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Inspection Summary


Overall summary & rating

Good

Updated 13 February 2017

Services we rate

We rated this hospital as Good overall. Below is a summary of reasons broken down by core service.

Overall we rated the medical care as good because:

  • There were clear systems to manage a deteriorating patient and patient risks were appropriately identified and acted upon.

  • Medicines were stored appropriately, with a separate locked cupboard for controlled drugs. Fridge temperatures were checked daily.

  • Staff were encouraged to report incidents and we saw evidence of learning taking place as a result of incidents.

  • An experienced team of consultants and nurses delivered care and treatment based on a range of best practice guidance.

  • There was good access to seven-day services and the unit had input from a multidisciplinary team. Staff managed pain relief effectively and monitored patients’ nutrition and hydration needs closely.

  • Staff at all levels had a good understanding of the need for consent and systems were in place to ensure compliance with the Deprivation of Liberty Safeguards.

  • The endoscopy unit was Joint Advisory Group (JAG) accredited.

  • The acute neurorehabilitation unit was CARF (Commission on Accreditation of Rehabilitation Facilities) accredited.

  • Readmissions for oncology patients undergoing treatment were triaged through the acute assessment unit using the UKONS tool kit.

  • Staff treated patients with respect and we saw staff interacting in a friendly and professional way with patients and their families.

  • The medical services in each area provided compassionate care and staff ensured patients were treated with dignity and respect at all times. Many staff signed up to the hospital ‘Dignity Pledge’.

  • Patients spoke positively about the care they received and the attitude of motivated and considerate staff and were satisfied with the care they received.

  • Access and flow was clear, there was no waiting list for chemotherapy and no problems with bed availability.

  • All staff had good understanding of meeting the needs of patients living with dementia and patients with learning disability.

  • There were good governance structure within the hospital and interlinked with medical services.

  • Staff felt their contribution was valued and the morale was high in each area we visited.

However,

  • The quality of the documentation could be improved as there were no documentation of MDT discussion in any records, entries were not clearly signed and dated and resuscitation forms were not completed in full.

Overall we rated surgical services as good because:

  • All staff showed in depth awareness of the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLs) and were aware of the processes in place if their patient needed to be restrained.

  • The service boasted outstanding cutting edge technology and had plans to ensure the technology they used within surgeries was cutting edge.

  • Staff understood how to report incidents on an online system and the service ensured that learning was disseminated to all staff.

  • The service was clean, well-organised and free from clutter.

  • We found there to be a sufficient number of staff including nurses, surgeons and resident medical officers. There was 24 hour, seven-day resident medical officer cover for wards.

  • Automatic alerts were sent to the outreach team if a patient’s observations were deteriorating via the electronic National Early Warning Score tool (NEWS).

  • Care was evidence based and based on national guidance from the National Institute for Health and Care Excellence (NICE) and the Royal Colleges. The service also had a programme of annual local audits.

  • The service maintained good clinical outcomes for patients.

  • The surgical service provided a caring, kind and compassionate service which involved patients in their care. All the feedback from patients and their relatives were positive.

  • There was an effective system of clinical governance and risk registers were up to date and proactively managed. Learning from risk issues was disseminated to staff and staff understood their role within the hospital.

  • All complaints were dealt with in an efficient manner within the provider mandated timeframe.

However

  • None of the consultants we observed adhered to the Bare Below the Elbows Policy.

  • Not all patient records were locked away.

  • Not all equipment was in date and safety tested.

  • Electronic risk assessments were not made available in paper form in the patient notes.

  • There was no clear vision for the surgery services that could be embedded into practice.

Overall we rated critical care services as good because:

  • All incidents had been investigated by an appropriate member of staff and had a clear outcome with learning identified.

  • Controlled drugs (CDs) were stored and managed appropriately and met the standards of clinical guidance 46 of the National Institute of Health and Care Excellence.

  • The critical care outreach team (CCOT) used a live electronic system to monitor patients across the hospital, alerting them to patients who were deteriorating enabling them to respond rapidly.

  • At the time of our inspection, 100% of critical care staff were up to date with mandatory training.

  • Staffing levels met the guidance the Intensive Care Society (ICS) core standards for intensive care units.

  • Critical care contributed to the Intensive Care National Audit and Research Centre (ICNARC) case mix programme.

