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Chorley and South Ribble Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 21 April 2017

Chorley and South Ribble Hospital provides a full range of district general hospital services including urgent care centre, critical care, coronary care, general medicine including elderly care, general surgery, orthopaedics, anaesthetics, stroke rehabilitation, midwifery-led maternity care, and breast service.

The hospital has around 220 beds, large operating theatre complex, outpatient suites, and education facilities.

We inspected the hospital as a focused follow up to the inspection in July 2014 where the hospital was found to require improvement in the safe, responsive and well led domains and good in the effective and caring domains. We visited Chorley and South Ribble Hospital between 27 and 30 September 2016.

Following this inspection we have rated the hospital as requires improvement overall and the trust needs to make improvements. Staff were noted to be caring and patient focused and the caring domain was rated as good in all service areas.

We saw several areas of outstanding practice including:

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  • In outpatients the introduction in dermatology of a computerised diary colour codes patients by procedure enabling the service to plan a block of 12 week care in one go to suit the requirements of each patient. It also flags and calculates potential breeches giving better patient flow, facilitating comprehensive audit of care provision and outcome of treatment.
  • In the urgent care centre the housekeeper helped make sure elderly patients being discharged home had basic groceries provided such as bread or milk.

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

Importantly, the trust must:

Urgent Care services

  • Take action to help control risks associated with the room identified for mental health patients must be actioned and appropriately documented.
  • Ensure records of controlled drug use in registers are kept in line with trust policy.
  • Ensure mandatory training compliance reaches and consistently achieves the trust target.
  • Ensure clinical staff are aware of and adhering to the requirement for senior review of specific patient groups prior to discharge from the ED.
  • Ensure action plans following CEM audits target areas of poor performance and improve practice and that clinical staff are aware of and engaged with the process of clinical audit.
  • Ensure version control for policies, procedures and guidance is robust and that these are kept up to date and reviewed regularly.
  • Ensure the department has a dedicated risk register with start dates, timelines, mitigating action and responsible person and review dates included.
  • Ensure major incident plans are updated to reflect the current use of the department.
  • Improve communication and improve the negative culture centred on a lack of communication and feelings of mistrust amongst staff.

Medical Care (including older peoples care)

  • The trust must ensure that all staff receive appraisals and complete mandatory training to enable them to carry out the duties they are employed to perform.
  • The trust must ensure that records are kept secure at all times, so that they are only accessed by authorised people.
  • The trust must ensure procedures in place around medicine management are robust and that policies are followed.
  • The trust must ensure the risk registers are consistent and demonstrate mitigating actions and review dates.

Surgery

  • Take appropriate actions to improve compliance against 18 week referral to treatment standards.
  • Take appropriate actions to reduce the number of cancelled operations and the number of patients whose operations were cancelled and were not treated within the 28 days.
  • Take appropriate actions to improve staff training compliance in adult and children’s safeguarding training.

Critical Care

  • Improve the uptake of mandatory training particularly in safeguarding children and adults.

Maternity & Gynaecology

  • The hospital must ensure midwifery and support staffing levels and skill mix are sufficient in order for staff to carry out all the tasks required for them to work within their code of practice and meet the needs of the patient.
  • The hospital must ensure all necessary staff completes mandatory training, including Level 3 safeguarding training and annual appraisals.
  • The hospital must complete risk assessments for midwives carrying medical gases in their cars and develop a Standing Operating Procedure (SOP) or protocol for carrying medical gases by car.
  • The hospital must ensure that all staff receives medical devices training to ensure all equipment is used in a safe way

Outpatients and diagnostic imaging services

  • Ensure that clear processes and structures are in place for the management and reviewing of governance, quality and risks.
  • Review the processes for managing access and flow for outpatient services to ensure patients are not at risk.
  • Ensure staff complete mandatory training as per the trust policy.

In addition the trust should:

Urgent Care services

  • Have access to written information in languages other than English.
  • Encourage staff to use an approved method of translation rather than relying on web based public translation tools.
  • Improve access to regular teaching for medical staff.
  • Ensure staff meetings are regularly held with minutes taken to record discussions.
  • Introduce a mandatory daily handover between staff starting and finishing work, and document the details being discussed.
  • Rotas should be stored in an organised and accessible to the right staff at all times.
  • Improve root cause analysis to include the root cause of the incident.
  • Improve the attendance of staff invited to safeguarding meetings
  • Provide staff with results from hand hygiene and cleanliness audits for their department to help make sure they are able to monitor staff performance rather than results inclusive of multiple wards or directorates.

