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Blackpool Victoria Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 4 February 2014

Blackpool Teaching Hospitals NHS Foundation Trust operates from three sites:

  • Blackpool Victoria, which is the main hospital site and the focus of much of its work.
  • Clifton Hospital, which currently has four wards, mainly for elderly care and rehabilitation (with one outpatient clinic).
  • Fleetwood Hospital.

This report relates to the acute core services at the Victoria Hospital site.

Blackpool Victoria is a large acute hospital that treats more than 80,000 day-case and inpatients and more than 200,000 outpatients from across Blackpool, Fylde and Wyre every year. Its Emergency Department sees more than 80,000 attendances every year. The hospital has 767 beds and employs more than 3,000 members of staff. It provides a range of services from maternity to care of the elderly, and from cancer services to heart surgery.

Blackpool Victoria is one of four hospitals in the North West that provides specialist cardiac services and serves heart patients from Lancashire and south Cumbria.

We found that the trust had undertaken work on improving clinical pathways. This was engaging clinicians, and these were well used. This was having a positive impact on the mortality data that was being measured. Some pathways (e.g. heart failure) require further work.

The hospital’s reporting of incidents was poor in some areas where some staff did not report near misses, and some staff reported incidents on behalf of others. This means that the hospital and trust could potentially miss out on valuable learning and therefore improve services.

The quality of patients’ clinical records was poor; handwriting was sometimes illegible and often difficult to read. Accessing information was challenging because of the filing of case notes. This may delay access to important clinical information and impact on continuity of care. Delays in access to case notes is already a challenge, particularly in outpatients.

We saw good participation in clinical audit and use of the data from this. This is an important way for the trust to develop its clinical services.

The trust has a higher than expected rate of primary postpartum haemorrhage (significant bleeding after childbirth). There is also a high rate of hysterectomy in these patients. This is under investigation by the trust.

We observed good caring by all levels of clinical and medical staff, and high levels of patient satisfaction for the way that staff delivered treatment and care.

The trust had made improvements to its services following feedback from its patients (e.g. ward 12) although some areas, such as stroke services, still required additional action. It had also improved facilities for patients in children’s and maternity services.

Many people we spoke to did not know how to share feedback or complaints with the trust. This is a valuable opportunity to develop services that is being lost to the trust.

Inspection areas

Safe

Requires improvement

Updated 4 February 2014

Overall we found implementing patient new clinical pathways had a positive impact on the hospital’s patient care management. This work engaged clinicians. We saw that the patient pathways were well used within the trust. Work on other pathways (e.g. heart failure) is required.

In some areas, incident reporting could be improved through both timely reporting and reporting near misses. Among junior grades, greater ownership of reporting is needed.

There were significant challenges with medical records. We observed a number of examples of illegible handwriting in patient notes. Delays in access to records lead to delays in care, and filing systems made accessing information within hospital records difficult.

Staffing levels were good in some areas (e.g. children’s care services), but in other areas staffing levels were low or were designed to support poor systems.

The trust had upgraded and improved some facilities on the Blackpool Victoria site. We also noted areas of poor hand-washing and examples of dirty equipment. We also saw inappropriate use of some facilities such as a sluice room being used to see patients.

Effective

Requires improvement

Updated 4 February 2014

The hospital was using evidence-based clinical pathways. We also noted that Summary Hospital-level Mortality Indicator data showed an ongoing reduction in mortality. It is believed there is a strong link between these two elements. There is, however, further work to be done before mortality reduces to a level closer to the England average. The current efforts in some areas appear to be having a positive impact.

There was widespread use of the World Health Organisation surgical checklist. In addition, the surgical ‘five steps to safer surgery’ process has been recently implemented.

There was good audit participation and use of the data to amend or alter services in response to issues raised by audit.

We were concerned that the rate of primary postpartum haemorrhage (haemorrhage after birth) rate was high and that the number of patients subsequently requiring hysterectomy following this was also high. We note that the Royal College of Obstetrics and Gynaecology (RCOG) is involved in attempting to understand these high rates (this is at the request of the trust).

Good multidisciplinary working is evident in many areas.

We heard of an ongoing investigation by the trust into diabetic care and patient management. We also heard of implementation of the recommendations of an external report on breast surgery and outpatient clinics following some issues identified by the trust’s internal review processes.

