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Inspection Summary


Overall summary & rating

Outstanding

Updated 20 April 2016

We carried out an announced inspection visit from 9 to 11 December 2015. We held focus groups with a range of hospital staff including; nurses of all grades, junior doctors, consultants, midwives, student nurses, administrative and clerical staff, physiotherapists, occupational therapists, pharmacists, domestic staff, porters and volunteers. We also spoke with staff individually.

We talked with patients and staff from all ward areas and outpatient services. We observed how people were being cared for, talked with carers and/or family members and reviewed patient records of personal care and treatment.

We carried out an unannounced inspection on 21 December 2015 at Worthing Hospital.

Overall we found that Western Sussex Hospitals Foundation NHS Trust was providing outstanding care and treatment from Worthing Hospital. 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. NHS Quest members 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.

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 the overwhelming majority of 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 on-going to bring about improvements.

  • An example of this was the 4 hour Emergency Department 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 and the figures for HSMR places the trust in the top 20% of hospitals.

  • Information regarding patient 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 at Worthing Hospital contacted us to tell us about their belief that Worthing Hospital 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.

  • 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.

  • An overwhelming majority of consultants from Worthing Hospital contacted us and were very positive about how the trust provided service from this site. The majority of consultants employed at Worthing 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.

  • One small group of consultants from one speciality were less favourable about their engagement with the trust. They were led by a doctor who did not work at the trust and who had spread their allegations widely outside the organisation, without using the trust incident reporting and governance structures. We interviewed the protagonist prior to the inspection and also spent a whole day interviewing consultants regarding potential bullying and harassment. We found no indication of corporate bullying – in fact quite the opposite. Consultants told us the executive team were open and approachable and they felt valued and listened to. The main issues of concern appeared to stem from two things – the appointment of an external rather than a favoured internal candidate and some issues of standardising practice across the two sites.

  • The trust has had an external review of the service where concerns had been raised. The report of the review gave no indication that patient safety issues were hidden or ignored. Patient safety had a very high focus amongst trust staff and outcomes were generally very favourable compared to other trusts.

  • 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 view 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 has introduced a ward accreditation scheme that was being rolled out to all wards. This scheme focussed on promotion of the trust Vision and Values through monthly monitoring of key metrics.

Outstanding practice

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

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. Specific areas and staff groups of particular note included the whole neonatal team and children’s services team, the emergency floor team, the Specialist Palliative Care Team, the volunteers across the hospital and the cleaning team.

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 a 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.

The staff knowledge of safeguarding vulnerable adults and children and how they should proceed if concerns arose was a significant strength. There was very good joint and interagency working. The transfer of responsibility for the management of ‘at risk’ babies from maternity (during the antenatal period) to paediatrics (following delivery) was seamless.

The culture of safety and learning from incidents and complaints was well embedded. All staff felt responsibility for reporting mistakes and incidents and there was good dissemination of learning following investigation or review.

Worthing Hospital was the first hospital in the country to provide visitors with the opportunity to use a hand scanner that detected abnormal heart rhythms and offer immediate clinical assessment. The 'Scan Station' in outpatients gave directions of how to get to the cardiac department when an abnormality was detected where the result was discussed and an ECG performed to exclude or identify Atrial Fibrillation, if necessary. Staff told us the idea of widening the self-testing was being considered with potential for early identification and management advice for conditions such as hypertension.

Worthing Hospital had won three catering awards. These included an 'Eat Out Well Award' (Gold) issued by West Sussex Environmental Health Service. The 'Eat Out Eat Well Award' had been developed to reward caterers who make it easier for their customers to make healthy choices when eating out. A 'Food for Thought Award' was won by both the main kitchen (Silver) and the Education Centre (Gold).

The  trust wide work on the care of people living with dementia was notable. The trust maintained a dashboard that was used as a tool for monitoring the implementation of the dementia strategy. Direct feedback from relatives and observation showed people with dementia received very good care. A hospital administration manager talked to us about the initiative to get staff/visitors and other people to make and donate 'Twiddle muffs' to occupy and calm patients with dementia. The really outstanding part of this was not the activities but the 'whole hospital' approach that involved non-clinical staff, volunteers, executive team members as well as clinical staff from all settings including the operating theatres and outpatients department.

The introduction of a ward accreditation scheme based on values, the trust vision and a safety focus was beginning to demonstrate how the monitoring of key performance indicators at local level and comparing these to similar wards could be used as an effective tool for improving the quality of services.

