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Inspection Summary


Overall summary & rating

Good

Updated 29 November 2016

Milton Keynes University Hospital NHS Foundation Trust consists of one medium-sized district general hospital. The trust provides a full range of hospital services including an emergency department, critical care, general medicine including elderly care, general surgery, paediatrics and maternity care. In total, the trust has 517 hospital beds. In addition to providing general acute services, Milton Keynes Hospital increasingly provides more specialist services, including cancer care, cardiology and oral surgery.

We inspected Milton Keynes Hospital NHS Foundation Trust as part of our comprehensive inspection programme in October 2014. Overall, we rated this trust as “requires improvement and noted some outstanding practice and innovation. However, improvements were needed to ensure that services were safe, effective, and responsive to people’s needs.

We carried out a focused, unannounced inspection to the trust on 12, 13 and 17 July 2016, to check how improvements had been made in the urgent and emergency care, medical care and end of life care core services. We also inspected the maternity and gynaecology service.

Overall, we inspected all five key questions for the urgent and emergency care and medical care core services and found that improvements had been made so that both core services were now rated as good overall.

For the maternity and gynaecology service, at the last inspection, all five key questions were rated as good. At this inspection, we rated safety and well-led as good.

We found that significant improvements had been made in the end of life care service and that the key question of safe was now rated as good.

Applying our aggregation principles to the ratings from the last inspection and this inspection, overall, the trust’s ratings have significantly improved to be good overall. This was because four key questions, namely effective, caring, responsive and well-led, were rated as good, with safe being requiring improvement.

Our key findings were as follows:

  • All staff were passionate about providing high quality patient care.
  • Patients we spoke to described staff as caring and professional. Patients told us they were informed of their treatment and care plans.
  • The emergency department was meeting the 95% four hour to discharge, or admission target, with a clear escalation processes to allow proactive plans to be put in place to assist patient flow. For July 2016, the department was performing at 96%.
  • The emergency department leadership team had significantly improved the department’s performance in meeting the four hour target to improve safety in seeing and assessing patients. The department leaders had implemented a range of systems and processes to drive improvements throughout the service.
  • The Hospital Standardised Mortality ratio (HSMR) was significantly better the expected rate and generally outcomes for patients were positive.
  • Whilst bed occupancy was very high, at 97%, above the threshold of 90%, patient flow was generally effective in the service.
  • The service performed well for referral to treatment times; scoring 97% across the medical specialities.
  • Improvements had been made in the completion and review of patients’ ‘do not attempt cardio pulmonary resuscitation” forms.
  • The trust had established a maternity improvement board to review incidents and risks and to drive improvements in the service. Information was used to develop the service and continually improve.
  • There was a lower rate than the national average of neonatal deaths. The maternity improvement board was monitoring this to make further improvements in the service.
  • The culture within the nursing and midwifery teams was caring, supportive and friendly.
  • Safety concerns and risks were monitored regularly in the maternity service and plans were in place to address areas of concern. Changes in practice and training had been put in place following lessons learned from incidents.
  • Staff knew how to report incidents appropriately, and incidents were investigated, shared, and lessons learned.
  • Staff understood their responsibilities and were aware of safeguarding policies and procedures.
  • There were generally effective systems in place regarding the handling of medicines.
  • Equipment was generally well maintained and fit for purpose.
  • Staffing levels were appropriate and met patients’ needs at the time of inspection.
  • Patients’ individual care records were written and managed in a way that kept people safe
  • Standards of cleanliness and hygiene were generally well maintained. Reliable systems were in place to prevent and protect people from a healthcare associated infection.
  • Mandatory training generally met or was near to meeting trust targets.
  • Appropriate systems were in place to respond to medical emergencies. Appropriate systems and pathways were in place to recognise and respond appropriately to deteriorating patients.
  • Patients’ needs were assessed and their care and treatment was delivered following local and national guidance for best practice.
  • Staff morale was positive and staff spoke highly of the support from their managers.
  • Local ward leadership was effective and ward leaders were visible and respected.

We saw several areas of outstanding practice including:

  • The medical care service had a proactive elderly care team that assessed all patients aged over 75 years old. This team planned for their discharge and made arrangements with the local authority for any ongoing care needs.
  • The medical care service ran a ‘dementia café’ to provide emotional support to patients living with dementia and their relatives.
  • Ward 2 had piloted a dedicated bereavement box that contained appropriate equipment, soft lighting, and bed furnishings to provide a ‘homely’ environment for those patients requiring end of life care.