  • An acute pain team and consultant pain specialist was available Monday to Friday and a pain control nurse was available 24-hours, seven days a week.

  • The service was benchmarked against the national Intensive Care Society (ICS) core standards for intensive care and against other similar units within the provider’s network.

  • We found good MDT working throughout the service.

  • We observed that patients were involved in discussion and decisions about their care and treatment.

  • Less than 0.5% of patients experienced an out of hours discharge or a discharge delayed between four hours and 12 hours. Less than 0.2% of patients experienced a discharge delay of over 24 hours.

  • The service used an ‘Eye Gaze’ system enabling patients with very restricted physical and communicative capability to form messages to staff.

  • Between April 2016 and October 2016, there had been no formal complaints.

  • We saw evidence that there was effective governance in place and the service’s management took an active stance to governance, risk management and quality measurement.

However;

  • Staff inconsistently documented fire escape checks on the south unit. For example, in September 2016 only two out of four weekly checks were documented and between June 2016 and August 2016 eight out of 13 checks were documented.

Overall we rated the outpatients and diagnostic imaging services which included paediatric services as good because:

  • There was a genuinely open culture in which all safety concerns raised by staff and people who use the service were highly valued as integral to learning and improvement.

  • Outpatient and diagnostic imaging areas were clean and equipment was well maintained. Staffing levels were as planned for safe care. Patient records were available for appointments.

  • Staff told us there were good opportunities to develop their skills and knowledge further with access to internal and external courses.

  • Patients told us and we observed that staff were caring, compassionate, and treated patients with dignity and respect. Patients told us they felt informed about their treatment and had been involved in decisions about their care.

  • Patients were able to access services in a way and at a time that suited them. We saw examples where care had been individually tailored to patients.

  • There were effective governance processes in place. Staff worked well together in teams, and were positive about the leadership of the service at both local and senior level. There was an open culture and staff were encouraged to make suggestions to improve services for patients. There was a clear proactive approach to seeking out and embedding new and more sustainable models of care.

Services we do not rate

We do not currently have a legal duty to rate termination of pregnancy or the regulated activities they provide but we highlight good practice and issues that service providers need to improve.

We found the following areas of good practice:

  • There were systems in place to ensure both the reporting of incidents and the sharing of lessons learned from these across the hospital were effectively managed. Staff were aware of their responsibilities with regards to duty of candour requirements, confirming there was an expectation of openness when care and treatment did not go according to plan. The governance structure provided accountability and oversight of risk.

  • Infection prevention and control (IPC) measures ensured that both the ward and mezzanine theatres were clean and suitable for purpose. The service was well-organised and free from clutter.

  • Medicines were managed and stored appropriately. Pain relief medications were employed post-procedure to manage patient’s symptoms.

  • Documentation was concise and clear. We saw evidence that legislation relating to the termination of pregnancy (TOP) was followed in all cases examined.

  • Nursing staff demonstrated an awareness of safeguarding procedures and how to recognise if someone was at risk or had been exposed to abuse. They knew how to escalate concerns and were up-to-date with appropriate levels of training.

  • Patients were assessed for a variety of risks on admission to the wards, using nationally recognised tools. Automatic alerts were sent to the outreach team if a patient’s observations were deteriorating via the electronic National Early Warning Score tool (NEWS). Appropriate procedures were taken post-procedure to ensure that patients were safe prior to discharge from the hospital.

  • Nursing staffing and medical levels in the ward and mezzanine theatre were sufficient for staff to perform their roles. There was 24 hour, seven-days a week, resident medical officer cover for the ward.

  • Hospital policies were current and appropriately referenced relevant national guidance. These were regularly reviewed and updated, including the TOPS policy.

  • Patients were given verbal and written information on what to expect following a TOP procedure. Patients were able to contact the ward 24/7 after discharge for support or advice. Counselling was available to all patients before, during and after they had received treatment.

  • Nursing and medical staff completed a variety of local audits to monitor compliance and improvement. The specialist nurse audited records of all TOP procedures to ensure that all Department of Health Required Standard Operating Procedures (RSOPs) were met.

  • All relevant professionals were involved in the assessment, planning and delivery of patient care. Staff reported that they felt valued as a member of the multidisciplinary team (MDT). All staff participated in annual appraisals.

