Archived: Burton Hospitals NHS Foundation Trust

We carried out this comprehensive inspection because Burton Hospitals NHS Foundation Trust had been flagged as a potential risk on the Care Quality Commission’s (CQC) Intelligent Monitoring system. The trust was one of 11 trusts placed into special measures in July 2013 after Sir Bruce Keogh’s review into hospitals with higher than average mortality rates. There were concerns about the systematic approach in place for ensuring the collection, reporting and action on information about the quality of service, a lack of support for junior doctors, medical staffing levels, appropriate skills mix of staff and equipment safety checks being carried out.

We inspected Queen’s Hospital, Sir Robert Peel Community Hospital and Samuel Johnson Community Hospital. The announced inspection took place between 24 and 25 April 2014 and unannounced inspection visits took place on 6 and 7 May 2014.

Overall, this trust requires improvement. We have rated the trust as requires improvement for safety, responsiveness and leadership, and good for caring and effectiveness.

Our key findings were as follows:

• The trust has made progress since the Keogh inspection in July 2013. On inspection in April 2014 47 of the 61 actions had been delivered, and as of June 2014 only seven actions were remaining.
• Staff were committed to the organisation and the delivery of high quality care, and they saw patient experience as a priority.
• There remained challenges in relation to staffing across the trust. Recruitment is a recognised challenge for the trust. Bank, agency and locum staff were used to fill vacant posts, some staff worked additional hours and there remained a high dependency on temporary staff.
• There were areas within the trust that were not complaint with national guidance on staffing levels.
• There were areas where the training of staff was not adequate, specifically resuscitation training and appropriate levels of safeguarding training. Not all staff had appropriate knowledge of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards to ensure that patients’ best interests were protected.
• There were a number of concerns relating to care being delivered to children. We raised our concerns immediately with the CEO and Chairman and the trust was responsive. We have subsequently been advised of a number of actions and an ongoing review that was due to begin.
• Monitoring of quality had improved and in many areas. However there were areas where further focus and assurance was required.
• The trust demonstrated a commitment to caring for patients living with dementia, and had had a strategy in place since 2009. However this was not delivered consistently across the trust.
• The current Resuscitation Council Guidelines were not reflected in the trust’s resuscitation policy or in the resuscitation department’s staffing levels. The resuscitation committee had not met since November 2013.
• The trust’s end of life provision was not clearly defined and information relating to the service was not used to inform resources. There was a designated board lead. However there were no clear lines of accountability and assurance of the delivery of end of life care.
• Do Not Attempt Cardio Pulmonary Resuscitation (DNA CPR) paperwork was not fully completed, and there was a lack of guidance for staff to follow on the action they should take if mental capacity assessments found that an individual lacked capacity.
• Incident reporting systems were in place. However, learning was not always shared across the trust and staff use of the system was variable.

• We identified areas where there was no clear ownership of the risks on the risk register and lack of assurance that improvements were in progress.

• The board receives a quarterly report on complaints, detailing ongoing challenge with responding to complainants. The report contains processes and themes. However it does not detail how they intend to address the lack of responsiveness and ensure organisational learning.

We saw several areas of outstanding practice including:

• The recent efforts of the board to improve visibility. Engagement with staff was evident, and in particular the CEO and director of nursing had an impact.
• In May 2014, the maternity services were recognised by an independent provider of healthcare intelligence and quality improvement as providing excellent care.
• The service was one of the only maternity services nationally to use the enhanced recovery programme for women following a caesarean section, if it was clinically appropriate for them.
• The breast clinic ran a bra-fitting initiative for women to overcome pain and discomfort after a mastectomy, and this was being adopted by other breast care clinics across the country. The success of the initiative had not been formally audited at the time of our inspection, but the patient feedback was very positive.
• The orthopaedic team’s introduction of the enhanced recovery pathway for hip and knee replacements had reduced patients’ length of stay. National data demonstrated that their hip and knee revision rates were significant lower than other trusts.
• A tool developed by a nurse and a pharmacy colleague, which assessed the impact of certain medicines in contributing to patient falls, had been shortlisted for a national award. This tool was used on wards and believed to have contributed to the reduction in the number of falls.
• The bereavement office participated in the doctor’s training programme, delivering joint training with coroners on a range of issues, including the completion of death certificates. This resulted in a significant reduction in the number of death certificates completed incorrectly.

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

Importantly, the trust must:

• Complete the outstanding actions from the Keogh review that have not yet been delivered and are now overdue. During the inspection we were told of 14 partial or completely outstanding actions. However on 19 June 2014 the trust confirmed that only seven actions were outstanding.
• Ensure that all relevant staff in the trust are appropriately trained.
• Review staffing levels in areas where standards are not met and concerns have been raised in the location reports.
• Review children’s services and specifically the arrangements and facilities for the stabilisation of high dependency children on the paediatric ward.
• Review the resuscitation committee, including identifying a non-executive director to chair the committee and schedule regular meetings. Ensure resuscitation equipment is accessible and the trust’s resuscitation policy reflects current best practice.
• Review the Do Not Attempt Resuscitation (DNA CPR) paperwork currently in use, and take action on the findings to ensure that this is fit for purpose and staff are trained in the completion of this paperwork.
• Review the pathway of care for patents at the end of their life and ensure all nurses know who to contact and when.
• Take action on the findings of the recent records audit, which found that children’s documentation did not include information such as immunisation history, whether they were known to social services, and specific discharge checklists.
• Take action to ensure that the care for people living with dementia is embedded in all appropriate divisions across the trust.
• Review the training provided to staff in the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards, as not all staff had appropriate knowledge of these areas to ensure that patients’ best interests were protected.
• Review bed capacity to reduce the number of medical outliers and minimise the number of times patients are moved during their stay in hospital.
• Take action on the findings of the WHO surgical safety checklist audit and strengthen the assurance process.

Professor Sir Mike Richards

Chief Inspector of Hospitals

July 2014