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Inspection Summary


Overall summary & rating

Good

Updated 19 January 2016

Whiston Hospital is part of St Helens and Knowsley Teaching Hospital NHS Trust and provides a full range of hospital services, including an urgent and emergency care facility, general and specialist medicine, general and specialist surgery full consultant led obstetric and paediatric hospital service for women, children and babies.

Whiston Hospital is situated in Prescot and serves a population of approximately 350,000 people residing in the surrounding area of Knowsley, Halton and St Helens. In total, the trust has 887 beds.

We carried out this inspection as part of our scheduled program of announced inspections

We visited the hospital on the 19, 20, 21 August 2015. We also carried out an out-of-hours unannounced visit on 05 September 2015. During this inspection, the team inspected the following core services:

  • Urgent and emergency services
  • Medical care services (including older people’s care)
  • Surgery
  • Critical care
  • Maternity and gynaecology
  • Children and young people
  • End of life
  • Outpatients and diagnostic services

Overall, we rated Whiston Hospital as ‘good’. We have judged the service as ‘good’ for safe, effective, and well led and 'outstanding' for caring. We noted that there were elements of outstanding practice in caring overall and in caring and well led in outpatients and diagnostic services. However maternity and gynaecology were judged as requiring improvement in three of the five areas safe, responsive and well-led.

Our key findings were as follows:

Leadership and management

  • The hospital was led and managed by a cohesive and visible executive team. The team were very well known to staff and were regular and frequent visitors to the wards and departments. Staff were well engaged and were aware and committed to the organisational vision of five star patient care. There were good opportunities for staff to be included and active in service design and delivery. There was a range of reward and recognition schemes that were highly valued by staff. Staff were supported and encouraged to be proud of their service and achievements. Successes were actively acknowledged and celebrated.
  • There was a positive culture throughout the hospital. Staff were open and honest and were very proud of the work they did and proud of the services they provided although there was additional work to be done to support a positive culture in maternity services. Overall staff morale was good with the exception of some staff in maternity services who were concerned regarding recent changes to shift patterns and internal rotation. Some also expressed a desire for their senior manager to be more visible and accessible to them. The senior team are aware of this concern and expressed a commitment to addressing the issues identified.

Access and Flow

  • Access and flow in the emergency department remained a continuous challenge. The trust had a mixed performance against the four hourly national target over the year.
  • The proportion of all patients that attended the emergency department and were treated within four hours was 93.2% (2,099 attendances) between October and December 2014, 91.7% (2,548 attendances) between January and March 2015 and 93.2% (2118 attendances) between April and June 2015.
  • An action plan was in place to improve performance in the four-hour waiting time targets. This included actions to review medical staffing arrangements to improve treatment and discharge times and to improve medical cover during nights and weekends.
  • Patient flow through the hospital and discharge had improved. Between July 2014 and July 2015 data showed that there had been 87 medical outliers at the hospital. At the time of our inspection there were ten medical outliers. These were managed effectively from the point of admission which resulted in reduced bed moves during the hospital stay. Patients who were outliers were reviewed on a daily basis by a member of the medical team.
  • There had been issues with delayed and out of hours discharges from critical care. More recently the figures for delayed and out of hours discharges had improved and are now comparable with similar units in other hospitals. This improvement has been attributed to team work, improved communication between departments and bed managers, a tightening up of the discharge process and more accurate data collection.
  • Bed occupancy rates were higher than the England average from July 2014 to December 2015 in maternity, with the rates ranging from 73-88 % compared to 56 to 60% nationally. This meant the maternity services were running at a higher than usual capacity and we were not made aware of plans for managing this. Only 9.3% of midwives were trained to complete the new-born infant physical examinations and there was a lack of paediatric doctors to complete these. This led to delays in discharge within the maternity service.
  • Patients were seen and assessed by the special palliative care team within 24 hours of referral. A rapid discharge processes were in place in getting people to their preferred place of care prior to their death.
  • The outpatient department undertook 234,725 outpatient appointments during 2014/15. The trust met internal and national referral to treatment targets and was easily meeting the national six week target for patients waiting for a diagnostic appointment. The also trust performed better than the England average during 2013/14 and 2014/15 for patients waiting less than 32 and 62 days for treatment. We found the trust was consistent with the England average for patients seen by a specialist within two weeks from 2013/14 to 2014/15.

