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St Mary's Hospital Requires improvement

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

Inspection Summary


Overall summary & rating

Requires improvement

Updated 8 April 2020

St Mary's Hospital is operated by Isle of Wight NHS Trust. The trust is the only integrated acute, community, mental health and ambulance health care provider in England. The trust provides health services to an island population of 140,000. Acute services at the trust are provided at St Mary’s Hospital in Newport, with 246 beds and 22,685 admissions each year. Services include Accident and Emergency (A&E), urgent care services (by referral only), medicine and surgery, intensive care, maternity, special care baby unit (SCBU) and paediatric services.

Community services include district nursing, health visiting, community nursing teams, as well as inpatient rehabilitation and community post-acute stroke wards. Mental health services provide inpatient and community based mental health care. Ambulance services deliver all emergency and non-emergency ambulance transport across the Island. The emergency call centre takes both emergency 999 calls as well as NHS 111 calls. The urgent care service provides an out of hours GP service including medical advice, assessment and treatment.

The trust has been in special measures for quality since 2017 and in special measures for finance since March 2019. The trust is currently rated as requires improvement, with an inadequate rating for Use of Resources. The acute services at St Mary’s Hospital are currently rated overall as requires improvement.

Following the last comprehensive inspection of the trust in May and June 2019, the trust was served a warning notice under Section 29A of the Health and Social Care Act 2008 requiring them to make significant improvements by 31 December 2019 about the following concerns for the acute service delivered at the location St Mary's Hospital:

  • Staff fully completing patient documentation.

  • Staff following the trust’s policies and procedures to support the identification and management of the deteriorating patient.

  • Patients experiencing delays in their care and treatment once they were admitted to the hospital in relation to stroke care and cancellations of surgical operations due to lack of bed availability.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

We carried out an unannounced follow up inspection of the trust in February 2020 and we were on site at St Mary’s Hospital on 3 and 4 February 2020.

During this focused inspection, we looked at all the issues raised in the warning notice. We did not re-rate the service because we did not inspect any of the full key questions (safe, effective, caring, responsive, well led) of the acute services. Therefore, the rating for St Mary's Hospital and the Isle of Wight NHS trust remains at requires improvement.

We will continue to monitor the performance of this service and will inspect it again as part of our ongoing next phase NHS programme.

We found that staff at this hospital had started to address the concerns raised at the inspection in June 2019. Requirements for significant improvement set out in the warning notice following the May and June 2019 inspection under Section 29A of the Health and Social Care Act 2008 were met. While there was evidence of significant improvement, there were still some areas the provider needed to improve.

We found the following areas where the service still needs to improve:

  • Medical staff did not fully complete patient assessment documents.

  • Duplication of required information throughout medical and nursing documentation increased the risk of staff not completing patient risk assessments.

  • Across most services inspected, staff did not always complete patient fluid balance records.

  • There were examples of some incomplete patient records in most of the wards and units we inspected.

However, we found the following areas where improvements had been made since the previous inspection:

  • Nursing records were fully completed for patients on the coronary care unit.

  • Most staff signed and dated their entries in patient records.

  • Most patient risk assessments had been completed and updated as needed.

  • Most staff followed the trust’s processes to identify, monitor and act upon patients at risk of deterioration.

  • More stroke patients were cared for by staff with the right skills, training and experience.

  • Specialist support from staff, such as speech and language therapists and specially trained nurses, were available for patients who needed it.

  • Improvements had been made to promote better outcomes for stroke patients.

  • In the emergency department, more staff completed hourly patient safety checks.

  • Trust audits demonstrated improvements with the timeliness of patient discharge summaries.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve.

Following the comprehensive inspection in May and June 2019, the provider was issued with several requirement notices. These included requirement notices for regulations 12 (safe care and treatment) and 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014. We have not issued any further requirement notices as these requirement notices remain in place and will be reviewed at the next comprehensive inspection of this service.

Nigel Acheson

Deputy Chief Inspector of Hospitals (London and South)

Inspection areas

Safe

Requires improvement

Updated 8 April 2020

Effective

Requires improvement

Updated 8 April 2020

Caring

Good

Updated 8 April 2020

Responsive

Requires improvement

Updated 8 April 2020

Well-led

Requires improvement

Updated 8 April 2020

Checks on specific services

Medical care (including older people’s care)

Inadequate

Updated 8 April 2020

This rating is from the previous comprehensive inspection. We did not re-rate this service as part of this focused inspection.

The staff had responded to issues raised in the warning notice served.

There was improvement in how staff assessed and responded to risk.

More stroke patients were being cared for by staff with the right skills, training and experience.

Specialist support from staff such as and speech and language therapists and specially trained nurses was available for patients who needed it.

Improvements had been made to promote better outcomes for stroke patients.

