The Care Quality Commission
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Archived: Weston Area Health NHS Trust

This is an organisation that runs the health and social care services we inspect

Overall: Requires improvement read more about inspection ratings
Important: We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

All Inspections

26th February to 28th March 2019

During a routine inspection

Overall trust

Our rating of the trust stayed the same. We rated it as requires improvement because:

Safe, responsive and well-led were rated requires improvement and effective and caring were rated as good. The rating of well-led at core service level was requires improvement overall, and the rating for trust management, was also requires improvement. This led to a combined overall rating for the trust of requires improvement.

We rated well-led at the trust as requires improvement because:

  • While there had been improvements in the stability of the board, we had concerns about the capacity of them to meet all of the demands being placed on the trust. We saw that support for this issue was being procured through close working relationships with a neighbouring trust, as well as through the use of funding to support some additional posts. However, there remained the challenge of a lack of succession planning to provide any kind of leadership infrastructure which further jeopardised the performance of the trust.
  • The trust was not compliant with the requirements of the fit and proper persons regulation, with a board level director in a seconded role not subject to FPPR tests.
  • Mandatory and safeguarding training levels continued to fail to meet targets, with opportunities for training often hindered by the staffing challenges faced by the trust.
  • Capacity constraints meant that pharmacy was used as a supply service, meaning there was significant risk around clinical support to wards. This was a known risk and had been on the corporate risk register since July 2017 with no reduction in risk rating. Action had not been taken to reduce the significant workforce risk. There were limited internal process for monitoring the pharmacy service and results of medicines audits were not always shared with pharmacy. The department responded reactively to incidents and the lack of pharmacy or medicines audits meant they were not identifying concerns before they become an incident. However, an annual pharmacy report went to the Quality and Safety Committee (a sub-board committee) and a monthly pharmacy report was submitted to the Clinical Effectiveness Group which reported directly to the Quality and Safety Committee. We heard consistently of a negative working culture in all the areas we visited on this inspection with the exception of surgery, – experienced at operational level, and not addressed at leadership level. Staff survey results remained a concern, and, while an improving picture, still contained many areas of poor performance. Added to this was a lack of visibility of the senior leadership team with a feeling of being disconnected articulated by operational staff at all levels.
  • The executive and non-executive team evaluated an integrated performance report at the monthly board meeting. However, there was a lack of statistical process control to enable the leadership team to analyse performance in a proactive way. This meant that the reports provided for analysis of past performance but did not create a space to enable the forecasting of future activity.
  • The arrangements for identifying, recording and managing risks, issues and performance was not always effective or effectively managed.
  • Engagement with unions was poor, with little provision made for representatives to carry out their roles effectively.

However:

  • We were assured that the leadership team at the trust were fully sighted and conversant with the challenges of their roles. During our interviews with the senior leadership team we were assured there was a common recognition of the challenges facing the organisation and its ability to provide high quality care in a sustainable way. It was clear from our conversations, that the chief executive officer demonstrated the strengths, insight, integrity and resilience needed to perform his function.
  • Beyond the capacity challenge, the trust enjoyed a leadership team which was fully recruited and contained a diverse range of skills and experience. The trust had received funding from the NHS challenged provider fund which had funded additional posts to support elements of the capacity challenge.
  • The trust articulated and was engaged in some key strategic work within the local health economy. There was a clear interconnected vision and strategy for the quality of care and services for patients and the local population. Internally, the trust was working towards its strategy, and externally it was a key stakeholder in the development of the Healthy Weston programme, as well as driving the linking up of services with local trusts.
  • Staff at the trust were trained from induction onwards to understand and recognise the duty of candour. This approach was amongst the best we have seen and was clearly having a positive impact.  
  • The trust had been performing well above average for the NHS referral to treatment time target and met the standard overall.
  • There were effective arrangements for the work of volunteers who were highly regarded and valued in the trust.
  • Urgent and emergency services (also known as accident and emergency services or A&E) remained inadequate. This remained the same as our inspection in 2017. Safe and well-led remained inadequate. Caring remained as good and effective remained requires improvement, with responsive improving from inadequate to requires improvement. In safe, we found staff did not always assess and respond appropriately to patient risk and monitor their safety. The service did not have enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. There was not a cohesive or stable leadership team in the emergency department. This was compounded by a culture in which some staff did not feel supported. However, patient outcomes were generally in line with similar services, and staff cared for patients with compassion and provided emotional support when they were distressed.
  • Medical care was rated as requires improvement overall. This remained the same as our inspection in 2017. Safe and well led remained as requires improvement but responsive improved to requires improvement from inadequate. Effective improved from requires improvement and caring remained as good. In safe, the service did not always follow best practice when prescribing, giving, recording and storing medicines. Patients did not always receive the right medication at the right dose at the right time. The service did not have enough nursing and therapy staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. Acutely unwell patients who needed side rooms did not always receive the recommended level of monitoring by nursing staff. However, the service took steps to control infection risks well most of the time. Staff kept equipment and the premises clean. When an infection was confirmed, they used control measures to prevent the spread of infection. Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary. The service also used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors. Managers used this to improve the service.
  • Child and adolescent mental health services were rated overall as inadequate. This was a drop from outstanding at our inspection in 2015. Safe and well led both went down from good to inadequate, effectiveness went down from outstanding to requires improvement, responsive went down from good to inadequate, and caring went down from outstanding to good. Staff did not protect young people from avoidable harm because they did not actively monitor the waiting list or revisit the risks of young people waiting to access treatment. There were not enough staff to meet the demands of the service. There was a high turnover rate and staff had felt the impact of this on their workload. The service had received an increase in referrals that was putting strain on its ability to see young people quickly. The service was not well led and there was a lack of ownership in local management. Staff did not document risk assessments of all the young people receiving care within the service.
  • Surgery was rated good at this inspection, which is the same rating as our last inspection in 2017. Safe, effective, and well led improved from requires improvement to good. Caring remained good, but responsive went down from good to requires improvement. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service controlled infection risk well. There were systems to monitor and maintain standards of cleanliness and hygiene, to prevent the spread of infection. The service had suitable premises and equipment and looked after them well. The World Health Organisation’s (WHO) five steps to safer surgery process was well embedded and followed within theatres. The service managed patient safety incidents well. The service used safety monitoring results well. However, the management of medicines could be improved to ensure best practice. The service provided mandatory training in key skills, however, not all staff were fully compliant with their training, particularly medical staff. Junior doctors were not confident the processes to support urology patents overnight and at weekends were functioning effectively.
  • On this inspection we did not inspect critical care, maternity, services for children and young people, or end of life care. The ratings we gave to these services on previous inspections in 2015 and 2017 are part of the overall rating awarded to the trust this time.
  • Our decisions on overall ratings take into account, for example, the relative size of services and we use our professional judgement to reach a fair and balanced rating.

