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The Queen Elizabeth Hospital Inadequate

Inspection Summary


Overall summary & rating

Inadequate

Updated 24 July 2019

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

  • Staff did not always identify, monitor and respond appropriately to changing risks to people who used services, including deteriorating health and behaviour that challenges.
  • The numbers and skill mix of nursing staff were not always suitable for the needs of the patients and medical staffing establishment levels were not in line with national guidance.
  • The number of staff completing mandatory training fell far short of the trust’s targets for all subjects and staff groups. Not all staff understood how to protect patients from abuse.
  • Risk assessments for patients were not always completed or updated appropriately and action was not always taken to remove or minimise risks. Not all staff identified and acted quickly upon patients at risk of deterioration.
  • Staff did not always ensure that information relating to a patients’ care and treatment was appropriately recorded. Records systems did not support staff to deliver safe care and treatment.
  • Not all services had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
  • Staff did not protect patients’ dignity when providing care or protect their privacy when discussing them. Staff did not always treat patients with compassion and kindness or take account of their individual needs.
  • The design, maintenance and use of facilities and premises did not always keep patients safe, particularly those with mental health concerns.
  • The arrangements for investigating incidents and for implementing changes to practice as a result of learning from serious incidents and deaths was not robust. Investigations lacked appropriate detail, themes were not always identified, and learnings were not effectively shared. Follow up to ensure changes had been implemented was poor. Duty of candour was not being consistently carried out when required.
  • Monitoring results to improve safety and assess the effectiveness of care and treatment was inconsistent, when in place this was not robust. The accuracy and validity of data being utilised to monitor care was questionable.
  • Care and treatment was not always based on current national guidance and best practice. Managers did not always check to ensure staff followed guidance.
  • Staff did not always protect the rights of patients’ subject to the Mental Health Act 1983. Staff did not always understand the relevant consent and decision making requirements of the Mental Capacity Act 2005. We were not assured that staff knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health.
  • Audit activity to support and monitor the implementation of national guidance was limited. When local audit was used, this was not utilised fully, and action places were not monitored or reviewed effectively to ensure improvement in services. Performance in national audits was mixed, with limited evidence of learning and action taken to improve performance.
  • Patient’s needs, such as specific nutrition and hydration and pain levels, were not being identified and monitored appropriately in all areas across the hospital. Patients at the end of life were not always identified. Systems and processes were not always in place to meet patient’s individual needs.
  • Staff competency was not monitored effectively in all areas to ensure staff had the right skills and abilities to provide appropriate care. Appraisals were inconsistent and supervision meetings to provide support and development were not always in place.
  • People could not access care and treatment in a timely way. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with national standards.
  • The service did not investigate concerns and complaints thoroughly to enable lessons to be learned and shared with all staff. The service did not include patients in the investigation of their complaint.
  • Not all leaders had the integrity, skills and abilities to run services. Not all recognised, understood or managed the priorities and issues that their service faced. Staff were not always supported to develop their skills and take on more senior roles.
  • Not all services had a vision for what they wanted to achieve and a strategy to turn this into action. In those that did, leaders and staff did not always fully understand or know how to apply them and monitor progress.
  • Positive multidisciplinary working was not in place across all areas in the hospital. Services and divisions were working in silos. Culture and morale remained poor with limited evidence of shared learning and benchmarking to improve services. Where staff felt able to raise concerns they felt that these were not always listened to or addressed.
  • Governance processes and systems to manage risk, issues and performance were not effective. Staff, at all levels, were not always clear about their roles and accountabilities. systems to manage performance effectively. Risks were not always identified and escalated to reduce their impact. Plans to cope with unexpected events were not always in place. Staff did not always contribute to decision-making to improvements in quality of care.

  • Leaders and staff did not always actively and openly engage with patients, staff, equality groups, the public and local organisations to plan and manage services. There was limited collaboration with partner organisations to help improve services for patients.

