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Stoke Mandeville Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 10 July 2015

Stoke Mandeville Hospital is one of seven hospitals that form part of Buckinghamshire Healthcare NHS Trust. The hospital is an acute district general hospital and provides a range of emergency and elective medical, surgical and specialist services, as well as maternity and outpatient services.

A comprehensive inspection of the acute services of Buckinghamshire Healthcare NHS Trust was conducted in March 2014. Following this inspection, urgent and emergency care and end of life care were rated as required improvement overall. However, urgent and emergency services were rated as ‘inadequate’ for responsive services at Stoke Mandeville Hospital, and end of life care was rated as ‘inadequate’ for providing effective services.

We therefore inspected this urgent and emergency care services and end of life care services as part of an unannounced focused inspection.

Overall, the urgent and emergency care services and end of life care services at this hospital ‘requires improvement’. However, each service had demonstrated improvement since the last inspection. The ratings from this inspection did not affect the overall ratings for the trust (from March 2014) which was ‘requires improvement’

Our key findings were as follows:

Urgent and Emergency Care Services

  • Overall we rated this service as ‘requires improvement’. This the same as the previous rating in March 2014. However the service had improved its rating in three of the five domains we inspected in providing a caring, responsive and well-led service.

  • During this inspection we found improvements in safety procedures, for example, more equipment had been purchased to monitor and treat patients. Medicines were appropriately managed and infection control procedures were being followed although this needed to be more consistent. Patients were assessed and treated within standard times and the modified early warning score was used effectively to identify deterioration in a patient’s clinical condition. The service still had to improve its assessment and documentation of patient risks, for example, for falls and pressure ulcer damage. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions for patients needed to be appropriately documented.

  • National guidance was being used to support patient care and treatment.. Local clinical audit programmes were developed to review and improve standards. National audits demonstrated that the Emergency Department performed similar to other trusts. Patients received effective pain relief and had appropriate nutrition and hydration.

  • Seven day services had extended and there had been improvements in senior medical presence and emergency nurse practitioner availability out of hours and at the weekend. There was still a need to increase this presence further to meet national guidelines. It was acknowledged that this needed to continue to improve as more staff were recruited. There was a recruitment plan to support this.

  • Multi-disciplinary teams worked well together, although there were still some delays to patients requiring review by medical specialty teams. The rapid access early assessment care team (REACT) worked effectively to discharge frail and elderly patients, with 70% of referrals being ready for discharge within 24 hours. There was a new psychiatric in-reach liaison services (PIRLS) that had improved the support of people in the Emergency Department who had a mental health condition.

  • Staff treated patients with care and compassion and with dignity and respect. Patients, relatives and carers, told us they had good experiences of care and their care and treatment was explained so that they could be involved. Staff made time to offer emotional support to patients who were anxious or distressed.

  • Services were being planned based on the needs of the local population and action was being taken, in conjunction with health and social care partners across Buckinghamshire, to respond to service demands. There were new services to speed assessment and treatment of emergency patients and avoid patient admissions to hospital. The new services included an initial assessment and treatment centre in the Emergency Department, assessment and observation unit (AOU), short stay acute medical unit, and ambulatory care service.

  • The service had improved its performance against the national emergency access target, that is for 95% of patients to be admitted, transferred or discharged within four hours. However, the target was not being met consistently. Escalation procedures identified specific trigger points for a hospital wide response to emergency pressures. Escalation was working in the Emergency Department although the hospital response needed to improve. We observed the Emergency Department to be busy but calm. Many patients were still waiting for excessively long periods in the Emergency Department although patients did not spend long waiting times on a trolley or in corridors.

  • The transfer of patients between Wycombe Hospital and Stoke Mandeville Hospital still required review to ensure patients were appropriately transferred.

  • The vision and strategy for the service was well developed and the trust was working with partners to improve the coordination of urgent and emergency care across the health and social care system in Buckinghamshire. The pace of change had been rapid over the last 12 months and there had been significant and clinically led service developments.

  • Staff engagement had improved and staff identified a culture of positive leadership and support.

  • The department had an effective governance structure and information was being used to monitor and improve the quality and safety of services. Risks were escalated and acted upon, but recorded actions were not timely to demonstrate ongoing work around patient flow and workforce planning.

  • The service could identify many examples of innovation and improvement and action was being taken to ensure the sustainability and resilience of services.

