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Bedford Hospital Requires improvement

On 4 December 2018, we published a report on how well Bedford Hospital uses its resources. The ratings from this report are:

  • Use of resources: requires improvement  
  • Combined rating: requires improvement  

Read more about use of resources ratings

Inspection Summary


Overall summary & rating

Requires improvement

Updated 4 December 2018

At this inspection, we inspected urgent and emergency services, surgery, outpatients, maternity and children and young people services. We did not inspect medical care, critical care or end of life care services at this inspection, but we combine the last inspection ratings to give the overall rating for the hospital.

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

  • Our rating for safe remained requires improvement because not all services achieved appropriate staffing levels or ensured mandatory training was completed. Medicines were not always managed safely and services did not always control infection risks well.
  • Our rating for effective remained requires improvement because there was variable performance in some national audits monitored and not all services monitored the effectiveness of pain relief. Some policies and guidance had expired review dates and not all staff received an annual appraisal.
  • Our rating for caring remained good because feedback from patients confirmed they were treated with compassion and offered emotional support. Patients and their families were involved in decisions made about their care and treatment.
  • Our rating for responsive improved. We rated it good because patients could access services when they needed them. Waiting times from referral to treatment were mostly better than the England average. Complaints were treated seriously and lessons learnt were shared with staff.
  • Our rating for well led remained requires improvement because not all managers had the necessary skills for their role and timely action was not always taken to address concerns. Risk registers were not always updated. Some staff reported a bullying and intimidation culture from the senior leadership team, whilst others reported they felt respected and valued by the team.
Inspection areas

Safe

Requires improvement

Updated 4 December 2018

Effective

Requires improvement

Updated 4 December 2018

Caring

Good

Updated 4 December 2018

Responsive

Good

Updated 4 December 2018

Well-led

Requires improvement

Updated 4 December 2018

Checks on specific services

Medical care (including older people’s care)

Good

Updated 20 April 2016

Overall, we rated the service as good for being safe, effective, caring, responsiveness and well led because:

There were excellent facilities to provide appropriate care for patients living with dementia. The trust had implemented processes to meet patient needs. However, patient information leaflets were limited to English only, and staff reported using family members for assistance with translation, which was poor practice.

Medical patients in outlying wards were effectively managed and a policy was in place. Bed management meetings were held three times a day to discuss and prioritise bed capacity and patient flow issues. Discharge coordinators and the complex discharge team helped to facilitate appropriated patient discharge.

Wards were generally clean and had effective systems in place to minimise the risk of infections.

Referral to treatment performance was in line with national targets.

Incidents were reported and staff were generally aware of what preventative actions could reduce the risk of avoidable harm to patients.

Although there was a high level of nursing staffing vacancies within some teams and reliance on agency staff, staffing levels did generally meet patient needs at the time of our inspection. Medical staffing was in line was national guidance.

There was some evidence of progress to providing seven day a week services.

Mortality ratios were similar to those of similar trusts and the service had systems in place to review mortality rates. Care was provided in line with national best practice guidelines and the trust participated in all of the national clinical audits they were eligible to take part in. Multidisciplinary team working was generally effective. Pain relief, was assessed appropriately and patients said that they received pain relief medication when they required it.

The medical care service was generally well-led at a ward level, with evidence of effective communication within ward staff teams. The leadership and culture promoted the delivery of high quality person-centred care as governance and risk management systems were in place in the service. The visibility and relationship with the middle and senior management team was generally clear for junior staff. All staff were committed to delivering good, safe and compassionate care.

Generally, patients received compassionate care and their privacy and dignity were maintained.

However, we found that:

Not all essential equipment had been checked as required by trust procedures. Some wards were cluttered with insufficient storage for equipment. Appropriate systems were in not always in place for the prescription, storage, administration and recording of medicines.

Patients did not always have good outcomes as they did not always receive effective care and treatment that met their needs. Performance and outcomes did not meet trust targets in some areas.

Most staff said they were supported effectively, but there were no regular formal supervisions with managers. Appraisal rates did not meet trust target.

