Great Western Hospitals NHS Foundation Trust

We carried out an announced inspection between 21 and 23 March 2017 and an unannounced inspection at Great Western Hospital on 26, 27 and 28 March 2017 and 3 April 2017. This was a focused inspection to follow up on concerns from a previous inspection. As such, not all domains were inspected in all core services.

The inspection team inspected the following six core services at Great Western Hospital:

• Urgent and emergency services
• Medical care (including older people’s care)
• Surgery
• Critical care
• Services for children and young people
• Outpatients and diagnostic imaging

We also inspected:

• Urgent care services (provided as a community service).

We did not inspect end of life care or maternity and gynaecology services (previously rated good). We did not inspect the effective, caring or responsive domains for services for children and young people (previously rated good). The effective domain was inspected but not rated for outpatients and diagnostic imaging.

Overall we rated Great Western Hospitals NHS Foundation Trust as requires improvement.

We have deviated from the aggregation principles by not aggregating the ratings for (community) urgent care services to the overall trust rating. This is in recognition of the fact that, at the time of our inspection, the trust had only been running these services for six months. We also deviated from the aggregation principles for the well led rating at provider level. Please see the well led section below.  

Safe

We rated the safe domain as requires improvement overall. Urgent and emergency services, medical care, surgery, critical care, services for children and young people, the urgent care centre and outpatients and diagnostic imaging were all rated as requires improvement.

• As a result of high demand we found the emergency department was frequently full, with patients in all cubicles and around the nurses’ station. There were occasions where the emergency department was deemed to be unsafe as a result of the number of patients within the department. However, this was improving. We also found that as a result of pressures for beds in surgery some patients had to use facilities which were not always appropriate for recovering from their surgery.
• The checking of temperatures for medicines needed to be improved. Daily checks of medicines were not always completed in the emergency department or critical care. We found in medical care that some areas did not have regular temperature checks. This meant that medicines used may not have been fit for use due to the temperatures they may have been stored at outside of the recommended temperature range.
• The storage of medicines needed to be improved. In medical care we found that some of the storage shelves did not allow for stock rotation, which increased the risk of medicines being out of date. In the urgent care centre medicines which should have been locked away were not. We also found in critical care that the fridges used to store medicines could not be locked. This meant that medicines could be removed without authorisation.
• Equipment used was not always checked in line with guidance to ensure it was fit for purpose. Daily checks of equipment did not always take place for emergency equipment. There were some days where checks were not recorded for the paediatric intubation trolley in the emergency department and the emergency equipment trolleys in critical care. We also found in the service for children and young people that heated water blankets did not have expiry dates or water change dates recorded.
• There were areas throughout the hospital which did not have sufficient numbers of suitably qualified staff on shift to keep people safe. This included the emergency department observation unit where we observed a patient walking out of the department without staff knowing. Within medical care, services for children and young people, surgery and critical care there were wards and theatres which went through periods of understaffing which meant that staffing numbers did not always meet national guidelines. In medical care we found that ambulatory care was sometimes left with no staff in it for short periods of time due to lone working arrangements.
• Mandatory training rates needed to be improved in the emergency department for medical staff, in the urgent care centre, medical care, outpatients and diagnostic imaging, critical care, and surgery. In services for children and young people all medical staff fell below trust targets for all mandatory training and paediatric basic life support training was below target in all staff groups.
• Safeguarding practices needed to be improved in the urgent care centre, outpatients and diagnostic imaging and in services for children and young people. In outpatients and diagnostic imaging only 20% of medical and dental staff had completed level two safeguarding adults training against a trust target of 80%. In the urgent care centre no one was level three trained for children’s safeguarding. In services for children and young people staff did not have ready access to relevant safeguarding information on a patient due a filing backlog.
• The security and completeness of records needed to be been improved. We found in medical care and critical care that patient records were not always stored securely. We also found that in critical care patient allergies and venous flushes were not always documented. In medical care we found that not all patient documentation was completed in full and handovers between wards was not consistency provided to a high standard. This meant that patients' full needs were not always met.

However:

• There was a positive incident reporting culture and openness and transparency was encouraged. Opportunities for learning were sought when an incident occurred and learning was shared between teems. Where never events occurred in surgery we found they were investigated fully and actions had been taken to prevent them from happening again.
• We found all areas within the hospital, apart from a few exceptions, were visibly clean and tidy. We saw staff following National Institute of Health and Care Excellence standards for hand hygiene and we found that audit results were positive.
• We found that staffing levels for both medical and nursing staff were in line with recommended guidance in the emergency department, critical care and the urgent care centre. Within medical care there were sufficient doctors to provide safe care for patients.
• Risks to patients were appropriately assessed in the emergency department where we found observations and treatment decisions were made in a timely way. We found that patients' records were legible, complete, up to date and accurate in the emergency department, surgery, and critical care.