End of life care

  • Overall we rated this service as ‘requires improvement’. This was the same as the previous rating in March 2014. However the service had improved its rating in two of the five domains we inspected in providing an effective and caring service.
  • During this inspection we found improvements. Nursing and medical care had improved and patients received better symptom control and anticipatory drugs for pain relief. Patients nutrition and hydration needs were being assessed.

  • Patients and relatives gave examples of compassionate nursing care. They felt involved and informed regarding their care and treatment.
  • The specialist palliative care team was well led and staff were passionate about improving the quality of services. Staff across the hospital provided good emotional support for patients. The chaplaincy provided one to one spiritual support and worked closely with the bereavement officers to ensure relatives received a sensitive and individual service following the loss of a loved one.
  • The hospice day care services provided well considered emotional support for their patients and conducted patient satisfaction surveys to measure effectiveness.
  • Records were not always stored securely and in places could be accessed by patients and relatives. Do not attempt cardiopulmonary resuscitation (DNACPR) forms were not consistently completed.
  • Patients being taken to the mortuary frequently arrived without any identification wrist bands. Technicians were reliant on a nurse from the ward coming down to the mortuary to identify the patient.
  • Staffing levels in the mortuary were not safe. Technicians were often working long hours alone without support and they did not have appropriate equipment for bariatric 9obese)patients.
  • Patient areas were clean and staff followed infection control practices.
  • There were interim care plans in use following the withdrawal of the Liverpool Care Pathway in 2014. However, these care plans, called Hearts and Minds – end of natural life, were not consistently completed to provide holistic care for patients. Staff did not have a clear understanding of end of life care and ceilings of care, which would involve the cessation of all invasive treatments and non-essential medication, were not consistently applied. The trust was working on a care pathway called “getting it right for me” and had involved staff and patients to develop this.
  • The trust had participated in the 2013/14 National Care of the Dying Audit – Hospitals (NCDAH) and did not achieve five of their seven key performance indicators (KPI’s) but was similar to the England average for most of the clinical indicators of care. Local audit to monitor the effectiveness of services was not well developed.
  • There was evidence of good multi-disciplinary working practices on the elderly care wards, with doctors, nursing staff and allied healthcare professionals working together to ensure that patients at the end of their life were cared for in the correct setting. However, there could sometimes be discharge delays. The trust was still not monitoring patients preferred place of death although rapid discharge was being supported by the specialist palliative care team.
  • There was good support from the specialist palliative care team and referrals, once completed, were responded to within 24 hours. Support and advice was available 24 hours a day seven days a week. Training was available for staff in relation to caring for patients at the end of their life.
  • The hospital did not have a central register to identify a patient who was on an existing end of life care pathway and this could delay their care and treatment. However, a new electronic record, the Buckinghamshire Care Co-ordination Record was being implemented to ensure that patients who were receiving end of life care were identified more easily.
  • Patients at the end of their life were still being moved several times around the hospital despite trust guidelines recommending that patients on the end of life care pathway should not be moved.

  • The director of nursing holding responsibility for end of life care at trust board level. A new trust strategy was being developed but communication around this needed to improve. A review of the service had been undertaken and some key areas of work were in progress which included the new care pathway and the treatment escalation plan. A dashboard was being used to monitor some key indicators relating to care but audit to monitor the quality and safety of end of life care services needed to develop. The trust had held engagement meetings with staff and patients to establish how best to move the end of life care service forward.

We saw several areas of outstanding practice including:

  • The rapid early assessment care team (REACT) provided nursing and therapy support to facilitate the early discharge of frail and elderly patients admitted to hospital. Patient pathways were to community hospital or to the patient’s own home and equipment could be delivered on the same day to support patients at home. The team saw 3 to 4 patients a day and 70% were discharged within 24 hours.
  • There was a new psychiatric in-reach liaison services (PIRLS) that had been developed with the local mental health trust. This joint working had improved the support of people in the ED who had a mental health condition.
  • The specialist lymphodema nurses at the hospice recently received a second place award for oedema management; this accolade was given by the Journal of Wound Care.

