Dorset County Hospital NHS Foundation Trust

Dorset County Hospital NHS Trust has a single site acute hospital, Dorset County Hospital, and has been a foundation trust since 2007. The trust provides acute and some community services to a population of around 250,000, living within Weymouth and Portland, West Dorset, North Dorset and Purbeck. It also provides renal services for patients throughout Dorset and South Somerset to a total population of 850,000. The geographical spread of the community means the trust also delivers satellite services in other NHS locations including local community hospitals.

Dorset County Hospital has approximately 400 inpatient beds. We inspected the following core services at Dorset County Hospital : Urgent and emergency care, medical care, surgery, critical care, maternity and gynaecology, children and young people, end of life care, outpatient and diagnostic services. We inspected satellite outpatients, day surgery and renal dialysis at two other NHS locations.

We inspected this trust as part of our planned, comprehensive inspection programme. We carried out an announced inspection visit to the hospital from 8 to 10 March 2016, and additional unannounced inspection visits between 16 and 21 March 2016. During this time we also visited outpatients, day case surgical services and dialysis services provided at two other trust sites.

Overall, we rated this trust as ‘requires improvement’. We rated it ‘good’ for providing a caring and ‘requires improvement’ for safe, effective, responsive and well led services. At provider level, we rated ‘well led’ as requires improvement.

We rated, medical care, surgical services, critical care and services for children and young people as good. Urgent and emergency care, maternity and gynaecology, end of life care and outpatient services were rated as requires improvement.

Our key findings were as follows:

Is the trust well-led?

• The trust was in the process of reviewing its strategy, focusing on strengthening collaboration and partnership working with other organisations to deliver integrated and more sustainable services, with better outcomes and experiences for patients. The strategic goal was that Dorset County Hospital would become a leading integrated healthcare hub with a range of secondary and primary care services located on the site. The strategy and services of the trust would in part be determined by the outcome of the Dorset Clinical Services Review and the work of the Developing One NHS in Dorset Vanguard.

• There was a commitment to safe care and improving performance across the trust. The executive team recognised the need for a shift of focus to develop a culture of continuous quality improvement supported by a consistent governance framework. This had not yet been achieved and the board was not sufficiently informed about the improvements needed in some services such as end of life care.

• Improvements were needed in the governance arrangements at the Trust. Recent external reviews confirmed that ward to board governance and reporting for trust wide assurance on quality needed improvement. The senior management were using the findings and recommendations to develop, for example, a quality strategy, a governance framework, and an improved mortality review process.

• Progress and improvement against quality improvement projects was inconsistent across the trust. The trust identified that quality improvement training was needed within the leadership training programme, a key strand of the recently developed People Strategy.

• Trust wide staff had contributed to the recently developed set of values and behaviours to support the delivery of compassionate and safe care. Staff were positive about working for the trust and the quality of care they provided, many described the hospital as more than a place of work. They described a trust culture that was open and patient focused.

• The NHS staff survey demonstrated staff engagement was similar to trusts nationally. The trust had taken some actions to ensure Black, Asian and minority ethnic groups had similar equal opportunities and career progression. Action was ongoing to improve this.

• There was a wide range of public engagement and involvement. The trust had developed innovative ways of engaging patients and obtaining feedback to improve services, including ‘patient based experience’ methodology.

• Cost improvement programmes were identified with clinical staff, and these were assessed and monitored to reduce the impact on quality and risk. However, expected savings had not been achieved in all areas and increased activity was contributing to costs and ability to make savings in the future. The trust was continuing with its financial recovery plan to reduce its financial deficit and would need to negotiate its current position under the national sustainability transformation plans.

Are services safe?

• The majority of staff understood when to report an incident, these were investigated and lessons learnt shared. However, some staff in outpatients and diagnostic imaging felt discouraged from using the system as they did not always receive feedback and lessons learnt were not always shared. Some staff in surgical services were using a supplementary paper-based system which was outside of the trust policy. There was a high level of harm-free care. Staff were aware of the Duty of Candour legislation and the service had a system for tracking incidents that triggered a Duty of Candour response.