Some improvements with completion of records had been made, however there remained gaps in patient documentation.

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.

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.

End of life care

Good

Updated 4 September 2019

Our rating of this service improved. We rated it as good because:

  • There was strong, clear and visible clinical leadership that enabled the service to improve at pace. The end of life care and the specialist palliative care services were under one leadership of the integrated palliative and end of life care team. There was joined up working across the trust with a single point of referral and contact.
  • Staff cared for patients with compassion and kindness and their dignity was respected and maintained. Staff were passionate about their vision and the improvements they wanted to make to benefit patients, their care and support.
  • There were appropriate governance arrangements to monitor the service provision for all patients. There were action plans to address the shortfalls and monitoring systems to ensure continuous compliance to regulation.
  • The trust assessed, monitored and improved the quality and safety of the services it provided. It undertook audits to assure staff consistently completed and reviewed evidence-based and end of life documentation. Data was collected from bereaved relatives and reported every six months and as a result, service improvements were identified.
  • The trust had implemented safety systems. Staff completed and updated risk assessments for each patient. They kept clear records and escalated concerns when necessary.
  • Staff were trained in safe administration of medicines via syringe drivers. There was now a structured training for their use and only staff who had completed their competencies could use the equipment.
  • The lead clinician regularly checked and monitored that best practice was used to inform decisions about patient’s treatment and care. Wards were now monitored through unannounced inspection of their areas and were given feedback on their performance against the services strategy and vision.
  • The trust planned and provided services in a way that met the needs of local people.
  • Staff were aware of what constituted end of life incidents. The trust reported incidents relating to end of life care. There was a risk register to provide oversight of risks relating to end of life care that was monitored.

However:

  • Key services were not available seven days a week.
  • Staff did not always start patients who were known as end of life care onto the end of life care pathway, especially those in the last few days of their life, in a timely manner.
  • There were delays in the transfer of deceased from wards to the mortuary.

Surgery

Requires improvement

Updated 8 April 2020

This rating is from the previous comprehensive inspection. We did not re-rate this service as part of this focused inspection.

The staff had responded to issues raised in the warning notice served.

Although gynaecology was inspected as an additional core service at the previous inspection in May and June 2019, for the purposes of this inspection any references to gynaecology form part of the surgery core service report.

Most patient charts and care plans were completed, dated and signed.

Most patient risk assessments had been completed and updated as needed.

However, on Whippingham ward:

Patient charts and care plans were not completed or reviewed as patient needs changed, and staff did not date or sign the records.

Risk assessments had not always been completed and updated as needed.

Records had not always been followed through on later records and could not easily be found.

Urgent and emergency services

Requires improvement

Updated 8 April 2020

This rating is from the previous

comprehensive inspection. We did not

re-rate this service as part of this focused

inspection.

The staff had responded to issues raised in the warning notice served:

There was improvement in how staff assessed and responded to risk.

Some improvements with completion of records had been made, however there remained gaps in patient documentation.

Gynaecology

Inadequate

Updated 4 September 2019

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

  • There were examples of medical staff showing wilful or routine disregard of standard operating or safety procedures.
  • Systems had not always ensured patient safety.
  • Some medical staff had not engaged in the service and had disregarded risk and safety processes to monitor the safety of the service.
  • Staff did not recognise concerns, incidents or near misses.
  • There was a lack of evidence of learning from events or action taken to improve safety.
  • Incidents had not been routinely reported on the trusts electronic reporting system. Therefore, investigations and learning had not taken place.
  • Staff had not always assessed risks to patients or kept good care records.
  • Although the trust provided mandatory training in key skills for staff, not all staff had attended, and the level of compliance remained below the trust’s target.

  • Managers had not made sure all staff were competent.
  • Not all staff treated women with compassion and kindness.
  • Women were frequently and consistently unable to access services in a timely way for an initial assessment, diagnosis or treatment.
  • Although the trust had regular daily bed management meetings there were also regular bed capacity issues.
  • Staff did not understand how their role contributes to achieving the strategy.
  • There were a number of strategies in place and on display on the wards however, not all staff could articulate them. The strategies had been included in meeting minutes did but not comprehensively cover all domains of the clinical quality strategy.
  • There continued to be 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 several strategies to improve working relationships. However, these were not seen to have improved the situation.
  • There is little attention to some staff development and there are low appraisal rates for some staff.

However:

  • Most staff understood how to protect women from abuse, and managed safety well.
  • The service managed infection risks well.
  • The service managed medicines well.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it.
  • Most staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Nursing and support staff respected women’s privacy and dignity and took account their individual needs. These staff provided emotional support to women, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
  • Staff were clear about their roles and accountabilities. The outpatients service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

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.

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.
Other CQC inspections of services

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