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Eastbourne District General Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 27 January 2017

We inspected Eastbourne 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.

CARING

  • All services inspected were rated as good for caring.

  • Data and our observations confirmed the very positive feedback received from patients with respect to the caring nature of staff.

  • Staff treated patients with dignity, respect and kindness. Patients felt supported and said staff cared about them. Patients and staff worked together to plan care and there was shared decision-making about care and treatment

  • The trust’s Friends and Family Test performance (% recommended) was generally better than the England average between July 2015 and June 2016. In the latest period, July 2016 trust performance was 97.9 % compared to an England average of 95.4%. This was an improvement on the performance in the FFT in August 2014, when the score was 67% trust wide.

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.

  • Ensure that play specialist staff are employed to lead and develop play services in all areas where children are cared for.

In addition the trust should:

  • 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 provide for the specialist palliative care team at Eastbourne District general Hospital weekly multidisciplinary meetings to discuss all aspects of patient’s medical and palliative care needs.

  • 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.

  • Develop and implement a programme of regular audits for end of life care.

  • The trust should ensure audits of infection control practices in ED including hand hygiene are used to improve practice.

  • Investigate and reduce the mixed sex breaches on surgical wards at EDGH. The reason for these should be documented in all cases.

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

  • Work with local stakeholders to address the delays to patient pathways and continue to progress towards meeting their referral to treatment time targets.

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

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

  • The trust should ensure hazardous waste management and disposal practices in the ED meet national control of substances hazardous to health guidance.

  • 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 a patient receiving their first treatment within 62 days of an urgent GP referral is met.

  • The diagnostic imaging department should ensure they are reporting incidents in line with legislation and demonstrate following their own policy.

  • 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 and reporting times.

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

  • The children's service should develop clear criteria for the transfer of patients by private car between sites.

  • The children's service should ensure that children are not transferred to the Conquest Hospital late at night, through timely decision making and effective planning of the transfer.

  • The children's service should ensure that outpatients appointments are not subject to cancellation and delays,.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 27 January 2017

Effective

Requires improvement

Updated 27 January 2017

Caring

Good

Updated 27 January 2017

Responsive

Requires improvement

Updated 27 January 2017

Well-led

Requires improvement

Updated 27 January 2017

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 27 January 2017

Overall, we rated maternity and gynaecology services as requires improvement because:

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

  • A lack of specialist training for nurses who cared for gynaecology patients presented a risk that may have impacted upon patient care.

  • Most of the maternity policies and procedures were outside their review date. This meant staff might not have been informed around all the relevant and current evidence-based guidelines, standards or best practice.

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.

  • Staff checked and maintained equipment to ensure that it worked safely.

  • Staff received up-to-date mandatory training in all safety systems. This included responding to childbirth emergencies such as post-partum haemorrhage (excessive bleeding after childbirth) and cord prolapse. Cord prolapse is when the cord comes out before the baby during labour, which can cause a reduced supply of blood and oxygen to the unborn baby.

  • 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 patients who used services were generally positive and met expectations.

  • Appraisal rates met trust targets.

  • Staff treated patients with dignity, respect and kindness. Patients felt supported and said staff cared about them.

  • Patients and staff worked together to plan care and there was shared decision-making about care and treatment.

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

  • 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 its 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.

Medical care (including older people’s care)

Requires improvement

Updated 27 March 2015

Whilst we saw areas of good practice during the inspection we identified concerns requiring improvement.

We were concerned about 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 as not sufficient.

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

There was 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) 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 computer-based monitoring and recording system (VitalPAC) to provide real-time information across multidisciplinary teams and alert staff if patients deteriorated. The integrated patient care document provided a comprehensive overview of the patient and their needs.

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 the trust had undergone had left many junior staff feeling disenfranchised, if not by the changes themselves then by the pace of change. They did not feel that their views were listened to outside their own department. Senior managers at board level were, in the main, not visible enough to staff.

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.

Urgent and emergency services (A&E)

Requires improvement

Updated 27 January 2017

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

  • Consultant cover did not meet the minimum requirements of the Royal College of Emergency Medicine and there was a 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 increased pressure on staff.

  • Compliance with hand hygiene was variable and there was not a robust improvement plan in place to address this.

  • Waste management did not meet national guidance and presented infection control risks.

  • Pain management was inconsistent and there was room for improvement in the documentation of risk assessments and observations, including in fluid charts and comfort rounds.

  • There was limited provision for paediatric services and no trauma surgery services at this site and incidents indicated staff had not always acted sufficiently quickly to ensure appropriate transfers took place.

