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Weston General Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 26 June 2019

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

  • There remained issues with nursing and medical staffing which did not ensure safe care at all times in the emergency department, medical care wards and the children and adolescent mental health services. The trust provided mandatory training in key skills to all staff; however, they did not make sure everyone completed it. In medical care and surgery we found the services did not always follow best practice when prescribing, giving, recording and storing medicines. Patients did not always receive the right medication at the right dose at the right time. We also found the process for supplying medicines for patient discharge in the discharge lounge could cause delays.
  • There was a higher than expected risk of readmission for patients discharged after care and treatment in general medicine, gastroenterology, stroke medicine and geriatric medicine. We also found there were difficulties in identifying patients who were re-admitted with a surgical site infection. In the emergency department we found the service monitored the effectiveness of care and treatment but there was no effective system to report on results and limited substantial evidence to show that the service had taken action in response to poor outcomes.
  • The trust tried to plan and provide services in a way that met the needs of local people, however they were restricted by the uncertainty of its future. Patients did not always have timely access to initial assessment, diagnosis or urgent treatment, and the people with the most urgent needs did not always have their care and treatment prioritised. We found the emergency department was frequently crowded; patients were cared for in non-clinical areas and some were accommodated overnight, without access to suitable bathroom facilities.
  • Managers for the emergency care division, which included urgent and emergency care and medical care, had the abilities but did not always use the right skills to run a service providing high-quality, sustainable care. Some staff told us they felt undervalued by service leads. The service did not have effective governance systems to provide assurance of quality and safety. We also found there were compatibility issues with IT systems across the trust.

However,

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. In medical care and surgery, we saw the services used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors. Managers used this to improve the service. The trust controlled infection risk well.
  • Patients had enough food and drink to meet their needs and improve their health and provided health promotion information for patients to support them to manage their conditions and health choices. Staff also assessed and monitored patients regularly to see if they were in pain.
  • Staff were kind and caring to their patients. The patients we spoke with were largely positive about the compassion and kindness of staff, and their dedication to giving good care, and we observed patients being treated with care and respect throughout their stay in hospital. In the child and adolescent mental health service young people could have open discussions about their personal, cultural, social and religious needs with staff, as they knew staff would respect their wishes and help meet their needs.
  • The trust treated complaints seriously, investigated them, learned lessons from the results and shared these with all staff, although they did not always meet the deadlines to deal with complaints.
  • In surgery we found the surgical leadership were clear about their roles and understood the challenges faced by the service. There were governance processes and oversight in the surgical division.
Inspection areas

Safe

Requires improvement

Updated 26 June 2019

Effective

Good

Updated 26 June 2019

Caring

Good

Updated 26 June 2019

Responsive

Requires improvement

Updated 26 June 2019

Well-led

Requires improvement

Updated 26 June 2019

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 26 June 2019

Some domains had improved but the overall rating of this service stayed the same. We rated it as requires improvement because:

Medicines management needed improving. We found medicines had not been stored according to best practice guidelines and some had no expiry dates on them. Some patients had their medication delayed or missed when waiting in the discharge lounge. Medicines for discharge of patients in the discharge lounge could be delayed due to a lack of registered staff available to provide and explain medicines to patients.

There were not enough nursing and therapy staff to always safely care for patients and staff did not always follow trust policies when caring for patients. Acutely unwell patients did not always receive the appropriate level of monitoring.

Not all staff had attended mandatory training.

Service leads did not always use the best methods of engaging staff and inviting opinion. Some staff felt inhibited, undervalued and unsupported by senior managers.

Most staff felt they could raise concerns but were doubtful that any actions would result.

However,

Records were kept in an organised way and staff had completed risk assessments for patients. These were transferred to care plans for staff to follow.

Staff were knowledgeable about safeguarding procedures and knew how to access support if they needed it.

Most staff were knowledgeable about what incidents to report. We found some staff were not clear about what they reported as an incident but incidents which were reported were investigated fully and improvement actions were identified. Staff used safety monitoring and audit results to inform their practice and make improvements. National standards and guidelines informed their practice and policies were developed using this information.