• Systems were in place to enable staff to assess and respond safely to deterioration in patients’ health.

• Medicines were generally stored and managed appropriately other than the small amount of emergency medicines stored insecurely in the emergency trolleys. Some Patient Group Directions (PGDs) held in departments were not the most current versions, as not up to date and authorised. PGDs are instructions that permit authorised to staff to give medicines to patients without the patients having an individual prescription. PGDs need to be accurate and authorised to protect staff and patients. Staff had not followed trust policy for updating PGDs in some departments.

• The mandatory training target set by the trust at 85% had not been met across all areas of the trust.

• Safeguarding training compliance had increased to meet the target. Staff were aware of the procedures for safeguarding of vulnerable adults and children. Children safeguarding checks were always undertaken, and processes were in place to escalate concerns to the local authority if needed.

• Regularly serviced and maintained equipment was available for patients’ use in most areas, with a prompt response from the maintenance team when equipment required repair. Some equipment in the emergency department was not clean or fit for use.

• Patient records were not always secured safely, in lockable storage equipment to ensure confidentiality.

• There were not always enough nursing, midwifery, therapy and medical staff with the right skill mix to provide safe care. Staffing levels had been reviewed, but changes to staffing levels identified as necessary from the reviews had not been fully implemented at the time of the inspection. The trust had a lower proportion of middle grade doctors than the national average, which put pressure on the medical teams. The trust was working to improve this.

• Staff adhered to the bare below the elbow policy and maintained safe standards of infection prevention. The trust scored higher than the national average for cleanliness in the patient-led assessments of the care environment (PLACE), scoring 99%. The hospital’s infection control team carried out audits which led to improvements in standards of hygiene. However, the procedure for using the mortuary trolley did not adhere to infection control policies or procedures.

• Some parts of the environment in the emergency department were in need of repair and made cleaning difficult.

• In the operating departments, staff did not consistently complete the ‘Five Steps to Safer Surgery’ checklist to minimise the risk of patient harm.

Are services effective?

• Most services followed pathways and protocols based on national guidance, such as the National Institute for Clinical Excellence (NICE) guidelines. Generally, patients’ care was planned and delivered in line with current evidence-based standards. There was monitoring of performance against national targets and the results of audits were used to improve treatment.

• However on the maternity unit care and treatment did not consistently take account of current guidelines and legislation. For example we found some women did not have ongoing mental health checks throughout pregnancy, the maternal pulse was not consistently recorded on commencing a CTG trace for foetal wellbeing, and CTG traces were not reviewed in line with best practice guidelines.

• The trust was recently more focused on improving end of life care for patients. But there had been a slow response to best practice guidance and the results of successive national care of the dying audits. The Achieving the Five Priorities for Care of the Dying Person care plan was in the process of being introduced, and its use was yet to be audited.

• The majority of staff were trained and had the skills and knowledge required to undertake their role. There were educational opportunities available for all grades of medical and nursing staff. There were arrangements in place for the supervision and appraisal of staff. Although not all staff on the CRCU and in diagnostic and imaging had received an annual appraisal.

• On the maternity unit, most of the consultants performed a limited number of caesarean sections, which had the potential to impact on their competence. Also in maternity, consultants did not always give adequate supervision to junior registrars. There was little communication from the consultants to the nurses looking after the gynaecology patients and their attendance was described as “variable”.

• Patients’ consent for treatment, observation or examination was sought by staff. When people lacked mental capacity to make decisions, staff understood their responsibilities around making best interest decisions. Staff were aware of the impact of the Mental Health Act (2005) and the Deprivation of Liberty Safeguards. However, not all ‘Do not attempt cardiopulmonary resuscitation’ forms were supported by mental capacity assessments when it was stated patients lacked capacity.

• The trust was still working towards a full 7-day service. There was access to physiotherapy, pharmacy and microbiology seven days a week. The critical care outreach team was only available Monday to Friday 8am -8pm and there was no formal ‘hospital at night’ service. While staff said there was good access to the palliative care team and said they were helpful and supportive, there was not a face-to-face specialist palliative care service, seven days per week. Women who were at risk of miscarriage were only offered scans between Mondays and Fridays. Women were required to attend the emergency department or were referred to a neighbouring trust out of hours.