  • Delays to triage, assessment and treatment were continually poor and changing leadership and clinical governance systems had not addressed this significantly.

However we also found areas of good practice:

  • Staff worked in a culture that empowered them to report incidents and errors and senior teams provided investigations and feedback. Where an incident resulted in patient harm or occurred due to a staff mistake, appropriate training and support was provided. There was consistent evidence the duty of candour was used 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 special bereavement and keepsake resources for the parents of infants who experienced sudden infant death syndrome.

  • 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.

Since the visit dated September 2014, there have been significant improvements in the quality of care being provided by Eastbourne Hospital emergency services. There are still areas where the service needed to continue to make improvements (detailed above) but we saw mitigation of risk where there were shortfalls and robust plans with timescales for the improvements to be made. Staffing continued to be a challenge for the trust but consultants were working as an effective team and providing additional cover where there were gaps in the rota. Additional nurses had been recruited, including specialist paediatric nurses and improvements in training for healthcare assistants.

The departmental leadership was clearer. The leadership of the ED had recently been restructured to help manage the five year plan and improve quality and performance. A nurse director and deputy nurse director provided senior leadership within the clinical unit and a head of nursing a newly appointed deputy head of nursing and a service manager were responsible for the ED and CDU. Band seven matrons led shifts. A service manager had responsibility for flow and patient journeys through the department.

Surgery

Good

Updated 27 January 2017

We found the surgery services at Eastbourne District General Hospital (EDGH) to be good because:

  • The hospital had good medicine management processes in place, which related to the security and storage of medicines on all the wards we visited. In general, medicines in theatres were well managed but we observed the block signing of controlled drugs which was contrary to best practice guidance.

  • The trust was compliant with the intercollegiate document, safeguarding children and young people: role and competences for health care staff (March 2014). Staff we spoke to were able to demonstrate an understanding of their responsibilities to safeguarding vulnerable adults.

  • The identification, reporting and investigation of incidents had improved significantly since our previous inspection. We saw minutes of meetings where incidents including never events were discussed and learning fed back to staff via ward meetings and newsletters, which were available in hard copy and circulated by email. There were readily observable changes made across the trust in relation to never events that had occurred, with learning widely disseminated. Learning from Morbidity and Mortality meetings needed further development. Records were brief and suggested limited discussion and challenge.

  • The recently introduced electronic observation recording system had led to improvements in the management of deteriorating patients. Earlier recognition and identification resulted in more timely review by the critical care outreach team, who had oversight of all NEWS Scores for all patients in the hospital. Where the NEWS score was elevated to a higher level there was automatic review by the medical emergency team.

  • The incidence of both pressure damage and falls had shown a sustained improvement over time. Ward and departmental safety thermometer results showed improvements across the service. Medicines management had been added to the safety thermometer as an additional performance measure.

  • 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.

  • Infection prevention and control measures had improved since our previous inspection. The ‘Bare below the elbow’ policy was enforced more rigorously through the daily safety huddles. Hand hygiene audits showed sustained high levels of compliance with results maintained above 97% since February 2016.

  • The trust rate of surgical site infections (SSIs) was better than the national average.

  • Equipment checks were now given a higher priority. Daily checks of essential equipment were taking place with records available to confirm senior oversight of equipment checks occurring.

  • Care pathways used in surgery referred to national guidance from the National Institute for Care and Excellence (NICE) guidance and other bodies such as the British Orthopaedic Association guidelines. We observed staff following national best practice guidance in theatres.

  • Consent was obtained in accordance with the trust policy and guidance from the professional regulatory bodies. Staff had an understanding of what informed consent entailed. They had received training in the Mental Capacity Act 2005 and knew how this impacted on their work.

  • Friends and Family Test results showed a higher than average response rate and the scores were higher than the England average. Over 98% of surgical patients would recommend the hospital.

  • The hospital staff tried to ensure that the individual needs and preferences of patients were met. There was a system in place to identify patients who might be a little confused and need careful support in decision making.The coloured butterfly markers allowed staff to differentiate these patients from those with more advanced dementia.The dental team provided exemplary planning of care for patients with learning difficulties who needed dental surgery. Every adaptation was offered to make the appointment as comfortable and relaxed as possible.

  • A robust governance system was being introduced. At the time of our inspection visit it was partially rolled out with a clear timeline for continued introduction of key aspects of the framework.The triumvirate management structure for the division gave clear lines of reporting, clear accountabilities and responsibilities and was known to staff. All those we spoke with were clear who their immediate manager was; this was not the case on the last inspection visit in 2015.

