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Whipps Cross University Hospital Requires improvement

We are carrying out a review of quality at Whipps Cross University Hospital. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 12 February 2019

Our rating of services stayed the same. We rated it them as requires improvement because:

  • Since our last inspection of acute services at Whipps Cross Hospital in 2016, 2017 and 2018, the trust had addressed or shown improvement for most of the previously reported concerns and requirement notices, for which we commend them. Evident improvements included significantly improved standards of care, dignity and privacy in medical care, the improved culture around medicines management, and improved record keeping in surgery. However, we found several areas of improvement to address such as the pockets of bullying in the emergency department and the maintenance of equipment and the environment.
  • Although the trust had improved referral to waiting times (RTT) in the surgical service, further improvement was required to ensure the trust was meeting the national standard. In outpatients, only one specialty met the national RTT target.
  • In outpatients, we also found substantial waiting lists for clinic appointments with relatively high cancellation and did not attend rates. Although rebooking and follow-up practices varied between specialties, individual specialties such as ophthalmology scheduled ad-hoc clinics to reduce waiting lists and meet local demand.
  • Patient flow within the hospital remained an ongoing challenge and impacted other services such as bed occupancy in critical care. In the surgical service, late starts, patients discharge out of hours and cancelled operations had not improved.
  • The trust did not meet the Department of Health’s standard of 95% for time to treatment and decision to admit, transfer or discharge. Performance between January and July 2018 (86%) was worse that the England average but just above the London average (85.8%).
  • Although the trust had improved the culture in areas such as the eye treatment centre in outpatients and medical care services, we found pockets of bullying in the emergency department which the leadership team did not have oversight of.
  • Staff feedback on development opportunities varied between each service. In medical care, doctors in training were very positive about the support and teaching they received whilst outpatients staff told us they had inconsistent access to training and development opportunities.
  • The trust did not provide up to date monitoring data for mandatory training, staff vacancies, sickness and turnover rates and appraisal completion rates for outpatient services. Similarly, in diagnostics, the trust did not provide a breakdown of mandatory training compliance rates for nursing or medical staff by module.
  • Although the trust had shown improvement in staffing levels in some services, the trust still had challenges with staffing in some of the services we inspected. The emergency department had high nursing and consultant vacancy rates. Managers told us processes in human resources (HR) had contributed to delays for the appointed nurses from overseas to start.
  • The availability of equipment continued to present challenges for staff in some services. The diagnostic service had a significant amount of aging equipment which was prone to breakdown which had resulted in clinic delays and early closure. Surgical staff witnessed similar issues in accessing equipment or getting broken equipment repaired despite the trust making a significant investment in replacing equipment which urgently needed replacing.
  • The diagnostic service had no schedule in place for quality assurance testing of the home computers and did not complete regular quality assurance checks on equipment including mobiles, despite being advised to do so by the medical physics expert’s advice.
  • Although senior leaders and service managers had, for the most part, a good understanding of risks to the service, the trust did not have oversight of some issues despite them being logged on the risk register. Service leads did not mitigate risks appropriately in some instances. Radiographers raised concerns about personal safety at night due to the location of an equipment. Although the service lead was aware of this and had acquired an additional machine, the location had still not been determined.
  • Although the fire safety group and operations team had improved fire safety in the hospital, we found partially blocked fire escapes routes on Cedar ward and Faraday ward and a lack of assurance around fire safety within outpatients, including poor organisation we observed during an evacuation.
  • The trust’s response rate to the NHS Friends and Family Test (FFT) had been lower than the national average. Staff told us the low response rates were due to the trust recently changing to an electronic method of collecting FFT data and individual teams had developed initiatives to address this.

