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Inspection Summary


Overall summary & rating

Good

Updated 7 December 2018

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

Our rating of services stayed the same. We rated it as good because:

  • Our rating for safe remained requires improvement overall. Not all services had enough staff with the right qualifications, skills and training. Not all staff had attended mandatory training and not all staff complied with infection control practices and medicines management was not always managed safely.
  • Our rating for effective remained good overall. Not all guidance was up to date. The services provided care and treatment based on national guidance and had evidence of its effectiveness. Patients at the trust had a higher than expected risk of readmission for elective admissions compared to the England average. We saw action plans were in place to address this.
  • Our rating for caring remained good overall. All services were rated good for caring. Staff cared for patients with compassion. Feedback from patients confirmed staff treated them well and with kindness.
  • Our rating for responsive remained outstanding overall. The trust planned and provided services in a way that met the needs of local people. Services were planned to consider the individual needs of patients. Adjustments were made for patients living with a physical disability. The hospital had disabled access across all areas of the medical services. Waiting times from referral to treatment were longer than the England average in four specialities from May 2017 to April 2018. As of April 2018, RTT data was improving, the trust was 4% below the national average overall.
  • Our rating for well led remained outstanding overall. Leaders at all levels with the right skills and abilities to run a service providing high-quality sustainable care. Senior leaders were visible and demonstrated commitment.
Inspection areas

Safe

Requires improvement

Updated 7 December 2018

Effective

Good

Updated 7 December 2018

Caring

Good

Updated 7 December 2018

Responsive

Outstanding

Updated 7 December 2018

Well-led

Outstanding

Updated 7 December 2018

Checks on specific services

Critical care

Good

Updated 7 December 2018

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

  • The clinical environment, premises and equipment were well maintained and adapted where possible to meet the needs of the patient.
  • Staff understood their roles and responsibilities and worked collaboratively to protect patients from abuse.
  • There were appropriate systems and processes in place to ensure that patients were kept safe through continual monitoring. The service planned for emergencies and ensured that all staff knew their roles and responsibilities.
  • Staff ensured that patient’s records accurately reflected treatment plans and assessments.
  • The service managed patient safety incidents well recognising types of incidents and learnt from investigations.
  • The service monitored the effectiveness of the care and treatment provided against national standards and guidance. Using audit data to compare to peers and identify areas for improvement. Staff were made aware of findings and involved with learning.
  • Patients were provided with enough food and drink to meet their needs and improve their health.
  • Staff were supported to develop their skills and knowledge through competencies and appraisals.
  • The service ensured that individuals needs were met when planning and implementing care and treatment.
  • Patients were able to access the service when they needed to. Referrals were timely and ITU and HDU teams were responsive to the needs of patients.
  • The service managed complaints effectively, considering concerns raised and ensuring that staff learnt from concerns raised.
  • Critical Care leaders were visible and offered support and advice where necessary. Nurses in charge of units were good role models.
  • There was a positive culture across both ITU and HDU. Staff felt supported and valued and there was a sense of common purpose based on shared values. Teams worked collaboratively.
  • Although governance was managed across two divisions, there was a systematic approach to identifying risks and quality of care. Trends were monitored by clinical and governance teams and actions taken to address any areas of concern.
  • The service engaged and collaborated with partner organisations effectively using peer reviews and networks to improve practice locally.

However:

  • Medical staff’s mandatory training compliance was below the trust target of 80%.
  • Medical staff did not always wash their hands before or after the point of care.
  • The supernumerary nurse on HDU and ITU were used to ensure that nurse patient ratios were maintained. This was against national guidance.
  • The ITU consultants had additional responsibility for the paediatric emergency bleep, which meant that they were not always available to immediately attend ITU when called. This was against national guidance.
  • High ambient temperatures at the time of inspection meant that some medicines were not always kept at the correct temperatures.
  • There were a number of out of hour transfers between ITU and HDU and HDU and main wards. These were not always in response to clinical activity.
  • The HDU and ITU did not provide adequate washing facilities for male and female patients due to restrictions of the clinical environment.
  • Staff moves and perceived lack of support affected job satisfaction within ITU.