Caring

Good

Updated 4 February 2014

We spoke to many patients who reported a positive experience of care within the trust. We noted specific examples, which supported the staff and the hospital’s approach to patient care. We saw members of staff building good relationships with patients and their families.

Overall the hospital has tried hard to preserve the dignity and privacy of each patient.

There were good examples of end of life care and a strong input from the chaplaincy.

Responsive

Requires improvement

Updated 4 February 2014

There are good facilities in areas where the trust has upgraded and invested, such as Ward 12 (Gastro), the children’s unit and maternity. However, we also saw areas where improvements still need to be made. In some areas the trust has made improvements in response to audit results, such as stroke services. We also saw examples of facilities (e.g. outpatients services use of a sluice room for seeing patients) that were inappropriate for patients’ needs or activity levels.

We saw good examples of how the trust has responded to the needs of individual patients by adjusting clinical lists (e.g. children’s services). Also good examples of staff supporting vulnerable patients and patients being discharged in a supportive manner from accident and emergency and critical care.

Many patients do not understand how to give feedback or make a complaint to the trust.

Well-led

Requires improvement

Updated 4 February 2014

The executive team’s visibility had increased within the trust, and the trust had taken many positive steps to achieve this. However, we found that in some areas there was a disconnect between the board and clinical services.

There was a positive culture among those working in the hospital, and many members of staff expressed strong loyalty. Staff expressed positive feelings towards the organisation and their work.

Staff also felt able to praise the work of other teams, and many were highly complementary of each other.

We heard examples of innovation that the trust was not assessing. One example of increased radiographer-led reporting and one of speech and language therapists supporting patients in their own home were both shared openly. We were unable to form a view of whether these innovations had merit, but note that they were worthy of formal evaluation. There does not appear to be an effective mechanism to evaluate and then either support or dismiss ideas or improvement opportunities.

Checks on specific services

Maternity and gynaecology

Good

Updated 29 January 2016

At the last inspection areas were identified in the maternity services which were inadequate and others that required improvement and an action plan had been developed to address these which has been monitored regularly. At this inspection in September 2015 we found improvements had been made in the number of incidents being reported and the number of post-partum haemorrhages had reduced at the trust. Staffing levels in maternity services were being safely managed and a new midwifery staffing model had been introduced which had impacted positively on the department.

We found that women using maternity services had a high regard for staff and clinical teams, who were caring and treated patients with dignity and respect. There was a good incident reporting culture and systems were in place to ensure lessons were learned. Policies and procedures were up to date and in line with NICE guidance.

The outcomes for patients were in line with the England average on most of the compared measures. Where they were worse this had been investigated and actions taken. There was a good system to triage patients who were admitted to the unit. Patients were offered choice of place for delivery and were included in the decision making for their care. There was good inclusion of the patients and systems for engagement with patients and staff were in place.

However, not all areas of the maternity unit or equipment met with infection prevention and control guidance. The systems for checking the maintenance of equipment and its readiness for use in an emergency were not robust. Training compliance in some key areas including skills and knowledge in emergency situations did not yet meet the trust’s target.

Medical care (including older people’s care)

Requires improvement

Updated 4 February 2014

The systems and processes in place to maintain the safety and effectiveness of the service required improvement. Some staff relied on others to report incidents and others rarely reported ‘near misses’, believing it was not necessary to report an incident unless a patient came to harm or an incident actually occurred.

Record keeping was poor. Some patients’ records were incomplete and difficult to read and interpret, and there were a large number of errors in the recording of medicines on one ward.

There was no mechanism for the identification and onward referral of patients with heart failure who were admitted to general medical wards. In addition, there was no treatment pathway in place for patients with heart failure.

Staffing levels were sufficient for staff to be able to provide safe and effective care. Patients were looked after by caring and compassionate staff, and the services were responsive to people’s needs. We found that, generally, the wards and departments were well-led, although there was a disconnect reported to us between the staff providing hands-on care and the executive team. 

Urgent and emergency services (A&E)

Requires improvement

Updated 29 January 2016

We rated urgent and emergency service overall as requires improvement. We rated the services as good for being safe, caring and responsive and requires improvement for being effective and well-led.

At this inspection in September 2015 we found some areas had improved since the last inspection. However, the results of national CEM audits showed that there were improvements to be made in a number of areas where they were in the bottom 25% of participating trusts nationally. Plans were in place to improve and these were regularly monitored. The time to mental health assessment remained a concern with many patients waiting over four hours for assessment although the trust was working with external partners providing mental health services to address this.

