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This service was previously managed by a different provider - see old profile

We are carrying out checks at St Mary's Hospital using our new way of inspecting services. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Inadequate

Updated 6 June 2018

We did not rate acute services overall at last inspection in November 2016, as not all services were inspected.

At this inspection, our overall rating of acute services went down since inspection in 2014. There was minimal improvement and areas of deterioration across the three services inspected November 2016. We rated acute services as inadequate because:

  • There were significant concerns about safety across acute services and particularly emergency and urgent care, medicine, surgery and end of life care services, where we rated safe as inadequate. Safety systems, staffing and learning from when things go wrong also needed to improve across most other services including maternity, children and young people services and diagnostic imaging.
  • The effectiveness of medicine and end of life care service was inadequate with improvements also needed in emergency and urgent care, surgery and diagnostic imaging.
  • Emergency and urgent care, medicine, surgery, critical care and end of life care services were not sufficiently responsive to the needs of patients.
  • Leadership, management and governance needed significant improvement across acute services as not sufficient to delivery high quality care and the improvement. Well led was rated inadequate in emergency and urgent care, medicine and end of life care services. This also required improvement across most other services including surgery, maternity, children and young people services, outpatients, and diagnostic imaging.

However:

  • Overall, staff cared for patients with compassion, provided emotional support. They involved them and those close to them in decisions about their care and treatment
  • Critical care and outpatient services were rated good overall.
Inspection areas

Safe

Inadequate

Updated 6 June 2018

Effective

Inadequate

Updated 6 June 2018

Caring

Good

Updated 6 June 2018

Responsive

Requires improvement

Updated 6 June 2018

Well-led

Inadequate

Updated 6 June 2018

Checks on specific services

Outpatients and diagnostic imaging

Good

Updated 9 September 2014

There were effective procedures to support a safe service for patients. Staff were caring and treated patients with dignity and respect. Patients were seen within national waiting times and told us they were happy with the care they had received while attending their appointments within the outpatient department.

Most of the patients we spoke with felt they were seen promptly and were kept informed if clinics were running late. Each clinic had a board that displayed the length of time patients might expect to wait to be seen. The service was undertaking a review to improve its efficiency and responsiveness to the needs of the local population. The leadership of the service was good and there were examples of innovative practice to support people and improve treatment and diagnosis on the island.

Maternity

Requires improvement

Updated 6 June 2018

  • The mandatory training evidence supplied by the trust showed the staff had not completed all mandatory training. The uptake was low and this may put patients at risk of receiving outdated care and practices.
  • Emergency equipment was not regularly checked to ensure that these were safe, available and ready for use in an emergency.
  • The arrangement relating to the birthing pool had not been risk assessed and we were not assured that equipment, staff training and infection control processes were in line with guidelines to keep women safe.
  • Medicines were not checked regularly and this included control medicines.
  • Medical staff looking after babies had not completed the necessary safeguarding training and at the recommended level.
  • Infection control processes were not followed and system for identifying clean and dirty equipment was not adequate. Cleaning schedules were not available for the birthing pool and records of cleaning were not adequate to provide assurance.
  • There was not always adequately trained staff to provide care, guidance and support to other staff during the night and at the weekends.
  • There was a risk of unauthorised access to the maternity unit due to the lack of reception staff and there was no system to record visitors to the unit.
  • The five steps to safer surgery were used; however there was low compliance and this was not embedded in daily practice. This may pose risks of surgical errors as checks were not fully adhered to at each stage of procedures.
  • Nursing staff were confident in raising safeguarding concerns and had completed appropriate training to identify and report any safeguarding concerns. This was also considered as part of women’s assessment.
  • The environment was appropriate and there was a dedicated labour suite with level access to the operating theatre and the neonatal intensive care unit.
  • Staff did not receive regular supervision of their practice and the yearly appraisal rate was well below the trust’s target.

