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Inspection carried out on 15 October to 14 November 2019

During a routine inspection

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 carried out on 9 April 2019

During an inspection to make sure that the improvements required had been made

We undertook an inspection, which we announced the day before,  of the operating theatre department at Poole Hospital NHS Foundation Trust on 9 April 2019. This inspection was focussed on the improvements required following a warning notice issued to the trust on 8 August 2018.

The warning notice was issued in relation to Regulation 12 (1) (2)( a) (b) (e) (g) and (h) (Safe care and treatment), Regulation 15 (1) (e) (Premises and equipment), Regulation 17 (1) (2) (a) (b) (d) and (e) (Good governance) and Regulation 18 (1) (2) (a) (Staffing). The warning notice set out the following areas of concern, where significant improvement was required:

  • Governance and risk management arrangements were not operating effectively.
  • Safe care and treatment were not always provided in a way to reduce risk to patients. This included; staff not consistently following the five steps to safer surgery policy (also known as the World Health Organisation (WHO) checklist), poor communication when collecting patients for theatre, staff not following best practice for infection control, medicines management policies not being followed, and incomplete checks of theatre anaesthetic machines. There were also delays in investigating incidents and making improvements.
  • The premises and equipment were not properly maintained, with maintenance tasks outstanding.
  • The systems to ensure staff received appropriate support, training, professional development and supervision were not operating effectively. There were insufficient numbers of suitably qualified staff. Senior staff supported staffing in theatres, which did not enable sufficient administration time for these systems.

The warning notice gave the provider a timescale of three months in which to comply. Following the last inspection issuing of the warning notice the provider sent to us an action plan, outlining the areas and actions they would take to address the concerns,

In this follow up inspection, we found although improvements had been made, change was ongoing and new systems were not yet fully embedded. There was further work needed to continue the improvements. The requirements of the warning notice had been partially met.

We have not rated the service following this inspection because it had a very limited focus. We looked at specific key lines of enquiry, under two of our key questions, safe and well led.

During this inspection, we found the following improvements had been made:

  • Mandatory training compliance had improved and exceeded the trust compliance target of 90%.
  • The environment was mostly maintained, and equipment was serviced regularly. The day theatres were challenged by building work adjacent to the unit and generally needed updating.
  • Staff mostly carried out daily checks on emergency equipment and other daily tasks.
  • Staff carried out safety checks in line with the NHS world health organisation five steps to safer surgery. Audit results and a review of three patient notes confirmed patient risks associated with surgery were assessed and managed if required.
  • There was enough nursing staff to keep people safe, but there was a high use of agency staff which had not improved since our last inspection.
  • Staff were aware of their responsibility to report incidents. Learning from incidents was mostly shared with staff to improve practice. The surgical leadership had been strengthened. Since our last inspection a permanent theatre matron, a permanent general manager for anaesthetics, critical care and theatres, a permanent general manager surgery and trauma orthopaedics and a new clinical director for anaesthetics, critical care and theatres, and a new clinical director for surgery had all been appointed.

  • There was a standard agenda for the regular governance meetings, this supported consistency in the overview and scrutiny of various areas of safety, risk and quality.
  • There was an audit programme with actions plans which included a range of topics including consent, NHS five steps to safer surgery, hand hygiene, scrub technique and saving lives.
  • Risks were identified on the risk register and managed effectively.
  • Staff wellbeing and retention had improved.
  • Standard operating procedures had been reviewed to ensure they met current professional guidelines.
  • Incidents were investigated and managed promptly to minimise risks to patients.
  • Completion of repair and maintenance tasks which had been reported to the estates team were monitored effectively to minimise risks to patients.
  • There was raised awareness of the freedom to speak up guardian role and staff were encouraged to use this communication route, should they wish to raise a concern.

However, we also found the following issues the service provider needs to improve:

  • Staff did not always adhere to infection prevention and control measures in the operating theatre department and day theatres.
  • The room temperature in operating theatre three was below recommended minimum temperature. This was not in line with national guidance for the prevention of surgical infections and a breach of the Workplace (Health, Safety and Welfare) Regulations (1992).
  • A risk assessment for one type of laser equipment used within theatre had not been reassessed since 2015, and it was possible the mitigating actions were not up-to-date with current evidence-based practice.
  • Medicines were not always stored securely, which meant there was a risk unauthorised people could gain access to medicines.
  • All staff, who participated in invasive procedures, were not always involved with all stages of the patient safety checks.
  • Review of staffing establishment was not carried out regularly in the day surgery unit and was last completed in 2017.
  • Maintenance tasks were not always completed in a timely manner.