  • Consent and capacity were considered by nursing staff when a patient was admitted for a TOP procedure. All staff demonstrated an awareness of the Mental Capacity Act (MCA) and its implications.

  • Patient’s privacy was maintained throughout their stay, as they were admitted to single occupancy rooms. Feedback from patients about the ward where TOP patients were cared for was consistently positive.

  • All patients referred to the service received timely treatment.

  • Translation services were readily available for those who first language was not English.

  • Patients were given sufficient information to make an informed choice about the sensitive disposal of pregnancy remains. Appropriate storage arrangements were in place.

  • Hospital-wide processes ensured that any complaints would be reviewed and responded to appropriately.

  • The hospital had developed a clinical vision and strategy and communicated this to staff at all levels. Nursing staff reported that their line managers and the senior team were supportive and approachable. All staff we spoke with told us they felt able to raise concerns.

However, we also found the following issues that the service provider needs to improve:

  • In the recovery area of mezzanine theatres, we found equipment that was out of date and some equipment was not safety tested.

  • Not all staff had attended recent additional training in women's health. Only 55% of staff on 4th floor south ward had attended the women’s study days in either April or September 2016.

Inspection areas

Safe

Good

Updated 13 February 2017

We rated safe as good because:

  • Between April 2015 and October 2016 there were no never events in the hospital. We found there were systems in place to report safety incidents and near misses. Learning from incidents that occurred was shared across the service. Staff were aware of their responsibilities with regards to duty of candour.

  • The medical governance committee and medical advisory committee reviewed every patient death. In addition, morbidity and mortality (M & M) meetings were held where a patient death was unexpected or where clinicians felt there was learning to be made.

  • There were clear systems to manage a deteriorating patient and patient risks were appropriately identified and acted upon.

  • There was a 24/7 pharmacy team with out of hours provisions in place.

  • There were adequate processes in place to identify and reduce the risks associated with surgical procedures. The service complied with the World Health Organisation (WHO) Surgical Safety Checklist in theatres.

  • We found staffing levels and skill mixes were planned, implemented and reviewed to keep people safe at all times across the hospital. Any staff shortages were responded to quickly through the appropriate use of bank and agency staff.

  • Patients were assessed for a variety of risks on admission to the wards, using nationally recognised tools. Appropriate procedures were taken post-procedure to ensure that patients were safe from avoidable harm.

  • Staff had awareness of what actions they would take in the event of a major incident, including a fire.

However,

  • The quality of the documentation could be improved as there was no documentation of MDT discussion in some records we looked at, some entries were not clearly signed and dated and resuscitation forms were not completed in full.

  • Very few consultants we observed adhered to the “Bare below the elbows” policy.

  • Not all patient records were locked away.

  • Not all equipment was in date and safety tested.

  • Electronic risk assessments were not made available in paper form in the patient notes.

  • We saw some hand hygiene practices which were not in line with hospital policy or best practice when caring for patients with specific infections.

Services we do not rate

We do not currently have a legal duty to rate termination of pregnancy, we found the following areas of good practice:

  • Although no incidents had been reported for termination of pregnancy services (TOPS) in the year previous to the inspection, we found there were systems in place to report safety incidents and near misses. Learning from incidents that occurred in other departments was shared across the service. Staff were aware of their responsibilities with regards to duty of candour.

  • Infection prevention and control (IPC) measures ensured that the environment was clean and suitable for purpose.

  • Medicines were managed and stored appropriately.

  • Patients were assessed for a variety of risks on admission to the wards, using nationally recognised tools. Appropriate procedures were taken post-procedure to ensure that patients were safe from avoidable harm.

  • Nursing staff demonstrated an awareness of safeguarding procedures and how to recognise if someone was at risk or had been exposed to abuse. They knew how to escalate concerns and were up-to-date with appropriate levels of training.

  • Nursing and medical staffing levels in the ward and mezzanine theatre were sufficient for staff to perform their roles relating to TOP procedures.

  • Staff had awareness of what actions they would take in the event of a major incident, including a fire.

However:

  • In the recovery area of mezzanine theatres, we found equipment that was not safety tested.

Effective

Good

Updated 13 February 2017

We rated effective as good because:

  • Hospital policies were current and appropriately referenced relevant national guidance.

  • Patients were cared for by appropriately qualified staff who received an induction to their department and achieved specific competencies before being able to care for patients independently. Medical staff received regular training as well as support from consultants.

