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

Inspection Summary


Overall summary & rating

Good

Updated 26 January 2018

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

  • Effective, caring, responsive and well-led care were good. The trust had a good track record in delivering effective, caring and well led care and had made significant improvements in the responsiveness of services we inspected. Although some aspects of safety across the trust have improved since our 2016 inspection, there were still concerns about safety within the three services we inspected.
  • Surgery was good when we inspected in January 2016. However, we have rated as requiring improvement following this inspection as there were new concerns about the safety and leadership of the service since our previous inspection.
  • Critical care was found to be providing effective, caring, responsive and well led care. Caring within this service was found to be good rather than outstanding as it had previously been rated following the previous inspection in January 2016.
  • Overall, services for children and young people had improved which is reflected in their rating which has moved from requires improvement to good. Caring had improved from good to outstanding and responsive, well led and safety from requires improvement to good. Effective remained good.

Are services safe?

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

  • During our previous inspection in 2016, we found that safety was not given sufficient priority across the trust. Since our previous inspection, this position appeared unchanged. We rated safety as requiring improvement in surgery and critical care though it was assessed as good in services for children and young people.
  • Medicines were not always managed safely in surgery and critical care. Medicines were not always stored securely, some medicines could be accessed by non-clinical staff and there was there was variation in safety checks of controlled drugs in surgical services.
  • There was no dedicated pharmacist in critical care and medicines reconciliation was not routinely taking place.
  • There were insufficient numbers of staff with the right qualifications, skills, training and experience to keep people safe and provide the right care and treatment in surgical services.
  • Infection prevention and control was not robust in some areas and some equipment and premises were not sufficiently clean. There was no assurance process for daily clinical cleaning in surgical services.
  • In surgery, staff did not always use the results of safety monitoring well to improve patient care.
  • Whilst incidents were reported, investigated and learning was shared, the number and frequency of surgical never events did not demonstrate that sufficient organisational learning had taken place.
  • The records of patients care and treatment did not always contain updated safety risk assessments and appropriate individualised care plans. Up to date records were therefore not always available to all staff providing care when needed.
  • Premises were not all in good order and there were considerable maintenance issues waiting to be addressed in the surgical service.

Are services effective?

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

  • We rated effective as good in surgery, critical care and services for children and young people.
  • Patients received care and treatment in line with national guidance including those from royal colleges. Policies and practice procedures had been developed and were based on guidance and were reviewed. Care bundles were embedded in practice which supported the care of very unwell patients in critical care.
  • Staff from different departments and disciplines worked together as a team for the benefit of patients. Hospital staff also worked well with those in the community to make sure patients continued to be cared for.
  • With the exception of adult nurses providing direct care to children and young people, staff were competent in their roles. Patients received care from staff that were suitably skilled, trained and proficient.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients who lacked the capacity to make decisions about their care.
  • Patients’ pain was assessed, treated and reviewed effectively.

Are services caring?

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

  • We rated caring as good in surgical and critical care services. We found caring had improved to be outstanding in services for children and young people.
  • Patients were treated with care and compassion. Patients and their relatives were complimentary about the care and treatment they received.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • Staff offered emotional support to patients and their relatives. Where appropriate, staff could refer patients and their relatives experiencing stress and anxiety to additional services and/or support groups.
  • End of life care for children provided at Gully’s place was exceptional. Staff were compassionate to families’ needs and went above and beyond to grant children’s last wishes.

Are services responsive?

Our rating of responsive had improved from requiring improvement to good. We rated it as good because:

  • The trust, in conjunction with system partners, made efforts to plan services in a way that mostly allowed patients to receive the care they needed in the right place at the right time. It was of note that the trust continued to do this whilst awaiting the results of the Dorset wide clinical services review, ensuring that patient’s care was not adversely affected whilst this was underway.
  • Complaints were responded to in an increasingly timely manner and findings used to improve care.
  • There had been significant improvements to the critical care environment to ensure that patients had access to adequate bathroom facilities. This meant that patients who were able to could tend to their personal care needs without needing to leave the ward which had not been the case previously.
  • The trust had appropriate arrangements in place to identify and plan care for patients with a learning disability and individuals living with dementia or other mental health conditions.
  • Where the trust struggled to deliver services within accepted timeframes, or in line with national guidance, action was taken to ensure the risks to patients were minimised.

