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Inspection Summary


Overall summary & rating

Good

Updated 31 January 2020

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

  • People were protected from abuse and staff were clear in their responsibilities to safeguard people, including families and carers. Most infection prevention and control practices were carried out effectively. Staff responded well to patients at risk.
  • Treatment was effective and patients had good outcomes. There was a strong culture of having multidisciplinary input into care and treatment. Care was delivered in line with national guidance, evidence-based practice and legal frameworks. Pain relief, nutrition and hydration were mostly managed well.
  • Patients, those who cared for them and women in the maternity unit spoke highly of the care and treatment given to them. Patients and women were treated with compassion and kindness. People were able to make their own decisions and supported to do so. The right people were involved when patients were not able to decide for themselves.
  • Services were designed to meet the needs of local people. It was recognised when patients were individuals and had different needs. Cancer patients were being seen within the national standards.
  • The staff leadership teams had the skills, knowledge, and experience to manage services. High-quality and patient-centred care was promoted. There was a clear set of values for staff which were based on the experience for the patient. Staff were well supported and there was good morale and a strong culture. Staff were willing to challenge poor practice and support each other. There was a strong culture around innovation, research, development and improvement. Staff had good systems to assure themselves they were providing a good, safe and quality service.

However:

  • Although the trust worked tirelessly to resolve the vacancy levels, there was a high use of agency staff, and not all medical posts were filled. Not all staff had updated all their mandatory training and this including child safeguarding having further declined and infection prevention and control not meeting the standard. We recognised this was against a high benchmark at this trust. There had been missed opportunities for earlier identification of the safeguarding concern in maternity and we found errors in medicine management. Not all emergency equipment was being checked as it should be. Not all patient records or risk assessments were completed as well as they should be.
  • Not all staff were receiving annual performance reviews. Although there was no evidence to suggest staff were not skilled and competent, the leadership could not be assured of this or whether any development needs were being recognised or met.
  • Not all patients or those caring for them said they felt involved and informed in decisions about their care and treatment or offered emotional support following life changing news.
  • Due to high demand, not all referral to treatment standards (18 week standard) were being met for surgical procedures. The trust was also below the England average.
  • There were concerns around governance being both consistent, well managed and effective. There was limited evidence to show the organisation learned when things went wrong or patients or carers complained.
Inspection areas

Safe

Requires improvement

Updated 31 January 2020

Effective

Good

Updated 31 January 2020

Caring

Outstanding

Updated 31 January 2020

Responsive

Good

Updated 31 January 2020

Well-led

Good

Updated 31 January 2020

Checks on specific services

Medical care (including older people’s care)

Good

Updated 31 January 2020

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

  • Staff understood how to protect patients from abuse and managed their safety. The service controlled infection risk. Staff assessed risks to patients, acted on them. They managed medicines well. The service managed safety incidents and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Patient records were not being stored securely at our last inspection meaning unauthorised people may have had access. At this inspection we found the majority patient records were stored securely.
  • Safety checks on resuscitation and emergency equipment were following trust policy to make sure they were ready for use. This was an improvement from our last inspection.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could mostly access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

  • The service did not make sure all staff completed mandatory training updates in key skills, although this was against a high benchmark at this trust.
  • On two wards the resuscitation equipment was stored behind locked doors meaning there could be a delay in accessing this in an emergency.
  • Staff did not always complete the patient’s first assessment of risks to their health and safety.
  • Detailed records of patients’ nursing care and treatment were not continually maintained. Records were not always clear. However, they were mostly up-to-date, stored securely and easily available to all staff providing care.
  • Nurse and medical staffing remained a challenge and a known risk to the trust. At our last inspection we found nurse staffing levels were not safe. At this inspection, we found a number of initiatives had been implemented to address the shortfall.
  • At our last inspection staff did not always involve all patients in their care, by explaining next steps and involving them in decisions about their care. At this inspection we received similar feedback from some patients and their relatives who did not feel involved.
  • Staff did not always provide emotional support to patients, families and carers.
  • Demand on the medical care services continued to be a challenge for the trust. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not always in line with national standards.
  • Staff did not always complete patients’ fluid and nutrition charts. This was identified as a concern at our last inspection.
  • There was variable performance for all wards in the audit data around patients being assessed for malnutrition within 24 hours of admission as per trust protocol.
  • Staff appraisal rates were not meeting trust targets.
  • Minutes of governance meetings were hand written which meant they were not very clear and difficult to read.

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.

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.