Medical Care (including older peoples care)

  • The trust should ensure that patients are discharged as soon as they are fit to do so.

  • The trust should ensure that patients are not moved ward more than is necessary during their admission and are cared for on a ward suited to meet their needs.
  • The trust should ensure that patients have access to pressure relieving equipment at all times.
  • Consider implementing formal procedures for the supervision of staff to enable them to carry out the duties they are employed to perform.

Surgery

  • Take appropriate actions to improve staff appraisal completion rates.
  • Take appropriate actions so that emergency equipment is securely stored.

Critical Care

  • Consider improving appraisal rates as these were lower than at the previous inspection.
  • Consider improving the management of the followed up of audit action plans.
  • Consider increasing the number of staff who had undertaken a post qualification course in critical care nursing in order to meet the Intensive Care Standards guidelines.
  • Consider improving the access to specialist critical care trained pharmacist services on weekends.

  • Consider increasing the monitoring of patient satisfaction as the service did not participate in the NHS friends and family test.

  • Consider improving the level of Physiotherapy staffing to meet the minimum expected standards.

Maternity & Gynaecology

  • The hospital should improve the recording of the review dates and version control of all policies and procedures.
  • The hospital should improve attendance at governance meetings.
  • The hospital should improve staff annual appraisal rates.
  • The hospital should increase staff training uptake for Female Genital Mutilation (FGM) training.
  • The hospital should work to better understand the variation inunplanned home birth rates to ensure safety of patients and babies.
  • The hospital should strengthen the risk registers to support the management of risk.

Outpatients and diagnostic imaging services

  • Consider monitoring and reviewing the procedures for caring for vulnerable patients attending for cancer therapy.
  • Consider improving the environment in the Outpatients department to ensure privacy and dignity is maintained.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 21 April 2017

Effective

Requires improvement

Updated 21 April 2017

Caring

Good

Updated 21 April 2017

Responsive

Requires improvement

Updated 21 April 2017

Well-led

Requires improvement

Updated 21 April 2017

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 21 April 2017

At the previous inspection in July 2014 we rated the service as good overall. Following this inspection we rated have this service as requires improvement overall because:

  • All staff reported a shortfall in staffing and an increasing quantity of work and activity within the service. Management told us that the midwifery staffing levels had not been formally reviewed since 2011. This was also a concern raised at the time of the last CQC inspection in 2014. Although it was noted that  since 2014, there had been an increase of 10 full time midwives.
  • The maternity service was currently waiting for the Birthrate Plus (a national tool available for calculating midwifery staffing levels) review and report, which will calculate the number of clinically active midwives required to deliver a safe high quality service.
  • Due to staffing issues and sickness absence rates, there was a heavy dependence on midwives working extra hours. The trust did not use agency staff but used their in-house bank staff on an ongoing basis. Midwives working over and above their normal working hours provided additional midwifery staffing. Community staff gave us examples of working a 24-hour shift and managers working a 60-hour week.
  • All midwifery staffing, including community were flexed to meet the needs of the service user. Managers were aware of the staffing shortfall and recruitment was underway. Staff informed us that the current measures in place were not sustainable and insufficient to mitigate the risk of harm. Due to the pressures of work, staff morale was low but staff of all professions supported each other well to work as a team. There was a desire to provide the best care they could to the patients and the inability to achieve this led to dissatisfaction amongst midwives.
  • Not all staff attended annual mandatory training or received their annual appraisal performance review in order to discuss and evaluate job performance and career development.

