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Provider: Great Western Hospitals NHS Foundation Trust Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 19 January 2016

Great Western Hospitals NHS Foundation Trust consists of one acute hospital (Great Western Hospital) and four community hospitals, of which three provide inpatient services. There are a total of 450 acute beds (including 12 critical care beds and 38 maternity beds) at the Great Western Hospital. Chippenham hospital as 37 beds spread over two wards, one ward of 25 beds at Warminster hospital and one ward of 26 beds at Savernake hospital. The trust provides acute and community healthcare services to a population of around 480,000 people from Wiltshire and the surrounding areas.

Overall, Great Western Hospitals NHS Foundation Trust was rated as requiring improvement. We rated it as good for caring and as requiring improvements in safety, effectiveness, being responsive to patients’ needs and being well-led. Maternity and Gynaecology services and End of Life care were rated as good overall with all other core services rated as requiring improvement. We rated safety within the Urgent and Emergency care services as inadequate. Within the community services, we rated services to children and young people as outstanding. All other community service was judged as good.

Our key findings were as follows:

  • The trust was open and generally had a good culture for incident reporting. Safeguarding processes and practices were good.
  • There was information available for patients and visitors on how to make a complaint. Clear processes were in place for the management of complaints and concerns. Investigations occurred, and lessons were shared.
  • Patients were treated with compassion, kindness, dignity and respect. Staff within the Children and Young Peoples community teams were focused on the needs of the children and young people, putting them at the heart of everything they did. Care was delivered with empathy and honesty.
  • There were concerns with staffing and how this impacted upon patient safety. Within the Emergency Department the design and layout meant that waiting patients, including children, were not adequately observed. The physical isolation of the observation unit and lack of environmental safeguards, posed unacceptable risks to patient and staff safety. Staffing levels did not always meet patient need. Staffing levels in the Emergency department (ED) did not take into account the requirement to care for patients who queued in the corridor or the sub-waiting room. There were also concerns about the level of staffing within the children’s ED and the ED observation unit. The midwife to patient ratio exceeded (was worse than) recommended levels and one to one care for women in established labour was not achieved 100% of the time.
  • Some accommodation in the ED and minor injury units (MIUs) was cramped and not conducive to the exchange of private conversations or the protection of patients’ privacy and dignity.
  • Compliance with level three safeguarding training within the maternity and gynaecology services was significantly below the trust standard.
  • Not all staff were consistently adhering to good hand hygiene practices or using protective personal clothing.
  • There was good multidisciplinary working to promote quality care. Patient outcomes, mortality and morbidity were generally monitored though action plans to address shortfalls were frequently incomplete so progress could not be assured.
  • Whilst practice in some areas was good, consent to care was not consistently obtained in line with legislation and guidance including the Mental Health Act. Deprivation of Liberty Safeguards were not monitored and had expired without staff being aware.
  • The ED was not consistently meeting the national standard for 95% of patients to be discharged, admitted or transferred within four hours of arrival at A&E or for consultant-led referral to treatment time (RTT) targets in five of the six surgical specialties. Bed occupancy rates were higher than the England average. Both the acute and community hospitals faced a high number of patients who were fit for discharge, but without transfer of care packages.
  • Whilst not designed for that purpose, the day surgery unit (DSU) was frequently used to accommodate patients overnight.
  • As a result of the second class post imposed due to financial pressures some patients missed appointments whilst others did not receive MRSA washes or preparations for endoscopy procedures in time.
  • At the time of the inspection, the trust was in breach of its licence from Monitor following a significant departure from the financial plan in late 2014 resulting in a deficit of £9 million against a planned surplus of £1million. The consequent actions, including independent reviews of governance arrangements, identified significant shortfalls that are in the process of being addressed. Governance processes within some divisions was found to be weak.
  • The trust were committed to maintaining the quality of care whist also striving to manage demands for services and the flow of patients into, through and out of hospital. At the time of the inspection the necessary improvements had not been made and sustained.
  • The trust was open about the issues faced and took feedback well. The significant scrutiny from regulators and commissioners was adding to the challenges for the leadership team.

We saw several areas of outstanding practice including:

  • The diagnostic imaging team had some areas of outstanding practice, one of which, the palliative ascites drainage, was highly commended by the British Medical Journal (BMJ) in 2015. Innovative practice was seen with the introduction of the intra operative breast radiotherapy project.
  • In the critical care unit we were given examples of staff ‘going the extra mile’ for their patients, including a patient attending a family wedding in London, with transport being arranged by the unit and staff escorting the patient for the day.
  • The consultants provided specialist pre and post pregnancy counselling and support service to women. This and other specialist clinics developed to manage high risk pregnancies had been recognised as best practice. The lead consultant had won an All-Party Parliamentary Group Maternity Services Award during 2011. This service style had since been adopted by other Maternity Services across the country and show-cased at Harvard, USA.
  • The midwives successful audit and interdepartmental training to prevent cerebral palsy in pre- term babies born at the hospital
  • Children were treated with respect and their ability to give consent for their own treatment was taken seriously.
  • The multi-disciplinary working within the community. For example the neurology community team worked with a patient, their carers, social services, housing authorities and other clinicians including the palliative care team to arrange the adaptation of accommodation for a patient with motor neurone disease.
  • The wheelchair service who committed to providing wheelchairs for patients diagnosed with motor neurone disease within two weeks by prioritising the adaptations that were required to be completed. They also provided a priority service for patients who were receiving end of life care.
  • The community respiratory team, how they worked with others, lead training initiatives for GPs and physiotherapists and held brief informal training updates to nursing teams during their lunchbreaks. There were weekly teleconferences and meetings every six weeks between colleagues to discuss the latest guidance. The lead nurse also chaired quarterly meetings of a respiratory network of health professionals who worked in respiratory services.
  • The tissue viability team led by a nurse consultant demonstrated an outstanding level of evidence-based practice and innovation in the management of pressure ulcer care. Regular, quarterly pressure ulcer audits contributed to a quality improvement collaborative for pressure ulcers work plan and the organisational action plan for pressure ulcer reduction. An estimated £40,000 a year was expected to be saved due to the reduction in the length and frequency of nursing visits, with time saved to be used to visit more patients. Great Western Hospital is the first provider nationally to roll out the use of these systems.
  • Specially trained health visitors and school nurses took part in an on-call unexpected child death rapid response team. When a child or young person who lived in Wiltshire died unexpectedly, the police would be contacted alongside the rapid response team. Whilst the police would investigate the circumstances surrounding the death, the staff within the rapid response team were responsible for providing emotional support to the parents. By using health visitors and school nurses that had been specially trained, it utilised their skills at communicating with parents to support them at the worst moment in their lives.
  • The children and young people's community teams had excellent multi-disciplinary and multi-agency working. This extended across the local communities they served, health and social care as well as the ministry of defence to support children of military families.
  • The leadership across the children and young people's community team was very visible and staff were full of praise for their immediate team leaders and wider management team within the community. They felt supported and valued by their team leaders and managers.
  • The looked after children team had produced a health passport for all their children and young people. This contained full details of each individual child's health and medical history. Details of appointments, immunisations were also included. Young people were able to take these passports with them once they left the care of the local authority to help them make a good start in their adult lives.
  • The children and young people speech and language therapy team (SALT) were linked directly to local schools. This was to make sure children and young people received more intensive support and received early intervention when necessary.
  • The Governance Database developed and used by the Integrated Community Health Division (ICHD) was a spreadsheet used by staff to record audit information and outcomes, serious incidents and investigations that took place and training records. There was also information about staffing levels, complaints and safeguarding issues. Staff at all levels were aware of and used the database regularly.
  • The division had recently developed a four day community induction programme. Once staff had completed the GWH trust induction they were expected to undertake the community induction. This applied to new staff, staff who had a new role within the trust and staff employed in the last year that had not had a chance when they started to attend the specific community induction. The programme was very detailed and staff told us they had really appreciated the induction as it gave them an insight into the services offered and lone working, fire safety and medical cover for example.
  • Two consultants provided bespoke training on some of the community hospital wards. This was well received and attended by staff. They felt this enhanced the feeling of working in partnership to ensure the best care and support is provided for the patients.
  • The community services participated in ‘IWantGreatCare’, this was a continuous, real-time collection, monitoring and analysing quantitative and qualitative patient and relative feedback and could act as an early warning system.
  • People’s individual needs and preferences were central to the planning and delivery of services. The service was flexible, provided choice and ensured continuity of care in the wider community. The involvement of other organisations and the local community was seen to be integral to how patient care was planned and ensured the service met people’s needs.
  • End of life care had become part of the induction and mandatory training programme, these programmes of learning had been devised by the palliative consultant and end of life nurse.

