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Bradford Royal Infirmary Requires improvement

Reports


Inspection carried out on 9 January 2018 to 8 February 2018

During a routine inspection

  • 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 carried out on 11/01/2016

During an inspection to make sure that the improvements required had been made

Bradford Teaching Hospitals NHS Trust is an integrated trust, which provides acute and community health services. The trust serves a population of around 500,000 people in the Bradford and surrounding area. The trust operates acute services in Bradford Royal Infirmary and St Luke’s Hospital. The trust has three community hospitals; Eccleshill, Westbourne Green and Westwood Park. Eccleshill Hospital was closed at the time of the inspection. In total the trust has around 900 beds and employs approximately 5,500 members of staff.

We carried out a follow up inspection of the trust from 11-13 January 2016. This was in response to a previous inspection conducted as part of our comprehensive inspection programme in October 2014. In addition, an unannounced inspection was carried out on 26 January 2016.

Follow up inspections do not always look at every service the trust provides. They focus on the areas identified as requiring improvement in the previous inspection and any areas of concern identified in the time since the last inspection. In addition, not all of the five domains: safe, effective, caring, responsive and well led were reviewed for each of the core services we inspected.

At the comprehensive inspection in October 2014 we found the trust was in breach of regulations relating to care and welfare of people, assessing and monitoring the quality of the service, cleanliness and infection control, safety, availability and suitability of equipment and premises, respecting and involving service users and staffing. We issued a number of notices which required the trust to develop an action plan for how they would comply with the regulations where breaches had been found. We reviewed the trust’s progress against the action plan during this follow-up inspection.

Overall, we rated Bradford Royal Infirmary as requires improvement at this inspection.

Our key findings were as follows:

  • We found that there had been improvements in some of the services and this had resulted in a positive change in the overall ratings from the previous CQC inspection, notably in critical care and outpatients and diagnostic imaging.
  • However, the ratings remained the same in accident and emergency, surgery, medicine and children’s and young people’s services. This was because we either did not see significant improvement since our previous inspection or because we identified new areas of concern.
  • In relation to outpatient services, the trust had taken the necessary steps to ensure that the backlog of over 250,000 non-referral to treatment patient pathways had been clinically reviewed and actions taken to reduce risks to patients, including prioritising appointments and the assessment of potential harm. An improvement plan had been developed and systems and processes had been changed. The trust had revised executive, clinical and managerial leadership arrangements for outpatients and invested in additional administrative staff and a rolling programme of staff training.
  • 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. There were still a large number of patients waiting for outpatient appointments and there was a downward trend in referral to treatment times, which could delay access to treatment.
  • The trust had taken action to address the staffing concerns identified in our previous inspection. The trust had introduced integrated patient acuity monitoring systems to assess patient acuity and staffing levels on a daily basis. Staffing levels were assessed in daily matron huddles that were led by the head of nursing and staffing levels were risk rated and monitored by the chief nurse. Nurse staffing levels had been reviewed across the trust and in December 2015 the Board of Directors had approved a £2.5millon spend on staffing.
  • However, we found that there were significant nurse staffing shortages in urgent and emergency services, medicine, surgery, and services for children and young people.
  • Governance and assurance arrangements had been reviewed since the last inspection. However, we found that they were not robust enough to identify issues relating to, for example, medicines storage and reconciliation, issues relating to the availability of portable oxygen cylinders on resuscitation trolleys and gaps in records in urgent and emergency services. This was of particular concern because we identified these issues in the comprehensive inspection in 2014 and the trust had an action plan in place to address them. We wrote to the trust to ask for information about how they would address our concerns. The trust has provided us with assurance that our concerns would be addressed promptly and we have seen evidence that medicines reconciliation rates are now above the trust’s target and that action has been taken to ensure that portable oxygen cylinders are available. The trust has a robust plan to improve the quality of records in the urgent and emergency service.

