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Inspection Summary


Overall summary & rating

Good

Updated 3 June 2016

Luton and Dunstable hospital is part of Luton and Dunstable University Hospital NHS Foundation Trust and it is a medium size acute hospital comprising all acute services. There were approximately 679 beds at this trust including 544 general and acute, 76 maternity and 23 critical care and high dependency beds.

We carried out this inspection as part of our comprehensive inspection programme, which took place during 19 to 21 January 2016. We undertook two unannounced inspections to this hospital on 27 January and 4 February 2016.

We inspected eight core services, and rated three as good overall, being surgery, maternity and gynaecology and end of life care. Three core services were rated as outstanding being urgent and emergency care, children, young people and families and outpatients and diagnostics. Two services, medicine and critical care, were rated as requiring improvement.

We rated the Luton and Dunstable Hospital as good for two of the five key questions for effective and caring. We rated two key questions, responsiveness and well led, as being outstanding. For well led, the hospital had three outstanding ratings, four good ratings and one core service that required improvement; against our aggregation rules this would be rated as good however, during our quality review in order to reflect the positive findings, this was overruled and well led was rated as outstanding. We rated one key question, safety, as requiring improvement. Overall, we rated the hospital as good.

Our key findings were as follows:

  • Staff interactions with patients were positive and showed compassion and empathy.
  • Feedback from patients was generally very positive.
  • Staff morale was generally good and dedication and staff commitment to providing positive outcomes for all patients was high.
  • Staff reported incidents appropriately, and learning from incidents was shared effectively.
  • Staff we spoke with knew what duty of candour meant for them in practice and was evidenced by the way incidents had been managed.
  • Most environments we observed were visibly clean and most staff followed infection control procedures. Equipment had been generally well maintained.
  • Safeguarding systems were in place to ensure vulnerable adults and children were protected from abuse and staff followed these procedures.
  • Appropriate systems for the storage and handling of medicines were generally in place.
  • Nurse staffing levels were variable during the days of the inspection, although in all areas, patients’ needs were being met.
  • Medical staffing was generally appropriate and there was good emergency cover.
  • Working towards providing a seven day service was evident in most areas.
  • Patients generally had access to services seven days a week, and were cared for by a multidisciplinary team working in a co-ordinated way.
  • Patients’ needs were generally assessed and their care and treatment was delivered following local and national guidance for best practice.
  • Outcomes for patients were often better than average.
  • Pain assessment and management was effective in most areas.
  • Most patients’ nutritional needs were assessed effectively and met.
  • Staff generally had appropriate training to ensure they had the necessary skills and competence to look after patients. Staff were suitably qualified and skilled to carry out their roles effectively and in line with best practice.
  • Services were generally responsive to the needs of patients who used the services.
  • The emergency department consistently met the four hour target for referral, discharge or admission of patients in the emergency department which was recognised at a national level.
  • The number of bed moves of more than one was low within the hospital compared to the national average.
  • The trust’s average length of stay was lower than the England average for elective admissions.
  • There was support for vulnerable people, such as people living with dementia and mental health problems.
  • We saw there were systems in place to monitor medical outliers effectively throughout the trust.
  • We found surgical services were responsive to people’s needs and outcomes for patients were good.
  • The service regularly carried out operations on a Saturday to meet local need.
  • Surgical care and treatment for patient having a fractured neck of femur was comparable to the national average.
  • Cancellations of operations were similar to the national average.
  • The maternity service held stage two baby friendly accreditation.
  • We found there was a real commitment to work as a multidisciplinary team delivering a patient centred and high quality service in the children’s and young people’s service. Neonates, children and young people were at the centre of the service and the highest quality care was a priority for staff.
  • The specialist palliative care team had a clear vision in place to deliver good quality services and care to patients. There was a long term strategy in place with clear objectives.
  • Waiting times for diagnostic procedures was lower than England average.
  • The trust consistently met the referral to treatment standards over time.
  • There were effective systems for identifying and managing the risks at the team, directorate and organisation levels.
  • Generally, there were effective procedures in place for managing complaints.
  • There was a strong culture of local team working across most areas we visited.
  • Leaders in all services were visible and the majority of staff felt valued and supported.
  • The emergency department had an established and experienced leadership team who were visible and approachable to staff at all levels and had a clear and committed focus to drive improvements in patient safety and the quality of care and treatment throughout the department.
  • Visionary leadership from the Board to all areas of ED resulted in the ownership of the emergency pathway throughout the hospital. The leadership team in ED over the past five years had transformed the service from one of the worst performing ED’s in the country, to one of best performing nationally. This significant improvement in performance, despite a continuing rise in year on year attendances, had been recognised at a national level by senior NHS and government leaders.
  • The management of risks within services was generally robust and risks had been addressed in a timely manner.