Following this inspection, we told the provider that it must take action to comply with the regulations and that it should make other improvements. We also issued the provider with one requirement notice that affected the operating theatre department. Details are at the end of the report.

Dr Nigel Acheson

Deputy Chief Inspector of Hospitals (South)

Inspection carried out on 20 to 21 June 2018

During an inspection to make sure that the improvements required had been made

We undertook this unannounced focused inspection in response to concerns about the safety and quality of patients’ care in the eight main theatres and three-day theatres. The trust had reported seven never events within theatres since May 2016, and we received information of concerns from three whistle-blowers. The inspection took place from 20 to 21 June 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.

We found:

  • Incidents were being raised, however, investigation of incidents were not always addressed quickly enough. Although actions were in place to enable improvement, communication in the service was not wide enough to embed improvements.
  • The service was not doing all it could to keep patients safe from infection.
  • The systems in place to ensure the premises were properly maintained and that equipment was looked after were not operating effectively.
  • Staff did not always follow policy and procedures for the safe storage and recording of medicines.
  • Compliance in main theatres with two elements of the 15 mandatory training requirements were significantly below the 90% target. Compliance with adult basic life resuscitation training was 45% and the prevention and control of infection 66%.
  • Many staff told us about the challenges with staff recruitment and retention. In May 2018 the vacancy rate in main theatres was approximately 10%. Most of the vacancies were band 5 and band 2 staff. Staff worked 1,180.50 hours overtime in main theatres and day surgery theatres in May 2018, which staff told us was unsustainable.
  • Staff appraisal rates were well below the trust target.
  • Leadership was ineffective. Medical and theatre staff leads had undertaken no specific training for the role, for example, risk management or leadership training.
  • The governance and risk management systems in place were not operating effectively to identify, assess and reduce risks to the health, safety and welfare of patients.
  • Recognition, assessment and management of risks to patient safety was unsatisfactory. Safety processes, such as compliance with the World Health Organisation (WHO) ‘Five steps to safer surgery’, had not been effectively implemented.
  • Staff working in theatres did not always feel that a safety culture was prioritised in relation to incidences of non-compliance with the WHO ‘safer surgery checklist’. Staff knew how to raise concerns, but some told us they did not always feel comfortable to do so.
  • The trust did not always actively encourage feedback. All staff we spoke with in theatres were not aware of the trust’s Freedom To Speak Up Guardian (FTSUG) role.
  • The service did not always act on feedback promptly, for the purposes of continually evaluating and improving services. The trust participated in the national staff survey in 2017, which was published on 6 March 2018. In six areas the surgical care group scored substantially lower that the trust overall. The surgical group scored significantly higher for harassment and bullying by staff than the trust overall.
  • Due to the risks observed on inspection, we raised these concerns to the trust’s senior management team, who took some action to address these.

However:

  • Staff did fulfil their duty of candour responsibilities.
  • We found that the trust had changed how anaesthetic medicines were drawn up, following a requirement notice from the inspection in September 2017. The change was in line with professional guidance.
  • The trust had put a theatre safety action plan in place prior to this inspection.

Importantly, the trust must:

  • Within governance systems and processes, ensure there is a structured system in place to enable staff working in theatres to identify risks, raise training concerns and discuss and learn from incidents.
  • Undertake planned audits as scheduled, and ensure action plans are put in place if required.
  • Identify all risks relating to the service on the surgical care group risk register, and demonstrate how the risks being managed.
  • Prioritise hip fracture patients for theatre, to ensure their outcomes are not compromised.
  • Follow trust policy with regards to the records of temperatures where medicines are stored.
  • Act on the findings of the NHS survey for theatre staff within the surgical care group, to reduce clinical risk to patients and improve staff wellbeing and retention.
  • Review standard operating procedures at the date the service has indicated, to ensure they meet with current professional guidelines.
  • Investigate and manage incidents promptly to minimise risks to patients.
  • Address the inconsistency with the completion of the WHO ’Five steps to safer surgery’ checklist.
  • Undertake equipment checks of the anaesthetic machines at the frequency recommended by professional guidelines.
  • Store medicines and record the administration of controlled medicines as trust policy.
  • Not store equipment in front of the medical gas isolation switch off valves, as this makes it more difficult for staff to access the valves in an emergency.
  • Ensure staff work in a way that prevents and controls infection, including increasing compliance with control of infection training.
  • Support staff with the completion of adult basic life resuscitation training.
  • Monitor the completion of repairs jobs reported to estates, at a frequency that is sufficient to minimise risks to patients.
  • There needs to be sufficient number of suitably qualified, competent, skilled and experienced staff to enable senior staff to complete management tasks. The appraisal rate for nursing staff in theatres was 48% and in theatre recovery 78%.