Effective

We rated the effective domain as good overall. It was rated as good for urgent and emergency care, surgery, critical care. It was rated as requires improvement for medical care and the urgent care services. It was inspected but not rated for outpatients and diagnostic imaging.

• In the emergency department, medical care, surgery, critical care and outpatients and diagnostic imaging we found that patients' care and treatment were planned and delivered in line with guidance, standards, best practice and legislation. This included guidance from the National Institute of Care Excellence and the Royal College of Emergency Medicine.
• Information about patients' care and treatment was routinely monitored and action was taken to improve the effectiveness of treatment where shortfalls had been identified. In surgical services the trust had a better rate of re-admission compared to the national average. In emergency care the department performed well in the latest Royal College of Emergency Medicine audits.
• Staff had the skills required to carry out their roles effectively. In all services inspected we found that staff had qualifications, experience and had received competency training in line with their role requirements. Most services performed better than the trust target for completion of appraisals.
• Patients received care and treatment from different disciplines who worked together in a coordinated way. All departments communicated well with each other to ensure effective treatment for patients. This multidisciplinary working approach continued over weekends where there were 24 hour diagnostics, critical care outreach, physiotherapy, pharmacy, and mental health liaison services.
• Within all services we found that the nutritional and hydration need of patients were fully assessed and that actions were taken to address concerns as soon as they were identified. Within the trauma unit innovative systems were in place to improve nutrition and hydration for patients.

However:

• In the urgent care centre policies, protocols and patient pathways were not in line with best practice legislation. Many policies were out of date, with some of them being several years out of date.
• In some areas of the trust outcomes required improvement. In medical care areas of the national stroke audit, MINAP audit and the national heart failure audit required improvement. In the urgent care centre outcomes were not routinely collected but were being introduced after the inspection.
• In critical care the provision of therapy services did not meet national standards. We found there was insufficient access to physiotherapy and dietetic services.

Caring

We rated the caring domain as good in medical care, surgery, critical care, outpatients and diagnostic imaging, and the urgent care centre. In urgent and emergency care we rated caring as outstanding.

• In all areas feedback from patients was consistently positive. We spoke withpatients their relative whotold us they recived care that was compassionate, they were involved as partners in care, and supported to cope emotionally with their care.
• Inspectors observed patients being treated with kindness and respect and saw that patients and their relatives were active partners in their care. They were well informed of treatment options and were involved in decision making.
• Emotional support was available to patients, either through the use of a psychiatric liaison nurse orstaff taking the time to sit with patients and talk to them. There were good examples of staff listening and acting appropriately to patients suffering from emotional distress.

However:

• Privacy and dignity was compromised in the discharge lounge, the surgical assessment unit, theatre recovery, ophthalmology and the urgent care centre. Conversations with patients could be overheard in the urgent care centre assessment rooms, the discharge lounge and the ophthalmology department. We found that in the surgical assessment unit, the discharge lounge and theatre recovery privacy was difficult to maintain when a patient required the toilet or to use a bedpan.

Responsive

We rated the responsive domain as requires improvement overall. It was rated as requires improvement for urgent and emergency care, medical care, surgery and outpatients and diagnostic imaging. It was rated as good for critical care and the urgent care centre.

• Patient flow through the hospital required improvement. The trust found it difficult to discharge patients from medical, surgical, and critical care services who required social care or patients who had a complex discharge.
• This resulted in the emergency department regularly being full to capacity, which meant that patients could not be seen in a timely way for assessment or treatment. The emergency department regularly breached targets for time spent in the department with most breaches being attributable to beds throughout the rest of the hospital not being available.
• Although medical outliers were managed well, the number of them was impacting the number of elective operations which could take place.
• Facilities were not always fit for purpose as a result of the numbers of patients being treated at the hospital. The medical expected unit was not always able to separate male and female patients, compromising privacy and dignity. In the emergency department patients were regularly cared for around the nursing station without screens to protect their privacy and dignity.
• For three months out of the past 10 the trust was performing worse than the national standard for two week urgent cancer referrals There were a high number of patients waiting for non-cancer outpatient appointments, with the most in ophthalmology. There were also delays in the sending out of letters for patients after their appointment.
• We found that in medical care and outpatients and diagnostic imaging translation services were available, but they were not always utilised. In medical care relatives were sometimes used with compromised confidentiality.