Are services well-led?

Our rating of well-led stayed the same. We rated it as good because:

  • We rated the leadership as good for critical care and services for children and young people. Previously, in 2016, leadership of the children and young people’s service was rated as requiring improvement and we saw clear evidence of improvement in this area. We rated leadership of surgical services as requiring improvement.
  • Managers within critical care and services for children and young people demonstrated the right skills and abilities to run a service providing high quality sustainable care.
  • Managers promoted a positive culture that supported and valued staff creating a sense of common purpose based on shared values.
  • Managers led their staff using appropriate knowledge, skills and experience to provide high quality care. They provided support and training to all staff to enable them to provide good services.
  • The three services we inspected engaged well with patients, staff, and the public and local organisations to plan and manage appropriate services.
  • Critical care and children and young people’s service leads had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. However, in surgery they had not demonstrated sufficient pace in addressing concerns previously raised following our inspection in 2016. A series of never events also showed that organisational learning was not robust in preventing reoccurrence.
Inspection areas

Safe

Requires improvement

Updated 26 January 2018

Effective

Good

Updated 26 January 2018

Caring

Good

Updated 26 January 2018

Responsive

Good

Updated 26 January 2018

Well-led

Good

Updated 26 January 2018

Checks on specific services

Critical care

Good

Updated 26 January 2018

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

  • The intensive care unit provided care and treatment in line with national guidance and the Royal College guidelines these to meet patient’s needs.
  • Patients’ care was planned and took account the needs of people in vulnerable circumstances and their needs were supported while receiving care.
  • There were effective assessment processes for assessing patients’ risks and their safety was monitored. The intensive care team worked cohesively and regularly reviewed and responded to patients’ risks.
  • The trust had invested in the unit to ensure that patients had access to appropriate bathroom facilities.
  • The intensive care team worked closely with the outreach team in the identification and early intervention to support deteriorating patients across the other wards and units. Patients were escalated to the unit as required to ensure that critically care patients received early input and the most appropriate care and support.
  • The unit was fully engaged in research activities and supported the National Institute for Health Research (NIHR) studies.
  • Staff provided kind and compassionate care.

However

  • Not all nursing staff had received an appraisal of their work as appraisal rates were 84% which was below the trust target of 95%.
  • Aspects of the environment did not support robust infection prevention and control.
  • Medicines were not always stored safely and securely.

We were not fully assured that mixed sex breaches were always being reported in line with national guidance.

Outpatients and diagnostic imaging

Good

Updated 25 May 2016

We found the outpatients and diagnostic departments at Poole Hospital were good for safe, caring, responsive and well-led services.

Staff were encouraged to report incidents and the learning was shared to improve services.

Staff compliance with mandatory training was good in outpatients and diagnostic imaging.

Two radiographers worked overnight and were responsible for plain film X-rays for the main hospital and the emergency department. One on-call radiographer carried out computerised tomography (CT) scans and worked alone if called in. Radiographers reported a heavy workload and raised issues regarding manual handling. Between 10.00pm and 8am, radiology was supported by an overnight, outsourced radiologist service. Staff confirmed that this service worked well and did not compromise patient care.

In diagnostic imaging, staff were confident in reporting ionised radiation medical exposure (IR(ME)R) incidents. Staff followed procedures to report incidents to the radiation protection team and the care quality commission.

The environments were visibly clean and staff followed infection control procedures. There were monthly environmental audits carried out by the infection prevention team. There was appropriate management and storage of medicines. Records were available for clinics using an electronic document management system. Patients were assessed and observations were performed, where appropriate. However, there was not a tool in use to help identify a deteriorating patient.

Nurse staffing levels in the department were appropriate to patient needs, and there were few vacancies (approximately 8% at November 2015). Radiographer staffing levels were five vacancies (25%) across the service. Staff reported this affected the on-call rota and was placing a strain on their workloads. However, there was an ongoing recruitment plan for nurses and radiographers.