In addition, the trust should:

  • Consider a standard agenda for the surgical speciality and monthly anaesthetists meetings, to support consistency in the overview and scrutiny of various areas of safety, risk and quality.
  • Continue to raise awareness of the freedom to speak up guardian role (FTSUG), encouraging staff to use this communication route, should they wish to raise a concern.
  • Ensure any gaps in compliance following the trust boards review of guidance relating to the FTSUG are addressed.
  • Support the new clinical leads in theatres to agree a personal development plan promptly to assist them in fulfilling their responsibilities.

Following this inspection, we served Poole Hospital NHS Foundation Trust with a Warning Notice under Section 29A of the Health and Social Care Act 2008, on 8 August 2018. The notice required the provider to make significant improvements by 13 November 2018.

Professor Ted Baker

Chief Inspector of Hospitals

Inspection carried out on 6 Sept to 12 Oct 2017

During a routine inspection

Inspection carried out on 26 - 28 January and 8-10 February 2016

During a routine inspection

Poole Hospital is the hospital provided by Poole Hospital NHS Foundation Trust. The trust gained foundation status in 2007 and provides services to a local population of around 500,000 people, although this figure rises significantly between May and September each year, as Dorset is a popular holiday destination.

Poole Hospital has approximately 638 inpatient beds. The hospital provides the following services: urgent and emergency care, medical and older people’s care, surgery, critical care, maternity and gynaecology care, care of the young person, end of life care, and outpatient and diagnostic services. We inspected each of these eight core services at the hospital.

Poole Hospital is the trauma unit for East Dorset and the designated Cancer Centre for Dorset, providing medical and oncology services for the whole of the county, serving an approximate population of 750,000.

The Trust has an unusual case-mix, undertaking a very high proportion of non-elective work, with only 15 acute trusts across the country delivering a higher percentage of non-elective activity. Given the distribution of acute services within east Dorset, the Trust does not provide the usual range of elective services, with orthopaedics, urology, ophthalmology and interventional cardiology being largely provided by the neighbouring trust in Bournemouth.

We inspected this hospital as part of our planned, comprehensive inspection programme. We carried out an announced inspection visit to the hospital from 26-28 January 2016, and additional unannounced inspection visits from 8 -10 February 2016. The inspection team included a Chair, a CQC Head of Hospital Inspection, managers, inspectors, planners and analysts. Doctors, nurses, allied healthcare professionals, senior NHS managers and an ‘expert by experience’ were also part of the team.

We inspected the following core services at Poole Hospital: Urgent and emergency care, medical care, surgery, critical care, maternity and gynaecology, children and young people, end of life care, outpatient and diagnostic services.

Overall, we rated this trust as ‘requires improvement’. We rated it ‘good’ for providing effective, caring and well-led services and ‘requires improvement’ for safe and responsive services.

Our key findings were as follows:

Are services safe?

  • Staff were encouraged to report incidents. The Trust overall had a culture of safety where incidents were mainly appropriately reported and followed up. Learning was shared and changes made as a result of this to improve the safety of services. However, clinical safety incidents were not consistently reported in the maternity service where midwives told us that they were not always able  to report incidents due to staffing pressures. The children and young person’s service had also not always ensured learning from incidents was embedded in practice.
  • The rate of NRLS reported incidents per 100 admissions is 45% higher than the England average: 12.2 per 100 admissions, against an England average of 8.4 per 100 admissions. There was one never event reported in the trust and 88 serious incidents between August 2014 and July 2015.
  • Patients arriving to the emergency department by ambulance were assessed and treated within national standard times. The trust time to treatment had been better than the England average since October 2013.
  • Staff carried out risk assessments and management plans for patients in a timely way although this was not entirely robust within the care of the elderly wards. Some patient risk assessments and fluid charts on these wards were incomplete.
  • The early warning score system needed to be used more reliably for the escalation of patients whose condition might deteriorate.
  • In some operating theatres, staff did not follow the five steps for surgical safety reliably or accurately in order to minimise the risks to patients.
  • The NHS safety thermometer is a monthly snap shot of the prevalence of avoidable harms, in particular new pressure ulcers, catheter-related urinary tract infections, venous thromboembolism (VTE) and falls. At the trust, from July to September 2015, 97% of care was harm free.
  • Medicines were not consistently managed in some areas across the hospital. Medicines were not always kept safe at the correct temperature, or stored securely in line with current legislation, in the ED, critical care and surgery departments.

