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Northwick Park Hospital Requires improvement

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

Inspection Summary


Overall summary & rating

Requires improvement

Updated 31 August 2018

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

  • We rated caring at Northwick Park hospital as good. We rated safe, effective, responsive and well-led as requires improvement.
  • Critical care improved from requires improvement to good.
  • Maternity went down from requires improvement to inadequate.
  • Urgent and emergency services, medical care, surgery and children and young people’s services remained as requires improvement.
  • We rated well-led as inadequate in medical care and maternity.
  • We rated safe as inadequate in maternity services.
Inspection areas

Safe

Requires improvement

Updated 31 August 2018

Effective

Requires improvement

Updated 31 August 2018

Caring

Good

Updated 31 August 2018

Responsive

Requires improvement

Updated 31 August 2018

Well-led

Requires improvement

Updated 31 August 2018

Checks on specific services

Critical care

Good

Updated 31 August 2018

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

  • Since the last inspection, there was improvement in certain aspects of flow. The proportion of out of hours discharges had significantly reduced from 14% at that time to the current 2.0%.
  • There was also significant improvement in non-clinical transfers out to another critical care unit. Intensive Care National Audit Research Centre (ICNARC) data between April 2017 and 31 December 2017 showed this was 0.2%, when it was reported as10 times the national average at the last inspection. The recent data compared favourably with similar units which was 0.4% and nationally which was 0.3%.
  • There was evidence of improved multidisciplinary working across the service.
  • One hundred per cent of patients were reviewed by a consultant within 12 hours of admission to the CCU in accordance with the faculty of intensive care medicine (FICM) recommendations.
  • Managers shared learning from incidents with staff and staff had an opportunity to reflect on how they could improve.
  • The critical care outreach team provided a 24 hour a day seven days a week service to patients. They followed up 95% patients within 24 hours when they moved to a ward.
  • There was a positive and friendly culture on the unit. We observed good team working amongst staff of all levels. Staff told us that they were proud to work for the hospital and were well supported by their colleagues.
  • Staff treated patients with kindness and compassion. Feedback from patients was consistently positive about the care they had received on the unit.

However:

  • Patient flow through critical care was still a significant issue. 13% of patients were delayed for more than the recommended four hours and 38% of patients waited over 24 hours before being discharged to a ward. This was attributed to lack of bed capacity in the rest of the hospital.
  • Incidents of mixed sex accommodation breaches were only recently being recorded and investigated appropriately.
  • The CCU was an outlier for delayed discharges; the number of patients who waited more than 24 hours from decision to discharge for transfer to a bed on a ward was higher than the national average.
  • The unit’s risk register did not reflect all the risks we identified during our inspection. For example, we found that the restricted bed space in the high dependency unit was not included.

Outpatients and diagnostic imaging

Good

Updated 21 June 2016

Outpatients and diagnostic imagingservices at Northwick Park Hospital did not consistently offer appointments within defined target times.

There was a system in place to highlight which patients had waited longest and should be prioritised for the first available appointments. The trust had attempted to reduce the backlog of patients waiting for appointments, but financial constraints meant that additional clinics had been stopped.

We found that management of risks associated with emergency situations in some areas within the outpatient services including haematology had not been appropriately recognised, assessed or managed.

We found that there were regular shortages of nursing staff of up to 20% in the outpatients departments.

We found the method for tracking medical records was not reliable. Notes were stored in the medical records department and were collected by medical records staff in preparation for outpatient clinics. Staff were not always aware of or have access to the incident reporting system through Datix.

We found limited evidence of the effectiveness of outpatient services and at times staff were not always caring or respectful of patients.

The services had begun to integrate across the three hospital sites following the merger in 2014, but there was more work needed.

We saw good evidence of how diagnostic services respond to patients’ needs and how outpatients track the progress of patients on the waiting lists for appointments.

Urgent and emergency services

Requires improvement

Updated 31 August 2018

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

  • Mandatory training compliance was still poor for medical staffing and did not meet the trust target. This included safeguarding training.

  • The department still faced significant issues with ambulance turnaround which led to high numbers of black breaches.

  • There was evidence that the department reported incidents. However, similar to the previous inspection we were not always assured lessons learnt were embedded into practice. Some staff reported they did not receive feedback from incidents they reported.

  • Effective risk management arrangements were not in place for mental health patients and this placed patients at risk of unsafe care and treatment. The process for ensuring emergency department staff completed one to one observations of patients was not robust.