We saw several areas of outstanding practice including:

  • The emergency department had a robust process for managing the access and flow in the department which was a multi-disciplinary approach to patient care and had helped to achieve the four hour target consistently since 2012 which was recognised at a national level.
  • The dementia nurse specialist for the hospital was licensed to deliver the virtual dementia tour to hospital trust staff. The virtual tour gave staff an experience and insight to what it is like living with dementia and this was very popular and gave staff an understanding of people’s individual needs.
  • We saw strong, committed leadership from senior management within the surgical division. The senior staff were responsive, supportive, accessible and available to support staff on a day to day basis and during challenging situations.
  • Implementation of Super Saturday for elective surgery lists helped to reduce waiting lists. Two separate general surgeons were on call to meet patient needs.
  • The hospital had an Endometriosis Regional Centre, which was accredited for advanced endometriosis surgery within the region.
  • Paediatric services had developed new models of care for the child in the right place, with the right staff, across tertiary, secondary and primary care boundaries.
  • There were a range of examples of how, as an integrated service, children’s services were able to meet the complex needs of children and young people. The level of information given to parents was often in depth and at times complex. Staff managed to communicate with the parents in a way they could understand.
  • The neonatal unit had been at the forefront of introducing new treatments and procedures including nitrous oxide therapy, high frequency ventilation and cooling therapy which had resulted in a significant reduction in its mortality and morbidity. The use of innovative ways of working with almost 24 hours a day, seven days a week consultant cover due to the introduction of new consultants and meeting European Working Time Directives had led to the team being able to treat more complex babies.
  • There was a range of examples of working collaboratively and the children’s and young people’s service used innovative and efficient ways to deliver more joined-up care to people who used services. We observed the service prided itself on meeting the transitional needs of young people living with chronic conditions or disabilities through engagement with adult and community services to improve transition from children and young people’s services to adult services.
  • The outpatients’ and diagnostics division had very clear leadership, governance and culture which were used to drive and improve the delivery of quality person-centred care. Divisional leads were frequently involved with patient care and problem solving to ensure smooth patient pathway through departments.
  • Involvement of clinical staff in the development and design of the orthopaedic hub and breast screening unit have enabled clinical needs to be met and promoted a positive patient experience.
  • Joint ward rounds with pharmacy staff and ward based clinicians encouraged shared learning promoting an improved patient experience and possibly improved outcome.

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

  • The trust took immediate actions during the inspection to address areas of concern regarding the staffing levels, medicines’ management and bed space concerns in the high dependency unit.

