St Mary's Hospital

The Isle of Wight NHS Trust is an integrated trust. Services are provided to a population of approximately 140,000 people living on the Island, there is significant increase in population during holiday and festival seasons. St Mary’s Hospital in Newport is the trust’s main base for delivering acute services for the Island’s population.

The hospital has 246 beds and handles 22,685 admissions each year. Services include urgent and emergency care, medicine and surgery, intensive care, maternity services, services for children and young people, neonatal intensive care unit and outpatient services, including planned care such as chemotherapy.

We carried out this short notice inspection of the Isle of Wight NHS Trust to follow up on some areas that we had previously identified as requiring improvement or where we had questions and concerns that we had identified from our ongoing monitoring of the service or if we had not inspected the service previously. We inspected three of the eight core services urgent and emergency care, medical care (including older people’s care), and end of life care. We undertook site visits 22- 24 November 2016.

We did not inspect surgery, critical care, maternity& gynaecology, services for children and young people, or outpatients& diagnostic imaging. For information on these services please see the inspection report published in August 2014.

Overall we rated urgent and emergency care as requires improvement, medical care (including older people’s care) as inadequate and end of life care as requires improvement. Services were caring but the safety of urgent and emergency care and medical care was inadequate as were responsive and well led services for medicine.

• The trust had a system in place for reporting and recording incidents. However, learning and action points were not disseminated to ward staff. Systems and processes were not always reliable and appropriate to keep patients safe. There were a significant number of open incidents which required investigating

• The hospital experienced difficulty meeting the demand for its medical services. Patient moves occurred frequently including at night. This can be confusing for patients and there is a risk of placing patients at risk. The use of escalation beds means single sex accommodation was not always being provided and neither was this being reported and monitored. End of life care patients were also moved for non-clinical reasons which resulted in lack of continuity of care for patients.

• Medical staffing levels did not meet national guidance. At less than 16 hours cover per day the medical consultant cover in the emergency department was below recommendations from the Royal College of Emergency Medicine.Consultant in the emergency department did not have sufficient time to supervise the education of junior medical staff. There was insufficient medical cover across medical services, particularly out of hours this included a shortage of older people medicine consultants and medical cover for the end of life care service was not as expected. A specialist palliative care service was not available seven days a week, telephone advice was available.

• The emergency department did not meet minimum registered nursing levels for safe care, with no evidence of how staffing was managed to meet fluctuations in demand. There was 16 hours of children nurse cover per week which did not meet the current recommendations of one children nurse per shift. In the medical service there was a significant shortage of nursing staff.

• The children’s waiting room which was also used as a mental health assessment room but did not provide a safe environment.

• Medicines were not always stored safely and securely and good infection control practices were not consistently adhered to.

• Ineffective systems of risk identification and management meant that opportunities to prevent or minimise harm were missed.

• It was not clear whether staff had completed mandatory training on end of life care and mandatory training data was not provided by the trust for all specialities.Where information was provided the up take was low. Therefore we were not assured regarding what training was provided or when staff attended. There was insufficient medical staff in the emergency department with child safeguarding level 3 training.

• Staff in some areas reported that they had received an appraisal, however we did not receive supporting information from the trust across all areas. Where we did receive information the appraisal rate was low, for one ward this was zero. Not all staff in the coronary care unit had the appropriate training and none had been competency assessed. Staff had limited awareness and a lack of knowledge in managing the process of deprivation of liberty safeguards.

• Medical records were not always secure and confidential patient information was compromised. A significant number of Do Not Attempt Cardio Pulmonary Resuscitation’ (DNACPR) forms were not completed according to national guidelines.

• There were not robust processes to facilitate rapid discharge of patients at the end of their life and most patients were not transferred to their preferred place of death. Staff did not take extra care to ensure continued levels of privacy, dignity and compassionate carefor the patients and families and friends when approaching the of their life and a side was not available.

• Staff were not aware of how the trust was implementing the action plan as a result of the End of Life Care - Dying in Hospital Audit 2016 or how the end of life care strategy was to be implemented.

• The governance structure was not efficient. Meetings took place but outcomes and action plans were not joined up. The quality, risks and performance issues within end of life care were not monitored through the executive governance framework. In the medical service the governance processes were not effective at assessing or monitoring systems to improve the safety and quality of the services provided. There was not a robust local clinical audit plan in place in the emergency department to drive improvements to quality and performance. They also performed poorly in a number of the national audits they participated in.

• In the emergency department the governance structure did not provide a clear route to escalate issues of concern and there was no evidence that senior trust managers took account of the views of frontline staff. In the medicines service staff was discouraged from raising concerns and there was a blame culture. Staff did not feel engaged with and described the culture in the organisation as leading to integrated working.

• The trust did not have a robust system for handling, monitoring complaints and concerns. Response to formal complaints did not meet NHS Complaints Policy July 2016 standards. Learning was not consistently shared across the organisation.

• Staff had access to a wide range of clinical guidelines based on, for example, on the National Institute for Health and Care Excellence (NICE) and the Royal College of Emergency Medicine (RCEM) to ensure care and treatment was evidence based. However, we observed care did not consistently take account of evidence based practice and guidance, and clinical pathways were not always implemented fully. For example, priorities of care plans were not routinely completed for patients nearing the end of their life.

