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Inspection carried out on 13 Nov 12 Dec

During a routine inspection

Our rating of services improved. We rated it them as good because:

We rated the outpatient services as good. We did not inspect any other services at the hospital on this occasion.

Inspection carried out on 11-13 January 2016 and 26 January 2016

During an inspection looking at part of the service

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 four community hospitals; Eccleshill, Shipley, Westbourne Green and Westwood Park. Eccleshill Hospital was closed at the time of the inspection.

St Luke’s Hospital provides general medicine for adults as well as rehabilitation and therapy services. The hospital also provides outpatient services for adults and children.

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 this inspection of St Luke’s Hospital we re-inspected the safe domain for medicine as we previously rated this service as requires improvement. We did not inspect the other domains for medicine as they were previously rated as good. We also re-inspected the safe, responsive and well-led domains in outpatient services as they were previously rated as inadequate for safety and requires improvement for the responsive and well-led domains.

At this inspection we rated St Luke’s Hospital as requires improvement. This was because outpatients was rated as requires improvement overall. Medicine remained rated as good overall, however safety was still rated as requires improvement.

Our key findings were as follows:

  • In relation to outpatient services, the trust had taken the necessary steps to ensure that the backlog of over 250,000 on non-referral to treatment patient pathways identified in May 2014 and April 2015 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, which could delay access to treatment.

  • Policies and procedures in outpatients and diagnostics were not always up to date.

  • At the previous inspection in October 2014, concerns were raised about the out of hours medical cover at St Luke’s Hospital and the management of the deteriorating patient. At this inspection we found that all staff had a good understanding of the arrangements for medical cover out of hours. The trust had also commissioned an external review of medical staffing at St Luke’s and had concluded the medical cover was adequate for the service.

  • We had concerns about nurse staffing levels in medicine and found a number of occasions when the number of staff on duty was significantly below the planned level. We saw occasions when there was only one registered nurse and two health care assistants to look after 27 patients.

  • Nursing records were not stored securely on Ward F3. This meant there was a risk of confidential patient information being accessed.

  • In medicine, improvements had been made with safeguarding training and mandatory training rates were now above the trust target of 95%.

  • Ward and outpatient areas were visibly clean and staff generally followed infection prevention and control practices. There had been no cases of MRSA or Clostridium difficile on the medical wards at St Luke’s from January 2015 to the time of our inspection.

We saw several areas of good practice including:

  • Systems were in place to report and learn from incidents, wards monitored safety and harm-free care and safety thermometer information was now visible.

  • We saw evidence of shared learning between Bradford Royal Infirmary and St Luke’s Hospital. Staff at St Luke’s were able to tell us about a recent serious incident that had occurred at Bradford Royal Infirmary.

  • There were robust arrangements in place to ensure that only suitable patients were admitted to St Luke’s Hospital. We observed a nurse on F6 take a handover of a new patient and they challenged the staff member to ensure the patient was medically stable and appropriate for the ward

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

Importantly, the trust must:

  • 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 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.

  • The trust must ensure that robust arrangements are in place to ensure that policies and procedures (including local rules in diagnostics) are reviewed and updated.

  • Ensure patients notes are securely stored to ensure patients’ confidentiality is maintained.

  • The trust must ensure 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.

In addition the trust should:

  • Consider identifying a nominated individual at the hospital who is responsible for coordinating any concerns out of hours and at the weekend.

  • 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, and community in-patient health and children’s services. The trust serves a population of around 500,000 people from Bradford and the surrounding area. The acute services are provided in two hospitals, Bradford Royal Infirmary and St Luke’s Hospital. The trust also has four community hospitals; Westwood Park, Westbourne Green, Shipley and Eccleshill.

The community hospitals are part of the elderly and intermediate care service in the division of medicine at the trust and provide a less acute environment. These services are aimed at avoiding the need for patients to be admitted to an acute hospital for rehabilitation and restoring functional abilities following an acute hospital stay. At the time of the inspection only two community hospitals had in-patient services operating: Westwood Park and Eccleshill.

St Luke’s Hospital provides general medical services for adults and outpatient services for adults and children. The hospital also provides rehabilitation and therapy services.

We inspected the trust from 21 to 24 October 2014 and undertook an unannounced inspection on 4 November. We carried out this inspection as part of the Care Quality Commission’s (CQC) comprehensive inspection programme.

Overall, we rated St Luke’s Hospital as requires improvement. We rated medical care services as good. We rated outpatients as inadequate. We rated the hospital good for being caring and effective but inadequate for safety, and requires improvement for responsiveness and being well-led. The ratings within the report were based on the evidence gathered at the time of the inspection.

Our key findings were as follows:

  • 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. A patient could have multiple pathways if they are accessing several services for the same referral simultaneously . 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.
  • There were no concerns over mortality at this hospital.
  • There were concerns regarding the access to out-of-hours medical advice. There was no on-site medical cover provided overnight, on Sundays or on bank holidays and the most senior nurse on the wards during these times was a band 5 staff nurse. This put patients at risk, due to possible delays in accessing treatment.
  • Most staff were clear about the vision and strategy for the service. Changes to the risk management processes were in place, but required further embedding in practice.

We observed areas of good practice including:

  • There were arrangements in place to manage and monitor the prevention and control of infection. There was a dedicated team to support staff and ensure policies and procedures were implemented. We found all areas visited visibly clean.
  • Care and treatment followed best practice and national guidance.
  • Patients received appropriate hydration and nutrition. Patients were supported to eat and drink and this was accurately recorded.
  • The wards at St Luke’s Hospital were suitable environments to provide care. Improvements had been made to make the wards more dementia friendly. Decoration had been improved to aid reminiscence and generate conversation.
  • Patients and relatives told us that they had been treated with compassion and that staff were polite and respectful. However, patient information was not readily available in languages other than English.

  • 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 there is access on the wards to sufficient numbers of suitably skilled staff, particularly medical staff, at all times.

In addition the trust should:

  • Review the referral system of patients to the ward services to ensure it is fit for practice and maintains an audit trail.
  • Share with staff information regarding audits and reviews of practice so that trends and good practice can be identified.
  • Review the approach and uptake of clinical supervision.
  • Review access to patient information in languages other than English.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 21 February and 6 March 2014

During an inspection in response to concerns

We conducted this inspection in response to information we received about the provision of care on ward F6 at St Luke�s hospital.

We found the majority of the patients we spoke with were positive about their experiences but there were mixed feelings about the standard of the food. We spoke with seven patients in total; the first patient had no complaints about the care they had received and said the �care was lovely.� A second patient we spoke with was happy with the care they had received and stated that they were well supported. The third patient we spoke with said the nurses were �the best they�d come across.� A person�s relative we spoke with was complimentary of the care provided and said �staff were fantastic.� However, three patients felt the standard of the meals provided was not good but another patient felt the food was acceptable and they always found something on the menu they liked.

During the inspection we saw staff interact with patients and staff were polite and respectful in their approach. We found certain risk assessment processes were accurately completed and this provided assurance that patients were being regularly assessed in terms of their well being.

In relation to nutrition and fluid balance monitoring, we found inconsistencies in how patient's dietary requirements and fluid needs were being monitored. In addition, there were inconsistencies in how paperwork was used and staff understanding in terms of ward protocol was variable.