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Bedford Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 20 April 2016

Bedford Hospital NHS Trust provides a range of hospital care services to over 270,000 people living predominantly in north and mid Bedfordshire and is the vascular hub for Bedfordshire, Luton and Dunstable, and Milton Keynes. The trust provides a full range of district general hospital services to its local population, with some links to hospitals in Luton and Dunstable, Milton Keynes and Cambridge.

There are approximately 425 inpatient beds and 28 day case beds within the hospital.

We carried out an announced comprehensive inspection of the trust from 15 to 17 December 2015. We undertook two unannounced inspections on 6 and 7 January 2016. We held focus groups with a range of staff in the hospital, including nurses, junior doctors, consultants, midwives, student nurses, administrative and clerical staff, allied health professionals, domestic staff and porters. We also spoke with staff individually.

Overall, we rated Bedford Hospital as requires improvement. We found improvements were needed to ensure that services were safe, effective, responsive to patient’s needs and well-led. We found that caring was good. Patients were treated with dignity and respect and were provided with appropriate emotional support.

Four of the eight core services at Bedford Hospital were rated requires improvement (surgery, maternity and gynecology, children and young people and outpatient and diagnostics). Four services were rated as good (urgent and emergency care, medical care, critical care and end of life care).

Our key findings were as follows:

  • Staff were kind and caring and treated people with dignity and respect.
  • Overall the hospital was clean, hygienic and well maintained.
  • Equipment was not always appropriately checked and maintained.
  • Vacancy rates had improved in November 2015 to 6.8% but remained worse than the trust target of 1.8%. Nursing vacancies averaged 9.1%. The trust had identified this as a risk and a recruitment programme was underway.
  • Temporary staff were used to fill vacant shifts. An induction process was followed for temporary staff.
  • Not all staff had completed mandatory training and not all relevant staff had not completed other recommended training for example, Advanced Paediatric Life Support.
  • Between June 2014 and June 2015 the trust had reported one case of Methicillin-resistant Staphylococcus Aureus (MRSA), this was in May 2015. There were 13 reported Clostridium difficile cases and four reported Methicillin Sensitive Staphylococcus Aureus (MSSA) cases. Incidences were similar to or better than the England average.

  • Most patients were complimentary about the hospital food and women told us that they received support to feed their babies. We saw that the initiation of breast feeding rate was 85% in May 2015 which was better than the national average of 75%.

  • Patient’s pain was well managed and none of the patients we spoke with reported being in pain.
  • Patients at the end of life were given adequate pain relief and anticipatory prescribing was used to manage symptoms.
  • Mortality was slightly worse than the expected range of 100 with a value of 102. However, this had improved compared to the preceding period. The trust were implemented a series of actions to address this concern.
  • The trust were generally meeting the national targets set regarding patients access to treatment in surgical and outpatient settings.
  • The trust were meeting the standard for patients admitted, referred or discharged from the emergency department within four hours.
  • There were governance processes in pace to provide oversight of incident reporting and management, including categorisation of risk and harm. However, we were not assured that the trust demonstrated a sufficient depth of analysis or learning of incidents, and therefore we were not assured that improvements in practice to prevent reoccurrence had been achieved.
  • We saw evidence of learning from some incidents but were not assured of the ongoing monitoring of changes made and therefore their sustainability.
  • Staff generally felt they were well supported at their ward or department level.
  • Staff reported on the whole executive directors were visible.

We saw several areas of outstanding practice including:

  • The hospital offered Endovascular stent-grafts for popliteal aneurysms, which is an alternative method to open surgery, early indication suggest it is safer and more effective for the patients.
  • Image guidance for endoscopic sinus and skull base surgery is used for sino-nasal tumours, revision sinus surgery and disease abutting the optic nerve, carotid artery and skull base. For patients it means safe surgery, closer to home.
  • One stop neck lump clinic. This speeds up the diagnosis of head and neck cancer by Tru-Cut biopsy solid tumours and avoids general anaesthetics in most cases, with the potential to speed up treatment.
  • The critical care complex had designed and built an attachable portable unit for the end of a patient’s bed, to prevent disruption to the patient’s care and welfare. The unit was used when patients needed to go for a computerised tomography (CT) scan or a magnetic resonance imaging (MRI).
  • A high risk birthing pool pathway was developed and implemented at the beginning of 2015. This meant that women with high risk pregnancies had the opportunity to experience the benefits of water whilst in labour. Midwives who were involved with the development of this project were selected as finalists in the Royal College of Midwives Innovation Awards 2015.
  • Dementia facilities met the needs of patients living with dementia. Facilities included a cinema area, activity tables, coloured and picture coded bays and the inclusion of the wanderguard system. Under bed lighting assisted patients to differentiate between beds and flooring at night, and reported falls had decreased since the lighting was implemented.