  • Our previous concerns about the safety of children who were cared for in the stabilisation room pending transfer out of the hospital had largely been addressed. There were suitably qualified and trained staff to support critically ill children until the paediatric transfer team arrived. The service had been reviewed by the Royal College of Paediatrics and Child Health in August 2015 and an action plan had been developed to address the recommendations made in this report.
  • Our previous concerns about the care of patients requiring non-invasive ventilation (NIV) had been addressed. Patients requiring NIV were now grouped together in the respiratory unit on ward 23 and the service was compliant with British Thoracic Society Standards.
  • The trust had invested significantly in the estate and the environment. This included building a new hospital wing at the Bradford Royal Infirmary site, which was due to open around November 2016. Paediatric and critical care services would be relocated to the new wing, along with a new care of the elderly ward. The new wing would address many of the issues with the hospital environment identified in the previous inspection and the trust had commenced a full condition survey of the remaining estate. The trust was also in the process of redeveloping the accident and emergency department and gastroenterology.
  • In the interim, the trust had taken action to address some of the issues with the environment, particularly in critical care. However, wards 7, 9 and 15 remained very cramped with limited space around beds. We were concerned that in an emergency situation this would present a challenge.
  • There was a dedicated infection prevention and control team with arrangements in place to prevent the spread of infection. However, we observed staff not following infection prevention and control practices on a number of occasions. The MRSA, MSSA and C-difficile rates for the trust were above the England average for the period August 2014 to August 2015.
  • Policies and procedures were not always up-to-date. We saw policies and procedures that were past their review date and in critical care some of the policies we looked at did not refer to current guidance and standards. Staff in urgent and emergency services were unable to provide us with records to support patient group directives (PGDs), which allowed nurses to administer certain drugs.
  • The trust used the five steps to safer surgery process in the operating theatres to improve patient safety and reduce the risk of clinical incidents. The five steps included the use of the World Health Organisation surgical safety checklist. However, we observed patients receiving surgery when the surgical safety checklist process had not been followed fully. This meant there was a risk that safety issues might not be identified before a procedure took place.
  • Confidential patient information was not always stored securely. In urgent and emergency services, we had concerns about the security of patient identifiable information relating to victims of domestic violence.

We saw several areas of outstanding practice including:

  • The trust was collaborating with another local trust to work towards recruiting and retaining a workforce that reflected the 35% black, Asian and minority ethnic (BAME) population in the Bradford area. Between June 2014 and September 2015, the trust had improved the BAME representation on the trust Board of Directors from 0% to 29%.
  • The trust was leading the “Well North” programme, which was a collaborative programme aimed at improving the health of some of the poorest communities in the most deprived areas in the North of England.
  • The Bradford, Airedale, Wharfedale and Craven Managed Clinical Network for Specialist Palliative Care had won the British Medical Journal “Palliative Care Team of the Year” award in 2015.
  • The trust had performed better than the England average for all indicators in the 2015 Hip Fracture Audit.

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

Importantly, the trust must:

  • Ensure that infection control procedures are followed in relation to hand hygiene, the use of personal protective equipment and the cleaning of equipment.
  • Review and risk assess the environment on ward 24 and put in place actions to mitigate the risk of the spread of infection.
  • Ensure that the use of PGDs in accident and emergency is in-line with trust policy.
  • Ensure that relevant staff working in surgery complies with the five steps to safer surgery process and that the WHO surgical safety checklist is consistently followed.
  • Ensure there are improvements in referral to treatment times and action is taken to reduce the number of patients in the referral to treatment waiting list to ensure that patients are protected from the risks of delayed treatment and care.
  • Ensure that robust arrangements are in place to ensure that policies and procedures (including local rules in diagnostics) are reviewed and updated.
  • Ensure that patient information is held securely and patient confidentiality is maintained in relation to information about victims of domestic abuse in accident and emergency and the storage of property bags for deceased patients.
  • Ensure that there are in operation effective governance, reporting and assurance mechanisms that provide timely information so that risks can be identified assessed and managed.
  • Ensure that there are alert systems in place to identify when actions are not effective and need to be reviewed.
  • Ensure that at all times there are sufficient numbers of suitably skilled, qualified and experienced staff in line with best practice and national guidance, taking into account patients’ dependency levels.
  • Ensure that all staff have completed mandatory training, role specific training and had an annual appraisal.

