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Tetbury Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 29 March 2017

We carried out a comprehensive announced inspection of Tetbury Hospital as part of our programme of independent healthcare inspections under our new methodology. The inspection was carried out through announced visits on 13 and 14 September 2016 and an unannounced visit on 21 September 2016.

We inspected and reported on the following three core services:

  • Emergency and urgent care

  • Outpatients and diagnostic imaging

  • Urgent and emergency  services

Third party providers used some facilities at the hospital for example, Tetbury Hospital owned the X-ray equipment but did not perform or report on the X-rays. Other providers ran clinics from the outpatient and diagnostic imaging department and used the day surgery unit. We did not inspect their practice as part of this inspection.

Our key findings were as follows:

The overall rating for Tetbury Hospital was requires improvement.

Emergency and urgent care was rated as requires improvement overall. In the safe and effective domains it was rated as requires improvement and the caring, responsive and well led domains were rated as good.

Surgery was rated as good overall. The safe domain was rated as requires improvement and the caring, effective, responsive and well led domains were rated as good.

The outpatient and diagnostic imaging department was rated as good overall. In all domains except for effective the department was rated good. We do not rate effectiveness in outpatients and diagnostic imaging due to insufficient evidence being available.

Are services safe at this hospital?

We rated safety as requires improvement:

  • Cleaning schedules, fridge temperatures and daily checks of theatre equipment were not always recorded as complete.

  • Emergency drugs were not tamper-evident.

  • Patient allergies were not always recorded on prescription charts.

  • The hospital did not have a policy or guidance on quality standards for sepsis screening and management.

  • The hospital did not have a supply of blood products for use in an emergency.

  • There was poor compliance with some areas of mandatory training.

  • Safeguarding processes for children and young people attending the minor injury unit (MIU) were not robust. Emergency Nurse Practitioners were not adhering to the safeguarding arrangements in MIU, which required every child and young person to undergo a safeguarding assessment.

  • The resuscitation trolley and portable resuscitation equipment (grab bag) in MIU did not hold all the appropriate equipment for the resuscitation of children and young people.

  • Monthly hand hygiene audits were not completed regularly in MIU.

However:

  • From April 2015 to March 2016 the hospital reported no never events, deaths or serious incidents. There were no cases of hospital-acquired infection.

  • Staff were clear about the process for reporting incidents and were encouraged to report incidents and concerns. There was evidence of learning and improvement following incidents.

  • Although the hospital did not provide specific training in the duty of candour staff were aware of the principles of this. They were open and honest and apologised to patients when things went wrong.

  • The hospital maintained good levels of cleanliness and hygiene and staff mostly took appropriate precautions to prevent and control the spread of infection. Staff were seen to adhere to the hospital’s cross infection policy

  • The hospital had a lead for safeguarding and from April 2015 to March 2016 the hospital reported no safeguarding incidents.

  • The hospital reported minimal use of agency staff and had a team of bank staff who already worked in the hospital to fill vacant shifts.

  • Sufficient staff were available to treat and care for patients who attended the MIU.

Are services effective at this hospital?

We rated effectiveness as requires improvement:

  • Analysis of national guideline updates did not always identify changes relevant to the hospital.

  • There were no mechanisms in place to ensure ready access to professional children’s nursing leadership within the service.

  • Competency assessments and peer review were not in place to support shared learning between staff on a continual basis.

However:

  • Care and treatment was evidence-based and hospital policies followed guidance from the Department of Health and the National Institute for Health and Care Excellence (NICE).

  • New and updated policies and guidelines were discussed and approved at the monthly medical advisory committee (MAC) and the hospital quality committee (HQC) meetings.

  • The hospital had a low rate of unplanned transfers to other hospitals and from April 2015 to March 2016, there were no unplanned patient readmissions.

  • Staff received clinical supervision and all had appraisals completed within the last year. The hospital had systems to monitor and supervise staff.

  • The hospital collected information from patients on various aspects of their experience in the hospital and reported this annually.

