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St Mary's Hospital Requires improvement

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


Other CQC inspections of services

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

Inspection carried out on 3 to 4 February 2020

During an inspection looking at part of the service

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 carried out on 14th May to 20th June 2019

During a routine inspection

Our rating of services improved. We rated it them as requires improvement because:

  • There were many areas still to develop for patient care and delivery, especially in medical, gynaecology and surgical services.

  • There had been ongoing issues with patient flow through St Mary’s Hospital and over occupancy for admissions. At time some patients were nursed in non-patient bed spaces, which risked patient safety as well as had compromised privacy and dignity of patients impacted upon.

  • There were delays for patients to receive care and treatment including for stroke care.

  • Policies and procedures were in place for recognising the deteriorating patient and the patient nearing end of life; however, the staff did not always apply these guidelines in a timely way.

  • Patient records were not always completed in full or in a timely way to promote optimum care as treatment.

  • The trust recognised and reported in 2018/2019 that key issues and risks had included a failure to deliver some national access targets including in the emergency department.

  • There was limited development of seven day working.

  • The frailty pathway was under development and therefore remained a risk until established.

  • The trust mandatory training uptake had been low in some wards and departments including for resuscitation and safeguarding.

  • There was insufficient support and supervision of junior doctors and this was reflected in the status of the General Medical Council enhanced surveillance.

  • Complaints were not responded to in a timely manner the themes were noted as communication, values and behaviours of staff and waiting times.


  • Since our last comprehensive inspection in January 2018 the trust had formed new divisional teams with experienced leaders.

  • Ten week improvement plans had been applied to the areas of highest concern to drive improvement and changes had been made.

  • End of life care services had much improved from the new strategy to the care delivery.

  • There were new structures, processes and some systems of accountability to operate a governance system designed to monitor the service and provide assurance.

  • The estates department had a plan for improvement to the emergency department design to become in line with expectation of the service.

Inspection carried out on 21 January 2019

During an inspection looking at part of the service

Isle of Wight NHS Trust provides all acute health services to a population of approximately 140,000 people living on the Island. There is a 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.

We carried out an unannounced focused inspection of the emergency department at St. Mary’s Hospital on 21 January 2019. The purpose of the inspection was to review the safety of the emergency department as part of a focused winter inspection programme. At the time of our inspection the department was under adverse operational pressure.

We did not inspect any other core service or wards at this hospital or any other locations provided by Isle of Wight NHS Trust. We did visit the urgent care centre, the ambulatory emergency care unit and the acute medical unit. During this inspection we inspected using our focussed inspection methodology. We did not cover all key lines of enquiry. We did not rate this service at this inspection.

The trust has one emergency department (ED), located at St Mary’s Hospital in Newport. It provides a 24-hour, seven day a week service. It is a designated trauma unit but patients with multiple trauma are usually flown directly to the major trauma centre in Southampton.

The ED consists of a major treatment area with 10 cubicles, a minor treatment area with three cubicles, resuscitation room with three trolley bays and a new rapid assessment and treatment area. Children have a separate waiting room and are treated in three rooms adjacent to the major treatment area. There are separate rooms for mental health assessment, eye examinations and application of plaster casts. Adjacent to the emergency department is a newly formed urgent care centre for the treatment of patients with minor illnesses and injuries.

Our key findings were as follows,

  • Despite recent recruitment of additional band seven nurses there remained a significant shortage of qualified nurses. In the month prior to our inspection there was heavy reliance on agency nurses. Although agency nurses are fully qualified they do not always have the specialist experience needed in ED and have sometimes not worked in the department before.

  • Staffing information displayed in the department during our inspection showed that eight nurses were expected to be on duty but only six were present. As a result, the nurse in charge was having to assess newly arrived ambulance patients, look after patients requiring care in the corridor, assist in the resuscitation room, take over from nurses on meal breaks as well as co-ordinate the care of all the patients in the department. It was not possible for one nurse to do all of this and we found several aspects of patient care had not been completed.

