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Inspection Summary


Overall summary & rating

Good

Updated 26 September 2018

Our rating of services improved. We rated it them as good because:

We rated the safe, effective and well led domains as good, with the caring domain rated as outstanding. We rated the responsive domain as requires improvement. The safe domain increased by one rating to good. All other domains remained unchanged.

Our inspection of the core services covered at the Royal United hospital were as follows.

  • Urgent and emergency care. Our overall rating of this service stayed as requires improvement. The core service ratings remained requires improvement in the safe and responsive domains. The well led domain dropped one rating to requires improvement. The effective and caring domains remained as good.
  • Medical care. Our overall rating of this service increased to good. All domains were rated as good, with both the effective and responsive domains increasing by one rating.
  • Critical Care. Our overall rating of this service increased to good. All domains were rated as good, with an increase of one rating in the safe, effective, responsive and well led domains.
  • Children and Young People. Our overall rating of this service stayed as good. There were no changes to any of the domains, with the safe, effective, responsive and well led domains rated as good and the caring domain rated as outstanding.
  • Maternity services. Our overall rating of this service increased by one to outstanding. The effective domain remained as good, the safe domain increased one rating to good and the caring, responsive and well led domains increased one rating to outstanding.
  • On this inspection, we did not inspect surgical services, end of life care or outpatient services. The ratings awarded to these core services at the previous inspection in August 2016 form part of the overall rating awarded to the trust this time.
Inspection areas

Safe

Good

Updated 26 September 2018

Effective

Good

Updated 26 September 2018

Caring

Outstanding

Updated 26 September 2018

Responsive

Requires improvement

Updated 26 September 2018

Well-led

Good

Updated 26 September 2018

Checks on specific services

Critical care

Good

Updated 26 September 2018

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

  • There were clearly defined and embedded systems, processes, and practices, which kept patients safe and safeguarded them from abuse.
  • There was a positive and open incident reporting culture.
  • Lessons were learned and themes identified. Action was taken and practice changed when things went wrong.
  • There was good multidisciplinary team working. Staff on the unit and support services, such as physiotherapy, pharmacy, dietitians, and others were committed to working collaboratively to support patients.
  • Patient flow in critical care had improved. There were limited delays for patients being admitted, discharged or moved to a ward at night.
  • Leaders had the skills, knowledge, experience and integrity they needed. There was a strong commitment to delivering a safe service and saving lives.
  • There were clear priorities for ensuring sustainable, compassionate, inclusive and effective leadership.
  • Staff felt supported, respected and valued by senior managers in critical care and the surgical division. Staff we spoke with said there was a good team spirit, and were positive and proud to work for the unit
  • The unit did not comply with modern building standards, which included adequate bed spaces and other safety features. This has been assessed and was well managed within the unit. There were plans to redevelop the unit in 2019.
  • Not enough nurses had their post-registration qualification in critical care nursing.
  • The unit did not offer a follow up clinic for patients admitted to critical care. This meant the unit was not fully compliant with National Institute for Health and Care Excellence (NICE) clinical guideline 83 “Rehabilitation after critical illness in adults”.

Outpatients and diagnostic imaging

Good

Updated 10 August 2016

We rated this service as good overall because:

  • There were good systems in place for incident reporting and learning from when things went wrong.

  • Systems were in place for the safe administration of medicines and for the prevention of infection.

  • The departments were clean and tidy and they scored well within cleaning and hand hygiene audits.

  • Nursing staffing was good in terms of numbers and skills within outpatients and diagnostic imaging departments,

  • Staff were competent in the roles they were being asked to perform. There was good multidisciplinary working both within the trust and with other external organisations such as other health care providers. A comprehensive audit programme was in place across outpatients and diagnostic services.

  • Staff treated patients as individuals, and showed them respect and treated them with dignity. Patients told us how professional, kind and caring staff were towards them and how they provided emotional support for their patients. The family and friends test showed very positive results. This was reiterated in the positive comments of the 40 patients we spoke with during our inspection.