  • Staff generally adhered to infection control procedures, but systems and processes for monitoring infection control standards in some services were not always reliable or appropriate to keep people safe. Premises and equipment were not always kept clean and cleaning was not always done in line with current legislation and guidance. Most wards and clinical areas were clean. However, areas in the delivery suite and ANDA were visibly dirty.
  • In the Emergency Department, patients were sometimes at risk of harm as they did not always receive name-bands within an appropriate time; this meant they could have had the wrong treatment or care if they were unable to tell staff their name.
  • Equipment was checked and stored appropriately in most clinical areas. However some of the equipment remained unchecked and unsuitable for immediate use in a post maternity clinic. Within the theatre complex, there was an insufficiently robust system for calling for emergency assistance. There were sufficient amounts of specialist equipment on, for example, the stroke unit, where adaptive cutlery and crockery was used.
  • Staff understood their safeguarding responsibilities towards vulnerable adults and children, but in the ED, there was low take up of training for reception staff.
  • Mandatory training compliance was sometimes below the trust target, and this was often as a result of staffing levels, as staff could not always be released to attend.
  • There were not consistent numbers of staff in terms of staffing levels and skill mix as planned by the trust on medical and older people’s wards and in paediatrics. The Trust had tried to mitigate this risk by having on-going nurse recruitment which was successful in some areas. Midwives said they were regularly short-staffed and were not able to consistently provide one to one care to women during labour.
  • Medical staffing levels were mainly appropriate. There were areas where further recruitment was necessary.
  • In diagnostic imaging, staffing was a concern. There were five radiographer vacancies (25% of the workforce) affecting MR and CT scanning. Staff reported heavy workloads and concerns with the demands on the on-call rotas.
  • Senior clinical staff were aware of the Duty of Candour regulation and the importance of being open and transparent with patients and families.

Are services effective?

  • The treatment and care provided in most services took account of current evidence-based guidelines. However, although evidence-based guidelines for the care and treatment of sepsis patients in the emergency department were followed, although some records had important pre-sepsis checks omitted.
  • Services participated in national and local audits. There was appropriate monitoring of performance against national targets although this needed to improve medical services and for end of life care.
  • Pain relief was given in a timely manner. Pain scores were used as part of the normal observations to record patients’ pain and to ensure that medicines for pain were effective. However, the use of pain tools designed for children were not being used within ED.
  • Patients nutrition and hydration needs were met appropriately. Patients who required intravenous fluids had these prescribed, administered and recorded appropriately.
  • Patients received drinks and food in a timely manner. There were protected mealtimes and staff to support patients who required extra help.
  • Care and treatment for people following a stroke was below the national average and the trust had been slow to implement improvements.
  • Patients were cared for by a multi-disciplinary teams working in a co-ordinated way. Staff reported good working relationships and clear lines of clinical responsibility with specialist teams who were called to review patients.
  • Many services had developed across seven days a week. However, there were reported delays for patients who required mental health assessment out of hours and over the weekends: these services were supplied by a local mental health trust. Stroke inpatients also received significantly less physiotherapy than patients’ nationally.
  • Many staff had access to specific training to ensure they were able to meet the needs of the patients they delivered care to and there were educational opportunities available for all grades of medical and nursing staff.
  • Staff had clinical supervision and appraisal, although appraisal rates for medical staff in the Emergency department were low.
  • Staff had immediate access to patient information. There were robust systems and processes to ensure that information was kept secure, but was available to all clinical staff that needed access to them.
  • Most staff followed consent procedures and had overall good understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards which ensures that decisions are made in patients’ best interests.

Are services caring?