  • There were periods of time during the evening when there were no nurses in the major treatment area, the minor treatment area or the rapid assessment area.

  • Although a formal review of nursing levels was undertaken in September 2018, it was not clear whether the increase in nursing numbers would be implemented.

  • Initial assessment (triage) of ambulance patients did not take place according to guidance produced by the Royal College of Emergency Medicine and the Royal College of Nursing. Although a handover generally took place within 15 minutes of arrival, there was no face-to-face assessment of these patients by an experienced nurse. Subsequent observations and assessments were often undertaken by a healthcare assistant.

  • The department was crowded throughout our inspection with patients receiving care and treatment (such as intravenous infusions) in corridors.When we arrived, one patient had been in the department for 15 hours. The patient had been nursed in the corridor for three hours.

  • During the evening there was no nurse in the rapid assessment and treatment area for 30 minutes. This meant that newly arrived ambulance patients (up to four at any one time) were being assessed by a healthcare assistant.

  • During a review of the records of patients in the major treatment area we found that four out of six patient safety checklists were incomplete.


  • Almost all staff spoke positively about working in the emergency department.
  • There had been improvements in patient flow since new processes for GP referred patients had been implemented.
  • All critically ill patients were seen quickly by a senior emergency department doctor and were treated according to national guidance.
  • Junior doctors felt well supported and were positive about the training they received in the emergency department.
  • The new role of patient flow co-ordinator helped to ensure that patients waiting for specialist assessment or to be admitted to a ward were not forgotten.

Professor Edward Baker

Chief Inspector of Hospitals

Inspection carried out on 23 to 25 January and 20 to 22 February 2018

During a routine inspection

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.


  • 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 carried out on 22-24 November 2016

During an inspection looking at part of the service

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

Inspection carried out on 4–6 June 2014 and 21 June 2014

During a routine inspection

Isle of Wight NHS Trust is an integrated trust that includes acute, ambulance, community and mental health services. 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 A&E, the Beacon Centre (providing walk-in access to GP services), emergency medicine and surgery, planned 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 comprehensive inspection because the Isle of Wight NHS Trust is an aspirant foundation trust, prioritised by Monitor. The Care Quality Commission's (CQC) latest intelligent monitoring tool identified the trust as being in band 5 (band 1 is the highest priority for inspection, band 6 is the lowest priority).

The team of 41 included CQC inspectors and analysts, doctors, nurses, patients and public representatives, Experts by Experience and senior NHS managers. The inspection took place from 4 June to 6 June 2014, with an unannounced visit on 21 June between 4pm and 11pm.

We inspected A&E, medical care (including older people’s care), surgery, critical care, maternity and family planning, services for children and young people, end of life care, outpatients and the ambulance service.

Overall, we rated this hospital as ‘requires improvement’. We rated it ‘good’ for providing caring services, but it required improvement for the services to be safe, effective, responsive and well-led.

We rated medical care and end of life care as ‘requires improvement’. A&E, surgery, critical care, maternity and family planning, children and young people’s services, outpatient services and ambulance services were ‘good’.

Our key findings were as follows:

  • Staff were caring and compassionate and treated patients with dignity and respect.
  • Staff followed good infection control practices. The hospital was clean and well maintained and infection control rates in the hospital were within an acceptable range.
  • The hospital monitored harm-free care in all inpatient areas and had taken action to reduce avoidable harms, such as pressure sores and falls.
  • Incidents were reported but staff did not always receive feedback and the lessons learned were not widely shared.
  • Serious incidents were investigated and there was evidence of changes, but these were sometimes not implemented in a timely manner.
  • The trust had considered guidance from the National Institute for Health and Care Excellence (NICE), but these were not consistently implemented, monitored or adhered to.
  • Nurse staffing levels had been reviewed and in some areas the need for a change in staff number and skill mix had been identified. In some areas of the hospital, the right number of staff with the right skills and knowledge to meet patients’ specific needs were not present. For example, there were insufficient numbers of nurses trained to care for sick children in the A&E department and insufficient numbers of medical and nursing staff trained to care for patients who had had a stroke.
  • Some patients were being placed at risk by the hospital’s bed management system. Patients were being moved from wards where staff had the appropriate skills and knowledge to one where staff did not have such skills and knowledge.
  • The hospital had a named consultant for each ward and if a patient moved wards then they were allocated to a new consultant. Patients did not have one named consultant for the duration of their stay and did not necessarily have the specialist they required.
  • There was a palliative care team to support patients who were coming to the end of their life. However, patients were not always being identified as being on an end of life care pathway in a timely manner, and did not always receive the care and support they required.
  • Do not attempt cardio-pulmonary resuscitation (DNA CPR) decisions were not clearly documented, reviewed and were not always discussed with the individual or their family.
  • There were clear processes for taking people’s wishes into account and seeking their consent where they had capacity to do so. People who did not have the capacity to consent did not always have their needs considered in safe and proportionate way, as not all staff were informed about the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.
  • There was a good service for children in the inpatient wards, day care, outpatients and neonatal intensive care unit (NICU) areas. There was, however, a lack of clarity over where sick children should be taken in an emergency when resuscitation might be required, as they could be taken to the ward, A&E, or, if very young babies, to the NICU. This had caused uncertainty and children’s care and treatment had been delayed. At the unannounced visit on we founded the Trust had had changed the pathway for all children to be taken to A&E, but this was without fully considering the opinions and concerns of the paediatric staff. Risks to care were still being identified.
  • The ambulance service provided flexible and responsive services to meet the needs of people on the island.
  • There were good medicine management systems in the hospital, but the system in the ambulance service did not ensure the safe handling, storage and management of medication at all times.  The trust had made improvements during our unannounced inspection.
  • Staff were supported though mandatory training and appraisals.

We saw several areas of outstanding practice including:

  • There was evidence-based care for orthopaedic patients having hip and knee operations.
  • A wide, shared-care network for managing children with the most complex and rare conditions had enabled families to be supported and children treated closer to their homes. It also enabled them to access the best possible advice. For example, the children’s ward was a level 1 paediatric oncology shared-care unit, and the hospital could also offer care to visitors to the island with oncological problems.
  • The pharmacy service was operational seven days a week. The service was innovative and worked effectively within multidisciplinary teams to improve patient care. For example, electronic prescribing had reduced medication errors and was being used when venous thromboembolism risk assessments occurred. The service offered an advice line and was involved in the preadmissions initiation of antibiotics with ambulance services.
  • An integrated call centre (Integrated Care Hub), opened in 2013 and provided access to the 999 emergency calls service, the NHS 111 service, the GP out-of-hours service, district nursing, adult social care, telecare services, non-emergency patient transport services and mental health services. Key services were accessed out of hours through the Hub.
  • Ambulance staff used electronic tablets to enable operational staff to complete their e-learning.
  • The ambulance service was participating in a trial in early intervention in sepsis. The aim was to identify patients who might have sepsis, and to reduce their mortality through early intervention prior to admission to hospital.
  • The Individual Learning Plan (ILP) had been developed and implemented to support the development of staff competency in the ambulance service. This was introduced in 2014 and staff were given learning objectives and were required to demonstrate learning as part of their continuous professional development.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must ensure that:

  • Staff receive training on the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. The principles must then be applied to ensure that where people do not have capacity to consent the correct procedures are followed.
  • The leadership of end of life care services is supported to improve across the trust. A strategy for the service needs to be implemented and the quality and risks to the service need to be appropriately monitored.
  • Staff are competent in being able to recognise a patient who is on an end of life journey, so that decisions are made and their care managed appropriately. The trust must also ensure that staff have received the appropriate training and understand the tools available to them. This includes the use of the ‘AMBER care bundle’ and the use of syringe drivers.
  • DNACPR orders are completed in their entirety, in a timely manner, for all patients where this decision has been made. There must be clear documentation as to how this decision was reached. Discussion with patients and their relatives should happen and be appropriately documented.
  • Risk assessments in relation to patient care are completed and used to inform the patients’ plans of care.
  • All patients have a named consultant for the duration of their stay, with clear referral and an acceptance criteria when there is change in their consultant for clinical need.
  • The provision of care for patients who have had a stroke is reviewed to ensure that the pathway is fully reflective of national guidance.
  • National guidance is reviewed, gap analysis completed, and improvement plans put in place and monitored, where required, to ensure that practices are in line with national recognised guidance.
  • There is a lead nurse qualified in the care of children (RN children) and sufficient registered children’s nurses are employed to provide one per shift in the A&E departments receiving children, as per the Standards for Children and Young People in Emergency Care Settings 2012.
  • There is a single point of access for children in an emergency situation where resuscitation may be required. There should be joint working with the A&E and paediatric teams to ensure that any changes are safely implemented.
  • Nursing staffing levels are reviewed in the A&E department and the stroke ward to ensure that they are staffed to the agreed establishment and skills mix in line with current guidance.
  • There is an effective and safe procedure for the obtaining, recording, handling, using, safe keeping and the dispensing of medicines used by the ambulance service.

In addition, the trust should ensure that:

  • The use of bed rails is risk assessed and the patients’ consent acquired for them to be used. In cases where patients are unable to consent, then there should be clear assessment of their capacity and a clear reason for the use of the bed rails.
  • There is effective working with specialists and expertise in multi-disciplinary teams, particularly where clinical expertise is unavailable or limited in the trust.
  • The environment of the eye clinic is reviewed to ensure that it is fit for purpose and safely meets the need of the patients visiting the department.
  • Consultants have protected time for outpatient clinics so they are not cancelled at short notice when they are called to attend to emergencies.
  • Nursing staff are not disturbed while undertaking a medication round.
  • Patients have protected meal times.
  • All medication and intravenous fluids are stored in line with current guidance in all areas.
  • The number of patient bed moves for non-clinical reasons and out of hours is reviewed and action is taken to minimise this.
  • In all outpatient areas where children are seen, there is a dedicated children’s waiting area.
  • All resuscitation equipment is checked on a daily basis, unless an area is closed.
  • The provision of a separate children’s area in the A&E department is considered in line with current building guidance.
  • The process for implementing change following an investigation into an incident is reviewed to ensure that it occurs in a timely manner.
  • The provision of controlled drugs in the resuscitation area in the A&E department is reviewed.
  • The process for streaming patients in the A&E department is reviewed to ensure the decisions are being made by staff who have the knowledge and skill required to do so.
  • Seven-day services continue to develop, particularly for patients requiring emergency care.
  • Patient information held by the ambulance service is securely stored at all times.
  • There is a clear and current system in place to red flag addresses where there are concerns about safety for ambulance crews to use to make informed choices and manage risk when attending these locations.
  • There is a review of the specialist medical care that is available for patients who have had a stroke.

Professor Sir Mike Richards

Chief Inspector of Hospitals

August 2014

Inspection carried out on 10, 11 January 2013

During a routine inspection

We assessed the regulated activities, diagnostic and screening procedures, surgical procedures and the treatment of disease, disorder or injury. We inspected two surgical wards, the discharge lounge and rehabilitation unit. The inspection was carried out over two days; one inspector and a clinical advisor for theatres were part of the inspection's team. We spoke with 21 patients and relatives, 14 staff including nurses and physiotherapists.

Patients we spoke with were happy with the care they received and we identified areas of good practice such as monitoring and recording of surgical site infections and referral to specialist advisors such as pain specialist. We saw that consent to treatment was well documented and patients were assessed for specialist stockings to reduce the risk of blood clots. Staffing levels were well maintained and there were no significant vacancies in any of the areas we visited. Patients did tell us that the staff were �busy� but this did not have a significant impact on the care they received. They said that staff responded well to the call bells with occasional waiting times but nothing that they would complain about.

Inspection carried out on 22 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.