However, we also found:

  • The trust had addressed the warning notice issued for medicines management in the April 2018 inspection of surgical services. In most cases, we found improvement in the storage of medicines and Controlled Drugs and improved staff awareness of policies overall. However, further improvements were still required for example with tracking the dispensing of pre-packs.
  • Most staff had good awareness of incident reporting, how to raise concerns and duty of candour. There was an open culture of incident reporting and a willingness to learn from incidents for most services except for outpatient services.
  • There were comprehensive, clearly defined and embedded processes to protect people from abuse. Staff were knowledgeable about safeguarding and were confident to escalate concerns. Staff were aware of their responsibilities as set out in the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS).
  • All areas of the hospital we inspected were visibly clean, tidy, and clutter free with adequate supplies of personal protective equipment (PPE) available for use when required. Although we observed good compliance with infection prevention and control across the hospital, hand hygiene audit results for the emergency department required significant improvement.
  • The trust had introduced measures to better anticipate and manage patient risks including an improved integration of the national early warnings scores (NEWS) system. Although staff had good knowledge of what to do in the event of a patient deteriorating, we found inconsistent NEWS documentation in patient records in the emergency department.
  • Throughout our inspection, we saw consistent evidence of effective multidisciplinary team (MDT) working across all disciplines and wards. Ward staff worked closely with staff across acute and community services as well as practitioners in the local health economy.
  • Staff demonstrated compassion to patients and their relatives in all the services we inspected. Patients told us they felt listened to by health professionals and felt informed and involved in their treatment and plans of care. However, there were some isolated incidents where patients felt staff were too busy to provide the support they needed.
  • Most people using the trust’s services were treated with dignity and respect with significant improvements in medical care. However, we found patient dignity and privacy was compromised in the GP x-ray department changing area and in outpatients where there was a lack of screens for procedures such as taking blood pressure.
  • Staff delivered patient care in line with good practice and evidence-based guidance from relevant bodies. Most of the staff we spoke with told us they could easily access policies and guidelines on the trust intranet.
  • Dedicated teams provided care to patients living with dementia or a learning disability and support to staff using national resources to aid communication. Although, the trust had recently refurbished three medical wards to national dementia friendly standards, the emergency department and outpatients’ environments were not dementia friendly.
  • The trust had only one learning disability clinical nurse specialist across all the trust sites. However, staff within the pre-assessment unit took innovative steps and had developed a patient passport having researched the needs of patients living with a learning disability.
  • Although the estates remained a challenge for the trust and obtaining funding for site re-development was an ongoing piece of work, the trust had still made improvements to the environment to provide a better and safer patient experience. However, the outpatients’ environment required further improvement.
  • The trust’s nurse education team provided specialist training opportunities to clinical staff, including simulations and interactive workshops. Some services had practice development nurses (PDN) who provided training to update nursing skills.
  • The trust had a range of services available to support patients. For example, bereavement services, 24-hour chaplaincy and access to translation and advocacy services for patient where English was their second language.
  • The service dealt with concerns and complaints appropriately and investigated them in the required time frame including future actions and any learning for staff.
  • Most staff we spoke with felt they were listened to by service and trust leadership and felt they could approach managers if they needed support.
  • A patient forum provided oversight of care standards and presented their experiences in board meetings in line with the trust’s engagement strategy.
  • Most of the services we inspected had shown improvements in implementing a strategy for the service. Services such as critical care, the emergency department and medical care had developed a strategy with staff involvement and with external partners with a focus on the frail elderly.
  • Leadership structures were clearly embedded for most services except for outpatient services. The trust had made notable improvements in the governance structure in the surgical and medical service.
Inspection areas

Safe

Requires improvement

Updated 12 February 2019

Effective

Good

Updated 12 February 2019

Caring

Good

Updated 12 February 2019

Responsive

Requires improvement

Updated 12 February 2019

Well-led

Requires improvement

Updated 12 February 2019

Checks on specific services

Medical care (including older people’s care)