• Pain management was variable across the hospital. Patients who had undergone surgery told us their pain levels were regularly assessed and they received adequate pain relief. Pain assessment tools were not used for patients who had difficulty communicating verbally and patients’ pain was not being routinely monitored or managed effectively in the critical care unit.

• Information was not always provided to the patient’s GP in a timely manner. There had been a delay in providing discharge letters and clinic letters for cardiology patients, and clinic letters for dermatology and haematology patients.

• There was effective multidisciplinary working with staff working together to provide patient care in a coordinated way.

Are services caring?

• Patients and their relatives were positive about the caring attitude of staff and said staff treated them with dignity and respect.

• Patient surveys showed that staff were caring and protected people’s privacy and dignity. The hospital’s ‘patient-led assessment of the care environment’ (PLACE) audit score for privacy and dignity was 92%, above the national average of 86%. Friends and family test results were generally positive with the majority of people happy to recommend the hospital.

• Patients said they felt involved in their treatment and had been able to make their own decisions.

• The multi-faith chaplaincy service was available to provide emotional and spiritual support if requested. Patients also said staff helped them emotionally with their care. However, there was no psychology service at this trust so critical care patients with complex emotional needs could not be referred for formal psychological support.

Are services responsive?

• The hospital often faced challenges with patients’ flow through the hospital and the number of available beds. The bed occupancy was consistency above the England average. The staff took a flexible approach to managing this situation including opening additional beds when able to do so. Other initiatives to improve the access and flow of patients through the hospital and, to promote shorter lengths of stay included the hospital@home service. Discharge planning was instigated at the time of admission. Ward staff and the discharge team worked with partners to improve the coordination of patient discharges and transfers, but not all wards made effective use of the discharge lounge.

• Improvements were needed in the responsiveness of critical care, and maternity and gynaecology services. There were delayed transfers from the critical care unit, which was not a suitable environment for patients ready for care on a ward.Mixed sex breaches were not identified and reported in line with national guidance.

• Services were planned to meet the needs of the local population and in coordination with other health and social care services.These included the services provided in the hospital site and those provided at other locations such as dialysis services in satellite units. Patients with respiratory problems had access to the Dorset adult integrated respiratory service (DAIRS) a small outreach service that coordinated care between the hospital and patients’ own homes.There was a day surgery unit in Weymouth, and a one stop breast clinic for timely and accurate diagnosis for patients awaiting breast cancer diagnosis. Outpatient clinics and diagnostic imaging were available at community clinics.

• There were translation services available for patients whose first language was not English. Sign language interpreters were also made available. Patient information was available and could be provided in other languages on request.

• Staff understood how to provide support to vulnerable people, including those living with dementia or a learning disability or difficulty. There was no specialist liaison nurse for learning disabilities.

• Staff tried to resolve patients’ concerns before they became complaints. Complaints were taken seriously, and changes made in response to patient feedback. There were improvement plans for improving timeliness of responses, in line with response times agreed with individual complainants.

Are services well led?

• Service leads had identified priorities for improvement, although the strategic vision was in part dependent on the Dorset Clinical Services Review. Strategies were also driven by the recent Vanguard project for more coordinated acute services across Dorset.

• Service leads had articulated a vision and the priorities for end of life care services, but these had not been implemented. The leadership and governance of end of life care services had not been sufficient to ensure that necessary action plans were implemented in a timely way, and that quality, performance and risks were effectively monitored and managed.

• Staff were aware of the trust’s vision. All staff were passionate about improving services and providing a high quality service. Most staff felt both the trust and local leadership teams were visible and supportive. The exception was the maternity and gynaecology service where consultants did not all work well as a team and working relationships were strained. In some areas, managers were put under pressure to work clinically and were then not able to complete all aspects of their role.

• There was strong patient and staff engagement including ‘experience based design’ surveys to find out how people felt about their care and treatment. Many of the wards displayed recognition awards for teams and individual staff.