However:

  • There were systems and processes in place to monitor standards of cleanliness and hygiene. In the main infection control and prevention was handled well.
  • There were systems and processes in place for medicine management to prescribe, administer, record and store medicines.

The appointments of a new chairman and chief executive was seen as a positive. There were actions being taken to increase the level of engagement of staff across the hospital and staff recognition schemes had been reintroduced.

  • There were pockets of cohesive team working with learning, continuous improvement and innovation in some areas and departments.
Inspection areas

Safe

Inadequate

Updated 24 July 2019

Effective

Inadequate

Updated 24 July 2019

Caring

Requires improvement

Updated 24 July 2019

Responsive

Requires improvement

Updated 24 July 2019

Well-led

Inadequate

Updated 24 July 2019

Checks on specific services

Medical care (including older people’s care)

Inadequate

Updated 24 July 2019

  • The service did not manage patient safety incidents well. Staff recognised incidents, but the quality of investigations was not always robust. Staff were not trained to complete root cause analysis or investigate complex issues.
  • The service did not control infection risk well. We saw a number of examples of poor infection control practice in ward areas.
  • The service did not ensure that premises was safe. There were control of substances hazardous to health (COSHH) breaches and risks associated with extremely hot water in unsecured sluice rooms.
  • The service did not store medicines well. We saw examples of poorly managed and stored intravenous fluids.
  • Staff did not keep appropriate records of patients’ care and treatment. Records were not clear, did not contain a plan of care, there were frequent omissions in records and they were not secure.
  • Staff did not understand how to protect patients from abuse. Staff gave inconsistent responses in how to raise safeguarding concerns and failed to act on a safeguarding issue.
  • The service provided mandatory training in key skills to all staff but not all staff had completed it.
  • The service did not have 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. There remained a very high vacancy rate for nursing staff with frequent use of agency. There was a reliance on locum doctors in a number of areas.
  • The service did not provide care and treatment based on national guidance.
  • The service did not monitor the effectiveness of care and treatment. We saw examples of poor audit results such as NEWS2 audit which were not repeated to measure improvement. Records audits showed consistently poor results without significant improvement.
  • Staff did not always have access to up-to-date, accurate and comprehensive information on patients’ care and treatment.
  • Staff did not understand their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. Staff gave inconsistent responses when asked about the MCA. We found instances where the MCA was not properly considered.
  • Staff did not always care for patients with compassion. We saw numerous instances of neutral care interactions and occasions when a small number of staff appeared indifferent to their caring role. Three people complained about long call bell waits and we observed a number of occasions when call bells were slow to be answered.
  • Staff did not always involve patients and those close to them in decisions about their care and treatment. Several patients and relatives told us they had to ask multiple times for information relating to their care. We observed two relatives who had not been informed of changes in care of their family member.
  • The service did not take account of patients’ individual needs. We saw and heard examples of the service failing to meet the needs of patients.
  • The service was slow to respond to complaints, even those requiring a simple explanation.
  • The trust did not have managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. There was a significant lack of improvement since our last inspection and lack of capacity in divisional leadership to effect sustainable change.
  • The service did not have a coherent vision or strategy. Staff did not identify with the division’s priorities. They did however relate to the trust values and vision.
  • The culture was mixed in the division. Some staff told us of improvements however, we had received whistle blowing information prior to the inspection from concerned staff. We were aware of examples of poor communication in the service that impacted staff morale.
  • The trust did not have effective systems for identifying risks. Some risks on the risk register had been on the register for up to eight years. We identified risks that the service had not addressed, and the service had failed to act on known past risks.
  • The trust did not trust collect or use information well; information had not been used to drive improvements.
  • There was insufficient evidence to demonstrate that the trust was committed to improving services by learning. There had been no significant improvement since our last inspection. The service had failed to learn from previous concerns raised by the coroner under regulation 28.

