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Conquest Hospital Requires improvement

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Inspection Summary


Overall summary & rating

Requires improvement

Updated 26 January 2017

We inspected the Conquest Hospital as part of the East Sussex Healthcare NHS Trust inspection on 4,5 and 6 October 2016. The trust had been previously inspected in September 2014 and March 2015. On both inspections we identified serious concerns and gave the hospital an overall rating of inadequate. The trust was rated inadequate overall because the two location reports and the concerns that we identified across the trust relating to culture and governance. A Quality Summit which included all key stakeholder organisations was held in September 2015 and, following that meeting, I recommended that the trust be placed into ‘Special Measures’. This meant that the trust was subject to additional scrutiny and support from the local clinical commissioning groups and NHSI who provided an improvement director to advise and to monitor the implementation of action plans to address the shortcomings identified. The commission also maintained a heightened programme of engagement and monitoring of data and concerns raised directly with us.

This inspection was specifically designed to test the requirement for the continued application of special measures at the trust. Prior to inspection we risk assessed all services provided by the trust using national and local data and intelligence we received from a number of sources. That assessment led us to include six acute hospital services (emergency care, surgery, maternity and gynaecology, children and young people, end of life care and outpatients) in our inspection. The two other acute hospital services (medicine and critical care) and community services were not inspected as they had indicated good performance at previous inspections and our information review suggested that this had been sustained.

We did consider how medical services and the high number of medical patients impacted on patient flow and whether this affected other core services. We also visited medical wards as part of the review of end of life care.

We did not inspect community services as part of this inspection as they were currently rated ‘good’ overall. We did consider where new initiatives developed by the community services impacted upon the work of the two acute hospitals.

Following this inspection we have re-rated the services inspected. For other services we have maintained ratings from previous inspections. We have aggregated the ratings to provide an overall rating for the trust of requires improvement.Caring was rated as good, whilst safe, effective, responsive and well-led are all rated as requires improvement. This constitutes a significant improvement from the previous rating of inadequate.

.Our key findings were as follows: -

SAFE

  • The incident reporting culture had been significantly improved.
  • We saw clear evidence of learning from a Never Event with robust investigation and embedded changes to practice across the hospital.
  • Staff understanding of duty of candour had improved.
  • Infection control oversight had been significantly strengthened and hand hygiene practice was largely compliant.
  • We were able to see fledgling improvements in the provision of services trustwide with clear indicators of positive changes from data provided by the trust and from national data we hold at CQC about the trust.
  • Daily ‘Safety Huddles’ were being rolled out across the hospital. These encouraged the wider multidisciplinary team to share concerns and consider ways to improve the care of patients.
  • Where compliance with VTE risk assessment and prevention had been a concern in our previous inspection report, there was now evidence of high rates of compliance with 95% of patients having a properly completed VTE risk assessment in July 2016.
  • Safeguarding vulnerable adults and children was given sufficient priority.
  • Medicines management processes had been significantly improved.
  • The transfer of patients from ambulance to the emergency department was subject to delay and not being monitored.
  • There was a significant backlog in the reporting of x-ray examinations.
  • Record keeping was not consistent across the trust notably in the documentation of risk assessments within the emergency department and full completion of risk assessments in paediatric services.
  • Where electronic recording and escalation of observations had been introduced this had demonstrably improved the outcomes for patients.
  • Staff recruitment continued to be problematic with high levels of bank and agency use in some areas. There were departments such as the emergency department where the staffing arrangements were not in line with the national recommendations.

EFFECTIVE

  • Pain was managed well with new initiatives in the care of children and young people and better recording of pain scores across the hospital.
  • Stroke services had been consolidated at the Eastbourne site. A recent report issued by the Stroke Association in November 2016 showed that the hospital was providing good access to stroke services.
  • End of life care and emergency departments were not meeting national audit standards in some areas.
  • The assessment of mental capacity by staff remained inconsistent across the trust.
  • The wishes of patients about the upper limit of treatment when on an end of life care pathway was not always recorded. Staff had not always discussed the 'ceiling of care with patients or their families.
  • There were no services now rated as inadequate
  • Policies were largely up to date and referenced by best practice, with the exception of maternity services.
  •  Surgery services were no longer an outlier for clinical outcomes.
  • Auditing programmes were more developed than on previous inspection visits but further work was needed to ensure that the full cycle of data collation being used to drive improvements needed further embedding.