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

Importantly, the trust must:

  • The trust must ensure patients privacy and dignity is always maintained at all times.
  • The trust must ensure all reasonable efforts are made to make sure that discussions about care and treatment only take place where they cannot be overheard.
  • The trust must ensure patients always have privacy when they receive treatment or when they used washing facilities.
  • The trust must ensure that where a person lacks capacity to make an informed decision or given consent, staff must act in accordance with the requirements of the Mental Capacity Act 2005 and associated code of practice.
  • The trust must improve the incident reporting process to ensure all incidents are reported, including those associated with staffing levels.
  • The trust must ensure lessons learnt and actions taken from never events, incidents and complaints are shared across all staff.
  • The trust must ensure risk registers reflect the risks within the trust.
  • The trust must ensure effective and timely governance oversight of incident management, that actions agreed correlate to the concerns identified, are acted on and lessons learned are shared accordingly; including categorisation of risk and harm, particularly in maternity services.
  • The trust must ensure patient records are accurate, complete and fit for purpose, including ‘do not attempt cardio-pulmonary resuscitation’ forms.
  • The trust must ensure that systems and processes are in place to ensure the documentation and monitoring of the cleanliness of equipment.
  • The trust must ensure that policies are comprehensive.
  • The trust must ensure there are the appropriate numbers of qualified paediatric staff in the emergency department and paediatric unit to meet standards set by the Royal College of Paediatrics and Child Health 2012 or the Royal College of Nursing.
  • The trust should ensure that where staffing fill rates do not meet trust target, associated risks are identified and mitigated.
  • There must be sufficient numbers of staff trained to the expected standard to give life support to paediatric patients.

In addition the trust should:

  • The trust should ensure all vacancies are recruited to.
  • The trust should ensure all staff have received their required mandatory training to ensure they are competent to fulfil their role. Including safeguarding training.
  • The trust should ensure staff receive and appraisal to meet the appraisal target of 90% compliance.
  • The trust should ensure that all trust policies are up to date and that they are consistently followed by staff.
  • The trust should ensure that patient information can be accessed in different languages.
  • The trust should ensure all equipment has safety and service checks in accordance with policy and manufacturer’ instructions and that the identified frequency is adhered to.
  • The trust should ensure all equipment is in date.
  • The trust should ensure facilities for paediatric patients meet national guidelines.
  • The trust should ensure facilities for patients with mental health needs meet national guidelines.
  • The trust should ensure ligature points are identified and associated risks are mitigated to protect patients from harm.
  • The trust should ensure consultant cover meets with the Royal College of Emergency Medicine’s (RCEMs) emergency medicine consultants workforce recommendations to provide consultant presence in the ED 16 hours a day, 7 days a week as a minimum.
  • The trust should ensure delays in ambulance handover times are reduced to meet the national targets.
  • The trust should ensure that infection control practices are followed by staff.
  • The trust should consider reviewing the admission process for elective surgery are in line with national guidance and to ensure patient privacy and dignity is maintained, with assessments completed in rooms with adequate equipment to meet patient needs.
  • Ensure that records of all patients diagnosed with sepsis contain the ‘Sepsis Six’ sticker to alert staff to the patients diagnosis as per national guidance
  • The trust should ensure that action plans are in place to improve patient outcomes against national audits.
  • The trust should ensure staff that are involved in blood transfusion are up to date with competencies and training.
  • The trust should ensure all drug cupboards and medication fridges are in good working order and locked at all times to maintain safe use of drugs.
  • The trust should ensure patient records are stored safely.
  • The trust should ensure patients belongings are kept safe at all times.
  • The trust should ensure that they implement follow up clinics for critical care patients, as recommended in NICE guidance
  • The trust should ensure that staff document and monitor the time and decision to admit to the critical care complex.
  • The trust should reduce delays experienced by patients in transferring to a ward bed when they no longer required critical care.
  • The trust should ensure that they assess all surgical patients with mortality risk of between 5 and 10% for admission to the critical care complex.
  • The trust should ensure that all medicines are within the recommended date.
  • The trust should ensure that medicines are stored appropriately.
  • The trust should ensure that controlled drugs records are kept up to date and are accurate.
  • This trust should review the entrance to the gynaecology ward to ensure the needs of all patients are met.
  • The trust should develop a policy on restraint and / or supportive holding and staff should receive training to ensure they understand how to apply the policy.
  • The trust should ensure that safeguarding referrals are made in line with trust policy.
  • The trust should patient observations are taken and recorded in line with the agreed time frames according to their risk assessment.
  • The trust should ensure pain assessments for children are consistently completed.
  • The trust should ensure that there a concealment trolley appropriate for bariatric patients.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 20 April 2016

Effective

Requires improvement

Updated 20 April 2016

Caring

Good

Updated 20 April 2016

Responsive

Requires improvement

Updated 20 April 2016

Well-led

Requires improvement

Updated 20 April 2016

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 20 April 2016

We rated maternity and gynaecology services as requiring improvement. We found the service requiring improvement for being safe, responsive and well-led, and good for being effective and caring.