However:

  • There was an integrated service between the community midwives and the two birth centres at RPH and CDH.
  • Care at the Chorley Birth Centre was provided in a calm, relaxed and spacious environment that had been specifically designed and equipped to support normal births. The centre comprised of spacious en-suite birthing rooms, each with a birthing pool, specialised birthing equipment and separate family rooms.
  • There were clear systems for reporting incidents and managing identified risk within the service.
  • Clear protocols and prompt cards were in place for all staff with relevant training in the management of obstetric emergencies. Regular training sessions were held with the ambulance service regarding transfers from the birthing centre at Chorley to the obstetric unit at RPH.
  • CBC used a carbon fibre “Baby Pod” as a transport device for unwell babies who need transferring to RPH by ambulance. The unwell baby is comfortably secured in position by a vacuum mattress and soft positioning straps. The vacuum mattress is moulded around the baby and air is removed with the aid of a vacuum pump to hold the mattress in shape. All resuscitation procedures can be continued while the baby is securely positioned in the pod.
  • Medicines were delivered, stored and dispensed safely.
  • The wards were adequately maintained and equipment was readily available and fit for immediate use. Resuscitation equipment was available and fit for use by suitably trained staff.
  • We found that committed and compassionate staff delivered maternity and gynaecology services. All staff treated patients with dignity and respect. People we spoke to were positive about the care they had received.
  • Gynaecology staff informed us that referral to treatment times met the national recommendations, with rapid access to clinics available.

Medical care (including older people’s care)

Requires improvement

Updated 21 April 2017

We rated medical services at Chorley and South Ribble Hospital as requires improvement overall because:

  • There were staff vacancies in most areas and there were occasions on wards when there had been a reliance on agency or bank nurses as well as locum doctors. Data provided showed there were occasions when the staffing levels were less than 80%.
  • Overall compliance with mandatory training for all staff was below trust target. The trust target was 80%.
  • There was a risk that personal information was accessible to members of the public as patient’s records were not always stored securely.
  • There were systems for handling and disposing of medicines however incidents had occurred and we identified areas that required improvement.
  • Clinical staff had access to information they required. However, patient’s risks were not always being identified, monitored or addressed.
  • There were ongoing issues with the access and flow of patients across the medical wards and there were occasions where there was insufficient bed capacity on the medical wards to meet the needs of people. However there were systems in place to ensure those patients on non-medical wards were reviewed by the medical team.
  • There were occasions when patients experienced one or more moves during their hospital stay with some patients being moved during the night.
  • There were governance structures in place which included a risk register. However there were inconsistencies across the divisional and trust risk register. Actions on the register had no additional mitigation action or timeframes for completion and it was unclear if these were being managed in an effective way to lower the risk.
  • Policies and procedures were in place however we are not assured all of these reflected current practice as they were not always reviewed as planned.

However:

  • The trust were monitoring and taking actions regarding staffing levels including rolling recruitment, including overseas and regular monitoring of staffing levels during the day to help mitigate the risk.
  • Wards were visible clean and the majority of staff followed good hand hygiene practices.
  • The majority of staff were aware of the trusts values and vision.
  • Staff were proud of the work they did and well supported by their managers and worked collaboratively together to ensure patient were cared for.
  • Staff treated patients and their relatives with respect and dignity and communicated with them effectively. Patients were happy with their care, felt informed, and were involved in care planning.

Urgent and emergency services (A&E)

Requires improvement

Updated 21 April 2017

  

In our previous inspection in July 2014, we gave Urgent and Emergency Services an overall rating of Good. Following this inspection, we have changed this rating to requires improvement. This is because:

  • The daily recording of controlled drug use, stock and record checks was not done consistently.
  • Compliance with staff training was low with only 42% of doctors and nurses compliant overall.
  • Not all medical staff were aware of the need to obtain senior clinical review prior to discharging certain high risk patients such as those suffering chest pain.
  • Attendance at monthly safeguarding meetings was poor.
  • Processes were in place to manage risks to patients but these were not always followed. For example, doctors were unaware of the need to obtain a senior medical review prior to discharging certain patients and low levels of staff were compliant with advanced paediatric life support training.
  • Trust major incident plans required the UCC to accept all emergency patients should a major incident be declared but no provision was in place for when the UCC closed at night.
  • Whilst local guidance was in place and accessible, we found that review and update processes were not robust and some guidance appeared to be several years out of date.
  • Although the department took part in national audit programmes, we saw little evidence of action to address poor results. Instead staff relied on incidents of poor practice to help them identify issues. Staff were unaware of clinical audits being undertaken in the department.
  • Medical staff told us teaching did not take place often enough in the UCC.
  • Although services were in place for people living with dementia, staff gave vague responses when asked about care.
  • Reception staff were unable to locate approved phrase books to assist with language barriers which meant they used a public web based translation service if patients did not have written details with them. Although leaflets were available providing information following discharge from the UCC, none of these were displayed in languages other than English.
  • Despite senior staff being aware of complaints through monthly governance meetings, we were less assured that this information was disseminated to staff as staff meetings were infrequent.
  • Although risk registers were in place, these did not include enough information and were not specific to the ED. Some risks such as issues with meeting national targets were not included.
  • Governance was in place in the department but this was not robust. For example, data was collected centrally but not broken down specifically to departmental level. This left us concerned that staff were unaware of basic governance matters such as overall cleanliness or record quality. Staff reported that staff meetings did not occur regularly.
  • The culture was affected negatively by staff feeling unsure about plans for the future. They described an atmosphere of mistrust and suspicion. We also heard numerous staff tell us communication was not good which contributed to this.
  • Staff engagement and communication was described as ‘awful’ by staff, particularly about the change from ED to UCC provision.

