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Inspection Summary


Overall summary & rating

Outstanding

Updated 20 April 2016

Western Sussex Hospitals NHS Foundation Trust became a foundation trust on 1 July 2013, just over four years after the organisation was created by a merger of the Royal West Sussex and Worthing and Southlands Hospitals NHS Trusts. St Richard's Hospital in Chichester, West Sussex is one of three hospitals provided by the trust.

The trust serves a population of around 450,000 across a catchment area covering most of West Sussex. The three hospitals are situated in the local authorities of Worthing, Chichester and Adur. These areas have a higher proportion of over 65's compared to the England average. The three local authorities have a lower proportion of ethnic minority populations compared to the England average.

Adur and Worthing are in the middle 20% in England for deprivation. Chichester is in the top 40% of least deprived areas in the country.

The hospitals provide 953 inpatient beds which include 77 maternity beds and 32 critical care beds. Of these, 430 are at St Richard's Hospital. The trust employs over 5,600 staff (Whole Time Equivalent at end of August 2015). In the year 2013-14, there were more than 127,000 inpatient admissions and 533,000 outpatient attendances; over 135,000 patients attended the accident and emergency department.

The trust annual income is around £403 million. The trust has made a surplus every year, since the merger of the predecessor trusts, up to 2014/2015 and has paid back £21 million of legacy debt.

We inspected this trust as part of our comprehensive hospital inspection programme. Our inspection was carried out in two parts: the announced visit, which took place on the 9, 10 and 11 December 2015 and the unannounced visit which took place on 21 December 2015.

Overall we found that St Richard's Hospital was providing outstanding care and treatment to the community it served. We saw many examples of very good practice across all areas of the hospital. Where we identified shortcomings, the trust was aware of them and was already addressing the issues.

The trust is one of the 16 members of NHS Quest, a member-convened network for Foundation Trusts who wish to focus on improving quality and safety within their organisations and across the wider NHS. The members of NHS Quest work together, share challenges and design innovative solutions to provide the best care possible for patients. The trust was also a winner of a Dr Foster Better, Safer Care at Weekends award.

There was a strong governance structure and assurance framework. The board executive and non-executive directors were clear on their responsibilities and understood the hospital well. The governance was organised through four cross-site divisions (medicine, surgery, women and children and core services), each had a consultant from that speciality as a Chief of Service.

Our key findings were –

The executive team provided an exemplar of good team working and leadership. They had a real grasp of how their hospital was performing and knew their strengths and areas for improvement. They were able to motivate and enthuse staff to ‘buy in’ to their vision and strategy for service development. Middle managers adopted the senior manager’s example in creating a culture of respect and enthusiasm for continuous improvement.

Innovation was encouraged and supported. We saw examples that, when raised directly with the Chief Executive and her team, had been allowed to flourish and spread across the services.

We saw respectful and warm relationships internally amongst staff teams, the wider hospital team and outwards to external stakeholders and the local community.

Across the hospital there was an embedded culture of learning from incidents. Staff were encouraged to have an open and honest attitude towards reporting mistakes and incidents that were then thoroughly investigated. There was strong evidence of learning from incidents both locally and across the organisation.

The hospital was performing better, and sometimes much better than comparable trusts across England on many measures. Where this was not the case, the trust had clear action plans and investigations ongoing to bring about improvements.

An example of this was the 4 hour Emergency Department (ED) target where new and innovative approaches coupled with strong monitoring systems had resulted in the trust meeting the target over 95% of the time. They were amongst only a handful of trusts to meet the quarter four target.

In 2014/15 the trust improved their infection control ratings for the sixth successive year.

There was good management of deteriorating patients and systems in place to allow early identification and additional support when a patient’s condition became unexpectedly worse.

Monitoring by the Care Quality Commission had not identified any areas where medical care would be considered a statistical outlier when compared with other hospitals. The trust reported data for mortality indicators, the summary hospital level mortality indicator (SHMI) and hospital standardised mortality ratio (HSMR). These indicate if more patients were dying than would be expected given the characteristics of the patients treated there. The figures for the trust were as expected. Information about patients’ outcomes was monitored. The trust participated in all national audits it was eligible for. Where improvements were identified, the trust was responding and was making progress implementing its action plans in order to improve the quality of care they were providing.

Across all disciplines and in all core services we found a good knowledge and understanding of the policies and guidance relating to safeguarding vulnerable adults and children. Trust staff were involved in local initiatives, working with other key agencies to improve outcomes for babies and children from challenging or vulnerable families.