We found that the clinical governance system was not robust. Senior staff within the maternity unit did not manage incidents in a timely manner and in accordance with best practice. We reviewed the trusts serious incident policy and maternity risk policies and found that the staff in the maternity unit were overall following the trust policy but there were gaps and weaknesses in the policy. In response to our concerns, the trust redacted the local maternity risk policy and strengthened its trust serious incident policy to include identification of immediate action to be take post incident, identification of immediate learning for dissemination across the trust, the implementation of trust patient safety alert and updated templates for serious incident investigation reports to included learning and conflict of interest.

In response to a cluster of serious incidents in maternity, the trust was reviewing all intrapartum deaths and stillbirths in the past year and had commissioned an external review of the maternity service.

Staff planned and delivered care to patients in line with current evidence-based guidance, standards and best practice. For example, we observed that staff carried out care in accordance with National Institute of Health and Care Excellence (NICE) and Royal College of Obstetricians and Gynaecologists (RCOG) guidelines.

Patients told us they had a named midwife. The ratio of clinical midwives to births was one midwife to 30 women which was worse than the national target of one to twenty eight women. The trust provided evidence of one-to-one care during labour which is recommended by the Department of Health. Women told us they felt well informed and were able to ask staff if they were not sure about something.

Patients and their relatives spoke highly of the care they received in both the maternity and gynaecology wards.

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.

Urgent and emergency services (A&E)

Good

Updated 20 April 2016

We rated the emergency department within Bedford Hospital to be good.

Patient records contained sufficient detail to ensure all aspects of their care was clear. Risk assessments, including skin damage and falls risks, were consistently completed.

Evidence based guidance was used within the department and was relevant and up to date.

Multidisciplinary working was a strength of the department and relationships with internal and external services helped to avoid unnecessary attendances and facilitated early discharges.

The department took part in local and national audits and showed learning from audit outcomes.

Patient’s feedback was positive about the care they received and we saw good examples of compassionate care within the department.

The department was consistently meeting the four hour target, with escalation processes implemented at the earliest opportunity to allow proactive plans to be put in place to assist flow.

Leaders showed a good understanding of risk, quality measures and factors required to meet national targets. Working partnerships with internal and external providers were good, allowing holistic patient care.

All staff were passionate about providing high quality patient care.

The department did not comply with guidance relating to both paediatric and mental health facilities. Following our inspection actions were put in place to address this.

We saw minimal information or guidance on caring for patients living with dementia. Staff had limited knowledge of caring for those living with dementia and tools available were not utilised.

Mandatory and safeguarding training attendance did not meet the trusts target for both nursing and medical staff.

Surgery

Requires improvement

Updated 20 April 2016

We rated surgery services as good for effective, caring and responsive, and requires improvement for safe and well-led because:

The pre-operative screening process did not ensure that all patients attended for pre-operative assessment prior to their operation. This meant that there was a risk patients may not have been fully informed about their procedure, had all risks identified and had all relevant tests carried out before arriving for surgery. Following the inspection, the trust informed us that an additional safety check had been implemented, to track the attendance of patients.

There was confusion over the management of positive Methicillin-resistant Staphylococcus Aureus (MRSA) results following MRSA screening taken at pre-operative assessments and staff did not always follow the trusts infection control policy.

The policy for anticoagulation advice for patients was out of date on September 2014. There was no clear guidance for the management of all patients on anticoagulation who required surgery. We saw this impact on patient care. We raised this with the trust that approved new guidance in January 2016.

There was a culture of incident reporting, but staff said they did not always receive feedback on incidents submitted. Staff were unaware of never events and serious incidents that had recently occurred and no learning had been shared.

Medicines were not always stored safely and securely to prevent theft, damage or misuse.

There was support for patients with a learning disability and reasonable adjustments were made to the service to accommodate patients with individual needs. Information leaflets and consent forms were not available in other languages. An interpreting service was available.

Medical staffing levels were appropriate and there was good emergency cover. Consultant-led, seven-day services had been developed and were embedded into the service. There was a high number of nursing vacancies; agency and bank staff were used to cover vacant shifts.

The environment was visibly clean.

Treatment and care were provided in accordance with evidence-based national guidelines. There was good practice, for example, assessments of patient needs, monitoring of nutrition and falls risk assessments. Patient care records were appropriately completed with sufficient detail.

Multidisciplinary working was evident.