  • Good governance systems were in place across outpatients and diagnostic imaging. Staff told us how their immediate line managers and divisional managers were always available and felt their view were listened to and respected. Managers also told us how proud they were of their teams and the care they provided to patients. Staff put patients at the centre of everything they did and the trust supported them to do that with an open and honest culture. Staff and patients had opportunities to give their feedback on services and they felt listened to.

However:

  • Staffing was more problematic with the medical staffing numbers. This was mainly because of senior doctors retiring and subsequent problems in recruiting suitably experienced and qualified staff.

  • Within some specialties patients were waiting long periods of time for their appointments. The trust was working to resolve the waiting times and acknowledged they still had improvements to make. We saw evidence that complaints were discussed at departmental meetings and changes were made where necessary to help prevent further complaints. We observed good practice for patients with dementia and learning difficulties.

Urgent and emergency services

Requires improvement

Updated 26 September 2018

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

  • Compliance in mandatory training for medical staff fell below the trust target of 90% in the majority of subjects and not all staff in the urgent care centre had completed specific training in paediatric assessment.

  • The safety of children and vulnerable adults could not always be assured. Staff were not always completing safeguarding processes effectively and ligature points posed a risk to patients suffering mental health crisis.

  • There was significant crowding in the department. The risks and pressures associated with exceeding hospital capacity were concentrated on the emergency department but patients were not always monitored for the duration of their stay in the department to ensure they were safe.
  • Patients spent too long in the department. There were frequent delays in most stages of their care. the hospital could not accurately report the time to initial assessment despite being told at the last inspection that they must.
  • Medical and nurse staffing levels did not ensure safe care at all times, especially when the department was crowded.
  • Medicines were not always managed in accordance with best practice guidance, specifically around the management of prescription forms and fridge temperatures.
  • The observation area did not always meet the needs of patients. The environment was sometimes disruptive for patients and bays were not always single-sex, although staff tried to achieve this as much as they could.
  • Department leads did not always have shared priorities with their senior managers so that they could make progress with plans for improvement.
  • We were not assured that the incident reporting system was working effectively so that the risks and harm experienced by patients was properly understood.

However

  • Nursing staff had the training, skills and support they needed to provide safe care and we saw many examples of kind and compassionate care for patients.
  • Infection control practices kept people safe and free from the risk of infection. Premises and equipment were kept clean; staff washed their hands and used personal protective equipment.
  • Confidentiality in the department was taken seriously, with screens at the booking-in desk and discussions about patients undertaken where they could not be overheard. Documentation was held securely and computers were logged off when not in use.
  • Whilst the hospital did not record their triage times, patients were prioritised and streamed to ensure that the most unwell patients were seen quickly and patients who did not require emergency care were referred elsewhere.
  • The treatment provided to patients was based on relevant best practice guidance. Staff followed up to date clinical protocols and there were good systems for decision-making support.
  • The department was comprised of a diverse, multi-professional team with the right skills and qualifications that ensured they could meet the individual needs of vulnerable patients.
  • The department was designed and equipped to provide a suitable and safe clinical environment to patients with a wide range of clinical and non-clinical needs.
  • Local leadership was good and relationships between staff and managers were respectful and positive. Department leads were supportive of their staff, were approachable and well-liked. There was a learning environment where there were regular teaching activities and staff were enthusiastic about taking on enhanced roles and getting involved in quality improvement.
  • There was a positive working culture in the department. Staff supported each other and worked as an effective, professional team even when they were busy and the department was under pressure.

Maternity

Outstanding

Updated 26 September 2018

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

The Care Quality Commission last inspected the maternity service as part of a maternity and gynaecology inspection, the report being published in August 2016. The rating for maternity and gynaecology service was good overall. We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings.