Staff of all grades and from all disciplines contacted us to tell us about their belief that the St Richard's was a very good hospital. They talked with great pride about the services they provided and all agreed they would be happy for their family members to be treated there. They talked of their commitment to making sure they did their very best to provide optimal care for patients. They talked about initiatives to improve patient care they had been involved in.

Specifically, all consultants from St Richard’s Hospital who contacted us were very positive about how the trust provided services from this site. The majority of consultants employed at St Richard's responded to our invitation to submit written comments or to meet with us. They told us the executive team and medical director in particular, were supportive, encouraging of new ideas and approachable. They told us about the work that had been done to improve the mortality figures overall and in specific areas. This included the changes to the pathways for patients who suffered a fractured neck of femur where changes to the care and treatment of this condition had reduced the number of elderly patients who died as a result of this.

Medical, nursing and midwifery staffing levels were safe and allowed staff to provide good care. Staffing acuity tools were in routine use and staffing was reviewed frequently – in some areas such as ED this was done four hourly. However, there were areas where the trust did not meet the recommendations of professional bodies such as the royal colleges. This included medical staffing in the critical care unit and the number of supervisor of midwives. In both these cases the trust was already taking action.

Volunteers from across the hospital were also keen to tell us about how much they enjoyed working at the hospital. They told us they were supported and accepted as a part of the hospital team. Those working in clinical areas described a sense of belonging and felt their work helping people to eat and drink or occupying elderly patients was valued.

We received an unprecedented number of letters and emails from people who used the service prior to, during and after the inspection visit. The overwhelming majority of these were very positive and told stories of staff going above and beyond the expected level of care. Staff we spoke with were exceptionally compassionate when talking about patients and we observed kindness not only towards patients but towards each other whilst on site.

The results of the Friends and Family Test supported the views of the many patients who contacted us. In most areas the hospital consistently scored above the national average.

The commitment of staff to providing good care coupled with good strategic and operational planning led to a service that was responsive to the needs of individuals. We saw flexibility and a willingness to make local changes to improve how people were cared for. There were numerous initiatives that improved patient experiences and allowed them equal access to care. These included Learning Disability nurses visiting the ED, interagency joint working in the hospital and community and the Harvey’s Gang project.

The trust had introduced a ward accreditation scheme which was being rolled out.

Outstanding practice

We saw much that impressed us but of particular note was;

The positive attitude of outpatient and diagnostic imaging staff was an outstanding feature of this hospital. The outpatient nursing staff knowledge of vulnerable adult and safeguarding children and how they should proceed if concerns arose and compliance with training in this area. The management of medical records meant that more than 99% of full records were available to staff in clinics.

The level of 'buy in' from all staff to the trust vision and value base was exceptional. We were flooded with requests from staff wanting to tell us about specific pieces of work they were doing, how much they liked working for the trust and how supportive the trust executive team were of innovative ideas and further learning as a tool for improvements in patient care. The trust ambassadors worked to promote the positive work that the trust was doing to other staff and visitors.

Multidisciplinary working was a very strong feature across the hospital that resulted in better patient care and outcomes. There was clear professional respect between all levels and disciplines of staff. We saw real warmth amongst teams and an open and trusting culture. Exceptional examples of this included how 'Harvey's Gang' was growing and developing as more staff became involved in local initiatives such as the joint working 'Five to Thrive' protect and Family Nurse Partnership which improved outcomes for the children of young and vulnerable parents.

The trust had won a Dr Foster Better, Safer Care at Weekends award.

The level of feedback from patients and their families was exceptional. We received many letters and emails before, during and after the inspection visit. It was overwhelmingly and almost exclusively positive. Amongst the hundreds of people who contacted us to say how good the hospital was, there were just a few who felt unhappy with the care they had received.

We were contacted by many consultants working at the hospital, from across all specialities who wanted to tell us about how good it was to work at the trust. They wanted to tell us the executive team were approachable and supportive, that their ideas were listened to and they felt the trust provided very good care to most people.

In ED the focus on access and flow, coupled with the work being done with local stakeholders such as GP's and CCG's had resulted in a department that was mostly able to meet the key performance targets. People were seen quickly and were not kept in the department overly long.