  • The band 5 nursing vacancy rate was high.

  • Some guidelines on the trust intranet had not been reviewed and were out of date.

  • Pain scores were not always documented in the paediatric emergency department. We found sometimes there was no evidence of pain scores or pain relief for children with painful conditions.

  • The department were performing below the national average in many of the Royal College of Emergency Medicine (RCEM) audits. We were told there were plans to re-audit a number of them but this had not yet taken place.

  • Appraisals rates were poor and below the trust target for nursing staff.

  • We did not see much health promotion information around the department.

  • The department did not meet the target to admit, discharge, or transfer 95% of patients within four hours between in any of the 12 months preceding or inspection.

  • Patients were still waiting for long periods before staff moved them to an appropriate ward or department once a decision to admit and been made. Access to services and patient flow continued to be a significant problem for the department and patients experienced long waits. The clinical decisions unit was often being used inappropriately for patients waiting for beds within the hospital.

  • Some staff raised concerns about the culture in the department. Some staff felt they were not listened to by the trust, especially when it came to decisions about service development.

  • There were no joint governance meetings between the emergency department and the urgent care centre. This meant learning from serious incidents was not shared with the urgent care centre.

  • There was now clinical governance at a departmental level. However, we were not assured this was as effective as it could be because things such as risk, incidents and complaints were not standing agenda items.

However:

  • Staff understood how to protect patients from abuse. Staff knew how to recognise and report abuse and they knew how to apply it.

  • The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.

  • Staff monitored patients who were at risk of deteriorating appropriately. Early warning scores were in use in both adult and paediatric areas.

  • Multidisciplinary working was evident in most areas of the department.

  • Staff were professional and care for patients in a caring and compassionate manner. Feedback from patients and relatives was positive.

  • The department had a frailty pathway, supported by specialists, to safely reduce admissions and length of stay for elderly patients and ambulatory care pathways.

Maternity

Inadequate

Updated 31 August 2018

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

  • We found systems, policies and procedures in the response to emergency paediatric crash calls via 2222 were not disseminated appropriately to all staff within the hospital and were not operated effectively.
  • Robust systems were not in place to ensure the security of the maternity unit. There was a risk that unauthorised people could gain access to theatres and the delivery suite via the theatre lift. Electronic doors on the main entrance could be pulled open at night by force and used by members of the public. During our unannounced inspection 14 June 2018, we were informed that security would be present at night at the entrance of the maternity to ensure that people do not enter the department. This was only an interim arrangement as permanent security solutions had not been decided or actioned.
  • There was no security on the doors between the delivery suite and theatres. This meant there was a risk of unauthorised access to both areas.
  • During our previous inspection in October 2015 we reported that mandatory training compliance was below the trust’s required standards. During this inspection we found mandatory training targets were still not being met by all maternity staff.
  • The flooring in the toilets in the antenatal clinic was also loose in places and posed an infection control risk.
  • We saw that straps on the cardiotocography (CTG) machine were not changed between patients, this posed a risk of cross infection from one patient to another.
  • There were no ‘tailgating’ notices on maternity wards. This created the risk of unauthorised people gaining access to the maternity wards.
  • The trust did not have an abduction policy for maternity. This meant staff may not know how to respond in the event of an infant or child abduction or suspected abduction.
  • There was no alert system in place for staff working in the community who may require support whilst working off-site.
  • The trust’s ‘shoulder dystocia guideline’ did not clarify which teams would attend an obstetric crash call.
  • Between February 2017 and January 2018 there were 39 complaints about maternity. The trust took an average of 46 working days to investigate and close complaints, this was not in accordance with their complaints policy.
  • The service did not have an open culture that welcomed review, where staff felt able to challenge each other in a friendly environment. Managers told us cultural considerations had been secondary to ensuring clinical governance systems were developed and embedded within the service.
  • Some staff said they felt there was a lack of consultation and communication by the divisional leadership and new working practices had been imposed on staff.
  • Managers and senior staff told us there had been tensions between some band 7 maternity staff and managers. Some senior midwifery staff told us they felt unable to challenge staff or take ownership of their department.
  • Risks on the risk register were not actioned in a timely way or at the earliest opportunity.