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

  • The emergency department did not fully comply with guidance relating to both paediatric and mental health facilities. The paediatric emergency department had a door that was propped open, allowing access by all staff and patients presenting potential security risks The ED did not a have dedicated mental health assessment room that had had a robust risk assessment, allowing equipment in the room to be used as missiles. The trust took immediate actions to address this during the inspection to make these areas safe.
  • Initial clinical assessments were not always carried out in a timely way in the paediatric area, and escalation for medical review and assessment was inconsistent. This was escalated to the trust who took immediate actions during the inspection to address this. This was followed up on the third day of inspection and all children had been clinically assessed within the 15-minute period. The trust also ensured this was actively monitored on an ongoing basis.
  • There were inconsistent checks of resuscitation equipment throughout the department, not in line with trust policy. The trust took urgent action to address this during the inspection and to monitor this on an ongoing basis.
  • Staff, patients and visitors did not observe appropriate hand washing protocols when entering/leaving the department or when moving between clinical areas. The trust took action to address this and to monitor on an ongoing basis.
  • Some patients’ privacy was not respected when booking in at the reception desk in the emergency department when the department was busy.
  • The non-invasive ventilation policy was out of date and had not been reviewed. New guidance relating to this had been released in March 2016, which meant there was a risk that staff were not following current guidelines. The service was aware that it was out of date and was planning to review this; however, there was no time scale for this.
  • The medical care service did not have a specific policy for dealing with outlying patients, and therefore, there was no formal procedure to follow in these instances.
  • External, regional health service planning had affected the maternity service’s development plans.
  • In the maternity service, some examples were shared with inspectors of poor communication, inappropriate behaviours and lack of teamwork at consultant level within the service. From discussion with senior managers, it was clear that some issues had been recognised and active steps were being taken to optimise communication and team working. Such behaviours were not observed during the inspection.
  • Not all medical staff had the required level of safeguarding children’s training.
  • There was poor compliance with assessing the risk of venous thromboembolism (VTE) and the maternity service had actions plans to place to address this concern.

Importantly, the trust should:

  • Review and monitor the access and security of both the adult and paediatric emergency departments.
  • Monitor the facilities available for respecting the privacy and confidentiality of patients and relatives during the booking in process in the adult and paediatric emergency departments.
  • Monitor the initial clinical assessment times within the paediatric emergency department.
  • Monitor that recommended checks are carried out on all resuscitation equipment and documented the adult and paediatric emergency departments.
  • Review and monitor the mental health assessment room to ensure it is fit for purpose in the adult emergency department.
  • Monitor the effectiveness of staff, patient and relatives’ adherence to infection control procedures within the adult and paediatric emergency departments.
  • Monitor staff compliance with mandatory training requirement to meet the 90% trust target in the adult and paediatric emergency departments.
  • Ensure that all resuscitation and emergency trolleys are fit for purpose and robust audits are completed.
  • Ensure that agency staff have appropriate induction with evidence of completion.
  • Review the isolation facilities available on Ward 17 for patients with infections.
  • Review the storage of hazardous chemicals and needles to ensure that no unauthorised people could have access.
  • Review the non-invasive ventilation policy, incorporating the new guidance available.
  • Review the consistency of consultant cover out of hours and at weekends across the medical wards.
  • Review the arrangements for timely discharge of patients from the AMU.
  • Review the procedures for the management of outlying patients.
  • Review the process for recording the number of bed moves for patients, including out of hours and at weekends.
  • Review the specific arrangements for caring for patients with autism.
  • Review the completion of assessments for venous thromboembolism (VTE) to ensure patients’ safety needs are met.
  • Review arrangements for monitoring the cleaning of equipment in the maternity service.
  • Review the provision of pain relief provided to women in labour to ensure patients’ needs are met.
  • Review the arrangements for post-operative recovery to ensure mothers and babies can be cared for together, unless in emergencies.
  • Monitor the safeguarding children’s training provision for medical staff in the maternity service.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 29 November 2016

Effective

Good

Updated 29 November 2016

Caring

Good

Updated 29 November 2016

Responsive

Good

Updated 29 November 2016

Well-led

Good

Updated 29 November 2016

Checks on specific services

Maternity and gynaecology

Good

Updated 29 November 2016

On the last inspection, all five key questions were rated as good. At this inspection, we rated safety and well-led as good. We found that:

  • The trust had established an improvement board to review incidents and risks and to drive improvements in the service. Information was used to develop the service and continually improve. The service was focused on continuous improvement.
  • There was a lower rate than the national average of neonatal deaths. The maternity improvement board was monitoring this to make further improvements in the service.
  • Changes in practice and training had been put in place following lessons learned from incidents. Improvements had been made in response to serious incidents.
  • There was sufficient equipment on the wards to keep women and babies safe including new areas for resuscitating babies, blood pressure monitoring devices and a centralised cardiotocography (CTG) system. Systems were in place to make sure that women were monitored and looked after closely.
  • Whilst there was not always adequate space for storage of equipment not in use, the service had noted this as a risk and had raised awareness amongst staff teams to constantly assess the situation for risks to patients.
  • Staff were adequately trained, encouraged, and supported to continue with their professional development. Midwifery, gynaecology nurse, and medical staffing met patients’ needs at the time of inspection.
  • At times of peak demand, the service escalated the overall safety status of the maternity unit as necessary. Appropriate escalation plans were in place.
  • There was a clear vision for the service and staff understood the trust’s values.
  • Leadership was well defined and visible. Leaders had been appointed in all the maternity and gynaecology sub specialities with clear work plans and objectives.
  • Midwives and gynaecology nurses’ roles had been developed to support the service and provide a greater level of expertise for patients.
  • Governance, risk management and quality measurement systems were in place and used to monitor and improve safety, treatment and outcomes for patients.
  • The culture within the nursing and midwifery teams was caring, supportive and friendly. All nursing and midwifery staff we spoke to told us that they were happy at work.

However we also found that:

  • Some gaps in emergency trolley documented checks were found and the service actioned this immediately when we raised it as a concern.
  • There was poor monitoring of the risk of venous thromboembolism (VTE) and the service had actions plans to place to address this concern.
  • Women could be separated from their babies after a caesarean section due to limited recovery space in the operating theatres.
  • There were at time gaps in the implementation and recording of information about intentional rounding carried out on labour ward. The service was monitoring the completion of these records.
  • External, regional health service planning had affected the service’s development plans.
  • In the maternity service, some examples were shared with inspectors of poor communication, inappropriate behaviours and lack of teamwork at consultant level within the service. From discussion with senior managers, it was clear that some issues had been recognised and active steps were being taken to optimise communication and team working. Such behaviours were not observed during the inspection. The service website information was very limited.

Medical care (including older people’s care)

Good

Updated 29 November 2016

Overall, we rated medical care at this hospital to be good because:

  • The Hospital Standardised Mortality ratio (HSMR) was significantly better the expected rate and generally outcomes for patients were positive.
  • Staff understood their responsibilities to raise concerns and report incidents and near misses and learning from incidents was used to drive improvements across the service.
  • Infection prevention and control was generally robust, with staff adhering to the infection control policy.
  • All equipment viewed was in service date, and had been maintained or electrically safety tested and was fit for use.
  • Records were kept securely and were completed appropriately.
  • Risks to patients were identified and escalated appropriately.
  • Nurse staffing levels were appropriate, with staff flexed to cover vacancies.
  • Patients generally had their needs assessed and their care planned and delivered in line with evidence-based, guidance, standards and best practice. Risks to patients were identified and escalated appropriately.
  • Staff generally had a good understanding of the Mental Capacity Act and consent to care.
  • Patients received compassionate care, and patients were treated with dignity and respect. We saw that staff interactions with patients were person-centred and unhurried. Staff were focused on the needs of patients and improving services.
  • Whilst bed occupancy was very high, at 97%, above the threshold of 90%, patient flow was generally effective in the service.
  • The service performed well for referral to treatment times; scoring 97% across the medical specialities.
  • Services met patients’ needs, especially those living with dementia.
  • Local ward leadership was good and ward leaders were visible and respected.
  • There was a positive culture across the medical wards with staff telling us they enjoyed working at the trust. Morale was high across teams.

However, we also found that:

  • Across a number of wards, we found resuscitation trolleys were not checked consistently. On inspection, we found where they had been checked, equipment and some medicine inside the trolleys were found to be out of date. We raised this as a concern and the trust took immediate action to address this by reviewing all resuscitation trolleys and ensured that ward leaders were accountable for these checks.
  • Induction of agency staff was not always robust as some wards did not follow the trust’s policy for agency staff induction and we founds some wards were not keeping any records of these inductions.
  • We found that medicines were not always stored securely or safely on wards 15 and 16.
  • The non-invasive ventilation policy was out of date and had not been reviewed. New guidance relating to this had been released in March 2016, which meant there was a risk that staff were not following current guidelines. The service was aware that it was out of date and was planning to review this; however, there was no time scale for this.
  • Not all patients were routinely being transferred or discharged from AMU within 72 hours of admission, though the service had reduced the number of patients with longer than planned stays from April to July 2016. The service did not have an action plan to improve their performance. We were advised that this had recently been added to the trust’s transformation work streams.
  • Whilst the risk register generally reflected the wards’ safety and quality of care and treatment, we did find some risks were not recorded on the service’s risk register.