The attention and consideration of peoples' individual needs and genuinely patient centred care was evidenced across the hospital. The work of the learning disabilities nurse specialists, the neonatal outreach nurses and the SPCT were all notable. In the critical unit the staff remained focussed on the person and not the technology, with people being pushed out of the unit in a wheelchair, if they were well enough, to help them maintain a sense of normality. Staff encouraged fathers to stay overnight on the postnatal ward to provide support to their partner and to begin the bonding process with their baby.

The trust wide learning from incidents and complaints was well embedded. In all areas of the hospital, staff gave examples of where improvements had been made as a result of complaints, comments or incidents.

The executive team provided exceptional leadership and had a very good understanding of how the hospital was working in both the longer term (through a sound assurance framework) and on a day to day basis (through a regular ward and department presence and open door sessions). There was clear team work amongst the executive team and their positive leadership style filtered down through middle managers to local managers.

The Medicines division was involved in a trust wide NHS Quest initiative which focused on improving quality and safety. This involved the trust taking part in collaborative improvement projects for sepsis and cardiac arrest. Work was in progress on these initiatives at the time of our inspection.

The ‘Knowing Me’ initiative along with the other initiatives to improve hospital experiences for people with dementia.

The involvement of a learning disabilities nurse for patients admitted who had a learning disability improved the outcome and experiences for this group of patients.

The level of staff engagement and involvement in service planning was exceptional, with the Trust Ambassadors giving a very clear message about staff ‘buy in’ and belief in the work they were doing.

The very strong governance systems allowed the trust to focus on safety and improved patient outcomes at all levels. Local managers could see how the wards and departments in their control were performing. The board involvement allowed proper assurance through involvement in governance meetings.

The trust executive had a very sound understanding of their hospitals. They did not need to look up how areas were performing as they were very aware of the areas of strengths and weaknesses.

However, we also saw things which the trust should review and take action where necessary;

The hospital should ensure all staff mandatory training is up to date.

The hospital should ensure the numbers of chemotherapy trained nursing staff on duty reflect the established number required at all times.

The Medicine Division should recruit consultants to ensure an adequate level of medical expertise which reflects the England average.

The hospital should ensure all staff receive an annual appraisal to ensure their continuous professional development needs are met.

The hospital should ensure there is an adequate supply of pressure relieving equipment for patients on all wards.

The hospital should ensure continuity on recording of medicines fridge temperatures on all wards, and that emergency medicines are checked in accordance with their own policy, to ensure they are always readily available for use in an emergency.

The hospital should review the levels of medical and nursing staff on each shift in critical care, in line with established national guidelines. The hospital should also consider the working practices of existing senior physicians during the pilot phase of a telemedicine model of care.

The hospital should review the security and storage of hazardous waste and chemicals on the critical care unit.

The trust should ensure grading of referrals occurs within acceptable timescales.

The trust should ensure that RTT is met in accordance with national standards.

The trust should ensure staff who work in the diagnostic imaging department and who provide care to children have the appropriate level of safeguarding training.

The trust should ensure drugs in OPD that require refrigeration are stored in a temperature checked fridge, which should be used for the sole purpose of storing drugs.

The trust should review the availability of supervisors of midwives.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 20 April 2016

Effective

Outstanding

Updated 20 April 2016

Caring

Outstanding

Updated 20 April 2016

Responsive

Requires improvement

Updated 20 April 2016

Well-led

Outstanding

Updated 20 April 2016

Checks on specific services

Maternity and gynaecology

Outstanding

Updated 20 April 2016

Overall, we rated maternity and gynaecology services as 'Outstanding'.

People were protected by a strong comprehensive safety system, and a focus on openness, transparency and learning when things went wrong. This was demonstrated in safety thermometer results which showed the maternity service had achieved 100% since December 2014.

The service provided effective care in accordance with recommended practices. Outcomes were good and the service frequently performed better than the trusts own target. This was especially true of the work being done to reduce stillbirths and admissions to SCBU and NICU's. The service continually monitored outcomes for women and used incidents and complaints as opportunities for learning and improving services. There were high levels of multidisciplinary team working, both within the service and with external partners. Compliance with training was good and staff were offered additional opportunities for learning and development.

Care was compassionate and supportive and staff treated women and their families with respect and dignity. Outside the inspection visit we were contacted by many women who used maternity and gynaecology services who told us about their experiences. All those who contacted the CQC were extremely positive about the care and support they received. Performance in the FFT and the Maternity Services Survey 2015 showed performance above the national average.

Medical care (including older people’s care)

Outstanding

Updated 20 April 2016

Overall we rated medical care services as 'Outstanding'.