  • Bank and agency staff competence was also assessed regularly and they had appropriate clinical qualification.

  • Staff at all levels had a good understanding of the need for consent and systems were in place to ensure compliance with the Deprivation of Liberty Safeguards.

  • Care was evidence based and based on national guidance from the National Institute of Clinical Excellence (NICE) and the Royal Colleges. The hospital had a programme of annual local audits.

  • The hospital had a pain clinical nurse specialist (CNS) in post that worked alongside the pain team and reviewed patients every day.

  • There was evidence of good multidisciplinary team working across all staff groups.

  • Most services were available 24 hours 7 days a week, with the exception of Outpatients.

  • New evidence-based techniques and technologies were used to support the delivery of high quality care. We saw that opportunities to participate in benchmarking, peer review, accreditation and research was proactively pursued by staff.

  • The continuing development of staff skills, competence and knowledge is recognised as being integral to ensuring high quality care.

Services we do not rate

We do not currently have a legal duty to rate termination of pregnancy, we found the following areas of good practice:

  • Hospital policies were current and appropriately referenced relevant national guidance. These were regularly reviewed and updated, including the TOPS policy.

  • Patients were given verbal and written information on what to expect following a TOP procedure. Patients were able to contact the ward 24/7 after discharge for support or advice. Counselling was available to all patients before, during and after they had received treatment.

  • Nursing and medical staff completed a variety of local audits to monitor compliance and improvement. The specialist nurse audited records of all TOP procedures to ensure that all Required Standard Operating Procedures (RSOPs) were met.

  • Pain was assessed and well managed on the ward, with appropriate actions taken by staff to keep patients comfortable.

  • Care was delivered by a range of skilled staff who participated in annual appraisals.

  • All relevant professionals were involved in the assessment, planning and delivery of patient care. Staff reported that they felt valued as a member of the multidisciplinary team (MDT).

  • Consent and capacity were considered by nursing staff when a patient was admitted for a TOP procedure.

However:

  • Only 55% of staff on 4th floor south ward had attended the women’s study days in either April or September 2016.

Caring

Good

Updated 13 February 2017

We rated caring as good because:

  • All staff we observed treated patients with respect and we saw staff interacting in a friendly and professional way with patients and their families.

  • All patients we spoke with explained positively about the care they received and the attitude of motivated and considerate staff and were satisfied with the care they received.

  • Patients and their relatives and families were kept informed of on-going plans and treatment. They told us that they felt involved in the decision making process and were given clear information about their treatment.

  • Staff maintained patient privacy and staff demonstrated dignity was a high priority by signing up to the hospital’s dignity pledge.

  • Patients had access to a neuro-psychologist and health psychologist to meet their mental health needs. This team also worked closely with therapies staff to ensure patient’s emotional needs were met. Patients also had access to other complimentary therapies such as; reflexology and aromatherapy.

  • Patient’s social needs were understood and patients were supported to maintain and develop their relationships with those close to them, their social networks and community.

  • Appropriate information was provided on discharge and patients had access to 24-hour advice, should they need it.

Services we do not rate

We do not currently have a legal duty to rate termination of pregnancy, we found the following areas of good practice:

  • Patient’s privacy was maintained throughout their stay, as they were admitted to single occupancy rooms. The records we reviewed indicated that staff had a good awareness of ensuring patients’ dignity was maintained whilst providing them with care and treatment.

  • Feedback for the ward where TOP patients were cared for was of a consistently positive.

  • Patients were provided with emotional support by nursing staff and had access to an independent counsellor. Appropriate information was provided on discharge and patients had access to 24-hour advice, should they need it.

Responsive

Good

Updated 13 February 2017

We rated responsive as good because:

  • There were clear admission pathways for patients to access the medical services.

  • Access and flow was clear, there was no waiting list for chemotherapy and no problems with bed availability.

  • All staff had good understanding of meeting the needs of patients living with dementia and patients with learning disability.

  • The neuro-rehabilitation unit exceeded in meeting their patient’s individual need.

  • The service was responsive when planning services to meet the needs of patients.

  • The admission and discharge processes were clear and thorough.

  • The hospital took progressive and innovative steps towards ensuring that their patients were assisted in their individual needs.