  • The hospital monitored staff employed under practising privileges. There was an electronic system that flagged when appraisals or Disclosure and Barring Service (DBS) checks were due. These were up-to-date at the time of our inspection.

  • People’s consent to care and treatment was sought in line with legislation and guidance. Written consent was taken and forms were filed in patients’ records. Staff were knowledgeable about the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. The hospital provided training on these subjects.

  • There was good evidence of multidisciplinary working between staff in the hospital, GPs and outside organisations.

  • Parents said the management of their own and relatives’ pain in the MIU was effective. They praised the sensitivity of the Emergency Nurse Practitioners.

  • Staff actively involved patients, relatives, parents, children and young people in consent processes in MIU and outpatients.

Are services caring at this hospital?

We rated caring as good:

  • There was a high level of patient satisfaction with the service. All the feedback we received from patients regarding their care and treatment was positive and complimentary. The hospital had good results from the NHS Friends and Family Test.

  • We observed staff treating patients with kindness, dignity and respect.

  • Staff recognised when patients were anxious and provided them with reassurance.

  • Patients and their relatives or those close to them were encouraged to be involved in all stages of their treatment.

  • Parents said staff would go the “extra mile” to care for their relatives and they would highly recommend the MIU to their friends and family.

  • Patients and relatives said they were treated with dignity and respect in MIU and outpatients and they were always listened to and felt able to raise concerns.

However:

  • There was a lack of privacy for patients when discussing their operation and condition.

  • The response rate to the NHS Friends and Family Test was low.

Are services responsive at this hospital?

We rated responsiveness as good:

  • Services were planned to meet the needs of the local population. They provided timely and convenient care to NHS and private patients.

  • Referral to treatment (RTT) times were consistently below (better than) the NHS England target.

  • Patients with complex needs were assessed and plans made for them prior to their admission. There was good access and facilities at the hospital for people with a disability. The hospital had a Dementia Strategy policy and a lead for dementia services. Staff also received training in dementia.

  • Staff managed admissions to reduce waiting times for patients.

  • The hospital had strict admission criteria. Staff were knowledgeable about this and knew when and how to take action if they were unsure whether a patient was suitable for a procedure at the hospital.

  • Clear information was provided to patients about how to make a complaint or raise a concern. The hospital received few complaints. The hospital took actions to resolve complaints and lessons were learned and shared with staff.

  • For the reporting period April 2016 to June 2016 following improvements to the triage arrangements, patients were triaged in the MIU within 15 minutes of arrival at reception.

  • A review of children and young people’s experiences of health services was captured as part of a service development review of Tetbury Hospital in 2016.

  • Staff were aware of the complaints policy and procedure and supported patients and relatives to raise issues and concerns.

However:

  • There was no policy or lead for children and young people with a learning disability.

  • Feedback from parents, children and young people was not captured in the Tetbury Hospital patient survey and the friends and family test to support the development of child friendly services at the hospital.

  • There were limited printed information leaflets available about the care for children who had attended outpatients and the MIU. Information was not child friendly and often only given verbally.

Are services well-led at this hospital?

We rated well-led as good because:

  • The hospital had a clear vision and strategy and this was understood by staff. Staff were aware of the organisation’s values and the commitment to providing a quality and responsive service to patients.

  • There was an effective governance structure to support the delivery of good quality care. Staff were aware of their roles and responsibilities and what they were accountable for. There was a strong culture of delivering kind and compassionate patient-centred care.

  • We saw evidence of incidents and complaints discussed at governance meetings and information was shared at staff meetings.

  • Leaders were visible and approachable and had open door policies. Staff said leaders were accessible and they did not have any problems in raising concerns with them.

  • The hospital actively sought the views of patients, people close to them and staff about the service they provided. People were actively engaged and involved in decision-making.

  • Services which were not provided locally were identified and implemented at the hospital.

However:

  • Not all risks were included in the hospital risk register including the lack of piped oxygen and blood supplies.

  • There were no mechanisms in place to ensure ready access to professional children’s nursing leadership within the service.

