical outcomes. This was supported by colleagues and was considered to be an innovative development in tracking the decision making process in treating critical care patients.

  • The use of the trust’s simulation centre had helped staff in developing advanced communication skills.

  • Innovative approaches were used to gather feedback from people who used the service. One example was that patients and carers were invited to the opening of a new bed area to get their views on patient privacy.

End of life services

  • A project was set up and led by a ward sister at Hayward House following a high rate of incidents related to falls. An independent falls expert was invited to look at the environment and the day to day culture of nursing practice on the ward at Hayward House. This review found a lack of focus on patients who were at high risk of falling. Steps were taken following the review to reduce the risk of falls on the ward. Two cohort bays were set up. [A cohort bay is for patients at high risk of falling to be cared for together in the same area so their needs are managed more efficiently and safely]. A cohort nurse was allocated to the cohort bay. The cohort nurse wore a brightly coloured tabard to reduce the risk of interruptions and diversions. Changes to the ward environment included a colour theme to make it easier for patients to find their way around and equipment clutter removed from corridors. A six month review in June 2015 showed these changes had led to a 43% reduction in total falls, a 38% reduction in unwitnessed falls and a 67% reduction in repeated falls.

Maternity and gynaecology services

  • A member of staff designed an electronic application specifically for women using the trust’s services called the ’Pocket Midwife’. It was free to download and anyone could access it. It had information about each stage of pregnancy, and all of the maternity leaflets and maternity guidelines could be accessed easily. The service could add news flash information to the application for women to see, such as sending a reminder to women about flu vaccinations.

Outpatients and diagnostic imaging

  • The chemotherapy department demonstrated numerous examples of improvement and development. The service had developed projects to help the service run quicker and smoother for staff and patients. For example, the service had developed a purple bags initiative. This allowed patients to access treatment quicker after having their blood tested and authorised. Another initiative improved the flow of patients through the clinic by introducing a system for staff to quickly and easily see when a chair was available for patients to start their treatment.

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

Importantly, the trust must:

  • The trust must ensure consultant cover in the maternity service for the labour suite meets national recommendations and guidance.
  • The trust must ensure that there are sufficient numbers of suitably qualified, competent, skilled and experienced nurses working in the critical care service. The Core Standards for Intensive Care Units minimum requirement is for 50% of nurses in intensive care units to have a post-registration award in critical care nursing. There were 26% of nurses with this qualification at the time of our inspection.

  • Ensure that trained nurse presence on the neonatal unit meets the ‘British Association of Perinatal Medicine Guidelines (2011).’(BAPM).

  • Ensure that there is sufficient neonatal consultant cover during the out of hour’s period so that both hospital sites can access their own individual on call consultant. This is in line with the BAPM standards (3rd edition – section 5.1.4).

  • The trust must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced staff deployed to meet the needs of patients on the inpatient ward at Hayward House.

In addition the trust should:

  • The trust should ensure patients’ fluid and food charts are completed accurately
  • The trust should ensure oxygen is prescribed in line with the trust’s policy for patients who require it.
  • The trust should ensure immunosuppressed patients are not nursed in the same area as those with infections.
  • The trust should consider the installation of air conditioning in the Wolfson Cystic Fibrosis Unit to reduce distress for patients in warm weather.
  • The trust should ensure clinical waste bins awaiting collection are secure.
  • The trust must ensure City Hospital is secure at night time.
  • The trust should ensure all equipment, including electrical, has been appropriately serviced and received portable appliance testing when necessary.
  • The trust should ensure fire alarm break glass points have the necessary equipment so they can be activated.
  • The trust should ensure the proper and safe management of medicines by staff following the correct procedures for checking and administering medication to patients.
  • The trust should ensure assistance given to patients with oral hygiene is documented correctly and consistently by staff.
  • The trust should ensure staff have feedback on the auditing of fluid charts.
  • The trust should ensure adequate training is available for all staff using the inpatient adult risk assessment booklet NUH01873S in relation to pages 13, 14 and 15.
  • The trust should ensure all complaints and the outcome of the investigations are shared with the area concerned and the wider directorates.
  • The trust should ensure, as good practice, that prescription charts have the name of the prescriber written in capital letters with their contact number for identification purposes.
  • In the trust’s Family Health division 67% of staff had not completed training in the safe use of medical equipment. The trust should ensure staff are trained and competent to use equipment safely.
  • The trust should ensure that workforce requirements in the maternity service are analysed in terms of what women using the service need, rather than what midwives do.
  • The trust should ensure up to date guidance is available for staff in the maternity service regarding criteria for admission to the midwifery led unit.
  • The trust should ensure a home from home philosophy and environment for women giving birth in the midwifery led unit.
  • The trust should ensure there are operating theatre facilities and time dedicated for planned caesarean section operations.
  • The trust should ensure maternity service actively recruit user representatives.
  • The trust should ensure all senior and specialist staff in maternity services are visible on the wards and participate with clinical activities.
  • The trust should ensure women and their families using the maternity service have clear and accessible information about how to make a complaint.
  • The trust should ensure the maternity service meets the national neonatal audit programme standards for temperature taken at birth, and mothers receiving steroid medication in the antenatal period.
  • The trust should ensure confidentiality of information about women using the maternity service. Women’s names and details of their treatment should not be displayed where they may be seen by visitors.
  • The trust should ensure that all staff receive feedback about incidents.
  • The trust should ensure that nursing assessments are fully completed and babies care plans are reviewed regularly.
  • The trust should ensure that a complete record is kept for each baby, which includes appropriate information and documents the care and treatment provided.
  • The trust should ensure that each staff member has an annual appraisal.
  • The trust should ensure that each staff member attends mandatory training.
  • The trust should ensure that medical cover in the critical care service meets the Core Standards for Intensive Care Units recommendations at all times.
  • The trust should ensure all ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) forms are completed in line with the trust’s DNACPR policy.
  • The trust should have an end of life care strategy to ensure patients receive end of life care in line with national guidance and research based good practice.
  • The trust should increase the number of consultants in the specialist palliative care team to reflect the recommendations of the Association for Palliative Medicine of Great Britain and Ireland and the National Council of Palliative Care.
  • The trust should increase the specialist palliative care nursing team to ensure patients can access specialist palliative care services and receive a face-to-face consultation seven days a week, in line with National Institute for Health and Care Excellence (NICE) Quality Standard number 10 published in 2011 for end of life care for adults.
  • The trust should ensure end of life care champions are allocated protected time each week for carrying out their role.
  • The trust should consider updating their end of life care bundle to ensure staff record patients’ preference for involvement of the pastoral care team.
  • The trust should provide a structured programme of end of life care training for all staff to ensure patients receive appropriate care at the end of their life.
  • The trust should ensure effective monitoring of ‘fast-track’ discharges and compliance with patients’ wishes regarding preferred place of care and preferred place of death. Good practice in these areas should be shared across the trust and appropriate action taken to address any issues.
  • The trust should provide a structured programme of end of life care training for all staff to ensure patients receive appropriate care at the end of their life.
  • The trust should ensure the system for maintaining and testing clinical equipment is timely, effective and consistent to ensure it is safe to use.
  • The trust should ensure risk assessments are carried out where environmental issues may have an impact on outpatient services.
  • The trust should ensure there is a sufficient and effective portering service for patients attending outpatient clinics from the wards and when required to transport deceased patients to the mortuary.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 8 March 2016

Effective

Good

Updated 8 March 2016

Caring

Good

Updated 8 March 2016

Responsive

Good

Updated 8 March 2016

Well-led

Good

Updated 8 March 2016

Checks on specific services

Maternity and gynaecology

Good

Updated 8 March 2016

Overall we rated the service as good but safety required improvement.

There were established local and divisional risk and governance arrangements. Staff felt the service had a profile on the trust board agenda. There were processes in place to share lessons learnt from incidents and investigations.

The trust promoted breastfeeding and women were supported in their chosen method of feeding. Women were positive about the care they had received. We observed staff interacting with women and their partners in a respectful compassionate way. Women and their partners felt involved with their care and were happy with explanations given to them. Partners would have liked to have the choice to stay to support women throughout the night.