In addition, the trust should:

  • Ensure that all staff complete mandatory training in line with trust targets, including conflict resolution training.
  • Ensure that all relevant staff have the necessary level of safeguarding training.
  • Ensure all staff have had an annual appraisal.
  • Ensure that information for people who use this service can obtain information in a variety of languages and signage reflects the diversity of the local community.
  • Ensure that all services take part in relevant national audits to allow them to be benchmarked amongst their peers and to drive improvements in a timely way.
  • Ensure the High Dependency Unit contributes to the Intensive Care National Audit and Research Centre (ICNARC) database, to allow benchmarking against similar services.
  • Ensure the time to initial clinical assessment performance information is monitored to give an effective oversight of performance.
  • Ensure that all handover documents are completed within the emergency assessment unit.
  • Ensure there are consistent processes to enable patients to self-administer their medicines.
  • Ensure that there is a standardised consultant led board rounds implemented within the medicine service.
  • Ensure that patients receive the recommended input from therapists.
  • Ensure environmental repairs are completed in ward areas and kitchen areas.
  • Ensure that defined cleaning schedules and standards are in place for all equipment.
  • Review the consent policy and process to ensure confirmation of consent is sought and clearly documented.
  • Ensure patients have their Venous Thromboembolism (VTE) re-assessment 24 hours after admission
  • Continue to ensure lessons learnt and actions taken from never events, incidents and complaints are shared across all staff groups.
  • Review the security systems at maternity ward entrances to further improve the safety of women and their babies on the unit.
  • Improve the timing of reporting incidents to the National Reporting and Learning System (NRLS).
  • Establish parameters for the gynaecology performance dashboard to enable the service to identify areas of compliance that needed addressing.
  • Establish appropriate support is available to parents in the maternity unit following the death of their baby.
  • Ensure effective collection and oversight of the end of life care service with regards to rapid discharge performance and preferred place of death for patients’.
  • Provide adequate waiting area facilities for patient on beds or trolleys within diagnostic areas.
  • Provide appropriate facilities to ensure privacy and dignity is maintained for patients who wear gowns for clinical investigations.
  • Review plaster technician facilities to ensure appropriate storage and treatment areas are available across the trust.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 3 June 2016

Effective

Good

Updated 3 June 2016

Caring

Good

Updated 3 June 2016

Responsive

Outstanding

Updated 3 June 2016

Well-led

Outstanding

Updated 3 June 2016

Checks on specific services

Maternity and gynaecology

Good

Updated 3 June 2016

Overall, we rated maternity and gynaecology services as good.

Patients were protected from the risk of avoidable harm and, when concerns were identified, staff had the knowledge and skills to take appropriate action. Incidents were recorded, investigated and, where necessary, actions were taken to prevent recurrences.

Environments were visibly clean during the inspection and the service had robust infection control systems in place. Equipment was generally checked regularly and well maintained.

Medicines were stored and handled safely. Records were completed and stored in accordance with trust policies.

Safeguarding vulnerable adults, children and young people was a priority for the service. We saw staff responded appropriately to signs or allegations of abuse and worked effectively with others to implement protection plans. There was active engagement in local safeguarding procedures and we saw effective work with other relevant organisations during the inspection.

Doctor, nurse and midwife staffing levels and skill mix were planned, implemented and reviewed regularly. Staff shortages were responded to quickly and appropriately. There were effective handovers at shift changes to ensure staff could manage risks to patients.

Patients’ care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation. Information about patients’ care and treatment, and their outcomes, was routinely collected and monitored. This information was used to improve care. Access to medical support was available seven days a week throughout the service.

Feedback about the service and staff was largely positive. People were treated with dignity, respect and kindness during all interactions with staff and relationships with staff were largely positive. Staff responded compassionately when people needed help and supported them to meet their basic personal needs as and when required. People’s privacy and confidentiality was respected.

Services were planned and delivered in a way that met the needs of the local population. The importance of flexibility, choice and continuity of care was reflected in the services provided.

The service consistently met the 92% standard for percentage of patients on an incomplete pathway waiting less than 18 weeks from referral to treatment for gynaecology. Patient flow in the service was generally effective.

Governance arrangements were effective and there was a clearly defined strategy and governance structure in place.

However, we also found that:

Not all staff had received an appraisal or completed their mandatory training (particularly safeguarding level three) and the trust’s target had not been met in all cases. The service had plans in place to address this.