Chemotherapy

Not sufficient evidence to rate

Updated 20 April 2016

Services for children & young people

Good

Updated 4 December 2018

  • There was a strong, visible patient and family-centred culture. Staff were highly motivated and inspired to provide care and treatment that was kind, compassionate and promoted patients’ dignity, and respected people’s needs.
  • Leadership was strong, supportive and visible. The leadership team understood the challenges to service provision and actions needed to address them. Staff were committed to providing the best possible care for children, young people and their families. Staff felt ownership for the service and were proud to be part of the children’s service.
  • The service had a vision of what it wanted to achieve and clear objectives to ensure the vision was met. The vision was developed with involvement from staff.
  • Staff understood their responsibilities to raise concerns and report patient safety incidents. There was an effective governance and risk management framework in place to ensure incidents were investigated and reviewed in a timely way. Learning from incidents was shared with staff and changes were made to delivery of care because of lessons learned.
  • The service made sure staff were competent for their roles. Mandatory training in key skills was provided to all staff and the service made sure everyone completed it. Staff were encouraged to develop their knowledge, skills and practice.
  • The service generally provided care and treatment based on national guidance and evidence of its effectiveness. Local and national audits were completed and actions were taken to improve care and treatment when indicated.
  • The children’s unit was imaginatively decorated, and equipment and toys were used creatively to create a fun, warm and child-friendly environment. Play was seen as an essential part of children’s care. There was a wide range of age appropriate toys, games and books for children and young people, including an outside play area. Play therapists supported the care and treatment of children and young people and arranged a schedule of activities.

However:

  • Medical staffing levels did not always meet planned levels or national recommendations. However, we found there was generally enough staff to keep people safe from avoidable harm and to provide the right care and treatment.
  • Written records were not always legible and medical staff who made entries could not easily be identified. Patient medical records were not always stored securely.
  • We found some policies and guidance had expired their review date. This meant there was a risk staff were referring to out-of-date guidance. At the time of our inspection, 26% of paediatric guidelines were out-of-date. The trust provided assurance that all out of date guidance had been risk assessed, prioritised and allocated.
  • Prescriptions of medications, recording of administration or reason for not administrating were not consistently recorded in line with the trust policy. The review of antibiotic medication was not always recorded on prescription charts after three days in line with trust guidelines.
  • Not all the environment was maintained in accordance with Department of Health guidance. Flooring in some rooms within the children’s outpatient department did not comply with relevant Health Building Note (HBN) requirements.

Critical care

Good

Updated 20 April 2016

Overall, we rated the critical care services as good.

We judged the safety of critical care services as good. Staff on the critical care complex (CCC) knew how to use the trust’s online incident reporting system and did so. All serious incidents were analysed and discussed at weekly meetings.

The environment was visibly clean and staff followed the trust policy on infection control. Medical and nurse staffing levels was appropriate and there was good emergency cover.

There was good compliance with regard to mandatory training.

The critical care outreach (CCO) team provided 24-hour support to the risk of deteriorating patients outside of the CCC. The CCC assessed and responded to patient risk such as the review of patients admitted.

Critical care services were effective. The treatment and care provided followed current evidence-based guidelines. The service submitted data to the Intensive Care National Audit and Research Centre (ICNARC). Data from audits showed there were good outcomes for patients treated in the critical care services.

Staff had awareness of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS).

We found critical care services to be caring. Staff built up trusting relationships with patients and their relatives by working in an open, honest and supportive way. Patients received good care, compassion, dignity and respect. We observed patients received good emotional support.

We rated responsive as requires improvement. Flow out of the CCC posed problems and many patients’ discharge exceeded the recommended discharge time of four hours. ICNARC dated from March to June 2015 showed that the CCC had more delayed discharges (more than four hours) than similar intensive care units. Due to the delay in discharges, the CCC often breached the same sex guidelines. They completed the national forms in relation to sex breaches but did not complete an incident report for sex breaches. However, monitoring data demonstrated that the trust had no issues with flow into the department.

Patients discharged to the ward had follow-up support from the CCO team.

