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Victoria Infirmary Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 19 September 2018

We rated it them as requires improvement because:

We rated urgent and emergency care at the hospital as requires improvement overall due to the safe and effective domains being rated as require improvement.

We did not inspect the outpatients service.

Inspection areas

Safe

Requires improvement

Updated 19 September 2018

Effective

Requires improvement

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

Requires improvement

Updated 19 September 2018

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 15 January 2015

Medical services at Leighton Hospital were well-led, and delivered by caring and compassionate staff. We observed staff treating patients with dignity and respect and patients we spoke with were positive about their interactions with staff.

However, clinical outcomes for patients in some areas required improvement. Our analysis of data showed that particular improvements were needed in the management of patients with diabetes and those who had had a stroke. There also gaps in the provision of some out-of-hours services for patients with upper Gastrointestinal (GI) bleeds and in providing thrombolysis for patients that had suffered a stroke. In addition, some specialist nursing posts had not been filled at the time of our inspection.

Patients were regularly at Leighton Hospital longer than they needed to be, usually as a result of delays in providing, or the availability of, care home placements or care at home packages.

Discharge letters were not prepared and issued promptly, leading to possible delays in follow-up care and treatment for patients. There was continual pressure on the availability of beds which meant that some patients could not be placed in an area best suited to their needs. Some of the areas used for escalation beds, especially the primary assessment area, did not provide an appropriate environment for the care of patients overnight.

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.