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

Importantly, the trust must:

  • Ensure staff receive up to date safeguarding, mandatory training appraisals and training on the Mental Capacity Act.
  • Improve governance processes to demonstrate continuous learning, improvements and changes to practice as well as board oversight and assurance.
  • Ensure there are sufficient numbers of midwifery staff to provide care and treatment to patients in line with national guidance.
  • Ensure effective infection prevention and control measures are complied with by all staff.
  • Ensure safe storage of medicines, including intravenous fluids.
  • Improve the access and flow of patients in order to reduce delays from critical care for patients being admitted to wards and reduce occupancy to recommended levels.
  • Review nurse staffing levels and skill mix in the emergency department (ED), including children’s ED, the ED observation unit and minor injury units, using a recognised staff acuity tool.
  • Take steps to ensure there are consistently sufficient numbers of suitably qualified skilled and experienced staff employed to deliver safe, effective and responsive care.
  • Ensure all staff who provide care and treatment to children in the emergency department are competent and confident to do so.
  • Make clear how patients’ initial assessment should be carried out by whom and within what timescale within the ED.
  • Monitor the time self-presenting patients wait to be assessed in the emergency department and take appropriate action to ensure their safety. This must include taking steps to improve the observation of patients waiting to be assessed so that seriously unwell, anxious or deteriorating patients are identified and seen promptly.
  • Ensure that clinical observations of patients in the emergency department are undertaken at appropriate intervals so that any deterioration in a patient’s condition is identified and acted upon.
  • Risk assess and make appropriate improvements to the design and layout of the emergency department observation unit to reduce the risk of patients harming themselves or others.
  • Clarify the use of the observation unit, setting out its purpose, admission criteria and exclusion criteria to ensure that patients admitted there are clinically appropriate and receive the right level of care.
  • Ensure best (evidence-based) practice is consistently followed and actions are taken to continually improve patient outcomes.
  • Ensure chemicals and substances that are hazardous to health (COSHH) are secured and not accessible to patients and visitors to the wards.
  • Ensure sharps bins are used in accordance with manufacturer’s guidance to prevent the risk of a needle stick injury.
  • Ensure staff members are aware of the risk of cross infection when working with patients with isolated infectious illness.
  • Ensure risk assessment tools in place to identify risks of thrombosis, pressure damage, moving and handling, nutritional and falls are consistently completed and appropriate action taken.
  • Ensure National Early Warning Scores used to identify from a series of observations when a patient was deteriorating are appropriately actioned when high indicator scores were seen.
  • Ensure that patients with mental health issues on medical wards are appropriately managed.
  • Ensure appropriate review and action are undertaken when Deprivation of Liberty Safeguards have been put in place.
  • Ensure consistent compliance with the Mental Capacity Act. Ensure all appropriate surgical patients have their mental capacity assessed and recorded to ensure consent is valid, and the hospital is acting within the law.
  • Ensure patients’ records are fully completed and provide detailed information for staff regarding the care and treatment needs of patients.
  • Ensure the provision of single sex accommodation.
  • Ensure all areas of the premises and equipment are safe and secure, and patient confidential information is held securely at all times.
  • Ensure patients being admitted overnight to the day surgery unit have appropriate facilities which meet their needs, maintains their privacy and dignity, and reflects their preferences.
  • Provide a responsive service to reduce waiting times and waiting lists for surgery procedures. Theatre efficiency, access and flow, delays, transfers of care, and bed occupancy must be improved to ensure patients are safely and effectively cared for.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 19 January 2016

Overall, we rated safety of the services in the trust as ‘requires improvement’. A total of twelve ‘safe’ judgements were made by the inspection team. Within the acute trust, six services were judged as ‘requires improvement’. The Urgent and Emergency care services were judged as ‘inadequate’. Only the end of life services were rated as good. Within the community, all four services were judged to be good.