In addition the trust should:

  • Review use of the public address system in accident and emergency to ensure that patients are aware that they are being called and where they should go.
  • Review the signage to the accident and emergency department within the hospital grounds to ensure that the department is clearly signposted.
  • Improve assessment facilities for patients admitted into accident and emergency with mental health concerns.
  • Review the arrival to initial assessment times in accident and emergency to ensure that patients are reviewed in a timely manner.
  • Risk assess the isolation facilities in accident and emergency to ensure that they meet current infection control standards.
  • Ensure cramped single rooms on wards 7, 9 and 15 are risk assessed to inform staff of the procedure in an emergency situation.
  • Review and monitor the demand for the outreach service to ensure the needs of deteriorating patients out of hours are met.
  • Review pharmacy cover against the Core Standards for Intensive Care Units (2013) (Pharmacy cover guidelines) which states that there should be at least 0.1 whole time equivalent specialist pharmacist for each single Level 3 bed and for every two Level 2 beds.
  • Complete a review of unmet demand for beds which was identified as an action from the previous inspection and quality key indicators reports.
  • Ensure that the amount of epidural waste destroyed is recorded, in-line with best practice.
  • In maternity, the trust should ensure that PAT testing of electrical equipment takes place and is recorded.
  • Consider having a policy regarding the use, monitoring and security of the baby milk refrigerators.
  • Address the environmental issues on ward 2 to ensure patients and families have privacy and their dignity is respected.
  • Review the practice of transferring patients from theatre to recovery with endotracheal tubes in place without any monitoring to ensure that any risks to patients are minimised.
  • Ensure that staff in surgery and theatres understand the definition of a serious incident and a never event.
  • Review ward 12 to ensure that patients are cared for by staff with appropriate skills and experience.
  • Review the availability of play facilities for children.
  • Review nurse staffing levels in services for children and young people to increase the availability of a senior staff member to provide clinical support and leadership to junior staff.
  • Review the use of interpreters in outpatients and diagnostics to ensure that patients’ privacy is maintained.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 21-24 October 2014 and 4 November 2014

During a routine inspection

Bradford Teaching Hospitals NHS Foundation Trust is an integrated trust, which provides acute services and a limited number of community in-patient health services. The trust serves a population of around 500,000 people from Bradford and the surrounding area and employs around 5,000 staff. The acute services are provided in two hospitals, Bradford Royal Infirmary and St Luke’s Hospital. The trust has four community hospitals; Westwood Park, Westbourne Green, Shipley and Eccleshill.

Bradford Royal Infirmary has around 900 beds and provides urgent and emergency services, medical and surgical services including general surgery, gynaecology; orthopaedics; ear, nose and throat (ENT); critical and high dependency care services; children’s and young people’s services. The hospital also provides an acute stroke service, consultant led maternity services, outpatient services for adults and children. There are also rehabilitation and therapy services provided.

We inspected the trust, which included this hospital from 21 to 24 October 2014 and undertook an unannounced inspection on 4 November. We carried out this inspection as part of our comprehensive inspection programme.

Overall, we rated Bradford Royal Infirmary as requires improvement. We rated it inadequate for safety, good for being caring and requires improvement for being effective, responsive to patient’s needs and being well-led.

We rated surgery, end of life, maternity and gynaecology services as good. Urgent and emergency care (ED), medical, children and young people’s services were rated as requires improvement. We rated outpatients’ services as inadequate. The ratings within the report were based on the evidence gathered at the time of the inspection.

Our key findings were as follows:

  • There had been changes in the leadership team at trust level, with some changes in the leadership and management within the divisions and clinical services at the hospital. Along with these changes there had been the introduction of new governance and assurance arrangements, which had yet to be embedded.
  • We had serious concerns over the very large back log of patients waiting for a review of their outpatient care pathway. There were over 205,000 patient pathways to be reviewed. The trust had taken steps to address this and was validating the information on patients in the back log. However, we had concerns over the length of time it had taken to put in suitable actions and the time it would take to assess the impact on individual patients.
  • Following the inspection we requested further information from the trust in accordance with Section 64(1) of the Health and Social Care Act 2008 (HSCA) regarding this backlog. The trust’s response indicated that actions were in place and that the backlog was reducing. The timescale for completing the review of all these patient pathways was March 2015.