  • The majority of staff reported positive changes in their workplace culture and spoke of approachable and supportive middle managers. We saw real warmth in the relationships between ward leaders and nurses and from the HoN towards their wider team. One team of staff felt their manager was less approachable and they felt less supported but this appeared to be about an individual middle manager’s approach.

  • Black and minority ethnic (BME) reported that they felt supported and accepted as part of the hospital workforce. We saw respectful and confident interaction between BME staff and white British staff on the wards we visited.

    However

  • The trust systems for the management of patient records were new and not yet fully embedded.Patient records had been moved off site and were retrieved when needed but staff reported some delays in this. There were times still when patient records were not available for pre-assessment clinics and consultations.

  • There was a high vacancy rate of 12% for surgical nursing staff and the service was highly reliant on bank and agency staff for both nursing and medical staffing. Recruitment continued to provide challenges and whilst the trust had taken many steps to address this, the problem of recruiting sufficient permanent staff continued. The nursing staffing levels had improved since our previous inspection visit in September 2014. Theatres staffing met the recommendations of the AfPP and ward level planned nursing staffing versus actual staffing was usually met, albeit with temporary staff.

  • The trust’s referral to treatment time (RTT) for admitted pathways for surgical services had been worse than the England overall performance since July 2015.

  • There were 735 mixed sex breaches on surgical wards at EDGH during a 12-month period. The reason for these was not documented in most cases.

Intensive/critical care

Good

Updated 27 March 2015

The intensive care service used procedures to ensure that patients received safe and effective care. Clinical outcomes were monitored and were similar to units of similar size. Practice changed where required improvements were identified. Staff were caring and compassionate, working to maintain privacy and dignity of their patients. However, some improvements were needed in bed management processes to ensure that patients did not remain in the intensive therapy unit (ITU) longer than required and patients requiring critical care were managed in an appropriate setting. Clinical leadership on the unit was strong and supported staff development. However, changes to the clinical unit management team led to a lack of engagement with ITU staff, making it difficult for clinical staff to develop plans for the future.

Services for children & young people

Requires improvement

Updated 27 January 2017

We rated this service as requires improvement because:

  • There was no play service provision at the hospital.

  • Incident reporting, whilst improved from 2014, was still inconsistent and did not reflect the number of incidents that should have been reported

  • The hospital had no paediatric recovery nurse

  • Paediatric nurse cover overnight in the emergency department was limited.

  • A number of pathways and policies were still in development

  • Waiting times for outpatients appointments for some patients were excessive

  • The appointment system was not working well and patients were not being sent letters regarding upcoming appointments

  • Transfers to the Conquest hospital were taking place very late from the SSPAU

  • There were no explicit criteria to guide staff as to whether a child should be transferred by ambulance or fit to go by private car.

However:

  • The Friston Unit was clean, uncluttered and had a good play area for children.

  • We saw a good example of staff adhering to the duty of candour

  • We were given positive accounts about the compassionate care children had received from parents and children themselves

  • All staff were aware of the vision and strategy for the trust and how services for Children and Young People fits in.

  • Initiatives had been introduced to help keep children out of hospital.

  • There were plans in place to have a paediatric nurse in the emergency department and on the wards on a rotational basis.

  • Links between acute and community services were good.

  • There was clear line management and staff were aware of their responsibilities.

  • Service development was being encouraged.

End of life care

Requires improvement

Updated 27 January 2017

Overall we rated the end of life care service at Eastbourne District General Hospital 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 (2005) assessments and recording of ceilings of care (best practice to guide staff, who do not know the patient, to know the patients previously expressed wishes and/or limitations to their treatment) for patients with a completed Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) form.
  • Patients did not have access to a specialist palliative support, for care in the last days of life in all cases, as the hospital did not have a service seven days a week.
  • The specialist palliative care team at the hospital did not have a weekly multidisciplinary meeting to discuss all aspects of patient’s medical and palliative care needs.
  • The hospital did not have a rapid discharge process for end of life care patients to be discharged to their preferred place of death.
  • The hospital did not monitor or record end of life care patient’s referrals to the chaplaincy team.
  • 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 that we saw were all completed in accordance with national guidance.
  • 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 medical team at the local hospice.
  • A current end of life care policy was evident and a steering group met regularly to ensure that a multidisciplinary approach was maintained.

We identified some improvements in the service but judged that it still needed further work and investment to ensure it could continue to meet the needs of the patients it served. There was better end of life care planning and recording of individual care needs and preferences.