The trust was open and had a good culture for incident reporting. Safeguarding processes and practices were good. However we found concerns with staffing and how this impacted upon patient safety. Within the Emergency Department the design and layout meant that waiting patients, including children, were not adequately observed. The physical isolation of the observation unit and lack of environmental safeguards, posed unacceptable risks to patient and staff safety. Staffing levels did not always meet patient need. Staffing levels in the ED did not take into account the requirement to care for patients who queued in the corridor or the sub-waiting room. There were also concerns about the level of staffing within the children’s ED and the ED observation unit. The midwife to patient ratio exceeded (was worse than) recommended levels and one to one care for women in established labour was not achieved 100% of the time. Some accommodation in the ED and minor injury units (MIUs) was cramped and not conducive to the exchange of private conversations or the protection of patients’ privacy and dignity. Compliance with level three safeguarding training within the maternity and gynaecology services was significantly below the trust standard. Not all staff were consistently adhering to good hand hygiene practices or using protective personal clothing.

Duty of Candour

  • There was a system in place to ensure people were kept informed if something went wrong. There were also systems in place to ensure such incidents were investigated and actions were put in place. Although not all of the staff we spoke with understood the term, they all understood the importance of being open when mistakes were made and believed that the services acted within the spirit of the regulation.
  • Division maintained a duty of candour register and we saw evidence that the regulation was being complied with.
  • Staff training records did not include details on the number of staff who had been trained in duty of candour.

Safeguarding

  • Staff understood their responsibilities and were aware of the safeguarding policies and procedures and the processes for reporting suspected abuse. Staff were confident about what constituted a safeguarding incident and the action they would take to keep patients safe.
  • There was a safeguarding lead nurse in the Emergency Department where the electronic patient record prompted staff to consider safeguarding in their assessment of each patient. There was also an appropriate system in place to ensure staff were identifying child safeguarding concerns as the clinical lead for children audited 10 children’s records per week. We saw that relevant staff within the community were alerted when children had attended the emergency department or minor injuries units.
  • A safeguarding web page had been developed on the hospital intranet for staff. Here staff were able to access referral forms and view a decision-making flow chart. The safeguarding lead nurse described an increase in reported safeguarding concerns as staff awareness increased. Learning from safeguarding concerns had been fed back into ward meetings and safeguarding was a standard item on the trusts divisional governance meetings.
  • Whilst in most areas safeguarding training compliance was at or near the trust target of 80%, compliance with level three safeguarding training within the maternity and gynaecology services was only 36% and only 53% within the acute children’s services. However, records showed plans were in place to address this, with staff booked on future training. Compliance with safeguarding training within the community was considerably higher than that within the acute setting, with some areas and teams achieving 100%.

Incidents

  • Staff were aware of how to report incidents and were encouraged to do so. Situations such as staff shortages and waiting times had become normal and staff were not always completing incident forms for these when they occurred. The trust reported a lower number of incidents per 100 admissions compared to the England average (8.9 per 100 admissions compared with 9.4 per 100 admissions for the NHS England average in the period from February 2014 to January 2015).
  • The trust had reported two Never Events in the period May 2014 – April 2015, one within surgery and one in Dermatology. (Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented.) There had been no Never Events reported in the community setting. One further Never Event had been reported in August 2015. This was related to a procedure being performed on the wrong patient. The investigation had been completed but an action plan to prevent reoccurrence had not yet been implemented.
  • Staff told us feedback and learning from incidents was provided in various forms, dependent upon the type and impact on patient care. This was provided on a one to one basis by senior staff and or cascaded through team meetings and staff handovers, and where they existed, newsletters. However, not all staff felt they received adequate feedback from incidents. Learning from incidents was not taking place in all areas, nor were the benefits of learning from serious incidents being shared in all areas or across the trust.
  • The “don’t walk by” safety approach adopted by the trust’s provider of facilities was having a positive impact on safety. The introduction of a £25 prize for the best “don’t walk by” report had been received positively.

Cleanliness, Infection control and hygiene.

  • There were areas of concern with infection control practices. Although overall the environment was clean and tidy there were some exceptions to this. In the dermatology department there was dust and debris on high surfaces. In the day surgery unit there was debris on the floor and the female toilet was unclean, and in the critical care unit there was dried staining on beds and a commode. Staff were not consistently adhering to good hand hygiene practices or using protective personal clothing such as aprons and gloves when required. There had been 12 reported cases of Clostridium difficile up to the end of July 2015, therefore the trust was at risk of breaching its annual trajectory of 20 for the 2015/16 year.

Environment and equipment

  • Whilst in most areas we inspected the environment was good, premises were not always fit for purpose. Within the Emergency Department the design and layout meant that waiting patients, including children, were not adequately observed. The physical isolation of the observation unit and lack of environmental safeguards, posed unacceptable risks to patient and staff safety. Some accommodation in the ED and minor injury units (MIUs) was cramped and not conducive to the exchange of private conversations or the protection of patients’ privacy and dignity. Equipment was not always appropriately and safely stored. Some equipment was also becoming unreliable or outdated, such as the decontamination and sterilisation equipment and equipment for measuring patient’s visual fields. Not all maintenance checks were in date.
  • Environmental hazards such as chemicals and substances that are hazardous to health (COSHH) were observed in areas that were not locked and therefore accessible to patients and visitors to the wards. Cleaning materials including chlorine tablets were in the sluices, which were unlocked. Sharps bins were in place throughout the medical wards and departments for the safe disposal of used needles and other sharp equipment. However, these not consistently closed when not in use and some were over two thirds full and still being used, putting staff were at risk of a needle stick injury.

Staffing

  • Staffing levels did not always meet patient need. Staffing levels in the ED did not take into account the requirement to care for patients who queued in the corridor or the sub-waiting room. There were also concerns about the level of staffing within the children’s ED and the ED observation unit.
  • The trust used the Shelford Safer Staffing Tool 2014. Acuity and dependency measurement currently took place at least twice yearly (January and June).
  • Staffing requirements on SCBU or the paediatric ward were not calculated using a recognised acuity tool to determine how many staff were required to care for their patients.
  • Nurse staffing within critical care did not meet the Core Standards for Intensive Care Units (2013) recommended ratio of one nurse to care for one level three patient, and one nurse to care for two level two patients.
  • The midwife to patient ratio exceeded (was worse than) recommended levels and one to one care for women in established labour was not achieved 100% of the time.
  • Within the community caseloads were fairly and effectively distributed, with regular discussions occurring regarding caseload size. A capacity management tool had recently been introduced within the community which reviewed staffing numbers ad workload on a daily basis.
  • Vacancy rates for nursing and therapy staff in some services within the community were high.
  • Trust wide, the percentage of bank and agency staff was 2.5%, significantly lower than the England average of 6.1%. However, not all shifts were covered to provide a full cohort of staff. This was of particular concern in urgent and emergency care where the staffing levels did not take into account the need to care for patients who queued in the corridor or sub waiting room.
  • The trust were making continuous efforts to recruit staff through local, national and international recruitment campaigns and ‘return to acute care’ courses for registered nurses.