  • We were concerned about the skills and experience of some staff, particularly in the stabilisation room used for children waiting to be collected for transfer to another hospital for paediatric intensive care. An outcome from a serious incident related to the stabilisation room had not been acted upon. We raised these concerns with the trust. The trust acted on the concerns raised.

  • The hospital building and estates were old and many areas were no longer suitable to meet the needs of patients or staff. In some areas space was compromised making moving patients and accessing hand wash sinks difficult and direct observation was limited. There were insufficient side rooms and in some areas such as children’s services there were insufficient bathing facilities.
  • There was work in progress to increase and improve on the facilities within the hospital including the addition of a new wing to house the children’s service, critical care and improve endoscopy services. There was some anxiety amongst the staff working at the trust as to how the services would be reconfigured as part of the estate development.
  • There was a dedicated infection prevention and control team with arrangements in place for the prevention of infection. However, the layout in many areas in the hospital presented challenges. For example the inadequate number of side rooms (including a lack of ensuite facilities), meant that patients were not always suitably isolated. Access to hand wash sinks was compromised in a number of areas such as the critical care unit. Not all infection prevention practices were adhered to at all times putting patients at risk. The trust was on target for its trajectory for Clostridium difficile infection rates but had breached the zero tolerance level for Methicilin-resistent Staphylococcus Aureus (MRSA).

  • There were staff shortages across all areas. Staffing levels and skill mix did not regularly meet best practice or national guidance. We were particularly concerned about the number of qualified staff working in children’s services, in the recovery areas of the operating theatres and maternity services. There had been some improvements made in the urgent and emergency care department and medical services. The trust was actively recruiting into vacant posts and staff were working additional hours to cover gaps on shifts. Some bank and agency staff were also used to cover shortages.

    • Not all staff had completed their mandatory training, particularly for safeguarding training at Levels 2 and 3 or had received an appraisal. Access to training for some staff groups had been affected by the staff shortages as they were unable to attend courses. However, there was positive reports from medical staff about the quality of their training in the hospital.

  • We were concerned about the skills and experience in some areas, particularly in the stabilisation room used for children waiting to be collected for transfer to another hospital for paediatric intensive care.
  • We were also seriously concerned about the care of patients being treated with non-invasive ventilation, who were placed in wards across the hospital under the care of physiotherapists, which did not meet with best practice and national guidance. Subsequent to the inspection the Trust provided us with information that they were acting on these concerns

We observed areas of good practice including:

  • Generally, treatment and care followed best practice and national guidance and outcomes for patients were positive.
  • Patients reported good experiences and were treated with kindness with their dignity and privacy protected. Patients and their relatives reported that they felt involved in decisions about their care. Women on the maternity unit reported good experiences and were happy with the care they received. Staff received feedback from complaints so that improvements in their service could be made.
  • The support from the chaplaincy service was excellent. However, the facilities for spiritual support were inadequate impacting on the experience of those wishing to access this service.

We observed areas of outstanding practice:

  • The surgical services had introduced a complementary system of ‘green bands’ worn by patients on their wrists displaying personal and procedure information. This was an effective additional safety measure to the World Health Organization (WHO) Five Steps to Safer Surgery checklist.
  • Working in collaboration with Macmillan Cancer Support, the hospital specialist palliative care team (HSPCT) were awarded the International Journal of Palliative Nursing multidisciplinary teamwork award for the positive impact that their work had on the care they provided.
  • The HSPCT were the first team in the country to link the AMBER care bundle to the Gold Standard Framework for end of life care register, which showed an increase of 38% to 57% in the identification of patients in their last year.
  • The palliative care liaison service work with ethnic minorities had won a Department of Health and Social Care award under the category ‘Improving Lives for People with Cancer’ and was awarded with a commendation.
  • The elderly care wards, particularly Ward 29 and Ward 30, had made improvements to the care of older people, including those living with dementia. The environment had been adapted and was an exemplar for dementia-friendly environments.
  • In diagnostic imaging, all ultrasound sonographers were independent reporters. There was a high proportion of advanced practitioners which had helped improve access to services.