However:

  • During our previous inspection in October 2015 we reported 'fresh eye' checks were not always being carried out for women in labour. During this inspection we found the checks had been completed in accordance with best practice recommendations.
  • During our previous inspection we reported that staff did not always get feedback when the reported incidents. However, during this inspection we found improvements as incidents were widely reported and openly discussed with staff.
  • During our previous inspection in we found women’s pain scores were not recorded in their care records. During this inspection we found improvements in the recording of pain scores.
  • During our previous inspection we reported that the trust’s 85% standard for staff appraisals was not met. During this inspection we found this had improved and the trust’s standard was being met across maternity services.
  • During our previous inspection we reported the area used for triaging patients was not big enough to accommodate patient flow. However, during this inspection we found the triage area had recently been developed to facilitate women’s journey through maternity.
  • During our previous inspection we reported that antenatal clinics frequently ran over two hours late. During this inspection we found improvements with women waiting between 15 and 45 minutes for their appointment.
  • The trust had achieved UNICEF Baby Friendly accreditation and was working towards the gold award.
  • As of April 2018, the trust had no active maternity outliers.
  • In response to the ‘Better Births’ national maternity review (NHS England 2016). The birth centre had introduced caseloading.
  • Work was in progress on a bereavement room that would be completed in June 2018 and available to parents who had suffered the loss of a baby.

Maternity and gynaecology

Requires improvement

Updated 21 June 2016

We found concerns regarding the safety arrangements in the maternity services.These related to midwife shortages, not having safety thermometers on display and some staff reporting that they did not get feedback after reporting incidents.

Staff shared concerns with us about the environment, temperature and faulty equipment in the Day Assessment Unit.(DAU).

The records we reviewed showed venous thromboembolism (VTE) assessments were carried out and maternity early warning score (EWS) assessments were being completed. Gynaecology was also completing EWS. There were up-to-date evidence-based guidelines in place, however we were not able to find evidence that ‘Fresh eye’ checks were being recorded every hour for women during labour.

We did observe good practice in terms of effective multidisciplinary team working, multidisciplinary handover on delivery suite and that staff had the right skills, qualifications and knowledge for their role.

Some women experiencing pregnancy loss were being cared for in a room without sound-proofing. This meant that women in the room could hear the sounds of babies crying and this could cause distress. However, people told us they were consistently treated with dignity, kindness, and respect throughout the services.

We requested the current percentages of women seen in the labour ward within 30 minutes by a midwife, and the percentage seen by a consultant within 60 minutes, to determine timeliness of assessment. This information however was not being recorded.

Most of the people using the service told us that did not know who to make a complaint. Between October 2014 to September 2015 the service received 64 complaints. 13 of these were still open and being investigated at the time of the inspection. Some complaints had been open for over two months.

The Trust had a clear vision and strategy however the staff we spoke with did not demonstrate awareness or understanding of it. The trust vision and strategy was not visible throughout the wards and corridors. We saw the services' business plan for 2015 – 2016. It did not include the vision of the service.

Medical care (including older people’s care)