Our full Inspection report summarising what we found and the supporting Evidence appendix containing detailed evidence and data about the trust is available on our website – www.cqc.org.uk/provider/RA3/reports.

26th February to 28th March 2019

During an inspection of Specialist community mental health services for children and young people

  • Staff did not protect young people from avoidable harm because they did not actively monitor the waiting list or revisit the risks of young people waiting to access treatment. There were not enough staff to meet the demand on the service. There was a high turnover rate and staff had felt the impact of this on their workload.
  • The service had received an increase in referrals that was putting strain on its ability to see young people quickly. This was due to the cutting of local services that young people would have previously have gone to before a referral to CAMHS was required. This reflected a national trend in the same direction. As a result, staff saw young people that were increasingly more complex and unwell in their presentation. This combined to create a service, which had previously been rated outstanding by CQC in 2015, that was struggling to cope with the demand and was therefore no longer operating at a level over and above its duty of care.
  • There were extensive waits for the service that put young people at risk and breached the 18-week referral to treatment target set by commissioners. The long waits due to the lack of staff within the service risked a negative impact on the health of young people and restricted who were offered a service. The pressure on the service had impacted the number of referrals being rejected and therefore young people were being re-referred into the service.
  • The service was not well led and there was a lack of ownership in local management. Staff expressed concerns with safety, vacancies and capacity of the service and we were shown evidence of these concerns being raised that had not been acted on promptly and effectively. Staff felt that the trust did not understand the service.
  • The governance arrangements did not support the delivery of a good quality service and the governance meeting functioned inadequately. The governance meeting had occurred only twice since June 2018 and the meeting minutes for the September meeting contained limited information. Staff felt business meetings were not regular enough to be useful and did not provide time for them to discuss issues. There were inadequate systems in place to demonstrate the effective running of the service, this meant that local management were not sighted on key performance indicators. The data systems in place at the time of the inspection meant that there was unreliable information being provided and data was not accurate.
  • The lack of effective management had impacted the service. Staff consistently reported that they did not feel respected, supported or valued at work. They reported high levels of stress, were not happy and did not feel engaged with the service.
  • There were not enough staff within the team to provide more intensive support to those experiencing crisis through the rapid access clinic. As a result, all staff held mixed caseloads that included young people requiring help in a crisis.
  • Staff were not up to date with mandatory training with overall compliance at 75% on the first day of the inspection with child safeguarding and fire training below 75%. Staff expressed concern that staff did not have the correct skills to support all the pathways provided. Staff did not all receive regular supervision to provide them with opportunity for reflective practice. There was limited specialist training open to staff working at the service.
  • Staff did not document risk assessments of all the young people receiving care within the service. There was no clear risk assessment tool being used by the staff and it was unclear where risk information was kept within the paper files. Staff did not document care plans for all young people in the notes we reviewed.
  • There was an unsafe culture in the use of paper records that had compromised the care of young people while impacting on their confidentiality. Notes were not stored safely and securely at all times.
  • Staff used an electronic records system to record and escalate incidents. However, we saw that not all incidents involving young people had been recorded. Learning from incidents was not robust enough to prevent repeated incidents occurring.

However:

  • The trust had taken our feedback seriously, and had a critical friend visit from the CCG as well as inviting CAMHS experts from NHSI to come in to support with improving the service. Additionally, processes were amended so that any patient going on to the waiting list would be risk assessed as to their current status and whether they needed to be seen as an emergency. Advice to patients and families was also updated to ensure they were aware of how to seek help during the time they spent on the waiting list. The trust had developed an action plan to address the issues. The plan included:
  1. The urgent care assessment team (UCAT) had started to risk assess all patients on the waiting list, as well beginning to see patients as  part of the urgent referral process, to reduce the workload on the remainder of the team
  2. Additional management capacity had been created in CAMHS to support the team. There was a demand and capacity review being undertaken to assess workload at an individual and service level
  3. There were weekly and monthly reports coming to the Medical Director, Director of Nursing and Director of Operations  to monitor waiting list times and risk assessment of the waiting list.
  4. There were strengthened governance arrangements with the assistant general manager reporting back any governance risk issues, to the directorate governance committee.
  • Staff demonstrated knowledge of safeguarding processes. There were cover arrangements in place for sickness, vacancies and annual leave. Staff followed personal safety protocols.
  • Staff completed a mental health assessment of young people entering the service. Where a young person had been in hospital there was well documented care programme approach record. Care pathways guiding staff on the treatment to provide according to a young person’s presentation were used and reflected National Institute for Health and Care Excellence (NICE) guidance. Staff used recognised rating scales to show progression through treatment.
  • Young people accessing the eating disorder pathway received a comprehensive physical health assessment. Staff encouraged young people to lead healthy lives.
  • Staff demonstrated a clear attitude of respectful, compassionate care. Young people could have open discussions about their personal, cultural, social and religious needs. Staff were skilled at using a range of communication tools.
  • The service had a clinician of the day service to respond to young people and families phoning into the service. Staff followed up young people who did not attend an appointment to ensure their safety.
  • The service received a critical friend report from a professional external to the service to help them identify performance issues and a potential way forward.