  • There was no nursing representation at board level or above matron level within the hospital

There were a number of areas where the provider needs to make improvements. Importantly, the provider must:

  • Adapt guidance for adults, children and young people on quality standards for sepsis screening and management.

  • Review oxygen provision to ensure patient risk is minimised.

  • Ensure theatre daily equipment checks are completed.

  • Ensure all emergency resuscitation drugs are tamper-evident.

  • Review their policies, processes and systems for obtaining blood products in an emergency.

  • Ensure robust safeguarding arrangements in line with hospital policy are in place for children and young people attending the minor injury unit (MIU).

  • Ensure all equipment in the MIU is in date and correctly labelled.

In addition the provider should:

  • Ensure all bins used for disposing of clinical waste are appropriate.

  • Review arrangements in respect of storing contaminated equipment for sterilisation.

  • Ensure patient allergies are recorded on prescription charts.

  • Consider following the guidance of the National Early Warning System (NEWS) to identify and respond to deteriorating patients.

  • Consider providing more privacy for patients when discussing their operation and condition.

  • Consider providing separate areas for male and female patients.

  • Develop a tool to obtain feedback from children, young people and their families.

  • Develop clinical outcomes and performance indicators patients attending the Minor Injuries Unit.

  • Ensure there are robust arrangements in place for the provision of professional children’s nursing leadership.

  • Take steps so that patients seated in minor injuries unit waiting areas can be observed by staff.

Ensure hand hygiene audits are completed monthly in MIU in line with hospital policy.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 29 March 2017

Effective

Requires improvement

Updated 29 March 2017

Caring

Good

Updated 29 March 2017

Responsive

Good

Updated 29 March 2017

Well-led

Good

Updated 29 March 2017

Checks on specific services

Urgent care centre

Requires improvement

Updated 29 March 2017

We rated urgent and emergency care in the minor injury unit as requires improvement overall because:

  • The resuscitation trolley drugs were not tamper evident.

  • The resuscitation trolley and portable resuscitation equipment (grab bag) in the unit did not hold all the appropriate equipment for the resuscitation of adults and children and young people. We raised this with the nursing staff at the time of our announced inspection and improvements were immediately made.

  • The grab bag contained out of date swabs and gauze. This was raised at the time of our announced inspection, however out of date swabs and gauze was still present at the time of our unannounced inspection. After raising this again it was immediately addressed.

  • Staff were not fully adhering to safeguarding arrangements for children and young people, meaning they were not always protected from abuse or avoidable harm

  • The emergency drug box was not sealed.

  • The unit did not have a sepsis screening tool or sepsis policy to help identify those patients at risk of sepsis and ensure correct and timely intervention.

  • Patient clinical outcomes were not monitored regularly or robustly.

  • There was a lack of clarity around the mechanisms in place to ensure ready access to professional children’s nursing leadership which was not in line with national guidance, Royal College of Nursing (RCN 2014)

  • Limited printed information was available for children and young people attending outpatients and MIU at Tetbury Hospital

  • Competency assessments and peer review were not in place to support shared learning between staff on a continual basis.

  • There was a lack of opportunity for staff to review each other’s clinical practice and learn from each other
  • Whilst there was evidence of multidisciplinary team working and learning needs were up to date there were concerns expressed about staff learning from each other and receiving supervision.

  • There was no assurance that clinical procedures undertaken on children and young people in the unit and outpatients were in line with current standards.

However:

  • Clear information was provided to patients about how to make a complaint or raise a concern. There was evidence of learning from incidents and complaints. Staff were aware of their responsibilities in regards to this.

  • Sufficient numbers of nursing staff were provided and maintained to ensure that the department operated smoothly and safely and safe arrangements were in place to ensure agency staff had knowledge of the unit.

  • There was good evidence of multidisciplinary working between staff in the hospital and outside organisations.

  • Learning needs of staff were up to date
  • We received positive feedback about staff from all of the patients we spoke with. Patients were treated with respect by staff when they visited the minor injuries unit.

  • The unit was achieving all national indicators for the assessment, treatment and discharge of patients.

