You are here

Bradford Royal Infirmary Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 15 June 2018

  • The medical services were rated as requires improvement in safe and effective but good in caring, responsive and well-led. The service did not always have appropriate numbers of staff to ensure patients received safe care and treatment. However, despite the 18% overall nursing vacancy rate for medicine, the service did manage staffing well and reviewed staffing throughout the day. There is concern regarding the sustainability of the current situation as there is also a 15% nursing turnover rate and a 5% sickness rate. The service was not meeting trust targets for mandatory training completion. The service did not always have suitable premises. The trust had been identified as an outlier for stroke mortality data and they were Band D in the Sentinel Stroke National Audit Programme (SSNAP). Results for the 2015 Heart Failure Audit were worse than the England and Wales average for all of the four of the standards relating to in-hospital care and

    for all of the seven standards relating to discharge.

    The Myocardial Ischaemia National Audit Project (MINAP) from April 2015 to March 2016 was noted to be below the national average for being admitted to a cardiac ward and better than average for being seen by a cardiologist. Also a lower proportion of patients were referred for angiography than the England average. Training that staff needed to undertake for their job roles was not consistently up to date. However, staff cared for patients with compassion and treated them with dignity and respect and we saw areas of outstanding practice. The service had an outstanding approach to multidisciplinary working. Staff described effective working relationships between consultants, doctors, nurses, health care assistants and allied health professional staff.

  • The maternity services were rated as requires improvement in the safe, effective and well led domain; caring and responsive were rated as good. We found some of the areas of concern had not changed from the last inspection. Mandatory training rates and compliance with the World Health Organisation (WHO) safety checklist was variable. Infection prevention and control audit data was not being consistently collected each month. We also found some concerns in relation to medicines management and midwifery staffing. Care and treatment was evidence based however we found a number of guidelines past their review date. Some patient outcome data was worse than regional averages. We were concerned over the identification of some risks to the service and the slow pace in implementing actions from audits and reviews. However, we also found that care was patient centred and compassionate and we received positive feedback from the patients and relatives we spoke with.

  • In surgical services we rated all domains as good. We found that relevant staff working complied with the five steps to safer surgery process and that the WHO surgical safety checklist was consistently followed and audited. Policies and pathways were based on guidance from the Royal College of Surgeons and the National Institute for Health and Care Excellence (NICE). Staff worked together as a team for the benefit of patients. Doctors, nurses and other healthcare professionals supported each other to provide care. The trust’s performance for elective and non-elective admissions relating to overall length of stay was better than the England average. Staff told us the division had strong leadership and senior managers were visible and engaged with staff.
  • The urgent and emergency care services had improved overall and was rated good in all domains. The new emergency department met our previous concerns about the limitations of the previous department’s facilities; the department worked closely in liaison with the acute assessment area, the medical admissions unit and the ambulatory care unit to support the efficient flow of patients. Leadership and governance of the emergency department was stable with elements of good practice and staff spoke positively about the clinical leadership of the department; medical and nursing staff at all levels were clear about their roles; the culture was positive, friendly and open with high staff morale. The vision and strategy for the emergency department was supported by the clinical services strategy for 2017 to 2022 and the department embraced the overall mission of the trust to provide the highest quality healthcare. Information was used to monitor and manage the operational performance of the department, and to measure improvement. However, the sepsis audit figure, for antibiotic administration within 1 hour, was only 16% against national average of 44%; there were staffing concerns and the introduction of the electronic patient record in September 2017 adversely affected the completion of mandatory training.
  • Overall we found that care was patient centred and compassionate and we received positive feedback from the patients and relatives we spoke with.
  • This demonstrates positive improvement since the last inspection but as two of the services that were not inspected on this visit had elements of requires improvement this has not allowed the hospital to raise its rating overall. The concerns in those services will continue to be monitored through our engagement programme.
Inspection areas

Safe

Requires improvement

Updated 15 June 2018

Effective

Requires improvement

Updated 15 June 2018

Caring

Good

Updated 15 June 2018

Responsive

Requires improvement

Updated 15 June 2018

Well-led

Requires improvement

Updated 15 June 2018

Checks on specific services

Critical care

Good

Updated 24 June 2016

We rated this service as good overall.

We found the relationships within the unit had improved. Senior managers now attended team meetings and were more visible on the wards. Governance structures were still not embedded and clinical leads had only recently come into post.

Staffing was adequate to meet patient needs and medical staff now worked one week in seven on ICU, in-line with national standards. Nursing staff had access to critical care training at the local university. Following the previous inspection we found that the service had reviewed the ward area and redesigned access to the sinks to improve infection control. The service planned to move the four HDU beds from a bay on a ward to a larger area which would allow patients to be cared for in a more suitable environment.