Cleanliness and Infection control

  • Patients were cared for in a visibly clean and hygienic environment.
  • Staff followed the trust policy on infection control and adhered to the ‘bare below the elbows’ policy.
  • Cleaning schedules were in place, and there were clearly defined roles and responsibilities for cleaning the environment and cleaning and decontaminating equipment.
  • There were arrangements in place for the handling, storage and disposal of clinical waste, including sharps. There was a suitable supply of hand wash sinks and hand gels available.
  • Staff were observed wearing personal protective equipment, such as gloves and aprons, while delivering care. Gowning procedures were adhered to in the theatre areas.
  • Patients identified with an infection were isolated in side rooms. We saw that appropriate signage was used to protect staff and visitors. The trust had employed a number of infection control link nurses and a surgical site infection specialist nurse worked across both sites. Their role was to provide training and to liaise with staff so patients that acquired infections following surgery could be identified and treated promptly.

Nurse staffing

  • Nurse staffing levels were determined using an evidence based tool.
  • The expected and actual staffing levels were displayed on a notice board on each unit/ward and these were updated on a daily basis.
  • Staffing levels were planned to ensure an appropriate skill mix to provide care and treatment for patients.
  • However, nurse staffing levels, although improved, remained a challenge in some areas. This was particularly the case in medical care services and maternity and gynaecology. Staffing levels were maintained by staff regularly working overtime and with the use of bank or agency staff. Where possible, regular agency and bank staff were used which meant they were familiar with policies and procedures. Any new agency staff received an induction prior to working on the wards.
  • The trust had implemented a number of initiatives to address shortages in nurse staffing including: actively recruiting nursing staff from overseas and linking with local universities.

Medical staffing

  • Medical treatment was delivered by skilled and committed medical staff.
  • Consultant cover was provided 24 hours a day seven days a week on the critical care unit.
  • In the emergency department the proportion of registrars and junior doctors was greater than the England average. The proportion of consultants was below the England average (19% compared with the England average of 23%). The proportion of middle grade doctors was also below the England average (4% compared with the England average of 13%).
  • Consultant staff in children’s and young people’s services reported a shortfall in middle grade doctor staffing. Ten middle grade doctors were required but the service only currently employed eight. The two remaining vacancies were filled by locum doctors and through extra staffing in A&E.
  • The trust's own specialist consultant in palliative medicine was on secondment at the time of inspection. Cover was provided by the community consultant in palliative medicine for St Helen’s, Knowsley and Halton who provided five sessions per week at the hospital. In addition the hospice’s specialist registrar provided two sessions per week. Managers were aware of this shortfall and plans were in place for the recruitment of a specialist consultant.
  • Staff rotas were maintained by the existing staff and through the use of agency or locum consultants. Where locum doctors were used, they underwent recruitment checks and induction training to ensure they understood the hospital’s policies and procedures. The majority of locum and agency doctors had worked at the hospital on extended contracts so they were familiar with the hospital’s policies and procedures.

Mortality rates

  • Multidisciplinary mortality and morbidity reviews were held for a 20% random sample of every death in medical services. If the review indicated any issues these were then rated as amber and further in-depth investigation took place. There had been six amber reviews in the last nine months prior to inspection.
  • Mortality and morbidity reviews were held in accordance with trust policies and were underpinned by policies and procedures. Deaths were reviewed thoroughly and appropriate changes made to help to promote the safety of patients.
  • Mortality meetings were held in the form of critical reviews for any deaths involving children. The service linked with maternity services to ensure a multi-disciplinary approach to review and learning.

Nutrition and hydration

  • Where possible there was a period over meal times where all activities on the ward stopped, if it was safe for them to do so. These protected meal breaks enabled staff to assist patients who needed assistance to eat and drink.
  • A coloured tray and jug system was in place to highlight which patients needed assistance with eating and drinking. The mealtime co-ordinators wore red aprons and other staff wore blue aprons at mealtimes. The mealtime co-ordinators communicated with the catering staff and ensured all patients had a hot meal.
  • Patients we spoke with said they were happy with the standard and choice of food available. The menus were comprehensive and there was a wide variety for patients to choose from. Patients said they were also encouraged to go to the hospital restaurant to eat their meals and that they ordered their meals the same day to ensure they chose what they felt like eating that day
  • Meals were managed and served by the housekeeping staff in children’s services and nurses did not have an oversight of the meals provided or consumed.

