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Inspection Summary


Overall summary & rating

Good

Updated 19 September 2018

Our rating of services stayed the same. We rated it them as good because:

  • Records were clear, up-to-date and available to all staff providing care. Staff always had access to up-to-date, accurate and comprehensive information on patients’ care and treatment. All staff had access to an electronic records system.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The services prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time.
  • The services provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
  • Information about the outcomes of patients’ care and treatment was routinely collected and compared against national data. Information was monitored in different meetings to identify areas for improvement. The maternity service used safety monitoring results well.
  • Staff gave patients enough food and drink to meet their needs and improve their health.
  • There was good evidence of multi-disciplinary team work to make sure patients were transferred / discharged to the appropriate location at the right time and with the support and involvement of carers and relatives. The newly developed frailty service was starting to reduce patient admissions and reduce re-attendances. The mental health liaison team facilitated communication with the community mental health teams and home-based treatment team, enabling people to be discharged from hospital with more intensive mental health support.
  • In the main, services made sure staff were competent for their roles, although some improvements were required with competency re-training in maternity services. Managers appraised staff’s work performance to provide support and monitor the effectiveness of the service. However, appraisal rates were variable across the service.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Privacy and dignity was maintained. We saw staff reassuring patients who were anxious or upset, with specialist support available if this was needed. The Friends and Family test had a good response rate for medical care services which demonstrated a high percentage of people would recommend these services.
  • The services were planned and provided in a way that met the needs of the local people. The medicine and emergency care division recognised the needs of the local population and used various sources of data such as public engagement and the use of local data and statistics to design and plan the services provided.
  • Services had a vision for what they wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.
  • Services had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.
  • Managers across the hospital promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • Services used a systematic approach to continually improve quality and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish.
  • Services had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
  • Services engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.
  • Services were committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation.

However;

  • We observed failure to follow infection prevention and control procedures on a number of occasions across wards and departments. There was also a lack of adequate assurance of compliance with infection prevention and control procedures.
  • Nursing vacancy, turnover and sickness rates were all above the trust targets in medical care services, as was the use of bank staff. Some services did not always have enough staff with the right qualifications, skills, training and experience to provide care and treatment. Including the requirement for registered children’s nurses in urgent and emergency care services and limited flexibility in numbers of midwives to cope with increased capacity and demand, or short notice sickness and absence.
  • Completion levels of mandatory training for some subjects, particularly level 3 safeguarding children were variable in all the services we inspected.
  • Maintenance and safe storage of equipment in maternity and medical care services was not at satisfactory levels. We saw sluice rooms unlocked in several wards, with cleaning solutions accessible to patients and visitors.
  • Patient risk assessments were not completed consistently including a lack of risk assessments relating to patients’ mental health needs or behaviour; the World Health Organisations five steps to safer surgery maternity safety checklist was not completed fully in theatre and patients attending the emergency department were not routinely assessed for venous thromboembolism in line with best practice guidance.
  • Staff did not understand their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. We found there was an inconsistent approach for assessing the needs of patients who lacked capacity.
  • Not all services were provided seven days a week. For example, at weekends consultant review of medical and stroke patients was limited to only new patients although the staff could request review for other patients, or regarding concerns. Physiotherapy and occupational therapy services were available for stroke patients Monday to Friday, however only new stroke patients were seen at weekends due to more limited availability of therapy services.
  • We were not fully assured that all patients received timely pain relief in the emergency department. Children attending the department via the waiting room were not always assessed, prioritised or given pain relief at this point of care.
  • Delayed discharges were an ongoing challenge for medical services. There was a backlog of dispatch of discharge letters on the acute medical unit some up to six weeks. Specialist leaders identified concerns in delays for follow up appointments particularly in rheumatology.
  • The trust did not always meet the national standards for access to services. As at the last inspection we found the service did not always meet national standards to admit, transfer or discharge patients within four hours.
  • Complaints were not always responded to in a timely manner which meant they did not meet the trust targets for closure of complaints. Although, concerns and complaints were treated seriously, investigated and learned lessons.
  • Whilst the systems and processes were in place to support leaders of medical care services, the capacity to deliver change was limited by continuing operational pressures and challenges in recruiting and retaining staff. There was an overall lack of pace in achieving stability and sustainable improvement in the service.