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

Importantly, the trust must ensure :

  • Patient risk assessments and the documentation that supports these are routinely completed in the Emergency Department.
  • There is effective clinical engagement for a hospital wide focus to patient flow and escalation processes.
  • There are timely GP discharge summaries following a patient admission to the Emergency Department.
  • There is a timely replacement for the Liverpool Care Pathway and all staff follow the current interim policies.
  • Staff complete the end of life care plans (Hearts and Minds – end of natural life) appropriately so The National Institute for Health and Care Excellence (NICE) guidelines for holistic care are followed.
  • All staff consistently and appropriately complete the DNACPR forms and discussions between patients and relatives are recorded in patient records.
  • The overhead lighting lamps in the hospice are replaced to reduce the risk of patients coming into contact with hot surfaces.
  • Staffing levels in the mortuary are reviewed to give staff adequate rest time between shifts and to reduce the levels of lone working.
  • Mortuary staff have appropriate equipment for bariatric (obese) patients to reduce the risk of harm to staff from inappropriate manual handling.
  • Deceased patients are clearly and appropriately identified when being transferred from wards to the mortuary.
  • All staff involved in end of life care can identify a patient at the end of life (12 months) to ensure that referrals to the specialist palliative care team are made in a timely manner.

In addition the trust should ensure that :

  • Recruitment of medical and nursing staff continues to improve models of care, decrease the current workloads of staff in acute and emergency medicine and ensure appropriate medical staffing at night.
  • Infection prevention and control practices are consistently followed in the Emergency Department.
  • Risk registers are maintained and kept up to date in the Emergency Department and records of incidents, once reported, are completed in a timely way.
  • Infection control risks, in relation to storing patients’ belongings in the bereavement office, are addressed.
  • Interpreter services are provided to enable patients who do not speak English as their first language to receive the same level of care as other patients at the end of their life
  • Transfer arrangement between Wycombe Hospital and Stoke Mandeville Hospital are clarified for staff and patients.
  • Communication from senior management teams to all staff providing end of life care to improves.
  • Patients who received end of life care are not moved unnecessarily between wards.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 20 June 2014

Effective

Good

Updated 20 June 2014

Caring

Good

Updated 20 June 2014

Responsive

Requires improvement

Updated 20 June 2014

Well-led

Requires improvement

Updated 20 June 2014

Checks on specific services

Maternity and gynaecology

Good

Updated 20 June 2014

The ward areas were modern and clean. Women and their partners said that the staff were caring and friendly. Women were encouraged to discuss their plans and choices with their midwife and to be actively involved in the planning and decision making. The average ratio of births to midwives was higher than the national average, but this had improved recently. There were, however, some comments from women on the postnatal ward about insufficient staff and staff being under pressure.

There was good multidisciplinary team working and learning throughout the service. Staff development and continuing professional development in general was a priority within the service.  The leadership of the service was described as strong and effective. The head of midwifery and her team were well focused and fully engaged.   Reporting arrangements to the board and within the division required improvement and the service did not have a strategy to develop its services. There was a risk management strategy to manage operational and performance risks.  Risks were appropriately managed although the the lack of available postnatal care beds was not identified as a risk. Staff were good at implementing innovations in care.

Medical care (including older people’s care)

Requires improvement

Updated 16 February 2017

Overall, we rated medical care as ‘requires improvement’ because:

We found the pharmacy service was not able to provide an effective service, particularly on the elderly care wards. There were vacancies in the pharmacy department, which impacted on the performance of the service. There were delays in patients receiving discharge medicines, medicines reconciliation targets were not met and pharmacists were not always part of the multidisciplinary team.

Ward staff were responsible for ensuring medicines were handled in accordance with the trust medicines management policies. However, we found expired medicines on the ward and staff did not consistently record fridge temperatures

We found staff did not always maintain medical records securely. During our visit we saw both paper and electronic records were left unattended and accessible to unauthorised people.

Although staffing levels had improved since the previous inspection, we found the elderly care wards were not always staffed to the optimum staffing levels. This meantstaff were under pressure to meet patients’ needs, particularly when patients were assessed with high needs and required one to one care.

The system to ensure patients with a deprivation of liberty safeguard (DoLS) authorisation was in place and up to date was not effective. The trust had been in discussion with the local authority to improve the process and was monitoring the situation.

We observed some poor compliance with infection control procedures. For example, on ward 8 we found equipment had a layer of dust, the linen store door was open and staff told us patients often wandered in to the room, which posed an infection control risk. We also witnessed an incident where a member of staff had displayed poor infection control practice.