The capacity of the service to meet demand remained an issue. The bed occupancy for the unit was about 92% and patients were sometimes being cared for in recovery in the nucleus theatre because there was not a bed available on ICU. It was unclear if the new unit would be sufficient to reduce the occupancy rates because the number of ICU beds was not being increased. There had been no review of unmet demand for beds, which was identified as an action from the previous inspection and quality key indicators reports. The service was still not seeing all patients within 12 hours of admission although improvements had been made and processes put in place to mitigate the risk.

Patient outcomes information was not always completed and audits from patient outcomes were not always available. However the service did complete Intensive Care National Audit and Research Centre (ICNARC) data and it was used to benchmark against similar organisations. The service had not reviewed policies and procedures to ensure they adhered to professional standards and guidelines.

Delayed discharges of over four hours still occurred. However, the number of delayed discharges of over four hours had reduced since the last inspection and delayed discharges were better than similar units. Quicker discharges were facilitated by staff attending bed meetings to discuss discharges from ICU.

Outpatients and diagnostic imaging

Requires improvement

Updated 24 June 2016

We rated the service as requires improvement. We found that a great deal of work had been undertaken to improve the arrangements for booking appointments, addressing concerns over the identified backlog with outpatient appointments and develop assurance mechanisms. However, the new systems and processes had not yet been embedded within the outpatient service and further work was required to establish the new centralised patient booking system. Staff did not feel engaged with the changes and expressed frustration at the new systems and processes. A programme of training and development had been introduced as part of the improvement plan to establish the centralised patient booking service. This was work in progress at the time of this inspection.

We found that there were systems and processes in place for incident reporting and learning from incidents.

There were staff shortages across outpatients and diagnostic and imaging services, with some specialities particularly impacted at times such as dermatology clinics. There were arrangements in place to assess whether staffing levels were safe, access support through agency or locums and from colleagues in other clinics.

There had been a reduction in the number of patients waiting on the total RTT waiting lists and in particular the backlogs identified in August 2014 and April 2015. However, there were still a large number of patients waiting for appointments, which could delay access to treatment.

There were times when there were delays in accessing interpreting services and on occasion patients’ relatives were translating questions, which may not have been appropriate or protecting patient privacy.

Urgent and emergency services

Good

Updated 15 June 2018

A summary of our findings about this service appears in the overall summary.

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

  • Patients were clinically streamed on arrival in the department, with the oversight of qualified nurses and triaged promptly, usually with medical input.
  • Staff acted promptly to escalate their concerns when a patient’s condition deteriorated, so that the patient received the most appropriate care and treatment.
  • Patients consistently gave positive feedback about their experience in the emergency department. Staff provided appropriate and timely support to help patients cope emotionally with their care and treatment.
  • Almost all patients were assessed with 15 minutes of arrival during our inspection, which mainly met our previous concerns that not all patients were being assessed promptly, and waiting times of patients between four and 12 hours showed a long term trend of improvement.
  • An agreement with a neighbouring mental health trust provided support for patients experiencing ill mental health and we observed this multidisciplinary arrangement worked well although we did observe some delays for assessment.
  • Medical and nursing staff, of all grades, were deployed in sufficient numbers to support a safe service, staff received regular appraisals and staff development opportunities were consistently well received by staff.
  • The emergency department followed recognised evidence-based care and treatment guidelines and participated in national audits to enable its practice to be compared.
  • The emergency department had implemented electronic patient records so that the records of patients were complete, accessible, audited and met our previous concerns as to patient confidentiality.
  • Staff reported incidents and applied safeguarding procedures for adults and children appropriately; Staff had an appropriate understanding of consent, mental capacity, and deprivation of liberty safeguards.
  • Risks were identified, regularly reviewed and mitigation and action was taken. the department’s processes and systems were reviewed through regular audit and monitored to support improvement.
  • The new emergency department met our previous concerns about the limitations of the previous department’s facilities; the department worked closely in liaison with the acute assessment area, the medical admissions unit and the ambulatory care unit to support the efficient flow of patients.
  • Leadership and governance of the emergency department was stable with elements of good practice and staff spoke positively about the clinical leadership of the department; medical and nursing staff at all levels were clear about their roles; the culture was positive, friendly and open with high staff morale.
  • The vision and strategy for the emergency department was supported by the clinical services strategy for 2017 to 2022 and the department embraced the overall mission of the trust to provide the highest quality healthcare.
  • Information was used to monitor and manage the operational performance of the department, and to measure improvement.