The CCC did not have psychological support for patients, relatives or staff. This had been identified as a recommendation by the Guidelines for the Provision of Intensive Care Services (GPICS) standard report for 2015.

Patients discharged from CCC did not have access to follow-up clinics. This contravened NICE guidance 83. Senior staff described the business plan they wished to implement regarding follow-up clinics.

The records did not identify patient documentation regarding the time and decision to admit to CCC. Staff confirmed they did not record the data. This meant the unit did not know if they were meeting the four-hour target of the decision to admit. However, the trust responded following feedback and amended its electronic patient record system to record this information.

Staff understood the procedures regarding complaints. However, they said that any complaint received would firstly be resolved locally. If a local resolution was not achievable, the trust’s complaints service was available to patients and their families/representatives. This meant that the outcomes, themes or lessons learnt were not cascaded to staff on all complaints received.

Patients’ relatives said they were involved and kept informed. There was good awareness of the needs of people living with dementia, learning disability or mental health needs. They had access to the allied mental health professional (AMHP) and liaised closely with them.

We rated the critical care service as good for well-led. A clear vision for the future of the critical care service team was not evident. Senior management said there was not a strategy for critical care and wished to implement the trust wide strategy prior to reviewing the CCC’s strategy.

The critical care bi-monthly minutes for mortality and morbidity did not have a systematic review of all mortality and morbidity within the unit. There were no actions identified with no time scales attached.

Senior staff and clinicians attended critical care governance meetings. Discussed at governance meetings were the risks to the service and significant events in other areas of the hospital. There were identified actions and who would be responsible for them.

Staff said the recent reconfiguration of the service had improved morale. The staff survey reflected this.

End of life care

Good

Updated 20 April 2016

Overall, we rated the service as good for safety, responsiveness, caring and well led. We rated effectiveness as requires improvement.

The trust had in place a replacement for the Liverpool Care Pathway (LCP) called Bedford Hospital care of the dying patient, supporting care in the last hours or days of life (C of D). The care plan provided guidance for staff to deliver end of life care and treatment in line with current evidence-based guidance, standards, best practice and legislation. Implementation of the C of D care plan had been slow but the SPCT were monitoring implementation of the C of D care plan and had completed actions to improve implementation across the service.

The SPCT had begun a process to monitor the quality of the service effectively. For example, we saw the SPCT had carried out a retrospective medical case review of all ward deaths for a week in February 2015. The notes were reviewed against the One Chance To Get It Right standards The information from this audit was fed into and monitored at the SPCT meeting, end of life steering group, mortality board and to the hospital management board.

Patients we spoke with were very happy with the care that had been provided to them. Relatives we spoke with were happy with the care that their relatives had received

The trust, supported by the partnership for excellence in palliative support (PEPS) team (commissioned by Bedfordshire Clinical Commissioning Group (CCG) and managed by a local hospice) and the local hospice, planned and delivered services in a way that met the needs of the local population. The discharge planning process was supported by the PEPS team which enabled patients’ discharge was arranged appropriately.

Overall, we saw that leadership was good. Local leadership was knowledgeable about quality issues and priorities, they understood what the challenges were and took action to address them.

The trust had both an executive director and a non-executive director who provided representation of end of life care at board level.

Patients did not always have their mental capacity assessed in accordance with the requirements of the Mental Capacity Act 2005 (MCA) and associated code of practice. We looked at 32 ‘Do Not Attempt Cardio-Pulmonary Resuscitation’ (DNACPR) forms across all ward areas and the emergency department. 16 forms stated that the doctor had not informed the patient directly where a clinical decision for a DNACPR had been made. In these cases, there was no formal mental capacity assessment of the patient’s ability to understand this decision. The DNACPR policy did not prompt staff to complete a capacity assessment as part of the decision making process.

The trust took part in the National Care of the Dying Adult of Hospitals (NCADH) in 2013 to 2014 and achieved one out of seven of the organisational key performance indicators (KPIs). The trust scored lower than the England average of 9/10 clinical KPIs. The trust did however, score substantially better than the England average for the clinical KPI about the percentage of cases receiving a review of care after death. The trust had an action plan in place to improve some aspects of end of life care.