There was evidence that care was being provided according to National Institute for Health and Care Excellence (NICE) guidelines.

Staff had access to training and had annual appraisal but did not have formal clinical supervision.

Staff provided compassionate care, and ensured patients and relatives were well supported whilst in the department. Patients were well informed and routinely involved in the planning of their care and treatment. Staff recognised when a patient required extra support to be able to be included in understanding their treatment plans. Patients and relatives we spoke with gave us positive feedback about the department.

There was evidence of service planning to meet people’s needs. For example, with there had been changes to seven day working in radiology, and a re-design of the therapies directorate. National waiting times were consistently met for outpatient appointments, cancer referrals and treatment and diagnostic imaging. There was good support provided for patients with a mental health condition and patients living with dementia.

Patients whose first language was not English had access an interpreter although some staff were not aware of how to access this service. The self-service checking in system, located in outpatients, presented multiple languages on screen. The service received very few complaints that were upheld and, where possible, concerns were resolved locally.

Governance processes to monitor risks and quality required further development in the outpatient and diagnostic department.

Staff were not clear about the overall vision and values of the trust but told us that the departmental patient experience and the provision of high quality care was their main concern. All staff spoke of the ‘Poole Approach’, which is a culture, embedded across the whole trust.

Nursing staff in the outpatient department felt well supported by their immediate line managers. They told us that they felt well supported and valued. However, some staff in diagnostic imaging did not identify a strong leadership presence and did not feel well supported. All staff said they enjoyed working for the trust due to the strong team support from colleagues.

Public and patient engagement occurred through feedback such as surveys and comment cards.

Urgent and emergency services

Good

Updated 25 May 2016

We rated the service in the emergency department (ED) as good for safe, effective, caring, responsive and well-led. We saw a high standard of care and treatment delivered by competent, caring and compassionate staff.

The department had a culture of safety where incidents were reported. Learning was shared and changes made as a result of this. The department was visibly clean. Staff adhered to infection control procedures. Equipment was available, fit for purpose and clean. However, medicines were not always appropriately managed and stored.

The department had appropriate medical staffing levels that included a consultant present for 12 hours a day and senior medical cover for 24 hours per day. There was an appropriate number of suitable trained and skilled nurses in the department. There was a lead nurse for the unit, as well as skill mix of emergency nurse practitioners, advanced nurse practitioners and children’s nurses. There were a low number of nursing vacancies within the department. Agency staff were seldom used as staff worked flexibly to provide appropriate skill mix and staffing levels. Recruitment to a small number of vacancies was ongoing.

The safeguarding requirements for children, young people and vulnerable adults were understood, and there were appropriate checks and monitoring in place. However, there was no flagging system to identify patients with a learning disability.

The department provided effective care that followed national guidance and this was delivered to a high standard. Pain relief was offered appropriately and the effectiveness of this was checked. Multi-disciplinary work was in evidence and the department ran its services seven days a week.

Patients gave positive comments about the care they received, the attitude of the staff. Patients and relatives told us they were treated with compassion, dignity and respect, and staff were observed treating them with kindness and courtesy. Patients’ were kept informed of treatment options and were involved in decisions about their care.

The service had some improvement to make in consistently meeting the 4 hour emergency access target of 95%. The hospital was not consistently meeting the national emergency access target of 95% of patients who required hospital admission to be transferred to a ward or discharged from ED within four hours. However, this target was achieved in 5 months in the last year, and was above 90% for a further 5 months.. Patients were however, assessed and treated within standard times. There was good support provided for patients with a mental health condition and patients living with dementia.

The ED was well led by senior nurses and doctors, and the departmental strategy and vision was recognised by staff. The culture within the department was one of accessible leadership with mutual trust and respect, leading to the maintenance of an effective team. There was appropriate monitoring of incidents, quality and performance by senior staff.

Maternity and gynaecology

Good

Updated 25 May 2016

Maternity and gynaecology services were rated good for effective, caring, responsive and well led-services However we rated safe as requires improvement.