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

Importantly, the trust must:

  • “Ensure that the significant backlog of outpatient care pathways is promptly addressed and prioritised according to clinical need. Ensure that the governance and monitoring of outpatients’ appointment bookings are robust and able to identify any potential system failures so that action can be taken in a timely manner.
  • Ensure that there are appropriate arrangements for the prevention and control of infection including the isolation of patients throughout the hospital, including the urgent and emergency care department; that infection prevention and control practices are adhered to, particularly on Ward 9. Ensure that there is suitable access to hand wash sinks, particularly on the critical care unit and high dependency unit. Review the number of side rooms available with ensuite bathroom facilities for the management of patients with infections. Ensure the procedures for cleaning and disinfecting endoscopes are consistent with accepted practice.

  • Ensure that the environment and facilities meet the needs of patients on wards, particularly on Wards 2, 16 and 17. Ensure that there are adequate bathroom facilities on Ward 2 to meet the needs of the children on that ward. Review and improve the environment on Ward 7, Ward 9, and Ward 24 and in the Diabetes Centre.
  • Ensure that there are sufficient numbers of suitably skilled, qualified and experienced staff in line with best practice and national guidance taking into account patients’ dependency levels, particularly on medical wards, including the provision of staff out of hours, on bank holidays and at weekends; children’s and young people’s services including the children’s stabilisation room and that staffing levels meet planned staffing levels; critical care; the recovery areas of operating theatres, maternity services and within the urgent and emergency care department to ensure the safe streaming (triage) of patients attending reception area.
  • Embed the use of a dependency acuity tool in practice and ensure that written guidance/ or protocol is developed to support staff whilst assessing a patient’s acuity.
  • Ensure that patients are placed on the most appropriate ward to meet their needs, including a review of the care of patients requiring non-invasive ventilation to ensure that they are admitted to a suitable ward with appropriately skilled and experienced staff in line with best practice guidance.

  • Ensure that equipment is checked according to best practice guidance and trust policy. Ensure that all checks are appropriately recorded, including resuscitation equipment.

  • Ensure staff receive appropriate training and support through supervision and appraisal including the completion of mandatory training, particularly the relevant level of safeguarding training so that they are working to the latest up to date guidance and practices.
  • Ensure that patient records are maintained up to date, are patient centred and contain the relevant information about their treatment and care, including patients awaiting discharge to eliminate unnecessary delays.
  • Ensure formal arrangements are developed for the receipt, recording and storage of surgical instruments.
  • Ensure medicines are stored safely on all wards and fridge temperatures are checked in line with national guidance.
  • Ensure staff understand and engage with the trust and division visions, values and strategies. Increase staff engagement and consultation within the hospital particularly on the development of services.
  • Ensure staff receive feedback on incidents and that shared learning occurs.
  • Review the patient flow of higher dependency patients throughout the hospital to ensure care is given in the most appropriate setting.
  • Review the care pathway for children undergoing surgical procedures including individual fasting times and timings for theatre.
  • Review the access to and capacity of the child development service, especially in relation to access to autism services.
  • Ensure patients have their medicines reconciled in accordance with trust targets.
  • Ensure that improvements are made to provide effective bereavement, chaplaincy and mortuary facilities.
  • Ensure that safe manual handling procedures are in place in the mortuary through the use of suitable equipment.

In addition the trust should:

  • Review the queuing arrangements for patients in the ED reception area; consult with, and involve, reception and administrative staff in the redesign and improvement of the ED.
  • Review and ensure that NICE 83 guidelines for rehabilitation in critical care, mainly in relation to post-discharge follow-up, are followed.
  • Review the provision of ED facilities for patients living with dementia.
  • Provide patients in the ED waiting area with information about waiting times.
  • Improve lighting and access to the ED at night.
  • Review the use of the public address system used to address patients in the ED.
  • Review the provision of side rooms in the ED.
  • Record the cleaning of children’s toys in the paediatric emergency area.
  • Review public and staff access to results of the Safety Thermometer dashboard for their area.
  • Ensure the referral system is fit for purpose and maintains an audit trail.
  • Ensure staff receive information regarding audits and reviews of practice so that trends and good practice can be identified.
  • Review the trust’s approach and uptake of clinical supervision.
  • Review access to patient information in languages other than English.
  • Review dedicated management time allocated to ward managers.
  • Review the adequacy of facilities for staff and waiting patients within the endoscopy unit.
  • Address issues so that critical care delayed discharges are reduced and that patients are discharged from critical care to a ward within four hours of the decision to discharge being made.
  • Re-commence audits of Ventilator Associated Pneumonia (VAP) to assess outcomes for ventilated patients.
  • Review the processes for providing critical-care outreach support from 5pm and overnight.
  • Review the handover arrangements to improve their effectiveness.
  • Make the phlebotomy service available for patients if clinics are not running to time.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 1, 2, 3 July 2014