28 February 1,2,9,10,13 and 14 March 2017

During a routine inspection

We carried out a focused follow up inspection at Weston Area Health Trust between 28 February and 2 March 2017 and returned to visit some wards and departments unannounced on 9, 10, 13 and 14 March 2017.

This inspection was to follow up on the findings of our previous inspections in May and August 2015, when we rated the trust as requires improvement overall. Medical care was rated as inadequate, urgent and emergency care, critical care and surgery were rated as requiring improvement and maternity and gynaecology, services for children and young people, outpatients and diagnostic imaging and end of life care were all rated as good.

At this inspection we inspected the following services at Weston General Hospital

  • Urgent and emergency care
  • Medical care including care of the elderly
  • Surgery
  • Critical care

We did not inspect

  • Maternity and gynaecology
  • Children and young people
  • Outpatients and diagnostic imaging
  • End of life care

As part of this inspection, CQC piloted an enhanced methodology relating to the assessment of mental health care delivered in acute hospitals; the evidence gathered using the additional questions, tested as part of this pilot, has not contributed to our aggregation of judgements for any rating within this inspection process. Whilst the evidence is not contributing to the ratings, we have reported on our findings in the report.

We rated Weston General Hospital as requires improvement overall with the urgent and emergency care services rated as inadequate, medicine and older people as requires improvement and surgery and critical care as good.

There had been some progress since our previous inspection with surgery and critical care moving from requires improvement to good overall. In medical care responsive was rated as inadequate with all other key questions rated as requires improvement. However, the ongoing pressures on the emergency department continued to be reflected in the ratings for urgent and emergency care with safety remaining as inadequate and responsive and well led failing to improve also being rated inadequate.

We had serious concerns that systems or processes to manage patient flow through the hospital were not operating effectively and did not ensure care and treatment was being provided in a safe way for service users. We served the Trust with a Section 29A warning notice on 24 March 2017. The notice required the Trust to make the significant improvements by 15 May 2017 in the following areas:

  • Systems or processes to manage patient flow through the hospital must operate effectively to ensure care and treatment is being provided in a safe way for patients and to reduce crowding in the emergency department.
  • Review the emergency department as the single point of entry to the hospital for both emergency and expected patients to reduce crowding.
  • Ensure access to a specialist senior doctor to review patients overnight in the emergency department is timely and does not delay patient admission to wards.
  • Ensure the use of the corridor in the emergency department is an appropriate and safe area for patients to receive care and treatment.

Our key findings were as follows:

  • We found the trust had been under increasing pressure to manage flow in the hospital for several months and the emergency department was under sustained pressure from an increase in attendances.
  • There was a lack of support for the emergency department from the wider hospital services and a lack of trust wide ownership around patient flow. This meant patients were frequently and consistently not able to access services in a timely way and some patients experienced unacceptable waits for some services.
  • There was a fragile medical infrastructure in the emergency department with a crucial reliance on locum medical staff at consultant and middle grade positions. However, shortly after our on-site inspection a recent partnership with another local acute trust had secured some input for clinical leadership one day a week.
  • The corridor area in the emergency department was frequently used when there were more patients than cubicles available. This was not a suitable or safe environment for patients to receive emergency care and treatment, and was not fit for purpose.
  • The trust mortality rate had been higher than the expected level for the recent reporting periods of July 2015 to June 2016. A review of mortality and an associated action plan were in place; however, the lack of recorded minutes and actions in speciality mortality review meetings was of concern. It was unclear if learning was shared or action taken as a result of reviews of patient deaths.
  • Since our previous inspection there had been some changes to the executive team with some people now in permanent roles and others being interim positions. More changes were due in April 2017 with a new medical director and director of operations starting in post. While the current executives worked well together they had been drawn into managing operational pressures in the emergency department on a regular basis. There was a potential for the two new appointments to lead to a change in approach. In a small trust the pressures on individual executives and senior managers was greater, with many undertaking many roles and holding responsibilities which in a larger team would be more evenly shared. At times this led to extreme pressure on individuals. A review of governance had begun to implement change but was immature and lacking in clinical leadership at directorate level to provide robust assurance.

Safe

  • We rated safety as requires improvement overall with safety in urgent and emergency care rated as inadequate, in medicine it was requires improvement and good in surgery and critical care.
  • Medical staffing levels and skill mix did not ensure safe care at all times in the emergency department and medical wards. There was a fragile medical infrastructure with a critical reliance on locum medical staff at consultant and middle grade positions.
  • In the emergency department there was no clinical lead consultant medical leadership to focus direction and ensure safety was a high priority.
  • There were risks to children that medical staff did not have the appropriate skills and capability due to the lower numbers seen of emergency cases of paediatric cardiac arrest or deteriorating child.
  • The facilities in the emergency department did not all meet patients’ needs and were inappropriate. The corridor area was not a suitable or safe environment for patients to receive emergency care and treatment and was not fit for purpose. This area posed environmental risks and was a poor patient experience.
  • There had been little progress in reducing mortality at the trust. While an action plan was in place, progress with some areas was limited and there was a lack of attendance and accountability at the mortality meetings and learning points and actions were not evident in all specialities.
  • Trust policy for the management of medicines was not always adhered to, for example checking of controlled drugs, recording of medicine refrigerator temperatures and recording of signatures of agency nurses and locum doctors.
  • Pharmacy staffing levels did not meet service, clinical and medicines governance demands and achieve medicines related Commissioning for Quality and Innovation (CQUIN) and Carter model hospital indicators, and therefore protect patient safety.
  • Mandatory training compliance required improvement, particularly in basic life support and dementia awareness. With doctors not reaching compliance targets more often than nursing staff.
  • We found a fire exit in the stroke unit was blocked and could cause delay of evacuation in the event of a fire. The trust took action when we raised the issue but it continued to be poorly managed and had not been fully rectified on our unannounced visit. This was included on the risk register but not being managed effectively.