We saw several areas of outstanding practice including:

  • The trust had developed a pressure ulcer (PU) risk assessment tool used by the tissue viability nurses across the wards. This took into account the grade of the PU risk and a care plan was determined which included the equipment to be used for the patient.
  • The additional needs pathway and coordinated approach to a patient with additional needs reduced the need for repeat procedures and enhanced the patient’s experience.
  • In order to improve the response time and access to timely treatment for a patient, if a critical or abnormal finding on an X-ray was seen detected radiology staff could book another follow up appointment with the appropriate specialist at the time of reporting.

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

Importantly, the trust must:

  • Continue its efforts to meet four-hour emergency department national targets.
  • Meet the DH target for handovers between ambulance and emergency department.
  • Ensure there is the appropriate skill mix of staff and patient’s privacy and dignity is maintained at all times on the coronary care unit.
  • Ensure there is a system in place to assess and improve the quality and safety of the services provided following a serious incident. This must include actions to mitigate the risks relating to the health and safety of service users. (Maternity services).
  • Ensure systems in place for the storage of medicines are safe.

In addition the trust should:

In urgent and emergency care services:

  • Improve mandatory training and staff appraisal compliance in some areas.

In medical care services:

  • Conduct a review of training of the medicines policy in relation to the administration of regular medication via oral or intravenous routes.
  • Ensure that the implementation of the care certificate is implemented across all services within the national timeframe.
  • Ensure that all staff are applying the mental capacity act principals to the use of bedrails.
  • Ensure that hazardous chemicals are stored appropriately in a locked cupboard when not in use.

In surgery:

  • Ensure all prosthetists receive an appraisal in a timely manner

In critical care:

  • The trust should ensure that the use of CCTV cameras does not impact adversely upon patients’ dignity and respect.
  • Ensure that all dialysate fluids are kept locked and only accessible to appropriate staff.
  • Ensure that all equipment for use in the resuscitation of patients is in date and regularly checked.
  • Consider the intensive care society standards for supernumerary staffing when calculating the nurse establishment.

In maternity and gynaecology

  • Ensure all midwives are competent in the assessment of CTG monitoring.
  • Ensure the procedures for CTG monitoring, including assessment, are in line with best practice guidance.
  • Ensure the systems for checking emergency equipment include details of which parts of the equipment are checked and how this is completed.
  • Ensure the matrix used to grade incidents is reviewed to ensure near misses are included.
  • Ensure specific maternity safety thermometer is used to monitor the delivery of harm free care.
  • Ensure the bereavement rooms are a less clinical and provide a more comfortable environment for bereaved patients and their supporters.
  • Ensure records are filed in such a way as to afford easy access for medical staff to the record required.
  • Ensure medical records are stored confidentially in all areas.
  • Ensure all anaesthetists are up to date with the obstetric skills and drills training.
  • Ensure band 7 shift co-ordinators on the delivery suite work in a supernumerary capacity to meet best practice guidance.
  • Ensure the system for documenting patients being admitted to the delivery suite, including those coming into the unit for ante-natal assessment at evenings and weekends are reviewed to ensure it is clear where patients are at all times .
  • Ensure there is a seven day service for ante-natal patients to access support, including in early pregnancy.

Children and young people’s services

  • Ensure staff consistently follow trust policy and best practice in relation to completing vital sign observations for children and young people.
  • Ensure nurses on wards 3F and 4F take an active part in managing meals and mealtimes.
  • Ensure food and nutrition is always stored and accessed safely.
  • Ensure staff receive training about when to consider the Mental Capacity Act for young people over 16 years old.
  • Ensure a variety of opportunities are provided for children, young people and their parents to comments about the service.
  • Consider promoting use of the translation service in all instances when a child or young person when English is not their first language.
  • Consider additional steps to ensure all children and young people departments provide relevant and required governance reports when expected.
  • Consider analysing staff survey according to directorate so specific experiences and ideas are used to influence the development of the service neonatal, children and young people service.
  • Consider setting target dates by which plans should be achieved so improvements can be measured.
  • Make the development of robust succession plans for the neonatal unit and children’s wards a priority involving staff in the planning and delivery process.
  • Consider reviewing the environment of the neonatal unit alongside best practice for example the Health Building Note 09-03: Neonatal units department of health publication.