Urgent and emergency services (A&E)

Good

Updated 29 November 2016

We rated the emergency department (ED) as good overall. We found there to be improvements made since the last comprehensive inspection in October 2014. It was judged to require improvement for safety and good for effectiveness, caring, responsiveness and well led. We found that:-

  • The department was meeting the 95% four hour to discharge, or admission target, with a clear escalation processes to allow proactive plans to be put in place to assist patient flow. For July 2016, the department was performing at 96%. The rapid assessment hub was efficient and ensured patients in majors received timely initial assessment and treatment.
  • The leadership team had significantly improved the department’s performance in meeting the four hour target to improve safety in seeing and assessing patients. The department leaders had implemented a range of systems and processes to drive improvements throughout the service.
  • There were robust meetings for clinical improvement and governance and learning from incidents was disseminated throughout the department.
  • All staff were passionate about providing high quality patient care. Patients we spoke to described staff as caring and professional. Patients told us they were informed of their treatment and care plans.
  • Evidence based guidelines were used within the department and were relevant and up to date.
  • The department had a clear strategy and vision to continuously improve the service. Staff morale was positive and staff spoke highly of the support from their managers.
  • Nurse staffing levels met patients’ needs at the time of the inspection and the department liaised with the paediatric ward to rotate the trained children nurses to work in the paediatric emergency area. Medical staffing met national recommendations and effective out of hours cover was provided.
  • Staff were competent in the roles and supported via effective appraisals and supervision.
  • Multidisciplinary working was in evidence in the department.
  • Suitable arrangements were in place to safeguarding children and adults.
  • Medicines were generally managed safely.
  • Appropriate systems and pathways were in place to recognise and respond appropriately to deteriorating patients. Appropriate arrangements were in place to provide safe and treatment for people with vulnerabilities.

However, we also found that:

  • The department did not fully comply with guidance relating to both paediatric and mental health facilities. The PED had a door that was propped open, allowing access by all staff and patients presenting potential security risks The ED did not a have dedicated mental health assessment room that had had a robust risk assessment, allowing equipment in the room to be used as missiles. The trust took immediate actions to address this during the inspection to make these areas safe.
  • Initial clinical assessments were not always carried out in a timely way in the paediatric area, and escalation for medical review and assessment was inconsistent. This was escalated to the trust who took immediate actions during the inspection to address this. This was followed up on the third day of inspection and all children had been clinically assessed within the 15-minute period. The trust also ensured this was actively monitored on an ongoing basis.
  • There were inconsistent checks of resuscitation equipment throughout the department, not in line with trust policy. The trust took urgent action to address this during the inspection and to monitor this on an ongoing basis.
  • Staff, patients and visitors did not observe appropriate hand washing protocols when entering/leaving the department or when moving between clinical areas. The trust took action to address this and to monitor on an ongoing basis.
  • Not all risks in the department had been recognised and assessed since the last inspection, such as ensuring patients privacy within the department; this was observed in the booking in process and doors being left open into the paediatric emergency department. The trust took immediate action to address this during the inspection.
  • Some patients’ privacy was not respected when booking in at the reception desk when the department was busy.

Surgery

Good

Updated 6 March 2015

Intensive/critical care

Good

Updated 6 March 2015

Services for children & young people

Good

Updated 6 March 2015

End of life care

Good

Updated 29 November 2016

Overall, we rated the service as good for safety. Significant improvements had been made since the October 2014 inspection. We inspected the safe key question and we found that:

  • Improvements had been made in the completion and review of patients’ ‘do not attempt cardio pulmonary resuscitation” forms.
  • Staff knew how to report incidents appropriately, and incidents were investigated, shared, and lessons learned.
  • Staff understood their responsibilities and were aware of safeguarding policies and procedures.
  • There were effective systems in place regarding the handling of medicines.
  • Equipment was generally well maintained and fit for purpose.
  • Chemicals hazardous to health were generally appropriately stored.
  • Risks in the environment and in the service had been recognized and addressed.
  • Staffing levels were appropriate and met patients’ needs at the time of inspection.
  • Patients’ individual care records were written and managed in a way that kept people safe
  • Standards of cleanliness and hygiene were generally well maintained. Reliable systems were in place to prevent and protect people from a healthcare associated infection.
  • Mandatory training was provided for staff and compliance was 100%.
  • Records were accurate, well maintained and stored securely.
  • Appropriate systems were in place to respond to medical emergencies.
  • Patients’ needs were assessed and their care and treatment was delivered following local and national guidance for best practice.

Outpatients

Good

Updated 6 March 2015