We rated it as outstanding because:

  • Since our last inspection during 2016 the maternity services had been able to strongly evidence wide service improvements and these had exceeded patient expectations.
  • There was a strong focus on safety with staff of all levels understanding their responsibilities to report all incidents and near misses. Effective actions had been taken to mitigate risks and learning from safety issues had been consistently shared widely.
  • There was strong and effective leadership in place. Leaders understood the day to day and strategic pressures and objectives and had plans in place to monitor and address these. There was effective communication across the service and between colleagues who highly valued each other.
  • The maternity service achieved good patient outcomes or above what was expected compared to other similar services. The service was the lead performer nationwide for key performance indicators for the newborn hearing service.
  • The service had proactively engaged with different cultures and groups in the local community. Understanding and learning from this had been used to improve parents’ experiences of the service.
  • Medical and midwifery staff across the service felt well supported by managers who were accessible and knowledgeable. There was a positive, ‘can do’ culture which was firmly rooted in the desire to provide the best quality patient led maternity care.
  • Concerns and complaints were taken seriously and staff acted promptly and with consideration and understanding. Positive actions taken by staff had resulted in a reduction of 88% of formal complaints made last year about the maternity service.
  • There specialist midwifery led teams in the hospital and all community services with expertise and experience to support with obstetric care related to safeguarding issues and other identified vulnerabilities. This was done with effective partnership working with other agencies.
  • The service had creatively looked for alternative ways to gather feedback on experiences from women and their partners. There were multiple sources of evidence demonstrating feedback had been used to make service improvements.
  • Women and their partners had consistently received compassionate, thoughtful, kind and considerate treatment and care. This had often exceeded expectations.
  • There had been overwhelmingly positive feedback regarding the development of new facilities for parents who had experienced loss. This had exceeded the expectations of the people who had used the service.

Maternity and gynaecology

Good

Updated 10 August 2016

Overall, we rated the service as good because:

  • There were effective safeguarding processes in place. Staff were knowledgeable about safeguarding, understood their responsibilities and had access to support.

  • There were effective incident reporting processes, which staff understood and confirmed they received feedback for learning.

  • Staff cared for pregnant women before, during and after birth with kindness, compassion, dignity and respect.

  • Patients told us they felt involved with their care, had their wishes respected and understood.

  • Systems were in place to support access and flow around the maternity services.

  • There was evidence of personalised care provided to gynaecology and maternity patients and their relatives. This included gynaecology patients with memory loss conditions who had additional care and support needs.

  • There were thorough risk management and governance structures and processes in place. These linked risk and governance meetings at both departmental and trust level. This produced an effective flow of information from ward to board and vice versa.

  • The gynaecology and maternity services had an annual audit programme and evidence of learning and improving practice as a result of audits.

  • Gynaecology cancer patients received appropriate care, which followed national standards and guidance.

  • There was evidence of good clinical outcomes for maternity and gynaecology patients.

  • There was evidence to show risk and quality measures were interrogated for service improvements and responsive actions were taken.

  • There were systems to share information and learning.

  • A positive and proactive culture was evident.

However, some improvements were needed:

  • There was no staff trained to provide specialist bereavement care for maternity and gynaecology patients experiencing loss, or to advise other staff who required specialist support in this sensitive area.

  • The two designated areas identified to care for bereaved women and their families were inappropriate, lacking privacy, space and facilities.

  • Improvements were required in records to demonstrate decisions relating to maternity care being midwifery or consultant led.

  • Improvements were required in records to demonstrate that one to one care was provided to women in established labour 100% of the time.

  • Additional equipment was required on the delivery suite and improvements were required to evidence all equipment had been safely maintained.

  • Improvements were required on the standards of cleaning and improved evidence was required to show how this was audited.

  • The obstetric consultant staffing levels did not meet national recommendations for the size of the maternity services provided on the Princess Anne wing at the Royal United Hospital.

Medical care (including older people’s care)

Good

Updated 26 September 2018

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

Staff followed systems to protect patient safety and kept safety as an overriding principle in their daily work.

The service used audit processes to monitor patient outcomes and used the information to improve services. Staff were competent to undertake their roles and were able to seek support when they needed it. National guidelines were followed to provide evidence based patient care and staff kept patients’ needs at the heart of their work. They were sensitive to patients and relatives needs and included them in care when appropriate.

Staff used complaints and incidents as a method of learning and improving services.