  • Medical staffing was at safe with low use of locum staff. The percentage of staffing grades was comparable with the England average.

Effective

Requires improvement

Updated 19 January 2016

The team made judgements about 11 services. Outpatient services are not currently rated for effectiveness. Of the eleven judgements made, eight were rated as good, and three required improvement.

There was good multidisciplinary working to promote quality care. Patient outcomes, mortality and morbidity were generally monitored though action plans to address shortfalls were frequently incomplete so progress could not be assured. Whilst practice in some areas was good, consent to care was not consistently obtained in line with legislation and guidance including the Mental Health Act. Deprivation of Liberty Safeguards were not monitored and had expired without staff being aware.

Evidence based care and treatment

  • Despite delays in discharges, predominantly for patients needing social care packages or continuing healthcare, the length of stay for surgical patients within the hospital was mostly below (better than) the England average.
  • Guidelines were generally up to date and available via the intranet, although within the ED, some links to them were broken, were mainly generic from national colleges and had not been adapted locally. There was little evidence of audit to identify if they were followed.
  • Within the community services the evidence based guidance and best practice was clearly seen, with staff seeking information and research nationally, using academic networks and professional associations. Systems were in place to ensure new information was appropriately cascaded.

Patient outcomes

  • Information about patient outcomes was collected and monitored, with the trust participating in a number of national audits in order to benchmark practice and performance against that of other trusts. In places we saw little evidence that actions had been taken to improve performance in areas where shortfalls had been identified. However systems were in place to monitor the completeness of actions within the community division.
  • Patient mortality and morbidity was reviewed by the surgical teams, but with variable input and content, and insufficient evidence to show how agreed actions were delivering improvements.
  • The unplanned ED re-attendance rate in 2014/15 was better than the England average but was generally higher (worse than) the set standard of 5%.
  • At the time of the Inspection the Hospital Standardised Mortality Rate (HMSR) was 84.2 (August 2015). This placed the trust in the top quartile of organisations in the South West.

    • There were a number of quality improvement programs underway such as projects to reduce catheter associated urinary tract infections and sepsis. Improvements made to the management of patients with sepsis had resulted in reduced critical care admissions, reduced length of stay and reduced mortality to well below the national average. At the time of the inspection, the trust was about to launch an initiative to save 500 lives over the following five years to include not just sepsis but also recognition of deterioration, acute kidney injury and a reduction in falls and pressure ulcers.

Multidisciplinary working

  • Multidisciplinary working was evident throughout the services, promoting a quality service to patients. In the national lung cancer audit and bowel cancer audit, the trust was better than the England average for discussing patients at a multidisciplinary level. Within diagnostic imaging there was excellent multidisciplinary work both within and outside the hospital.

Consent, Mental Capacity Act & Deprivation of Liberty safeguards

  • Whilst practice in some areas was good, consent to care was not consistently obtained in line with legislation and guidance including the Mental Health Act. In urgent and emergency care there was a lack of records of verbal or informal consent, and it was noted that only 62% of medical staff had received training on consent and the Mental Capacity Act. In medicine patients mental capacity had not been assessed and recorded where appropriate and it was not clear how best interest decisions had been made. Deprivation of Liberty Safeguards were not monitored and for two patients had expired without staff being aware, this increased the risk of patients having their liberty restricted without the appropriate safeguards in place.

Caring

Good

Updated 19 January 2016

The overall rating for caring was good. We judged the caring provided by staff as good in every service within the acute trust and the community with the exception of community services for children and young people where we judged it to be outstanding.

Patients were treated with compassion, kindness, dignity and respect. Staff within the Children and Young Peoples community teams were focused on the needs of the children and young people, putting them at the heart of everything they did. Care was delivered with empathy and honesty. From September 2014, the trust scored above 90% in the NHS Friends and Family Test, when asking patients if they would recommend the hospitals.

Compassionate care

  • Patients were treated with compassion, kindness, dignity and respect. CQC intelligence monitoring identified a risk for the inpatient survey when patients were asked ‘did you find someone on the hospital staff to talk to about your worries and fears.’ However feedback from people we met, including patients and their families, was mainly positive, and in some places such as community childrens and young peoples services, excellent. From November 2014 the trust performance was similar to the England average in the Friends and Family test. This is a single question survey as required by NHS England asking patients whether they would recommend the department to their friends and family.

  • The Patient Led Assessments of the Care Environment (PLACE) 2015 scored the trust at 92.4% for privacy, dignity and wellbeing. The comparative England average was 85.1%. However some accommodation in the ED and minor injury units (MIUs) was cramped and not conducive to the exchange of private conversations or the protection of patients’ privacy and dignity.
  • From September 2014, the trust scored above 90% in the NHS Friends and Family Test, when asking patients if they would recommend the hospitals.

Understanding and involvement of patients and those close to them

  • Overall patients understood and were involved in their care and treatment. The exception to this was in the medical wards where many patients did not know the plan for their care and treatment and felt communication relating to this was poor.
  • Staff within the Children and Young People’s community teams were focused on the needs of the children and young people, putting them at the heart of everything they did.
  • Within the Children continuing care team, an agreement of care was produced setting out what each child and family could expect as well as expectations of the family.

Emotional support

  • There was excellent emotional support provided to both children and their families within the community such as a rapid response service for unexpected child deaths that occurred in Wiltshire. Staff provided an on-call service working closely with the police to provided support to parents at such a devastating time.

  • Chaplaincy support was available as well as a multi faith area and a room for people to use described on the trust website as “set aside for you to come and be quiet, whatever your philosophy of life, whatever your religion.”

Responsive

Requires improvement

Updated 19 January 2016

Overall, we rated the responsiveness of the services in the trust as ‘requires improvement’. Of the twelve judgements across the trust, four were judged to require improvement with seven found to be good, and services for children and young people within the community found to be outstanding, showing that although the trust was responding to people’s needs this was not consistent.

The areas requiring improvements were Urgent and Emergency care, Surgery, acute services for children and young people and outpatients and diagnostic imaging services. The ED was not consistently meeting the national standard for 95% of patients to be discharged, admitted or transferred within four hours of arrival at A&E or for consultant-led referral to treatment time (RTT) targets in five of the six surgical specialties. Bed occupancy rates were higher than the England average. Both the acute and community hospitals faced a high number of patients who were fit for discharge, but without transfer of care packages.