  • All staff made a concerted and sustained effort to ensure that patients, carers and relatives were treated with kindness and support. We observed that staff were consistently kind and compassionate, putting the patient at the centre of care. Receptionists at the front door made a concerted effort to put any visitors or patients at ease, and this level of high support and regard continued throughout the hospital. Staff told us they were encouraged, no matter how busy, to stop to take time to help or reassure anyone in the hospital and this sometimes involved escorting people to unfamiliar areas, rather than just telling them how to get there.
  • However, on the medical and care of the elderly wards, some concerns were expressed about personal care prior to our inspection, and staff understanding of people living with dementia. Further feedback from some patients and relatives on medical wards indicated they did not (always) feel informed or involved in decisions about their care. This inconsistency was also reflected in feedback we received at our listening /public engagement event immediately prior to our inspection.
  • Many other patients, relatives and families told us they were kept informed of plans for on-going care and treatment. They said they had been given personalised support, adapted to their ability to take on complex or emotional information.
  • Patients and their families were supported by staff to reduce anxiety and concern. They felt involved in the decision-making process and had been given clear information about treatment options: they then felt enabled to ask questions of senior medical and nursing staff and be supported to make the decision that was right for them or for their loved one. There was further emotional care from the chaplaincy and bereavement services, and counselling support where required for patients and families.
  • Dignity and respect for patients was maintained at all times during treatment or examination. There were signs on curtains to remind staff and relatives that they needed to ask permission before entering.
  • Overall, the trust consistently scored better than the England average for the Friends and Family test.

Are services responsive?

  • At the time of the inspection the hospital’s services, and those of other acute hospitals in Dorset, were subject to the Dorset Clinical Services Review to redesign and improve quality of care for people in the county.
  • Bed occupancy in the hospital ranged between 86-98%. This was consistently above the England average. It is generally accepted that at 85% level, bed occupancy can start to affect the quality of care provided to patients, and the orderly running of the hospital.
  • Performance in meeting national emergency access target for 95% of patients to be admitted, transferred or discharged from ED within 4 hours had varied through the year. The target was met between May 2015 and August 2015, and again in September 2015. Overall the trust performance had been in line of better than the England average but the average was approximately 91%.
  • The trust reported 72 black breaches between November 2014 and October 2015. This is when ambulances are not able to hand over patients within one hour. A lack of physical capacity in the hospital was the main reported reason for this. The ambulance median time to treatment was around the standard of 60 minutes.
  • The percentage of patients waiting 4 -12 hours in the department for a bed in the hospital had been decreasing since October 2014. However, the trust still remained below the England average.
  • The acute medical admissions ward, rapid assessment consultant evaluation unit (RACE), and medical investigations unit had contributed to the trust’s ability to support older patients and manage the increasing pressures on beds.
  • There were 32 medical outliers at the time of inspection. These patients were appropriately assessed, and there was a robust process to ensure junior and senior medical staff from the relevant speciality reviewed medical outliers regularly.
  • In November 2015, 93% of patients with fractured neck of femur had surgery with 36 hours of being medically fit, 96% within 48 hours and 89% within 24 hours of being medically fit.
  • The trust had identified patient flow through the hospital as a significant concern. In the period October to December 2015, the trust had mixed achievements in meeting the 18 week incomplete pathway for referral to treatment (RTT) standard. National standards detail that 92% of patients should start treatment within 18 weeks of referral for treatment. This data was for patients who were having elective surgical procedures carried out at the hospital. General surgery and trauma and orthopaedic service met this target. However, ENT and oral surgery services did not meet this target, with compliance rates ranging from 87% to 91%.
  • The hospital’s cancellation rate for operations was similar to the England average. The percentage of patients whose operation was cancelled and were not treated within 28 days was lower (better) than the England average.
  • The critical care unit had a low rate of elective surgical operations being cancelled because a critical care bed was not available. However, patients fit for wards were not always transferred out of critical care within 24 hours. Thames-Valley and Wessex networks leads carried out a review in July 2015. The trust was identified as an outlier on the NHSE national dashboard. A further review was planned for January 2016.
  • In critical care, there were 39% of delayed discharges over 12 hours to wards due to lack of bed availability in the rest of the hospital, which meant patients could not be discharged to a ward at the earliest opportunity. This had resulted in patients that should be deemed as mixed sex breaches. There was an action plan in place which included meeting with director of operations to discuss this issue and identify solutions. This would be fed into the Best Practice Organisational Flow Group. The trust had recognised this was an on-going problem and was not meeting the NHS England key performance indicator.
  • Maternity senior managers had not completed an assessment of needs to analyse how the service should be planned and delivered to local people. This meant the managers could not be assured the service provided appropriate care to meet the needs of the local population. The trust wide bed occupancy rates for maternity and gynaecology were higher than the England average and fluctuated between 65% and 83%. For example, from April 2015 to June 2016 the trust reported a bed occupancy rate of 82.8% compared with the England average of just over 60%.
  • Pregnant women had prompt access to maternity services. The national and trust target for booking women for ante natal care by 12 weeks and 6 days gestation was 90%. The hospital consistently exceeded the trust and national targets for April 2015 to September 2015 with an average of 96.2% of women booked within the timeframe.
  • Staff told us the 24 hour paediatric assessment unit improved patient flow. They felt having a facility whereby patients could be observed for longer than four hours allowed the paediatric team to reduce their admission rate to inpatient areas. GPs could refer children to the assessment unit, and following triage children were then admitted or they could return home. There was a system for recording waiting time within the assessment unit.
  • The trust short notice cancellation rate for outpatient appointments was lower (better) than the England average. ‘Did not attend’ rates were also lower (better) than the England average and phone calls and texts were used to remind patients of appointments.
  • The trust was meeting cancer waiting times for patients to see a specialist within 2 weeks and from decision to treat to first definitive treatment within 31 days. The trust also met the waiting times target for from 2 Week Wait referral to first definitive treatment within 62 days (April 2014 to October 2015) in 14 out of the 19 months. Overall performance for this period was 86.6% (target ≥85%).
  • The hospital delivered patient centred end of life assessments in a timely way. The hospital specialist palliative care teams assessed newly referred patients within 24 hours as outlined in the Operational Policy for the Poole Palliative Care Service. The community specialist palliative care nurses assessed patients within three days of the referral.
  • The trust operated a Rapid Discharge Home to Die (RDHD) pathway which served to discharge a dying patient who expressed wanting to die at home within 24 hours.. However, the trust had recognised through audit that patients were not always appropriately highlighted as suitable for fast track Continuing Health Care funding and there was a widespread deficit in knowledge about the CHC funding process.
  • The trust was working in partnership with social care services to effectively support the discharge or patients, particularly patients with complex needs.
  • Clinical staff did not always know how to access information to support them in meeting the needs of patients with a learning disability. There was not a specialist nurse, team or link nurse scheme to support where staff could receive advice and support to enable them to support these patients effectively.
  • There was a clear and comprehensive complaints process. Staff understood how to manage complaints and there was evidence of learning from concerns and complaints. Patient feedback was sought and welcomed across the trust. This feedback was obtained from patient surveys and comment cards. The comments were largely positive.