  • There was an effective complaints process, with evidence of appropriate investigations and there was culture of learning from complaints across all areas.

  • Complaints were dealt with in a timely manner in accordance with the provider policies and met the hospitals’ timeline target.

Services we do not rate

We do not currently have a legal duty to rate termination of pregnancy, we found the following areas of good practice:

  • Patient flow was well considered in relation to TOP procedures. All patients referred to the service received timely treatment. There were robust admission and discharge processes in place to support patients throughout their hospital journey.

  • Patients were given sufficient information to make an informed choice about the sensitive disposal of pregnancy remains.

  • There were no recent complaints relating to TOPS but there was hospital-wide processes ensured that any such complaints would be reviewed and responded to appropriately.

Well-led

Good

Updated 13 February 2017

We rated well-led as good because:

  • We saw good senior and local leadership. Staff across the service enjoyed working at the hospital. They described an open culture and felt supported by their immediate and hospital management teams.

  • Staff felt their contribution was valued and the morale was high in each area we visited.

  • The management team had oversight of the risks within the services and mitigating plans were in place.

  • Senior management and divisional managers were visible on wards

  • There was an effective system of clinical governance and risk registers were up to date and proactively managed. Learning from risk issues was disseminated to staff and staff understood their role within the hospital.

  • The hospital gathered patients’ views using patient feedback surveys. We saw that results were analysed and service improvements were made as a result.

  • The leadership drives continuous improvement and staff are accountable for delivering change. Safe innovation is celebrated. There was a clear proactive approach to seeking out and embedding new and more sustainable models of care.

However:

  • We found through staff interaction there was no clear vision for the surgery services that could be embedded into practice.

Services we do not rate

We do not currently have a legal duty to rate termination of pregnancy, we found the following areas of good practice:

  • The hospital had developed a vision and strategy and communicated this to staff of all levels, enabling them to feel invested in the development of the service.

  • The service ensured that all patients admitted for a TOP procedure had the correct documentation in place. The governance structure provided accountability and oversight of risk.

  • Nursing staff thought that their line managers and the senior team were supportive and approachable. Executive and divisional leads held regular meetings to facilitate staff engagement.

  • There was an open culture and staff felt able to raise any concerns.

Checks on specific services

Medical care (including older people’s care)

Good

Updated 13 February 2017

Medical care was the main activity of the hospital.

The medical specialities were located in three buildings (south, north and the platinum medical centre).

As part of this inspection End of life care  was also reviewed and is included in this report as the numbers of patients receiving end of life care at the hospital was low.

We rated this service as good because it was safe, effective, caring, responsive and well-led. 

Critical care

Good

Updated 13 February 2017

The hospital has two critical care units in two separate buildings. The north building has a 15-bedded intensive care unit for level 3 care and the south building has a nine-bedded intensive care unit for level 3 care and a seven-bedded high dependency unit for level 2 care.

The south unit has two negative pressure rooms with linked anterooms.

We rated this service as good because it was safe, effective, caring, responsive and well-led.

Outpatients and diagnostic imaging

Good

Updated 13 February 2017

The Outpatient department  provided facilities for consultants with practising privileges to assess and examine patients and to provide clinical areas where minor procedures can be undertaken. The outpatient department was situated within the Platinum Medical Centre (PMC).

Outpatient diagnostic imaging was mainly conducted from the PMC. Inpatient imaging was provided from the South building. In the North building there were outpatient therapy services which included; physiotherapy, occupational therapy and speech and language therapy.

As part of this inspection Children and young persons services were also reviewed and is included in this report as the numbers of patients receiving this service at the hospital was low and only restricted to outpatients. The service is supported by a Paediatric Lead Clinical Nurse Specialist and paediatric staff nurses.

We rated this service as good because it was safe, effective, caring, responsive and well-led.

Surgery

Good

Updated 13 February 2017

Surgical care was a large service for the hospital with 12 operating theatres. 

The main three surgical procedures are orthopaedics, general surgery and cardiac interventions.

The surgical services were located in three buildings (south, north and the platinum medical centre).

We rated this service as good because it was safe, effective, caring, responsive and well-led. 

Termination of pregnancy

Updated 13 February 2017

We do not currently have a legal duty to rate this service or the regulated activities it provides but we highlight good practice and issues that The Wellington Hospital needs to improve.