  • Following the inspection, we raised the concerns regarding infection control procedures and capacity to consent procedures with the trust and requested assurance that improvements would be made. The trust provided us with evidence that action had been taken and was being monitored to ensure sustained improvement and adherence to standards. We reviewed the action taken in May 2018 when we returned to the trust to carry out our well-led inspection. We found that whilst some improvements had been made, these were still not fully embedded and a review of the consent policy was required to ensure it met the requirements of the Mental Capacity Act 2005.
Inspection areas

Safe

Requires improvement

Updated 19 September 2018

Effective

Good

Updated 19 September 2018

Caring

Good

Updated 19 September 2018

Responsive

Good

Updated 19 September 2018

Well-led

Good

Updated 19 September 2018

Checks on specific services

Critical care

Good

Updated 15 January 2015

The trust was providing a good critical care service overall. However, to maintain safe care, some improvements were required relating to medical and nursing staff numbers.

There was evidence of strong medical and nursing leadership in the critical care unit that led to positive outcomes for patients. The service submitted regular Intensive Care National Audit and Research (ICNARC) data so was able to benchmark its performance and effectiveness alongside other units nationally.

There was a clear understanding of incident reporting and an embedded culture of audit, learning and development. However, the unit’s risk register contained risks had been there for a number of years and it was not clear whether these had been reviewed as planned or what the actions were.

The unit employed two nurses specifically in practice educator roles, which enabled them to support both new staff and those requiring additional support or performance management. Based in critical care, there was also a well-developed outreach service staffed on a daily basis by experienced band 7 nurses from the critical care unit. On the days of our inspection the unit had five to six empty beds at the start of the morning shift. It was safely staffed with the appropriate number of trained nurses per patient plus a senior co-ordinating nurse, clinical services manager and both junior and consultant medical staff.

Outpatients and diagnostic imaging

Good

Updated 15 January 2015

Patients attending the outpatient and diagnostic imaging departments were treated in a dignified and respectful way by caring and committed staff. Staffing numbers and skills mix met the needs of the patients in the department. However, consultants were sometimes called away to deal with emergency situations in other parts of the hospital or clinic’s over ran the times allocated. This meant that, at times, patients waited a long time to see their doctor.

There was a clear process for reporting and investigating incidents. Learning from incidents was shared and there were examples of changes in practice in response to incidents. Staff received training in safeguarding adults and children, the mental capacity act, health and safety, patient confidentiality and infection control.

The outpatient and diagnostic imaging departments were clean and well-maintained although the outpatient departments were sometimes quite cramped in terms of space and seating arrangements. Patient records generally were available for clinics and were secured and stored securely. There were occasions in the dermatology clinics at Leighton Hospital when patient records were not available for an appointment. In such cases staff prepared a temporary file for patients that included the most recent diagnostic and test results coupled with essential patient information so that the patient’s appointment could go ahead. Staff acknowledged that this was not ideal; however it meant the patient did not have to reschedule their appointment.

There was good local leadership and a positive culture within the service. Staff worked well as a team and supported each other.

Urgent and emergency services

Good

Updated 19 September 2018

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

  • Staff understood how to protect patients from abuse. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • The service prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time.
  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Outcomes for patents could be shown to have improved. This had improved since the previous inspection.
  • The service had enough staff with the right qualifications, skills, training and experience to provide care and treatment to adults. However, there was limited flexibility in numbers to cope with increased capacity and demand, or short notice sickness and absence.
  • Appraisal completion rates had historically been low but were improving following implementation of an action plan.
  • Staff of different groups worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • There was good evidence of working together to treat and care for patients who frequently attended the department.
  • The clinical decisions unit demonstrated a holistic approach to planning people’s discharge, transfer or transition to other services, which was done at the earliest possible stage.
  • In the main, patients received treatment within one hour of arrival in line with the best practice guidance.
  • The percentage of patients waiting between four and 12 hours from the decision to admit until being admitted was better than the national average.
  • The divisional and service level leadership, culture and overall governance structure had the capacity, capability and integrity to ensure that the strategy could be delivered and risks to performance addressed.
  • The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.
  • Staff were engaged, supported and felt valued by senior staff.