However:

• A number of steps had been taken to improve patient flow. This included moving the ambulatory care service to increase capacity and the introduction of the medical expected unit. There were also effective patient flow meetings to establish who could be discharged.
• High numbers of patients were streamed from the emergency department to the urgent care centre. We found that the urgent care centre was seeing patients quickly and seeing them within four hour targets.
• Reasonable adjustments were made to support patients in vulnerable circumstances throughout the hospital. Staff had a good understanding of the adjustments needed to support people living with dementia and learning disabilities.

Well Led

We rated the well led domain as good overall. It was rated as good for urgent and emergency care, medical care, critical care, outpatients and diagnostic imaging and the urgent care centre. It was rated as requires improvement for services for surgery and children and young people. We have deviated from our ratings aggregation principles in recognition of the significant improvements made since our last inspection. There was good board oversight of quality, safety and the trust's financial situation, which had improved. Significant challenges in respect of capacity, access and flow were well understood. The trust was working with partners to address these challenges to ensure future sustainability of healthcare in Swindon. 

• There was a clear vision and strategy within the services which was underpinned by realistic goals. The urgent care centre was working to develop its strategy in line with the unscheduled care division. This strategy was being acted upon with innovative workstreams through the emergency department, medical care, surgery, services for children and young people and outpatients and diagnostic imaging.
• Governance functioned effectively within all of the core services inspected and where reviews were underway (in services for children and young people and the urgent care centre) there were clear timescales and actions.
• Leaders of services throughout the organisation had a good understanding of the challenges faced by their departments and had the knowledge, skills and experience to lead effectively. Staff throughout the organisation spoke positively about their leaders and were confident to go to them if needed.

However:

• Staff within services for children and young people felt disconnected from the rest of the trust. The leadership had not been embedded locally and there was no representation of services for children and young people on the board.
• Nurses in services for children and young people did not recognise the trust as a good place to work. We were told that they often had to work long hours without access to a drink and without having a break. Nurses did not know the strategy of the women’s and children’s division.
• In surgery there were areas where there was a lack of management oversight. Also, actions identified to mitigate risks on the risk register were not always effective.
• In the emergency department, and surgical services staff felt that the executive team was not visible enough and that attempts to engage with staff could be better.

We saw several areas of outstanding practice including:

• The work of the education lead in the emergency department to improve education through various initiatives and work steams, including improved appraisals, training as part of the governance days and introduction of structured workbooks and teaching sessions.
• The understanding and involvement of patients and those close to them in the paediatric emergency department we observed during triage. The nurse put patients at ease and made sure that the process was explained in a compassionate way.
• The understanding of the emergency department leadership team of performance, governance, risks and its impact on patient care.
• The use of an emergency department monthly governance day to engage staff with governance and learning from incidents, concerns or near misses.
• The use of social media in the emergency department to engage staff to be more engaged with governance, share learning and discuss concerns with senior members of staff.
• The work of the clinical trials team in the emergency department to increase trial recruitment from very few patients a year to several hundred patients a year and the impact this has had on patient experience in the department.
• The medical care service had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicine.
• The medical care service had introduced digital technology for patients living with dementia which enabled them to access personalised reminiscence material.
• The trauma unit within surgery provided a picture menu which showed photographs of all food options that the hospital provided. This could be used for patients with communication difficulties, such aspatients with learning difficulties so they could more easily identify what food they would like at mealtimes. This had been hugely successful on the ward and at the time of the inspection this was being rolled out across the hospital.
• The outpatient service had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicine.
• The outpatient service had introduced digital technology for patients living with dementia which enabled them to access personalised reminiscence material.
• The monthly staff newsletter in the urgent care centre contained information on departmental news, department performance and updates on policies and procedures.
• The trust had introduced acute neurology clinics, located close to the short stay/ambulatory care unit, for patients who attended the acute medical unit and would have needed to be admitted in the past for further opinions and tests. These patients could now be discharged with an appointment, either the following day or the day after. This initiative had led to a significant number of admissions being avoided and provided a positive experience for patients.
• The cardiology department inserted the first four lead pacemaker for a patient in the world. The medical staff were monitoring the patient’s recovery and rehabilitation as part of an international research project to assess the advantages of the new technology.
• A  GP was employed in ambulatory care four days a week. The purpose of this new position was to improve communication with GPs to ensure basic tests had been completed prior to the patient attending the ambulatory care unit. It was anticipated that this would help to increase the flow of patients through the department and prevent patients attending the unit unnecessarily.