However:

  • The service planned for emergencies and staff understood their roles if one should happen.
  • There had been improvements in nurse shift fill rates.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
  • Staff provided emotional support to patients to minimise their distress. We saw some excellent examples of individual emotional support such as by a care assistant on Necton Ward.
  • The trust planned and provided services in a way that met the needs of local people.
  • People could access the service when they needed it. Waiting times from treatment were and arrangements to admit, treat and discharge patients were in line with good practice.

Services for children & young people

Good

Updated 24 July 2019

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

  • The service provided mandatory training in key skills. Nursing staff mandatory training compliance was 90% on Rudham ward and 91% on NICU. Staff had safeguarding training and they knew how to recognise, and report abuse to protect patients.
  • The service had suitable premises and equipment, looked after them and controlled infection risk well.
  • Staff kept detailed records of patients’ care and treatment, completed and updated risk assessments for each patient and followed best practice when prescribing, giving, recording and storing medicines. Care and treatment was based on national guidance.
  • The service had enough nursing and medical staff with the right qualifications, skills, training and experience to keep people safe from harm and to provide the right care and treatment. Managers made sure staff were competent for their roles, appraised staff’s work and performance. Staff of different specialities worked together as a team to benefit patients.
  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
  • Staff gave patients enough food and drink to meet their needs and improve their health. They assessed and monitored patients regularly to see if they were in pain and promoted good health.
  • Staff understood how and when to assess whether a patient had the capacity to make decisions about their care and understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff cared for patients with compassion, provided emotional support and involved patients and those close to them in decisions about their care.
  • The trust planned and provided services in a way that met the needs of local people and took account of patients’ individual needs. Waiting times from referral to treatment were in line with good practice.
  • Managers at all levels in the service had the right skills and abilities to run a service providing care and they promoted a positive culture that supported and valued staff.
  • The service had effective systems for identifying risks, collected, analysed, managed and used information well to support its activities and engaged with patients and staff to plan and manage appropriate services. The service treated concerns and complaints seriously.

However:

  • Mandatory training compliance for medical staff did not meet trust target (90%) for any of the eight modules.
  • Safeguarding children level three training compliance for nursing and medical staff did not meet trust target of 95%. Nursing was 89% and medical staff was 85%.
  • The service did not have enough consultants to meet royal college of paediatric and child health (RCPCH) guidance and consultant handwriting was not always legible in all medical records.
  • Not all nursing staff in NICU handed over care of the babies when leaving the nursery for an extended period of time and one member of nursing staff was heard to use discriminatory language when speaking about a patient with known mental health issues.
  • Staff on Rudham ward did not have a portable telephone call so that they could make confidential calls in a private area away from the nurse’s station.
  • Governance structures were not embedded, not robust and did not give enough consideration to children and young people’s services and did not monitor the progress of the CYP strategy which staff were unaware of.
  • There was no representation of CYP services at the quality and safety committee meetings, mortality review meetings or the mental health governance committee meetings and the service did not have a CYP specific learning disability nurse.

Critical care

Good

Updated 19 September 2014

Patients and their families said that staff were attentive and caring. Staff treated people with kindness, dignity, respect, compassion and empathy, while providing good care and evidence-based treatment. Staff worked well as a team, felt supported by their line managers, and were highly motivated to provide patients with the best care possible.

 

The service had a clear vision and credible strategy to deliver high-quality care and promote good outcomes. The service was actively involved in national and local research and audit projects, and demonstrated innovation through involvement in equipment design. The trust engaged with patients and visitors, and acted on their feedback.

 

The trust’s track record on safety was good. There were reliable systems, processes and practices in place to keep people safe and safeguarded from abuse. The trust learned when things went wrong, and improved safety standards as a result. We were concerned that there were no side room facilities for coronary care patients; however, we were reassured that this was already on the service risk register, and that senior managers were taking appropriate action by looking at ways to resolve this issue.

Some outcomes for people using the service were good compared to other services. There were periods in the past year where bed occupancy levels were above the England average. These capacity issues meant that patients were not always cared for in the most appropriate setting for their needs, and elective surgery got cancelled.