However:

  • There was an open, no-blame culture of reporting and learning from incidents with the majority of incidents resulting in low or no harm.
  • Staffing was adequate for both medical and nursing staff despite vacancies.
  • Areas were visibly clean and tidy with cleaning staff available each day. Environments were pleasant light and airy.
  • Safeguarding was managed centrally; with useful flow charts and support from lead nurses should staff have any queries.
  • Guidelines were based on national guidance.
  • Pain was monitored and a range of pain relief was available should it be required.
  • A range of food and refreshments were available for patients and loved ones visiting the department
  • Staff competencies were maintained using information sharing and teaching. Revalidation was monitored regularly.
  • Staff had access to the information they required to provide care for patents.
  • Staff were aware of the need for consent and we saw evidence that consent was obtained appropriately.
  • Patients told us staff caring for them were ‘friendly’ and ‘supportive’.
  • Patients completed surveys which showed 93% would recommend the service to friends and family members.
  • We saw staff caring for patients in a kind and sensitive manner, taking account of their situations. The housekeeper described obtaining basic food items for some elderly patients who attended.

Surgery

Good

Updated 21 April 2017

The surgical services were previously rated as requires improvement for safe, responsive and well-led in July 2014 following our last inspection. This was because we had concerns around equipment management and poor compliance against 18 week referral to treatment standards.

At this inspection we gave the surgical services at Chorley and South Ribble Hospital an overall rating of Good because: -

  • Patient safety was monitored and incidents were investigated to assist learning and improve care. Patients received care in visibly clean and appropriately maintained premises.
  • Medicines were stored safely and given to patients in a timely manner. Staff assessed and responded to patients risks and used an early warning score system. The theatre teams followed the five steps to safer surgery procedures and staff adherence to was monitored through routine audits.
  • Equipment and consumable items were readily available for use by staff. The equipment we saw was appropriately checked, cleaned and serviced regularly under a planned maintenance schedule.
  • The services provided effective care and treatment that followed national clinical guidelines and staff used care pathways effectively. The services performed in line with the England average for most safety and clinical performance measures.
  • The staffing levels and skills mix was sufficient to meet patients needs. Patients received care and treatment by trained, competent staff that worked well as part of a multidisciplinary team.
  • There were systems in place to support vulnerable patients. Most complaints about the services were resolved in a timely manner and information about complaints was shared with staff to aid learning.
  • Patients and their relatives spoke positively about the care and treatment they received. They told us they were kept fully involved in their care and the staff supported them with their emotional and spiritual needs. Patient feedback from the NHS Friends and Family Test showed that most patients were positive about recommending the surgical wards to friends and family.
  • The hospitals values and objectives had been cascaded across the surgical services. There was effective teamwork and visible leadership across the services. Staff were positive about the culture within the surgical services and the level of support they received from their managers.

However, we also found that: -

  • The services performed worse than the England average for 18 week referral to treatment (RTT) waiting times between August 2015 and June 2016 for most surgical specialties. The surgical division RTT recovery plan included actions to improve 18 week wait times and to improve patient flow and efficiency in the wards and theatres by March 2017.
  • Most staff had completed their annual appraisals and mandatory training; however the proportion of staff that had completed their appraisals and had completed adult and children's safeguarding training was below the hospitals expected levels.

Intensive/critical care

Good

Updated 21 April 2017

We previously inspected the hospital in July 2014 and gave critical care services an overall rating of requires improvement. Following this inspection we have rated critical care services at Chorley and South Ribble Hospital overall as good because:

  • The critical care services were well led and staff were aware of the trusts vision and values.