RESPONSIVE

  • The emergency department indicated a deteriorating performance against access standards.
  • The trust was not maintaining the delivery of treatment to patients within 18 weeks of referral from GP's or within 62 days for patients referred onto a cancer pathway.
  • Patient flow through the hospital was challenged leading to patients being cared for in suboptimal clinical areas.
  • A Frailty Nurse Specialist team had been set up to work across the acute hospitals and community services to reduce the number of unnecessary admission (particularly from care homes) and to support patients who were best cared for in the community.
  • Patients on an end of life care pathway did not have access to a rapid discharge service.
  • The outpatients service was no longer rated as inadequate with significant improvements to the call centre.
  • The hospital staff tried to ensure that the individual needs and preferences of patients were met. Our previous report from September 2014 talked about staffing shortages and a culture that led to task focussed nursing care and a lack of consideration of individual needs. This was not something we observed on this inspection visit.
  • The trust was very responsive to meeting the complex needs of patients notably those living with dementia or learning disabilities.
  • Appropriately trained staff were not available to support children who were particularly anxious or in pain through play
  • Response times to complaints had improved significantly since April 2016. We saw evidence of appropriate responses to complaints, and learning from complaints and concerns. The trust had improved the way they responded to complaints as well as the response times.

WELL LED

  •  No services were rated as inadequate for leadership.
  • The senior leadership was now sighted on operational and strategic issues and had clear and well considered plans for service improvement.
  • Staff told us that the executive team were much more visible around the hospital than they had been prior to the appointment of the new chair in January 2016 and new chief executive in April 2016.
  • Nursing staff also talked to us about the Director of Nursing (DoN) who was felt to be a consistent and steadying influence as the trust went through a period of significant change. Nurses said they trusted the DoN and felt she was ever present, approachable and understood the challenges at ward level.
  • The organisational culture had transformed since our last inspection. Staff were largely positive, well engaged and felt valued by the organisation. However, there were areas where staff were still feeling daunted by the changes and where morale was low. This was particularly the case with medical records and some administrative staff where the systems they worked with and, in some cases, their place of work had changed.
  • Governance had been significantly strengthened in terms of structure and the quality of board papers and data.This had led to a strong sense of accountability within the trust.
  • The senior team remains relatively new in constitution and some elements of governance and performance management have only recently been introduced
  • The trust was yet to complete the transition to a new operational structure.
  • At service levels our inspection identified some weaknesses in the management of risk and mortality.
  • Innovation was now encouraged and we saw several areas where staff had been encouraged and supported to introduce changes to bring about improvements in quality and safety. Staff felt more engaged in developing the service and were allowed more involvement in how services were provided.

We saw several areas of outstanding practice including:

  • Following the project lead midwife’s maternity review, the trust had introduced a programme of project groups related to maternity. These included the pilot scheme of a new homebirth and triage role for community midwives, and a perinatal mental health specialist midwife role.
  • A consultant orthopaedic surgeon had written a national guide for the Royal College of Surgeons on avoiding unconscious bias which was published in August. The guide focused on overcoming the unconscious opinions that everyone forms about people when they first meet them and offered advice to get beyond this. This national guidance referenced the trust’s Anti-bullying Policy in the Doctors’ Clinical Handbook and highlighted the progress and work made within the trust to address perceptions of bullying and harassment.
  • We saw an example of best practice for care provided to dental patients with special needs or learning disabilities.A multidisciplinary planning meeting was conducted in advance of the attendance. The appointment was used to provide one stop care including taking bloods, scans and giving the patient a haircut to minimise distress to the patient. There were a variety of options provided for location; aspects of care could be initiated in different locations such as properly supported sedation in the patient’s home and anaesthesia in the car park or in the hospital depending on the need.
  • A dedicated multidisciplinary team had established a five-year plan to establish an innovative rehabilitation care plan as part of an out of hospitals services transformation programme. This programme included staff from multiple specialties and enabled ED staff to work with colleagues from across the trust and in the community to develop future services, including an ambulatory rehabilitation unit and a rapid access care service. The programme planned to introduce nurse practitioner roles for frailty, crisis response and proactive care who would provide an integrated rehabilitation service alongside hospital and community-based specialists. This programme would significantly improve working links between the trust’s hospitals and local authority social care services and enable rehabilitation services to be provided more responsively to avoid the need for hospital admissions. There was significant support and infrastructure for staff to develop this programme and they had been invited to present their plans and work so far at a national Health and Social Care Awards ceremony.
  • Patients on a cancer pathway had a dedicated booking team in the booking centre. All referrals were received electronically and an email was sent to the GP to indicate it had been received. The booking team escalated concerns about appointments to service managers. Weekly cancer patient tracking list meetings provided clinical oversight of patients on cancer pathways.
  • The paediatric team had introduced a ‘consultant of the week’ system whereby a designated consultant answered enquiries from local GPs about sick children in their care. This recent initiative had reduced the number of admissions because GPs had a specific point of contact and could be supported to care for the child in the community, where practical.
  • An entrepreneur programme was being established that focused on the reduction of ambulance handover delays.
  • There were good initiatives being developed and encouraged to meet people’s individual needs. The hospital’s League of Friends team had knitted comfort bands for patients, which helped them stop picking at intravenous lines. A ‘distraction box’ was also available to help provide stimulation for patients with dementia and reduce their anxiety in an unfamiliar environment. A nurse had developed a number of resources to help provide emotional support to parents who lost a child to sudden infant death syndrome.
  •  A member of the maintenance team had given up his own time to paint a mural on the wall of the recently decorated ultrasound unit to soften the environment for young patients

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

Importantly, the trust must :

  • Ensure that consultant cover meets the minimum requirements of 16 hours per day, as established by the Royal College of Emergency Medicine.

  • Must develop play services in line with national best practice guidance.

In addition the trust should:

  • The surgery directorate should  ensure completion of anaesthetic machine logbooks

  • The surgery directorate should ensure compliance with: inadvertent perioperative hypothermia, NICE guidance clinical guideline CG 65.

  • The surgery directorate should ensure accurate record keeping of controlled drugs in theatres.

  • The surgery directorate should improve the quality, content and outcomes of mortality and morbidity meetings.

  • The surgery directorate should ensure  compliance with the guidance contained in venous thromboembolism (VTE) in adults: reducing the risk in hospital QS3.

  • The surgery directorate should ensure compliance with National Patient Safety Alerts regarding safer spinal and epidural needles.

  • The surgery directorate should ensure a consistent governance structure across the two surgical directorates.

  • Review all maternity policies and procedures that are outside their review date and take action to ensure all policies reflect current national and evidence-based guidance.

  • The hospital should discuss and record ceilings of care for patients who have a DNACPR.

  • The trust should have a defined regular audit programme for the end of life care service.

  • The trust should record evidence of discussion of an end of life care patient’s spiritual needs.

  • The trust should implement a formal feedback process to capture bereaved relatives views of delivery of care.

  • The trust should ensure that all staff received regular mandatory training for end of life care.

  • The trust should provide a formal referral criterion for the specialist care team for staff to follow.

  • The trust should define and streamline their end of life care service to ensure staff are clear of their roles and who to contact.

  • Develop a rapid discharge process for end of life care patients to be discharged to their preferred place of death.

    Extend the Palliative care team service to provide support and advice over the full seven days. As the hospital did not currently have this provision, some patients did not have access to specialist palliative support, for care in the last days of life in all cases.

  • Work towards meeting the requirements of the key performance indicators of the National Care of the Dying Audit (NCDAH) 2016.

  • Continue to consider ways to improve staff recruitment and retention such that it meets the national recommended levels.

  • Play services should be developed and a play specialist employed.