End of life care

Inadequate

Updated 24 July 2019

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

  • The service did not have enough medical staff with the right mix of qualifications and skills to keep patients safe and provide the right care and treatment. Medical staffing was not in line with national guidance. This was raised at our last inspection.
  • The individualised plan of care (IPOC) was not consistently used across the organisation and was therefore not embedded in practice. This had been raised as an issue during our last inspection in 2018 yet no improvement had been made.
  • Completion of do not attempt cardio pulmonary resuscitation (DNACPR) forms was not consistently in line with Resuscitation Council UK guidelines. Despite this being raised at our previous inspection as a requirement notice where the trust must improve we found inconsistencies remained. An overall improvement of only 14% had been achieved.
  • End of life patients were not always identified at an early stage to ensure adequate symptom control in a timely manner. This meant that patients did not receive the highest quality care that met their individual needs.
  • There was no stable leadership team to support and promote end of life care. The service was over reliant on the end of life care facilitator and staff were unclear who was responsible for the service.
  • Leaders did not demonstrate the right skills and abilities to deliver a high-quality service. There was a lack of ownership of end of life care from senior leaders. Staff we spoke to during our inspection were not aware of who the lead was for end of life care.
  • The service monitored the effectiveness of care and treatment, but we did not always see evidence that they used the findings to improve the service. The trust took part in the National Audit for Care at the End of Life (NACEL). Results from the first round of this audit showed areas for improvement, however information provided by the trust stated that the results had not yet been presented to the board and we were not assured that any actions would be taken in the interim before the second round of the audit.
  • The trust end of life strategy did not give definitive timescales or commitments to achieve its aims and service improvements, and staff we spoke with did not know what the strategy was.
  • Staff told us that end of life care was not seen as a priority throughout the trust.
  • There was a lack of oversight in ensuring that the end of life strategy was implemented, including the IPOC. The IPOC was not routinely used throughout the trust. Without it being used and audited, the trust did not have oversight of their performance in end of life care.
  • We were not assured that issues were escalated appropriately and acted upon. In two sets of three end of life steering group meeting minutes that we reviewed it was documented that the issues to be escalated would be agreed outside of the meeting.
  • The trust did not have effective systems for identifying risks throughout the service. We identified risks during our inspection that the trust had not identified as risks. Information provided by the trust stated that there were no risks for end of life care on the trust risk register.
  • The trust did not hold data on how many referrals were made to the palliative care team. This prevented the trust from having oversight of the service and meant that we were not assured patients had access to the palliative care team when they needed it. This information was provided at our last inspection which meant there has been a reduction in oversight of the service.
  • Data provided to demonstrate whether patients achieved their preferred place of death showed inconsistencies, and incorrect statements were attributed to some of the figures. Therefore, we could not be assured that the data presented was accurate.

However:

  • Staff understood how to protect patients from abuse and knew who the trust safeguarding lead was and how to contact them. Staff were able to describe the safeguarding process.
  • The service had enough nursing staff, with the right mix of qualification and skills, to keep patients safe and provide the right care and treatment.
  • Staff from different disciplines worked together as a team to benefit patients, both within the trust and community services. A weekly multi-disciplinary team (MDT) meeting took place which included members of the hospital end of life care team as well as representatives from the local acute community trust and the local hospice.
  • Staff cared for patients with compassion. Feedback from patients and relatives confirmed that staff treated them well.
  • The service took account of patients’ individual needs. Patients and relatives had access to the chaplaincy and bereavement services, and staff could access interpreting services when required.