During an inspection to make sure that the improvements required had been made

When we last visited the provider in October 2013 we found the service was non-compliant with four outcomes including respecting and involving people, care and welfare, staffing and assessing and monitoring the quality of service provision. Compliance actions were set for three of the outcomes and a warning notice was served for staffing; we returned to check if improvements had been made.

We visited a range of departments and services including the Accident and Emergency Department (AED), Medical Admissions Unit (MAU), Elderly Admissions Unit (EAU), Ward 9 (Stroke Unit), Wards 29 and 30 (Elderly Care), Ward 20 (Emergency Surgery and Surgical Assessment Unit) and Ward 23 (Orthopaedic).

In relation to respecting and involving people, we found improvements had been made across all the wards / departments we visited, particularly in the AED and ward 29. We saw many positive examples where staff purposefully ensured people's privacy and dignity was maintained and staff spoke with patients in a respectful and polite way. The changes to the physical environment of the AED meant that patients were clerked in and assessed in different areas of the department; this enabled patients to discuss their health condition in private and not in an open area. We spoke with several patients in the AED and, in the main, they spoke positively of their experiences including the efficiency in how they were assessed / treated and the positive attitude of doctors and nurses.

In relation to care and welfare, across all the wards and departments we visited, we saw patients looked comfortable and it was clear people had been supported where necessary with personal hygiene and general cares. We observed staff being genuinely supportive to patients, including during meal times. Where possible, wards ensured meal times were protected and activity was reduced to a minimum so staff could focus attention on supporting patients to eat and drink. One relative we spoke with on ward 29 felt that their father had been looked after well and they described the nurses as caring and helpful. A patient we spoke with, on the same ward, commented that the nurses always promptly arrived when called and would encourage them to eat. Overall, we saw improvements had been made with care records and planning of care was centred on the patient. There were some examples of care records being too generic and the trust responded promptly when this was highlighted.

In relation to staffing, the trust had made significant progress in several areas including improving recruitment processes, increasing staffing numbers, more closely monitoring staffing numbers and firming up assurance processes. The trust had employed extra consultants in the AED and increased middle grade doctor staffing levels. Medical input on the MAU had also increased and wards were reporting their planned versus actual nurse staffing levels on a daily basis. However, of the staff rotas we reviewed, including from the AED, there were several examples where shifts fell short of the ideal number of qualified nurses and which had not been filled with bank or agency staff. Nursing staff we spoke with acknowledged some shifts were short but felt staffing levels overall had improved. The trust were aware of the on-going challenges faced with staffing levels and were pro-actively reviewing how to maintain ideal staffing levels including recruiting from abroad.

We reviewed quality assurance processes and noted significant changes and improvements had been made, including the flow of information and the responsiveness of the executive team. Senior staff we spoke with described how assurance processes felt 'tighter' and there was improved 'line-of-sight' from the board to wards. Positive changes had also been made to some senior nurse roles including matrons. Matrons were responsible for managing the wards and their lines of accountability were clearer. This was seen a positive by the nursing staff with spoke with on the wards.

Inspection carried out on 12 September and 14, 22, 23, 24, 30 October 2013

During an inspection to make sure that the improvements required had been made

Accident and Emergency (AED)

In the AED we found areas of the department, particularly in and around the main reception and triage areas, to be significantly overcrowded during busy periods and patients were required to openly discuss personal information and injuries/illness. We found people's privacy and dignity was regularly compromised. A patient said they felt the department was confusing and had no privacy when you first arrived. A nurse we spoke with said, “Triage is not private enough here. You get no privacy. People are interrupting all of the time.”

Another patient we spoke with said, “I have no complaints, the staff are very good here.” We found there were unsafe delays with some people's triage and subsequent treatment, this was particularly so for people walking in to the department who were moderately/seriously injured/unwell.