  • The trust should ensure incidents occurring in the ED are investigated thoroughly and all staff are included in the dissemination of the outcomes.

  • The trust should ensure nurse to patient ratios in the ED are managed in relation to the individual needs of patients based on acuity.

  • The trust should ensure that RTT is met in accordance with national standards.

  • The trust should ensure that standard for patients receiving their first treatment within 62 days of an urgent GP referral is met.

  • The diagnostic department should ensure all policies and procedures are up to date.

  • The diagnostic imaging department should ensure they have a recent audit from their Radiation Protection Advisor.

  • The diagnostic imaging department should monitor their waiting times and reporting times.

  • The diagnostic imaging department should ensure staff attend mandatory training in line with the trusts target.

  • The maternity services should ensure medication locks are suitable and do not allow unauthorised patient access.

  • The maternity services should ensure there is a clear procedure documented for pool evacuation.

  • The trust should consider improving the environment in the Day Assessment Unit waiting area as flooring could be a trip hazard and the room is unwelcoming.

  • The maternity services should ensure a robust mechanism is in place to monitor and audit abortion HSA4 notification completion.

  • The maternity services should ensure resuscitation trollies are fully stocked with items that are in date, at all times.

  • The maternity services should ensure cleaning schedules are adhered to and audit is appropriately used to monitor this in the obstetric theatres.

  • The children's service should address the lack of storage space and cramped conditions on the Kipling ward.

  • The children's service should develop transition planning for children with long term conditions approaching adulthood.

  • The children's service should improve efficiency of appointment and clinic booking systems to avoid long delays in accessing paediatric review and to improve efficiency.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 26 January 2017

Effective

Good

Updated 26 January 2017

Caring

Good

Updated 26 January 2017

Responsive

Requires improvement

Updated 26 January 2017

Well-led

Requires improvement

Updated 26 January 2017

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 26 January 2017

We rated this service as 'requires improvement' because:

  • The triage system did not ensure all calls were answered in a timely manner and sometimes led to calls being missed.

  • We were told of delays in the day assessment unit out of hours due to staff being moved to the delivery suite. We witnessed this during our un-announced inspection on a Saturday.

  • Midwives were not always able to attend the daily risk meetings and feedback was not always ensured.

  • Cleaning schedules in theatres were not always completed and we saw high level dust on inspection.

  • Sterile equipment on the labour ward resuscitation trolley was not in date and two sterile packages were ripped open and left on the trolley.

  • Mandatory training fell below trust targets in many areas across the whole department.

  • Several of the maternity policies and procedures were outside their review date. This meant the service might not have worked to all the relevant and current evidence-based guidelines, standards or best practice.

  • There were delays for patients using gynaecology services and referral to treatment times were consistently worse than the 18-week target.

  • Mirrlees ward was often taking patients that were not gynaecological patients (medical outliers).

However;

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Daily risk meetings and the sharing of incident learning ensured that staff learned from incidents to prevent recurrences.

  • When staff identified issues we saw that they initiated projects to try and understand the causes for this. For example (HIE) cases were further reviewed to look for causes and possible actions to reduce recurrence.

  • There was enough equipment to allow staff to safely treat patients. Equipment was regularly checked and maintained to ensure that it worked safely.

  • Staff followed infection control procedures and demonstrated a good understanding of these. The use of personal protective equipment (PPE) was audited to ensure staff were following guidelines.

  • Staff received mandatory training in safety systems, including responding to childbirth emergencies such as post-partum haemorrhage (and

  • Safeguarding vulnerable adults and children was given sufficient priority. Staff received an appropriate level of safeguarding training to allow them to identify safeguarding concerns and knew how to raise these.

  • Outcomes for people who used services were generally positive and met expectations.

  • Appraisal rates met expected trust targets. Staff we spoke with found senior staff members supportive.

  • Staff treated people with dignity, respect and kindness. Patients felt supported and said staff cared about them. We saw a rapid disciplinary response from staff members when a patient’s dignity was not considered by a colleague who made an inappropriate comment.

