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Provider: Great Western Hospitals NHS Foundation Trust Requires improvement


Inspection carried out on 29, 30 September and 1, 2, 11, 15 October 2015

During a routine inspection

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

CQC inspections of services

Service reports published 19 January 2016
Inspection carried out on 29 September – 2 October 2015 During an inspection of End of life care Download report PDF | 291.31 KB (opens in a new tab)
Inspection carried out on 29 September to 2 October 2015 During an inspection of Community health services for adults Download report PDF | 417.06 KB (opens in a new tab)
Inspection carried out on 29 September – 2 October 2015 During an inspection of Community health services for children, young people and families Download report PDF | 379.91 KB (opens in a new tab)
Inspection carried out on 29 September - 2 October 2015 During an inspection of Community health inpatient services Download report PDF | 327.77 KB (opens in a new tab)
See more service reports published 19 January 2016

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