Good

Updated 12 February 2019

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

  • Following our last inspection in July 2016, we issued a requirement notice requiring the service to act to remedy breaches to Regulation 17 (2) (a) and 17 (2) (b), in relation to assessing, monitoring and improving quality and safety. We also issued seven actions the provider should take to improve. During this inspection, the service had dealt with or shown improvement for most of the previously reported concerns.
  • Staffing levels across most services had shown improvement and some were recruited fully to establishment. Where recruitment remained challenging for specific wards, leadership teams had developed initiatives to make existing staffing levels more reliable.
  • Staff delivered care and treatment in line with national guidance and standards and reviewed trust policies to ensure they were always up to date. Specialist teams benchmarked care using national audits and implemented action plans where standards fell short. The hospital had achieved a maximum level A in the Sentinel Stroke National Audit Programme (SSNAP) between December 2017 and June 2018.
  • There was extensive evidence of well-structured, cross-discipline engagement and professional development that contributed to a better skilled workforce and more specialist services for patients.
  • There was substantial evidence of improvement work as a result of audits, engagement and feedback. Where specialist teams identified opportunities for learning, they implemented action plans that were ambitious, innovative and evidence-based.
  • There was a demonstrable focus on ensuring safeguarding was a key focus of every member of staff and of all care delivered in the hospital. This was evident from the highly visible, proactive work of the safeguarding team to increase training and discussions and to update the trust policy in a way that would be useful to staff.
  • Patients and their relatives described staff that were kind, attentive and friendly. They noted how well doctors included them in discussions about their care and that staff adapted communication styles to help them understand.
  • Staff at all levels of responsibility were empowered and confident and demonstrated substantive positivity about a new working environment and culture that recognised their contribution. This was a significant improvement from our last inspection in 2016 and staff offered numerous, wide-ranging examples of how the work culture had improved.
  • Senior ward and divisional staff used incidents, complaints and performance track records to identify opportunities for learning. They implemented this thoroughly, with training, supervisions and structured team meetings. This was evident in all areas we inspection and included specialist teams such as the pain team and safeguarding teams.
  • Staff based service development and reconfiguration on the needs of the local population and had a demonstrable, detailed understanding of these. This included facilitating more streamlined working with community providers and colleagues and establishing greater input of social care professionals in care planning.
  • Senior divisional staff had acted on feedback from staff survey results to improve the health and wellbeing of their teams, provide more opportunities for professional development and establish opportunities for frequent structured meetings with colleagues.

However, we also found:

  • Vacancy rates for some clinical roles were significantly higher than trust targets, although the impact on services was minimised with the use of long-term locum doctors.
  • Trust operations staff worked closely with the security team but there were areas of persistent risk in relation to security.
  • Fire safety and operations staff had significantly increased and improved practical training but there was a need for more consistent oversight on some wards.
  • Pharmacy and ward teams had not established an effective system for the removal of expired or excess stock of controlled drugs.

Services for children & young people

Good

Updated 15 December 2016

Staff members demonstrated and were encouraged to adopt an open and transparent culture about incident reporting.

Patients were safeguarded from the risk of abuse and we saw that staff fully understood how to activate as necessary the trust’s local safeguarding policies and could describe national best practice guidance.

Children's services participated in a range of local and national audits, including clinical audits and other monitoring activities.

Nursing staff levels did not always meet national standards in the majority of clinical areas including the neonatal unit.

The environment in which children were cared for within Acorn, the general paediatric ward, was in the main appropriate, although residential accommodation for the parents was basic..

