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Bedford Hospital Requires improvement

We are carrying out checks at Bedford Hospital. We will publish a report when our check is complete.

Reports


Inspection carried out on 15, 16 and 17 December 2015

During a routine inspection

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 carried out on 19, 20 August 2014

During an inspection to make sure that the improvements required had been made

We visited Bedford Hospital NHS Trust on 19 and 20 August 2014 to follow up non-compliance around the trust's quality assurance systems and also to look at concerns that the Care Quality Commission (CQC) had received throughout 2014.

We visited the medical and surgical wards within the trust and spoke with 49 patients, two relatives and 52 staff members. Staff included the Chair of the Trust Board, Director of Corporate Affairs, Director of Nursing, Deputy Director of Nursing, Infection Control lead, nursing staff, student nurses, consultants, doctors, clinical managers, ward clerks, allied health professionals, allied health professional assistants and care assistants.

Safe

Staff had a good understanding of incident reporting. However, there was a lack of feedback at ward level to identify what areas of practice could be improved. Patient records were maintained. These demonstrated the care and treatment patients required and what action had been taken, ensuring patient risk was assessed and responded to.

Effective

We spoke with staff and found that they were knowledgeable and appeared to work well within their teams.

Caring

Patients and relatives told us that they had been treated well and received good care from considerate staff. Some patients commented on a marked improvement in the quality of care and staff interaction in the last two years.

Responsive

Staff worked proactively to ensure patients were discharged safely from the hospital working with relevant healthcare professionals. However, staff felt that there was a slow response from social services when preparations were being made to discharge a patient who required non nursing community services. Staff were aware of the complaints process and patients informed us that they had no complaints around their care. However, staff training for complaints handling and evidence to show lessons had been learnt from complaints was limited.

Well led

The trust's clinical and corporate governance systems had improved since our visits in July and November 2013. There were clear accountabilities within the governance systems for risk management and ensuring serious incidents, incidents and complaints were discussed from the ward level to Board level. However, the discussion of lessons learnt at ward level was limited. When we asked people if they would recommend the hospital to family or friends, they all stated that they would.

Inspection carried out on 25, 26, 28 November 2013

During an inspection to make sure that the improvements required had been made

In July 2013, we took enforcement action against this provider due to the seriousness of the concerns we had identified. In particular this related to staffing, staff support and quality monitoring systems. In addition we made compliance actions against a further five regulations where non-compliance was identified.

We conducted this inspection on the 25, 26 and 28 November 2013 to follow up on the progress and improvements made in relation to all the identified concerns. We visited 10 wards and departments during this inspection, and found significant improvements had been made. We found staff treated patients in a dignified manner, and were respectful and caring in their approach. We spoke with more than 30 patients or their relatives, and most were very satisfied with the care they had received.

We found the wards were calm and well organised, and following a recent recruitment drive, staffing numbers had been increased in most areas. We spoke with more than 60 staff, and found most were enthusiastic about the recent changes in the hospital, and were keen to talk about the improvement processes and initiatives they had been involved in.

The trust had restructured their governance systems and developed additional committees to monitor specific areas of quality and safety. Although not fully compliant in this area, the improvements made were so significant that we considered the impact to be greatly reduced and have taken regulatory action accordingly.

Inspection carried out on 3, 4, 9, 11 July 2013

During an inspection in response to concerns

We carried out our inspection on 3, 4 and 9 July 2013 during the day and night, visiting the Accident and Emergency Department, medical and paediatric units. Additional information was requested on 11 July as part of our inspection. We observed care provided to people, and spoke with approximately 25 patients and 20 people’s relatives about their experiences of using the service. We also spoke with approximately 35 members of staff working in different roles.

We identified concerns in the consistency of care provided to people in line with their assessed needs, and in the dignified manner in which this was delivered in some areas.

We found concerns in the systems for discharging patients from hospital and whilst improvements had been made over time, these were not consistent.

Prior to our inspection, serious concerns had been raised by Health Education England related to the consultant support, supervision and training opportunities for trainee doctors in paediatrics. Whilst the trust had taken actions to address this, these had not been sustained. During our inspection we identified major concerns in the systems to ensure each ward area was staffed with sufficient numbers of appropriately skilled and experienced staff, and also concerns in the consistency of support provided.