Requires improvement

Updated 31 August 2018

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

  • Leaders had failed to manage the high demand for the service and high bed occupancy, the service was still struggling to cope. Leaders had failed to address the length of stay for elective patients at Northwick Park Hospital.
  • Four risks identified on the risk register in 2017 and 2016 concerned the environment none of which related to the aging estate which did not always provide the best environment for providing care. Following the previous inspection we reported the environment of the stroke wards needed improving. During this inspection we found the stroke wards environment still needed improving.
  • The risk register did not include some of the concerns we found during the inspection including staff levels across the wards, mandatory training compliance and the movement of patients at night.
  • Most staff in the medical services knew the trust values. However most staff we spoke with were unaware of the integrated medicines divisional strategy. This was similar to what we found at the last inspection.
  • Although the service had taken action to address staff shortages, those actions had to date not resulted in improvements in permanent staff numbers.
  • Although the trust had systems for identifying risks and plans to mitigate risks, this did not always translate to improvements within the service. For example, there were inconsistencies in relation to document completion across the wards, kitchens, sluices and clean utility rooms were locked or unlocked, out of date medicines.
  • A total of 7,138 patients were moved at night between 11.00pm and 8.00am during the period 1st January 2017 to 31st December 2017. This means the trust was not focussed on getting patients a bed on a ward for their speciality.
  • The trust informed did not have data for the last year (2017) showing whether ward moves were due to non-clinical reasons.
  • From January 2017 to December 2017 the average length of stay for medical elective patients at Northwick Park Hospital was 13.5 days, which was longer than England average of 5.8 days.
  • The trust took an average of 43.1 working days (mean) to investigate and close these complaints. The trust responded to 45.4% of complaints within the target period of 40 working days. This is not in line with their complaints policy, which states that 80% of complaints should be responded to within 40 working days
  • The service did not have enough permanent nursing staff to ensure the provision of safe care and treatment. However, the service used bank and agency staff to cover gaps in the staffing provision.
  • Mandatory training in key skills for nursing staff was below the trust targets of 85% in three of the 10 core training areas. The overall completion rate was 80%. This was similar to what we found at the last inspection.
  • Mandatory training in key skills for medical staff was below the trust targets of 85% in none of the nine core training areas. The overall completion rate was 38%. This was similar to what we found at the last inspection.
  • Safeguarding adults level 2 training for medical staff was below the trust target of 85%. The completion rate was 58%.
  • Hand hygiene compliance was variable across the medical wards was monitored across the wards. Compliance varied from between 100% to 50%.
  • Care records were not being completed consistently. Some staff did not understand how to use all parts of the care record and were adding signatures to care plans without highlighting the specific aspects of the plan that were relevant.
  • Out of date medicines including a controlled drug (CD) which was a liquid medicine was found. This had a four-week expiry after opening. There was no opening date or expiry date on the bottle.
  • The temperature of ward fridges were consistently being recorded at more than eight degrees which meant that fridge temperatures were out of range and medicines were not being stored at the correct temperature.
  • There was not a systematic approach to keeping trust policies and guidelines up to date, which meant the trust could not be assured that staff were working with the latest guidance. We found this was similar during the previous inspection.
  • Fluid balance charts and malnutrition universal screening tool MUST assessments were not being completed consistently. We found this was similar in during the previous inspection.
  • The number of qualified nursing staff who had an appraisal in the period was 72.3% which was below the trust target of 85%.
  • The number of medical staff who completed the training was 57.5% which was below the trust target of 85%. However there had been an improvement since the last inspection in the number of nursing staff (92.7%) completing Mental Capacity Act training in the period April 2017 to January 2018,
  • We observed that patients on beds were sometimes transported in public lifts which meant visitors waiting for lifts saw these patients, which unnecessarily compromised their privacy and dignity.
  • We observed phones were unanswered on some wards. We did not know who calls were from but two relatives said it was difficult to get an answer when they rang the ward.
  • Signage to wards was sometimes misleading, and had not been updated to reflect where wards had been relocated. There was no sign to Kingsley ward (the haematology ward) in the lifts or on the list of wards beside the map. There were no signs on lifts that were meant for staff use only.

However:

  • There was a clear governance structure. The integrated medical division was responsible for all medical services across the three hospital sites within the trust and was led by a divisional clinical director, divisional general manager and divisional head of nursing, who worked across all three of the trusts sites.
  • Patients were being continually being assessed using the National Early Warning System (NEWS). Staff were knowledgeable in responding to any changes in the observations which necessitated the need to escalate the patient to be seen by medical staff or the critical care outreach team.
  • Serious incidents (SIs) were discussed as part of the monthly medicine clinical divisional quality and risk meetings clinical governance. SIs were investigated, had an action plan and lesson learnt identified.
  • Northwick Park Hospital consistently achieved grade A for overall performance for the Sentinel Stroke National Audit programme (SSNAP) over the six audit periods from October 2015 to July 2017. On a scale of A-E, where A is best.
  • Patients prescribed pain relief to be given ‘when required’ were able to request this when they needed it. Patient notes recorded whether patients had been asked about pain.
  • There was effective multidisciplinary team (MDT) working in the ward areas. Relevant professionals were involved in the assessment, planning and delivery of patient care. We found this had improved since the last inspection.
  • We saw clinical staff treat people with dignity, respect and kindness during their stay on the wards. Staff were seen to be considerate and empathetic towards patients. Most of the patients we spoke with were positive about the staff that provided their care and treatment.
  • From March 2017 to February 2018 the Friends and Family Test (FFT) response rate for medical care at Northwick Park Hospital was 41%. This was based on 6,737 responses. This was higher than the England average of 25%.
  • Most of the wards had day rooms or visitors room which staff could use to break bad news or have confidential conversations with relative. We saw staff providing emotional support to patients and relatives.
  • Most patients we spoke with said they felt involved in their care. Relatives we spoke to were mostly happy with the care their relatives received and felt they had been kept involved with their loved ones’ treatment.
  • The service took account of the needs of different people. Staff had received training in dementia and there was a mental health specialist nurse who provided advice relating to patients with mental health needs and an activities co-ordinator. Patients had access to translation services and relatives of elderly patients stay overnight.
  • The care of the elderly wards Fielding and Hardy had been made more dementia friendly using the Kings Fund environmental assessment tool.
  • Dickens ward had recently been restructured when the ward became a frailty medical assessment unit where elderly patients would be discharged after a short stay. The ward was aiming for a high daily discharge rate
  • Staff felt valued, supported and spoke highly of their jobs despite the pressures; Staff told us there was good team work and peer support and it was better when fully staffed, but when short staff it could be very stressful and it made their job much harder.
  • There was a culture of honesty, openness and transparency. We saw evidence of senior staff carrying out duty of candour responsibilities
  • Staff felt valued, supported and spoke highly of their jobs despite the pressures; Staff told us there was good team work and peer support and it was better when fully staffed, but when short staff it could be very stressful and it made their job much harder.
  • There was a culture of honesty, openness and transparency. We saw evidence of senior staff carrying out duty of candour responsibilities.