• In general staff treated people with compassion, kindness, dignity and respect. Feedback from patients and their families was positive.

• Staff felt supported and displayed resilience through team working and support from their department leaders.

• The trust ran a ‘carers are welcome here campaign’. This meant a carer was welcome to visit the hospital whenever they wanted to.

• The stroke lead nurse had developed same day access to scanning and Doppler tests to diagnose and treat patients promptly

• The trust had a protocol for the prescribing of anticipatory medicine for patients receiving end of life care and pain relief as available.

There were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

• There are 16 hours of cover by consultant grade staff in the emergency department daily.
• There is sufficient nursing staff on duty at all times in all areas calculated through use of a recognised staffing and acuity tool.
• Arrangements for staffing (nursing and medical) for the paediatric emergency department are urgently reviewed to ensure sufficient trained paediatric cover.
• All medical staff receive safeguarding children level 3 training.
• The medical rota supports junior medical staff receiving education as required by their training placements.
• There is a room in available for ED staff to assess patients in mental health crisis that does not compromise the safety of the patients or staff.
• The environment to see and treat children, including the children’s waiting area meets the requirements of the ‘Standards for Children and Young People in Emergency Care Settings’ by the Royal College of Paediatrics.

• Governance, risk management and quality measurement including the undertaking of audits is reviewed, improved and embedded across all departments ensuring all risks are identified and managed effectively.

• Nursing staff in the coronary care unit have competencies to care for patients on bi-level positive airway pressure (BiPAP).

• All incidents are investigated in a timely way and lessons from incidents are shared with all staff.

• There is a sufficient and safe number of doctors working on the coronary care unit (CCU) at all times.

• Single sex accommodation requirements for patients are maintained and any breaches are reported in a timely way.

• Staff identify patients who may need consideration of Deprivation of Liberty Safeguards (DoLS).

• Daily documented checks on each resuscitation trolley are complete.

• Intravenous fluids are stored in a locked room to prevent access to members of the public.

• Mandatory training rates for life support training and moving and handling improves to achieve the trust target.

• Complaints and concerns from patients are investigated and responded to in a timely way and lessons learnt shared across the organisation.

• All staff have yearly appraisals that are meaningful to their professional development.

• Review information governance protocols to ensure that patient identifiable or confidential information is kept secure at all times.

• All patients nearing end of life are assessed and have an individualised end of life care plan. There are monitoring mechanisms in place to ensure risks to patients were assessed.

• Medical staffing levels meet national guidance for end of life care.

• Consultants undertake training in end of life care.

• Patient capacity is formally assessed and documented on the DNACPR form and the forms are completed in accordance with national guidelines.

• There are improved discussions with the family/friends regarding end of life care.

• End of life care patients are not moved for non clinical reasons.

• Patients are able to die in their preferred place of care. Thereis a robust rapid dischargesystem in placefor end of life care patientsandthis is monitored

• Suitable arrangements are in place to identify, assess and manage risk in end of life care services, through actively reviewed risk register.

• The quality, risk and performance issues within end of life care are monitored and improved through the executive governance framework.

In addition the trust should:

• Review the pathways and care for children in the emergency department to ensure that their needs are met.
• Reviewing the process of flow through the emergency department and develop a strategy to engage clinicians and teams across the trust to improve flow through ED and the hospital.
• Should find a safe area for patients with a mental health condition to wait for their assessment.
• Should consider the purchase of an additional drug dispensing machine for the minors area, or manage the risks to minimise delays to administrating medicines for the patients when required.
• Should consider the development of a program of teaching sessions in-house to minimise long waits for phlebotomy, cannula insertion and IV drug administration training for nurses.

• Review protocols for the prescribing and administration of oxygen to patients. Ensuring the oxygen is prescribed prior to administration.

• Review the out of hours service provision at weekends for the medical service, ensuring that the risks of reduced services are managed.

• Review infection control practices for patients in isolation, ensuring that infection control protocols are adhered to.

• Reduce the number of bed moves after 10pm, and reduce the number of total moves per patient.

• The trust should provide training and access to the medicines systems for trust staff who work on the wards.

• Develop and implement an action plan for clear leadership to manage the frail, elderly patient pathway.

• Review the clinical hand wash basin provision in the sluice in Colwell ward to comply with infection prevention and control practices.

• Should assess and improve the discharge arrangements for patients from the hospital to the community or the patients home.

• Monitor the mandatory uptake of end of life care training across all specialities.

• Ensure staff are aware of how the trust is implementing the action plan as a result of the National End of Life Care Audit – Dying in Hospital, 2016, and their contribution to improvements.

• Ensure there is a review of how the trust meets the NHS Chaplaincy guidance.

• Further integrate the relationship between the trust and the hospice so it improves the planning of end of life care.

• Implement the AMBER care bundle across services.

• Where possible, provide side room for end of life care patients, and ensure that staff maximise patient privacy and dignity and comfort when nursed in a bay.

• Train appropriate ward staff on rapid discharge forms and monitor their use.

• Raise awareness with staff on how the end of life care strategy is to be implemented.

• Improve access to specialist palliative care service seven days a week.

Professor Sir Mike Richards

Chief Inspector of Hospitals