Clinical safety incidents were not consistently reported. Midwives told us that they were unable to report incidents due to staffing pressures.

Systems and processes for monitoring infection control standards were not always reliable or appropriate to keep people safe. The delivery suite environment was difficult to keep clean. We noted emergency obstetric equipment and equipment required to remedy a tongue tie in the antenatal clinic was dirty and also sterile equipment had expired. There was a risk of a hospital acquired infection if the equipment had been used..

Staffing levels and skill mix were not always planned, implemented and reviewed. Midwives told us the last staffing assessment had taken place in 2012 and this had not been updated to reflect the increase in activity in the service. The midwife to birth ratio did not meet national guidelines. The funded midwife to birth ratio was 1:31. Between April to September 2015 the midwife to birth ratio was 1:32-33. The Royal College of Obstetrics and Gynaecology guidance (Safer Childbirth: Minimum standards for the Organisation and Delivery of Care in Labour, October 2007) states there should on average be a midwife to birth ratio of 1:28. The England average was 1:29. Midwives were unable to consistently provide one to one care for women during labour.

Consultant presence on the ward was 60 hours per week compared to the Royal College of Obstetricians and Gynaecologists good practice recommendation of 98 hours per week. The consultants provided a further 108 hours per week on call.

Overall attendance at mandatory training updates was below the trust’s 95% target. There was a risk that not enough staff had attended updates to ensure they had suitable training to care for women safely.

Midwives followed comprehensive risk assessment processes from the initial booking appointment through to post-natal care. Identified risks were recorded and acted upon across maternity and gynaecology services.

The gynaecology ward participated in the NHS Safety Thermometer. That is a local improvement tool for measuring, monitoring and analysing patient harms and 'harm free' care. The ward conducted monthly audits in respect to patient falls, pressure ulcers, catheters and urinary tract infections. However, information about the audits was not displayed. It is considered to be best practice to display the results of the Safety Thermometer audits to allow staff, patients and their relatives to assess how the ward has performed.

Care and treatment was delivered in line with current legislation and nationally recognised evidence based guidance. Women had access to a variety of methods for pain relief throughout the service. Feedback from women and relatives about their care and treatment was consistently positive. We observed women were treated with kindness, compassion and dignity throughout our visit.

Women had prompt access to gynaecological treatment. For the period January 2015 to December 2015 the hospital exceeded the target of 92% of patients waiting less than 18 weeks for treatment following referral (incomplete pathway).

Translation services were available, and some midwives had undergone further specialist training to support women with additional needs such as learning disabilities and drug and alcohol addictions.

There were comprehensive risk, quality and governance structures and systems to share information and learning. Junior staff across the service described an open culture and felt well supported by their managers.

There was no clear strategy for maternity services. Managers told us they had produced a strategy which had not yet been presented to the board. However, the strategy did not have a plan of how its aims would be met. Senior managers did not consistently demonstrate an understanding of current service risks. The concerns regarding delays to care and the inability to consistently provide one to one care in labour had not been documented on the maternity risk register. Senior midwives described a disconnect between themselves and senior managers. They felt unable to speak freely and said they were not listened to.

There were comprehensive risk, quality and governance structures and systems to share information and learning. Junior staff across the service described an open culture and felt well supported by their managers.

Medical care (including older people’s care)

Good

Updated 25 May 2016

Overall we rated medical care as ‘good’.

We found that medical care (including older people’s care) was good, for effective, caring, responsive and well led and ‘required improvement’ for safe.

Processes and procedures were followed to report incidents. Themes from incidents were discussed at ward meetings and staff were able to give examples where practices had changed as a result of incident reporting. Staff adhered to the trust policy of bare below the elbows and the use of personal protective equipment. Nurses and healthcare assistants spoken with had a good knowledge of safeguarding and their responsibilities in raising concerns.

There was sometimes a shortage of staff on the medical and older people’s wards and safer staffing levels were not always met. The trust set a target of 90% compliance for all staff with mandatory training. This target was not achieved, this meant patients were at risk of being cared for and treated by staff who lacked updated knowledge and skills.