This was due to the responsiveness of the service in the care of individual patients, coupled with a clear understanding of the needs of the population that used the service. Pathways were designed in collaboration with external stakeholders and community providers. The staff listened to feedback and acted on what they were told to fine tune services in the best interest of their patients. The trust executive and board had an exceptional understanding of what their service was and who their patients were. This approach was fed down so the directorate had a really good understanding of what they were meant to be providing and who the service was for - and created services that met the identified needs. Medical leaders focussed on getting the basics right and building on that to provide excellent care.

For example, there were exemplary provisions made for patients living with dementia across the whole hospital. We received very high levels of very positive feedback from patients and relatives who had used St Richard's Hospital. The 'Sit and See' scheme allowed staff to experience the hospital from a patient perspective.

Patients at risk of deteriorating were monitored and systems were in place to ensure a doctor or specialist nurse was called to provide additional support. The trust had an open culture and was prepared to learn from clinical incidents. Across the Division of Medicine there were enough medical and nursing staff to keep patients safe. The trust found it difficult to recruit new nursing staff; but was able to effectively fill gaps across the division by using bank and agency staff.

We found care was provided in line with national and local best practice guidelines. Clinical audit was undertaken and there was good participation in national and local audit that demonstrated good outcomes for patients. Patient morbidity and mortality outcomes were within expectations for a hospital of this size and complexity and no mortality outliers had been identified. The improvements in the care of patients with strokes was notable.

There was a good knowledge of issues around capacity and consent among staff.

Patients received compassionate care and were treated with dignity and respect. Most patients and relatives we spoke with said they felt involved in their care and were complimentary about staff. One person told us, “The staff are very, very kind and helpful. You just feel completely confident that they know their stuff." The Medicines division had good results in patient surveys with results indicating an improvement in patient views over the last 12 months.

The Medicines division were effective at responding to the needs of the community. The trust’s performance management team understood the status of the hospital at any given time. Bed availability was well managed. Elderly care pathways had been well designed to ensure elderly patients were assessed and supported with their medical and social needs.

The medical services were well led. Divisional senior managers had a clear understanding of the key risks and issues in their area. Medical areas had an effective meeting structure for managing the key clinical and non-clinical operational issues on a day to day basis. The hospital had a risk register which covered most key risks. Staff spoke positively about the high quality care and services they provided for patients. They described the hospital as a good place to work with an open culture. The most consistent comment we received was that the hospital was a “nice” place to work and staff enjoyed working in their teams.

Urgent and emergency services (A&E)

Outstanding

Updated 20 April 2016

Overall we rate the emergency department as 'Outstanding'.

This was because the trust had demonstrated a very responsive and hospital wide approach to meeting treatment time targets. The hospital met, and sometimes exceeded, the national target of seeing, treating, admitting or discharging 95% of patients within four hours, ending the year in the top 20 trusts in the country. Departmental leaders and staff had implemented highly effective systems to maintain flow and escalate problems as soon as there were indications of delays in patient flow.

There were clear arrangements in place to protect patients from abuse and avoidable harm. Medical and nurse staffing was at safe levels through effective recruitment and there were no 'No Events' or 'Serous Incidents' reported within the emergency department. There was a strong organisational culture of reporting errors and incidents. Incidents and complaints were investigated thoroughly, and lessons learnt were shared. Infection prevention and control practice was well established and staff followed the trust policy and national guidance.

Patients were efficiently assessed, monitored, and cared for to prevent or respond to deterioration in their condition.

Patients were asked about their wishes and supported to make decisions about their care and treatment. We saw staff consistently offered care that was kind, respectful, and considerate, whilst promoting patient privacy and dignity at all times. Staff supported patients promptly in managing pain and anxiety and we observed staff discussing treatment and pain management with patients in ways they could understand.

The 2014 Western Sussex Trust staff survey showed the numbers of staff experiencing physical violence was worse than the national average score for acute trusts. In discussion with the trust this was identified as a result of the large numbers of patients with advanced dementia. The trust had worked with staff to address the risks by introducing a new elderly care pathway so these patients had a reduced length of stay in ED and could quickly be transferred to a calmer ward environment or discharged to the familiar surroundings of their home.

CCTV was not installed within the paediatric area of the emergency department and doors were not locked, potentially allowing the public access with the risk of possible harm to children.