However:

  • There had been no cases of methicillin-susceptible Staphylococcus aureus (MRSA) in the previous year.
  • There were systems and processes in place to reduce the risk of cross infection and clinical areas and wards we visited were visibly clean.
  • Sepsis screening and pathways were in place with early treatment seen to be improving. Within nine months, the number of patients with identified sepsis receiving antibiotics within one hour had increased from 11 % to 78%.
  • Staff took a proactive approach to safeguarding and were aware of local safeguarding procedures for both adults and children. Although there were some delays in investigations due to staffing pressures.
  • A substantial amount of work had been carried out on National Safety Standards for Invasive Procedures (NatSSIPs). The changes were being embedded in to practice across all surgical departments.
  • A prevention and reduction for pressure ulcers action plan had been created in November 2016, the action plan was in its infancy, however, processes were being put in place to improve awareness and ensure safe management of pressure ulcers.
  • Staff understood their responsibility to report concerns and incidents. The duty of candour was mostly understood by staff and staff openness and transparency about safety was encouraged.

Effective

  • We rated effective as requires improvement overall with urgent and emergency care and medicine and older people rated as requires improvement and surgery and critical care as good.
  • The hospital did not have an orthopaedic-geriatric service in line with national guidance due to recruitment problems.
  • Not all patients with fractured neck of femurs were operated on within 48 hours of admission, or admitted to an orthopaedic ward within four hours in line with national guidelines.
  • When benchmarked against other hospitals the trust performed worse than the England average in a number of national audit programmes including: the 2015 Bowel Cancer Audit where the hospital had a mixed performance compared to other hospitals. The trust scored ‘E’ for patients being directly admitted to the stroke unit. The heart failure audit for 2015 showed the trust was worse than the England and Wales average for three of the four standards relating to in-hospital care and four of the seven standards relating to discharge. The 2015 National Diabetes Inpatient Audit (NaDIA) scored better than the England average in five metrics and worse than the England average in 12 metrics. Quality improvements were not always sustained and audit findings were not shared and used effectively to improve quality and patient outcomes.
  • The inability to recruit senior medical staff led to a lack of clinical leadership and did not provide sufficient support to junior doctors and ensure optimum patient safety at times of increased capacity.
  • Multidisciplinary working was not all coordinated to provide effective care for patients. In the emergency department there were professional working relationship breakdowns between doctors and established routines which had not been effectively addressed. These impacted on patients as early speciality review was delayed and patients had to wait in the emergency department.
  • A dietician audit identified poor performance for the completion of the malnutrition universal screening tool (MUST) assessments within 24 hours of admission, where the MUST was not always completed accurately.

However:

  • Care and treatment was planned in line with current evidence based guidance. Clinical care pathways and toolkits were developed in accordance with national guidelines.
  • Patients received effective care in the critical care unit with practices and protocols in line with guidance and patients had the outcomes that should be expected.
  • There was an effective stroke pathway in place through the emergency department.
  • Patients’ consent to care and treatment was sought in line with legislation and guidance. Most staff had a clear understanding of the Mental Capacity Act 2005, Deprivation of Liberty Safeguards and patient consent.
  • Patients had their pain assessed regularly and managed promptly to ensure they remained as comfortable as possible.
  • Since the last inspection, the hospital had employed a dedicated acute pain nurse in line with the Royal College of Anaesthetists Accreditation Standards.
  • There was strong multidisciplinary working across wards and departments.
  • The Patient Reporting Outcomes Measures (PROMS) and the National Joint Registry for the period of April 2015 to March 2016 showed that more patients who had groin hernia operations felt better and fewer patients felt worse after their treatment than the England average.
  • The hospital performed well in the 2016 National Emergency Laparotomy Audit (NELA). The hospital achieved a green (>80%) rating for high-risk cases with a consultant surgeon and anaesthetist present in the theatre and of highest-risk cases admitted to critical care post-operatively.

Caring

  • Caring was rated as good overall and good for each core service.
  • Staff in the emergency department remained professional and compassionate while under considerable pressure in a full to capacity and pressured environment. They were seen to take the time to speak with patients and those close to them in a respectful and considerate way. We saw staff delivering compassionate care and treating patients with kindness, dignity and respect. Privacy and confidentiality was respected as much as was possible considering the constraints of the environment.
  • Patients who were delayed in the emergency department received nursing care and support, and were transferred to beds for their comfort and food and drink provided.
  • Patients on surgical wards commented on how the care from the nursing staff and allied health professionals was ‘superb’, ‘exemplary ’and staff had a ‘great sense of humour’
  • In critical care we observed staff treating patients with kindness, warmth and emotional intelligence.

However:

  • In critical care the patients’ diaries were not being seen as belonging to the patient and were not being given to all patients or their relatives when they left the unit.