We found the staffing levels within the AED were significantly low particularly in relation to nursing staff and senior medical cover; especially from midnight and throughout the night.

Medical Admissions Unit (MAU)

Patients we spoke with felt staff were polite and caring. One patient said, "Staff are respectful" and another said, "Staff were lovely on here." We found, in the majority of cases, people's nursing assessments had been completed accurately including pressure area care and nutritional assessments. We had concerns about the placement of some patients on the MAU into the eight bedded trolley bay area. It was increasingly being used to place significantly unwell patients due to pressures with bed space.

We also had concerns about staffing levels. A senior nurse we spoke with said, “From a consultant point of view we are badly staffed; we don’t keep the figures on it though.” A patient we spoke with said, “There isn’t enough staff, sometimes it takes a while for them to come, but my care has not suffered.” The MAU was short staffed in terms of consultant physicians and had two consultants and the Trust would have ideally liked six. The lack of senior medical input and expertise on the ward increased patient safety risk and caused delays in decisions being made in relation to patient treatment and discharge.

Elderly Medical Unit (EMU)

We saw that patients looked comfortable and it was clear people had been supported where necessary with personal hygiene and general cares. We found staff were supportive, particularly during meal times, and encouraged people to sit up and eat where necessary. One patient we spoke with said, “They have been very good to me” and felt they had been well looked after. Staff commented that, on occasion, staffing levels was an issue but we were told this was mainly if people were off sick or nurses were required to make up the numbers of staff on other wards, for example, ward 29.

Ward 9 (Stroke Unit)

During the inspection we observed positive interactions between staff and patients and staff ensured the ward environment remained calm and conducive to the needs of people suffering from neurological disorders. We found the ward to be well coordinated and one patient we spoke with said, from a clinical perspective, "I can not fault it." However, they described how they wanted a little peace and quiet because they had already been on two other wards in the space of a few days. The were some concerns in relation to senior medical cover. We spoke with the Consultant Stroke Physician and Clinical Lead for the service; they told us that according to guidelines the number of consultants required by the Trust was six. The service operated with 2.5 whole time equivalents and there were no registrars (senior doctors) in post for the service.

Ward 29 (Elderly Care)

Our observations and experiences of ward 29 were mixed but there were concerns in relation to dignity, respect and examples of poor practice in terms of basic nursing care. We spoke with one patient and they said, “The care has been fantastic, staff are courteous, I am treated with dignity definitely." From our observations there were examples where ward staff were abrupt in their responses to patients and not respectful. For example, we heard a patient explaining to a nurse that they did not like the chocolate pudding they had received with their lunch-time meal. The nurse said, “Why did you order it then?” and no alternative pudding was offered.

We spoke with one of the consultant doctors working on the ward and they described the work pressures particularly in terms of staffing and they said, “We are short staffed, everyone knows that.” We had concerns around staffing levels but also staffing skill-mix. This was because the needs of the patient group on the ward were specialist and demanded significant input from nursing staff; the problems with the staffing affected continuity of care which in turn affected the quality of care.

Ward 20 (Emergency Surgery and Surgical Assessment Unit)

Whilst on ward 20 we observed elements of care which were not respectful and did not support patients in making certain choices. For example, one person whose first language was not English was not supported in making decisions and nursing staff did not utilise the tools available to help the person understand, in their own language, the choices available to them. This was especially true during meal times.

We also had concerns in relation to staffing levels, especially nursing staff. We reviewed the nurse staffing rota for the previous month and there were significant shortfalls in the numbers of nursing staff on duty.

Ward 23 (Orthopaedic)

Whilst on the ward we observed positive interactions with patients and the caring nature of the healthcare team was noted. One person we spoke with said, “Everyone has been really kind and caring.” The patients we spoke with all said that the doctors and the therapists (occupational therapists and physiotherapists) had explained things to them; they said that they understood what treatment they had received and why.

In terms of care and welfare, one person we spoke with said, “I get good care. The staff are generally great and you can have a good laugh with them.

One nurse we spoke with said that the ward was very busy, especially in the afternoon. They told us that it was ‘easier’ in the morning because the occupational therapists and physiotherapists helped. They said that during the afternoon people had to get ready for theatre and staff didn’t always ‘see’ to people in a timely manner.