The results of a number of national audits showed medical services performed worse than the national average.

Patients and relatives were positive about the care they received. They told us staff were caring and treated them with respect. They felt involved in their care and recommended the hospital to others based on their own experiences.

Staff demonstrated an understanding of how to care for vulnerable patients including those with a learning disability or with dementia. Staff were supported by specialist teams in the trust to meet patients’ needs. They used tools to assess patients’ mental capacity and understood the procedures to follow if patients were at risk of a deprivation of liberty if they were restricted or restrained.

New staff underwent an induction process before there were assessed as competent to work on their own. Junior doctors were satisfied with their training opportunities and support available. Staff said they had effective access to professional development and in August 2016 90% of staff in the division of elderly care were up to date with mandatory training and 82% in integrated medicine. The annual appraisal uptake was 89% for integrated elderly care and for integrated medicine was 90% against a trust target of 90%. Staff said their managers provided good support and senior staff were approachable and accessible.

There was high level of bed occupancy trust wide. The service closely monitored bed capacity and had plans in place to manage demand if needed.

There was a culture of collaborative working and staff said they worked well together in multidisciplinary teams to coordinate patient care. We observed effective multidisciplinary meetings between staff, which showed they considered patient’s individual risks and needs.

Patient records were clearly completed and documented patient’s risk assessments and management plans.

The divisional leads had an agreed vision and strategy for services and a clinical governance framework. They had recognised the need to improve their management of risks, and had started to use a new approach to monitoring service risks. Staff reported incidents, and understood how to use the incident reporting system. Staff carried out root cause analysis to investigate incidents and learn from them. The service had a high proportion of harm-free care.

The services took part in national and local audits to check they provided care and treatment in line with good practice guidance. They developed action plans and worked with other health and social care providers to improve care pathways. For example, for patient suffering falls.

Wards were visibly clean and the infection control team carried out regular audits to identify any areas for improvement.

Urgent and emergency services (A&E)

Requires improvement

Updated 10 July 2015

Overall we rated this service as ‘requires improvement’. This was the same as the previous rating in March 2014. However the service had improved its rating in three of the five domains we inspected in providing a caring, responsive and well-led service.

During this inspection we found improvements in safety procedures, for example, more equipment had been purchased to monitor and treat patients. Medicines were appropriately managed and infection control procedures were being followed although this needed to be more consistent. Patients were assessed and treated within standard time. Staff in the department used the modified early warning score effectively to identify deterioration in a patient’s clinical condition. The service had to improve its assessment and documentation of patient risks, for example, for falls and pressure ulcer damage. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions for patients needed to be appropriately documented.

National guidance was being used to support patient care and treatment. Local clinical audit programmes were developed to review and improve standards. National audits demonstrated that the Emergency Department performed similar to other trusts. Patients received effective pain relief and had appropriate nutrition and hydration.

Seven day services had extended and there had been improvements in senior medical presence and emergency nurse practitioner availability out of hours and at the weekend. There was still a need to increase this presence further. It was acknowledged that this needed to continue to improve as more staff were recruited. There was a recruitment plan to support this

Multi-disciplinary teams worked well together, although there were still some delays to patients requiring review by medical specialty teams. The rapid access early assessment care team (REACT) worked effectively to discharge frail and elderly patients, with 70% of referrals being ready for discharge within 24 hours. There was a new psychiatric in-reach liaison services (PIRLS) that had improved the support of people in the Emergency Department who had a mental health condition.

Staff treated patients with care and compassion and with dignity and respect. Patients, relatives and carers, told us they had good experiences of care and their care and treatment was explained so that they could be involved. Staff made time to offer emotional support to patients that were anxious or distressed.

Services were being planned based on the needs of the local population and action was being taken, in conjunction with health and social care partners across Buckinghamshire, to respond to service demands. There were new services to speed assessment and treatment of emergency patients and avoid patient admissions to hospital. The new services included an initial assessment and treatment centre in the Emergency Department, assessment and observation unit (AOU), short stay acute medical unit, and ambulatory care service.