Critical care

Good

Updated 12 February 2019

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

  • Following our last inspection in July 2016, we issued16 actions the provider should take to improve. During this inspection, the service had dealt with or shown improvement for most of the previously reported concerns.
  • Nursing staff exceeded the 85% completion target for all 27 mandatory training modules.
  • At our last inspection, we found staff did not always have access to reliable equipment. During this inspection we found this had improved as the unit had procured a variety of medical equipment such as: six non-invasive breathing machines, one kidney machine, a number of epidural pumps, patient bedside chairs and a patient iPad.
  • Staff on each shift documented checks on emergency equipment, including resuscitation and airway trollies.
  • During our last inspection, we found that doctors did not consistently wash their hands when entering the unit. On this inspection, we found all staff complied with hand hygiene practice consistently. We observed staff asking relatives and other staff to wash their hands on entering the unit.
  • At our last inspection, we found staff did not always record actions taken or learning points for incidents and had inconsistent knowledge of incidents. On this inspection, we found learning from incidents and morbidity and mortality meetings had improved and processes were in place to provide more consistent communication and safer practice.
  • During our last inspection, there was limited evidence of relevant audit activity and learning was not always shared with staff. During this inspection, we found this had improved as there was a dedicated audit team who worked with the senior staff to develop audits to benchmark care and treatment standards in line with national guidance. Staff acted on audits and implemented improved working practice as a result.
  • At our last inspection, intensive care national audit and research centre (ICNARC) data suggested that between April 2015 to December 2015 the unit had higher than expected mortality levels (compared to similar units nationally). During this inspection, we found the expected mortality rates had improved at 1.2 which was slightly worse than the national average of 1.1.
  • The team could demonstrate improved outcomes for patients such as; the reduction of higher risk patients being admitted to the unit and the number of patients experiencing sepsis along with the reduction of patients having unplanned readmissions to the unit. The instances of patients being transferred from the unit throughout the night had significantly reduced.
  • Since the last inspection, the hospital had opened an HDU which increased the bed base from nine beds to the current 17. The matron and senior staff had successfully transitioned staff to an integrated ICU and HDU and reduced nurse vacancies simultaneously.
  • During the last CQC inspection, there was no protocol for weaning (reducing patients level of respiration support) and rehabilitation for long term patients. On this inspection we found this had improved as staff had developed an approach with three possible options.
  • During the last inspection, we found that due to bed pressures patients were sometimes transferred out of the unit for non-clinical reasons and many patients were transferred out overnight contrary to professional standards. During this inspection, trust data showed the unit was within expected range although bed pressures remained a challenge.
  • Staff we spoke with demonstrated good knowledge and understanding of patient risk, particularly for people living with dementia or learning disability.
  • The senior team demonstrated the high levels of experience and capability needed to deliver embedded system of leadership development and succession planning.
  • During our last inspection, we found the acute response team (ART) was not able to provide a 24-hour, seven-day service and plans to provide this cover did not seem sustainable. On this inspection, we found ART staffing levels had increased and plans were in place to continue to increase these staffing levels and rotate staff from the unit in the future.
  • During the last inspection, we found there was no documented long-term strategy for the division and staff had poor awareness of the leadership’s plans for the department. On this inspection, we found the service had implemented a strategy which had been developed with staff involvement.
  • We found a positive staff culture supported by clear career progression for all staff. The staff we met told us they felt cared for, respected and listened to by their peers and managers.
  • During our last inspection we found the risk register did not fully document all risks identified across the unit and senior leaders had limited awareness of key challenges and risks. On this inspection we found some improvements as the risk register was more comprehensive and more actively managed.

However, we also found:

  • During the last inspection, we found that due to bed pressures patients were sometimes transferred out of the unit for non-clinical reasons and many patients were transferred out overnight contrary to professional standards. During this inspection, trust data showed the unit was within expected range although bed pressures remained a challenge.
  • At the last inspection, we found there were mixed-sex accommodation breaches due to the lack of bed capacity and service leads had not highlighted this as a risk. During this inspection, we found mixed sex accommodation remained a challenge for the unit but had been documented on the unit’s risk register.
  • During our last inspection, we found high bed occupancy levels and the service did not meet the professional standards for delayed discharges. On this inspection, we found that the unit had not successfully addressed this.
  • At our last inspection, the unit was failing to comply with a number of the ‘London quality standards’ for adult critical care. For example, not all patients were seen and reviewed by the consultant in clinical charge of the unit at least twice a day, seven days a week. During this inspection, we found this was still the case but these figures were being reviewed due to lack of data as 20% of the data was missing.
  • Although the senior team encouraged staff to be involved in audits and research to improve patient experience and outcomes, staff could not always rely on the data as the unit experienced data collection issues which resulted in some unreliable performance information.
  • The trust did not provide mandatory training data for medical and dental staff as part of the provider information request and post inspection additional data request.

