1 May 2018
During a routine inspection
Our rating of services improved. We rated it them as good because:
- Staff treated people with the kindness, dignity, respect and compassion while they received care and treatment and there was a strong, visible, person-centred culture.
- Staff took the time to interact with patients and those close to them in a respectful and considerate way. Patients told us they valued their relationships with staff and felt that they often went ‘the extra mile’ for them when providing care and support.
- Patients and their relatives felt included in their plan of care. Patients told us nurses and clinicians spoke directly with them. They felt included in discussions about their treatment and staff took time to ensure they understood what was discussed.
- The trust planned and provided services in a way that met the needs of local people and of individuals who required additional support. The trust had placed significant emphasis on meeting the needs of people living with dementia and had a series of arrangements in place to care for and improve the experience of those patients at the hospital.
- There was a clear, strong, clinical leadership presence in the emergency department. Leaders understood the challenges to good quality care and identified the actions needed to address these.
- Managers across the trust promoted a positive culture that supported and valued staff. Staff felt respected, supported and spoke highly of their job despite the pressures, and were committed to delivering a good service.
- The medical care service had a clear vision and set of values, with quality and sustainability as the top priorities. Leaders understood the challenges to quality and sustainability, and had pro-active ongoing action plans in place to address them.
- The design, maintenance and use of facilities, premises and equipment, and standards of cleanliness and hygiene were in line with trust policies and procedures, and with best practice. We noted improvement in equipment storage, use of fire doors and equipment safety testing since our last inspection. Recent rebuilding work had been designed by the staff to meet the needs of local people.
- Documentation, training and staff understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards had improved since our last inspection. Staff understood how to protect patients from abuse and had training on how to recognise and report abuse and they knew how to apply it.
- There were good safeguarding systems, processes and practices in place to keep people safe, and these were well communicated to staff. Safeguarding training rates were above the trust target of 85%, with 100% compliance in child safeguarding.
- Staff had the skills, knowledge and experience to deliver effective care and treatment. Staff could access training to develop their skills and were supported to do so.
- The trust planned and reviewed staffing levels and skill mix so that people received safe care and treatment. Although there were higher vacancy rates on some medical wards, there were processes in place to manage it to avoid any negative impact on patients.
- The trust performed better than the England average for people being seen within two weeks of an urgent GP referral, and receiving treatment within 31 days for suspected cancer.
- Staff carried out comprehensive risk assessments for patients and risk management plans were developed in line with national guidance. An electronic patient records system contained a series of prompts and checks relating to patient risk. Staff could not move on to the next section of the record until they had completed mandatory prompts or checks.
- All levels of governance and management functioned effectively and interacted with each other appropriately.
However:
- Oral liquids in drugs trolleys and stock rooms were not always appropriately labelled to show when they had been opened. This meant there was a risk that staff would be unaware of when use of an oral medicine should be discontinued.
- In the outpatients department, about 50% of the resuscitation equipment had expired items on them; however, this was resolved by the time of our unannounced inspection.
- All mandatory training rates did not meet the target of 85%, with conflict resolution and manual handling having the poorest compliance. The completion rates of some mandatory training modules for nursing staff in medical care were low.
- Medical staffing was not at establishment in the emergency department, with half of the middle grade doctor posts vacant.
- The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the ED. The trust was not meeting the four-hour standard, even when the department was not busy.
- Staff did not have access to diagnostic services such as computerised tomography (CT) scans and ultrasound scans seven days a week. Staff told us they could only obtain diagnostic procedures for patients during the night or over the weekend on an emergency basis, and this required a consultant referral.
- In the outpatients department, the locks were broken on one trolley containing patient records. This meant that although patients records were out of sight which maintained confidentiality, there was a risk that they could be accessed by unauthorised persons.
- In the outpatients department, not all areas controlled the risk of infection well. In one area, the premises were visibly clean, but most of the hand washing gels were empty. We observed some clinicians not washing their hands between patients and others not wearing appropriate personal protective equipment (PPE).