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Inspection carried out on Announced: 27 - 29 September 2016 Unannounced: 5 October 2016

During a routine inspection

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 carried out on 10 December 2013

During a routine inspection

The focus of this inspection was the Acute Assessment Unit (AAU) of The Wellington Hospital. We visited the AAU, ITU (South) and the imaging department.

We spoke with patients and relatives of people using the service. Overall they were very happy with the quality of the care and treatment provided by the service. They were complimentary about staff and the information and care they had received. One person said "there were no surprises and everything went as planned", others described staff as "very helpful, pleasant and professional" and "they had nothing but praise for staff".

Interpreters were available daily to assist with discussions about care and treatment. People's privacy and dignity was maintained and they were encouraged to be involved in making their own decisions about treatment. There were effective systems in place for the safe care of people including warning scores, risk assessments and training for staff so that they could manage a medical emergency with suitable, checked equipment. Staff were well trained with processes for induction, supervision and appraisal.

The provider had systems to monitor the quality of the service provided and we saw evidence that incidents were fully investigated. People's feedback was requested and the hospital reviewed this and acted upon it to improve the service.

Inspection carried out on 8 January 2013

During a routine inspection

Patients told us that staff only delivered care activities that they gave them permission to carry out. Patients signed consent forms before surgical procedures were carried out.

Records showed that patients had risk assessments. These covered nutrition, falls, infection control and manual handling. Each patient had a care plan based on their individual needs. One patient said that staff were “very nice’’ and “they treat me like an individual’’.

Signs with information about infection control were displayed for staff and visitors. There were adequate hand washing facilities and alcohol hand rubs for use by staff and visitors. The areas we visited were clean and well maintained.

Each unit had a stock list of medicines and any over supply were disposed of by the pharmacists and pharmacy technician. Stock medicines were reviewed and adjusted as necessary. Controlled drugs were kept locked and were checked and signed for by two nurses at all times.

Staff told us that the current staffing ratio on the areas we visited were good. Managers had robust systems in place to ensure that staff shortages were identified early in order to prevent the units from being understaffed.

Patient satisfaction surveys were carried out and we saw the outcome of these. Clinical audits were regularly carried out on the units. On the acute neurological rehabilitation unit clinical audits were monitored and staff were given feedback about their outcomes.

Inspection carried out on 28 May 2012

During an inspection to make sure that the improvements required had been made

We did not speak to patients on this occasion because this inspection was to follow up outstanding actions. We did speak to patients during our initial visit in February 2012, who told us that the hospital was always clean and well maintained.

Inspection carried out on 21 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 9 February 2012

During a routine inspection

Patients are given adequate information about the hospital and its services.

Patients feel involved in their care and staff spend adequate time with them. Patients feel safe in the hospital and are treated with dignity and respect.

Reports under our old system of regulation (including those from before CQC was created)