End of life care

Requires improvement

Updated 12 September 2017

Although ward staff felt well supported by the specialist palliative care team (SPCT) it was a widely held belief among senior staff at the Margaret Centre and SPCT that a barrier to promoting a positive culture of end of life and palliative care being everyone’s responsibility and lay with the education of ward staff.

Despite issues regarding equipment being identified through audit and reported as acted on in March 2017, we found there was a lack of working equipment available within the mortuary. Twenty fridge spaces were available in the mortuary and deceased patients were frequently transferred to other premises. There were no bariatric fridge spaces and the audit stated that fridges were quite old. It recommended this issue for the trust risk register. Out of hours mortuary viewings were arranged and managed by the porters. However, the porters had not been trained in any mortuary duties.

More clinical nurse specialists and consultants had been recruited as part of investing in end of life and palliative care which was a positive step. However, not all posts had been recruited to and staffing levels remained on the risk register. Consultant levels had increased and were due to increase further. However, they were still below the national guidance [‘Commissioning Guidance for Specialist Palliative Care: Helping to deliver commissioning objectives’ (Dec 2012.)] which recommends a minimum requirement of one whole time equivalent consultant in palliative medicine per 250 hospital beds. Association for Palliative Medicine of Great Britain and Ireland recommendations and the National Council for Palliative Care guidelines of a minimum of one consultant per 250 beds. The hospital had 586 beds.

Provisions for relatives who were at the hospital with their loved ones for long periods of time were not consistent and differed from ward to ward. Some were provided with tea and coffee, others with tea, coffee and sandwiches. For relatives staying overnight, some wards could only provide chairs while others had fold down beds.

The availability of single rooms was at a premium in the hospital, which made dignified care for people at the end of their lives harder; this compounded the issue of patients being sent to the Margaret Centre, where care was provided in single rooms.

The discharge team told us they tried to meet a target of 48 hours for rapid discharge. However, although they monitored this on a day to day basis they did not measure this in any other way, such as over time or through any sort of audit and did not understand their effectiveness against this target or its effect on patient care.

Staff from both the SPCT and Margaret Centre we spoke with were not aware of a nominated non-executive director for end of life care, or of any representation at board level.

There was a culture for end of life care at the hospital to be seen as the responsibility of the SPCT. There was also a culture of patients being admitted to the Margaret Centre to die rather than being cared for at home or on the wards.

The mortuary was managed by an outsourced third party on behalf of the trust. There were systems in place that were not effective and others that the trust had no oversight of.

We also found:

There were mechanisms in place for learning from incidents to take place through a multi professional, cross divisional hospital group who led on all matters that related to end of life and palliative care.

The SPCT took working to resolve issues for patients receiving end of life care as something they took responsibility for within the hospital. They described being open, apologetic to people when things went wrong and resolving matters for patients.

Ward staff, the SPCT and staff at the MC were all able to describe the trust’s safeguarding referral process. They also knew when it was appropriate to seek help and advice as well as escalate potential safeguarding issues. We came across one current example of this in practice.

A programme of refurbishment was taking place at the Margaret Centre. Updates had already taken place to the premises to improve infection control and protect peoples’ privacy and dignity.

The compassionate care plan for the dying patient (CCP) was in use throughout the hospital. Staff we spoke with on hospital wards and at the Margaret Centre told us that the end of life care was hugely helped by having the CCP in place.

Patient deterioration, symptom management, continuing assessment and ongoing monitoring for each patient where appropriately discussed and reviewed in daily handover meetings at both the SPCT and MC.

We found plenty of examples where end of life care was being delivered to national guidelines and in compliance with National Institute for Health and Care Excellence (NICE).

DNACPR forms were in place and fully completed, including discussions with the family where appropriate. There was only one DNACPR form in use now.

The Margaret Centre and the SPCT staff worked on relationships with services within the hospital to promote better end of life care. Ward staff we spoke with thought both the SPCT and the MC staff were helpful.

Patients and relatives were positive about the care they had received.

Family meetings were held soon after referral to the SPCT. Family involvement was discussed in handover meetings of the SPCT and the Margaret Centre.