There was an effective multidisciplinary approach to care and treatment, which involved a range of staff in order to enable services to respond to the needs of women. All staff told us that the working relationships between the professional groups were excellent.

Staff wanted to continue to develop the service and demonstrated this through implementing new ideas.

Women using the maternity service received care based on the maternity service’s guidelines and national guidance. The guideline for admission of a woman to the midwifery led care unit was removed to review the admission criteria for low risk women and so there was no up to date guidance for staff to follow.

There were some displays of information for people using the service about how to make a complaint if they were dissatisfied. The majority of women and their families we spoke with did not know how to make a complaint.

The medical staffing was not in line with national guidance. The midwifery and medical vacancy rate was being acted upon but there were difficulties in recruiting staff, which meant they were unable to meet the national standards for safe staffing.

It was difficult to identify if women were high or low risk, and not all risk assessments were fully completed. Records were legible, dated and signed. However, the woman’s name and hospital, or NHS number, were not documented on each page in the majority of hand held records. This posed a risk of detached pages not being returned to the correct records.

The unit did not use Neonatal Early Warning scoring charts to assist in the early recognition of deterioration of new-born babies.

Medical care (including older people’s care)

Good

Updated 8 March 2016

Overall, we rated the medical care service at City Hospital as good, although the safety of those services required improvement.

There were sufficient numbers of staff to meet patients’ needs although recruitment was on-going to fill vacant posts and agency staff were used when required. Staff were encouraged to report incidents and serious incidents were thoroughly investigated. Although staff mostly demonstrated a good understanding of infection prevention and control, patients were sometimes put at risk of infection because routine hand hygiene was not always adhered to, and clinical waste was not stored securely prior to collection.

Medicines were stored and administered safely. Records were stored securely, though were not always completed in a timely manner. A hospital at night and critical care outreach teams were available to support staff during night hours if patients deteriorated. Staff were aware of safeguarding adult procedures and systems were in place to minimise the harm to patients at risk of falls. The correct equipment was not always available for staff to use, and servicing of equipment was not always undertaken on time. There was a lack of security of the hospital at night time.

Care pathways were in place for patients in line with the National Institute of Health and Care Excellence (NICE) guidance. Pain relief was given in a timely manner and patients were supported to receive adequate food and hydration. Staff worked across disciplines to provide joined up care to patients. Staff were competent in their role and understood the importance of gaining consent prior to treatment being given. The pharmacy department was not open after 1pm at weekends, which meant some patients’ discharges were delayed. However access to medicines was available from Queen’s Medical Centre.

Generally we found patients were cared for by compassionate staff who showed them dignity and respect, although behaviour of some staff was variable. Patients told us staff gave them privacy when it was needed and were kind; they also involved them in decisions about their care. Members of the hospital team were available to give patients emotional support when this was necessary.

Medical services in the City Hospital were reviewed and where necessary altered to reflect the demand and needs of patients. Processes were in place to ensure access to medical services and discharge for patients was appropriate, although some discharges for older people could be delayed. Hourly documented checks were in place to ensure staff could respond to patients’ individual needs. We could not be assured that learning from complaints was shared with all staff.

There was an effective governance framework in place to support the delivery of quality care with annual plans in place for each medical specialty. Wards had the ability to set up their own councils and directly influence decision-making as close to patients as possible. Senior staff were visible and staff felt supported.

Neonatal services

Good

Updated 8 March 2016

Overall, neonatal services at City Hospital were rated as good. We found services for babies to be effective, caring, responsive and well led. However, improvements were needed for the service to be safe so that babies were protected from avoidable harm.

The Family Health Directorate recognised nurse staffing did not fully meet the 2011 British Association of Perinatal Medicine Guidelines (BAPM). This was because the ratio of one nurse to one baby in the neonatal intensive care unit was not achieved. Staffing issues had resulted in cot closures, which we were told by staff had taken place on average four to five times a month to maintain safety within the service.

The children’s service workforce review document identified 25 vacancies within the neonatal service. Additional neonatal nursing staff had been and continued to be recruited following the receipt of this additional funding. However, due to staffing issues we were told that cot closures had taken place on average four to five times a month to maintain safety within the service.