  • We found that there were governance frameworks in place and risks were appropriately identified and monitored.
  • There was clear leadership throughout the service and staff spoke positively about their leaders.
  • Staff were able to report incidents and were knowledgeable about the types of incident they should report.
  • We saw evidence that learning from incidents and complaints was routine and this learning was disseminated.
  • Infection control was effectively managed and the department was visibly clean. Routine infection control audits were undertaken.
  • Nurse and medical staffing was sufficient to meet patient’s needs.
  • Patients received effective care and treatment that followed national clinical guidelines and was tailored to their individual needs.
  • This care was delivered by competent and professional staff.
  • The service participated in local and national audits.
  • Staff sought appropriate consent from patients before delivering treatment and care.
  • Staff treated patients with kindness, dignity and respect and provided care to patients while maintaining their privacy, dignity and confidentiality.
  • Patients spoke positively about the way staff treated them.

However:

  • Mandatory training uptake levels were low for some subjects, including safeguarding children and adult training.
  • Appraisal rates were low at 62% and this was a deterioration from the previous inspection.
  • Audits were not always followed up with action plans and a number of action plans had not been update for years in some cases.
  • The service, as a whole, was not meeting the Intensive Care Standards guidelines for 50% of nursing staff to have undertaken a post qualification course in critical care nursing.
  • There was limited monitoring of patient satisfaction.

End of life care

Good

Updated 14 November 2014

Care for patients at the end of life was supported by a consultant-led specialist palliative care team. Staff effectively followed end of life care pathways that were in line with national guidelines. Staff were clearly motivated and committed to meeting patients’ different needs at the end of life. Nursing and care staff were appropriately trained and supervised and they were encouraged to learn from incidents.

The palliative care team staff were clear about their roles and benefited from good leadership. We observed that care was given by supportive and compassionate staff. People spoke positively about the care and treatment they received and they told us they were treated with dignity and that their privacy was respected. The nursing staff and doctors spoke positively about the service provided from the specialist team.

Outpatients

Requires improvement

Updated 21 April 2017

We inspected the hospital in July 2014 and gave outpatient and diagnostic imaging services an overall rating of requires improvement. Following this inspection we have maintained the overall rating because:

  • The outpatients and diagnostics service was predominantly managed through the diagnostics and support services division. However key outpatient departments such as orthopaedics and ophthalmology were under a separate management structure. The recent changes in the divisional structure had led to some lack of clarity in terms of performance and governance.
  • At our last inspection we found staff had not received clinical supervision, as required by the hospital’s own policy and procedures. At this inspection we found this was still the case. Some staff told us that they had regular morning briefings and managers were accessible but they had not received and the trust did not provide details of staff uptake of clinical supervision.
  • At our last inspection we found concerns within the ophthalmology department; clinics were sometimes cancelled at short notice and frequently ran late. At this inspection we found there were still issues regarding medical staffing and access to services in ophthalmology. In Ophthalmology there had been follow- up capacity pressures which had led to service governance concerns. The service had reported two serious incidents related to delays in accessing care and treatment.
  • The trust performed worse than the England average for referral to treatment times for non-admitted referral to treatment pathways in October 2015 and remained below the average each month to June 2016. Of the 16 separate specialties reported nine were below the England average.
  • For incomplete pathways of the 16 separate specialties reported, nine were below the England average, the lowest scoring being plastic surgery at 75%.
  • The percentage of people waiting less than 62 days from urgent GP referral to first definitive treatment was worse than the standard for three of the four most recent quarters.
  • Although there was a clear process for reporting and investigating incidents, staff told us they had not received outcomes of incidents submitted. We found that improvements were required by the trust to ensure that staff received regular feedback on incidents.
  • We found some areas did have significant vacancies such as radiology and ophthalmology. Staffing numbers and skill mix met the needs of the patients.
  • The environment in the general outpatient area was well maintained, although we found that some areas of outpatients were crowded. Patients were treated with dignity and respect by caring staff. However we observed patients having blood pressure monitoring in an open corridor. Patients spoke positively about staff and felt they had been involved in decisions about their care. Care provided was evidence based and followed national guidance. Across outpatients and imaging services we found there was good local leadership and staff were committed to meeting the needs of their patients. Overall staff worked well as a team and supported each other.