We could see that discussions with patients and their relatives were now taking place around dying. All the DNACPR forms that we saw were correctly completed with clear reasoning and recording that the decision to withhold resuscitation had taken place. Previously, DNACPRs were poorly completed, with limited information as to why the decision had been made and whether there had been any family involvement.

The bed management arrangements had been revised since our previous visit and site managers were now clear that where a patient was receiving end of life care there was an expectation that they would be nursed in a side room. Movement of these patients was restricted and made only when all other possibilities had been considered.

Outpatients

Requires improvement

Updated 27 January 2017

We found the outpatient and diagnostic imaging services at Eastbourne District General Hospital to be 'requires improvement'. This was because:

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

  • The diagnostic imaging department did not clearly demonstrate or document the process of investigating incidents or follow its own incident reporting policy. The radiology manager did not have a clear understanding of reporting incidents under IR (ME) R.

  • The diagnostic imaging department had not met the target for mandatory training, which included safeguarding training.

  • The trust referral to treatment time (RTT) had fallen below the 92% standard from March 2016 onwards.

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

  • Morale was described as low by some staff 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.

However

  • The outpatient department had systems and processes in place to keep patients free from harm. Incident reporting was now embedded in everyday practice and there was evidence of learning from incidents.

  • Infection prevention and control practices were in line with national guidelines. The department was clean and there was a newly refurbished reception area. Staff adhered to the trust infection prevention and control policies.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. Equipment checks were taking place and labels were used to clarify when equipment had been cleaned and was ready for re-use.

  • 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. Records were available for clinics; the number of temporary records was monitored daily using the clinical administration dashboard. Less than 1% of appointments were held where records were not available, which was in line with the trust target.

  • Records were accurate, legible, complete and were stored securely. The outpatient service was in the process of centralising the records store and planned to scan all paper records onto an electronic system.

  • Safeguarding arrangements were understood and followed by staff. Training, to an appropriate level, was provided and senior advice was readily available.

  • The hospital had a comprehensive audit programme in place to monitor services and identify areas for improvement. The outpatient and diagnostic imaging departments participated in a variety of local and national audits to demonstrate compliance with best practise, professional standards and National Institute for Health and Care Excellence guideline (NICE) guidelines.

  • The outpatient services had sufficient numbers of competent staff to provide their services. Staff completed appraisals regularly and managers encouraged them to develop their skills further.

  • There were differentiated outpatient pathways to meet the needs of different groups of patients. Particular consideration was given to meeting the needs of patients on cancer pathways.

  • We observed good radiation compliance as per national policy and guidelines during our visit. A radiation protection supervisor was on site for each diagnostic test and a radiation protection adviser was contactable if required. This was in line with ionising regulations, 1999 and the ionising radiation (medical exposure) regulations (IR (ME) R, 2000).

  • Consent was obtained and recorded in line with national guidance and the trust policy. Staff had a sound understanding of the Mental Capacity Act (2005) and how this impacted on their work.

  • 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.

  • Patient engagement had developed and hospital staff worked with the local Healthwatch, a patient experience group and local community to listen and work together to improve experiences.

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

  • Staff in outpatients felt engaged and involved with their work in local departments and throughout the trust. They had a daily safety huddle and the key points discussed were displayed for staff working later in the day to see and be informed of..

We noticed considerable improvements in the way the outpatient services were now being managed when compared to the findings from our previous inspection visits.

We reported serious concerns about both the availability and condition of individual medical records after both the September 2014 and March 2015 inspections. In March 2014 we saw that one clinic of 24 patients had run with seven sets of notes unavailable. We were told this was usual. The trust did not hold data relating to missing notes at the time of that inspection. From the current inspection visit we saw data was now collated that the service was meeting the trust target of less than 1% notes missing. A new tracker system had been introduced and records storage had been moved offsite with a retrieval system put in place. The trust was in the process of introducing an electronic records system with all current records being scanned into the system before it went live.

The premises looked cleaner and some areas had been refurbished. At this inspection, we saw all cleaning audits were in line with these specifications. Scores for cleanliness audits showed high levels of compliance in all areas. Staff were adhering to the trust policies on infection prevention and control.

At our last inspection we saw the diagnostic imaging department did not provide space and privacy for patients in gowns to maintain their dignity. The department had been redesigned so this issue had been resolved.

The trust had seen an improvement in their performance over time against the two-week standard for urgent GP referrals and data suggested the trust met the 93% operational target with performance of 96.1%. At this inspection, 12 of the 16 speciality groups were better than the England average for incomplete pathways (18-week targets) and four were worse than the England average for incomplete pathways.