End of life

  • Develop an EOL strategy.
  • Appoint a palliative care consultant.
  • Discharge summaries should be sent to patients GPs when patients the have been seen by the trust SPC team.
  • Consider the provision of a fully functional electronic palliative care co-ordinating System (EPACCS) across all relevant sites would enable service providers across boundaries to share information.
  • Consider how the amber care bundle is to be rolled out as the facilitators post had ceased and there were currently no plans to replace this position.

In outpatients and diagnostic imaging services:

  • Ensure that the therapy review is concluded to facilitate the integration of therapies into the trust following their transfer from another provider.
  • Continue to seek ways to work with other partners to lessen the impact of the national shortfall of prosthetic services.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 19 January 2016

Effective

Good

Updated 19 January 2016

Caring

Outstanding

Updated 19 January 2016

Responsive

Requires improvement

Updated 19 January 2016

Well-led

Good

Updated 19 January 2016

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 19 January 2016

We gave the maternity and gynaecology services at Whiston Hospital an overall rating of Requires Improvement.

The maternity and gynaecology services at Whiston Hospital required improvement in the safe, responsive and well led domains.

There was a lack of systems to learn from incidents and improve practice. Equipment had not been adequately monitored, medicine storage was unsafe in three areas and the guidelines for detecting deterioration in patients were not always followed. There were some shortfalls in the midwifery staffing; however actions were in place to address this. There were issues with the access and flow of patients through the unit with particular effect on the delivery suite. Patients had limited choices for the birth of their baby due to a dominant medical model of care. There was a lack of leadership for the service and no vision or strategy for future developments. We did not see evidence of a robust risk management system.

The service was rated as good in the caring and effective domain.

Patients spoke highly of the care they received and the information they were given. There was good support for bereaved patients and those with complex needs. The policies and procedures in the service met national guidance and were regularly reviewed. Practices were audited and changes made if required. There was good infant feeding support and initiatives and patient outcomes were similar to the England average in most measures.

Medical care (including older people’s care)

Good

Updated 19 January 2016

We gave the medical care services at Whiston Hospital an overall rating of good. However, we found further improvements were needed in how the service provided care that was effective to patient needs

Patients received compassionate care and their privacy and dignity were maintained. Patients were involved in their care, and were provided with appropriate emotional support.

Incidents were reported by staff through effective systems and lessons were learnt and improvements made from Investigations where findings were fed back to staff. Staff were aware of how to ensure patients’ were safeguarded from abuse and neglect. The wards were visibly clean and staff followed good hygiene practices.

There were effective systems in place to ensure patient safety was monitored and maintained. Staffing levels were overall sufficient to meet the needs of patients. Care was provided in line with national best practice guidelines and medical services participated in the majority of clinical audits. There was a strong focus on discharge planning from the moment of admission and services to support timely discharge were provided seven days a week.

We found that staffs’ understanding and awareness of assessing people’s capacity to make decisions about their care and treatment were variable.

Services took into account the needs of the local people. There were good ambulatory care services and a specialist unit for the frail and elderly.

The hospital had implemented a number of schemes to help meet people’s individual needs, such as the forget-me-not sticker for people living with dementia or a cognitive impairment and the falling leaf symbol to indicate that a patient was at risk of falls. This helped alert staff to people’s needs.

Medical services captured views of people who used the services with changes made following feedback. A survey showed that people would recommend the hospital to friends or a relative.

Staff told us that they felt valued and supported. There was good staff engagement with staff being involved in making improvements for services. All staff were committed to delivering good, compassionate care and were motivated to work at the hospital.

Urgent and emergency services (A&E)

Good

Updated 19 January 2016

We gave the emergency and urgent services at Whiston Hospital an overall rating of good. However, we found further improvements were needed in how the service responded to patient needs.

This was because the Department of Health (DH) target for emergency departments is to admit, transfer or discharge 95% of patients within four hours of arrival. During this period the number of patients treated within four hours ranged from 91.3% to 93.2%. This was mainly due to a lack of available beds to transfer patients to and also due to delays of more than two hours in seeing a doctor.

The trust was not meeting the targets for ambulance handovers between January and July 2015. Trust data showed 831 ambulance handovers took between 30 and 60 minutes to complete and 199 handovers took longer than 60 minutes to complete during this period.

The staffing levels and skills mix was sufficient to meet patients’ needs and staff assessed and responded to patient’s risks.