Whilst not designed for that purpose, the day surgery unit (DSU) was frequently used to accommodate patients overnight.

As a result of the second class post imposed due to financial pressures some patients missed appointments whilst others did not receive MRSA washes or preparations for endoscopy procedures in time.

Service planning and delivery to meet the needs of local people

  • Services did not always meet the needs of local people. There was a lack of clarity with regard to the most appropriate pathway for patients who self- presented at ED with a minor injury. The observation unit, although not part of the general hospital bed base, was frequently used to accommodate patients who required an inpatient stay on a medical or surgical ward but beds were not available in the appropriate specialty. This practice reduced the effectiveness of the observation unit which was designed to avoid unnecessary hospital admissions and allow clinical decisions predicted to take more than four hours and less than 24 hours.
  • Whilst not designed for that purpose, the day surgery unit (DSU) was frequently used to accommodate patients overnight.
  • The hospital was not meeting NHS England consultant-led referral to treatment time (RTT) targets in five of the six surgical specialties (general, urology, trauma and orthopaedic, ear, nose and throat, and oral maxillofacial). The average percentage of patients treated within 18 weeks for August 2015 was 84.6% against the target of 92%. The average for the South of England NHS Commissioning area was 88%. Recovery to meet targets was planned for the end of the 2015/16 financial year (end of March 2016).
  • As a result of the second class post imposed due to financial pressures some patients missed appointments whilst others did not receive MRSA washes or preparations for endoscopy procedures in time. As a consequence treatment and procedures were delayed.
  • Within the community services, the trust worked in partnership with commissioners to plan and meet the needs of the population.

Meeting people's individual needs

  • Policies and procedures were in place to help ensure those patients living with dementia and those with learning disabilities were identified and supported. A team of specialist nurses were employed to support patients living with a learning disability. The community learning disability services had an in reach service, providing support to patients in hospital. Easy read information was made available. On admission to hospital, an alert system was in place to enable staff to make all adjustments needed to support the patient.

Dementia

  • There was a dementia care strategy in place and dementia champions in wards and departments. Jupiter ward had undergone environmental changes to become a dementia friendly ward, including softer floors in case of falls, signage to aid direction for patients, dementia informative clocks, use of colours to define areas and a seating area mid ward.

Access and flow

  • The trust had difficulties managing the access and flow of patients through the hospital despite a good understanding of occupancy and flow issues. The ED was not consistently meeting the national standard for 95% of patients to be discharged, admitted or transferred within four hours of arrival at A&E, although performance was improving with the target being met in June and July 2015. In addition the ED was not currently achieving the target for a median wait time of below 60 minutes. Patients queued in ED in the corridor or in a sub waiting room because at times of surge there were insufficient cubicles. Patients frequently stayed in the ED overnight as there were no beds available in the hospital. Speciality response times to ED were also variable. Following an external review in May 2015 an internal response time standard of 30 minutes was put in place. However this was not monitored.
  • For those patients receiving care and treatment in outlier beds (beds in another speciality), a dedicated consultant and registrar team was in place to ensure prompt and appropriate care management.
  • Despite a bed occupancy rate higher than the England average (between 92-96% since 2013/14 against an England average of 85.9%), cancelled operations were below (better than) the England average.
  • The acute and community hospitals faced a high number of patients who were fit for discharge, but without transfer of care packages. This meant funded ‘step up’ beds could not always be used appropriately within the community hospitals.
  • The trust was actively working towards seven day working. Preparatory work was underway, with funding of £600,000 allocated in June 2015 for the establishment of a larger ambulatory care and assessment unit and discharge lounge.

Learning from complaints and concerns

  • There was information available for patients and visitors on how to make a complaint. Clear processes were in place for the management of complaints and concerns. Investigations occurred, and lessons were shared.
  • The number of complaints dropped by 106 from 2012/13 to 2013/14. The trust board reports for August 2015 showed they had received 11 high to extreme complaints. One new complaint case had been taken on by the Parliamentary Health Service Ombudsman (PHSO) and ten cases were awaiting outcome from PHSO investigations. Two cases were being considered for investigation by PHSO with three cases investigated with recommendations made.

  • We reviewed a number of complaints case files which all demonstrated a supportive process to complaint management. The electronic system in operation allowed a clear trail of actions and timelines. Letters written to complainants were clear, and gave clear information about actions and timescales. However the chief executive only signed complaints rated as high. Complaints originally graded as high but downgraded by the divisions would not be signed at an executive level.

Well-led

Requires improvement

Updated 19 January 2016

The leadership, management and governance of the trust requires improvement in order to ensure the delivery of safe, high quality and person centred care. Of the twelve judgements across the trust, six were judged to require improvement with six found to be good.

At the time of the inspection the trust was in breach of its licence from Monitor following a significant departure from plan in late 2014 when a deficit of £9 million emerged against a planned surplus of £1million. The consequent actions, including independent reviews of governance arrangements, identified significant shortfalls that were in the process of being addressed. The trust had been committed to maintaining the quality of care in the face of this situation whist also striving to manage demands for services and the flow of patients into, through and out of hospital. At the time of the inspection the necessary improvements had not been made and sustained.

There have been changes at executive level and recent executive, interim and non-executive appointments had strengthened the board. Stakeholders and other regulators spoke positively about the leadership of the trust, in particular the chief executive. The leadership were dealing with significant internal and external challenges. Internally the financial situation and some aspects of performance, including the performance of the emergency department and the recovery of referral to treatment targets, had highlighted some fundamental issues about the quality of information within the trust. This meant that some situations had not been anticipated although the trust have reacted when they have emerged, an example of this would be waiting list information.

The inspection team found, and stakeholders and commissioners commented, that the trust were open about the issues they faced and took feedback well. The trust were under significant scrutiny from regulators and commissioners and that was adding to the challenges for the leadership team.

The trust’s vision had been communicated to staff and the trust values were well known. Staff across the organisation at all levels displayed a passion for providing good care and talked of their pride in colleagues and the services provided.

The trust had assessed themselves as Good across the five domains at trust level which raised questions about their insight into their performance. The executive team had rated themselves as requiring improvement for the well led domain but this had been changed to Good by the non-executive directors.