However:

  • The layout of the reception area did not support the confidentiality of patients.
  • Signposting to the emergency department in the hospital needed to be improved.
  • Nurse practitioner recruitment needed to be completed so that the ambulatory care unit (ACU) was fully staffed for extended hours.
  • Mandatory training needed to be fully completed by all staff, including staff training and competency assessments to support the safe use of patient group directions.
  • Improvements were required for sepsis outcomes for the emergency department, the unplanned re-attendance rate within seven days and to the high number of patients leaving the department before being seen.
  • Some key operational performance information (particularly compliance with the 95% standard) was not presented clearly in the emergency department.
  • Information for patients was not available in the reception area and further information in printed form was not available for patients and their carers, particularly about the support available for patients with mental ill health, dementia or learning disability.
  • The friends and family test for the emergency department had achieved a very low response rate particularly in the last 12 months.
  • The trust’s policy commitment to resolve complaints within 30 days was not always being met, although recent improvements in complaint handling had been achieved.
  • The links with primary care services needed to be developed further to support the emergency department’s role in health promotion and the use of joint patient pathways to avoid unnecessary referrals to the emergency department.

Maternity

Requires improvement

Updated 15 June 2018

We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings.

We rated this service as requires improvement because:

  • We rated safe, effective and well led as requires improvement, caring and responsive were rated as good.
  • We found some of the areas of concern had not changed from the last inspection. Mandatory training rates and compliance with the World Health Organisation (WHO) safety checklist was variable. Infection prevention and control audit data was not being consistently collected each month. We also found some concerns in relation to medicines management and midwifery staffing.
  • Care and treatment was evidence based however we found a number of guidelines past their review date. Some patient outcome data was worse than regional averages.
  • Care was patient centred and compassionate; we received positive feedback from the patients and relatives we spoke with.
  • We found patient care to be individualised and plans were in place to improve access and flow in the department.
  • We were concerned over the identification of some risks to the service and the slow pace in implementing actions from audits and reviews.

Maternity and gynaecology

Good

Updated 24 June 2016

We rated this service as good overall. We rated safety as requires improvement. Staffing levels and skill mix had improved since our previous inspection in October 2014. However, further planned recruitment was to take place and staff had not yet experienced the full benefit of the recruitment made towards the end of last year. Nurse staffing shortfalls continued for the labour ward, theatres and staff continued to cover shortages on the labour ward.

At the previous inspection, the morning staff handover consisted of four separate staff handovers, followed by a ward round. The arrangements were not always effectively managed, which at times resulted in overlap between teams and some delays. Since that inspection, the handover process had been reviewed. The changes were to reduce the lengthy process and improve the handover period.

We found staff had not always checked the resuscitation equipment daily to ensure it was available in an emergency. This was also identified at the previous inspection.

Daily checks of medicines and infant milk storage refrigerators were not taking place. This meant staff would not know if the medication or milk products had been stored within the correct temperature range and remained safe to use.

Although the overall figures for completion of mandatory training had improved, the individual figures for basic life support and movement and handling training were below the trust target of 95%.

There were effective systems for reporting, investigating and acting on adverse events and there was an up to date incident reporting and investigation policy. Staff were able to give examples of feedback received from incidents, lessons learnt and action taken where appropriate, to prevent a similar situation occurring.

The consultant obstetricians cover for the labour ward had increased, from 60 to 98 hours per week since the last inspection. This complied with the Royal College of Obstetricians and Gynaecologists (RCOG) best practice standard for consultant labour ward cover.

Women’s services were clean, well maintained and there were effective systems in place to monitor infection control.

Records relating to women’s care were of a good standard and stored securely in line with the data protection policy.

Medical care (including older people’s care)

Requires improvement

Updated 15 June 2018

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

  • The trust had been identified as an outlier for stroke mortality data and they were Band D in the Sentinel Stroke National Audit Programme (SSNAP). The trust had investigated this and identified an issue with the data submissions. The SSNAP team were to visit the trust in early 2018.
  • The trust performed worse than the England and Wales average for all of the four of the standards relating to in-hospital care in the Heart Failure Audit 2015 (published 2017). In particular, the input from specialist metric was 40% lower than the England average. The trust also performed worse than average for all of the seven standards relating to discharge.
  • The Myocardial Ischaemia National Audit Project (MINAP) showed the trust was below the national average for patients being admitted to a cardiac ward and better than average for being seen by a cardiologist. Also a lower proportion of patients were referred for angiography than the England average.
  • The service was not meeting trust targets set for mandatory training completion.
  • The service did not always have suitable premises.
  • The service did not always have appropriate numbers of staff to ensure patients received safe care and treatment.
  • The service did not always make sure staff were competent for their roles.
  • The environment throughout the service was not sufficiently adapted to provide people with care in a way that met their needs.
  • The service did not have a robust governance process for information management. We reviewed 14 policies and guidance documents and found that nine were out of their review date.