There was a good meeting structure that enabled accountability and direction for end of life care. The deteriorating patient improvement group met on a monthly basis and was the principle governance meeting for the hospital that was concerned with end of life care. This group was now developing in to the end of life care group, which was to be led by the director of nursing at the hospital.

Maternity and gynaecology

Good

Updated 15 December 2016

Patients and their relatives spoke highly of the care they received in both the maternity and gynaecology services

Staff planned and delivered care to patients in line with current evidence-based guidance, standards and best practice. 

We found all areas of the maternity and gynaecology service we visited to be visibly clean and well maintained.

There were good clinical multidisciplinary working relationships. Leaders were visible and approachable.

Surgery

Requires improvement

Updated 12 February 2019

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

  • Following our last inspection in April 2018, we issued the trust a warning notice requiring the service to make significant improvements to medicines management on surgical wards and to ensure the trust’s medicines management policy was followed in relation to medicines storage and expired medicines. We also issued ten actions the provider should take to improve. During this inspection, the service had dealt with or shown improvement for some of the previously reported concerns. However, there were still some areas for improvement such as consistent adherence to the trust policy and having a process to record ‘take away’ medicines dispensed by nurses on the wards.
  • During our last inspection, we found high vacancy rates for nursing staff and most surgical wards remained dependent on temporary staff. On this inspection, although we found the trust had completed a recruitment campaign which had reduced vacancy rates, the nursing vacancy rate still remained higher than the trust’s 6.3% target.
  • On our last inspection, we found the facilities used by the pain service were not fit for purpose. During this inspection, we found the pain service was still located in the same unsuitable area. The trust told us they had plans to relocate the service in the future once the next phase of theatre upgrading was completed.
  • During our last inspection, we found the consent process for surgical procedures was not completed in line with trust policies and best practice. On this inspection, we were informed that the trust was undertaking a trust wide review to understand what changes were required. A report was due to be completed later in September 2018 and so was not available at the time of our inspection.
  • On our previous inspection, we told the trust that they should improve the flow of patients across the hospital to reduce late and cancelled operations. On this inspection, we found there had been no significant improvement.
  • Trust data for referral to treatment waiting times (RTT) for all surgical specialities between September 2017 to July 2018 showed that overall RTT was 81.6%. Although this was a slight improvement from the last inspection figure (79.7%), it was lower than national standards.
  • On our last inspection the service planned to develop a surgical assessment unit (SAU) where they could assess and prioritise patients before they were admitted to a ward. On this inspection, this remained unchanged as managers had not found a suitable location. Although the trust told us they recognised that there was a risk of delay in medical staff reviewing the most acutely ill surgical patients and had introduced various methods to mitigate the risk; staff we spoke with acknowledged the triage arrangements but told us they felt the risk remained.
  • During the last inspection, we found staff did not have access to reliable equipment and there was no agreed replacement programme in place for theatre equipment. On this inspection staff told us there were still issues accessing equipment or getting broken equipment repaired.
  • Although the trust had recently made a significant investment in equipment which urgently needed replacing such as the anaesthetic machines, the division’s risk register showed 25 out of a total of 47 risks related to theatre equipment which was obsolete or at the end of their life.
  • Theatre utilisation rates between March 2018 and August 2018 across the main theatres varied between 70% and 72% against the trust’s target of 85%. Although performance had remained consistent to the rate from our previous inspection (70%) further improvement was required to meet the trust target.
  • Trust data showed that between January 2018 and August 2018, 2528 (16%) of patients were discharged out of hours (between 8pm and 8am). The trust’s performance had deteriorated as the previous figure between April 2017 and December 2017 was 13%.
  • Although the service had introduced an Enhanced Recovery Programme to improve the pathway for surgical patients, the programme was limited to one surgical speciality. This meant the potential to improve patient care and length of stay was not being fully embedded throughout the service.