End of life care

Good

Updated 31 January 2020

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

  • Safe care was provided across the end of life care service. Staff had processes they used to assess and respond to patient risk. Patient safety incidents were reported and investigated to ensure learning and change.  
  • Staff provided effective care within the end of life care service. The service provided care and treatment based on national guidance and evidence-based practice. The effectiveness of care and treatment was monitored, and findings used to make improvements. Staff were competent for their roles. Staff supported patients to make informed decisions about their care and treatment and provide consent.  
  • We saw effective multidisciplinary team working. There was a presence of the multidisciplinary team within the end of life care team, reaching out across the directorates and a truly holistic approach to assessing, planning and delivering care.  
  • Staff gave truly person-centred care. As much emphasis was placed upon the emotional needs of those close to the patients as the patients themselves. Staff treated patients with compassion, dignity and respect, took account of their individual needs, and helped them understand their planned care. 
  • The service was inclusive and took account of patients’ individual needs and preferences, and treated concerns and complaints seriously to investigate and share learning.  
  • The service provided consistent and high‑quality care. The leadership team understood and managed the priorities of the service, and there was a clear vision and strategy of ‘one chance to get it right’.
  • Staff felt respected, supported and valued, and there was an evident multi-professional and collaborative culture within the division. There were effective governance processes and management of performance and risk, with further governance improvements planned. Staff were committed to learning and improving services.

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.

Surgery

Requires improvement

Updated 31 January 2020

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

  • The service did not have enough employed nursing staff and junior doctors and used a high number of agency or locum staff to cover these gaps. Medical staff did not always meet trust training compliance for mandatory update training, although against a high benchmark at this trust. Infection control risk was not always well controlled. Safety checks of specialist and emergency equipment were not always completed or clearly recorded. Best practice guidance for taking patient observations in recovery areas, and the assessment of venous thromboembolism within 24 hours of admission were not well completed. Records were not always clear and up to date or stored securely. Medicine management systems could be improved to include the recording in controlled drug registers and monitoring of fridge temperatures.
  • Patient warming in theatre was not being done consistently and in line with best practice guidance. Staff did not always fully complete food and fluid charts, or document escalation and actions. It was not always recorded how patients’ mental capacity had been assessed to inform the decision-making process.
  • People could not access the service when they needed it and had to wait too long for treatment. Reduced activity and insufficient theatre capacity had resulted in underperformance in admitted patient pathways, and the trust had breached the 52 week wait for patients waiting for their treatment. There were a high number of patients admitted with fractured neck of femurs and these patients were not always operated on within 36 hours of admission. The surgical flow within the hospital was impacted by the high number of trauma patients admitted, this meant surgical patients were sometimes looked after on non-surgical or non-specialty wards, and the day of surgery admission unit was being used as an escalation area. There was limited adaptation within surgical inpatient wards to make them dementia friendly environments.
  • The vision and strategy were not documented with workable plans and actions. The governance meeting minutes to evidence discussions were basic and did not clearly demonstrate actions and follow up of these actions. There was not a structured review and judgement process for mortality and morbidity meetings. There were examples where good information governance practice was not followed by staff. There was not always a good understanding of quality improvement methods and the skills to use them. However, there were areas of quality improvement being completed in departments and specialty areas.

However:

  • Staff had training in key skills and understood how to protect patients from abuse. Staff assessed risks to patients and acted on them. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

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

Good

Updated 31 January 2020

We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings.

We rated it as good because:

  • Mandatory training was comprehensive and met the needs of women and staff. Midwifery staff received and kept up-to-date with their mandatory training; the service controlled infection risk well; managers regularly reviewed and adjusted staffing levels and skill mix; the design, maintenance and use of facilities, premises and equipment kept women safe. These were improvements from the last inspection in 2016.
  • Staff provided effective care within the maternity service. The service provided care and treatment based on national guidance and evidence-based practice. The effectiveness of care and treatment was monitored, and findings used to make improvements. Staff were competent for their roles. Staff supported women to make informed decisions about their care and treatment and provide consent.
  • Outstanding elements of care were observed. Staff treated patients with compassion, dignity and respect, took account of their individual needs, and helped them understand their planned care.
  • The service was excellent in responsiveness for care which was planned and organised to meet the changing needs of women, their partners and family. This included help for women in need of additional support or specialist intervention. The service had a dedicated safeguarding midwives’ team to provide support and resources for women in hospital or the community. There was good multidisciplinary team working. Multidisciplinary teams within maternity had a holistic approach to assessing, planning and delivering care.
  • The service was well led, and the leadership team understood and managed the priorities of the service, and there was a vision and strategy aligned to the pan-Dorset vision and plans, and national priorities.
  • Staff felt respected, supported and valued, and there was an evident multi-professional and collaborative culture within the division. There were effective governance processes and management of performance and risk, with further governance improvements planned.
  • All staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them. Leaders encouraged innovation and participation in research. The service had a development programme to prepare midwives with the management skills to progress. Staff had received awards for their innovations and hard work.

However:

  • Medical staff did not achieve the trust target for mandatory training, although this was against a high benchmark for this trust.
  • There were missed opportunities for early identification of a safeguarding concern.
  • There were medicine errors identified by the inspection team and medicines errors were under-reported. Also, patients did not always take their discharge medicines with them when they left hospital.