A never event occurred in August 2015 involving the wrong site procedure in the dermatology department. Never events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. When we inspected in January 2016, the trust had not yet agreed and implemented a key action; to implement a new dermatology surgical checklist.

Medical care services used specific pathways and protocols for a range of conditions, based on national guidance such as National Institute for Health and Care Excellence (NICE) guidelines. Hospital standardised mortality ratio was within the expected range. The trust performed above the England average on all three measures of the Myocardial Ischemia National Audit Project (MINAP) audit 2013 t0 2014. Outcomes for people who use services were below expectations in relation to heart failure treatment and care following a stroke. The trust had been slow to implement improvements in stroke care, but action plans were in place to drive improvements.

Multidisciplinary working was widespread and effective. There were arrangements for ensuring patients received timely pain relief. Patients at risk of malnutrition or dehydration were risk assessed by appropriately trained and competent staff. Staff made referrals to dieticians or speech and language therapists as required.

Feedback from patients and their relatives was nearly always positive about the way staff treated them. The culture we observed amongst all staff groups was caring and supportive. Staff encouraged patients and relatives to be partners in their care and make decisions. There was some inconsistency in interactions which caused distress.

Medical services were responsive to patients’ needs. The acute medical admissions ward, the rapid assessment consultant evaluation unit (RACE) for patients over 80 years of age, and the medical investigations unit had contributed to the trust’s ability to support older patients and manage the increasing demands for beds. The trust was working with partners to improve the coordination, safety and timely discharge of patients. However, there was a high number of delayed transfers of care. Staff took complaints seriously and responded in line with trust policy.

There was support for vulnerable people, such as people living with dementia and a learning disability. Staff applied the Mental Capacity Act appropriately, and the associated Deprivation of Liberty Safeguards.

Senior staff outlined the vision and strategy for their department. The leadership was strong and supportive, and staff worked well together. Staff felt valued by their immediate line management and said they were comfortable reporting incidents and raising concerns.

Quality and risk was assessed and monitored through audit. The matrons discussed actions to be taken forward at clinical leads meetings and risk meetings held for general medicine and department of medicine for elderly people. Risks, such as workforce, had been taken to the trust board. The senior team met with the executive team quarterly to present quality reports for medical wards and specialties, and department of medicine for the elderly.

Systems were in place to gain patient feedback and use it to improve services. The trust was involved in the ‘After Francis Research Project’, which involved gathering patients’ experiences. Where required, action plans had been developed to improve patient experiences.

Surgery

Updated 25 October 2018

We did not rate the surgery service due to the limited focus of our inspection. We looked at specific key lines of enquiry, under two of our key questions, safe and well led.

Services for children & young people

Good

Updated 26 January 2018

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

  • There was openness and transparency about safety, and continual learning was encouraged. Staff were supported to report incidents, including near misses. Both units were secured both day and night.
  • Staff were clear about their safeguarding responsibilities and if there was a concern about a child’s wellbeing safeguarding procedures were followed and understood. We saw evidence all staff had completed the appropriate level of training in safeguarding.
  • Care was planned and delivered in line with evidence based guidance, standards and best practice and the individual needs of the child and family were met through the careful care planning. Staff followed care pathways and used multidisciplinary records to support practice.
  • Staff used a paediatric early warning system for the early detection of any deterioration in a child’s condition, and we observed children and young people’s pain effectively assessed and treated.
  • Staff received annual appraisals and new staff were supported when completing their competency assessments, helping to maintain and further develop their skills and experience.
  • Services were provided seven days a week by medical and nursing staff. There was good multidisciplinary working evident across both units.
  • Parents and children gave feedback about the care and kindness received from staff, which was very positive. Staff worked in partnership with parents, children and young people in their care.
  • For children and young people at the end of their life staff worked with parents to provide outstanding emotional and compassionate support and developed the end of life unit - Gully’s place.
  • Inpatient services were tailored to meet the needs of individual children and young people. Access and flow through both departments was very good and complaints were dealt with in a timely manner. Staff listened to feedback and complaints and responded to them in a timely manner.
  • Play staff ensured that children and their families were supported during their hospital stay and their interventions during procedures reduced the anxiety and worry for the children for example during blood tests.
  • Area’s outside of the children’s unit and neonatal unit (NNU) for example radiology, provided specific ‘child friendly’ environments for children to wait and undergo investigations and worked closely with the play therapist team to reduce stress and anxiety during those procedures.
  • Staff at all levels of the children’s unit and NNU were proud of their work and were familiar with the Poole approach of being compassionate, open, respectful, accountable and safe.
  • Poole hospital NNU is the first and only unit in the United Kingdom to utilise a two-tier model of consultants and advanced neonatal nurse practitioners.