However:

  • At the last inspection the trust did not always meet the national standards for access to services. At this inspection we found the service did not always meet national standards to admit, treat and discharge patients within four hours.
  • Discharge planning was not always effective in the main emergency department
  • The initial triage of self-presenting patients was conducted by either the GP out of hours team, (a locally commissioned service provided by a primary care organisation) or by a member of the department’s staff. We identified concerns regarding the streaming process because there was an inconsistent approach to assessing patients between the different staff. No observations were taken when the GP Out of Hours staff were on duty; no pain relief was administered, there was no evidence of prioritisation of patient’s dependent on risk or need, and no documentation was completed.
  • The department was not designed to meet the needs of children. The service did not always have enough staff with the right qualifications, skills, training and experience to provide care and treatment to children.
  • There was no segregation between children and adults in the waiting area and there were very few resources for adolescents such as access to Wi-Fi and age related books and magazines.
  • There was no child protection information sharing system in place however there were plans to introduce this in the near future.

Maternity

Good

Updated 19 September 2018

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

We rated it as good because:

  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care.
  • The majority of staff had completed mandatory training and specific skills and drills for this service.
  • Most staff had received safeguarding training updates and understood how to keep patients safe.
  • Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The service used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors. The service used information to improve the service.
  • Staff provided medication, including pain relief, appropriately to patients in a timely manner.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
  • Staff gave patients enough food and drink to meet their needs and improve their health.
  • The service monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them.
  • Staff worked together as a team to benefit patients. Doctors, midwives and other healthcare professionals supported each other to provide good care.
  • Staff understood their roles and responsibilities under the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
  • Patients were kept comfortable and supported by staff. Partners were involved with care.
  • The service planned and provided services in a way that met the needs of local women. Women could access the service when they needed it.
  • The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.
  • There was an open and transparent culture with clear supportive leadership. There was a commitment to engagement with staff and public with monitoring of the service to promote improvements.

However:

  • Compliance for obstetric medical staff in resuscitation training and safeguarding training was low.
  • Staff did not always follow infection control guidance and best practice. We observed some staff not adhering to ‘arms bare below the elbows’ guidance or washing their hands prior to patient contact.
  • Some equipment had not been regularly maintenance checked.
  • The World Health Organization (WHO) maternity five steps to safety surgery checklist was not completed fully in theatre.

  • The service did not always make sure that staff were competent for their roles, particularly to provide support in theatre and almost half the midwifery staff had not received an appraisal of their work performance in the last 12 months.

Maternity and gynaecology

Good

Updated 15 January 2015

Maternity and gynaecology services provided good and effective care in accordance with both local and national guidance. We found midwifery staffing levels were calculated using a recognised dependency tool.

A triage service introduced by the service enabled women to be directed to the most appropriate support in a timely manner. However there was no dedicated list for elective caesarean sections. As a result we found that patients may have their surgery delayed if an emergency arose. In addition, anaesthetic support was provided on a second on call basis from the main critical care service. This could also lead to delays for women.

There were systems in place for reporting actual and near miss incidents across the maternity and gynaecology services. The service monitored all its risks and had local risk registers. Action plans were in place and regularly monitored to ensure that risks had been addressed. Staff had a good knowledge and understanding of the need to ensure that vulnerable people were safeguarded.

Staff understood and followed best practice infection control guidance. Services were delivered by committed, caring and compassionate staff. We observed that staff treated mothers and their partners with dignity and respect and planned and delivered care in a way that took their wishes into account. Emotional support was available for both mothers and their partners.

Medical care (including older people’s care)

Requires improvement

Updated 19 September 2018

We plan our inspections based on everything we know about services including whether they appear to be getting better or worse.

We inspected the hospital as part of an unannounced inspection between 20 and 22 March 2018. As part of the inspection we reviewed information provided by the trust about staffing, training and monitoring of performance.

During the inspection we visited ward 1 (cardiac care unit), ward 2 (planned investigation unit/ short stay) ward 3 (acute medical unit), ward 4 (care of the elderly), ward 5 (respiratory) ward 6 (acute stroke/ general medicine), ward 7 (elderly care), ward 14 (gastroenterology), ward 21b ( rehabilitation).

In addition, we visited ward 15, in use as an escalation ward at the time of inspection; and the endoscopy unit in the treatment centre.

We reviewed 48 patient records and nursing plans. We spoke with 36 patients and their families and carers, as well as observing communications and ongoing clinical care in different wards.

We spoke with 43 members of staff including doctors of all levels, nurses, healthcare assistants, bed managers, therapy staff, housekeepers and senior managers.

