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Provider: The Dudley Group NHS Foundation Trust Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 3 December 2014

We carried out this comprehensive inspection as part of the new hospital inspection programme and as a follow up to the Keogh review which took place in 2013. Of the 14 trusts inspected under the Keogh review for the quality and safety of their services, The Dudley Group NHS Foundation Trust was one of only three trusts that were not put into special measures. That review identified concerns regarding:

  • governance arrangements
  • the need to embed a culture of learning from incidents
  • how the trust uses and reviews mortality data
  • the system for bed management and patient flows
  • embedding patient experience in the organisation’s learning and strategy
  • staffing levels and skills mix
  • safety and equipment checks
  • pressure ulcer care.

Before the inspection conducted in March 2014, the Trust was identified in CQC’s intelligent monitoring system as a priority band 4 Trust. There are six bands within the monitoring system so this Trust had a relatively lower risk.

We noted that the trust’s action plan to address the concerns following the Keogh review had been put into place and signed off.

Our inspection of The Dudley Group NHS Foundation Trust included Russells Hall Hospital, Corbett Outpatient Centre and Dudley Guest Outpatient Centre.

The announced inspection took place between 26 and 27 March 2014, and unannounced inspection visits took place in the two weeks following this visit.

Overall, this trust was found to require improvement, although we rated it good in terms of having caring staff, and effective services.

We saw much support for the trust, both from the public and from the local health economy.

We saw a trust that was a considerable way along its improvement journey and saw many areas of strong development. Whilst some of the core service areas within the trust required improvements in leadership, we found the executive team and the trust board had a clear focus on improvement and as such we rated this trust as good for its overall leadership.

The improvements required by the trust were within the grasp of the trust and its leaders. We were confident that these could be achieved quickly.Key findings related to the following:

  • The trust’s staff are seen as highly caring by many of the patients we spoke to and praised the staff for ‘going the extra mile’.
  • The trust’s leadership team is seen as highly effective by the staff; and is recognised to be clearly in touch with the experience of patients and the work of the staff.
  • Staff value the Dudley Group as a place to work and a team spirit is clearly evident.
  • The trust has responded well to the Keogh review in 2013.
  • There are a number of areas of good practice in the trust, which should be encouraged. Staff feel able to develop their own ideas and have confidence that the trust will support them.
  • The emergency department (A&E) is busy and overstretched. There remain challenges in the flow of patients, but much of this relates to flow across the rest of the hospital. Only a small proportion relates to the emergency department itself.
  • The trust does not always follow its own policy in relation to DNACPR (do not attempt resuscitation) notices.
  • The ophthalmology clinics require review to ensure that all patients are followed up as required and that there is capacity for these clinics.
  • The trust must review its capacity in phlebotomy clinics as this is seen as insufficient.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 3 December 2014

Overall, we rated safety in the trust as requires improvement.

A serious incident known as a never event is classified as such because it is so serious that it should never happen. The trust previously reported two never events between December 2012 and January 2014.

The Strategic Executive Information System (STEIS) records serious incidents and never events. Serious incidents are those that require an investigation. Between December 2012 to January 2014, 168 serious incidents occurred at the trust. Between June 2012 and July 2013, the trust submitted 1,003 serious incident notifications.

During our inspection, we found the department staffed with medical and nursing staff in sufficient numbers to meet the needs of patients. We observed patients in the Minors and Majors areas being prioritised or triaged by a ‘triage trained’ nurse. This process ensured that the most appropriate plan of care was organised to meet their needs. Children were triaged in the separate paediatric department from 11am to 11pm. This meant that they were seen by specialist nurses and doctors during those hours.

We found that all of the areas we visited on the medical care directorate were clean and hygienic, which helped to protect patients from hospital-acquired infection. We saw that all areas were well maintained and free of clutter. In the 2013 NHS Staff Survey, the trust came in the top 20% of trusts nationally, regarding the proportion of staff stating that hand-washing materials were readily available ensuring people were protected from the spread of infection.

The proportion of patients risk assessed for venous thromboembolism (VTE) was within expectations but we found some concerns with the use of anti-embolism stockings in the critical care unit.

Some areas of the trust required improvement in aspects that we consider contribute to patient safety. In A&E we saw that space was an issue for the service and patients were waiting in corridors on a number of occasions. Staff were working under significant pressure. There was a plan for looking at capacity and flow across the acute trust and into the community.

In some areas we were concerned that not all staff understood the importance of incident reporting and the processes to use.