Appraisal levels did not meet the required target. Staff had awareness of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLs).

Patients told us that staff treated them in a caring way, and they were kept informed and involved in the treatment received. We saw patients treated with dignity and respect.

Surgical services were supported by dedicated senior staff, who were visible on the wards and theatre areas and staff appreciated this support. There was variable awareness amongst staff of the hospitals values. Staff were unaware of national audits undertaken within the hospital or of patients’ outcomes relating to national audits.

Intensive/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.

Services for children & young people

Requires improvement

Updated 20 April 2016

Services for children and young people at Bedford Hospital were judged to require improvement for safe, effective and for being well-led, and good for caring and responsive.

Incidents were not always reported and those reported were not always investigated in a timely manner. We noted that actions recorded did not always address the issues raised, in particular for staffing incidents and there was a lack of shared learning.

Nurse staffing arrangements on the paediatric unit were not sufficient to meet demand, we raised this with the trust who took prompt action to address this. Nursing staffing arrangements on the neonatal unit were adequate to meet requirements, most of the time.

Completion of mandatory training within the service was not compliant with the trust’s target of 90%, and staff had not completed other recommended training for example Advanced Paediatric Life Support. Following our inspection the trust implemented an action plan to address this.

Most staff had completed safeguarding training and there were suitable procedures in place for reporting safeguarding concerns. However, the trust policy was not always followed.

Patient dependency levels were not always assessed and observations were not always completed within agreed timeframes, as per the patient’s risk assessment for patients on the paediatric unit. There were also inadequate arrangements in place to care for patients with mental health needs.

The environment was observed to be visibly clean during our inspection, although the units’ own audits identified some areas of non-compliance.

Some equipment and medicines were out of date and relevant checks had not always been undertaken or not recorded. Records were suitably stored and most contained adequate detail.

A clinical audit plan had been developed for 2014/15 and 2015/16. However a proportion of audits had not been completed, and agreed actions and recommendations did not always address the issues identified.

Policies and care pathways relating to paediatrics and neonates were up to date and had considered national guidance as appropriate.

The service used a dashboard to monitor performance, although this was difficult to read ‘at a glance’ and not all relevant data had been included, raw data for some outcomes were provided.

All of patients and relatives we spoke with told us that they were satisfied with the care they received and felt that staff listened to them and were compassionate; and this was supported by our observations.

We found evidence of multidisciplinary support being facilitated throughout children’s services and patient’s individual needs were met most of the time, although some improvement was required to support patients with learning difficulties.

There were governance arrangements in place, the paediatric and neonatal unit quality group was the main meeting for paediatrics and neonates. Meetings were minuted although the level of detail was variable.

The risk register failed to consider a number of risks, including some we identified during inspection, for example staffing shortages.

Leadership worked well and staff felt listened to most of the time, but that management failed to respond to some issues raised in relation to staffing shortages.

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.

Outpatients

Requires improvement

Updated 20 April 2016

Overall we rated outpatients and diagnostic imaging services as requires improvement.

Safety concerns were not consistently identified or addressed quickly enough and necessary improvements were not always made when things went wrong. Infection control procedures were not always followed and clinic environments were not all fit for purpose. Staff working in clinics attended by children and young people did not have adequate training in safeguarding children, and staff were not all up to date with mandatory training. There were staffing shortages across clinical and support staff in many outpatient and diagnostic services. Very few services were provided seven days a week.

Medical records were maintained accurately and securely, and there was an effective records tracking and location system. Clinical areas were generally clean and well-organised. Staff used national and professional guidance when carrying out assessment, diagnosis and treatment. Staff had good opportunities for professional development but the outpatients and diagnostic services did not provide all staff with an annual performance appraisal. In some areas this fell well below the trust target of 90%.

Staff treated patients and their relatives with dignity and respect. Patients were given sufficient information to make decisions about their treatment and felt they were well informed. However, services did not always meet people’s needs and the needs of the local population were not fully identified or taken into account. The environment did not meet the needs of people with dementia or a visual impairment. Despite serving a multi-cultural population, outpatient and diagnostic services did not provide patient information in formats other than written English. There was no easily accessible complaints system and staff had a poor understanding of managing complaints. Patient feedback was limited.

Access to services was well managed. Waiting times for appointments met the national standards and patients were able to attend appointments swiftly, through an effective booking system.

Overall staff were positive about working in their teams and felt well supported by managers. However, the leadership, governance and culture did not always support the delivery of high quality assessment and treatment. There was no clear vision or strategy for the services. Governance and risk management systems did not consistently operate effectively and risks were not always managed in a timely way.

Chemotherapy

Not sufficient evidence to rate

Updated 20 April 2016

Radiotherapy

Not sufficient evidence to rate

Updated 20 April 2016