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Wycombe Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 10 July 2015

Wycombe 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 elective medical, and surgical services, as well as midwifery led maternity and outpatient services. Emergency services are provided for cardiac and stroke patients.

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, end of life care was rated as ‘inadequate’ for providing effective services at Wycombe Hospital.

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

Overall, the end of life care services at this hospital ‘requires improvement’. However, the 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:

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.
  • 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 (obese) 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.

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

Importantly, the trust must ensure that:

  • 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 to National Institute for Health and Care Excellence (NICE) guidelines for holistic care.
  • All staff consistently and appropriately complete the DNACPR forms and discussions between patients and relatives are recorded in patient records.
  • 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:

  • Infection control risks, in relation to storing patients’ belongings in the bereavement office, are addressed.
  • The provision of interpreter services 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
  • The multi faith room environment at Wycombe hospital is improved so that the facilitate can accommodate more than two people and can offer privacy for those wishing to pray.
  • Communication from senior management teams to all staff providing end of life care to improves.
  • Patients who receiving end of life care are not moved unnecessarily between wards.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 10 July 2015

Effective

Requires improvement

Updated 10 July 2015

Caring

Good

Updated 10 July 2015

Responsive

Requires improvement

Updated 10 July 2015

Well-led

Requires improvement

Updated 10 July 2015

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. Midwifery staffing levels were appropriate and there were always experienced staff on every shift to women and provide one to one care.

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 head of midwifery and her team were well focused and fully engaged. The service did not have a strategy to develop its services and there were concerns about underused services at Wycombe Hospital and potential delays to transfer women who required urgent care to Stoke Mandeville Hospital. The service did have a strategy to manage operational and performance risks and risks were appropriately managed.

Medical care (including older people’s care)

Requires improvement

Updated 16 February 2017

Overall we rated this service as requires improvement because:

The service had made a number of improvements since our 2014 inspection report. However, governance processes still did not effectively address safety concerns.

We found a number of issues which impacted patient safety such as medicine management, security of records and patient documentation. Senior staff were not aware of these issues and had not yet developed an action plan to address them.

The cardiology ward was in need of refurbishment and could pose an infection control risk as cracked and broken areas could not be adequately cleaned. This had been escalated to the risk register in December 2012 but no significant progress had been made to resolve this issue.

Staffing levels in the pharmacy service were not as planned and they could not deliver an effective service, including to the medicine division. Although the service prioritised patients with the greatest need, some key performance indicators were not achieved.

Staff did not follow policies and procedures to ensure the safe storage of medicines. Expired or unwanted medicines were stored alongside ward stock, which posed a risk that patients would receive incorrect or expired medicines. Staff did not record fridge temperatures on a daily basis and did not take action when the medicines fridge temperature was out of range.

We found prescription charts without clear prescriber identifiers’ and patient allergy status had not been signed in line with the trust policy.

Patients’ medical records did not always include a clear diagnosis and management plan. Some patients did not have a nursing care plan that reflected their needs or have risk assessments for pressure ulcers and malnutrition completed.

Patient information was not always stored securely. We found trolleys with patients’ medical records were left unlocked and unattended in public areas. We also found computer screens were open and unattended displaying patient test results in corridors and ward bays. There was a risk that unauthorised people could access confidential information. Staff on the stroke unit conducted their multidisciplinary board meeting in an open office behind the reception desk, which meant other patients and visitors could overhear confidential information.

There was not always adequate numbers of staff on duty and the data submitted showed the hospital did not meet their own planned staffing levels for August 2016. Not all staff had completed their statutory and mandatory training and this included safeguarding children and vulnerable adults level 2, Duty of Candour, infection control, medicines management and basic life support.

Not all staff had a good understanding of the principles of Mental Capacity Act and associated Deprivation of Liberty Safeguards (DoLS) and their responsibilities in relation to these areas, to support people whose circumstances made them vulnerable. We saw evidence that a patient had been given sedation to enable compliance with treatment without consent or a DoLS application.

Ward and senior managers had a good understanding of learning from incidents and complaints. However, there was little evidence that this learning was shared with staff. Managers did not always document minutes from meetings. This meant that staff who could not attend did not have an accurate record of issues discussed.

Although staff adhered to the ‘bare below the elbow’ policy to minimise spread of infection, we observed some staff did not use appropriate personal protective equipment and hand sanitiser when entering the ward.

Patients and relatives told us staff provided caring and compassionate care and they felt involved in their care. Staff recognised the importance of patient’s emotional wellbeing and had developed initiatives to support this. Staff assessed and managed patient’s pain and had access to the acute pain team if required.

The stroke and cardiac services provided services to meet the needs of patients. Paramedics and GP's could refer patients directly to the CSRU. The stroke unit ran a daily transient ischaemic attack (TIA) clinic which provided consultant review and access to diagnostic tests within the same appointment.

The hospital had clear vision and values, which staff knew about and were displayed in every ward area. The stroke and cardiac service had a clear strategy for development to expand the catchment area. The hospital participated in regional and national audits and had recently been awarded an A grading for the stroke service in the Sentinel Stroke National Audit Programme (SSNAP). There was also a local audit programme in place. The hospital had clear pathways for stroke and cardiac patients based of National Institute for Health and Care Excellence (NICE) guidelines.

The hospital had a clear governance structure and the medical division followed governance processes to ensure a review of performance, risk and quality. There was clear documentation of actions with detail of who was responsible for completing these. The service had made some significant improvements since our last inspection in 2014. However, we found some concerns particularly about medicines management, which had not been addressed.

There was a culture of collaborative, multidisciplinary working across teams to coordinate patients’ care. We observed multidisciplinary meetings where staff considered patient’s individual risks and needs and agreed plans to support their care and treatment.

All staff understood the concepts of openness and transparency and some gave examples of where they had used the principles of Duty of Candour in practice.

Staff told us the leadership across the service was good and the senior team were visible and accessible. Nursing staff had annual appraisals and good access to professional development. Although junior doctors told us they had good access to support and training, they did not always receive an annual appraisal.

Surgery

Requires improvement

Updated 16 February 2017

Overall we rated this service as requires improvement because:

Staffing levels in the pharmacy service were not as planned and they could not deliver an effective service, including to the medicine division. Although the service prioritised patients with the greatest need, 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 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 .

While staff in theatres followed the World Health Organisation (WHO) surgical safety checklist, we observed staff who did not always pay full attention for each stage of the process to ensure patients’ safety.

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. .

Departmental and managers’ meetings did not record discussion and actions and there was not a formal record of decisions or assurance that concerns were addressed.

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 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 good care they had received. 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 units 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 were effectively monitored and clinical outcomes were good.

Services for children & young people

Good

Updated 20 June 2014

Services for children and young people were good. Parents told us the staff were caring, and we saw that children and their parents and carers were treated with dignity, respect and compassion. The ward areas and equipment were clean. There were enough trained staff on duty to ensure that safe care could be delivered. Children were appropriately prepared for surgery and treatment and clinical outcomes were good.

The service was responsive to the needs of children and young people and their families and carers. Staff were positive the service and children’s experiences were seen as the main priority. The service did not have a strategy but there were actions around improving the service. The trust long term plans for the service were not clear to staff.

End of life care

Requires improvement

Updated 16 February 2017

Overall this core service was rated as ‘requires improvement’

We rated end of life services as ‘requires improvement’ for safe and effective care and 'good’ for being caring, responsive and well led.

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 all 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 completion in 2017.

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 2013/14

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

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

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 were aware 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 were used correctly.

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.