• There was a governance structure for the services and services participated in audit programmes. A recent trust wide review had demonstrated that the governance processes including the reporting and escalation process needed strengthening. At local level the clinical governance teams had variable oversight of audit, performance, risks, quality and finance. A newly formatted risk register had been introduced, the completion and use of these registers varied. Not all risk registers included all the risks and lacked evidence of mitigation and review.

We saw several areas of outstanding practice including:

• The hospital@home service provided a valuable service supporting medically fit patients to have earlier discharges to their homes. This service was provided 24/7 and helped improve access and flow in the hospital as well improving outcomes for patients.

• The support for renal dialysis patients was outstanding, with individualised care for patients to receive home dialysis and holiday dialysis when appropriate and safe.

• The genitourinary medicine service was a well-led, patient focused service that had identified the needs of the patient groups it served, many of whom were vulnerable. There was excellent multi-disciplinary working with external agencies and robust clinical standards in place, which the service, audited themselves against, always looking for how they could improve the service. Outpatient clinics and advice sessions were held, where possible, at venues that encouraged attendance from patients who had the greatest need for the service but could not attend or found it challenging to attend a hospital.

• The two bereavement midwives made home visits following a stillbirth or neonatal death. They made follow up visits to tell the parents post-mortem results in person and offered to provide antenatal care for women in any subsequent pregnancy. They also set up the monthly ‘Forget Me Not’ bereavement support group in a local children’s centre. They set up and closely monitored a private social media page for women who had lost a baby during pregnancy or after birth.

• A gynaecology specialist nurse ran the ‘Go Girls Support Group’ along with a former patient, to provide support for women diagnosed with a gynaecological cancer.

• Midwives ran specially designed antenatal, breastfeeding and smoking cessation sessions for ‘Young Mums’. They were also offered separate tours of the maternity unit.

• There were several examples of patient involvement in the co design and improvement of services and excellent use of experience based design (EBD) methodology.

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

Importantly, the trust must ensure:

• All equipment is clean and fit for purpose and ready for use in the emergency department. A clear process must be implemented to demonstrate the mortuary trolley has been cleaned, with appropriate dates and times recorded. 

• The five steps to safer surgery checklist is appropriately completed.

• Patients in the minor operations room (used as a majors cubicle) in the emergency department have a reliable system in place to be able to call for help from staff.

• There are sufficient therapy staff available to provide effective treatment of patients.

• The numbers of nursing on duty are based on the numbers planned by the trust all times of the day and night to support safe care.

• Sufficient palliative care consultant staffing provision in line with national guidance and to improve capacity for clinical leadership of the service

• The number of midwives is increased according to trust plans and in line with national guidance, to support safe care for women.

• Staff attend and or complete mandatory training updates.

• Turnaround times for typing of clinic letters are consistently met, monitored and action taken when targets are not met across all specialities within the trust.

• All patient records must be stored securely to maintain patient confidentiality.

• Risk registers at local, directorate and divisional level are kept up-to-date, include all factors that may adversely affect patient safety, and progress with actions is monitored.

• There is implementation of clear and measurable action plans for improving end of life care for patients. There is monitoring and improvement in service targets and key performance indicators, as measured in the National Care of the Dying Audits.

• Care and treatment in all services consistently takes account of current guidelines and legislation and that adherence is audited.

• Consultants supervise junior registrars in line with RCOG guidance.

• Continue the development of governance processes across all specialties and divisions, with a standardised approach to recording and reporting. Ensure the information is used to develop and improve service quality.

• Regular monitoring of the environment and equipment within the emergency department, and action taken to reduce risks to patients.

• Mixed sex breaches in critical care must be reported within national guidance and immediately that the breach occurs.

The trust should ensure:

• There are quarterly reports to the Board on progress against implementation of standards for patients with a learning disability.

• There is formal, systematic review and benchmarking against the recommendations in the Francis review ‘freedom to speak up’ report.

• Recommendations from the external mortality review are implemented.

Professor Sir Mike Richards

Chief Inspector of Hospitals