Vision and strategy

  • The trust had set out their five year vision as follows:

“Working together with our partners in health and social care we will deliver accessible, personalised and integrated services for local people. We will provide high quality care whether at home, in the community or in hospitals empowering people to lead independent and healthier lives. ”

  • The Trust’s vision was underpinned by four key strategic aims:

  1. To provide safe, high quality care which patients are satisfied with and staff are proud to provide and ensuring our services are embedded in and valued by our communities
  2. To maintain and strengthen relationships in our core markets in the communities of Swindon and adjoining parts of Wiltshire and further develop market share in the other areas of Wiltshire, Gloucestershire, Oxfordshire and Berkshire through:

    • Market growth (increase existing referrals).
    • Providing community services that we don’t currently provide.
    • Tendering for (appropriate) services
    • Repatriation of tertiary services, where clinically safe and appropriate and we can make a profit or repatriated services would meet our strategic aims

  3. In all services we will perform in the top 20% of similar sized hospitals and there will be a focus on productivity in all areas of our business
  4. We will work in partnership in all we do to ensure delivery of the best healthcare for our patients, commissioners and communities.

  • The trust was in discussion with commissioners, partners and other stakeholders about a revised strategy and the development of a five year plan. This was under development at the time of the inspection.
  • The trust launched a Quality Strategy in March 2014 setting out their aims. This identified seven priorities for improvement as follows:

    • Delivering safe, effective care, delivering excellence
    • Leading the best patient experience
    • Releasing time to care
    • Visible inspirational leadership
    • Culture of innovation and embracing of continuous Quality Improvement
    • Measurement of essential quality standards, providing assurance of patient safety and clinical effectiveness
    • Staff will understand their contribution to the whole organisation.

  • In August 2015 the board had agreed to sign off an initiative known as “500 lives”. The purpose was to bring all the various quality and safety initiatives under one title and to help ensure that the focus on quality and safety was maintained during the financial pressures. The title refers to the ambition to save an additional 500 lives over the next five years.
  • The trust has set our their values, known as STAR values, as follows:

    • Service – We will put our customers first
    • Teamwork- We will work together
    • Ambition – We will aspire to provide the best service
    • Respect – We will act with integrity

  • These values were developed with staff involvement as part of the trust’s application for foundation trust status which was granted in December 2008. The leadership of the trust refer to the values as being at the heart of everything the trust does and in the way that people work together and treat each other. The trust used the values as part of recruitment and appraisal processes. The trust had not developed the values beyond this, for example there was not a framework or similar document setting out expected behaviours. There was not a process in place for the trust to assure itself that staff were working in accordance with the values. The values were well known by the staff the team met during the inspection. It was clear that in both the community and acute services the value of teamwork was highly valued and the team saw numerous examples of strong teamwork.

Governance, risk management and quality measurement

  • The governance arrangements at the trust, in particular financial governance arrangements, had been subject to recent external review. There were action plans in place to deal with the identified shortfalls.
  • The trust had a board assurance framework that was regularly reviewed and updated. The framework identified key risks, controls and gaps in assurance. The team considered that there had been some blurring between this framework and the trust risk register. For example some entries contained a running commentary on the actions taken to address gaps dating back over a number of months. This made the framework appear to be a management record rather than a tool to reinforce strategic focus and better management of risk. There were action plans in place to deliver improvements identified by the team. This work included an evaluation of the trust position on risks including appetite for risk and acceptance of long running risks. This was due to be delivered by the end of November 2015.
  • The trust had seven board committees, all chaired by a non-executive director. The trust did not have a board committee with quality or safety in its title; these matters were dealt with by the Governance Committee. Over forty working groups and committees reported to the Governance Committee through a Patient Quality Committee chaired by the chief nurse. Matters relating to performance were dealt with by the Finance, Investment and Performance Committee. Executive directors were members, as opposed to attendees, of board committees. This raised questions about how executive directors were held to account within those committees. The membership of the board committees reflected the composition on the board in that there were a majority of non-executive directors who were members of each committee.
  • Not all the divisional governance arrangements worked well. In places there was no reporting to the divisional board meeting of audit results or progress of actions plans. For example, within surgery the regular audit of the World Health Organisation surgical safety checklist was not presented. The staff who would be accountable for any required improvements identified were not being challenged about improvements in quality and safety through clinical governance. The root cause analysis report from the Never Event made some recommendations, including how the quality of the checklist process was not considered, and how this carried a risk of it becoming too automated. There was no evidence of this recommendation being brought forward to clinical governance for consideration and action to improve theatre safety. The National Emergency Laparotomy Audit 2014 and Patient Audit 2015 had not been discussed at clinical governance despite a number of areas needing improvement.
  • The internal audit function was effective and targeted and there was evidence of the impact of audit on improvement in some but not all areas across the trust.

Leadership of the trust

  • The chair and chief executive had a strong supportive relationship and it was clear that they worked well together. The chair displayed a good grasp of the issues and had a clear division of where the trust is going although it was recognised that this was not yet fully articulated and had not been shared with staff. The chief executive was visible with Chief Executive Open Forums being well attended. Stakeholders, medical and non-medical staff referred to the visibility of the medical director and there was evident of clear impact in raising the profile of end of life care. The Chief Nurse had good visibility to matron level with this aspect of her role being delegated to her deputy. The leadership of community services was strong and visible and the level of engagement from the staff in this area was noticeably stronger that has been seen in similar services. There had been recent changes in some executive posts with the departure of the previous director of finance and chief operating officer; these roles had been filled at the time of the inspection, the latter with an interim appointment. Collectively the board had a good mix of skills and experience although it was clear that the executive team were very stretched to deal with all the current issues and the level of scrutiny.
  • The non-executive directors displayed insight and commitment. The team observed part of a board meeting and considered that some important papers were received without sufficient challenge. For example a paper on emergency department performance was accepted although the associated action plan did not contain dates and indicators. In discussion about this it was suggested that discussion could and would take place outside the board meeting however this approach means that such discussions are not placed on the public record. The team reviewed a selection of board and board committee minutes and noted that challenges were recorded. At the time of the inspection the trust were struggling to meet their target for mandatory training. Training compliance amongst the non-executive directors was 62.5% against a trust target of 80%. Action was being taken to address this. There was a board development plan in place.
  • Staff side reported that relationships with the leadership of the trust were positive. Communication had improved and there was a good dialogue. Conversations could be challenging but on the whole the leadership is engaging on the right issues in a timely way.