We also found that systems for checking essential equipment continued to require improvement since the last inspection when this was raised. The hospital managers took mitigating action before we left the site. However, there were some basic equipment shortages which were having a minimal effect on patients but are worthy of the hospitals attention.

We also noted a shortage of hand sanitizers in the entrance and an induction loop system to help hearing aid users was not working at the time of our inspection. Staff did not always utilise the language support for patient whose first language was not English and were satisfied for a relative to translate.

Leadership of the service through the service manager and lead consultant had been improved through the employment of a matron with sole responsibility for the A&E department. The new matron however, had only been in post for two months. We noted that nurse appraisal rates were below the expected and the frequency of departmental meetings was very low. Although the meetings had been reintroduced it was too early to understand the efficacy of them or the matrons role on the culture and understanding of risk and improvement in the department. However, there was a strong multidisciplinary team in the department and staff were positive and proud of the work they did.

The layout of the department continued to hinder the flow of patients, bed management ensured capacity was monitored and managed but when the department became busy patients waited on trolleys in the walkway whilst waiting for a cubicle. The service had escalation processes in place. The 4 hour wait standard was not always met but it was better than the England average. The percentage of patients leaving the department before being seen was slightly higher than the England average however the re-admission rate and percentage of patients waiting 4 to12 hours before being admitted were similar to the England average.

The separate, newly refurbished children’s department was not as busy as the adult side. Patient flow was good and it was rare for patients not to be treated within the four hour target. However, the average time each patient spent in the emergency department was above the England average between April 2013 to March 2015.

Staffing levels for both doctors and nurses had improved but bank and agency staff continued to be needed to cover vacancies. The emergency department was visibly clean. Patients nutrition and hydration needs had been assessed and patients had food and drinks where appropriate. Staff followed infection prevention protocols. There was a good skill mix of competent staff for both adult and paediatric patients. We saw effective collaboration and communication among all members of the multidisciplinary team and services were set up to run 7 days a week. Compliance with mandatory training did not yet meet the trust’s target but was on track to meet it by year end. Complaints were managed well and there was evidence of learning from them. The trust was investing in the senior staff through leadership training and coaching. Staff were positive and proud of the work they did.

Patients described a positive experience and we observed staff treating patients with compassion, respect and dignity. Patients were involved in their care and treatment being supported to make informed choices. The department Friends and Family test scores were consistently above the national average.

The organisational vision and values had been cascaded to all staff however there was a lack of documented service level strategy although the direction of travel was planned with eight key actions highlighted by the A&E leadership team. A trust wide strategic review was underway at the time of the re inspection.

There was a current A&E strategy, developed in December 2014, which was under review at the time of the inspection. The current work underway in developing a trust wide strategy would inform the future A&E strategy.The lead consultant and senior managers were aware of their challenges and there were escalation processes in place for dealing with additional demand.

The department risks were monitored through the unscheduled care risk register which was up to date. These risks, incidents and performance were reviewed through the regular clinical governance meetings and appropriate actions taken.

Surgery

Requires improvement

Updated 4 February 2014

There were effective systems and processes in the surgical ward and theatres to provide safe care and treatment for patients. Patient safety was monitored and incidents were investigated to assist learning and improve care.

National best practice guidance was not always followed. The trust followed best practice guidelines, such as those produced by the National Institute for Health and Care Excellence (NICE) and it participated in national clinical audits. However, trust compliance with national guidelines (such as the hip fracture guidelines relating to pre-operative assessment by an orthopaedic geriatrician) could be further improved. We understand however that a review is being undertaken by an appropriately trained senior nurse in line with the trust’s clinical pathways.

The staffing levels and skills mix was sufficient in the majority of areas we inspected. However, there were not enough appropriately trained nursing staff to meet patients’ specialist needs in the surgical assessment unit and ward 15a, mainly due to staff sickness levels. The trust has identified that it needs to improve staffing levels, and it has plans in place to improve these.

We found that patients’ notes were not always completed appropriately. Information such as daily reviews by doctors and discharge records were not always completed. Accurate medical records for each patient completed in a timely way are the basis for robust decision making. All staff should write in notes as soon as decisions are made.