Other Areas

During the inspection we also reviewed medicines, quality assurance and complaints. With medicines we had found issues with the ward pharmacy service for a prolonged period and this inspection was the first time we had observed clear progress. This was encouraging but the situation remained, until new staff were in position, that the service was stretched and improvements were needed in key areas.

In relation to quality assurance we noted there had been significant changes to the Board structures including introducing the role of Chief Operating Officer and Director of Informatics. We had significant discussion around the Trust's lack of a specific Board Assurance Framework (BAF) but there were alternative processes in place to monitor and review the Trust's progress in relation to its corporate objectives.

During the inspection we had concerns in relation to the AED, staffing on the wards and management and patient flow. In all cases, the executive team described how they had been aware of the problems. There appeared to have been delays in addressing certain problems in a responsive way. We also noted that, on occasion, feedback to the Board was not timely and/or accurate.

We also assessed how the Trust handled complaints. We noted that the Trust had made changes in several areas to ensure a more timely and detailed responses to complaints.

Inspection carried out on 3 May 2013

During an inspection to make sure that the improvements required had been made

We carried out this inspection to check on the progress made with the actions the Trust told us it was taking in order to be compliant with the management of medicines. We spoke with one patient about their self-administered medication and their medicine was being kept safely in-line with trust policy. However, in relation to the same patient, a nurse had signed the patient's drug chart to indicate they had taken two capsules of medication when they actually hadn't; the two capsules were still in a pot on top of the patient's locker.

We found a significant proportion of the prescription charts that we reviewed contained errors. We found recording errors or unresolved discrepancies on half of the eighteen charts we checked. We also found some evidence that the clinical service provided by the hospital pharmacy was limited and did not find all the errors on patients' medicine charts as they should. We also reviewed the trust's own recent pharmacy audit dated April 2013; the audit found that the dose of medicine was not included in the prescription in about a third of cases and just over a tenth of prescriptions had at least one prescribing error.

We found that the trust had made positive steps to address the issues raised at the previous inspection in relation to patients self-administration of medicines and we also found that controlled drugs were being safely managed.

Inspection carried out on 11 December 2012

During a routine inspection

At this inspection we found peoples consent was sought before treatment. The care and welfare of people who used the service was assessed and planned appropriately. The staff were supported to deliver care and records were accurate and fit for purpose. However there were some minor concern regarding the checking of medicines and prescribing by the pharmacy support and the safe self administration of medicines.

The expert by experience who joined us on this inspection spoke with 10 patients and 2 relatives, across 2 wards. Everyone they spoke with told them they or their relative had a good overall experience at Bradford Royal Infirmary. The people we spoke with told us they felt they or their relative had been treated with dignity and respect. Many of the people on the assessment unit had been admitted via the accident and emergency (A&E) department. They told us their experience in A&E was positive in that they were seen by a doctor and given an explanation regarding their condition and were kept fully informed. They all said they were looked after well and if necessary offered food/drink and toilet facilities. One person said although A&E was very busy he had “no complaints, they had seen the doctor during the night and again this morning”, they also said “I was given full information, what they have done and what they are going to do; I'm very impressed with it here”.

Inspection carried out on 22 March 2011 and 22 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 27 April 2011

During a themed inspection looking at Dignity and Nutrition

The patients we spoke to were generally positive about their experiences of care and treatment. Patients told us they were happy with the way staff cared for them, they said the staff are “lovely” and speak to them respectfully. Patients told us they had never felt embarrassed or uncomfortable during their stay in hospital. Overall patients felt staff responded quickly to their needs. Patients told us they understood the information they had been given and said when they asked for further explanation it was forthcoming.

Patients told us the meal times are not rushed and said they are given a choice of meals from the menu. Generally patients were satisfied with the quality of the food, one person described it as “adequate”, and another said the salads were the best. The patients we spoke to said they had not been asked about their dietary needs and preferences. Some patients told us staff checked if they had enough to eat, others said they did not. Patients told us they always have jug of water and said staff would get them iced water if they asked. Generally patients were not sure whether they could get snacks between meals if they wanted them but one patient said they felt staff would get them something if they asked.