Surgery

Good

Updated 20 April 2016

Overall we found that surgical services at St. Richard’s Hospital were 'Good'.

This was because patients were protected from avoidable harm. There were robust systems to report, monitor, investigate and take action on incidents. There were effective governance arrangements to facilitate monitoring, evaluation, reporting and learning. Risks were identified and acknowledged and action plans were put into place to address them.

We saw patients’ care needs were assessed, planned and delivered in a way that protected their rights and maintained their safety. Surgical care was evidence based and adhered to national and best practice guidance. The trust’s policies and guidance were readily available to staff through the trust’s intranet. The care delivered was routinely measured to ensure quality and adherence to national guidance and to improve quality and patient outcomes. The trust was able to demonstrate it continuously met the majority of national quality indicators. Patient surgical outcomes were monitored and reviewed through formal national and local audits.

There was clear leadership, and staff knew their reporting responsibilities and took ownership of their areas of influence. All staff spoke with passion and pride about working at St Richard’s Hospital and spoke enthusiastically about their role and responsibilities. We found staff attendance at mandatory training was good and staff were knowledgeable in how to safeguard and protect vulnerable patients.

Patients told us they were treated with dignity and respect and had their care needs met by caring and compassionate staff. During our inspection we observed patients being treated with kindness, respect, professionalism and courtesy. This positive feedback was reflected in the Family and Friends Test and patient survey results.

However, we found some areas had scope for improvement. We considered that existing mitigating strategies and the expertise of clinical staff meant that risks to patients were minimised:

The trust did not meet the referral to treatment (RTT) times for a number of surgical specialties. The ophthalmology, musculo-skeletal and ENT specialties were of particular concern.

We found there were some environmental challenges where lack of facilities such as adequate storage, clinic room and toilet facilities presented a potential risk to patients and impacted on their care and treatment.

Staff were not monitoring ambient room temperatures in rooms where drugs were stored. There is a risk that certain medicines become less effective if stored at incorrect temperatures.

The availability of junior doctors out of hours was raised as a concern as staff felt they could not always access medical support promptly.

Intensive/critical care

Requires improvement

Updated 20 April 2016

Overall we rated the CCU at St Richard’s Hospital as 'Requires Improvement'.

This rating reflects the areas of good practice we found through our review of clinical audits, staff training, patient notes and outcomes as well as other performance indicators such as cleanliness and action taken on local audits.

Leadership in the unit was coherent, robust and well respected by the staff. We saw examples of innovation in improving patient safety and good practice, particularly in relation to the successful pilot of a new electronic patient records system that combined patient tracking software with observation charts and electronic prescribing. Significant challenges relating to infection control and capacity were clearly understood by the matron and lead consultant. They had undertaken scoping exercises to address issues, such as the introduction of new bed space equipment.

Staff practised in line with clinical guidance of national organisations such as the National Institute for Health and Clinical Excellence (NICE), the Royal College of Physicians and the Intensive Care Society (ICS). Such guidance was embedded into the work culture and used to evaluate and improve practice through the sharing of learning and use of audits to update policies and procedures. Staff contributed to national audits compiled by the Intensive Care National Audit and Research Centre (ICNARC). The CCU team had access to multidisciplinary specialists who routinely contributed to decision-making and ward rounds in the best interests of patients. An established critical care outreach team (CCOT) supported patients across the hospital during limited hours.

The CCU was clean, hygienic and well maintained and staff demonstrated good infection control practices. However, there was room for improvement in the storage of waste and the management of related hazards. Equipment was serviced regularly and staff were certified in its use with regular training updates. We found full compliance with the trust’s medicine management policy.

A robust incident reporting system was in place that staff used confidently to investigate incidents and errors. There was evidence that learning from investigations had taken place with an effective system in place to ensure all staff were aware of updates to practice. Overall this contributed to an environment in which safety was prioritised and patients received individualised care. This reflected the culture in the unit, however we found a lack of clarity over how staff effectively obtained decisions from the senior executive team regarding risks they were concerned about, particularly with regards to capacity and staffing levels.

We observed a commitment to personalised care delivered by staff who were competent, passionate and keen to develop professionally.

There were on-going problems relating to short staffing according to standards benchmarked by the ICS, the Royal College of Nursing (RCN) and the Faculty of Intensive Care Medicine (FICM). The unit did not always have a consultant intensivist present or on-call, which meant patients were not always seen within 12 hours of admission by a consultant intensivist. Nurse to patient ratios of 1:2 or 1:1 were consistently met, however ICS core standards guidance that a supernumerary senior nurse coordinator be present 24-hours, seven-days, was not always complied with.