The closed circuit camera system (CCTV) in the maternity block was not appropriate. There was no CCTV at all ward entrances; there were cameras at the entrance to the building. The service was taking action to address this.

Women shared a waiting room for gynaecology and maternity appointments, which was not sensitive to the reasons why women attended their appointments. The service had a plan to address this.

The Supervisor of Midwives (SoM) ratio was worse than the recommendation of 1:15. The service had agreed a local arrangement for enabling the Supervisors of Midwives extra time allocation for work related to Supervision.

Whilst the gynaecology service did have a performance dashboard which monitored a range of outcomes, the newly established gynaecology governance group had not set the parameters for monitoring performance at the time of the inspection. The service was in the process of implementing clear performance measures for the service.

We saw that reporting incidents to the National Reporting and Learning System (NRLS) was not always timely. However, the trust were aware of the issue and improvements had been made as part of the overarching trust wide risk and governance improvement plan.

Information leaflets provided by the termination of pregnancy service were only available in English which did not reflect the diversity of the local population.

Medical care (including older people’s care)

Requires improvement

Updated 3 June 2016

Overall, we rated medical care at this hospital to be requiring improvement.

Safety within the medical service was rated as requiring improvement. Not all staff adhered to infection control preventions at all times. Infection control training was below the trust target for medical staff. We found inconsistencies in the recording of medicine administration on some wards. We found no process to enable patients to self-administer their medicines, which the service stated was to be addressed. Not all medical staff had had the required level of safeguarding adults and children’s training. Many nursing staff had not received their conflict resolution training.

Not all venous thromboembolism (VTE) assessments were completed in accordance with trust policy. The service was aware of this concern and was taking actions to improve completion of these assessments and carrying out regular audits. Whilst the service was improving the number of patients that received appropriate antibiotics within one hour for the management of suspected sepsis, not all patients were having appropriate treatment within the specified time. Consultant reviews were inconsistent. The mortality review report for December 2015 recommended a standardisation of consultant ward rounds within the medicine service. On most wards consultants visited their patients every two or three days.

Nursing and medical staff had regular mandatory training with the exception of conflict resolution. Although there was a high use of agency, bank and locums in medical and nursing specialities, we found no issues or concern within the staffing levels on the wards visited. We saw good practice regarding the safeguarding of vulnerable adults. Staff took a proactive approach to the early identification of safeguarding concerns. Staff understood their responsibilities to raise concerns and report incidents and near misses. We also found that equipment used for patient care was in service date and had been maintained or electrical safety tested. There were systems and processes in place to assess and manage the risks to patients.

We judged the effectiveness of this service as requiring improvement because patients were not always receiving effective care and treatment. The Hospital Standardised Mortality ratio (HSMR) was rising above the expected rate; the service was taking a series of actions to understand and address this issue. Outcomes for patients were variable as compared to similar services and where outcomes where below expectations, the service was taking a series of actions to address this.

There was some participation in relevant local and national audits such as national diabetes and the heart failure audit but outcomes were mixed and whilst plans were in place to improve performance, progress was variable. The trust SSNAP data regarding stroke indicated that there were issues with the stroke pathway and the service was taking a series of actions to improve performance indicators. Plans were in place to provide a seven day service, but not all patients were being reviewed by consultants on a daily basis.

The trust had effective evidence based care and treatment policies based on national guidance. Patients’ pain was assessed and pain relief provided appropriately. Patients’ nutrition and hydration status were assessed and recorded on all the medical wards. We saw evidence of effective multidisciplinary working with staff, teams and services working together to deliver effective care and treatment. Staff had the necessary qualifications and skills they needed to carry out their roles effectively. Staff were supported to maintain and further develop their professional skills and experience. Consent to care and treatment was obtained in line with legislation and guidance and deprivation of liberty was applied appropriately.