Radiotherapy

Not sufficient evidence to rate

Updated 20 April 2016

Surgery

Good

Updated 4 December 2018

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

  • Standards of environmental cleanliness were mostly good and when we identified lapses, they were addressed immediately.
  • The service had suitable premises and looked after them well.
  • Staff understood how to protect patients from abuse and had a good knowledge of their responsibilities to report safeguarding concerns and make referrals.
  • Staff gave patients enough food and drink to meet their needs and improve their health.
  • The service managed patient’s pain well.
  • The service monitored the effectiveness of care and treatment and used the findings to improve them.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.

  • Staff cared for patients with compassion, provided emotional support and involved them in decisions about their care and treatment.

  • Patients could access the service when they needed it.
  • The service took account of patients’ individual needs.
  • The service planned and provided services to meet the needs of local people.
  • The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.
  • The service had a vision for what it wanted to achieve in the short term and workable plans to turn it into action.
  • The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. Risks were clearly identified in the clinical groups risk register.

However:

  • Medicines were not always managed safely.
  • While most equipment was available when required, there were delays in obtaining pressure relieving mattresses in busy periods and pressure relieving cushions were not readily available.
  • Although staff assessed risks to patients and monitored their safety, when assessments alerted staff to the risk of a patient’s condition deteriorating, these patients were not always reviewed in a timely manner.

  • While the service had enough nursing staff with the right qualifications; vacancy levels, a significant volume of inexperienced staff and the use of temporary staffing, sometimes impacted on the timeliness of care.
  • The processes in place to prevent and control infection were not consistently adhered to.
  • Although staff kept records of patients’ care and treatment these were not always appropriate for each individual patient. Records were not always stored securely.
  • While the service managed most patient safety incidents well, nurses did not always recognise when incidents had occurred and required reporting.
  • The percentage of staff completing mandatory training did not reach the trust target of 90%.
  • Some clinical guidelines were past their review date and were not based on the most up to date evidence.
  • There was an inconsistent approach to monitoring patients’ fluid intake.
  • Appraisal rates did not meet the trust’s target of 90%.

  • Nurses frequently did not attend doctors ward rounds and the doctors and other professionals met separately to discuss patients.
  • There were some challenges with the provision of interventional radiology out of normal working hours.
  • Complaints were not always managed in a timely manner.

Urgent and emergency services

Requires improvement

Updated 4 December 2018

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

There were several breaches in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This included:

  • Poor mandatory training compliance.
  • Poor infection control and prevention practice.
  • Inconsistencies in the monitoring of equipment for ensuring safe use.
  • Reduced nurse staffing levels.
  • There were gaps in the provision of a qualified children’s registered nurse in the department.
  • Department meetings were separated by staff grade: there were no whole team meetings and there were no joint handovers between medical and nursing staff.
  • Staff appraisal rates were lower than the Trust target. Clinical supervision was not routinely provided or formally recorded for all relevant staff.
  • The service did not ensure there was a dedicated mental health room that was free from hazard.
  • Concerns raised during our inspection in 2015 had not been resolved.
  • Unauthorised people could enter the department unchallenged.
  • The environment in the majors’ area did not allow all the patients in each bay to be observed easily. The waiting room was too small to accommodate all the patients using it at sometimes. Patients were not observed in the waiting areas.
  • There were limited facilities for patients with individual needs. There was no hearing loop and there was no information available in foreign languages. Staff did not always use translation services when necessary and used family members instead.
  • Consent was rarely documented.
  • Patients checking in at the ED desk could be observed and overheard by waiting patients.
  • Patients were not always reviewed by a consultant within 14 hours of admission, in line with recommendations.
  • Time of waiting for a specialty review was not recorded. This included time spent waiting for a psychiatric assessment and time waiting to see a specialty doctor.