However:

  • Staff treated women with care, compassion and were respectful, ensuring their privacy and dignity was maintained at all times when receiving care.
  • Staff followed national guidelines and escalation tools were used for identifying deteriorating women and babies. This ensured that any changes in conditions are identified at an early stage and actions taken.
  • Policy and procedures for the management of sepsis were available to the staff and guidance was followed.
  • The unit had achieved baby friendly stage 1 for breastfeeding.
  • There was facility in the unit for bereaved women and they had support of a bereavement midwife based in the community.
  • Women received appropriate pain control of their choice during labour and they told us that their pain was well managed.
  • Women with low risk or uncomplicated pregnancies were offered midwife led care to have their babies at home or in hospital.
  • The governance arrangements were not well embedded and risks were not always identified in order for action plans to be developed and mitigate these.
  • The culture within the service was not supportive of staff to raise their concerns as staff felt they were not listened to.
  • There was no regular audit programme to identify trends in order to improve practices and the overall service delivery.
  • There was a lack of systematic approach to continually improve the service provision.
  • The unit was consultant led and midwives played an integral part in the management of women’s care. The unit had a consultant obstetrician as clinical lead.
  • There was a stable management team and staff were passionate about providing a service that met the needs of women.
  • Management team was working towards promoting home births and community based care and normalisation of childbirth.

Outpatients

Good

Updated 6 June 2018

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings.

On this inspection we rated the outpatients service as good because:

  • People who used the outpatient services were kept safe from avoidable harm because there were suitable arrangements to enable staff to identify and respond to risks.
  • There were sufficient numbers of staff, and they had been provided with safety training. Staff were further supported through service related policies and procedures in addition to evidence based professional guidance.
  • Feedback from people using outpatient services, and those close to them, was continually positive about the way staff treated them.
  • Services provided by the outpatient departments mostly reflected the needs of the local population.
  • Most patients were able to access the service in a timely way, with many specialties in line with or close to the national averages in waiting times.

However:

  • Outpatient services did not have clear, well-established and effective governance processes.
  • Outpatient services did not have clear and effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.

Maternity and gynaecology

Good

Updated 9 September 2014

Maternity services at St Mary’s hospital and in the community were well planned and organised. Midwifery staffing levels were below national recommendations but staff were working flexibly to ensure there were adequate numbers. There was recruitment to improve medical staffing level. Safety standards were followed and the environment was clean and the service was fully equipped.

Women’s care and treatment followed national evidenced based guidelines and staff were appropriately trained and worked well in multi-disciplinary teams. Women told us they received compassionate and supportive and supportive care and had choices and were involved in decisions about their care. Governance arrangement and risk management were effective and there was a leadership culture that promoted learning and continuous improvement.

Gynaecology

Requires improvement

Updated 6 June 2018

We previously inspected gynaecology jointly with maternity so we cannot compare our new ratings directly with previous ratings.

We inspected two domains only, as focused follow up to concerns, so cannot give an overall rating for this service

We rated safe as inadequate and well led as requires improvement

  • Systems in place did not always ensure patient safety. Some medical staff were not well engaged in the service and disregarded safety procedures. For example mandatory training levels did not all meet the trust target, the five steps to safer surgery World Health Organisation safety checklist was not always carried out properly and incidents were not routinely reported on the trusts electronic reporting system.
  • Equipment and consumables were not all within their expiry date and we were not assured the appropriate systems were in place to identify all equipment that needed servicing.
  • Staff generally spoke of positive relationships with their colleagues and managers. However, there were some difficult relationships with some members of staff that impacted on the wellbeing of their colleagues. The trust was aware of the issues and had implemented a number of strategies to improve working relationships.
  • Staffing levels in the gynaecology outpatients department had not been reviewed although the workload had increased in terms of extra and longer clinics. However staff worked flexibly and well together to ensure the workload was managed.
  • The gynaecology service did not have a systematic programme of clinical and internal audits to monitor quality and operational processes.
  • The trust had set up a new system for recording risks (November 2017) and the clinical business units managed their own risk registers. There were no gynaecology risks on the local risk register at the time of our inspection. Staff we spoke with were unclear about what was on the risk register and their role in adding to the register and mitigating risk.
  • We saw safety briefings were held across the gynaecology services their frequency was not consistent or to any particular template.