In maternity, historically the capacity of the service was stretched. A plan for managing this had been agreed with the Clinical Commissioning Group (who had limited the activity at the trust). In the event of staffing or patient capacity issues, the service would be suspended in accordance with the escalation policy.

In end of life care, we found that the systems for agreeing a DNACPR order (do not attempt resuscitation) for those patients at end of life were not always robust.

We found not all risks had all been identified or recorded onto the critical care risk register. The Medical High Dependency Unit (MHDU) was routinely staffed to less than the full capacity for the number of patients they could accommodate. We were concerned that the “flex” staffing arrangements in MHDU could place people at risk of unsafe care. We found that senior nurses were spending unreasonable amounts of time covering shifts with agency staff or the Trust’s own temporary nurses.

We did however see elements of good practice including safety huddles; use of safety dashboards; antibiotic prescribing; clean clinical areas and good hand washing and hand hygiene.

Effective

Good

Updated 3 December 2014

The trust was delivering effective care.

Using CQC’s Intelligent Monitoring data, the trust previously had a mortality alert as an outlier for skin and sub cutaneous tissue infections. At the time of our visit this had already been recognised by the trust and investigated. This issue was discussed with the medical director who felt that this related to small numbers within the data amplifying the concerns.

Current data shows that the trust’s mortality has been reduced and it is no longer an outlier in national monitoring. The Medical Director had led work on resolving this through mortality review meetings and pathway redesign. The Medical Director showed strong leadership in resolving these concerns.

In maternity services, we saw that there were around 5,600 births during the previous year. This had now been limited to 4,900 by the commissioners as a way of managing capacity in the trust. The trust had a higher rate of elective caesarean and other forceps deliveries when compared with nationally. The trust’s normal delivery rate was also slightly higher than that reported nationally. The trust’s outcomes as judged by the maternity indicators were within expected limits for all of the indicators (i.e. Perinatal mortality Emergency caesarean sections Elective caesarean sections Neonatal readmissions and Puerperal sepsis).

In many areas the trust had good practice and audit to support its work and access to nurse specialists, where required, was available. We saw good use of clinical guidelines and competency training. Most staff we spoke to had personal development plans to improve their clinical skills and training.

In maternity however, we found that monitoring information on the dashboard was inaccurate. Additionally, not all audits carried an action plan, and not all audits undertaken were part of an agreed plan for the service.

We spoke with the relative of a patient who had chosen to take part in a government-funded treatment trial. They told us that the consultant had explained the benefits and limitations of this prior to commencing the treatment.

Caring

Good

Updated 3 December 2014

Overall we rated the caring aspects of services in the trust as ‘good’.

Since April 2013, patients have been asked whether they would recommend hospital wards to their friends and family if they required similar care or treatment, the results of which have been used to formulate NHS Friends and Family Tests for Accident & Emergency and Inpatient admissions. The Inpatient FFT survey emphasises that the trust performed better than the England average during this period. The A&E FFT highlights that the trust was performing better than the England average for all four months, with the highest score being 73 in December. It also reflected that the most responses received were 1,071 in December.

The trust has performed ‘worse than other trusts’ nationally for 32 of the 69 questions asked in the 2012/13 Cancer Patient Experience Survey. It has also performed ‘better than other trusts’ for one other question in the survey (Patient has taken part in cancer research).

Analysis of data from CQC’s Adult Inpatient Survey 2012 showed the trust had performed worse than expected on two areas of questioning: the emergency/A&E department and waiting to get to a bed on a ward.

Many patients were highly positive of the care they had received. Staff were praised by patients for being very committed. Individual examples where staff went ‘over and above’ what would be expected are set out in individual sections. However, we noted in many areas patients were extremely appreciative of the efforts of staff to meet their needs.

We saw good voluntary sector engagement and a strong sense of community feel. One of the trust’s governors worked as a volunteer and we met him both in the governors meeting and also the following morning ‘on duty’ in the trust.

Responsive

Requires improvement

Updated 3 December 2014

Whilst many of the services provided a responsive approach to patient care, we felt a number of services required improvement. We could not be assured that services patients received would always respond to their needs.

We saw that the trust regularly breached the four-hour wait target for patients in A&E. The ability of the trust to respond to patients’ needs by providing access to secondary care beds from A&E was limited. Patients were often delayed in accessing beds in the hospital.

We saw in some areas a delay in discharge related to challenges in accessing medication in a timely way.

We found delays in admission and the flow of patients through the organisation, meaning patients were taking longer to arrive on the appropriate ward than should have been the case. We saw a number of outliers on different wards (patients who were not on the ward they should have been due to bed shortages); this meant they were not always receiving care from the nursing and clinical team that would best meet their needs.