However:

  • Staff knew their responsibilities for escalating concerns and reporting incidents.
  • Patient’s nutritional needs were met, with oral diet provided to patients who were in the department for long periods.
  • Patients were prioritised according to the clinical condition.
  • Patients were positive about the care received. They were included in discussions around care and kept informed of treatment plans.
  • From April 2017 to March 2018 the monthly percentage of patients that left the trust’s ED before being seen for treatment was better than the England average in all but two months, and from November 2017 to March 2018, no patients left before being seen.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

Maternity

Requires improvement

Updated 4 December 2018

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

We rated it as requires improvement because:

  • Conclusions from incident investigations did not always identify appropriate learning and actions. Learning identified through audit completion and perinatal mortality and morbidity meetings were not robustly shared within the division.
  • The working environment did not always encourage openness and honesty, and staff satisfaction and morale was mixed. Some staff were worried about the repercussions of speaking candidly and engaging with the senior leadership team.
  • Midwifery staffing levels were not always suitable for the level of care women and babies required.
  • Due to operational pressures, ward managers and matrons were regularly required to work clinically, which meant they did not have adequate time to support staff and implement changes.
  • Midwives had not received the required training and competency assessments to undertake ‘scrub’ or recovery duties. We also identified this as a concern during our last inspection in December 2015, and found little improvement had been made.
  • There were not effective governance processes established for the completion of emergency and daily checklists on Orchard ward and the delivery suite.
  • Medical staff compliance with mandatory training was variable and their safeguarding children training was below the trust target. Similarly, less than half of the maternity staff had attended a multidisciplinary ‘skills and drills’ training session.
  • Complaints were not always dealt with in a timely manner.
  • Patient records were not stored securely on the maternity ward and prescription records were not always completed with the patients’ weight and allergy status.
  • Actions taken by the service to mitigate identified risks were not always updated regularly on the risk register to evidence timely and appropriate action had been taken to address them.

However:

  • Staff cared for women and babies with compassion, dignity and respect. Women felt involved in their care and were given informed choice of where to give birth.
  • The maternity service worked closely with commissioners and other stakeholders to plan delivery of care and treatment for the local population. This collaborative working ensured future planning covered recommendations laid out by NHS England and the Department of Health.
  • The maternity service took account of women’s individual needs, including those who were in vulnerable circumstances or had complex needs. Bereavement care provision was in place to support families from their initial loss, throughout their time in hospital and return home.
  • The women’s and children division had a newly developed vision, which had been developed with involvement from staff at all levels. Staff were committed to fulfilling the vision.
  • The service used current evidence-based guidance and quality standards to inform the delivery of care and treatment. Staff monitored its effectiveness and used the findings to improve practice and the care provided. The service acted promptly to address any patient outcomes that were not in line with trust thresholds or national averages.
  • Women’s and babies’ nutrition and hydration needs were identified, monitored, and met. There was access to an infant feeding specialist to assist women and babies when needed, and the trust’s breastfeeding initiation rate was better than the national average.

Outpatients

Good

Updated 4 December 2018

  • We rated safe, caring, responsive and well led as good. Effective was not rated, as we are not confident we are collecting enough information to rate this area.
  • The service managed risk to patients well, this included infection control, having suitable premises and equipment, assessing and managing patients at risk of deteriorating, and understanding how to protect patients from abuse
  • There were enough suitably qualified and experienced staff to keep patients safe.
  • The service managed patient safety incidents well.
  • The service worked in line with national guidance, monitoring the effectiveness of care and treatment and using the findings to improve.
  • Patient were treated with compassion and respect.
  • Patients could access the service when they needed it, with waiting times mostly better than the England average.
  • The service took account of patients’ individual needs.
  • Managers had the right skills and abilities to run the service in order to provide high quality sustainable care.
  • Managers supported and valued staff through the promotion of a positive culture and engaged well with staff
  • The service used a systematic approach to improve the quality if its services, recognising risks and developing plans to reduce to eliminate these.
  • The service used feedback from patients to improve the service.

However,

  • Not all staff completed the required mandatory training courses.
  • Some clinics could become overcrowded and did not always have enough seating available.
  • The stock room where drugs were stored in the oncology clinic was not locked when occupied by a member of staff.
  • The service did not always manage complaints in a timely way.