Staff received mandatory training in order to provide safe and effective care. However, the numbers of staff that had completed mandatory training was below the hospital’s expected levels.

Patient safety was monitored and incidents were reported and investigated to assist learning and improve care. Patients received care in safe, clean and suitably maintained premises. There were systems in place to manage resource and capacity risks and to manage patients whose condition was deteriorating.

Care and treatment was provided in line with national clinical guidelines and staff used care pathways effectively. The services participated in national and local clinical audits such as the College of Emergency Medicine audits and performed in line with the England average for most safety and clinical performance measures.

The majority of patients had a positive outcome following their care and treatment. Patients received care and treatment by trained, competent staff that worked well as part of a multidisciplinary team.

Patients spoke positively about their care and treatment. They were treated with dignity and compassion. Patients and their relatives were supported with their emotional needs, and there were bereavement and counselling services in place to provide support for patients, relatives and staff.

There were systems in place to support vulnerable patients. Complaints about the service were shared with staff to aid learning. There was effective teamwork and clearly visible leadership within the department. The majority of staff were positive about the culture within the emergency department and the level of support they received from their managers.

Surgery

Good

Updated 19 January 2016

We gave the surgical care services at Whiston Hospital an overall rating of good.

This was because patients, carers and families were positive about the care and treatment provided. They felt supported, involved and staff actively engaged with patients whilst providing kind compassionate care. We observed positive interactions when staff were seeking consent. Staff supported patients and their relatives with their emotional and spiritual needs.

Safe systems were in place for reporting incidents, duty of candour and safeguarding issues. Staff were aware of current infection prevention and control guidelines. Equipment was sufficiently available, clean, safe and well maintained, appropriately checked and decontaminated regularly with checklists in use.

Medicines, including controlled drugs, and records were stored securely. The World Health Organization surgical safety checklist data was reviewed on a monthly basis. There was a documented strategic business continuity and internal major incident plan within surgical services with the possible key risks that could affect the provision of care and treatment.

Staff provided care and monitored compliance in line with national best practice guidelines. There was participation in national audits. Data from the audits was positive and the trust had appropriate action plans in place to address any identified shortfalls.

Patients were assessed individually for pain relief and for their nutritional requirements. Staff were competent and well supported by managers. Multidisciplinary team working was well established and effective within the surgical wards and theatres.

Discharge planning began at the point of admission with multidisciplinary input.

NHS England data showed national 18 week referral to treatment targets were being met. The number of elective operations cancelled was better than the England average and all patients that had their operations cancelled were treated within 28 days since April 2011. Trust data showed the number of surgical outliers on medical wards was very low.

The clinical & quality strategy outlined how the service would be improved by providing timely treatment by reducing cancelled operations and by improving discharge times. Surgical patient pathway improvement programme work streams were in place to promote efficiency.

Governance process allowed risks to be escalated appropriately. Risks were documented and escalated by the service appropriately with action plans in place to address the identified risks.

Intensive/critical care

Good

Updated 19 January 2016

We gave the critical care services at Whiston Hospital an overall rating of good.

There were sufficient numbers of suitably skilled and experienced nursing and medical staff on duty to care for patients.

Critical care services were being delivered by caring, compassionate and committed staff. We saw patients, their relatives and friends being treated with dignity and respect. The unit provided a critical care outreach service. We found that the critical care service was well led.

Patients and those close to them were positive about their care and treatment.

There were robust systems and processes in place for reporting incidents and there was evidence that learning from incidents was shared.

However, we found that medicines were not always stored securely and regular checking had not picked up on some out of date equipment on the resuscitation and difficult airway management trolleys.

When people required intensive care there were no significant delays in that care being delivered, however, there was often a delay in discharging patients once they had been judged as medically fit for discharge.

The unit continued to collect and submit data for the intensive care national audit and research centre (ICNARC) for validation, so it was able to benchmark its performance against comparable units. This data showed that patient outcomes were within the expected ranges when compared with similar units nationally.

Services for children & young people

Good

Updated 19 January 2016

We gave the Services for children and young people at Whiston Hospital an overall rating of Good; however in some areas we saw elements of outstanding practice.

Treatment and care were delivered in accordance with best practice and recognised national guidelines.

Children, young people and their families were respected and valued as individuals. Feedback from those who used the service was positive. Staff were compassionate, caring and provided effective care to children, young people and their families. Transition and acute community nursing support was comprehensive and made a positive impact for young people transitioning into adult services.