Surgery

Requires improvement

Updated 24 July 2019

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

  • Staff did not always complete mandatory training in line with the trust’s target. Medical staff had not completed any mandatory training modules to in line with the trust’s
  • Medical staff did not always complete training to recognise and safeguard patients from abuse. However, nursing staff had training on how to recognise and report abuse, and they knew how to apply it.
  • There had been no improvement in the quality audits relating to the World Health Organisation (WHO) and five steps to safer surgery checklist in main theatres. The service had failed to respond and adequately improve compliance with all five steps to improve patient safety.
  • The service did not always have enough nursing staff to keep people safe from avoidable harm and to provide the right care and treatment.
  • Patients did not always receive their medication at the right time. However, the service followed best practice when prescribing, recording and storing medicines.
  • People could not always access the service when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not always in line with good practice.
  • The timeliness of complaint responses did not meet local policy targets. Although the service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.
  • Main theatres did not always complete adequate assurance audits. Although the rest of the service had governance processes in place to monitor the quality of the services.

However:

  • The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
  • The service had suitable premises and equipment and looked after them well.
  • Staff kept detailed records of patients’ care.
  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The service used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors. Managers used this to improve the service.
  • Ward staff identified and responded to changing patient risks, including deterioration. Staff were confident to seek additional support from senior staff if required.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness.
  • Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary.
  • Staff assessed and monitored patients regularly to see if they were in pain. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain.
  • Managers monitored the effectiveness of care and treatment although there was limited evidence that they use them to improve service.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They followed the trust policy and procedures when a patient could not give consent.
  • 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 trust planned and provided services in a way that met the needs of local people.
  • The service took account of patients’ individual needs.
  • Managers at all levels in the division had the right skills and abilities to run a service and were sighted on improving the quality and safety of care.
  • Surgery had a vision for what it wanted to achieve and workable plans to turn it into action.
  • 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 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 information well to support all its activities, using secure electronic systems with security safeguards.
  • The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively.
  • Surgery was committed to improving services by learning from when things went well, promoting training, research and innovation.

Urgent and emergency services

Inadequate

Updated 24 July 2019

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

  • The service did not always ensure that staff identified, monitored and responded appropriately to changing risks to people who used services, including deteriorating health and behaviour that challenges.
  • The numbers and skill mix of nursing staff were not always suitable for the needs of the emergency department and medical staffing establishment levels were not in line with national guidance.
  • The arrangements for investigating incidents and for implementing changes to practice as a result of learning from serious incidents and deaths were not always robust. Duty of candour was not being consistently carried out when required.
  • Staff did not always ensure that information relating to a patients’ care and treatment was appropriately recorded. Records systems did not support staff to deliver safe care and treatment.
  • The design and use of facilities and premises in the emergency department did not always keep patients with mental health concerns safe.
  • We observed examples of care which demonstrated that national guidance was not always being followed in the department. There remained concerns about a significant number of out of date guidelines and policies.
  • Audit activity to support and monitor the implementation of national guidance was limited due to staffing shortages. Performance in national audits was mixed. There was limited evidence of learning and action when national audit results were in the lower UK quartile.
  • Patients with specific nutrition and hydration needs were not always identified and monitored appropriately.
  • Patients’ pain levels were not always identified and monitored appropriately.
  • There was not always evidence of positive multidisciplinary working in the urgent and emergency service.
  • Staff did not always understand the relevant consent and decision making requirements of the Mental Capacity Act 2005.
  • The privacy and dignity of patients was not always maintained. Staff members did not always display an understanding and non-judgemental attitude when talking about patients and relatives. There was mixed feedback from patients about the care provided by staff.
  • People could not access care and treatment in a timely way. The issues impacting upon flow had not been addressed since the time of our last inspection.
  • The department had not always ensured that systems and processes were in place to meet patient’s individual needs.
  • There had been an 83.7% increase in the number of complaints since our last inspection and it took an average of 33 working days to investigate and close complaints.
  • Leaders either had not identified or had not taken action to address some of the concerns that we identified during our current or last inspection. Not all risks identified during our current inspection or our last inspection had been included on the risk register.
  • Leaders did not receive sufficient support or time to undertake their leadership roles effectively and maintain sufficient oversight over the department.
  • There was no separate formal strategy for urgent and emergency services.
  • Staff felt able to raise concerns but did not feel that these were always listened to or addressed.