However:

  • There was not always enough medical staff with the right skill mix. Staffing levels had been reviewed, but changes to staffing levels identified as necessary from the reviews had not been fully implemented at the time of the inspection to meet the facing the future standards.

  • There was a risk children would be exposed to inappropriate adult conversation in the ear nose and throat (ENT) and fracture outpatient’s clinics as they were treated alongside adult patients.
  • Adult trained nurses who had not completed competencies to work with children were seeing children and young people in the adult preoperative clerking department.
  • The epilepsy and diabetes service had reduced capacity due to understaffing, which meant that some children might not receive the support they needed at the right time. The service was aware of this risk and business cases were being submitted for additional staff.

End of life care

Good

Updated 25 May 2016

End of life care at this hospital was rated as ‘good’. We rated the service as requiring improvement for responsive care. We rated the service good for safe, effective, caring and well-led care.

The trust had taken part in the National Care of the Dying Audit (NCDA) between 2013 - 2014 and at that time had not achieved six out of the seven key organisational targets and scored below the national average for six of the ten clinical key performance indicators. In the 2014 – 2015 NCDA the trust performed better than the national average in 10 out 12 measured indicators of performance. The data could not be directly compared as it did not measure against exactly the same performance indicators. However, it did suggest improvement when compared nationally with other end of life services.

Patients were protected from avoidable harm and abuse. There were reliable systems and processes in place to ensure that safe care was being delivered. Staffing levels were sufficient to provide safe care.

Staff at this hospital delivered person-centred care and treated people with compassion, dignity, kindness and respect. Feedback from patients and relatives was consistently positive.

There was good multidisciplinary working and staff were effectively trained. End of life care formed part of the mandatory training and staff induction programme at this trust. Staff received training in advanced communication which equipped them well when having sensitive discussions with patients and their relatives.

Staff across the trust reported timely access to advice and support from the specialist palliative care team and who were able to meet response times as outlined in the Operational Policy for Poole Palliative Care Service. The end of life care facilitator supported the care of dying patients across the hospital.

Patients were offered a range of pain relief interventions including medication and complementary therapies and pain was assessed, monitored and managed effectively. Staff had good working knowledge of end of life pain medicines to include anticipatory prescribing.

The leadership for end of life care was good. Service leads have produced a five year strategy which includes seven day working for the specialist palliative care team. The overalls aims and vision for end of life care were well understood by staff working in specialist palliative care and the trust had an awareness of the need to embed the strategy with staff working across the whole hospital. The Director of Nursing provided end of life care leadership at trust board level and had good oversight of end of life care issues across both the hospice and the main hospital.

The trust were undertaking regular audits to assess some patient outcomes in specific areas. However, the trust did not have an agreed set of performance indicators in order to measure the quality of the service on a continuous basis. The trust were collecting a variety of patient data at a local and national level but were not effectively using the data to improve patient outcomes.

DNA CPR orders were not always recorded by, or endorsed, by a consultant which meant decisions being made a patients resuscitation status may not have been shared by the consultant in charge of the person’s care.

The trust operated a Rapid Discharge Home to Die (RDHD) pathway which served to discharge patients who were diagnosed as dying with 24-48 hours if they expressed a wish to die at home. Local audit results from March to April 2015 showed that patients were not being discharged within 24 – 48 hours and the trust could not demonstrate improvement following this audit. Patients who were dying and had expressed a wish to die at home were not routinely discharged in a timely way. The trust were not routinely monitoring discharge delays for patients on the RDHD.