Surgery

Requires improvement

Updated 31 August 2018

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

  • Completion of mandatory training was variable and medical staff did not meet the trust’s target in any subject with some significantly below the standard.
  • Although there was evidence of learning from incidents and mistakes, outcomes did not always ensure practice was fully in line with national guidance or fully mitigate future risks of recurrence.
  • Staff knowledge and understanding of trust policies, or where to find them, was inconsistent and five serious incidents had been reported because of a failure to follow standards.
  • Theatre safety processes were audited and found between January 2018 and May 2018 the lead surgeon did not stay in the theatre for the final count of swabs and other items in 51% of the audit sample.
  • From December 2016 to November 2017 patients at Northwick Park Hospital had a higher than expected risk of readmission for elective admissions compared to the national average. However, the risk of readmission for non-elective patients was better than the national average.
  • Patients and relatives told us communication with doctors could be improved, particularly at weekends and when they were concerned about mental health needs.
  • There was a lack of clinical governance and leadership oversight in theatres that had led to lapses in electrical safety and medicines management.

However:

  • Risk management tools and procedures were embedded in practice and contributed to patient safety. This included tools to assess patient suitability for surgery and use of international standards, such as the World Health Organisation safer surgery checklist.
  • The trust had restructured areas in which we previously found concern and improved medical staffing cover to ensure specialist clinical needs were met.
  • There was a clear drive to deliver care in a culture that valued safety, openness and honesty. This included learning from incidents and good standards of dissemination of investigation outcomes.
  • Clinical staff demonstrated a drive to improve data quality for audits to ensure benchmarking and audit processes were accurate and vigorous. This included through internal exercises and externa peer review.
  • Multidisciplinary working was extensive and was part of day-to-day care and treatment as well as governance and risk management.
  • We observed consistently friendly, kind and compassionate care delivered by staff who understood how to facilitate privacy and dignity.
  • The hospital performed better than the national average for surgical referral to treatment times in 18 week specialty care pathways.

At our last inspection in October 2015 we told the trust they must:

  • Ensure staff, including consultants, always reported incidents.
  • Improve consultant radiologist cover at weekends.
  • Improve rates of mandatory training, including in the Mental Capacity Act (2005).
  • Improve the recording of nutrition and hydration.
  • Improve data completeness for bowel cancer surgery.
  • Ensure final checks of swab counts and instruments are undertaken with verbal confirmation before the surgeon de-scrubs.
  • Develop appropriate surgical care pathways.
  • Develop and communicate the vision and strategic aims of the surgical directorate to all staff.

At this inspection the trust provided evidence incident reporting had increased steadily over the previous three years and evidence that consultant radiologist cover had been improved at weekends. In addition, we saw consistently good standards of documentation for nutrition and hydration and processes to improve data management in cancer care. Specialist teams had also developed new evidence-based surgical care pathways. However, rates of mandatory training were variable and were very low for doctors in some subjects. In addition, surgical safety audits indicated the lead surgeon did not always remain in theatres for the final verbal count of swabs.