However:

  • Medicines were managed and administered appropriately.
  • The department had improved the oversight over the completion of competencies.
  • The new emergency department matron had taken action to increase the level of engagement of staff in the department.
  • There was a range of evidence of learning, continuous improvement and innovation within the ambulatory emergency care unit.

Diagnostic imaging

Updated 24 July 2019

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

  • The service did not manage patient safety incidents well. Staff did not recognise incidents or report them. Managers did not share lessons learned effectively with local team and the wider service.
  • The service provided mandatory training in key skills to staff but did not ensure that everyone completed it. Mandatory training compliance rate for the service was 70% below the trust target of 95%. Basic life support training which included anaphylaxis response was 41%.
  • Staff were unclear about their understanding and responsibilities when administering contrast media to patients.
  • Staff were unclear as to how findings from a diagnostic image which the reporting clinical specialist had concerns were significant and required further investigation, were escalated to ensure that patients received timely and appropriate care. The service did not have enough staff with the right qualifications, skills, training and experience in all areas to provide the right care and treatment.
  • The service had not ensured that policies and procedures were in place across the diagnostic imaging department.
  • This system to staff the out of hours service was not sustainable and presented a risk to the delivery of a robust and safe service to patients.
  • Most staff of different kinds worked together as a team to benefit patients. However, three radiographers told us that they felt bullied by some doctors from the emergency department out of hours, when the doctors wanted a scan performed on a patient.
  • Lessons learnt from complaints were not shared with staff.
  • The service did not have managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.
  • Morale amongst staff was low. Staff felt there was a disconnect between themselves and managers. Staff did not feel supported and valued. There was not a sense of common purpose based on shared values.
  • The service did not have effective systems for identifying risks, planning to eliminate or reduce them.
  • The service did not engage well with staff to plan and manage appropriate services.

However:

  • The service had suitable premises and equipment and looked after them well.
  • 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 they knew how to apply it.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • The service took account of patients’ individual needs.

Gynaecology

Requires improvement

Updated 24 July 2019

We rated the service as requires improvement because:

  • Staff did not always complete mandatory training in line with the trust’s target. The trust target was not met for any of the seven mandatory training modules for qualified nursing and midwifery staff in gynaecology. The module manual handling had the lowest compliance rate of 33% below the trust target of 95%.
  • Medical staff had not completed any mandatory training modules in line with the trust’s target. The trust target was not met for any of the eight mandatory training modules for medical staff in gynaecology. The module adult basic life support had the lowest completion rate of 52% which did not meet the trust target of 95%.
  • The service utilised a high number of locum medical staff and we were not assured that all staff had the appropriate training. The trust was unable to confirm that all medical staff had the relevant ultrasound scanning competency.
  • Not all nurses had the appropriate competencies in place to provide the right care and treatment. Nurses did not hold a recognised post qualification gynaecological course. Whilst competencies were in place the assessor had not completed their own competencies. However, there was access to clinical nurse specialists and midwives for advice and support.
  • The service did not routinely audit the effectiveness of care and treatment and use the findings to improve them. The service did not participate in Royal College of Gynaecology Safer Standards national audits.
  • People could not always access the service when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with good practice.
  • The timeliness of complaint responses did not meet local policy targets. Although the service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.
  • Leaders of the service did not always act on concerns raised in a timely manner. Staff did not feel empowered to improve the quality of care. Staff felt that they would escalate concerns, but no action would be taken.

However:

  • There were systems and processes in place to monitor standards of cleanliness and hygiene. These included up to date policies, cleaning schedules and checklists, infection prevention and control training.
  • There were systems and processes in place for medicine management concerning handling, storage and security of medicines. Staff kept medicines securely in the clinical areas we visited.
  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • The service used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. The service took account of patients’ needs.