Ward rounds by medical staff on some wards were not regularly undertaken. This made it difficult for staff to have regular and timely decision and discussions on the care of individual patients. This could cause delay in both care and discharge.

The surgical wards and theatres were clean, safe and well maintained. Staff worked effectively as a team within the specialties and across the surgical services. There was sufficient capacity to ensure patients could be admitted promptly and receive the right level of care. The trust had action plans in place to improve waiting times for patients awaiting surgery and to reduce the number of cancelled operations. However, the actions had not yet been fully implemented and their effectiveness could not be measured.

Patients spoke positively about their care and treatment. There were systems in place to support vulnerable patients. There was effective teamwork and clearly visible leadership within the surgical services. Staff were appropriately supported with training and supervision and encouraged to learn from mistakes. 

Intensive/critical care

Good

Updated 4 February 2014

There were effective systems and processes in critical care services to provide safe care and treatment for patients. Patient safety was monitored and incidents were investigated to assist learning and improve care. The critical care services performed in line with similar-sized hospitals and performed within the national average for most measures.

There were not enough appropriately trained nursing staff to meet patients’ specialist needs in the intensive therapy unit and the high dependency unit. The number of middle grade doctors was not sufficient to ensure that there was 24-hour cover available by at least one registrar. The trust had identified that it needed to improve staffing levels, and it had plans to do this.

We found that there was room for improvement in communication between the cardiac ITU and the general ITU and HDU.

Care was provided by trained staff in accordance with national guidelines, and staff used enhanced care pathways. The critical care services were clean, safe and well maintained. There was sufficient capacity to ensure patients could be admitted promptly and receive the right level of care. Patients or their representatives spoke positively about their care and treatment. There were systems in place to support vulnerable patients.

There was effective teamwork and clearly visible leadership within the critical care services. Staff were appropriately supported with training and supervision and encouraged to learn from mistakes. 

Services for children & young people

Good

Updated 4 February 2014

Children care was safe, effective and well-led.

The environment provided excellent service for children and young people. The layout of the facilities and the thought in design of the building was seen by the team as an excellent example of a children’s unit. There were appropriate toys, well equipped play areas and a sensory room for children with special needs. Children and young people received care from a range of staff who had specialist knowledge in caring and treating children and young people. Parents we spoke to reported that they had been kept informed and involved in the care of their child by the staff.

Children and young people were listened to and had the opportunity to shape the service for the future.

End of life care

Good

Updated 4 February 2014

The trust has a multi-professional approach to end of life care, working in partnership with Trinity Hospice and the trust’s palliative care services. This means that good practice was shared across both the trust and Trinity Hospice. The trust continues to use the Liverpool Care Pathway for people in the last few days of their lives. Staff we spoke to within all areas visited were aware of the procedure to follow in end of life care, ensuring a good experience for patients and a safe approach to care.

The palliative care team focused on ensuring the provision of high quality services that meet the needs of the patients and their families who used their service. It underpinned its practices with the belief that care for the dying is part of the core business of the organisation. If care was necessary within the hospital environment, the palliative care team provided support and information to the patient, their families and the care team working on the ward.

People told us that they were satisfied with the care they received from the palliative care team. For patients who remained in hospital, plans were put in place to ensure that their wishes were respected. We spoke to one patient and two families of patients who were using palliative care services at the hospital. They told us they were satisfied with the care being provided. One patient told us they were happy with all of the care and support provided by staff. They said, “It’s a wonderful place.”

The evidence we found indicated that the ‘care of the dying’ pathway was being followed from diagnosis until after death and that patients were receiving appropriate support and compassionate care.

Outpatients

Requires improvement

Updated 4 February 2014

Patients received effective, safe and appropriate care. The outpatient areas were clean and well maintained. However, we observed staff taking patients into sluice rooms to be weighed, which is not clinically appropriate.

Patients told us that waiting times were at times unacceptably long, up to 40 minutes in some departments. However, the 18 patients we spoke with told us that they were generally satisfied with the service they received.

We found that all of the outpatient areas respected patients’ privacy and dignity, as people were seen in consultation rooms.

We also noted that if English was not a patient’s first language an interpreter could be booked in advance of their appointment. However, we were unable to meet with any interpreters at the time of our inspection.

Staff were aware of how to report an incident and the procedure for completing the report.

We saw there were clear leadership structures in place and staff were very supportive of their colleagues. All outpatient staff said that they were well supported in their roles.