Services for children & young people

Requires improvement

Updated 31 August 2018

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

  • Mandatory training completion rates for nursing and medical staff were not meeting the trust target.
  • Processes and systems could not always be relied upon to protect children from abuse and harm. Children on the child protection register were not always identified, and arrangements for vulnerable patients between 16 and 18 years were not robust.
  • There was a lack of appropriate assessment for children with mental health concerns during nights and weekends, which meant they may stay in hospital longer than necessary.
  • Nursing vacancies were high across all areas of the service, with a high turnover rate between January and December 2017. This led to a high proportion of bank and agency staff being used to fill shifts.
  • Nutrition and hydration assessments were not always completed. We found gaps in feeding charts and the frequency of patient assessment reviews.
  • The pain tool, used by the service to assess and manage pain, was not consistently completed and reviewed.
  • The children and young people’s service did not have a nursing lead for patients with a learning disability or mental health concern. Advice was sought from the Children and Adolescent Mental Health Service Monday to Friday, but there was no support at night or weekends.
  • The service did not always provide a smooth and timely transition for patients moving between children and adult services. The trust did not have a transition policy and staff felt that guidelines required clarity.
  • Bed space capacity during the winter months was not meeting the increasing demand, particularly for patients with higher and more complex needs. The inpatient ward was providing high dependency care although this was not yet funded and there was no designated area.
  • Senior leaders of the trust were rarely seen on the children and young people’s wards. Medical staff told us there was no forum for them to raise ideas or concerns with the senior leadership team.
  • Audits were regularly undertaken within the service to check that guidelines were being followed. However, robust action plans were not always put in to place when gaps were identified.
  • The service did not have a forum for children and young people, and their carers, to provide feedback about the care and treatment received at the hospital.
  • Most staff within the children and young people’s service said that communication could be improved. In particular, staff said ward meetings did not always go ahead. Emails with a brief summary were sent out to staff who missed meetings.

However:

  • All areas within the children and young people’s service were visibly clean, and we found infection control protocols were adhered to.
  • Paediatric early warning scores were routinely recorded to identify patients that may be deteriorating.
  • We saw evidence of good multidisciplinary working throughout all areas of the children and young people’s service. Psychosocial and complex case meetings discussed the social and psychological wellbeing of patients.
  • We observed compassionate care being provided across all areas of the children and young people’s service by nursing and medical staff.
  • Children and their carers felt fully involved in their care and treatment. Doctors and nurses explained procedures in a relaxed and child friendly manner.
  • Transitional care was provided on the neonatal ward, enabling mothers to stay with their baby whilst receiving hospital care, and preparing for discharge.
  • The service had won a national patient experience network award for its’ use of technology and actively engaging with adolescent users of the diabetes services. This had led to a reduction in patient non-attendance at the diabetes clinics.

End of life care

Good

Updated 21 June 2016

We found the specialist palliative care team (SPCT) to be passionate about ensuring patients and people close to them received safe, effective and good quality care in a timely manner.

The patients and relatives spoke positively about their interactions with the teams involved in their care.

The trust had responded to the withdrawal of the Liverpool Care Pathway. The trust used a holistic document which was in line with the five priorities of care, was called the ‘Last Days of Life Care Agreement' (LDLCA). However, this document was not compulsory to use across the hospital leading to difficulties in following some care plans.

Patients’ records and care plans were regularly updated, matched the needs of the patient and were relevant to EOLC.

There were some concerns raised by specialist staff and from our observations about whether all generalist nurses, doctors and consultants had the expertise to recognise dying; and had the skills to have difficult conversations about planning care for those at the end of their life.

The SPCT were focussed on raising staff awareness around EOLC. However they said that this should be a trust wide responsibility.

The trust had recently run a pilot training scheme for staff on the elderly care wards. However this is not yet part of mandatory training.

Staff were aware of their responsibility in raising concerns and reporting incidents.They were keen to report any incidents in relation to palliative and EOLC in order to drive improvement.

There were few complaints in relation to EOLC and staff told us they preferred to deal with concerns or issues at the time to try to deal with it prior to it becoming a formal complaint.All staff understood their role and responsibility to raise any safeguarding concerns.

We found that leadership of the SPCT was good at a local level, and all staff reported being supported by their line managers. The SPCT were able to communicate the trust's vision. However they were not always able to explain how this was going to be met. Cross site working was in its infancy and staff expressed a difficulty in doing more due to the difficulties in physically getting between the hospitals in the trust.