We found medicine 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 the service’s responsiveness as good. Access and flow in and out of the medicine services posed problems with delayed discharges identified as an area that required improvement. The referral to treatment time was being achieved and the number of patients being moved between wards was low. Staff understood the procedures regarding complaints. However, they said that any complaint received would firstly be resolved locally. This meant that the outcomes, themes or lessons learnt were not cascaded to staff. 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.

We rated the medicine service as good for being well-led. There was a clear vision and strategy for the future of the service. Senior staff and clinicians attended governance meetings. Staff said the recent reconfiguration of the service had improved morale. The staff survey reflected this. Whilst the service had generally recognised the risks to patient safety and progress the quality of care and treatment, actions were not always clearly defined and therefore progress was variable. Learning from mixed performance at national audits was not always effectively used to drive forward improvements in a timely manner.

Urgent and emergency services (A&E)

Outstanding

Updated 3 June 2016

We rated the Emergency Department (ED) within Luton and Dunstable hospital as good overall for safety, effectiveness, and caring. We rated responsiveness and well-led as outstanding.

Openness about safety was encouraged and staff understood their responsibilities to raise concerns and report incidents. We saw that systems and processes worked together to keep people safe from harm and where areas for improvement were identified, this was acted upon.

There was a good level of staffing and skill mix for nursing and medical staffing. The department was visibly clean and well organised.

There was a good consistent track record on safety and quality performance and staff worked together at all levels to achieve this. Safety of the department was being regularly reviewed through investigating incidents and local audits.

The department worked well with other teams internally and externally to improve and achieve good patient outcomes.

Patient’s care and treatment was delivered in line with current evidence-based guidance and standards, and areas of best practice from external sources were routinely explored. Internal audits were consistently carried out with evidence of continuing improvement.

The department exceeded the target of 95% of all patients to be admitted, transferred or discharged within four hours of arrival to the emergency department every month. The trust had been meeting this target annually since February 2012 and was one of the top five performing trusts in the country.

We found the service to be caring towards their patients and each other. Patients were treated with dignity and respect and staff were encouraged to challenge behaviour in their colleagues that was not in line with the trust’s values. Patients that we spoke to described staff as caring and professional.

The service had an established and experienced leadership team who were visible and approachable to staff at all levels and had a clear and committed focus to drive improvements in patient safety and the quality of care and treatment throughout the department. The department had a clear vision and strategy to continuously improve this service which was recognised at a national level.

Surgery

Good

Updated 3 June 2016

Overall, we rated surgical services as good.

There was a culture of incident reporting and staff said they received feedback and learning from serious incidents. However, not all staff always received feedback on clinical incidents. Staff were able to speak openly about issues and serious incidents.

The environment was visibly clean and generally staff followed the trust policy on infection control, although there was variable completion of cleaning schedules available within some of the wards and theatres.

Medical staffing was appropriate and there were good emergency cover arrangements. 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 and sometimes staff worked additional hours to cover shifts but this was well managed and patients’ needs were met at the time of the inspection.

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. Multidisciplinary working was effective.

Patients outcomes were generally good but not all staff were aware of patients’ outcomes relating to national audits or performance measures.

Most staff had received annual appraisals and generally support systems for staff development were effective. Staff had generally completed mandatory training provided by the trust.

Staff had awareness of the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DoLS) and safeguarding procedures to keep people safe.

The consent process commenced in out-patients and consent was reconfirmed at the time of admission. However, this was not always recorded as the consent form was scanned onto the computer and the confirmation signature could not be added to this electronic form.

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 being treated with dignity and respect.

Patient care records were appropriately completed with sufficient detail and kept securely. The service had an effective complaints system in place and learning was evident.

We saw some patients were delayed in recovery following surgery due to lack of beds on the wards and some patients could wait in recovery for four hours. Drinks and snacks were offered during this time.

There was support for people with a learning disability and reasonable adjustments were made to the service. However information leaflets and consent forms were not available in other languages. An interpreting service was available and used.