Responsive

  • Overall, improvements were required to ensure that services within the hospital were responsive to patients’ needs. Effective was rated inadequate in urgent and emergency care and medical care and requires improvement in surgery and critical care.
  • There was no sense of urgency to respond and promote discharge to initiate flow through the emergency department to the rest of the hospital to reduce crowding in the emergency department. The bed management meetings were not dynamic in ensuring flow of discharges and admissions were acted on by the wider trust and not all required staff attended.
  • The emergency department was the single point of entry to the hospital for GP expected patients. There were no direct GP admission pathways in place and this further impacted on crowding in the emergency department on a regular basis.
  • Lack of timely access to a specialist senior doctor to review patients overnight in the emergency department was at times leading to delays in patient admission to wards.
  • Patients were not able to responsively access the care they needed. The trust did not consistently admit patients within 4 to 12 hours. This meant patients were in the emergency department longer, up to 20 hours and the department was much busier as a result.
  • Patient flow within the hospital affected theatre utilisation and cancellation rates. The ambulatory emergency care unit and discharge lounge were underutilised and the medical assessment unit was ineffectively used.
  • Medical patients were being cared for on surgical wards. The trust seemed unable to rectify this position and ensure patients received care on the appropriate ward for their speciality.
  • The trust did not consistently achieve the national standard for ambulance turnaround times. The trust does not separately measure the time to initial assessment for ambulance cases; this is included in the overall time to initial assessment in the emergency department. The trust consistently performed within the target for the latest 12 months. There had been a recent increase in patients leaving the department without being seen.
  • The hospital performed worse than the England average for length of stay in general medicine and surgery. The average length of stay for the trust was 10.1 days compared to the England average of 3.6 days for medical patients and for surgery it was 3 days for elective patients, compared to 3.3 days for the England average. For surgical non-elective patients, the average length of stay was 6.3 days, compared to 5.1 days for the England average.
  • Too many patients were delayed in their discharge from critical care to a ward. These delays were worse than the national average. Some patients were discharged onto wards at night as a bed had become available, when night time discharge was recognised as less than optimal for patient’s wellbeing and mortality.

However:

  • Despite the pressures and capacity issues the emergency department took account of patients’ specific needs. Individual care needs and adjustments were put in place.
  • Dementia was well considered across wards and units and patients were identified using a ‘forget me not’ magnet. There was an older people’s mental health liaison nurse who provided support for patients living with dementia. Staff were positive about this role and felt staff and patients were well supported.
  • The trust also employed a complex needs sister and a strategic lead for learning disability services. Staff notified these staff when a person with a learning disability was admitted and the strategic lead would then follow up the patient either in hospital or through discharge.
  • The management of meals and support provided to patients during a meal time on Kewstoke ward (care of the elderly) was responsive, where patient individual needs were central.
  • The dietetic department had expanded menu choices for those patients on a textured diet and had provided patients with their own specific modified menu so they could specify their own meal choices.

Well led

  • Overall leadership at the trust was rated as requires improvement.
  • Despite a strategic vision there was a lack of assurance for delivery of the vision as the trust remained reliant on external solutions.
  • The lack of progress in securing clinical leadership and a substantive medical workforce in the emergency department had not enabled improvements to the service to meet the needs of patients.
  • Some progress had been made since the governance review although there was recognition that further strengthening of directorate governance and board to ward assurance was required.
  • The trust was not meeting their contractual obligations under the Workforce Race Equality Standard.
  • Progress in reducing hospital mortality was not evident with commitment to sharing and embedding learning from mortality reviews to improve patient outcomes not consistent across services.
  • The most recent staff survey results placed the trust in the worse 20% for a number of key areas, some of which reflected lack of progress with current actions.

However:

  • The recent partnership working was seen as positive and some early progress for support had been put in place in the emergency department.
  • The director of nursing was seen as approachable and providing support to drive nursing in the trust.
  • Patient and staff stories were presented to the board and enabled members a better understanding of the challenges faced by staff and where improvements could be made for patient experience.

We saw several areas of good practice including:

  • The oncology and haematology department demonstrated outstanding practice with the way they assessed patient risk. Patients with a risk of neutropenic sepsis were easily identifiable through the use of a yellow jacket placed on patient notes.
  • Patients living with dementia were situated in the bays or side rooms that were most visible to the nursing station. Staff who provided enhanced supervision to these patients were wearing yellow tabards and were easily identifiable. Staff were allocated to a patient or a group of patients in a bay and were not to be removed unless another staff member had taken over from them. We saw the hospital's own ‘This is me’ booklet in the notes of a patient living with dementia. This booklet had been completed by a relative of the patient and explained the patient in detail, what they liked to be called, what they liked to do and what was their favourite food.

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

Importantly, the trust must:

  • Ensure that there are sufficient numbers of suitably qualified, competent, skilled and experienced doctors deployed within the hospital. This includes sufficient medical leadership within the emergency department and suitable levels of staff to ensure the corridor is safely staffed.
  • Take action to ensure that there are sufficient medical staff with sufficient skills in advanced paediatric life support in the emergency department.
  • Take action to ensure that medicine systems in the emergency department are safe for controlled drugs including signature list for agency nursing staff and locum doctors, to cross reference who had prescribed and administered medicines.
  • Take action to ensure that systems are in place to ensure patient flow through the hospital was responsive.
  • Ensure patients are being admitted promptly once the decision to admit has been made. Take action to ensure that safety checks in the emergency department are completed.
  • Take action to ensure that patients are cared for in a safe environment in the emergency department.
  • Review the medical staffing and ensure safe levels of medical cover and support to juniors on the medical wards in evenings and weekends.
  • Review the use of locum consultants and take action to ensure medical staffing is not vulnerable through recruitment of permanent consultant staff.
  • Be assured junior medical staff are being provided with appropriate support and are competent in their roles.
  • Ensure safe nursing cover is provided on Cheddar ward and agency usage is kept to a minimum.
  • Take action to mitigate risks included on the risk registers effectively, reviewing regularly and managing those risks identified on a timely basis to ensure safety to staff or patients is not compromised.
  • Manage quality and performance and ensure sustained learning and improvements from audits.
  • Take action to continually maintain a clear path for evacuation in the event of a fire within the stroke unit by ensuring fire exits are not blocked.
  • Take action to ensure patient flow from the emergency department through the medical wards to timely discharge is effective and timely in meeting the needs of patents, and ensuring good quality care and treatment.
  • Take action to address areas of concern and demonstrate patient outcomes monitored by the Summary Hospital – level Mortality Indicator (SHMI) are improved.
  • Improve the quality, attendance, accountability learning points and actions from mortality and morbidity reviews in all specialities.
  • Make sure the surgical directorate has an orthopaedic-geriatric service for pre and post-operative care.
  • Ensure all patients that had fractured neck of femurs were operated on in line with national guidelines and admitted to an orthopaedic ward within four hours.
  • Follow trust policy for the management of medicines, for example checking of controlled drugs, recording of medicine refrigerator temperatures and recording of signatures of agency nurses and locum doctors. (Accident and Emergency)
  • Review pharmacy staffing levels in order to meet service, clinical and medicines governance demands and achieve medicines related CQUINS and Carter model hospital indicators, and therefore protect patient safety.
  • Ensure multidisciplinary input and a collective approach to the running of the critical care unit. The medical team leaders must ensure they meet regularly with the senior nursing leadership to provide a multi-professional approach and contribution to all aspects of running the unit, including governance and provision of quality care.
  • Address the poor access and flow of patients in critical care in order to reduce the delays to patients who are fit to leave the unit, reduce the risks of patients not having timely admittance, eliminate breaches in same-sex rules, stop the relocation to or delay of patients in the operating theatre recovery area, and reduce the number of patients who are transferred to a ward bed at night.
  • Produce mortality and morbidity reviews for critical care where there is accountability for learning and change, and a demonstration as to how this has improved practice and safety.
  • Review the provision for and quality of life support training in the trust to ensure there are a satisfactory number of staff with the right experience and training on duty at all times.