There was a strong ethos of team working and staff enjoyed working in the trust. Staff up to and including matron level, supported each other and were respectful in their contacts.

Matrons and ward managers supported their staff well and all staff felt they could approach any manager at this level.

Service leads used processes to provide an oversight of how staff were performing and outcomes for patients.

Staff were aware of individual needs of patients and developed systems to meet those needs wherever possible. This included patients with learning disabilities, mental health needs and dementia.

Specialist staff connected with staff in the community to create a smooth pathway of care for patients with ongoing needs.

Critical care

Good

Updated 14 June 2017

We rated the service overall as good because:

  • The care and treatment delivered, and the practices and protocols around them were safe.
  • There was a strong culture around delivering safe care.
  • People were protected from abuse and avoidable harm.
  • Care was effective and patients had the outcomes that should be expected.
  • Staff were well trained and experienced at delivering care.
  • Staff were caring, compassionate, and treated patients as individuals.
  • The services met the needs of vulnerable people, and those with specific mental and physical needs.
  • There were good assurance frameworks to demonstrate how the quality and safety of care was reviewed and understood.
  • There was a good culture of staff and patient involvement in the unit.
  • There had been patient-focused improvements in the unit from the committed staff team.

However:

  • With a high mortality rate at this trust, the service was not demonstrating learning from reviews into patient deaths.
  • There were problems with patient flow in the rest of the hospital and this was affecting the ability to admit, transfer, and discharge patients in critical care at the right time.
  • There was a lack of multidisciplinary or a collective approach to the leadership and management of the critical care unit.

Surgery

Good

Updated 26 June 2019

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

  • Safe care was being provided in many areas of the surgical service. Staff understood how to protect patients from abuse. Patient risk was well considered and there were clear processes for escalation and support should a patient deteriorate. The world health organisation’s five steps to safer surgery was observed to be completed well and was embedded in practice. Patient safety incidents and patient safety performance was monitored, managed and learning identified to make improvements to the service.

  • There was effective care within the surgical service. Care and treatment were based on national guidance and evidence of its effectiveness. The effectiveness of care and treatment was monitored, and the trust were generally performing similar when compared to other trusts. Patient’s nutrition, hydration and pain was well managed. Teams worked well together to deliver care which benefitted the patient.

  • The care provided to patients was done so with compassion, dignity and respect. Patients spoken with were largely positive about the dedication and kindness of staff. Staff provided emotional support to patients when needed and involved them in decisions about care and treatment.

  • Although responsiveness requires improvement, the service was restricted by the future plans for the trust and thus for the surgical service. Theatre productivity was a priority for the transformation team and was reviewed regularly. Patients had access to the service when they needed it for planned and emergency surgery. There were strict guidelines to minimise cancellations for patients, particularly patients with cancer. The trust had learnt from the problems identified in the previous year and had arranged for additional bed capacity to support when the day surgery unit was used for escalation for inpatients.

  • The surgical leadership team were clear about their roles and understood the challenges for the service, although the vision and strategy were once again impacted by the trust’s future. There was a positive culture observed. Governance processes were established, and staff were clear about their responsibilities within this. There were effective systems for identifying risks and risk were well understood by staff and leaders.

    However,

  • In some area’s safety could be improved and brought in line with best practice. Mandatory training compliance for medical staff was not meeting trust targets and there were inaccuracies with reporting of this data. Medicines were not always managed appropriately, to include storage and medicines reconciliations. Staffing was challenged although being managed to keep patients safe. However, there were concerns from the junior doctors with the processes to support urology patients overnight and at weekends, which require further review and resolution.

  • There were a few areas which would help to improve the effectiveness of the service. Appraisals needed further focus to enable them to meet trust targets for all staff groups. Consideration could also be given to patients being re-admitted to hospital with a surgical site infection and how this is identified to allow investigation.

  • Responsive was rated as requires improvement. The responsiveness of the service was impacted by the theatres not being fully utilised as there were not enough surgeons to run theatre lists. Data provided from the trust also showed late starts in theatre were occurring frequently, and patients were not always discharged from recovery in a timely manner. Some environments could also be improved to include the day surgery unit and the theatre receiving unit, both of which were limited by their environment but being managed by the teams.