Are services well led?

  • The trust had published its vision, values, mission statement and objectives, and had taken action to assess and improve staff understanding of these. Staff used “The Poole Approach” (a delivery method of ensuring patients and relatives were at the heart of their care) as a daily strategy for internal and external communications.
  • Staff felt that the executive team provided a strong, visible and supportive presence within the trust. Staff were positive about all the directors in the trust. However, many staff identified that some senior staff who attended bed meetings were viewed as obstructive and unsupportive. They also described difficulties in accessing these staff. For example, some senior nurses described having to wait in a corridor for up to an hour for requests for extra staff to be signed and agreed.
  • The Director of Nursing provides end of life care leadership at trust board level and had good oversight of end of life care issues across both specialist palliative care and the acute medical wards.
  • The trust was part of the on-going Dorset wide clinical service review and the Developing One Dorset vanguard to integrate acute care. Most services had developed interim strategic plans within this context. However, there was not a service-wide strategy or vision for paediatric services or for maternity services. The paediatric service had lacked leadership at a senior nursing level until an acting matron was appointed in January 2016. Senior managers did not consistently demonstrate an understanding of current service risks.
  • Some services had effective clinical governance arrangements to monitor quality, risk and performance, but some local risk registers did not always reflect all of the concerns described to us by staff, or provide sufficient detail on actions being taken. The risk registers did not include key issues such lack of staffing on the paediatric wards or the maternity concerns regarding delays to care and the inability to consistently provide one to one care in labour. A few issues, such as lack of paediatric staffing, had not been formally raised to the executive team.
  • Staff told us they were proud to work for their trust and some had done so for many years.
  • Patient feedback was mainly through surveys and there was less evidence of other engagement opportunities.
  • There was active participation in research and quality improvement projects, and the Outpatient and Diagnostics departments had highlighted much innovative practice.

We saw areas of outstanding practice including:

  • The trust had developed a set of values called "The Poole Approach". The Poole Approach was established in the early 1990s as a philosophy of care. It pledges that staff at Poole Hospital will strive at all times to provide friendly, professional, patient-centred care with dignity and respect for all. These values were well embedded with staff working in the hospital. Staff were consistently kind and compassionate, putting the patient at the centre of care. Receptionists at the front door made a concerted effort to put any visitors or patients at ease, and this level of high support and regard continued throughout the hospital. Staff told us they were encouraged, no matter how busy, to stop to take time to help or reassure anyone in the hospital.
  • The rapid assessment consultant evaluation (RACE) unit provided a high multi-disciplinary quality of care specifically for older patients, over the age of 80. The unit provided a seven day service and was reducing the number of elderly patient admissions and the length of stay for elderly patients that were admitted.
  • For neonates, children and young people receiving palliative care, the trust had designed a special unit called the Gully’s Place Suite. This was a purpose-designed space which provided privacy and dignity for parents and families of babies, children and young people who required palliative and end-of-life care.
  • Nuclear medicine was an exceptionally well led multidisciplinary service, despite an increasing workload, with no breaches of waiting times. Patients interviewed confirmed an outstanding level of care, information provided to patients, and concerns responded to appropriately. The department has also safely introduced two new radio pharmaceuticals based on scientific evidence. Medical physics have developed a new dental phantom; a commercial product.
  • Non-invasive cardiology in CT and MRI imaging have reduced the need for invasive tests on patients with low and medium risk of coronary disease whilst ensuring high risk patients are transferred quickly to the neighbouring NHS hospital. There is excellent team working between cardiology and radiology to provide this service.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must ensure:

  • ​Action is taken to improve the cleanliness of clinical areas at St. Marys hospital and this is monitored to ensure good infection control practices.
  • Delivery rooms meet with Department of Health regulations
  • A review of the midwifery staffing to ensure sufficient staff are available to provide one to one care in labour.
  • Medicines are stored at the appropriate fridge temperature and are recorded daily.
  • Medicines are stored safely and securely including intravenous fluids. This should be in line with current legislations, trust’s policies and standard operating procedures.
  • Appropriate dates are placed on medicines once opened.
  • Patient group directions are correctly completed and in-date for staff to use.
  • Flooring is accessible for cleaning purposes and  equipment is clean and protected from dust.
  • There is a robust process for calling for emergency assistance in the theatre complex.
  • There is appropriate support for patients with a learning disability including better flagging and referral for patients to specialist
  • Equipment on the wards is in date and stored in a safe manner.
  • The five steps to safer surgery checklist is appropriately completed.
  • Review the emergency theatre arrangements to ensure patient safety and wellbeing is not adversely affected.
  • The staffing levels and skills mix is assessed in all areas and staffing is delivered as planned.
  • Patient records are secure stored so as not to breech patient confidentiality and to prevent unauthorised access, particularly in medicine and maternity departments.
  • All staff participate in mandatory training.
  • Risk register includes all factors that may adversely affect patient safety.
  • Learning from incidents are embedded in practice.
  • Implement a flagging alert system to identify Looked After Children within the trust
  • Ensure secure access arrangements to the paediatric unit are in place out of hours.
  • Implement policies and protocols for children and young people for absconding or for restraint.
  • Patients and members of the public are informed of the safety thermometer results.
  • Where relevant, DNA CPR forms must be endorsed by a consultant grade doctor.
  • There is a clear and measurable action plan which details how they will improve patient outcomes with regard to the organisational targets and key performance indicators as measured in the National Care of the Dying Audit.
  • Service leads review how they use data to improve patient outcomes.
  • An end-of-life care policy is developed that addresses the withdrawal and withholding of life-sustaining treatment for critical care patients.
  • That end of life care patients are given sufficient opportunity to identify their preferred place of care.
  • There are no mixed sex breaches in critical care.