Services for children & young people

Outstanding

Updated 20 April 2016

The children and young people’s service was rated 'Outstanding' because it had a strong, open culture of safety and developed reporting and learning from incidents and complaints. There was also strong governance and an effective assurance framework which resulted in a cycle of monitoring and improvement.

The children and young people who used the serviced experienced good care that resulted in outcomes that were generally above national benchmarks. Where there was underperformance, it was recognised and addressed through robust action. Staff knew how the service was performing in specific areas and were motivated to make improvements. Innovation and ownership of the service was strongly encouraged.

There was a culture of joint working and learning from others. This worked across the trust with examples such as 'Harvey’s Gang' (which the trust is justifiably proud of) and with other local providers and children’s agencies. The result of this was that children and families had a seamless journey through separate services, both internally and externally. Outcomes for very young children living in challenging circumstances benefited from this joint working.

Most importantly, the staff and leaders of the service were self-aware, they knew the limits of care they could provide safely, they understood the areas they needed to improve on and were working on these. They were very proud of their work and felt sufficiently comfortable in their position to share their pride widely and loudly to build on their strengths.

End of life care

Outstanding

Updated 20 April 2016

The overall rating for end of life care services for St Richard’s Hospital is 'Outstanding'.

The trust’s staff talked with enthusiasm about their proactive stance in getting people home to die if at all possible. This was supported by a strong rapid discharge policy that was sufficiently resourced to make it workable. The first national VOICES survey of the bereaved (2012) suggests that 71% of people wanted to die at home but that only 29% of people nationally who died in hospital felt they had sufficient choice about this. At the Western Sussex Hospitals NHS Foundation Trust, over 80% of people were supported to die in their preferred place of care. A strong culture of enabling rapid discharge supports people and their families in their desire to die in their home surrounded by the people they love and within a familiar environment that they retain more control over. The trust’s equipment library was a very good resource that enabled the rapid discharge of patients who wanted to be cared for at home in the last few days and hours of life.

A review of the data showed the trust had robust policies and monitoring systems in place to ensure it delivered good end of life care. However, it was the direct observation and conversations with staff, relatives and patients that made us judge the care outstanding. Individual stories and observed interaction provided assurance that staff of all grades and disciplines were very committed to the proactive end of life care agenda set by the board.

Staff provided a service that was caring. The specialist palliative care team (SPCT), mortuary and chaplaincy staff worked effectively and cohesively as a team to provide a seamless service. Most audits performed by St Richard's scored above England averages, which underpinned the rating given for this service. Feedback made directly to CQC, from relatives of people who had died at St Richard’s Hospital was overwhelmingly positive. They told us they, “could not have asked for more” and that staff in all areas of the hospital were caring, respectful and attentive. They talked about being involved and appreciated being supported to remain near their relative at all times.

The trust had prioritised the correct use of Do Not Attempt Resuscitation forms as a tool for engaging with patients and relatives about how they would like care to be delivered should there be an unexpected or expected but significant deterioration in the patient’s condition. Consultants had oversight of decisions made by junior doctors in consultation with family and we saw examples of clear challenge where a consultant was not content that sufficient thought had been given to the decision to withhold resuscitation that was requested by the relatives.

End of life care services were responsive. All teams worked hard to meet the needs of patients at the end of their life. There were some delays in discharges throughout the trust but these did not affect people needing end of life care where the trust managed to ensure that 79% of people were able to die in their preferred place of care.

The management structure, staff involvement and culture of the service were also outstanding. Staff feedback was exclusively positive throughout the inspection with all grades of staff supporting the trust focus on providing good end of life care. There was a positive vision for the future sustainability of the service.

Outpatients

Good

Updated 20 April 2016

Overall we found outpatients and diagnostic imaging to be 'Good'.

Staff contributed positively towards patient care and were proud of the services they provided. They behaved in a professional manner and treated patients with kindness, dignity and respect. Staff felt managers were approachable and kept them informed of developments within the trust.

Clinicians in outpatients had access to patients’ records more than 99% of the time. The outpatient and radiology departments followed best practice guidelines and there were regular audits undertaken to monitor quality.

All areas were clean, tidy and uncluttered with good infection control practices in place.

However, the trust had consistently not met referral to treatment times since 2013 for adults and from March 2015 for children's services.