  • The leadership team had undergone frequent changes with interim arrangements, which made it difficult for consistency across the surgical directorate. We found although risks were well understood and identified, the risk registers did not have clear actions to see a trail of the management of risks. There were also compatibility issues with IT systems used across the surgical service.

Urgent and emergency services

Inadequate

Updated 17 December 2019

  • Governance systems were still not operating effectively. We had limited assurance that the main governance forum in the emergency department provided good oversight of quality and risk at departmental, directorate or trust level, in order to support informed decision-making. The risk register was not up to date and was not an effective tool to manage risks or provide assurance that controls were effective. Incident management had improved and serious incidents were investigated and acted upon within appropriate timescales. However, there remained a significant backlog of other incidents and actions arising from incidents.

  • Although junior doctors were mainly positive about the support and supervision they received from senior medical staff, some still told us that the quality of supervision was variable depending on which consultant was in charge. Concerns were expressed about a lack of support and supervision at weekends. Middle grade doctors were unhappy about a lack of teaching and educational opportunities and a number of staff had left or were considering leaving for these reasons.

  • There was limited assurance that the nursing workforce had the skills and experience to provide safe care and treatment. A training needs analysis was underway but this still showed numerous training gaps. Training sessions were being provided but these were ad hoc and did not form part of a coordinated and structured training plan. There was still no structured or formal system of nurse supervision, although some progress had been made in identifying teams to be led by senior nurses.

  • Overall, the service has made good progress in addressing concerns; however, changes were not fully rolled out or embedded and progress was limited by management capacity. This was in the context of a service experiencing intense pressure due to increasing demand for services, poor patient flow in the hospital and continuing staff shortages.

However:

  • Governance systems, meetings structures and terms of reference had been reviewed and a new governance lead had been appointed.

  • The service had done a lot of work to address our concerns with regard to nurse supervision and training. A competency framework had been developed, a training needs assessment was underway, and a practice education nurse had recently been appointed. There had been a concerted effort to ensure all staff were trained in non-invasive ventilation.

  • The service had introduced a quality improvement/training forum, where mortality and morbidity reviews took place and audits were presented.

  • There was a programme of clinical audit and a review of clinical guidelines was underway. Action plans had been developed following national audits and there was evidence of actions being progressed.

  • The service had identified mentors from a neighbouring trust to support senior medical staff to develop leadership and supervisory skills.

Specialist community mental health services for children and young people

Inadequate

Updated 17 December 2019

  • Managers had ensured the service was fully recruited to, promoting optimal capacity of the team. Temporary staff had also been recruited to support with reducing the waiting times for people on the waiting list. The time young people were waiting between assessment and referral had reduced.

  • The risk of people on the waiting list was monitored by staff and managers maintained oversight of this. Care records contained clear and comprehensive risk assessments, and risk management plans were present where required. Managers had delivered specific training on care records and risk assessments.

  • We were assured sufficient priority and resources had been allocated by the trust to address issues around paper care records.

  • The trust had recruited a clinical nurse lead to govern and maintain oversight of clinical activity within the team.

  • Managers had good oversight of incidents that had occurred and were able to give us examples of how practise may be changed to prevent repeated incidents reoccurring.

  • Managers had developed process and policies to ensure the service was managing risk appropriately. Governance structures were in place to monitor the key areas of the service to identify risk. Managers were actively reviewing the service to develop ways of improving efficacy and quality of service delivery.

  • Managers maintained oversight of the performance, quality, safety and efficiency of the service.

However:

  • Although the risk of people on the waiting list was being monitored, staff had concerns about the process by which this was being completed.

  • The use of paper care records continued to cause risk.

  • Although managers had started to implement governance structures to review the quality of the service, they were not yet fully embedded to enable us to evidence their effectiveness.

Other CQC inspections of services

Community & mental health inspection reports for Weston General Hospital can be found at Weston Area Health NHS Trust.