Outpatients and diagnostic imaging

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.

Urgent and emergency services

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.

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)

Good

Updated 7 December 2018

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

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • The service had enough staff with the right qualifications, skills and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • The service manged patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The service monitored the effectiveness of care and treatment and consistently used the findings to improve them.
  • Staff provided patients with enough food and drink to meet their needs and improve their health.
  • The service managed patients’ pain effectively and provided or offered pain relief regularly.
  • The service monitored the effectiveness of care and treatment and consistently used the findings to improve performance. Some of the processes in place were variable and we saw action plans in place to manage these across the service for example; the stroke and diabetic service.
  • Staff worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Staff did not always understand their roles and responsibilities under the Mental Health Act (MHA) 1983, the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). Staff cared for patients with compassion.
  • Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff provided emotional support to patients to minimise their distress.
  • The trust planned and provided services in a way that met the needs of local people. Patients could access the service when they needed it.
  • Staff involved patients and those close to them in decisions about their care.
  • The referral to treatment time (RTT) for admitted pathways for medical care was consistently better than the England average for all specialities. The average length of stay was just above the England average and trust target of six days.
  • There were good discharge processes in place after concerns raised in the discharge audit of January 2018 resulting in a daily patient tracker report showing the status of the patient’s journey to include length of stay and progress.
  • Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • The service had managers with the right skills and abilities to run a service providing high-quality sustainable care.
  • The service had an embedded systematic approach to continually monitor the quality of its services.
  • Continuous improvement and learning from when things go wrong was evident across the service.

However:

  • There had not been any improvement in attendance at conflict resolution training identified as a concern in the January 2016 inspection, this meant that staff may not have the necessary skills to deal with patients who displayed challenging behaviour.
  • The service provided mandatory training in key skills to all staff but did not always make sure everyone completed it with attendance at some life support, fire safety and infection control courses being particularly low.
  • The service generally controlled infection risk well. However, not all staff followed the trust’s infection control guidance or comply with being “arms bare below the elbow” which meant there was a risk of patients not being kept safe from the spread of infection. Medical staff infection control training was at 62% and the trust must ensure staff are trained in infection control.
  • Staff did not always assess the risks to patients and monitor their safety to ensure they were supported to stay safe. We found inconsistencies in the completion of the malnutrition universal screening tool.
  • Staff kept appropriate records of patients care and treatment. However, not all records were kept in locked trolleys to maintain confidentiality.
  • We found ligature points in the discharge seating area within Ward 1 (emergency admission unit) which were bought to the attention of the trust. During the revisit on 20 August 2018 we saw action was being undertaken to address this.
  • The service prescribed, gave, and recorded medicines well. Patients received the right medication at the right dose at the right time. However, we found inconsistencies in the escalation of clinical room and fridge temperatures when this exceeded accepted guidance levels. The checking of hypoglycaemia (low sugar) boxes were not routinely monitored.
  • Most staff understand their roles and responsibilities under the Mental Health Act (MHA) 1983, the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). However, we found inconsistencies in the completion of patient records who were under the MCA or DoLS.

Surgery

Good

Updated 7 December 2018

Our rating of this service stayed the same. We rated it as good because:

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and knew how to apply it.
  • The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
  • Staff assessed risks to patients and monitored their safety, so they were supported to stay safe. Assessments were in place to alert staff when a patient’s condition deteriorated.
  • Staff kept appropriate records of patients’ care and treatment.
  • The service prescribed, gave, and recorded most medicines well. Patients generally received the right medication at the right dose at the right time.
  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately.
  • The service provided care and treatment based on national guidance and evidence of this effectiveness. They assessed staff compliance with guidance and identified areas for improvement.
  • Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made dietary adjustments for patients for religious, cultural, personal choice or medical reasons when required.
  • The service managed patients’ pain effectively and provided or offered pain relief regularly.
  • The service monitored the effectiveness of care and treatment and consistently used the findings to improve them.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them, when required, to provide support and monitor the effectiveness of the service.
  • Staff received an annual appraisal which they told us was constructive and provided a formal opportunity to review their progress and identify further training needs.
  • Staff supported patients to manage their own health, care and well-being and to maximise their independence following surgery and as appropriate for individuals.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff provided emotional support to patients to minimise their distress.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • The service understood the different requirements of the local people it served by ensuring that it actioned the needs of local people through the planning, design and delivery of services.
  • Services were planned to take into account the individual needs of patients
  • Patients could access the service when they needed it.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.
  • The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.
  • The service had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • The trust used a systematic approach to continually improving the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish.
  • The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
  • The service collected, analysed, managed and used most information well to support all its activities, using secure electronic systems with security safeguards.
  • The service engaged well with patients, the public and local organisation to plan and manage appropriate services, and collaborated with partner organisations effectively.
  • The service was committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation.

However:

  • The service provided mandatory training in key skills to all staff but did not always make sure everyone completed it.
  • Compliance rates for level three safeguarding training was below the trust target.
  • Not all patient records were kept in locked trolleys to maintain confidentiality.
  • Waiting times from referral to treatment were longer than the England average

Services for children & young people

Good

Updated 7 December 2018

The service was last inspected in January 2016 when the service was rated as outstanding for effective and well-led and good for safe, caring and responsive.

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

  • Leaders at all levels of children’s services demonstrated high levels of experience, capacity and capability needed to deliver excellent and sustainable care. Leaders led their service and supported the wider development of services for children across the whole hospital.
  • Children’s services had a strategy and supporting objectives and plans that were innovative while remaining achievable. There was a systematic and integrated approach to monitoring, reviewing and providing evidence of progress against the strategy and plans.
  • Leaders had an inspiring shared purpose and strived to deliver and motivate staff to succeed. There were high levels of satisfaction across all staff groups and staff were proud to speak up and raise concerns at all levels of the children’s service.
  • Governance arrangements were proactively reviewed and reflected best practice. The service used a systematic approach to continually improve the quality of its services and safeguarding high standards by creating an environment in which excellence in clinical care would flourish.
  • There was a holistic approach to assessing, planning and delivering care and treatment to children and young people in the children’s service. The service used safe and innovative approaches based on evidence based techniques to support the delivery of high quality care.
  • Staff were proactively supported and encouraged to acquire new skills and use their transferrable skills and share best practice. Children’s services recognised that the continuing development of its staff was integral to ensuring high-quality care.
  • Children’s services were committed to working collaboratively and had found innovative ways to deliver more joined up care. There was a holistic approach to planning young people’s transition to adult services which was done at the earliest possible stage.
  • Staff cared for patients with compassion and feedback from patients confirmed staff treated them well and with kindness. Parents and carers told us they were very happy with the care and support they received and feedback was overwhelmingly positive throughout the inspection.
  • Staff recognised incidents and reported them appropriately. Managers investigated incidents and provided feedback to staff. Lessons were learnt as a result of incidents and actions monitored. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The service had sufficient nursing staff with the right qualifications, skills, training and experience. Suitable measures were in place through the appropriate use of bank and agency staff known to the service who kept people safe from avoidable harm and abuse and provided the right care and treatment.
  • The trust’s neonatal critical care bed occupancy rate was higher than the England average in the period May 2017 to April 2018. Data in the last three months had shown the trust was below the 80% trust target.

However:

  • There were inconsistencies in recording of pain scores in paediatrics.
  • Medical staff were not meeting the trust standard of 80% for the mandatory training modules they were eligible for.
  • Medical staff were not meeting the 80% target for safeguarding adults training Levels 1 and 2.
  • There were high ambient temperatures at the time of inspection which meant that some medicines were not kept at the correct temperatures.

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.