The service had improved its performance against the national emergency access target, which is for 95% of patients to be admitted, transferred or discharged within four hours. However, the target was not being met consistently. Escalation procedures identified specific trigger points for a hospital wide response to emergency pressures. Escalation was working in the Emergency Department although the hospital response needed to improve. We observed the Emergency Department to be busy but calm. Many patients were still waiting for excessively long periods in the Emergency Department although patients did not spend long waiting times on a trolley or in corridors. The transfer of patients between Wycombe Hospital and Stoke Mandeville Hospital still required review to ensure patients were appropriately transferred.

The vision and strategy for the service was well developed and the trust was working with partners to improve the coordination of urgent and emergency care across the health and social care system in Buckinghamshire. The pace of change had been rapid over the last 12 months and there had been significant and clinically led service developments.

Staff engagement had improved and staff identified a culture of positive leadership and support.

The department had an effective governance structure and information was being used to monitor and improve the quality and safety of services. Risks were escalated and acted upon, but recorded actions were not timely to demonstrate ongoing work around patient flow and workforce planning. The service could identify many examples of innovation and improvement and action was being taken to ensure the sustainability and resilience of services.

National spinal injuries centre

Good

Updated 20 June 2014

The NSIC is a national centre for spinal injuries and develops guidelines for other units in the UK to follow. It has been internationally accredited. Staff built up trusting relationships with patients and their relatives through their interactions. Patients and relatives told us that they received considerable support. There was a sense of belonging for them. Care plans for patients with spinal injury identified goals set by the patients and these were monitored by them in partnership with the staff. There was support for current patients from former patients of the unit.

Staff within the Centre spoke positively about the service they provided for patients. There was enthusiasm and energy for providing a high quality of care for patients with spinal injury. The drive to recruit more nurses and healthcare assistants was seen as an example of positively and making a difference to the culture within the service.

Surgery

Requires improvement

Updated 16 February 2017

We rated this service as requires improvement because:

The pharmacy service did not have planned staffing levels and could not deliver an effective service, including to surgical patients.The service did prioritise patients with the greatest need but some key performance indicators were not achieved.

Staff on the wards did not always dispose of out of date medicines promptly. They did not always follow the trust’s controlled drugs policy when documenting receipt of controlled drugs. We found medicines that had not been stored at the correct temperature and gaps in temperature log books.

We found incomplete records for the anaesthetic machine logbooks in the operating departments and for the resuscitation equipment on the wards. It was not clear if staff completed the daily safety checks and the equipment was safe to use .

Theatre staff did not always comply with the trust’s uniform policy to minimise the risk of infection.

Staff did not have a good understanding of the principles of Mental Capacity Act and associated Deprivation of Liberty Safeguards and their responsibilities in relation to these areas, to support people whose circumstances made them vulnerable and who could not always give consent.

Patients’ record keeping was not to a consistent standard. Although patients told us they made informed decisions about their surgery, medical staff did not always document the conversation fully.

The division had not achieved the 18-week referral to treatment time indicator for 90% of patients admitted for an operation over the last five months.

Three trust policies and standard operating procedures were out of date for review. .

Not all departmental and managers’ meetings had minutes recorded. Therefore, the formal and permanent record of decisions that teams reached and actions staff agreed to take were missing.

The surgery service had enough staff with the right training and experience to keep patients safe. Although they used agency staff, they tried to make sure they used staff who were familiar with the service and its procedures. When wards needed more staff, the hospital followed the escalation policy and procedures to manage busy times.

Staff knew the process for reporting incidents. They received feedback from reported incidents and felt supported by managers when considering lessons learned.

Areas we visited were visibly clean and tidy, we saw most staff following good infection prevention and control practices.

There was good multidisciplinary working across teams at the hospital so patients received co-ordinated care and treatment. Staff planned and delivered patients’ care and treatment using evidence based guidance and audited compliance with National Institute Health and Care excellence (NICE) guidelines.

Nursing staff completed risk assessments for patients. If a patient became unwell, there were systems for staff to escalate these concerns and refer them to another hospital if necessary. The hospital provided care to inpatients seven days a week, with access to diagnostic imaging and theatres via an on-call system.

We saw staff care and treat patients with compassion. They were kind and treated them with dignity, and respect. There were systems to support patients with additional or complex needs. Patients felt informed and involved in their care. They said they would recommend the service to others.

Staff followed the governance processes to monitor the quality and risks of the surgical service. They completed audits and monitored patient outcomes, making changes to practice when necessary. Outcomes for patients were similar to the England average compared to data from national audits such as the bowel cancer audit. The divisional leads used the monthly quality reports and dashboards to support this.