Staff were both creative and flexible to ensure care met the needs of individual children and young people. Feedback from children, young people and parents was exceptionally positive.

Staff were passionate about delivering high quality care and went above and beyond the usual duties to ensure children and young people experienced high quality care

The staff worked well with other teams and worked hard to provide a service to meet the needs of the child or young person who presented to the hospital. Processes were in place to provide an initial or long term service to any child or young person brought to Whiston hospital.

Staff were passionate about working with children and young people and felt valued by senior managers.

There was a good track record of lessons learnt and improvements being made when things went wrong. This was supported by staff working in an open and honest culture with a desire to get things right.

Children, young people and their families were not provided with regular opportunities to comment about the services provided. The trust was in the process of sourcing a system to help them gain an understanding of how children and young people felt about the care provided.

End of life care

Good

Updated 19 January 2016

We gave the end of life care (EOL) services at Whiston Hospital an overall rating of good.

The palliative and end of life patient journey was supported by a strong Nurse led Specialist Palliative Care Team that worked closely with the ward based staff. There had recently been board approval to appoint a specialist consultant with recruitment underway.

We found that staff were committed to providing a good quality service that was delivered with compassion and dignity.

Staff were clear about their commitment to providing care that ensured patients ended their life in a dignified way in their preferred place of care. There were good systems in place for rapid discharge so that patients could return to their preferred place of care at short notice.

Patients were involved in their care, supported to make informed decisions and were provided with appropriate emotional support at a difficult time for patients and those close to them.

The trust had acted on the Department of Health’s National End of Life Strategy recommendations and was introducing the amber care bundle which encouraged talking openly about people's wishes and putting plans in place should the person die.

The service had a work programme in place and wished to develop this into a future strategy for the service. The trust had a board member with a specific lead for EOL care to ensure scrutiny and challenge regarding performance at a senior level.

Staff spoke positively about the support they were given by senior staff and management.

Systems were in place to prevent patients suffering avoidable harm. Incidents were reported by staff appropriately, they were investigated, lessons were learnt and improvements made to the service as a result.

Patients’ medication was well managed with the pharmacy team responding to requests promptly so patients received effective symptom control in a timely way.

Outpatients

Outstanding

Updated 19 January 2016

We gave the outpatients & diagnostic imaging services at Whiston Hospital an overall rating of outstanding.

Incidents were being reported and staff were aware of the reporting system and how to use it. There was evidence of learning from incidents and how this learning was shared across the service and trust wide.

Cleanliness and hygiene was of a high standard throughout the hospital outpatient departments and staff followed good practice guidance in relation to the control and prevention of infection.

The service used electronic medical records that were easily accessible when patients visited the service. Information about patient’s treatment and care needs were obtained from relevant sources before clinic appointments to enable the service to meet the patient’s individual needs. The electronic patient record enabled timely access to information and diagnostic test results during consultation which contributed to patients making fully informed decisions about their care and treatment.

Staff were aware of their role in safeguarding, a reporting process was in place, and staff knew how to escalate issues of abuse and neglect.

Patients attending the outpatient and diagnostic imaging departments received care that was evidence based and followed national guidance. Staff worked together in a multidisciplinary environment to meet patients’ needs.

Staff were competent in their roles and supported by management systems to provide a good quality service to patients.

The service had been proactive in working towards providing seven days services within radiology and pathology services.

Patients were treated in a compassionate, respectful and considerate manner. The majority of patients said the staff had a good attitude, this was also reflected in a patient satisfaction survey.

There were good examples of a clear pathway and assessment planning for patients with additional needs this to ensure they received the appropriate support in a timely manner. This included the use of identifying the need for pre appointment visits to relevant departments to be arranged if required.

Leadership within the outpatient and diagnostic imaging service was very positive, visible and proactive. Managers had a strong focus on the needs of patients and the roles staff needed to play in delivering good care.

All the staff we spoke with were aware of the feedback from the NHS friends and family test. The trust was ranked one of the highest in the country for extremely positive feedback received from patients.

The service had a range of forums to seek patients’ feedback such as the “patient power” group.

The trust ranked in the top 100 places to work in the NHS in an external health journal.

Many of the departments we visited had awards on display and staff and patients were proud to show us what they had achieved. There were many examples of national targets being shortened by internal targets to drive improvements throughout the service.