However, we also found:

  • The trust had recognised the need to complete a strategic review of services provided at Whipps Cross including surgery. The review was in its early stages, however, managers from the hospital were involved in developing plans for the service which more closely met the needs of the local population and provided high quality, effective pathways.
  • During our last inspection we found inconsistent completion of patient care records and had concerns around secure storage of records. On this inspection, we found this had improved as the records we checked were completed accurately and stored securely.
  • There was effective multidisciplinary team (MDT) working to support patients’ health and wellbeing with good access to services such as pain and tissue viability.
  • Staff recognised the importance of providing good standards of patient care regardless of how busy they were. Most of the patients and relatives we spoke with told us all staff, whether permanent or temporary, were compassionate and caring.
  • Staff told us they felt more supported following the recruitment to vacant posts in the senior leadership team.
  • The service had strengthened governance structures with new clinical leads for each speciality and more administrative support.
  • The service had made progress against the improvement plan developed following our previous inspection. Progress against some issues, for example, medicines had been achieved within a short time period.

Urgent and emergency services

Requires improvement

Updated 12 February 2019

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

  • We found at the last inspection there was inconsistent recording of national early warning scores (recording NEWS) to identify deteriorating patients. During this inspection, we found there was poor use of NEWS, as well as pressure ulcer risk assessments and hourly vital signs.
  • Similar to the last inspection, the departmental performance averaged 86% which was below the Department of Health’s standard for emergency departments that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the emergency department.
  • Matron’s audits showed there was poor hand hygiene practice in the department.
  • There was no re-audit planned of the lower performing standards in 2016/17 Royal College of Emergency Medicine (RCEM) audits.
  • Some staff told us they felt bullied at times by the way in which senior staff pressured them in order to meet key performance targets.

However, we also found:

  • At the last CQC inspection in December 2016, there was no dedicated place of safety room which could be used by patients detained under the Mental Health Act or with mental health conditions. During this inspection we found the trust had developed a room which provided a better and safer patient experience.
  • There was an improved leadership and clinical governance structure in place that continued to address outstanding departmental issues.
  • Staff were encouraged to raise concerns and to report incidents and near misses. The division effectively shared learning from incidents and good practice with staff through regular meetings, e-mails and departmental newsletters.
  • Emergency department staff appropriately managed, administered and monitored rapid tranquilisation.
  • We saw how staff showed understanding and a non-judgmental attitude when talking about patients with mental health needs, learning disabilities, autism or dementia.
  • There was evidence of increased admission avoidance in the over 65 patient group which was linked with increased multidisciplinary working in the emergency department.

Diagnostic imaging

Requires improvement

Updated 12 February 2019

We previously inspected diagnostic imaging jointly with outpatients so we cannot compare our new ratings directly with previous ratings. We rated it as requires improvement because:

  • During our inspection, we found that hospital in-patients were frequently left unsupervised in handover areas. We raised this with the service lead who acknowledged there were such occasions and told us that various safety measures including the installation of closed circuit television had been considered but not materialised.
  • During the inspection, radiographers in the emergency department x-ray department raised concerns about their personal safety at night time due to the location of an equipment.
  • Some radiographers expressed concern about the night duty working conditions as there were times when more than one patient was brought down from the wards with one escort. This meant it was difficult to safely monitor all patients.
  • The service had no schedule in place for quality assurance testing of the home computers. There was no assurance of Digital Imaging and Communications (DICOM) grey scale display function compliance.
  • The service did not complete regular quality assurance checks on equipment including mobile scanners despite being advised to do so by the medical physics expert.
  • We found there were long-standing concerns on the risk register about equipment and environment which were not addressed in a timely manner. Staff told us the service had a significant amount of aging equipment which was prone to breakdown. This resulted in clinic delays and early closure.
  • We found the GP x-ray department was in the old part of the hospital and the environment was poor. For example, the waiting area was cramped and poorly ventilated and the toilets and the waiting area were not accessible for patients using wheelchairs.
  • We found radiofrequency coils on the floor behind the magnetic resonance imaging (MRI) machine. We raised this with the site lead who told us there was a problem with funding agreement for a suitable storage unit. After the inspection, the trust confirmed that an agreement had been reached and the coils were no longer stored on the floor.