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

Importantly, the trust must:

• Ensure that the emergency department observation unit is sufficiently staffed to keep people safe.
• Ensure that medical staff in the emergency department receive appropriate mandatory training to enable them to carry out the duties they are employed to perform.
• Ensure that daily checks are conducted on resuscitation equipment and medicine fridges in the emergency department to assess that they are safe to use.
• Continue to develop and initiate plans and work streams in line with the improvement plan to improve flow in the emergency department at pace to improve safety and patient flow in the department.
• Ensure the promotion and control of infection at all times and in all areas within medical care.
• Ensure the security of patients’ confidential and personal information at all times within medical care.
• Ensure the safety of patients at all times within medical care, including ensuring sufficient staff are on duty to monitor and provide care and treatment to the patients. The trust should ensure patients are not left unattended in the ambulatory care department as a result of staff lone working.
• Ensure that the privacy and dignity of patients in medical care is respected and ensure that breaches of the national mixed sex accommodation do not occur.
• Ensure that staff in medical care consistently meet the trust target for mandatory training.
• Ensure that handovers take place consistently in medical care when transferring patients between wards and departments. The trust should ensure that assessments were carried out promptly by doctors following patients being admitted to the medical emergency unit.
• Ensure that there are clear pathways in medical care, including staffing levels, regarding the care of patients who require non-invasive ventilation (NIV).
• Improve the number of staff on surgical wards who have completed all their mandatory training in line with the hospital target.
• Improve access to patient toilet facilities within the surgical assessment unit and theatre recovery area.
• Improve the response times to patients’ complaints within surgery.
• Improve the timely completion of discharge letters to GP’s, including reducing the large backlog of letters which have not been sent within surgery.
• Ensure all staff in critical care are compliant with mandatory training, role essential training and current assessment of staff’s paediatric competencies (nursing and emergency procedures).
• Ensure there are adequate allocated hours from allied healthcare professionals to meet national recommendations.
• Ensure there are adequate numbers of suitably qualified, competent and skilled nursing and medical staff in areas where children are cared for in line with national guidance.
• Ensure all staff involved with the care of children are up-to-date with paediatric basic life support and mandatory training.
• Ensure medical and dental staff in outpatients and diagnostic imaging have received training in level two safeguarding vulnerable adults
• Ensure medical and dental staff in outpatients and diagnostic imaging are up to date with mandatory training, including adult basic life support, fire training and paediatric life support
• Improve the rates of mandatory training within the urgent care centre to bring compliance levels in line with the trust’s target.

In addition the trust should:

• Ensure that there are suitable quantities of cardiac monitors and trolleys in the emergency department to ensure safe patient careat times of crowding.
• Ensure the provision of specialist support to patients attending the emergency department who misuse alcohol or substances.
• Ensure that the executive team is more engaged with staff in the emergency department and plan times of visits better to prevent a negative impact on staff morale.
• Ensure that equipment used for personal care within medical care services is fit for purpose and that staff are able to provide assistance promptly if the patients become unwell while using equipment. This relates to inaccessible showers.
• Ensure that clinical equipment in medical care, such as needles and blades, is stored securely. The trust should ensure the safe storage of medicines, including creams and ointments, at all times. This should include ensuring that medicines aree stored following manufacturers' guidelines.
• Ensure that where oxygen cylinders are stored in medical care, there is appropriate signage to inform staff and visitors to the area.
• Ensure that staff working in all departments in medical care have access to emergency equipment and medicines in order to be able to respond promptly to medical emergencies.
• Ensure within medical care that care documentation, including care plans, pain and risk assessments were completed in sufficient detail to inform staff of the individualised care and treatment that was required for each patient.
• Ensure that nursing staffing levels in medical care consistently meet the assessed and agreed staffing establishment for all wards and departments.
• Esure that within medical care performance against national audits is improved.
• The trust should ensure that within medical care the patient’s confidentiality was consistently respected when requiring assistance with interpretation and/or translation.
• Ensure that within medical care the complaints process was followed in a timely way and in accordance with the trust policy and procedure.
• Ensure that staff within medical care are consistently informed and knowledgeable about the risk registers for their wards and departments.
• Improve completion of NEWS within surgery.
• Ensure fabric curtains are replaced by disposable curtains to meet national standards.
• The critical care service should ensure processes to monitor and audit compliance with cleaning processes in critical care.
• Ensure effective processes to learn from mortality and morbidity meetings in critical care.
• Ensure staff in critical care check essential equipment daily in line with policy.
• Ensure that in critical care, patients’ allergies are always documented and that staff sign for all medicines they administer.
• Ensure the safe storage of medical gasses.
• Ensure all patient medical records in critical care are stored securely.
• The critical care service should ensure practice guidance is regularly reviewed and updated.
• Continue to support the clinical nurse educator role in critical care to comply with national recommendations.
• Review the training and competency assessment of medical staff in critical care to ensure there is always staff on duty who are competent in airway management.
• Explore the improvement of the patient bathroom facilities in critical care to include shower facilities so that these facilities are not shared with relatives.
• Review the arrangements for the provision of follow-up clinics in critical care to ensure these are sustainable.
• Ensure staff have access to appropriate equipment necessary in children’s services to carry out their roles and provide care effectively and efficiently.
• Ensure all staff involved in the care and assessment of children and young people have safeguarding training in line with intercollegiate guidance.
• Ensure that systems are in place to ensure case conference notes of vulnerable children are filed in their records in a timely manner.
• Consider the wellbeing of staff within children’s and young people’s services in terms of regular access to rest breaks and hydration.
• Consider mechanisms which could improve the connection of, and communication between, front line staff and divisional leaders within children’s and young people’s services.
• Consider options for improving the connection between the Women and Children’s division and the rest of the trust, together with considering the representation of children’s services at board level.
• Ensure patients within all of the diagnostic imaging waiting rooms can be monitored by staff.
• Ensure that departments within outpatients have access to resuscitation equipment in line with hospital policy
• Provide leaflets within departments in outpatients and diagnostic imaging that are available in different languages.
• Ensure access for bariatric patients in outpatients is improved so they can be assessed and treated without compromising their privacy.
• Make improvements on the follow up backlog waiting list to meet people’s needs and minimise possible risk and harm caused to patients through excessive waits on outpatient appointments and excessive waits on the reporting of images.
• Make improvements on the backlog in typing time times in outpatients and the delay in letters being sent to GPs.
• Ensure arrangements are in place to replace aging diagnostic imaging equipment identified at risk of failure
• Improve the storage of medicines within the urgent care centre and ensure that medicines are checked and managed by staff.
• Improve the quality of records audits in the urgent care centre to ensure that maximum learning is taken from them.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We rated the urgent care centre to be requires improvement overall. This was because:

• We were concerned that following a serious incident the service did not explore all possible areas of improvement.
• Not all staff had received the appropriate level of safeguarding training which put patients at risk.
• Some medicines were not stored securely and some were not labelled correctly which meant it could not be identified when they were opened.
• The quality of records required improvement and the records audit process was not robust
• Compliance with mandatory training was variable so we could not be assured that staff were familiar with safe systems and processes.
• The business continuity plan was not robust to account for different situations such as adverse weather.
• There were incidents of inappropriate referral from the emergency department of patients who were too ill to be in the urgent care centre. Patients were sometime inappropriately streamed to the urgent care centre by the emergency department, NHS 111 and the ambulance service.
• Due to the computer systems in the emergency department and the urgent care centre being different, patients may be waiting up to eight hours without being outside of target times.
• Some patients did not have the waiting times explained to them which left them uncertain as to why they were waiting.
• Staff were uncertain about the future of the urgent care centre and required more reassurance from managers during the transition period.

However:

• Managers had recognised where services could be improved and various work streams were in place to mitigate and improve them.
• Staff understood their responsibilities to raise concerns and report incidents. Learning from incidents was shared with them.
• Staff held the appropriate qualifications and training to perform their role. Staff were given opportunities to develop and improve their skills and to progress within the service.
• Staff worked well with other services, such as NHS 111, the ambulance service, GP’s and, particularly ambulatory care, to ensure that treatment was effective.
• Feedback from patients was positive about the way staff treated them. Patients were treated with dignity, respect and kindness during all interactions.
• Staff encouraged patients to be partners in their care and supported them to make decisions. Staff responded compassionately when people needed help.
• Confidentiality was respected at all times.
• The department consistently met or exceeded the national standard which requires that 95% of patients are discharged, admitted or transferred within four hours of arrival at the urgent care centre.
• There was suitable support provided to patients with complex needs such as patients living with dementia or a learning disability. Staff understood the reasonable adjustments needed to ensure vulnerable people were cared for appropriately.
• The urgent care centre was accessible by patients with a disability and chaperone and translation services were available.
• Governance and performance management systems were being proactively assessed and established. The centre had set up a dashboard and governance processes in line with processes in the wider trust and were using them to monitor performance
• The urgent care centre used risk registers to identify where the biggest risks were and they were taking steps to mitigate known risks.
• Leadership the urgent care centre were proactive and well respected. The leadership within the unscheduled care division had the skills needed to integrate the urgent care centre with the division.
• Despite the amount of change going on within the urgent care centre, staff morale was positive; staff felt respected, valued, and supported by their leadership team.