Action the hospital SHOULD take to improve

  • Consultant presence in the delivery suite meets the Royal College of Gynaecologists and Obstetricians guidelines.
  • Clear guidelines for staff regarding the maximum numbers of women accepted the induction of labour.
  • Conduct a needs analysis to ensure the service is meeting the needs of the local population.
  • Develop clear plans to deliver the maternity service strategy.
  • Encourage improved working relationships between senior midwives and their managers.
  • Patients in the department are correctly identified with name bands in a timely way.
  • Review necessary improvements to achieve referral to treatment time targets.
  • There is a robust process used for monitoring requests for agency and bank nurses and whether they are fulfilled or not.
  • A patient is given the opportunity to wash or clean their hands before meals.
  • Staff check equipment regularly, and equipment is maintained or replaced in line with trust policy.
  • Staff complete risk assessments and actions required to reduce risks to a patient, in a timely way.
  • Appropriate arrangements happen with the local mental health trust to improve patient assessment and out of hours support.
  • Staff are offered regular supervisions and appraisals to promote staff development.
  • Training provision should ensure all staff have an accurate understanding of the trust’s deprivation of liberty safeguards policy.
  • Improvements in the care pathways for stroke and heart failure are embedded and sustained.
  • A decrease in the number of bed moves, and patients moved overnight.
  • An increase in the number of complaints responded to within 25 working days.
  • Delayed discharges from CCU should be improved including out of hours discharges from the unit.
  • Resuscitation trolleys in the critical care unit should be tamper-evident.
  • Mandatory training updates for critical care staff should meet trust targets ensuring staff complete updates in essential and core training.
  • Development of a safety checklist for patients undergoing invasive procedures such as insertion of central venous catheters.
  • Access to a follow-up clinic for patients discharged from the critical care unit should be further developed and to include better access for psychological and other support.
  • The hospital improves the access and flow of patients in order to reduce delays from critical care for patients being discharged to wards.
  • There is dedicated dietetics support for patient in critical care.
  • Policies and procedures should be regularly reviewed to provide up to date guidance for staff including withdrawal of treatment policy.
  • Support and develop the paediatric service so it can deliver service-wide strategy and vision.
  • Outpatient clinics are planned to meet the specific needs of children.
  • Play therapists are used by the outpatient department to help children cope during outpatient procedures.
  • Documents within electronic records for patients are filed appropriately once scanned to enable clinicians to find relevant information effectively.
  • Departmental and team meetings are held at an agreed frequency to enable good communication between managers and staff.
  • Seven day service provision in diagnostic imaging is reviewed and monitored to ensure stability of staffing.
  • Managers in diagnostic imaging provide forums for staff engagement.
  • All staff within outpatients and diagnostic imaging are aware of the department strategy.
  • There is an agreed set of performance indicators for end of life care to measure service quality in a timely manner.
  • There is a process for monitoring whether patients who express a wish to die at home are able to do so and that any delays in discharge are recorded and reviewed.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 24 January 2014

During an inspection to make sure that the improvements required had been made

This inspection was to follow up on the shortfalls in assessing and monitoring the quality of the service identified at our inspection in May 2013. In addition to this we looked at staffing in the pathology department in response to concerns received about staffing levels.

We spoke with sixteen staff this included nurses, doctors and pathology staff, the adult safeguarding nurse and department managers. We also spoke with the chief executive, director of nursing, deputy director of nursing and head of legal services. We did not speak with patients at this inspection.

We found there were enough qualified, skilled and experienced staff to meet people�s needs in the pathology department.

We found the trust had implemented learning and actions from incidents.

There was an effective system in place to regularly check and monitor the quality of the service people received. There were effective systems in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others.

Inspection carried out on 22, 23, 24 May 2013

During a routine inspection

We carried out unannounced visits to wards and units at Poole Hospital NHS Foundation Trust between 22 and 24 May 2013. Over the three days we inspected: Maternity at St Mary�s, community midwifery, main and day case theatres, NICU (Neonatal Intensive Care Unit), TCU (Transitional Care Unit), Acrewood and Bearwood (children�s wards), Sandbanks (oncology), B3( orthopaedics), C3 Green (trauma), A4 Arne (respiratory), A & E (accident and emergency), Discharge Lounge and Lytchett (elderly medicine).

When visiting wards and units we spoke with 32 patients, seven visiting relatives and 41 members of medical, nursing, auxiliary staff and equipment managers. We observed interactions between staff and patients including babies and children.

We also met with two representatives of the Council of Governors, the medical director, director and deputy director of nursing, the director and deputy director maternity and midwifery and ten consultants.

All patients we spoke with were positive about their experiences at the hospital. Comments from patients included, �Couldn�t wish for better�, �Hospital gets flying colours�, �It�s been very good actually� and �I think it�s a very good hospital�.

We found that patients consent was sought before they received any care or treatment. They also received the care, treatment and support to meet their individual needs.

Inspection carried out on 5 December 2012

During an inspection to make sure that the improvements required had been made

The purpose of this inspection was to check whether people and or their representative�s views were taken into account in relation to Do Not Attempt Resuscitation (DNAR) decisions.

We visited C3 Trauma Green, Lulworth ward, Lilliput ward, Rockley ward and Brownsea ward. We spoke with nursing and medical staff, the deputy director of nursing and the senior resuscitation nurse.

We did not specifically speak with people about their stay at the hospital. However, we observed that people being treated and cared for at the hospital were comfortable

We had received concerns about the building works and staffing levels on C3 Trauma Green. We requested staffing information from the trust and we did not identify any concerns from the information provided. There was an ongoing programme of refurbishment on C3 and the disruption to patients and staff was minimised wherever possible.

We found that overall Do Not Attempt Resuscitation (DNAR) decisions and records were fully completed. They included a record of the discussion with people and or their representatives where relevant.