Maternity

Requires improvement

Updated 24 July 2019

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

  • There had been limited improvement with mandatory training compliance. Mandatory training rates were below trust targets for both nursing and medical staff. For example, medical staff compliance with adult basic life support was 52.4%.
  • Safeguarding training compliance remained significantly under target, with only 46.2% of nursing staff compliant with safeguarding children level 3.
  • Leaders had failed to ensure that compliance with previous enforcement had been completed and sustained which meant a potential risk to patient safety. The 100% compliance rate for training and competence for all appropriate staff reviewing, interpreting and classifying Cardiotocography (CTG) traces, had dropped. Not all policies and procedures had been updated to reflect current national guidance in the timeframe stipulated.
  • Staffing vacancies were covered by bank and agency staff. Whilst there was a procedure in place to ensure that agency midwives had received suitable training, were competent to care for women and their babies and that swipe card access to the unit was monitored staff were unaware of this. We found there was no formalised process to record the return of swipe cards. We raised our concern on site and action was taken to review the process.
  • Leadership stability remained fragile with several of the positions still filled by locum or interim staff.
  • There remained no formal vision or strategy in place. The risk management strategy was still under review and had not progressed since December 2018.
  • Governance, risk, and quality performance processes needed to embed to sustain and drive the initial improvements seen during our focused inspection in December 2018. Oversight of previous actions and improvements was not robust and internal processes had failed to identify where performance had dropped, and action was required.
  • The multiple changes in leaders and the uncertainty brought with interim positions meant staff were unclear as to the future direction of the service. This meant a risk to the improved culture, which remained tentative. Not all staff felt engaged or that communication was open.

However:

  • The improvement in completion of records and risk assessments for all women and babies had been maintained. Safety incidents continued to be reported and monitored appropriately.
  • Staff training had increased in many areas since our last two inspections facilitating staff to provide improved care and treatment for the women and their babies in the department. Simulation training was utilised to facilitate this.
  • There was good multi-disciplinary team work across all areas of the service to provide women with a choice of evidence based care which kept the women and their babies at the focus of care delivery.
  • Staff working within the service supported women to make decisions regarding their care and treatment and place of birth. Staff cared for women and their families with compassion.
  • Staff that we spoke with were proud to work for this service and were increasingly proud of the standards of care that they were providing. There was an increasingly supportive culture in which staff were supported to develop both themselves and the service provision to women and their babies.

Outpatients

Requires improvement

Updated 24 July 2019

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

  • Although the service had suitable premises and equipment in most areas and looked after them well some areas did not meet the needs of the service. For example, the diabetic clinic consulting room. This impacted on staff being able to protect patient’ privacy and dignity when delivering care.
  • Outpatient areas did not routinely audit the effectiveness of care and treatment and use the findings to improve them. This had not improved since the previous inspection.
  • Non-admitted referral to treatment pathway rates were below the trust’s operational standard and the England average. This meant that patients were waiting longer for appointments after being referred by their GP.
  • The trust did not routinely collect data on late starting clinics or patient waits in outpatients. Main outpatients had begun to collect this data but had yet to analyse the information collected.
  • Car parking facilities did not always meet demand. Patients reported that they often had difficulty parking when attending for clinic appointments which caused them to be concerned that they would miss their appointment.
  • The outpatient’s department did not have a local 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.
  • We were not assured that local risk and performance was monitored appropriately. There was a lack of robust monitoring of referral to treatment times and control audits across all areas of outpatients.
  • The trust did not have processes in place to engage with patients, the general public and local organisations to plan and manage appropriate services. Staff were positive about engagement with local mangers but reported that engagement with the trust senior executive team was inconsistent.
  • There were processes and systems of accountability within clinical business units although these were not always effective. Outpatients were split over a number of different business units. There did not appear to be oversight and shared learning across all outpatient areas.

However:

  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care.
  • The service prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time.
  • 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 they knew how to apply it.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • The service took account of patients’ individual needs.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff. The average time to investigate and close complaints was **. This had improved since the previous inspection
  • The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.