Feedback from patients and staff had been used to develop and improve the service. The divisional leads and executive team considered the sustainability of the service and had a strategy in place to support this.

Staff told us the leadership across the service was good and the senior team were visible and accessible. Staff had an annual appraisal and could access additional training to develop in their role.

Intensive/critical care

Good

Updated 20 June 2014

Patients we spoke with gave us examples of the outstanding care they had received in the unit. Staff built up trusting relationships with patients and their relatives by working in an open, honest and supportive way. There was strong local leadership of the units. Openness and honesty was encouraged at all levels.

The unit had an annual clinical audit programme to monitor how guidance was adhered to. All staff, including student nurses, were involved in quality improvement projects and audit. There was good multidisciplinary team working. Patients underwent an assessment of their rehabilitation needs within 24 hours of admission to the unit, and the subsequent plan for their rehabilitation needs was clearly documented in the notes.

Services for children & young people

Good

Updated 20 June 2014

Services for children and young people were good throughout. Most parents told us the staff were caring, and we saw that children and their parents and carers were treated with dignity, respect and compassion. Ward areas and equipment were clean. There were enough trained staff on duty to ensure that safe care could be delivered. There were thorough nursing and medical handovers that took place between shifts to ensure continuity of care and knowledge of patient needs.

The services were responsive to the needs of children and young people and their families and carers. The ward sisters communicated well with staff, and staff were positive about the service and quality. Children’s experiences were seen as the main priority. Staff felt supported by their managers and were encouraged to be involved in discussing their ideas for improvements.

End of life care

Requires improvement

Updated 16 February 2017

Overall this core service was rated as ‘requires improvement’

Advance care plans were not fully documented for some patients, so staff and families were not routinely aware of patient’s care preferences before and after death.

DNACPR forms were not completed according to national guidelines, which include the need to document discussions with patients and families and that Mental Capacity Act decisions were documented.

Infection prevention and control practices were not being followed. We observed in the bereavement office deceased patients’ belongings were stored in cupboards in open plastic carrier bags; this has the potential for cross infection.

There was no protocol for withdrawing treatment as recommended in the 2015 National Institute of Clinical Excellence guidelines. However, the trust said that they were prioritising this guidance for review.

The hospital did not classify end of life care training as a mandatory subject as recommended by of the National Care of the Dying Audit 2013/14or completion in 2017.

There were governance processes, including evidence of investigation of incidents and audits and lessons learnt for staff to improve patient care.

Staff treated people with compassion, kindness, dignity and respect. Feedback from patients and their families was consistently positive. We saw good examples of staff providing care that maintained respect and dignity for individuals. There was good care for the relatives of dying patients, and staff showed sensitivity to their needs.

The trust had on going engagement with a people panel to ask for opinions and suggestions in what mattered to them regarding developing plans for end of life care. The panel were consulted regarding the trust wide end of life patient care plans called “Getting it right for me” We saw that the care plans were not consistently used for end of life care patients during the inspection. The trust wereaware of the concern and had appointed an end of life care facilitator to improve end of life care education for clinical staff and to ensure the care plans wereused correctly.

Patients’ needs were mostly met through the way end of life care was organised and delivered. However, a rapid discharge of those patients expressing a wish to die at home did not always happen in a timely way due to external delays with funding and care packages for complex needs

The people panel were consulted on the trust wide end of life care strategy, which was complete but not published at time of inspection. Staff we spoke with was aware of end of life care priorities and described high quality patient care as the key component of the trust’s vision.

Outpatients

Requires improvement

Updated 20 June 2014

Patients received compassionate care and were treated with dignity and respect. Patients told us that staff were kind and supportive, and they felt fully involved in making decisions about their care. Medicines and prescription pads were securely stored. The outpatient areas we visited were clean and equipment was well maintained.

However, many clinic appointments were cancelled at short notice. Clinics were busy and patients had to wait a long time. Patients and staff told us one of the biggest challenges was clinics running late. Outpatient clinics were over-booked; there was not enough time to see patients, so clinics often over-ran. Although there had been recent improvements, many staff, particularly in the general outpatient area, said they had not been listened to on key service changes and that outpatients had not been a priority for the trust.