We also found major failings in the trusts governance processes to ensure incidents and risks were identified, reported and responded to in order to maintain safe, effective care delivery.

Inspection carried out on 13 March 2013

During an inspection to make sure that the improvements required had been made

We carried out an inspection of Bedford Hospital on 13 March 2013, to review improvements made to the areas we had previously identified concerns with. As part of our inspection, we visited a number of ward areas, spoke with a range of staff in these areas and also spoke with a number of patients and people’s relatives.

We found the trust had made a number of improvements since our inspection in December 2012, related to the assessment and planning of people’s care, as well as the processes for monitoring the quality of care provided.

Everyone we spoke with who used the service said they were happy with the care, and that they found staff were caring. Several people told us that staff were “wonderful”. Others said they couldn’t fault the staff, and whilst they saw staff were busy and often ‘stretched’, they said the care was very good.

Staff we spoke with told us they had been made aware of concerns raised from our previous inspection. They said that a lot of work had been done by the senior management and matrons to support staff and drive improvements. The majority of staff told us they were happy with the improvements made and felt they were able to deliver better care to people due to new processes for planning and assessing care and people’s needs.

Inspection carried out on 27 December 2012

During an inspection to make sure that the improvements required had been made

We visited Bedford Hospital NHS Trust on 27 December 2012 to monitor improvements from concerns we identified at our inspection in July 2012.

We found changes had been made within the trusts executive team, including the recent appointment of a new Director of Nursing. New systems had been developed and implemented, particularly related to governance and quality assurance processes, and early signs showed these were having a positive impact on the trusts improvement journey. However they were not yet fully embedded in practice and more work was needed to ensure the trust was meeting all standards of quality and safety.

We visited three inpatient areas, the Accident and Emergency Department and also the paediatric assessment unit; we spoke with a number of patients and relatives in each area. People were complimentary of staff, although said the nurses were often very busy and overstretched. One person said “The staff are fantastic and the place is clean”. Another said “Lots of doctors have talked to me about what is wrong and what they are doing. Staff are very nice and friendly.”

However, in the acute assessment unit, people told us that they felt the unit was ‘chaotic’ as staff were so busy, with “so many patients coming and going”. We observed this during our visit, with many people standing around trying to get information. However, people did tell us that when they received the care, it was generally good, but was often delayed as the unit was so busy.

Inspection carried out on 31 July 2012

During a routine inspection

During our inspection of Bedford Hospital on 24, 26 and 27 July 2012, we visited many areas including Accident and Emergency, surgical and medical wards, short stay assessment areas, radiology, the discharge lounge, outpatients and maternity. We spoke with over 40 patients and 10 peoples' relatives, the majority of who told us they had had a positive experience during their attendance to the hospital. Most people told us they were very happy with the care and treatment they had received and spoke highly of the hospital and staff.

People who had attended the outpatients department told us they usually experienced delays with clinics starting late, delays in being seen at their appointment time, and they did not have a choice about their appointment times. At the time of our visit, we noted two people had waited 45 minutes beyond their original appointment time. However, one person told us they had some choice in their appointment time and the nurses in one clinic were “fantastic”.

Inspection carried out on 21 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 20 October 2011

During a routine inspection

We spent time in ten different departments of the main hospital and all areas of the maternity department. We spoke with a number of people who were either patients, or the friends or relatives of people who were patients at the time of this review.

On the whole the people with whom we spoke were pleased with the care and support that they received whilst in hospital and with the way in which the staff approached their care and treatment needs. They felt that staff took time to explain what was happening to them and to answer any questions they had about their condition or treatment plans. People felt that they received enough information to help them make informed choices about their treatment options and the about the focus of the care they wanted to receive.

They told us that they had consented to their treatment and fully understood what was to happening before the treatment commenced.

In the maternity department mothers told us that their delivery options were discussed with them and although they made decisions about the care they wanted this was flexible and any recommended or necessary changes were discussed with them.

People commented on how busy staff were but they did not feel that this impacted on the care provided.