Professor Sir Mike Richards

Chief Inspector of Hospitals

19-22 & 30 May 2015, 5 June 2015

During a routine inspection

Weston Area Health NHS Trust provides acute hospital services and specialist community children’s services to a population of around 212,000 people in North Somerset, with over 70% of people living in the four main towns of Weston, Clevedon, Portishead and Nailsea. A further 3.3 million day trippers and 375,000 staying visitors increase this base population each year.

It has three locations that are registered with the Care Quality Commission. These are Weston General Hospital which has 265 beds, The Barn in Clevedon and Drove House in Weston-super-Mare which both provide special children’s services.

At the time of our inspection the trust was subject to a transaction process, in which Taunton and Somerset NHS Foundation Trust was the preferred acquirer. This was at the Trust Development Authority’s Gateway 2.

We inspected this trust as part of our in-depth hospital inspection programme. The trust was selected as it is an example of a moderate risk trust according to our new intelligent monitoring model. Our inspection was carried out in two parts: the announced visit, which took place on the 19-22 May 2015, and the unannounced visits, which took place on 30 May 2015 and 5 June 2015.

Our key findings were as follows:

  • There were serious concerns about safety in urgent and emergency care services and in medical services at Weston General Hospital.
  • At times when there were a higher number of people attending the emergency department, patients were not always assessed or prioritised in a timely manner. This meant they were not protected from the risk of avoidable harm. We wrote to the provider to inform them of these concerns and required them to inform us of the action which they would be taking to rectify these issues. The response that we received showed that the trust had taken urgent action to deal with the risks identified.
  • In the area known as the high care unit on Harptree ward, there were insufficient numbers of appropriately qualified and skilled nurses nurses deployed to care for high dependency patients. We raised this as a concern with the trust during our inspection and subsequently required, in writing, additional evidence to demonstrate what had been put in place to ensure that patients were not at the risk of harm. We received information which demonstrated that the trust had taken action to resolve the immediate concerns raised.
  • Overall we found the trust to be visibly clean. There were areas in the hospital environment which were tired and worn and posed some risk to infection control, for example in critical care, although these areas appeared clean. The trust was refurbishing the theatre department at the time of our inspection.
  • The trust had a focus on reducing the number of cases of Clostridium difficile, methicillin-resistant Staphylococcus aureus and methicillin-sensitive Staphylococcus aureus. The number of Clostridium difficile cases was higher than expected during the 2014-15 year, although at the time of our inspection the trust had not had a case for 90 days. This had been attributed to the focus on antimicrobial stewardship and also the introduction of bedpan macerators on the wards. Wards had been closed seven times during the winter as a result of Norovirus of which there was said to be a high prevalence in the local community.
  • Incident reporting was in line with expectations for the size of the trust. However, not all staff felt able to report incidents, particularly junior doctors, and staff did not always receive feedback about incidents that had been reported.
  • Medical staffing was of concern. There were high numbers of vacancies for consultant posts which resulted in unsustainable rotas. The support, training and supervision of junior doctors was reported to be poor. Some junior doctors were undertaking procedures unsupervised, for which they felt ill-prepared and not competent to carry out.
  • There was good feedback about the provision of training for nursing staff. However, the support, training and supervision of junior doctors was reported to be poor. This was supported by the director of medical education in the trust. The General Medical Council survey of junior doctors in 2014 also showed this and the results of the survey for 2015 (released the week following our inspection) were worse than for 2014.
  • The trust was providing effective services in maternity and gynaecology, services for children and young people, end of life care and community health services for children. The effectiveness of the mental health community services for children and young people were outstanding. Improvements were required in order for the trust to be effective in delivering urgent and emergency care, medical care, surgery and critical care services. There was a comprehensive programme of nursing audits. In the areas needing improvement there was limited evidence that actions had been followed-up, the details of learning identified as a result of clinical review and audit, or that this had been disseminated.
  • Within medical services there was limited evidence of the measuring and monitoring of patient outcomes or that care and treatment was provided in line with evidence based guidance or best practice.
  • There was evidence that care was provided in line with best practice services for maternity and gynaecology; specialist community mental health services for children and young people; children and young people and end of life care.
  • Every service was found to be caring. The inspection team found staff had a patient focus throughout and were committed to doing their best for patients. We observed staff providing kind and compassionate care with dignity and respect. Care in services for children and young people within Weston General Hospital and for specialist community mental health services for children and young people was rated as outstanding, with other areas rated as good.
  • Improvements were required in order that the trust was responsive to patients’ needs. Although referral to treatment time targets were consistently better than the England average there was high bed occupancy and high numbers of patients who remained in hospital when they were medically fit for discharge, because there were challenges in securing ongoing care packages in the community.
  • The trust consistently failed to achieve the national target for 95% of patients being admitted, treated or discharged from the emergency department within four hours of arrival.
  • Patients at the end of their life were sometimes moved between wards to accommodate new admissions to the hospital. There was at times, a lack of clarity of how the bed management policy was operated and about how decisions were made about moving patients.
  • Within services for children and young people had open access policies for those known to the service. There was flexibility in the cut off time for support for the emergency department.
  • The trust had a clear strategy in place underpinned by values that had been developed with staff.
  • The trust was in a period of change with a change of chair and chief executive. Nursing leadership was strong at all levels.
  • The Patients’ Council established in 2012 was increasing in influence and ensuring that the voice of patients was heard.
  • Volunteers were playing a valuable part in the life of the trust in many roles, including the green teams who were keeping the courtyard garden areas in very good condition.
  • There were examples of innovation and improvement across services.

