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Inspection Summary


Overall summary & rating

Good

Updated 14 April 2020

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

  • The safe rating for the hospital was requires improvement overall. This was because urgent and emergency care and medical services were rate as requires improvement at this inspection. Critical care and maternity were not inspected at this visit and remained requires improvement in safe from previous inspections.

  • The effective rating stayed the same at good overall. Although urgent and emergency care were rate as requires improvement at this inspection.

  • The caring rating remained as good and all core services were rated as good for caring.

  • The responsive rating was good overall. This was because the requires improvement rating in outpatients remained from inspection in 2015. The team used their professional judgement to depart from the ratings principles to ensure a proportionate rating here as we had information which demonstrated that the concerns raised regarding the over running of clinics had been resolved and that the referral to treatment times for the trust were positive.

  • The well led rating was good overall. This was because all the core services except urgent and emergency care were rated as good.

Inspection areas

Safe

Requires improvement

Updated 14 April 2020

Effective

Good

Updated 14 April 2020

Caring

Good

Updated 14 April 2020

Responsive

Good

Updated 14 April 2020

Well-led

Good

Updated 14 April 2020

Checks on specific services

Medical care (including older people’s care)

Good

Updated 14 April 2020

Our rating of this service improved. We rated it as good because:

  • The service controlled infection risk well. Staff assessed risks to patients, acted on them. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients.
  • Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However;

  • Whilst the service provided mandatory training in key skills, the number of staff who completed it did not always meet trust targets.
  • Whilst staff understood how to protect patients from abuse, the number of staff who completed safeguarding training did not always meet trust targets.
  • Whilst there had been improvements in nurse staffing levels, some medical wards did not always have enough nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
  • The service used systems and processes to safely prescribe, administer, record and store medicines. However, antimicrobial medicine reviews were not always completed in line with trust policies. Medicines security audit findings showed medicines were not always securely stored.
  • Records were not always securely stored across the majority of medical wards. Whilst most records were clear, up-to-date and easily available to staff, we found poor compliance in areas such as completion of follow up assessments for venous thromboembolism (blood clots).
  • Key services were not always available seven days a week to support timely patient care.
  • Fluid balance charts were not always completed accurately.
  • Whilst staff assessed and monitored the majority of patients regularly to see if they were in pain and gave pain relief in a timely way, there was poor compliance against the hospital’s pain relief standards on two medical wards, indicating patients on these wards did not always receive appropriate pain relief.
  • Whilst the service treated concerns and complaints seriously and investigated them, complaint responses were not always within trust targets.

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.

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.

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.

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.

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.

Urgent and emergency services

Requires improvement

Updated 14 April 2020

Our rating of this service went down. We rated it as requires improvement because:

  • There were not always enough staff with the right qualifications, skills, training and experience to provide care and treatment to children and staffing of children’s nurses was not in line with national guidance.
  • The service did not ensure that nurses could legally administer specified medicines at all times by ensuring that new patient group directions were authorised and signed by staff immediately upon expiry of existing ones.
  • The service did not ensure that the security of documents such as prescription pads were maintained at all times.
  • The service did not ensure that all staff were up to date with their mandatory training.
  • Some patient pathways and policy documents had not been reviewed at the scheduled time.
  • Although people could access the service when they needed it waiting times for treatment were not within national targets and showed a declining picture.

However:

  • The service had enough staff to care for adult patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

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.
Other CQC inspections of services

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