Leaders were aware of challenges and were using strategies to solve these problems although this was work in progress. There were clear governance procedures and methods of feeding information to and from the trust board to the ward staff.

Staff felt supported and able to speak up about any concerns they had. They felt able to innovate and develop initiatives to improve patient care.

Staffing presented a challenge to the service and wards were always working below the planned number of staff. Staff were often moved between wards to address patient risk

There were some processes which were not followed according to trust policies and these could cause a risk to infection prevention and control. Some areas were in need of repair and a refurbishment plan was in progress which would deal with these issues. There was inconsistency in record keeping which could cause a risk to continuity of patient care.

Surgery

Good

Updated 10 August 2016

We rated surgery services as good because:

  • The trust encouraged openness and transparency about incident reporting and incidents were viewed as a learning opportunity. Staff felt confident in raising concerns and reporting incidents. However, not all staff reported receiving feedback following the reporting of an incident.

  • The trust encouraged an open culture. Staff were aware of the principles of Duty of Candour and apologised to patients when things went wrong.

  • Risks to patients were assessed, monitored and managed on a day-to-day basis. These included signs of deteriorating health and medical emergencies.

  • Reporting on the Safety Thermometer between December 2014 and December 2015 indicated the number of reported harms to patients were low.

  • The majority of feedback we received from patients and their relatives about their treatment by staff was positive. Patients gave us individual examples of where they felt staff ‘went the extra mile’ and exceeded expectations with the care they gave. Patients felt staff maintained their privacy and dignity at all times and provided them with compassionate care.

  • Consent to care and treatment was obtained in line with legislation and guidance. Patients were supported to make decisions and, where appropriate, their mental capacity was assessed and recorded. However, we did find one incident where part of the care and treatment of a patient who lacked capacity to make a decision was not recorded on the consent form.

  • Staff supported people living with a learning disability and those living with dementia to have a better experience of being in hospital. Staff were kind and patient with people living with dementia and a learning disability. We observed one-to-one care taking place and activities planned on their assessed needs. A specialist team of staff in the hospital provided support to patients living with a learning disability or dementia and for staff caring for them.

  • Patients care was coordinated when a number of different staff was involved in their care and treatment, for example physiotherapists and occupational therapists. All relevant staff were involved in the assessing, planning and delivery of patient care and treatment. Staff worked collaboratively to meet patients’ needs.

  • The hospital performed better than the England average in some national audits, for example, the national hip fracture audit 2015.

  • The trust monitored the number of bed moves after 10pm on the surgical wards. The numbers had reduced in November 2015 compared to October 2015. However, two patients told us they had been moved very late at night and found it very disruptive.

  • The service leadership was good and a cohesive clinical governance structure showed learning, change and improvement took place. Managers regularly reviewed the approach to risk management in the departments. A number of specialty meetings fed into the overall clinical governance and provided board assurance.

However:

  • Patient records were not being stored securely on the admissions suite, so there was a potential risk of access by unauthorised people.

  • The trust-wide Admitted Adjusted Referral to Treatment (NHS England consultant-led referral to treatment 18 week standard) performance was worse than the England average for all but one of the six months to May 2015, when the target was abolished. By November 2015 performance had deteriorated to under 60%. Over the entire period, all specialties performed below 90%.

  • The hospital performed worse than the England average in some national audits, including the Patient Reported Outcome Measures (PROMs) for April 2014 to March 2015, which is based on patients reporting to the hospital on their outcome following surgery for groin hernias, hip replacements, knee replacements, and varicose veins. In relation to groin hernias for both indicators and a mixed response in the varicose veins.

  • There were periods of understaffing on the surgical wards where the trust’s safer staffing numbers of qualified nurses were not met. Additional non-qualified staff were used at times to cover any gaps in the rota.