  • People and staff worked together to plan care and there was shared decision-making about care and treatment. Women’s wishes were understood and met if possible with clear explanation if this could not happen.

  • The service made reasonable adjustments to remove barriers when people found it hard to use or access services, for example, through provision of interpreters.

  • The service had good links to services within the community and outside organisations such as GP surgeries and social services.

  • Response times to complaints had improved significantly since April 2016. We saw evidence of appropriate responses to complaints, and learning from complaints and concerns.

  • The leadership was knowledgeable about quality issues and priorities, understood what the challenges were and took action to address them.

  • The service proactively engaged and involved all staff through the maternity service review and other channels and ensured that the voices of all staff were heard and acted on.

  • Staff felt respected, valued and supported. All staff we spoke to felt the culture had improved since our last inspection, and gave us examples of positive improvements.

  • The trust had a programme of project groups related to maternity, which drove improvements in different areas of the service.

  • The culture within the trust was good and staff felt supported and listened too. Staff were proud of the department and their work colleagues.

Medical care (including older people’s care)

Good

Updated 27 March 2015

Medical services provided at the Conquest Hospital were judged to be good. Some areas within the directorate require enhancing to ensure services retain a rating of good.

The concerns which required monitoring to maintain improvement were:

The level of medical cover during out-of-hours periods.

The review and analysis of serious incidents to ensure appropriate managerial oversight and dissemination of learning.

Failure to prevent repeated outbreaks of infection, including a case of MRSA where a patient was infected by a member of staff.

Inconsistent completion of Situation, Background, Assessment, Recommendation (SBAR) for patients requiring transfer or those whose condition was deteriorating.

Care and treatment were delivered in line with nationally recognised pathways of care and followed National Institute for Health and Care Excellence (NICE) and condition specific guidance.

Staff were seen to be caring and compassionate. Patients and their carers or family members could not speak highly enough of the staff who cared for them.

Staff were knowledgeable, well trained and skilled in their roles.

We saw areas of good practice, such as the use of a wireless monitoring and recording system to provide real-time information across multidisciplinary teams and alert staff if a patient’s condition deteriorated. The trusts own integrated patient care document provided a comprehensive overview of the patient and their needs enabling staff to locate information easily and build an understanding of the patient as an individual.

Services had been reviewed at trust level and, following independent scrutiny, several services had been centralised to provide a more specialised and focused response to patients.

At ward level, every patient was treated as an individual, integrated patient care documents enabled assessments to be completed and care and treatment tailored to the individual. The document also provided staff with a comprehensive picture of the patient, their needs and their acuity.

We found that leadership at local level was very strong. Matron-led wards and close liaison between department heads meant that in most instances learning was shared between teams.

The transformation process which the trust had gone through had left many junior staff feeling disenfranchised, if not by the changes themselves then by the pace of the changes. They did not feel that their views were listened to outside their own departments.

Urgent and emergency services (A&E)

Requires improvement

Updated 26 January 2017

 Overall we rated urgent and emergency services as ‘requires improvement’ because:

  • Staff worked in a culture that empowered them to report incidents. However, learning from incidents, including serious incidents, was limited and not all incidents had an investigation. In some cases, where an incident resulted in patient harm or occurred due to a staff mistake, appropriate training and support was provided.

  • Consultant cover did not meet the minimum requirements of the Royal College of Emergency Medicine and there was a significant shortage of middle grade doctors. Nurse staffing levels were variable and the department regularly operated with less than the number of nurses established, as needed to provide safe care. This increased risks to patients and the risk management and clinical governance systems had not addressed this.

  • Risk management in patient records was inconsistent and sometimes inaccurate. There was also variable standards in the monitoring of patients who were deteriorating.

  • There were significant variances in how staff assessed mental capacity and understanding of patients. This included contradictory, incomplete or inaccurate documentation.

  • Patients often experience lengthy delays while waiting for a mental health assessment, including referrals from the child and adolescent mental health team. There was also limited evidence staff were trained or equipped to provide care and treatment for patients with a learning disability.