Surgical services were well-led. Senior staff were visible on the wards and theatre areas and staff appreciated this support. There was generally a good awareness amongst staff of the trust’s values.

Intensive/critical care

Requires improvement

Updated 3 June 2016

Overall, we rated the critical care service as requires improvement.

We found that safe and well-led areas required improvement. However, we rated critical care services good for effective, caring and responsive.

We found areas that required improvement, particularly on the high dependency unit (HDU). Medicines were not being safely prescribed and administered on HDU. For example, high risk medicines administered when the prescription was not signed by the prescriber.

The level of nurse to patient ratio on HDU did not meet core standards for critical care services during the initial inspection (Guidelines for the provision of intensive care services (GPICS) 2015). The guidelines stated that the nurse to patient ratio for level two care (high dependency) was one nurse for two patients.

The HDU environment was found to be non-compliant with Department of Health 2013 best practice guidelines for critical care facilities (Health Building Note HBN 04-02) regarding size of bed spaces and provision of hand washing facilities. However, in response to concerns we raised at the time of the inspection, the HDU had undergone urgent reconfiguration and action had been taken to reduce the number of available beds available to 11, while keeping the staffing the same. Following the reconfiguration, we returned during an unannounced inspection and found that the nurse staffing levels met core standards for critical care services (GPICS 2015), there were larger sized bed spaces and medicines were being safely prescribed and administered.

There were also a low number of low or no harm incidents reported by critical care services and a good track record related to incidence of infection.

Critical care services were effective. The trust complied with the recommendations within guidance from the National Institute for Health and Care Excellence (NICE guideline 50) for acutely ill patients in hospital.

Patients’ pain scores were being recorded and appropriate pain relief was being provided. Care bundles (evidenced based procedures) were in place for the use of ventilators and central lines (a central venous access device which is a long thin tube inserted into a vein in the chest).

The Intensive care unit (ITU) contributed to the Intensive Care National Audit and Research Centre (ICNARC) database and the mortality ratio for the unit was within statistically acceptable limits.

A practice development nurse supported both units with competency completion and induction of new nursing staff.

Patients in the units were required to be screened for delirium using a recognised screening tool (CAM-ICU). However, none of the patients on HDU had been scored for delirium (National Institute for Health and Care Excellence NICE CG83). We raised this with the trust at the time of inspection. All patients had been appropriately assessed when we returned for the unannounced inspection.

HDU did not contribute to the ICNARC database, which meant outcomes were not being benchmarked against similar services. They were unable to meet NICE guidance for rehabilitation of the critically ill patients due to further resources required to increase physiotherapy and follow up clinic provision.

Critical care services were caring. People using the service, including patients and their families were positive about the care and treatment they had received on the critical care units. Staff involved the patients as much as possible in decision making and kept them informed about progress with treatment.

Overall critical care services were responsive to patient’s needs. There was provision of facilities for visitors to the ITU, including a waiting room, hot and cold drinks, toilet facilities and a private room, which could be used for discussions.

ITU performed within expected levels for delayed discharges and transferring patients from ITU to a ward overnight when compared with similar units in the ICNARC audit (2014/2015). However, HDU transferred on average 24% of patients to a ward overnight per month (six month period ending December 2015).

At a unit level there was acknowledgement and reporting of mixed sex occupancy. The trust policy was based on a local agreement with the clinical commissioning group which stated in the majority of cases it may be clinically justified for the patient to remain within the HDU environment if the speciality bed was unavailable to ensure their safety and quality of care. However, the official number of reported breaches for critical care was nil (between April 2014 and December 2015).

Translation services were not always accessed for patients who needed them. We found that staff used patients’ relatives to translate for staff on HDU.

Critical care services were led by a matron and a clinical lead consultant. The challenges and risks regarding HDU were understood by the leaders. However, actions had not been taken to address these prior to inspection. One of the actions taken, after we raised concerns, was to refocus the leadership for HDU, with the matron taking a senior nurse role until improvements were firmly embedded. The ITU and HDU were not operating as integrated services and had separate rotas, study days, charts and operational policies. There was also a lack of knowledge of the vision for the services demonstrated by staff.