However, we also found:

  • Staff understood their role in identifying and reporting safeguarding concerns to keep patients safe. They understood how to protect patients from avoidable harm and abuse.
  • All the imaging rooms and waiting areas we visited were visibly clean and there were hand sanitiser units throughout the department. There were adequate supplies of personal protective equipment (PPE) including gloves and apron dispensers available for use when required.
  • Staff had good awareness of incident reporting and how to raise concerns. The division effectively shared learning from incidents and good practice with staff through e-mails, team safety huddles and team bulletins.
  • Patients we spoke with provided positive feedback and told us staff treated them with kindness and were caring.
  • Policies and protocols including the updated radiography protocols were available for staff to access on the hospital intranet.
  • The imaging service sat within the clinical support services division (CSS) and was represented at board level by the CSS director of quality performance.

Outpatients

Requires improvement

Updated 12 February 2019

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings. We rated it as requires improvement because:

  • The trust was not able to provide up to date monitoring data for mandatory training, staff vacancies, sickness and turnover rates and appraisal completion rates. This meant the senior teams responsible for outpatients and medical records did not have assurances around the performance of key issues affecting the service.
  • Although governance systems and processes had generally improved since our last inspection, there were still gaps in risk and performance management and systems needed more time to be fully embedded.
  • There was a lack of assurance around fire safety, including poor organisation we observed during an evacuation.
  • Staff were not always able to manage local challenges relating to the estate and environment and this impacted the comfort of patients and the facilities available to them.
  • There were significant gaps in assurance relating to the ability of staff to assess and respond to patient risks. For example, facilities and processes for treating patients with an active tuberculosis (TB) infection did not protect people from avoidable harm.
  • There was a need for further improvement in the incident-reporting system, including in reporting and feedback.
  • Auditing and benchmarking against national standards was limited and there was no overall assurance about the standards of care provided.
  • There was limited use of IT and technology to drive improvements in access and capacity and this element of the outpatients transformation plan was not being consistently developed.
  • The environment in most areas was not dementia-friendly and not all areas had safe or comfortable waiting space for patients who used a wheelchair.
  • Achievement of the standard of 92% of patients being seen within 18 weeks referral to treatment time (RTT) had slowly increased for most specialities. However, only one speciality met the standard and managers told us further improvements were not possible without more doctors and/or more clinical space.
  • Cancellation and did not attend rates were relatively high and rebooking and follow-up practices varied between specialties. From August 2017 to August 2018, 2079 appointments were cancelled due to consultant annual leave being arranged after an appointment was offered.

However, we also found:

  • The trust performed better than national standards in access and treatment measures for patients diagnosed with cancer, including consistently high achievement of the 96% target of starting treatment within 31 days of diagnosis.
  • The senior leadership team had expanded services based on local demand and by sharing recruitment of new staff with the rest of the trust. This included more availability of gastroenterology and ear, nose and throat (ENT) clinics and the development of a new community-based rheumatology service.
  • Strategies were in place in some areas to increase capacity. This included joint consultant-GP community clinics and ad-hoc out of hours clinics in a number of specialties.
  • Patients rated the hospital consistently well in the annual patient-led assessment of the care environment (PLACE) for cleanliness, the environment and food quality.
  • Diabetes and endocrinology performed better than the 92% referral to treatment time (RTT) target of 18 weeks, with 100% of patients being seen within this time.
  • Some specialties had plans in place to expand capacity and reduce waiting times. This reflected localised good practice although there was limited evidence this was shared between teams.
  • Significant work had been completed to improve information to patients under the Accessible Information Standard. This included the implementation of new patient-led quality assurance and readership groups and the provision of information in a wider range of formats including Braille.
  • Patients provided consistently positive feedback about the standards of care they received. They referred to staff as kind and caring and in most cases said they felt listened to.
  • Staff acknowledged previous issues with the working culture and most individuals we spoke with said this had improved.

We found breaches of Regulation 15 and Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to premises and good governance and we issued two requirement notices to the trust.