However:

  • The service managed patient safety incidents well. Staff knew how to report incidents and gave examples of recent incidents they had reported.
  • Patients’ records were secure and well completed. The service used electronic patient records and staff were enthusiastic and engaged with the implementation and roll out.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. Staff had a good understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards.
  • Staff of different disciplines worked together as a team to benefit patients. Staff cared for patients with compassion and treated them with dignity and respect. Staff involved patients and those close to them in decisions about their care and treatment.

  • The virtual ward model had helped to decrease avoidable hospital admissions, had been embedded well and improved access and flow.
  • The divisional leadership team had a good understanding of the local demographic and their health needs. The service had a vision for the future and workable action plans developed with involvement from staff, patients, and key groups representing the local community.

Surgery

Good

Updated 15 June 2018

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

  • Patients were protected from abuse because staff had received training in safeguarding, there was a lead nurse for safeguarding and staff reported good support from the psychiatric liaison team.

  • Staffing numbers were reviewed regularly to ensure they were safe despite significant challenges.
  • Learning was evident in discussions with staff about incidents and staff knew how to report incidents.
  • The trust had ensured relevant staff working in surgery complied with the five steps to safer surgery process and that the WHO surgical safety checklist was consistently followed and audited.
  • Policies and pathways were based on guidance from the Royal College of Surgeons and the National Institute for Health and Care Excellence (NICE).
  • Enhanced recovery pathways were in place, for example for patients undergoing elective joint replacement surgery.
  • Staff worked together as a team for the benefit of patients. Doctors, nurses and other healthcare professionals supported each other to provide care.
  • The trust had a multi-faith chaplaincy service and bereavement service and patients confirmed staff provided emotional support. The bereavement service scored positively in recent audits.
  • All wards were dementia friendly and had a wide range of resources available for people living with and caring for people with a dementia. Specialist dementia nurses were employed by the trust and access to learning disability liaison support was available.
  • The trust’s performance for elective and non-elective admissions relating to overall length of stay was better than the England average.
  • The surgical division had a management structure in place with clear lines of responsibility and accountability; senior staff were motivated and enthusiastic about their roles and had clear direction with plans in relation to improving patient care.
  • Staff told us the division had strong leadership and senior managers were visible and engaged with staff.

However:

  • Although staff received mandatory training, compliance rates were variable; the rates of completion for Mental Capacity Act training and also for the completion of staff appraisals were below trust targets.
  • Environmental issues were identified with floors in theatres although these were in the process of being addressed by the trust.
  • The trust recognised there remained a risk of contamination of the clean scrub area during the movement of dirty instruments from theatre.
  • The trust had higher than expected risks of readmission for both elective and non-elective admissions when compared to the England averages.
  • The percentage of cancelled operations at the trust was higher than the England average.
  • The trust had received a concern from the National Joint Registry Outlier Committee drawing attention to the mortality rate for knee replacements.
  • The trust was not meeting its policy that complaints should be resolved within 30 days of receipt and took an average of 55 days to investigate and close.
  • Patients described the care they received in positive terms and friends and family recommendation rates were over 90% but response rates were very low.

Services for children & young people

Requires improvement

Updated 24 June 2016

We rated this service as requires improvement. There had been recent increases in staffing to account for winter pressures and the need for staff to attend the paediatric stabilisation unit. However, nurse staffing was below recommended levels. However, there were still frequent staff shortages for shifts across the service. At times staff levels did not achieve 85% of shifts filled.

The trust was progressing in the development of a new building which would address the concerns about the environment in which children were cared for.

The trust had addressed the safety concerns raised about the paediatric stabilisation unit during the comprehensive inspection in October 2014. There were suitably qualified and trained staff to support critically ill children until the paediatric transfer team arrived.

The service had undergone a change to leadership and management structure. The trust had established a children’s board and there were clear governance structures to report to the Trust Board. The trust had engaged with staff and the public to contribute to the design of the building to create an environment which was reflective of the needs of local children and families.

End of life care

Good

Updated 24 June 2016

We rated this service as good because people at the end of their life were cared for within the hospital by ward staff, who were supported by a hospital specialist palliative care team. This team worked closely to the national Gold Standards Framework to ensure that patients experienced a good quality of care at the end of their life. The team was supported by a consultant in palliative care medicine ensuring that appropriate and timely advice was available to staff across the wards and district. In addition, patients and their relatives had access to support through the ‘Gold Line’ a telephone service, available 24 hours a day, seven days a week.

Care was arranged to meet the needs of the individual and to ensure where possible that people were able to spend the end of their life in their preferred place of death. There were systems and arrangements in place to ensure that people’s diverse needs were respected and supported. There was collaborative working across multi-disciplinary teams and other agencies to ensure that patients with cultural, religious and special needs such as a learning disability were incorporated into their individual care packages.