In some areas the physical space (eg Phlebotomy and A&E) was insufficient for the needs of the people using it.

However, we also noted areas where the trust was highly responsive to patients’ needs. As example of this is a sonographer available on the surgical assessment unit and a holistic approach to fracture care.

We were told that the trust is undertaking an ambulatory care pilot scheme to ensure that it could improve the way it met the needs of patients coming in through A&E.

We saw good examples of how the trust protected vulnerable adults and applied safeguarding procedures.

The week before the inspection, the trust had held an international event at the hospital which had been coordinated by the hospital caterers association with dieticians from the trust and Interserve, the trust’s catering company. As part of this event, new leaflets had been produced for patients on how to maintain good nutrition and hydration.

During our listening event and throughout our hospital visits we were told by patients and relatives that problems with car parking at the hospital caused much stress. They said they found it very difficult to park and that the costs for car parking were too high. They were, however, aware that a weekly car parking pass could be purchased at a reduced rate. A relative told us, “I find the parking very stressful. There is not enough parking and I have to drive round and round to find a space.”

Well-led

Good

Updated 3 December 2014

We saw strong leadership throughout the organisation.

The leadership of the Chief Executive was praised by many members of staff at all levels and the focus from the Executive Team on taking the organisation forwards. Both the Chief Executive and the board were visible and highly engaged. Staff we spoke to knew them by name and by sight. Staff spoke of the executive team doing shifts on the wards. One member of staff told us that following one shift, the Chief Executive saw and recognised some of the challenges the team faced, and the next day an order for a specific piece of equipment was approved. There was confidence among the staff that the board really understood the challenges and practices in the trust.

Overall, we rated the trust as good at trust wide level (reflecting the role of the executive team and the board). However, at a location level, well-led was rated as requires improvement.

The Chief Executive expressed a view of one single hospital on three sites; and this is certainly how many of the inspection team perceived it to work. There was a clear sense of team spirit throughout the whole trust.

We noted that the trust’s action plan to address the concerns following the Keogh review had been put into place and signed off as complete by Monitor.

The NHS Staff Survey 2013 saw the percentage of staff reporting good communication between senior management and staff as tending towards a ‘better than expected’ result. Throughout our inspection we were given many examples referring to the Chief Executive and their visibility and commitment to the organisation.

The trust had been reviewed as part of the Keogh mortality review. We saw a trust that understood what it needed to do to move the organisation forwards and had focused on meeting those requirements.

The trust’s performance was better than expected or tending towards better than expected for 13 of the 28 NHS 2013 Staff Survey indicators. The trust was found to be performing well in regard to staff being satisfied in their jobs, staff being supported by immediate managers and staff stating that there was good communication between staff and senior managers

The trust’s performance was worse than expected or tending towards worse than expected for 11 of the 28 NHS 2013 Staff Survey indicators. Key points from these indicators are the lack of effective team working, staff not feeling that their role makes a difference to patients, staff being able to contribute towards improvements at work and staff experiencing physical violence from other staff in the last 12 months.

The NHS staff survey 2013 saw the percentage of staff having a well-structured appraisal in the last 12 months within the top 20% of trusts nationally and the percentage of staff having received job-relevant training, learning or development as tending towards better than expected. Medical and nursing staff told us that they had regular opportunities to speak with their line managers.

A member of staff at Dudley Guest Hospital told us of “strong ties between the multidisciplinary team”. Another told us they received six-weekly supervision and an annual appraisal.

The trust has taken part in all the audits it was eligible to participate in. The trust’s performance against the five National Bowel Cancer Audit Project indicators was found to be within expectations. The trust was found to be performing better than expected for two of the five indicators in the Myocardial Ischaemia National Audit Project. The trust was found to be performing within expectations for all three of the Antenatal and Newborn Screening Education Audit indicators.

We saw good attention being paid to professional development and training. All staff we spoke to had received both an annual appraisal and a mid-year review. All staff felt that they had a development plan that was agreed and access to support in achieving it.

The trust has implemented a vision and values drive. Its clear message was contained in the three values ‘Care’ ‘Respect’ and ‘Responsibility’. It was clear that staff understood these and were signed up to them.

In some areas we saw leadership that required some development. This included systems for sharing learning from incidents, workload in some teams and communication systems that were too cumbersome to be effective.

The NHS Staff Survey 2013 also saw the percentage of staff recommending the trust as a place to work or receive treatment as ‘within expectations’. All the staff we spoke with over the two days, and at staff focus groups, were confident that if their relative were admitted to the trust they would receive good, safe care.