  • Delays to triage and assessment increased patient risk. Although the senior leadership team implemented strategies to address this, there had been little substantive improvement at the time of our inspection.

However we also found areas of good practice:

  • There was consistent evidence the duty of candour was used in relation to incidents to maintain transparency and communication with patients and relatives.

  • Medicines management was of a high standard and nurse prescribers worked to Patient Group Directions.

  • The trust had responded to risks associated with low levels of paediatric nurses by increasing training for existing staff and recruiting new nurses.

  • A comprehensive programme of clinical audits was used to benchmark standards and quality of care against the guidance of organisations such as the National Institute for Health and Care Excellence.

  • Multidisciplinary working was embedded in the department and a dedicated hospital interventions team provided physiotherapy, occupational therapy and nurse practitioner support during patient admissions and discharges. A crisis response team was available to help avoid unnecessary hospital admissions by organising care at home.

  • An education programme was available to staff and included practical competency training from a dedicated practice development nurse as well as training from visiting specialists.

  • Patients and their relatives were treated kindly, with dignity and respect and recommendation rates for the department were similar to the national average.

  • Staff provided specific services to meet the needs of individual people. This included specialist support for patients living with dementia and translation resources for non-English speakers.

  • Although the hospital consistently failed to meet the Department of Health target that 95% of patients be admitted, transferred or discharged within four hours, a programme of significant development was underway to improve all aspects of the service times, including triage, assessment and treatment.

  • A frailty pathway service was in development to address the needs of the local population and this service aimed to reduce the need for hospital attendances and admissions and ensure patients had better access to home or community services.

  • A restructure of the clinical unit and management team was due to be completed by November 2016 and staff spoke positively about the increase in support, training and engagement they had experienced as a result of the changes. The department vision and strategy were included in a five year plan to improve access and flow through the department and improve specialist care pathways. A multidisciplinary team was also developing an innovative rehabilitation programme to ensure patients had access to support at home and reduce the need for repeat hospital attendances.

Surgery

Good

Updated 26 January 2017

Overall, we rated the surgical service at Conquest Hospital as ‘Good’. This was because:

  • People were being protected from avoidable harm and abuse.
  • Openness and transparency about safety was encouraged. Staff understood their responsibilities in relation to incident reporting. Incidents were investigated appropriately by staff with the necessary clinical knowledge and who had received training in leading such investigations. We were given examples of where changes to practice had been made following incidents. The service had experienced a ‘never event’ at the Conquest hospital which had involved the wrong administration route of a medicine. This had been rigorously investigated and changes had been made in order to ensure it was not repeated.
  • The services, wards and departments were clean and staff adhered to infection control policies and protocols. Pragmatic solutions had been found to some of the problems that were identified during previous inspection visits. This included the appointment of staff known colloquially (and with some pride) as “Theatre Fairies”. These staff kept the theatre environment clear of equipment, waste and other clutter that got in the way of safe and efficient theatre practice.
  • Record keeping was comprehensive and audited regularly. Records were now tracked using a barcode tracking system and most patients had their full notes available for consultations. An off-site records storage system was being used and whilst some staff were still unhappy about the need to relocate, the records management was more effective and working in the best interests of patients.
  • Decision making about the care and treatment of a patient was clearly documented. The electronic observation recording system had been used to drive improvement in the timely identification of patients at risk of unexpected deterioration. It had allowed for oversight of patients with elevated risk by the critical outreach team and concerns were escalated for review by the medical or surgical emergency teams more swiftly.
  • Treatment and care was generally provided in accordance with the National Institute of Health and Care Excellence (NICE) evidence-based national guidelines. There was good practice, for example, assessments of patient needs, monitoring of nutrition and falls risk assessments. There were examples of effective multidisciplinary working.
  • Performance against national audits such as patients with a fractured neck of femur (broken hip) audit showed evidence of good outcomes for patients.
  • Leadership was good and staff told us about being supported and enjoyed being part of a team. There was evidence of multi-disciplinary working with staff working together to problem solve and develop patient centred evidence based services which improved outcomes for patients.
  • Development opportunities and clinical training was accessible and there was evidence of staff being supported and developed in order to improve services provided to patients.
  • Feedback from patients was continually positive about the way staff treated people. We saw staff treated patients with dignity, respect and kindness during all interactions. Patients told us they felt safe, supported and cared for by staff.