There was a recognised shortfall in neonatal consultant cover during the out of hours period. Current practice meant the neonatal consultant staff covered both Queens Medical Centre and City Hospital neonatal units. This practice did not meet the BAPM standards. To mitigate the risk the service had recruited three additional consultants to help provide consultant level out of hours cover at both sites and medical cover for the transport service.

A lack of specialist radiology cover out of hours, meant babies were transferred to another hospital to receive this service.

Arrangements were in place to minimise risks to babies receiving care, and there was effective monitoring of quality and outcomes. Babies received evidenced based care and there was good multi-disciplinary working between children’s services, external providers and the mental health team.

Staff were caring, compassionate and respectful. Staff were positive about working in the service and there was a culture of openness, flexibility and commitment.

The neonatal service supports other neonatal units through its regional retrieval service and had good support from other NHS trusts when babies needed more specialist care and treatment.

Neonatal services were responsive and had mostly met babies and their parent’s needs. However, due to staffing issues we were told that cot closures had taken place on average four to five times a month to maintain safety within the service. Currently 18 cots are open to admissions on the neonatal unit.

Transitional care within the neonatal service was nurse led and had prepared and supported babies and their families for discharge home.

Clinical strategies and priorities were in place, against which were action plans with identified start and finish dates. The objectives were representative of the concerns identified in the service risk register.

A clear leadership structure was in place for the service. Staff said they were well supported by their clinical matron who they saw daily.

Governance processes and known clinical risks were monitored. Public and staff engagement processes captured feedback from both groups.

Following the findings from the ‘Trent Perinatal Network Review’ on 3 November 2014, improvements had resulted in improved consultant and nurse staffing levels but recruitment was ongoing.

Surgery

Good

Updated 8 March 2016

Overall we rated surgical services as good, with outstanding leadership.

Surgery services at City Hospital had systems to protect patients from harm and abuse. They managed and responded to risk effectively. The specialities and theatres had reliable processes to analyse learning from mistakes. Patient areas were visibly clean. There were robust arrangements for monitoring safety and cleanliness.

Staff were conscientious about mandatory training and ward managers had good local induction processes. Although there were wards with staff vacancies, ward managers ensured that patients were safely cared for. However, some equipment checks were not up to date, and some staff were unclear about their role in a major emergency.

The services were effective because they planned and delivered patient care and treatment in line with current evidence based guidance, standards, best practice and legislation. Managers and senior clinicians monitored this through audits and at governance meetings. Patients had comprehensive assessments of their needs. There was good multidisciplinary teamwork.

Staff were supported to deliver effective care and treatment including through meaningful and timely supervision and appraisals. Staff understood and documented arrangements for consent and understood how to apply the Mental Capacity Act.

Nurses, doctors and care assistants treated patients with dignity, respect and kindness during all interactions with staff. Patients felt supported. They were involved and encouraged to be partners in their care and in making decisions. Consultants and nurses spent time talking to patients, or those close to them. Patients received information in a way that they could understand. Staff found innovative patient orientated solutions to everyday problems.

The hospital had a new, modern admissions suite for planned surgery, did outreach work with the community and provided enough capacity to meet demand for operations. Services worked well to meet the needs of individual patients, such as people living with dementia.

However, some facilities such as the old theatres waiting area were less patient friendly.

Surgery services had a clear vision which was translated into measurable achievements by speciality action plans.

The leadership, management and governance of surgery services assured the delivery of high quality, person-centred care. Surgery leaders worked in partnership with other organisations to improve care outcomes.

Services used innovative approaches to gather feedback from people who used services and the public. Surgery services welcomed constructive challenge and feedback from the public and comparison with similar organisations.

Staff and leaders participated in continuous improvement and staff were accountable for delivering change. Innovation and achievement were celebrated and publicised.

Intensive/critical care

Outstanding

Updated 8 March 2016

We found the adult critical care services were good for safe, effective, and responsive, and outstanding for caring and well led.