Culture within the trust

  • There was evidence that senior leadership across the trust made efforts to encourage appreciative, supportive relationships amongst staff. The trust recognised staff through a Star of the Month Award and annual staff excellence awards, the latter involving nominations from staff, patients and the public.
  • Staff across the trust were open, transparent and very well engaged with the inspection process. There was good attendance at focus groups and drop in sessions in both the acute and community services. A number of staff also sought separate meetings with inspectors. Staff attending felt able to express their views and the majority said they had been encouraged to do so. It was clear from meetings during the inspection, from observations and from the examination of documents and records that there were many very positive examples of teamwork across the trust.
  • Staff talked about the trust being friendly and welcoming and the team met many staff with significant length of service within the trust. Staff talked passionately about their focus on patients and delivering great care. This included a significant number of staff who were in support roles and who clearly understood how their work contributed to the quality of care being delivered. This positive engagement and patient focus extended to the PFI contractors.
  • Student nurses were generally very positive about the support and training they received. All the students that the team met said they would be happy to work in or to be treated at the trust. This issues impacting on other staff had also impacted on students, for example the limited number of laptops available to support ward rounds. Junior doctors also mentioned the information technology challenges with too few computers. Both groups of staff praise the trust’s Academy for the educational opportunities provided.
  • The trust ran an “In Your Shoes” scheme which enabled staff to challenge colleagues, and particularly managers, to take on their roles for a day. The team tested the awareness of this scheme across the services inspected and it was very variable. Those staff who were aware of it struggled to provide examples of changes and improvements that had resulted from it. In contrast senior managers who had participated described the insights it had given them into the issues faced by staff.

Fit and Proper Persons

  • The trust had made preparations to meet the Fit and Proper Persons Requirement (FPPR) (Regulation 5 of the Health and Social Care Act (Regulated Activities) Regulations 2014). This regulation ensures that directors of NHS providers are fit and proper to carry out this important role. This regulation came into force in November 2014. The trust has taken the approach of asking directors to confirm they meet the definitions, the use of due diligence for new appointments, monitoring through appraisal and through the declaration of interest process at meetings. The due diligence aspects included checks of the Insolvency Register and Companies House.
  • This regulation and the action required by the trust had been considered by the board on 30 April 2015 in a paper entitled “Update on CQC new Fundamental Standards” and by the Governance Committee on 5 June 2015 in a paper entitled “CQC new Fundamental Standards action plans”. The latter paper refers to the declarations being made by directors and notes “the vast majority now complete”. We reviewed records and found that none of the processes had been fully completed. Specifically the checks undertaken were awaiting sign off by the chairman.
  • We reviewed recruitment and personnel files for recent executive and non-executive appointments. These indicated that policies and procedures had been followed but the evidence was not complete on the files.
  • The trust’s approach, policy and procedures had not been documented except as they appeared in the documents referred to above. Given that both papers dealt with a number of requirements aside from Fit and Proper Persons and did not contain that in their title the team considered that the current arrangements did not constitute a clear and transparent process. This needs to be addressed.
  • In examining this issue the team found that the personnel and recruitment records examined were chaotic. References and HR checks were not on the personnel files examined and the related recruitment files could not be found. This needs to be addressed in order for the board to be assured.

Public engagement

  • There were examples of positive engagement with patients and the public within individual services. There was also effective engagement with and through the trust’s governors. Individually and collectively senior leaders demonstrated an authentic commitment to meeting the needs of the communities served by the trust. Examples of practical action included support for and participation in a range of health education programmes and health information events. However the trust did not have a strategy for public and patient engagement in the design and delivery of services.

Staff engagement

  • The trust ran an “In Your Shoes” scheme which enabled staff to challenge colleagues, and particularly managers, to take on their roles for a day. The team tested the awareness of this scheme across the services inspected and it was very variable. Those staff who were aware of it struggled to provide examples of changes and improvements that had resulted from it. In contrast senior managers who had participated described the insights it had given them into the issues faced by staff.
  • With exception of managers, staff within the community Children’s and Young People’s service did not feel engaged with the overall trust. Staff felt the trust overall had not taken an interest in them or in children’s services as they were hosting the service and had not tendered for the provision of the service beyond March 2016.

Innovation, improvement and sustainability

  • The team received mixed feedback from staff as to the extent to which innovation and improvement was encouraged. Some staff talked very positively about how they were encouraged to innovate and brought examples to the team to demonstrate that. Consultants talked about the trust being proactive in terms of research and that this was well supported by the medical director. Others felt that innovation had been stifled by the trust’s current financial pressures. All staff spoken to by the team described how they had been invited and encouraged to submit ideas to save money.
  • It was evident that some of the cost saving measures, for example the requirement that all post be sent second class and a ban on colour photocopying or printing, had compromised care. This appeared partly to be a failure of communication as there were arrangements in place for concerns to be raised and for exceptions to be agreed but it was evident that many staff were unaware of these. Examples in respect of colour printing included the difficulty of reading neonatal early warning scores and stroke care plans (provided to patients) when printed in black and white. Examples in respect of second class post included patients not receiving MRSA washes or preparations for endoscopy procedures in time and consequently having their procedures delayed. These issues were raised with the trust during the inspection.
  • There was evidence that the significant financial pressures, in particular the cash position, was impacting on staff and potentially on safety. The impacts on staff included the pressures on the finance team in dealing with daily internal and external enquires about the payment of bills to suppliers. Administrative staff in key areas within the trust described being contacted direct by suppliers about the non-payment of bills. Staff said they felt that these calls were often challenging to deal with. During the inspection there was an example where the actions of staff prevented the potential cancellation of surgery when an expected delivery of decontamination chemicals was not received because a supplier had not been paid. The finance team arranged for the bill to be paid to ensure delivery the following day (at an increased charge) and staff left the hospital to collect bottles of chemicals from other sites to ensure an adequate supply. This was raised with the trust during the inspection.
  • Considerations about the sustainability of services were driving the discussions on medium and longer term strategy referred to above.
Checks on specific services

Community health inpatient services

Good

Updated 19 January 2016

Overall rating for this core service Good

We rated Great Western Hospitals NHS Foundation Trust as good overall for community inpatient services. This trust provided inpatient care and support at three community hospitals. There were 37 beds on two wards at Chippenham Community Hospital, 26 beds on one ward at Savernake Hospital in Marlborough and 25 beds on one ward at Warminster Community Hospital. Care and support were provided by nurses, healthcare assistants and therapy services including physiotherapists and occupational therapists. Medical cover was provided by visiting consultants and local general practitioners.

Community health services for adults

Good

Updated 19 January 2016

Overall rating for this core service GOOD

Overall we rated all these adult community services as good. The trust provides a range of community services including district nursing, physiotherapy, continence, podiatry, wheelchair services, learning disability services, dietetics, diabetes, respiratory,adult speech and language therapy, neurology and tissue viability. During the inspection we looked at community services for adults, community outpatients and diagnostic services.