Patients were satisfied with their meals. They told us they were given a daily sheet from which to make a choice. One person said that the was much better than previously.

In the maternity department people told us that their care appeared streamlined and that the midwives who visited them at home knew about their situation.

Patients we spoke with during the visit were very complimentary about the standard of cleanliness in all areas of the hospital.

We were told that pain relief was offered during medication rounds and that it could be requested outside these times.

Patients considered that there were adequate numbers of staff available and that in general they responded quickly to requests for help. People were aware of how they could complain about the care and services provided by the hospital.

Inspection carried out on 6 April 2011

During an inspection in response to concerns

We did not ask for the views of people who use the service as part of this review.

We spoke with a number of staff, on several different wards, in both children’s and adults’ services during our visit on 20 May 2011. We found that staff had varying levels of knowledge, experience and training.

We found that some staff were very knowledgeable about safeguarding procedures and protocols, what to look out for and how and to whom to report any concerns. Others were less clear.

Inspection carried out on 14 April 2011

During a themed inspection looking at Dignity and Nutrition

Many patients told us that they were satisfied with the care and treatment they received at Bedford hospital, however others told us they were not. Several people said that most of the time they were treated with courtesy and respect, and that their privacy and dignity had been protected, but again this was not the experience of everyone. This is captured in a number of comments made to us:

‘This is the best hospital I have been in, and I have been to three before this one’.

‘Excellent hospital’.

‘I have no complaints at all’.

‘I was in AAU before here and they didn’t pull the curtain’.

‘It depends which staff are on as to whether I get the care I should’.

‘Staff say they will be back but they forget, and then I have to ring the bell again’.

Some patients told us they felt their nutritional needs and dietary preferences were met. They gave positive feedback about the quality, range and availability of food. Other patients told us that they were not satisfied with the quality of food or choices available. Comments made included:

‘Good choices, really good’.

‘Good choice, nice food’.

‘The nurses make me toast here on the ward’.

‘Bland’.

‘I never get any salt and pepper’.

Inspection carried out on 6 January 2011

During an inspection in response to concerns

During our visit, we met with seven of the 11 people who were receiving care within the minor and major treatment areas of the accident and emergency department. We also spoke with one relative and members of staff.

Records showed that at the time of our visit a very low number of people had presented for treatment in comparison to other times. Staff told us “this was unusual”. Therefore the feedback from people on their experience within the department should take this into account.

We asked three people receiving care within the minor treatment section, if they had been able to get anything to eat or drink. They told us that they had not been in the department long enough to want anything. They also told us that they had seen vending machines and would have used them if they had wanted to.

Another person with their relative told us that they had not been offered anything to eat or drink. The person was about to be moved to another area in the hospital, and had been in the department under three hours. During that time staff explained that an assessment of their medical needs had been made, part of this was to determine if they would need a test or procedure that would be better carried out, if the person had not had anything to eat or drink before it. However staff had not explained this to the person or their relative.

When asked about the environment four people told us that they found the department warm and comfortable. We specifically asked people if they felt cold at anytime; everyone with whom we spoke said that they were comfortable.

We noted that when people were shown to an assessment cubicle, staff asked if they wanted the curtains drawn around them to give additional privacy.

The reception area was warm and comfortable with adequate seating and available wheelchairs. The entrance area had suitable toilet facilities that included accessibility for people using a wheelchair and children’s play area. They were clearly signed and were clean and well maintained. There were sufficient numbers of small hand basins with gel, soap and hot water sited in appropriate parts of the unit

During our visit, people told us that they felt that there were sufficient numbers of staff on duty. Overall people who were being treated in the accident and emergency department told us that their experience was positive. They found that staff were attentive, approachable and informative. Most people were very satisfied with their treatment and the experience of being a patient in the department.

One person said, “my family have needed to use this place in the past, I am very happy with my treatment both then and today”. Another person told us, “ I got here at about 10 and was seen within 10 minutes, the staff have been great, I didn’t have to wait to see a doctor or nurse”

Inspection carried out on 10 May 2010

During an inspection to make sure that the improvements required had been made

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.