There was a genuinely open and honest culture in which incidents and concerns were shared across the services and changes implemented to improve patient safety. National, trust, and local audit data was used to support service improvements.

Internal training and support for staff development was of a good standard and well established, however we did have concerns about limited access to the critical care module for registered nurses in CCD.

Care was patient centred and continually assessed on an individual basis. Emphasis was placed on the safeguarding of patients who were unable to communicate due to their clinical condition.

Patients and visitors consistently expressed satisfaction with the care and treatment they received stating that staff were very kind, caring and nothing was too much trouble.

There was a collective enthusiasm across all staff groups with a clear knowledge of the vision, values and strategic goals for the adult critical care and cardiac critical care services.

Staff told us they were proud to work in the department, felt very supported in their work and their opinions were valued.

End of life care

Requires improvement

Updated 8 March 2016

End of life care at this trust required improvement because people were not always protected from avoidable harm.

Staffing levels at Hayward House were at times compromised because the staff rota did not always reflect what was happening on the ward. This did not always ensure safe and effective care could be delivered.

Care and treatment was mostly delivered in line with local and national guidance and a holistic patient-centred approach was evident.

There was good multidisciplinary working at Hayward House and throughout the ward areas at the City Hospital.

Although patient outcomes were monitored for patients who had been referred to Hayward House, patient outcomes were not monitored throughout the trust. There was no auditing of patients preferred place of care or death. The trust was therefore unable to identify whether patients’ wishes were respected at the end of their life. We did however see that discussions took place around preferred place of death and care, but we were not assured these discussions took place with patients who had not been referred to the specialist palliative care team.

Do Not Attempt Cardio Pulmonary Resuscitation’ (DNACPR) decisions were mostly made appropriately and in line with national guidance. However, we found the forms were not always endorsed by a consultant.

The leadership for specialist palliative care services was evident; however, this was not the case for end of life care throughout the hospital, even though the leads were the same people. Staff throughout the trust were aware of, and spoke highly of, the specialist palliative care team but were unaware they also took the lead for end of life care. In addition, there was no vision or strategy for end of life care although there was a specialist palliative care annual plan for 2014/15.

Outpatients

Good

Updated 8 March 2016

We rated the outpatients and diagnostic imaging service as good overall.

Staff reported incidents appropriately and we saw evidence of incident investigation, actions and shared learning. Clinical areas were visibly clean with effective systems to ensure cleanliness was maintained. Medicines were stored appropriately and fridges and stock were checked regularly. Records were stored securely and were available on time for clinics. There were safeguarding policies and procedures in place and staff were aware of safeguarding leads. Staff were up to date with their mandatory training. Equipment was not always checked or maintained in line with trust policies and manufacturers guidance.

Outpatient and diagnostic imaging services worked to National Institute for Health and Care Excellence (NICE) and other national guidance. There were good examples of multi-disciplinary working. All staff we spoke with had received an annual appraisal, although outpatient and diagnostic imaging services fell just below the trust target of 90%. Radiology services offered a seven day service to hospital departments. Staff understood their role concerning the Mental Capacity Act 2005 and knew what to do when patients were unable to give consent for treatment.

Staff respected and maintained patients’ privacy and dignity. Patients were positive about staff and the way they were cared for. Staff gave examples of when they had gone the extra mile to help patients. Staff involved patients in their care and treatment.

In some areas, the environment had an adverse impact on the planning and implementation of outpatient and diagnostic imaging services.

The trust had not met cancer waiting time targets, which meant some patients did not have timely access to treatment. There were targeted clinics for communities or groups of people who were at risk of particular conditions. Interpreters and chaperones were available for patients who required them. There was limited information available in different languages. Staff were aware of the trust’s complaints policy and were able to describe what they would do in the event of a patient making a complaint.

There was a well-defined strategy for outpatient and diagnostic imaging services with clear links to the overall trust strategy. Risks were discussed at directorate meetings with clear actions and accountability to respond to them. Leaders were approachable and visible and were aware of the issues and risks affecting their service. Staff were well motivated and felt supported by their leaders. There was a patient centred and supportive staff culture. There were examples of where services sought continuous improvement and innovation.