Critical care services had a risk register where risks were documented, reviewed and updated. We also saw evidence of critical care delivery group and directorate meetings being held. Within the minutes of these meetings, we saw that incident reporting, staffing and performance indicators were discussed.

Services for children & young people

Outstanding

Updated 3 June 2016

Overall, we rated the service as outstanding.

We found there was a real commitment to work as a multidisciplinary team delivering a patient centred and high quality service. Neonates, children and young people were at the centre of the service and the highest quality care was a priority for staff.

Treatment and care by all staff was delivered in accordance with best practice and recognised national guidelines.

The service took part in national research programs and used the outcome of these to develop innovative and pioneering approaches to high quality care and monitored the safe use of these new approaches.

The Neonatal unit (NNU) was the lead unit for Hertfordshire and Bedfordshire since 2003 and its high performance was recognised by external bodies.

Both medical and nursing staff we spoke with were passionate about providing a holistic and multidisciplinary approach to assessing, planning and treating patients. This was demonstrated by regular multidisciplinary meetings and excellent communication with their patients and relatives.

There was a good track record on safety with lessons learned and improvements made when things went wrong. Staff knew how to report incidents.

Both the paediatric wards and the NNU were clean and staff adhered to infection control policies and protocols. Record keeping was comprehensive and audited regularly. Decision making about the care and treatment of a patient was clearly documented.

Staff felt valued and supported by their managers and received the appropriate training and supervision to enable them to meet patients’ individual needs. Senior management had created an environment where staff knew how to raise concerns and follow the duty of candour processes.

Patients received treatment and care according to national guidelines and the service used an audit programme to check whether their practice was up to date and based on sound evidence. The service was obtaining good-quality outcomes as evidenced by a range of national audits such as the Royal College of Paediatric Child Health (RCPCH) National Neonatal Audit Programme (NNAP) and the National Paediatric Diabetes Audit (NPDA).

The NNU had been at the forefront of introducing new treatments and procedures including nitrous oxide therapy, high frequency ventilation and cooling therapy which had resulted in a significant reduction in its mortality and morbidity. Staff were very proud about their cooling service which they had developed and continued to deliver.

There was a range of examples of working collaboratively and the service used innovative and efficient ways to deliver more joined-up care to people who used services. There was a holistic approach to planning people’s discharge, transfer or transition to other services.

Nursing and support staff provided flexibility within the department to provide high quality care that met patients’ care needs. Staff were supported to develop and learn new practices. The service had developed and provided courses such as children’s assessment knowledge and examination skills (CAKE) courses and STABLE courses for staff which was accessed by external organisations. These had been accredited by the Royal College of Nursing, RCPCH and the local university

There was a clear open, transparent culture which had been established within the leadership team. The service could demonstrate a clear vision and strategy for paediatrics which was led by a strong management team. Staff told us they felt consulted and part of the development of the strategy, they were engaged and enthusiastic about the new developments within the service.

The leadership drove continuous improvement and staff were accountable for delivering change. Safe innovation was celebrated. There was a clear proactive approach to developing new approaches to care and treatment.

End of life care

Good

Updated 3 June 2016

End of life services were rated as good overall.

Patients and relatives all spoke positively about end of life care. Staff provided compassionate care for patients. Services were very responsive to patients’ individual needs and those of their families and next of kin.

There were arrangements to minimise risks to patients with measures in place to safeguard adults from abuse, prevent falls, malnutrition and pressure ulcers and, the early identification of a deteriorating patient through the use of an early warning system.

End of life care followed national guidance and the trust participated in national audits. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.

The results of the 2013/14 National Care of the Dying Audit of Hospitals (NCDAH) highlighted a number of areas for improvement. The hospital had since made some progress on the implementation of the action plan.

Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) forms we inspected were appropriately completed.

Patients received good information regarding their treatment and care. The service took account of individual needs and wishes and their cultural and spiritual needs. The bereavement support staff provided good support to relatives after the death of a patient. The hospital had a rapid discharge service for discharge to a preferred place of care. The trust had not yet completed an audit of patients achieving their preferred place of dying.

There was an improvement plan in place for end of life care that was overseen by a strategy steering group. There had been a number of changes put into place in the previous twelve months. These included a new personalised care framework, to replace the discontinued Liverpool Care Pathway, improved rapid discharge processes and the appointment of an end of life care specialist nurse to roll out the new documentation and provide training.

There was evidence of clear leadership in both the palliative care team and at board level. The trust had a clear vision and strategy for end of life care services and participated in regional and locality groups in relation to strategic planning and implementation.

However we found that:

Not all advance care plans patients had made in the community had been reviewed by the hospital’s SPCT to ensure they were valid, current and that care and treatment provided was still meeting patients’ expressed wishes.

The trust had not completed an audit of patients achieving their preferred place of dying. This meant, because it was not identified, this information could not be used to improve or develop services. However, this information was collected by the community team and shared with the trust palliative care team. Access for the trust palliative care CNS team to view PPD (preferred place of death) on the community system had been provided following our inspection.

The trust did not collect information of the percentage of patients that had achieved discharge to their preferred place within 24 hours. Without this information they were unable to monitor if they were meeting patients’ wishes and how they could make improvements.  However, this information was collected by the community team and shared with the trust palliative care team.  Access for the trust palliative care CNS team to view PPD (preferred place of death) on the community system had been provided following our inspection.

Outpatients

Outstanding

Updated 3 June 2016

Overall, we rated the service as outstanding.

Diagnostic services had established a seven day working programme with flexibility of services to provide timely diagnostic procedures for patients. Appointments for both diagnostic services and clinic appointments were flexed according to demands of the service and to meet the individual needs of the patients.

The division were working towards increasing outpatient clinics to include evenings and weekends on a routine basis and offered flexibility according to patient condition and any demands on work/life balance.

The trust used electronic patient records which provided easy access to results reporting and details of previous contacts with the organisation. This meant that clinicians were well informed of the patients’ conditions and could always see the patients with their records available.

The division had a proactive approach to developing and training staff. They identified areas where recruitment was difficult and developed their own staff into these roles. This made staff feel valued and invested in, which enhanced retention of posts.

Nurse staffing levels were appropriate with minimal vacancies and staffing levels met patient needs at the time of the inspection. Staff in all departments were aware of the actions they should take in the case of a major incident

Patients’ needs were assessed and their care and treatment was delivered following local and national guidance for best practice. Staff had information they needed before providing care and treatment but in a minority of cases, records were not always available in time for clinics.

Staff were suitably qualified and skilled to carry out their roles effectively and in line with best practice. Staff felt supported to deliver care and treatment to an appropriate standard, including having relevant training and appraisal. Consent was obtained before care and treatment was given.

During the inspection, we saw and were told by patients, that the staff working in outpatient and diagnostic imaging departments were kind, caring and compassionate at every stage of their treatment. Patients we spoke with during our inspection were positive about the way they were treated.

Waiting times for diagnostic procedures was lower than England average and the trust consistently met the referral to treatment standards over time.

There were systems to ensure that services were able to meet individual needs, for example, for people living with dementia. There were also systems to record concerns and complaints raised within the department, review these and take action to improve patients’ experience.

Staff were familiar with the trust wide vision and values and felt part of the trust as a whole. Outpatient staff told us that they felt supported by their immediate line managers and that the senior management team were visible within the department.

There were effective systems for identifying and managing the risks associated with outpatient appointments at the team, directorate and organisational levels.

Regular governance meetings were held and staff were updated and involved in the outcomes of these meetings. There was a strong culture of team working across the areas we visited.