Medical care (including older people’s care)

Inadequate

Updated 6 June 2018

Our rating of this service stayed the same. We rated it as inadequate because:

  • The service was not consistently providing safe or effective care and treatment. Infection prevention and control practices put patients, staff and visitors at risk of cross infection. Staff did not always identify risks to patients, and where staff identified risks there was often lack of guidance about how to lessen the risk. Patient records had missing information. The records did not demonstrate staff always followed evidence based care pathways.
  • Within the medical staff, there was a lack of understanding about safeguarding and the Mental Capacity Act 2005 and associated Deprivation of Liberty Safeguards. Nursing staff did not always apply their understanding of the Mental Capacity Act 2005 into their practice.
  • There was a lack of assurance that staff had the necessary skill set to carry out their roles. There was an overall low rate of compliance with mandatory training and annual appraisals were below the trust target.
  • Staff did not consistently monitor and manage risks to patient safety and governance arrangements to identify shortfalls in performance were not yet robust. Opportunities to learn from audits, incidents and complaints were sometimes missed or there was delayed learning from them.
  • There were high vacancy rates in nursing and medical staff.
  • Staff and managers had not developed and implemented a strong vision and strategy for the service.
  • Despite some improvements in the culture, some staff still felt undervalued and disrespected. Some staff reported in some areas of the service there was still a culture of bullying.
  • The service was not fully developed to meet the needs of the local population. The individual needs of patients with dementia were not fully considered. There was no frailty pathway to address the needs of the growing elderly population of the island.

However:

  • The stroke unit and endoscopy unit used local and national audits to effectively monitor and improve their services.
  • The number of patients experiencing bed moves over night or experiencing multiple non-clinical bed moves during an admission had significantly decreased (improved).

There were some good examples of multidisciplinary working, including multidisciplinary board rounds and multi-agency ‘super stranded’ patient meetings. The introduction of a ‘navigator’ nursing team was supporting improved discharge processes.

Diagnostic imaging

Requires improvement

Updated 6 June 2018

  • The service did not always provided care and treatment based on national guidance and evidence of its effectiveness. The service did not follow the guidelines issued by the Royal College of Radiology on non-radiology clinicians reviewing images.
  • Learning from serious incidents was not shared with the whole team to minimise the potential for repeat occurrence, risking harm to patients. Staff were not using the three point identification procedure in daily practice.
  • Duty of Candour was not appropriately applied when incidents of patient harm occurred.
  • Staff did not undertake sufficient audits to demonstrate compliance with Ionising Radiation (Medical Exposure) Regulations 2000 (IR(ME)R)
  • There was a shortage of consultant radiologists which impacted on the quality of image reporting.
  • Insufficient numbers of staff had completed mandatory training, safeguarding training at the correct level, annual appraisals of their work, and the Mental Capacity Act 2005.
  • The waiting area in the main department was cramped and provided insufficient accommodation for the number of people using it.
  • The service had not always monitored the effectiveness of care and treatment in order to use the findings to improve care. Appropriate audits had not been done to ensure quality of practice was maintained.
  • The service did not manage complaints according to agreed timescales.

However:

  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness, and they were well informed about the procedures staff were performing.
  • The service worked well to provide a service to meet the needs of the island residents with extended working days and some walk in appointments.
  • Staff felt well supported by managers and were offered opportunities for further training and development.
  • The service leads were working towards Imaging Services Accreditation Scheme (ISAS), which is a structured approach to providing a high quality service, and will highlight the areas where the service can improve services and focus attention appropriately.

Urgent and emergency services (A&E)

Inadequate

Updated 6 June 2018

Our rating of this service went down. We rated it as inadequate because:

  • The service did not have enough nursing or medical staff, with the right mix of qualifications and skills, to keep patients safe and provide the right care and treatment.
  • Staff did not always complete and update risk assessments or safety checks for each patient. Triage assessments and monitoring of deteriorating patients were not carried out according to best practice.
  • Although staff recognised and reported individual safety incidents, there were few reports of near misses or safety incidents due to a shortage of staff or a crowded department. There was confusion about the number of serious incidents that had taken place in the department. Learning from incidents was not always shared or implemented.
  • The service did not make sure staff were competent for their roles. Managers did not appraise all staff’s work performance or hold supervision meetings with them to provide support and monitor the effectiveness of the service.
  • People could not always access the service when they needed it. Some patients spent many hours in the emergency department because of long delays to be admitted to a ward.
  • Managers did not have enough time or experience to run a service providing high-quality sustainable care. There had not been a matron for several months, there was only one sister and leadership support had only recently been provided by an interim head of nursing. Due to a shortage of consultants the clinical lead had had to prioritise clinical duties, leaving little time for governance or performance management responsibilities.

However:

  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • ED managers tried to promote a positive culture that supported and valued staff.

There had been improvements in recent months in the number of patients admitted or discharged within four hours. By December 2017 performance was similar to the England average.