However:

  • There was not an effective system in place that ensured completion of anaesthetic machine safety logbooks.
  • Controlled drug records in theatres were incomplete with some staff block signing for drugs.
  • The content and quality of records for mortality and morbidity meetings required improvement.
  • There was still a heavy reliance of temporary staff for both medical and nursing staff.

Intensive/critical care

Good

Updated 27 March 2015

The intensive care service uses procedures to ensure patients receive safe and effective care. Clinical outcomes were monitored, and practice changed where required improvements are identified. Staff were caring and compassionate, working to maintain the privacy and dignity of their patients. However, some improvements were required in relation to bed management processes, to ensure that patients did not remain in the intensive therapy unit (ITU) longer than required, which can impact on privacy and dignity. Leadership on the unit is good, but a change to the clinical unit management team has led to a lack of discussion when it came to dealing with planning issues, such as the clinical environment.

Services for children & young people

Requires improvement

Updated 26 January 2017

We rated this service as requires improvement because:

  • The environment was generally cluttered with equipment stored in the corridor. One bay was crowded with insufficient space for the number of beds. This was rectified during our inspection.

  • Feedback and learning from incidents was mixed with some staff saying that they didn’t get feedback when they had reported an incident. We also heard that some incidents weren’t reported as the process was too long or staff wouldn’t report some incidents in case there were repercussions.

  • Outpatient waiting times were excessive with 79 of 1106 patients waiting over 18 weeks for their appointment.

  • There was no play specialist to lead and develop play services.

  • There was no parents room that could be used to have private or difficult conversations

  • The outside play area was not able to be used due to the type of flooring. The equipment available had also been left for so long that it was not fit for use.

However:

  • Staff understanding of child safeguarding responsibilities, processes and protocols was well embedded. We found there was a strong focus on safeguarding when staff were caring for children.

  • Although cluttered, the equipment on the ward and the ward was clean. This was reflected in the cleanliness and hand hygiene audits.

  • The trust had appointed a consultant who had dedicated time to review all National Institute for Health and Care Excellence (NICE) guidelines and implement them.

  • Internal auditing was comprehensive and each audit was given a priority rating.

  • There was an appropriate response when a child’s condition deteriorated.

  • We observed compassionate care from all staff who had interaction with both children and their families

  • Safety huddles, which started at Eastbourne SSPAU and on the SCBU were introduced on the Kipling ward in August 2016

  • We heard how the culture across the ward was supportive, praising and caring which promoted close working relationships across the teams.

  • There was a published strategy for Womens and Childrens Services with explicit priorities and measurable performance indicators.

  • There was clear leadership of the children’s services with Board level representation.

End of life care

Requires improvement

Updated 26 January 2017

Overall we rated the end of life care service at the Conquest Hospital as ‘Requires Improvement’. This was because:

  • The service did not have a programme of regular audits for end of life care.

  • The trust provided formal training for some staff in end of life care. However, junior staff told us they were not confident at recognising an end of life care patient.

  • The trust did not meet the requirements of the key performance indicators of the National Care of the Dying Audit (NCDAH) 2016.

  • The trust had not implemented the standards set by the Department of Health and National Institute of Health and Care Excellence’s (NICE) guidance.

  • There were inconsistencies in the documentation in the recording of spiritual assessments, Mental Capacity Act assessments and recording of ceilings of care for patients with a Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) form completed.

  • Patients did not always have access to a specialist palliative support for care in the last days of life, as the trust did not have a service seven days a week

  • We found the service did not have clarity in its leadership. It was disjointed without a clear line of objectives that the staff could understand or follow.

  • There was no formal referral criterion for the specialist care team for staff to follow.

  • The risk register for the service was insufficient and did not reflect the needs of the service.

  • The trust did not collate service user’s views with a patients or bereaved relatives’ survey.