The hospital was involved in the 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 local leadership of services was very good. Staff told us they were approachable and open and they valued staff input. We saw particularly good examples in the ED where the hospital had continued to meet the four hour target despite a threefold increase in demand. Local leaders had worked with staff in the department and across the hospital to ensure flow through the department was maintained.

The chaplains were repeatedly mentioned as 'going the extra mile'. Staff and patients told us about the level of kindness and support shown by the team.

The improvements in the stroke service had resulted in significant and demonstrable improved outcomes for patients. In the preceding two years the SSNAP rating had moved up from a 'D' to a 'B'. This was particularly impressive given the scores were benchmarked nationally and were not adjusted to take account of the high admission rate from a population of greater age and complexity than the national average.

Welcome home packs were a really nice idea. The hospital worked with local supermarkets to provide frail and isolated patients with hampers that meant they did not have to worry about food for the first 24 hours. Packs included basics such as milk, bread, fruit and cheese.

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

The most notable issue was the referral to treatment times where the trust was not meeting the 18 week target in some specialities.

The trust should continue develop strategies to recruit and retain sufficient medical and nursing staff to meet the needs of the service.

The trust should ensure all staff have completed mandatory training and they receive an annual appraisal to ensure their continuous professional development needs are met.

The trust should ensure all staff are aware of the duty of candour requirements.

Senior staff should establish active processes for compliance with the European Waste Frame Directive (2008/98/EC) and the HSE Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 with regards to the storage and disposal of sharps bins and chemical storage on the critical care unit.

Senior staff must establish active processes to ensure compliance with the trust medicines policy in relation to stock rotation and the disposal of expired products.

The trust should consider ways of ensuring they meet the RTT admitted pathway targets.

The trust should review the discharge arrangements from the critical care unit to ensure patients are cared for in an appropriate environment.

The trust must ensure they have sufficient Supervisor 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

Medical care (including older people’s care)

Outstanding

Updated 20 April 2016

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 Medicines Division there were enough medical and nursing staff to keep patients safe. However, on the day of our inspection, the number of chemotherapy qualified staff on the Medical Day Care Unit was less than the established amount. The trust found it difficult to recruit new nursing staff; but was able to effectively fill gaps across the division using bank and agency staff.

Staff across the Medicines Division reported problems with the trust’s electronic prescribing system when prescribing and transcribing. Actions to mitigate the risks posed by e-prescribing were not recorded on the divisions risk register.

The environment at the Medical Day Care unit had led to a four week wait for patients requiring chemotherapy.

Attendance at mandatory training, as well as staff receiving an annual appraisal was below the 90% trust target. 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. We observed good clinical practice by clinicians during our inspection. Patient morbidity and mortality outcomes were broadly within what would be expected for a hospital of this size and complexity and no mortality outliers had been identified. There was a good knowledge of the issues around capacity and consent among staff. We found two deprivation of liberty safeguard (DoLS) assessment applications did not contain capacity assessments.

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 have been very nice and have always responded when I have called them.” The Medicines division had good results in patient surveys with results indicating an improvement in the views of patients 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 that elderly patients were assessed and supported with all their medical and social needs. Patients living with dementia were accommodated on two specific department of elderly medicine (DOME) wards. The AMU provided effective alternate pathways for GP's and other referrers.

Medical services were well led; divisional senior managers had a clear understanding of key risks and issues in their area. The 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 and as having 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 rated the emergency department as 'Outstanding'. It wasn't perfect but the staff and trust executive knew where any shortfalls and risks were and were constantly reviewing the provision to ensure it was meeting the needs of the people using the service.

Departmental leaders and staff had implemented systems to maintain flow and escalate problems as soon as there were indications of delays in patient flow. The trust had programmes of work to improve patient flow through the hospital. The hospital met 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.

We saw examples of a service that responded in an extremely compassionate way to meet the needs of a patient whose spouse had died the previous day in the same department. The service was very busy but the patient and their relatives were made to feel as though staff had all the time in the world to support and care for them.

Patients were asked about their wishes and were supported to make decisions about their care and treatment. We saw staff consistently offered care that was kind, respectful and considerate whilst promoting their 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 ED had a strongly embedded culture of learning from incidents. There were clear and effective processes for incident reporting, investigation and learning from incidents. Staff we spoke with knew how to escalate concerns in relation to patient safety and safeguarding. They were aware of Duty of Candour and could describe how they met this requirement.

The leaders of the service were well respected by the staff. Staff of all grades and disciplines talked positively about working in the department and for the trust.