Surgery

Requires improvement

Updated 6 June 2018

Our rating of this service went down. We rated it as requires improvement because:

  • The service was not providing safe or effective care and treatment. The service had not always adopted evidence-based guidance. Some standard operating procedures were not in place across the service and when guidance was revised it was not effectively communicated to staff.
  • Staff did not consistently monitor and manage risks to patient safety. The governance arrangements, to identify shortfalls in performance, were not robust. The systems to report and monitor the quality and safety of care and treatment were not applied accurately and opportunity for learning from audits and incidents was sometimes missed.
  • Known behavioural issues in theatres had not been addressed promptly. Some medical staff were not engaged in the service and disregarded safety procedures.
  • There were high vacancy rates in nursing, theatres and some key medical roles. There was a high dependence on agency and locum staff.
  • Although the leadership teams had started to identify and manage key service risks, this approach was not embedded.
  • Staff and managers had not developed and implemented a strong vision and strategy for the service.
  • Patient outcomes showed inconsistencies and, where outcomes were lower than expected, the service had not been swift in implementing improvements.
  • Patients experienced a higher proportion of cancelled operations than the England average and theatre utilisation rates were lower than target.

However:

  • Staff controlled infection risks well.
  • Staff were generally positive about the support they received from their line managers.
  • Patients said they received care from kind and compassionate staff, who, although busy, treated them with dignity and respect.
  • The service had implemented a winter plan in collaboration with the wider health economy

Intensive/critical care

Good

Updated 6 June 2018

Our rating of this service stayed the same. We rated it as good because:

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • The service controlled infection risk well.
  • Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary.
  • The service had enough nursing and medical staff, with the right mix of qualification and skills, to keep patients safe and provide the right care and treatment.
  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately.
  • The service followed best practice when prescribing, giving, recording and storing medicines. Patients received the right medication at the right dose at the right time.
  • Staff gave patients enough food and drink to meet their needs and improve their health.
  • Managers monitored the effectiveness of care and treatment and used findings to improve them. They compared local results with those of other services to learn from them.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They followed the trust policy and procedures when a patient could not give consent.
  • Staff cared for patients with compassion and provided emotional support to minimise their distress.
  • The service took account of patients’ individual needs.
  • People could access the service when they needed it.
  • Service leaders had the right skills and abilities to run a service providing high-quality sustainable care.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

However:

  • Patients stayed longer on this critical care unit than was always necessary meaning mixed sex accommodation requirements were not always met.
  • Seven day services were not fully established across all of the multi-disciplinary teams, although action had been taken which would develop the service to meet the seven day standard.
  • Not all GPIC standards had been met in full however there were mitigations and plans in place to address the shortfall.

Services for children & young people

Requires improvement

Updated 6 June 2018

Our rating of this service went down. We rated it as requires improvement because:

  • There was not enough nursing and medical staff with the right skill mix to provide safe care. The trust had reviewed staffing levels, and identified a shortage of medical and nursing staff. Recruitment to vacant posts was ongoing at the time of inspection. Nursing and medical staffing levels on the neonatal unit did not conform to the British Association of Perinatal Medicine (BAPM) standards and the overall medical staffing did not conform to the Royal College of Children’s and Child health (RCPCH).
  • Mandatory training rates for both medical and nursing staff were well below the trusts target of 85% in paediatric resuscitation, medicines management, new-born life support, Prevent training 1&2 and the mental capacity act.
  • Governance arrangements, to identify shortfalls in performance, were not robust. The systems to report and monitor the quality and safety of care and treatment were not applied accurately and opportunities for learning from audits and incidents were sometimes missed. The service did not appear to use a systematic approach to continually improving the quality of its services.
  • Policies on the intranet were not all up to date and in line with current National institute of clinical excellence (NICE) guidelines.
  • There were no available children’s development clinics on the Isle of Wight for the diagnosis and support of children requiring diagnosis of autistic spectrum disorders.
  • The Children and Adolescent mental health service (CAMHS) did not cover weekend and evenings, therefore children requiring a review before discharge would have extended stays in hospital.
  • Children could be exposed to inappropriate conversations in the outpatient departments, as there were no facilities for children and young people to wait separately from adults except in the ophthalmology department
  • Staff and managers had not developed and implemented a strong vision and strategy for the service.
  • There was a risk of unauthorised access to the neonatal unit due to the lack of reception staff and there was no system to record visitors to the unit.
  • There were not adequate age appropriate facilities across the trust for babies, children, young people and their families.