Outpatients and diagnostic imaging

Good

Updated 29 March 2017

We rated outpatients and diagnostic imaging as good overall because:

  • People were protected from avoidable harm. The trust had a range of safety measures in place and there were systems to report concerns or incidents and learn from them.

  • There were reliable systems, practices and processes to keep people safe and safeguard them from abuse.

  • Training was provided for all staff to ensure they were competent and effective in their roles. Sufficient numbers of nursing staff were provided and maintained to ensure that the department operated smoothly and safely.

  • The outpatient and diagnostic imaging services incorporated relevant and current evidence-based best practice guidance and standards. Any new procedures or treatments to be delivered had to be agreed by the medical advisory committee.

  • People’s consent to care and treatment was sought in line with legislation and guidance. We observed written consent was sought, and records placed in patients’ records.

  • We received positive feedback about staff and services from all of the patients we spoke with. Patients were treated with respect and shown kindness by all staff when they visited the outpatient clinics.

  • The needs of the local population were considered in the development of services provided by Tetbury Hospital. The hospital worked in collaboration with the commissioning groups and liaised with the NHS trusts that provided services to the local community.

  • People had timely access to initial assessment and diagnosis and waiting times for referral to treatment were consistently below the NHS England target of 18 weeks. The hospital was achieving 100% compliance with the government target of 31 days for patients, from having a cancer diagnosis until the start of their treatment.

  • Clear information was provided to patients about how to make a complaint or raise a concern. The hospital had received few complaints but had responded to them all within their given timescale.

  • There was an effective governance structure in place to support the delivery of good quality care in the outpatients department. Staff were aware of their responsibilities and their roles and who they were accountable to.

  • The hospital had reviewed and rewritten all its policies since 2013, with many being reviewed annually since then.

  • There were effective arrangements for identifying recording and managing risks. There was a risk register in place for the outpatient department area which was maintained and updated by the manager.

  • The hospital actively sought the views of patients and staff about the quality of the service provided. Opportunities were available for patients and staff to comment on all aspects of the care and treatment provided.

Surgery

Good

Updated 29 March 2017

We rated surgery as good overall because:

  • There were no surgical site infections from April 2015 to March 2016. During the same period there were no incidences of methicillin resistant Staphylococcus aureus (MRSA) or clostridium difficile.

  • The hospital reported no never events or serious untoward incidents.

  • There were low levels of staff sickness and staff turnover.

  • The hospital reported no safeguarding concerns.

  • The hospital had a low rate of unplanned patient transfers to other hospitals and there were no unplanned patient readmissions.

  • Medical staff were checked for their fitness to practise.

  • Staff were encouraged and supported to undertake training relevant to their role.

  • Staff worked together to assess, plan and deliver care and treatment. They treated patients with kindness, dignity and respect and recognised when patients were anxious and provided them with reassurance.

  • Patients with complex needs were assessed and plans were made for them prior to their admission.

  • Patient care records were always available.

  • Care was responsive and met the needs of the local population. Information about the local population was used to inform how services were planned and delivered.

  • Targets for referral to treatment times for NHS patients were always met from April 2015 to March 2016. Staff managed admission times to ensure patient waiting times were kept to a minimum.

  • There was a programme of clinical audit and governance.

  • Complaints were investigated. Actions were taken and lessons learned as a result of complaints.

  • Leaders were approachable and visible.

  • The hospital had a clear vision and set of values.

However:

  • Cleaning schedules, fridge temperature and daily equipment checks were not always recorded as complete.

  • Emergency drugs were not tamper-evident.

  • The day surgery unit did not have piped oxygen.

  • The hospital did not participate in national audits regarding patient outcomes.

  • The hospital had not adapted guidance on quality standards for sepsis screening and management. There was no policy regarding sepsis.

  • Patient allergies were not always recorded on prescription charts.

  • There was poor compliance with some mandatory training.

  • The hospital did not have a supply of blood products for use in an emergency.

  • Not all risks were identified on the risk register such as such as the lack of piped oxygen and emergency blood provision.