Services for children & young people

Good

Updated 26 September 2018

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

  • There were clearly defined and embedded systems, processes, and practices, which kept children safe and safeguarded them from abuse. The whole team were engaged in these safeguarding processes, with effective leadership from the named nurse for safeguarding children. Lessons were learnt and themes identified, taking action and changing practice as a result of when things go wrong.
  • There was exceptional multidisciplinary team working. Staff, teams and services, both internally and externally, were committed to working collaboratively. They had found efficient ways to deliver joined up care to the babies, children and young people, and their families.
  • We observed and heard about exceptional care being provided to babies, children, young people and their families. Feedback from children and parents was overwhelmingly positive. People were truly respected and valued as individuals. They were empowered as partners in their care and kept involved and informed.
  • The children and young people’s service was tailored to meet the needs of individuals. The services provided reflected the needs of children, young people and families. They were engaged and involved when improving the design and running of the services.
  • The facilities and premises met the needs of people using the service. The Dyson neonatal unit was a purpose-built centre, this was conducive to providing high quality, safe, care and treatment to neonates. The children’s centre was being redesigned to improve access and flow for day surgery.
  • There was a proactive approach to understanding the needs and preferences of children and young people. This ensured individual needs were met, promoted equality and enabled accessibility.
  • The children’s service demonstrated how they could be accessible, flexible and responsive to meet an increasing demand on the service. The paediatric demand management project had helped to improve patient flow, manage paediatric referrals, and support primary care.
  • There were clear responsibilities, roles and systems of accountability to support effective governance and management. The processes for managing risks, issues and performance were effective and well embedded.
  • Leaders had the skills, knowledge and experience to lead the service. They had a clear vision for the service which was supported by the strategy. Staff were engaged with this vision and strategy.
  • There was a highly positive culture. Staff were proud to work in the children and young people service, and came across as enthusiastic and motivated. They felt their input was valued and they worked as an inclusive team.

However:

  • The children and young people’s service recognised a risk around their nursing and medical staffing. There were times when the nursing team were understaffed or there were non-compliant rotas. The medical cover at night and weekends needed improvement.
  • Training for advanced paediatric life support required completion or updating to ensure more nursing staff could manage emergencies.
  • The processes for cleaning toys did not evidence that children were protected from the risk of infection.
  • There were no risk assessments for the environment or young people’s independent use of the adolescent room or quiet room. This posed a safety risk due to the number of ligatures and lack of staff supervision.
  • The children’s theatre recovery area was not appropriately separated from the adult recovery area. We identified this as a concern at our previous inspection.
  • Although pain was regularly assessed and managed, pain scores were not always clearly documented within patient records.

End of life care

Outstanding

Updated 10 August 2016

We have judged end of life care overall to be outstanding because:

  • Staff understood their responsibilities to raise and report concerns, incidents and near misses. They were clear about how to report incidents and we saw evidence that learning was shared across the teams.

  • The staff in the palliative care team, bereavement and mortuary service were all up-to-date with their mandatory training.

  • People’s care and treatment was planned and delivered in line with the latest guidance, standards and legislation. The trust had undertaken a range of service developments over the 18 months prior to our inspection to support the improvement of effective care for patients with end of life care needs. New documentation had been introduced to record a personalised care plan for a dying patient.

  • The trust had undertaken a project over the 12 months prior to our inspection called the Conversation Project, whose objective was to improve the identification of the dying patient and their subsequent care.

  • Patients were respected and valued as individuals and were empowered as partners in their care. The evidence was universally positive about the way they were treated by staff. Several patients and relatives stated they could not think of how the care could have been improved.

  • We found that people’s individual needs and preferences were central to the planning and delivery of end of life care. The trust worked with services in the local community to provide continuity of care where possible and engaged with commissioners and community services to drive improvements. Staff were proactive in their approach to understanding individual patients’ needs and wishes and in their approach to meeting the needs of vulnerable people.

  • We found some aspects of leadership, particularly that of the palliative care team to be outstanding. We found that nursing, medical and healthcare staff across the hospital were being engaged and motivated to improve the service they provided in respect of end of life care. There were clear governance structures for end of life care with the objectives of the end of life working group being clearly laid out and monitored. There was positive leadership at board level for end of life care.

  • All staff we spoke with were very positive about the trust as a place to work.