However:

  • The specialist palliative care team were a dedicated team who worked with ward staff and other departments in the hospital to provide holistic care for patients with palliative and end of life care needs in line with national guidance.

  • Staff recognised that provision of high quality compassionate end of life care to its patients was the responsibility of all clinical staff that looked after patients at the end of life. They were supported by the palliative care team and end of life care guidelines.

  • Staff at the hospital provided focused, dignified and compassionate care for dying and deceased patients and their relatives. Most of the clinical areas in the hospital had an end of life care link staff member.

  • Facilities were provided for relatives and the patient’s cultural, religious and spiritual needs were respected.

  • The hospital had systems and processes in place to keep patients free from harm.

  • Infection prevention and control practices were in line with national guidelines.

  • Areas we visited were visibly clean, tidy and fit for purpose. The environment was light, airy and comfortable.

  • Medical records and care plans were completed, contained individualised end of life care plans and contained discussions with families. The DNACPR forms were all completed in accordance national guidance and the trust policy.

  • The hospital had sufficient supplies of appropriate syringe drivers and staff were trained in their use.

  • Out of hours telephone support for palliative medicine was provided by the local hospice.

  • A current end of life care policy was available and a steering group met regularly to ensure that a multidisciplinary approach was maintained.

Since the inspection visit in September 2014 there have been a number of improvements to the end of life care provided at the Conquest Hospital. There are still areas where further improvement is needed but greater consideration was being given to identifying and meeting the needs of this group of patients. Some significant changes to the safety of the service that were evident included much better understanding of the rationale for reporting incidents and a more robust investigation process. We saw evidence across the hospital that there was now a commitment to sharing learning when things went wrong. The trust now had a single type of syringe driver for use with patients.

Patients with an end of life care plan were now identified at bed meetings and there was a commitment from senior staff that these patients should be cared for in single rooms, without being moved around, whenever possible. We attended the bed meetings and saw this happened in practice.

Completion of DNACPRs was now good. The records showed that there had been discussion with the patients and/or their relatives. There was consultant review of any decision made by a more junior doctor regarding resuscitation. Work still needed to be done to support staff around ‘ceiling of care’ discussions but overall there were significant positive changes in practice relating to the identification of people approaching end of life, the use of DNACPRs.

Outpatients

Requires improvement

Updated 26 January 2017

We found the outpatient and diagnostic imaging services at Conquest Hospital to be requires improvement. This was because:

  • There were 22,000 patient x-rays awaiting a report and a diagnosis.

  • Staffing numbers in the diagnostic imaging department were 33% below the numbers required to cover all examinations and the on call rota.

  • The trust referral to treatment time (RTT) had fallen below the 92% standard from March 2016 onwards, but had been the same as the England average since July 2015.

  • The trust was performing much worse than the 85% operational standard for patients receiving their first treatment within 62 days of an urgent GP referral.

  • Morale was low in the diagnostic imaging department. Staff felt they were not consulted on changes in the structure of the department and that there was disconnect between staff and managers.

  • The outpatient department had systems and processes in place to keep patients free from harm.

  • Infection prevention and control practices were in line with national guidelines.

  • Areas we visited were visibly clean, tidy and the environment was light, airy and comfortable.

  • A wide range of equipment was available for staff to deliver a range of services and examinations.

  • Medicines were stored in locked cupboards and administration was in line with relevant legislation.

  • Staff kept medical records accurately and securely in line with the Data Protection Act 1998.

  • The hospital had a comprehensive audit programme in place to monitor services and identify areas for improvement.

  • The outpatient services had sufficient numbers of appropriately trained competent staff to provide their services.

  • Staff completed appraisals regularly and managers encouraged them to develop their skills further.

  • Staff interacted with patients in a kind, caring and considerate manner and respected their dignity. Patients told us they felt relaxed when having their treatment.

  • The hospital was responsive to the needs of the local populations. Appointments could be accessed in a timely manner and at a variety of times throughout the day.

  • Staff in the outpatient department felt their managers were visible, approachable and effective.