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

  • The service did not always have enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • The service did not always control infection risk well.
  • Records were not always stored securely
  • Individual risks to patients were not always clearly documented
  • Staff did not understand their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005 and were unclear about trust processes for this area.
  • The service did not always take account of individual patient needs.
  • Referral to treatment times were not met in all specialities. There were delays in follow up in rheumatology.
  • There were delays in sending discharge letters and patients waiting for follow up appointments in some specialities.
  • There were a significant number of delayed transfers of care.
  • The ongoing challenge of staffing and sustainability of services compromised the ability of managers for leadership and progressing the development of services.

However

  • The service managed patient safety incidents and medicines well.
  • Safeguarding procedures were clear and staff understood their responsibilities.
  • Mandatory training was provided and met trust targets in the majority of wards.
  • Staff followed national guidance and monitored the service.
  • There was extensive multi-disciplinary team working to support patients’ needs.
  • Staff gave patients enough food and drink for their needs.
  • Staff were caring and patients spoke positively about the treatment they had received.
  • There was a positive and open culture where staff felt supported and showed a positive attitude.
  • The service undertook engagement and was committed to involving staff, service users and the public in developing and improving its services.

Surgery

Good

Updated 15 January 2015

Surgical services provided good care and treatment for patients. Patient safety was monitored and incidents were investigated to assist learning and improve care. Patients received care in clean, hygienic and suitably maintained premises. The staffing levels and skills mix was sufficient to meet patients’ needs and staff assessed and responded to patient risks appropriately

Surgical services provided effective care and treatment based on evidence-based national clinical guidelines and staff used care pathways appropriately. The services participated in national and local clinical audits to benchmark and improve care and treatment for patients. Surgical outcomes were, in the main, positive. However, the number of patients that had elective surgery and were readmitted to hospital following discharge was worse than the England average. There were plans in place to improve areas where national clinical and performance standards had not been achieved, such as compliance with the national hip fracture audit.

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. Patients were treated with dignity and received their care in a compassionate way. Surgical services were planned and delivered to meet the needs of local people. There was sufficient capacity to ensure patients admitted to the surgical services could be seen promptly and receive the right level of care. There was effective teamwork and clearly visible leadership within the surgical services. There was a positive culture within the service that was focused on patient safety and learning. There was routine public and staff engagement and actions were taken to improve the services in response to patient feedback. The management team understood the key risks and challenges to the service and how to resolve them.

Services for children & young people

Good

Updated 15 January 2015

Care provided by services for children and young people was supportive to children, young people and their families. People told us that the staff were “lovely” and “very kind”. There were processes in place for safeguarding and such concerns were identified and referred to the relevant authorities. There were robust arrangements in place to report and monitor incidents and near misses. Staff were clear about their responsibilities in this regard. However the process for reporting safeguarding concerns via the incident reporting system was not as robust. This meant that incident reporting systems may not accurately reflect the safeguarding concerns identified.

There were clear governance arrangements in place that monitored the outcome of audits, complaints, incidents and lessons learned throughout the service. Staff were positive about the culture in children’s and young people’s services and felt supported by their senior managers. Staff were able to be innovative and introduce new practices to improve the quality of the service provided.

Children’s and young people’s services were forward thinking in how services could to be adapted to provide flexibility and sustainability in the future. There was a strong commitment to developing relationships across health networks.

End of life care

Good

Updated 15 January 2015

Patients received a good standard of end of life care that involved relatives and carers. Care was provided by supportive and compassionate staff who respected patients’ need for privacy and dignity. Nursing and care staff were appropriately trained and they were encouraged to learn from incidents. Relatives of patients, nurses and doctors spoke positively about the service provided from the Specialist Palliative Care Team (SPCT). End of life care services worked collaboratively with both primary and tertiary care services to best meet patients’ individual needs.

Patients and those close to them spoke positively about the rapid discharge pathway that enabled patients to be discharged from hospital to home in the last hours/days of their lives. Staff gave examples of how this policy worked in practice and where this had happened for patients. There were also several examples of how the service met the spiritual, religious, psychological and social needs of patients. Future plans for the service included the introduction of the AMBER care bundle, a system that would provide a systematic approach to manage the care of hospital patients facing an uncertain recovery and who are were at risk of dying in the next one to two months.

The trust had policies and a number of monitoring systems in place to ensure that it delivered good end of life care. However there was limited medical input to the SPCT. General medical cover was provided on the wards for patients with end of life care needs. There was only one part-time consultant (two sessions per week) in palliative medicine.

Other CQC inspections of services

Community & mental health inspection reports for Leighton Hospital can be found at Mid Cheshire Hospitals NHS Foundation Trust.