We saw several areas of outstanding practice including:

  • There was an outstanding example of caring shown to a patient with a learning disability who was coming into the day-surgery unit for a procedure. One of the staff had contacted the patient’s care home and discussed the best way to manage the appointment for the patient. The arrangements were then made to reduce the anxieties of the patient, and allow one of the main carers to be with the patient as much as possible during the procedure. An ‘easy read’ booklet about coming into hospital was send to the care home to go through with the patient in advance of their visit. This showed a good depth of knowledge and sensitivity for people with different needs.
  • There was an outstanding staff newsletter produced each month. It included ‘celebration of success awards’ which were running for their second year. There were messages from public bodies, such as Public Health England, awards and recognition for staff and wards, updates on new staff, messages from patients, training and policy updates, and charity news and updates.
  • The patient safety midwife demonstrated a thorough understanding of risk and clinical governance processes. This person maintained clear audit and investigative trails which supported safe and current midwifery care in practice.
  • There was outstanding care for children, young people and their families and for specialist community mental health services for children and young people.
  • There were various examples of outstanding multi-disciplinary working between the different professional groups within the community children and young people’s services team and also with external agencies and professionals.
  • The outpatients’ manager responded and developed improvements as a result of incidents that originated outside the outpatients department. For example, problems had been caused by plaster casts that had been applied in other wards and departments. In response, the senior plaster technician in the orthopaedic clinic had devised a teaching programme to improve the skills of other clinical staff. This had been rolled out across the hospital and no further problems had occurred.
  • Following manual handling training in 2014/15 medical records staff had become concerned about the weight of boxes of records that they needed to lift. As a result, scales had been installed throughout the hospital to ensure that no boxes heavier than 11kg are lifted by staff. One of the medical records managers told us there had been a decrease in musculo-skeletal injuries since this change.
  • At the beginning of 2015 the imaging department had gained full accreditation with the Imaging Services Accreditation Scheme (ISAS). This is a patient-focussed assessment that is designed to ensure that patients consistently receive high quality services. The ISAS website states that ,as of May 2015, only 20 departments in the UK had achieved this accreditation
  • Members of staff within the specialist community mental health services for children and young people team were accredited by the Royal College of Psychiatrist’s Quality Network for Community CAMHS.
  • The trust had achieved Young People’s Friendly approval. This meant that the trust had been verified as providing a young people friendly services meeting the Department of Health ‘You’re welcome’ quality criteria.
  • Multi-disciplinary and interagency working practices and communication within specialist community mental health services for children and young people.
  • The written communication within specialist community mental health services for children and young people was outstanding.
  • The trust facilitated peer support group for foster carers who provided homes for children with learning disabilities.
  • The trust Patient Experience Review Group which considered the results of patient and staff surveys, considered information from the Patient Advice & Liaison Services (PALS) Manager and contributed to discussions about services.

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

Importantly, the trust must:

  • Ensure that patients arriving by ambulance are fully monitored and assessed for priority when in the corridor awaiting admission to the department.
  • All patients receive timely assessment in line with College of Emergency Medicine guidance to ensure that they receive suitable and timely treatment.
  • Ensure that all staff are aware of and work to standard operating procedures relating to the safer management of controlled drugs.
  • Ensure that there are suitable numbers of staff with the qualifications, skills and experience to meet the needs of patients within the high care unit.
  • Take action to improve medical staffing levels and skill mix in the emergency division to ensure that people receive safe care and treatment at all times.
  • Ensure that junior medical staff in the emergency division are appropriately supported, supervised and trained to ensure that they are competent to fulfil their role.
  • Ensure that the ambulatory emergency care unit and medical day case unit are appropriately staffed and equipped at all times.
  • Ensure that patients who attend the ambulatory emergency care and medical day case units are accommodated in areas which are fit for purpose and ensure their comfort, privacy and dignity.
  • Continue to take steps to reduce the incidence of avoidable harm as result of pressure ulcers, falls and medication incidents.
  • The audit and use of the whole range of the World Health Organisation surgical safety checklists must be improved and evidence provided to show it is being followed at all times. The hospital must ensure there is approval at board level for how the checklist is being used and audited.
  • Competency tests around the use of equipment in operating theatres must be improved to demonstrate it is vigorous. Considering there had been a high rate of medicine incidents, competency training must be introduced for medicines’ management. There must be an approved protocol for how competency is assessed.
  • The main operating theatres must ensure the management of all used surgical instruments is such to be assured the risk of cross-contamination is eliminated.
  • The hospital must ensure the medical cover in surgery services, out-of-hours, and specifically at night, is safe and the staff on duty meet the requirements of the out-of-hours policy.
  • The number of discrepancies in prescriptions in surgery services must be addressed and errors eliminated.
  • The hospital must ensure patient confidential records are secured and stored in such a way as they cannot be seen or removed by unauthorised people.
  • Staff in surgery services must get up-to-date with their mandatory and statutory training and meet trust targets.
  • The hospital IT systems must be improved to enable staff to extract and be able to use data about all aspects of theatre and surgery services.
  • As with most NHS hospitals, the hospital must improve the access and flow of patients in order to reduce delays from theatre for patients being admitted to wards, enable patients to be admitted when they needed to be, and improve outcomes for patients.
  • The governance of the surgery service must improve so there is a clear process for assessing and monitoring the safety, effectiveness and responsiveness of the service. The governance team must be able to demonstrate continuous learning, improvements and changes to practice from reviews of incidents, appropriate use of the risk register, mortality and morbidity reviews, formal clinical audits, complaints, formal feedback to staff, and using reliable data and information.
  • As with most NHS hospitals, the hospital must improve the access and flow of patients in order to reduce delays from critical care for patients being admitted to wards; reduce the unacceptable number of discharges at night; enable patients to be admitted when they needed to be; ensure patients were not discharged too early in their care; and improve outcomes for patients. The full consideration of Critical Care must be taken into account in hospital escalation plans and staff in the unit closely involved with day-to-day strategic planning.
  • The governance of the critical care service must improve so there is a clear process for assessing and monitoring the safety, effectiveness and responsiveness of the service. The governance team must be able to demonstrate continuous learning, improvements and changes to practice from reviews of incidents, appropriate use and review of the risk register, mortality and morbidity reviews (including overarching mortality ratios), formal structured clinical audits, complaints, formal feedback to and from staff, and useful feedback from people who use the service.
  • Staff in the critical care service must get up-to-date with their mandatory and statutory training and meet trust targets.

Professor Sir Mike Richards

Chief Inspector of Hospitals

20-22 May 2015

During an inspection of Community health services for children, young people and families

Overall community health services for children and young people were found to be good. We found that services were safe, effective, caring, responsive and well-led.

Weston Area Health NHS Trust provided specialist community services for children, young people and families in Weston-Super-Mare and surrounding areas. As part of this inspection we talked to professionals delivering these services. We also met and spoke with children, young people and their parents. We visited services at Drove Road in Weston-Super-Mare and at The Barn in Clevedon.

Overall we judged the safety of community health services for children and young people as good. Risk was managed and incidents were reported and acted upon with feedback and learning provided to most staff.

Care was effective. Care was evidence based and followed recognised guidance. There was excellent multidisciplinary team working within the trust and with other agencies.

Care and treatment of children and support for their families was delivered in a compassionate, responsive and caring manner. Parents spoke highly of the approach and commitment of the staff who provided a service to their families.

Backlogs and waiting lists for initial assessments for children and young people and there were concerns expressed about the flexibility of appointments and the number of cancelled appointments. This meant the responsiveness of the service required improvement. However, the service responded well to the individual needs of children, young people and their families.

There were clear lines of local management in place and structures for managing governance and measuring quality. However, most staff felt isolated from the main trust and highlighted a lack of engagement and visibility from senior managers.

20 May 2015

During an inspection of Specialist community mental health services for children and young people

We rated Weston Area Health NHS Trust specialist child and adolescent mental health services outstanding because:

  • All the interactions we saw between staff, children, young people and parents/carers were respectful, responsive, kind and considered. Staff demonstrated a thorough understanding of the effect on a child or young person of experiencing a mental health issue and the effective of living with a child or young person with mental health issues. We found evidence of excellent emotional support for children and young people and separate emotional support for parents and carers. The children, young people and families that we spoke with, without exception, commented on how caring and compassionate staff were towards them. Robust and innovative practices were used to consistently engage and involve children, young people and carers in their care and treatment.
  • The assessment of needs and risks was thorough, individualised and had a strong focus on working in partnership to achieve goals and outcomes that children, young people and families identified. Care and treatment were innovative and evidence based and there was a culture of monitoring outcomes against national benchmarks. We found excellent multidisciplinary and interagency working practices with highly effective communication between team members and other professionals, such as teachers and social workers. Staff were highly skilled and participated in local and national clinical audit and research.
  • The environment at both Drove House and the Barn was clean and well maintained. The walkways between buildings were clearly identified. Disabled access to both sites was very good and toys and facilities were available to cater for all age groups in the majority of waiting, treatment and therapy rooms.
  • We found that the team responded to urgent care referrals and care needs quickly and that children, young people and families received excellent care and treatment once they had been accepted into the service. However, there could be long waits to get an initial appointment. The team were working hard to rectify this and had developed plans to roll out the care and partnership approach (CAPA) across the service; this included plans to reduce the waiting times for appointments and be in a ‘steady state’, with waiting times for both the first appointment and for treatment within the recommended time frames by September 2015.
  • There were some staff shortages within the team but every effort was made to ensure that this did not affect care to children and young people. Staff worked extra hours to cover all the sessions that had been booked.
  • We found excellent senior clinical leadership within the service and high quality leadership at every level within the service. Leaders within the service had been proactive in raising the profile of CAMHS within the trust. However, staff felt that CAMHS was not recognised as much as it should be by the trust and that the senior leadership team within the trust had little understanding of what CAMHS did. The trust was subject to a transaction process, through which Taunton and Somerset NHS Foundation Trust, as the preferred acquirer, would in future deliver services, had compounded this.
  • In addition, the commissioners were considering whether to procure CAMHS as a separate service (separate from the acute trust) that could be joined with other community services across the region to enable a focus on the development and improvement of the wide range of community services available in the region. However, this would be managed as a separate process. In the interim, CAMHS would move across with the acute side of the trust to Taunton and Somerset NHS Foundation Trust.

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.