We rated all the five domains of this core service as good and found that some aspects of the effective and well led domains were outstanding.

The community services had a commitment to providing harm free and safe care. There were procedures in place to improve pressure care treatment through staff training and also the use of new innovative treatment techniques.

We found there were robust procedures in place for reporting incidents and staff we spoke with were aware of the processes to follow. We saw the learning from incidents was cascaded and improvements were initiated.

Equipment was well maintained and clinics and patient waiting areas were kept clean hygienic and safe.

Staff were completing mandatory training. The integrated health team was 80% compliant with mandatory training. which met the trust target of of 80%. Infection prevention and control mandatory training was completed by 85% of the team.

There were relevant and current evidence based guidance and best practice in use by clinicians across all the various services. We considered some of this to be outstanding practice. We found some outstanding practice where clinicians accessed information and knowledge through colleagues, clinical networks and professional associations.

Staff we spoke with said they considered that the trust valued training and they, “felt invested in”. Staff told us the training was generally of a high standard, was well planned, organised and professionally delivered.

Staff received annual appraisals and there were excellent levels of support from colleagues and managers. All staff we spoke with said they were well supported and supervised by their line manager. However there were inconsistencies around the arrangements for clinical supervision.

There were numerous examples of positive, professional multi-disciplinary working. We considered some of these to be examples of outstanding practice. This occurred within the integrated teams, between the county wide specialist teams, with GP surgeries and with hospital based clinicians. Staff were able to demonstrate knowledge of the various other professionals they worked with, how they shared information and also sought advice and support from different specialists.

Patients were treated with kindness, dignity respect and compassion by the clinical staff and also by reception and other staff working when they visited the community hospitals.

Various developments and changes in the planning and delivering of community services had taken place over the previous 18 months. There was a drive to implement integrated Integrated Teams to work closely around primary care to make care accessible to patients as locally as possible. The Integrated Teams provided a seven day service between 7am and 10 pm. The out of hours service between 10pm and 7am was commissioned to a private provider.

We saw and heard about various initiatives in place to improve the service to patients, including pressure care treatment, multi-disciplinary working with acute colleagues and early intervention treatment for stroke patients.

Patients living in the community were able to access care and treatment in a timely way, though there were some breaches of the 18 week national referral to treatment target in certain services. Action plans were in place to address the shortfalls in breaching these targets

Staff were well informed about the strategy for community services. They were able to explain the values and objectives, such as working closely with primary care services, providing a holistic service, promoting healthy lives and working in an integrated team of professionals.

There was a governance framework in place which gave clear guidelines over lines of responsibility. There were clear processes in place to monitor quality and risk and deliver an improving service. We found that there were some outstanding examples of auditing and action planning against identified shortfalls or areas for improvement by the different Integrated Teams and specialist county wide services.

The leadership and culture reflected the vision and values of the trust and encouraged staff engagement with delivering quality community based services. We found examples of outstanding leadership being provided by heads of locality and the clinical leads for the specialist services.

There was a culture of teamwork that permeated through the community adults service.

There were examples of services taking action to promote improvement and best practice and to improve the service delivered to the community. We saw examples of outstanding and innovative ideas being put into action.

During the inspection we spoke with approximately 70 staff, including managers, clinicians, administrators, technical staff and domestic staff. We also spoke with the trust director for community services.

We spoke with 39 patients and relatives. We visited locations across the geographical area where services were run and also where they were managed and coordinated. We observed care and support being provided by clinicians both in clinics and in the patients own homes. We ran drop in session in the three community hospitals where staff could talk to inspectors.

We looked at a sample of patients records and also trust documentation, including training records, policies, monitoring data and risk registers.

We took feedback from the public via our website and through public listening events. We also received feedback through the healthwatch organisation who had sought the views of patients.

Community health services for children, young people and families

Outstanding

Updated 19 January 2016

Overall rating for this core service Outstanding 

We found that services were safe, effective, caring, responsive and well led. The staff were competent, compassionate, enthusiastic and well supervised in their role. During the inspection, we met with managers, staff, children, young people and parents in a variety of community settings. We observed staff delivering care being in schools, outpatient clinics and in the child’s own home. There was an open reporting culture for any incidents that took place. Staff were encouraged to raise incidents and managers gave them feedback when appropriate. Staff were aware of their responsibilities to safeguard children and young people from abuse and worked closely with different agencies where appropriate. Recruitment had been a concern within the health visiting service, but we did not see any evidence that this had a negative effect on the care provided.

Care provided to children and young people was evidence based, using NICE guidance, Department of Health research and from advice from specialist centres. Local, regional and national audits were undertaken. Managers shared the outcomes with staff and, where services needed to improve, we saw action plans in place and plans to re-audit. Multidisciplinary and multi-agency working was embedded across the teams. We saw evidence that staff received regular supervision and appraisals.

We received excellent feedback from children, young people and their parents/carers about the care and treatment they received and the staff who provided it. Staff were skilled at communicating with children and young people and treated them with respect and dignity. Staff were friendly, warm, caring and professional. Staff always put the children and young people at the heart of everything they did and always involved them in their care and treatment. Specially trained health visitors and school nurses took part in a rapid response team to support parents in Wiltshire who had experienced the unexpected death of their child. We saw staff were responsive to the needs of children, young people and their families. Interpreting services were used for families where their first language was not English. Robust clinical governance structures were in place. Staff felt supported by their team leaders and managers within the community services.

End of life care

Good

Updated 19 January 2016

Overall rating for this core service GOOD 

We judged the overall service provision of end of life care as good. We found the service to be safe, effective, caring, responsive and well-led.

There were systems in place to keep patients safe. There was a good provision of equipment, including syringe drivers and mattresses for patient use in the community. We saw pre-emptive prescribing of anticipatory medications and availability of the ‘just in case’ medications.

End of life care was delivered through evidence based research and guidance. Education programmes had been developed and delivered, new documentation had been successfully introduced to the trust improving the pathway for patients

Patients and relatives spoke highly of the teams of nurses in the community; they were seen as very responsive to their needs. Out of hours there were good resources for staff to access including a 24 hour advice line managed by specialist palliative care nurses at a local hospice.

End of life care was seen as a priority for the trust. There was a clear overarching strategy for the service and plans to improve the delivery of care had already begun to take place with good results. The staff were able to collate evidence and influence change to improve services for patients.