However:

  • Staff were clear about their safeguarding responsibilities and if there was a concern about a child’s wellbeing staff understood and followed safeguarding procedures. All staff we spoke with had completed the appropriate level of training in safeguarding.
  • Most staff we observed controlled infection risks well.
  • Staff planned and delivered care in line with evidence-based guidance, standards and best practice and met the individual needs of the child and family through the careful care planning. Staff followed care pathways on electronic, multidisciplinary patient records to support practice.
  • Staff received annual appraisals and new staff were supported when completing their competency assessments, helping to maintain and further develop their skills and experience.
  • Parents and children gave feedback about the care and kindness received from staff, which was positive. All the children and their carers we spoke with were happy with the care and support provided by staff. We observed staff treated children, young people and their families with compassion, kindness, dignity and respect. Staff worked in partnership with children, young people and families in their care.
  • Guidance on how to make a complaint was readily available across the CYP service and was on the trust’s website.

End of life care

Inadequate

Updated 6 June 2018

Our overall rating of this service went down. We rated it as inadequate because:

  • There were significant concerns about implementation of safety systems. Staff did not complete and update risk assessments for each patient. They did not keep clear records and did not escalate concerns when necessary. Staff did not always complete records or omitted sections relating to patients’ care especially those in the last few days of their life.
  • Most staff were not trained in safe administration of medicines via syringe drivers. There was no structured training for their use and not all staff had completed their competencies. We found staff that had not attended the local train-the-trainer programme but were giving clinical training to the nurses on that ward on the safe use of syringe drivers.
  • Managers did not regularly check that staff always followed guidance and best practice was being implemented. There was limited comparison of local results with those of other services to learn from them.
  • The service did not make sure staff were competent for their roles. Managers did not always appraise staff’s work performance or hold supervision meetings with staff to provide support.
  • There was not always appropriate referral and information sharing when patients were discharged from hospital.
  • The trust did not plan and provide services in a way that met the needs of local people. The service did not meet the individual needs of all patients.
  • The end of life care and the specialist palliative care services had different leadership. This separation meant there was limited joined up working as they were leading on separate services and projects associated with these.
  • The governance arrangements in place were not sufficient to monitor the service provision for all patients. There was lack of action plans to address the shortfalls.
  • The trust did not consistently assess, monitor and improve the quality and safety of the services it provided. No audits had been undertaken to assure if staff consistently completed and reviewed evidence-based, end of life documentation. Data had been collected from bereaved relatives and reported on a cumulative basis. Hence there were no service improvements identified after every survey.
  • Staff were unaware of what constituted end of life incidents. The trust reported no incidents relating to end of life care. There was no risk register to provide oversight of risks relating to end of life care.

However:

  • Staff cared for patients with compassion and kindness and their dignity was respected and maintained. The end of life care and specialist palliative care services were passionate about their visions and the improvements they wanted to make to benefit patients and improve their care and support.

Ambulance services

Good

Updated 9 September 2014

The ambulance service had a very low occurrence of untoward incidents and clear ownership of risk. The ambulance station and vehicles were clean, and equipment was well stocked and maintained. Medicines management was not appropriate, as there was poor stock control and storage arrangements for medicines although this had improved during our inspection process.   Staff were well trained and supported by some examples of innovative practice. Planning for major incidents was fully in place in conjunction with partner organisations.

The service used evidence-based guidelines for treatment and was innovative in developments to support best practice. The early intervention in sepsis trial was an example of innovations and initiatives, which were used to support evidence-based care and treatment. The Individual Learning Plan was used to support the development of staff competency. The Hub, which coordinated access to care for the Island, was a good example of multidisciplinary working.

Patient satisfaction comments were consistently positive in surveys. Patients were treated with compassion, dignity and respect by ambulance staff. Ambulance crews listened carefully to patients and involved and supported them in understanding their care and treatment. Staff provided emotional support for patients and their relatives throughout their contact with the service.

The ambulance service had clear operational and clinical leadership. Ambulance staff told us that the level of integration of the ambulance service and being part of the trust allowed them to respond quickly for the benefit of patients. The ambulance service monitored the operation of the service against key performance indicators and consistently met its response time standards.

Other CQC inspections of services

Community & mental health inspection reports for St Mary's Hospital can be found at Isle of Wight NHS Trust.