Surgery

Good

Updated 20 April 2016

Overall we found that surgical services at Worthing Hospital were 'Good'. This was because;

Patients were protected from avoidable harm because there were robust systems to report, monitor, investigate and take action on any incident that occurred. There were effective governance arrangements to facilitate monitoring, evaluation and 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 Worthing 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.

The patients we spoke with during the inspection told us they were treated with dignity and respect and had their 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 feedback and patient survey results.

However, we found some areas that 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 at the current time.

We found there were some environmental challenges where lack of facilities such as adequate storage 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 inexperienced medical staff were often working unsupported.

There was a lack of surgical beds with the admissions ward, day care ward and theatre recovery frequently used to accommodate overnight stays because of bed shortages. This affected patients being admitted for surgery. Patients were sometimes recovered from anaesthesia in the operating theatre because the recovery bays were full of patients waiting to be discharged home or to a ward. Surgery was sometimes cancelled because there were often no beds for them to be admitted to.

Intensive/critical care

Good

Updated 20 April 2016

Overall we rated the CCU at Worthing Hospital as 'Good'.

This rating reflects the areas of good practice we found through our review of staff training, patient notes and patient outcomes as well as other performance indicators such as rates of unplanned readmissions and strategies to reduce discharge delays. Leadership in the unit was coherent, robust and well respected by the staff we spoke with.

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, who had undertaken scoping exercises to address them, such as a business plan to upgrade the enhanced surgical care unit to a level two care facility for HDU patients.

Staff practised in line with the clinical guidance of national organisations such as the National Institute for Health and Care Excellence (NICE), the Royal College of Physicians (RCP) 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 seven days a week.

The CCU was well maintained however, there was room for improvement in infection control practices, particularly relating to the correct use of aseptic non touch practices and more vigilant removal of dirty consumables. The unit was also not compliant with Health and Safety Executive or European Commission regulations relating to the safe storage and disposal of hazardous waste and equipment. We found some areas of non-compliance with the trust’s medicine management policy, particularly relating to stock rotation and the disposal of expired medicines.

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 from staff who had a good understanding of their personal needs. Relatives spoke highly of the care they had encountered and said they had found the senior nursing team to be responsive when they had been concerned about something.

The unit met the standards benchmarked by the ICS, the Royal College of Nursing (RCN) and the Faculty of Intensive Care Medicine (FICM) in relation to staffing levels. There was a consultant intensivist on-call 24-hours a day, seven days a week and patients were always seen by a consultant within 12 hours of admission. Nurse to patient ratios of 1:2 or 1:1 were consistently met and ICS core standards guidance that a supernumerary senior nurse coordinator be present 24-hours, seven-days, was always complied with.

Maternity and gynaecology

Outstanding

Updated 20 April 2016

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

This was because of the excellent work being done to engage with women and their partners through innovative and award winning use of social media and other routes. The trust was actively working to engage with harder to reach groups and had adapted services to the needs of a changing local community.

Multi-disciplinary work internally at the trust and with external partners had resulted in improved outcomes for woman and babies, particularly the most vulnerable or those in challenging circumstances.

The service provided effective care in accordance with recommended practices. Outcomes for women in the service were continuously monitored and incidents and complaints were used as opportunities for learning and for the improvement of services.

The service at one of the main sites was sometimes unable to cope with the demand and this resulted in the closure and women were diverted to the other site. This also resulted in some delay for women waiting for the induction of their labour and for elective caesarean sections.

Compliance with training was good and staff were offered additional opportunities for learning and development. The care was compassionate and supportive and women and their families were treated with respect and dignity.

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 developed through the reporting and learning from incidents and complaints. Strong governance and an effective assurance framework resulted in a cycle of monitoring and improvement. 

The children and young people who used the serviced experienced good care that resulted in outcomes 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 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 staff and leaders of the service were self-aware, knew the limits of care they could provide safely, understood 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

Staff provided an end-of-life care service that was outstanding. The specialist palliative care team, mortuary and chaplaincy team worked effectively and cohesively to provide a seamless service. Most audits performed by Worthing Hospital scored above England averages, which underpinned the rating given for this service.

The management structure, staff involvement and culture of the service were good. Patient and staff feedback was consistently positive throughout the inspection. 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 treated patients with kindness, dignity and respect.

Medical record management enabled clinicians in outpatients to have access to patients’ records more than 99% of the time. The outpatient and radiology departments followed best practise guidelines and there were regular audits undertaken to maintain quality.

All areas we visited were clean, tidy and uncluttered. Infection control practises were generally within guidelines, however some cleaning checklists were incomplete.

Staff felt managers were approachable and kept them informed of developments within the trust.

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