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Inspection Summary


Overall summary & rating

Good

Updated 30 July 2019

At this inspection we inspected urgent and emergency services, surgery, medical care including older people’s care service and maternity. We did not inspect critical care, outpatients, diagnostic imaging, services for children and young people or end of life care but we combine the last inspection ratings to give the overall rating for the hospital.

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

Inspection areas

Safe

Requires improvement

Updated 30 July 2019

Effective

Good

Updated 30 July 2019

Caring

Good

Updated 30 July 2019

Responsive

Good

Updated 30 July 2019

Well-led

Good

Updated 30 July 2019

Checks on specific services

Medical care (including older people’s care)

Good

Updated 30 July 2019

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • The service controlled infection risk well. There were effective systems in place to ensure that standards of cleanliness and hygiene were maintained.
  • The service had robust systems in place to ensure the safety of patients. this included risk assessments and monitoring of clinical outcomes.
  • The service generally had enough nursing staff with the right qualifications, skills, training, and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • The service had enough medical staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • Staff kept appropriate records of patients’ care and treatment.
  • The service prescribed, gave, recorded and stored medicines well.
  • Incidents were managed appropriately.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness.
  • Staff gave patients enough food and drink to meet their needs and improve their health.
  • The service managed patients’ pain effectively and provided or offered pain relief regularly.
  • Staff were competent for their roles.
  • Staff from different disciplines worked together as a team to benefit patients.
  • Staff cared for patients with compassion.
  • Staff provided emotional support to patients to minimise their distress.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • The service planned and provided services in a way that met the needs of local people.
  • The service took account of patients’ individual needs.
  • People could access the service when they needed it.
  • The service had managers with the right skills and abilities to run a service providing high-quality sustainable care.
  • Managers across the service promoted a positive culture that supported and valued staff.
  • The service used a systematic approach to continually improve the quality of its services.
  • The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
  • The service collected, analysed, managed and used information well to support most of its activities.
  • The service engaged well with patients, staff, the public and local organisations.
  • The service was committed to improving services by learning from when things go well and when they go wrong.

However,

  • The service provided mandatory training in key skills to all staff, but not all staff had completed it in accordance with the services targets.
  • Although the service treated concerns and complaints seriously, they were not always investigated, responded to, and closed in a timely manner.

Services for children & young people

Good

Updated 6 March 2015

Critical care

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 and diagnostic imaging

Good

Updated 6 March 2015

Surgery

Good

Updated 30 July 2019

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and knew how to apply it.
  • The service had suitable premises and equipment was generally looked after well.
  • Although there was a high number of vacancies for nursing and medical staff, the service ensured enough nursing and medical staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment were on each shift.
  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The service used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors. Managers used this to improve the service.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers assessed staff compliance with guidance and identified areas for improvement.
  • The service was working towards being a seven-day service.
  • Staff supported patients to manage their own health, care and well-being and to maximise their independence following surgery and as appropriate for individuals.
  • Staff understood their roles and responsibilities in relation to consent and under the Mental Health Act (MHA)1983, the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
  • Staff provided emotional support to patients to minimise their distress. Patients and those close to them were able to receive support to help them cope emotionally with their care and treatment.
  • Patients could access the service when they needed it. Waiting times from referral to treatment and arrangements to admit treat and discharge patients were generally in line with good practice. From January 2018 to December 2018, the trust’s average referral to treatment time for admitted surgical patients was 72.2% within 18 weeks which was above the England average of 68.3%.
  • From November 2017 to October 2018, the average length of stay for patients having elective surgery at Milton Keynes Hospital was 2.6 days, which was shorter than the England average of 3.9 days.
  • The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. Senior leaders were visible and demonstrated commitment.
  • The service had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community. Staff understood and demonstrated the trust’s vision and values.
  • The service engaged well with patients and staff to plan and manage appropriate services and collaborated with partner organisations effectively.
  • The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
  • The service was committed to improving services by learning from when things went well and when they went wrong, promoting training, research, and innovation.

However:

  • The service provided mandatory training in key skills to all staff but did not always make sure everyone completed it, with attendance at some life support courses being significantly lower than the trust target.
  • Medicines were not always stored correctly, and we were not assured that effective governance arrangements were in place to ensure controlled medicines were recorded correctly.
  • Systems and processes were in place to prevent and control infection, but they were not always followed. The service monitored staff adherence to most infection prevention and control procedures through audits although actions were not always taken to address lack of adherence.
  • While policies and guidelines were readily available, staff asked were not aware of any changes to some guidelines, and staff awareness of national guidance varied. Knowledge of guidance varied by level of staff, with band 5 and 6 nurses unaware of NICE guidance.
  • The service monitored the effectiveness of care and treatment but did not always use the findings to improve them. The trust participated in nation audits for example the National Emergency Laparotomy Audit and Patient Reported Outcome Measures and while outcomes were variable, the trust generally performed similar to the England average.
  • Over the two-year period from 2016 to 2018, the percentage of last-minute surgical cancellations at the trust where the patient was not treated within 28 days was consistently higher (worse than) than the England average.
  • Complaints were not always responded to in line with the trust’s complaints policy.
  • The service did not always have a fully embedded systematic approach to continually monitor the quality of its services. The service used a systematic approach to improve the quality of its services and safeguarding high standards of care.

Urgent and emergency services

Requires improvement

Updated 30 July 2019

Our rating of this service went down. We rated it as requires improvement because:

There were breaches in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This included:

  • Not all staff were compliant with hand hygiene and personal protective equipment guidelines.
  • Emergency equipment was not always monitored to ensure it was always available and safe to use in any emergency.
  • Not all patients had received an appropriate risk assessment. This included risk of falling, risk of developing pressure ulcers and malnutrition risks.
  • Most nurses had not received the required level of life support training appropriate to their role.
  • There was insufficient governance and oversight of audit results where expected standards had not been met.

We also found the following concerns:

  • People could not always access the service within the statutory timeframes. . There were 203 black breaches reported from January to December 2018.
  • Department meetings were separated by staff grade: there were no whole team meetings and there were no joint handovers between medical and nursing staff.
  • There was variable performance in a number of national audits relating to patient safety and treatment and in some audits, the service failed to meet any of the national standards. This included for example, the Moderate and acute severe asthma audit, and the Consultant sign-off audit. Action plans did not address all areas of non-compliance.
  • Patients were not always reviewed by a consultant within 14 hours of admission, in line with recommendations, and some waiting times for some speciality reviews were not recorded. This included time spent waiting for a psychiatric assessment and time waiting to see a speciality doctor.
  • Some audits carried out by the service did not meet expected standards and there were no robust action plans in place to address these quality issues.
  • Some issues identified during our previous inspection remained the same during this inspection.

However:

  • Staff knew their responsibilities for escalating concerns and reporting incidents.
  • Staff understood their responsibilities in protecting people from abuse and knew how to report concerns.
  • Patients were prioritised according to their clinical condition.
  • Care and treatment was provided based on national guidance and had evidence of its effectiveness.
  • Patients had their pain assessed and were provided with pain relief when required.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Patients were positive about the care received. They were included in discussions around care and kept informed of treatment plans.
  • Planning for service delivery was made in conjunction with a number of external providers, commissioners and local authorities to meet the needs of local people.
  • The department had a vision based on a five-year business plan, which set out the department’s requirements, and had been developed with involvement from staff and patient groups.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

Maternity

Good

Updated 30 July 2019

We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings. We rated it as good because:

  • There was a strong, visible patient centred culture. Staff were highly motivated and cared for women and babies with compassion, dignity and respect. Women felt involved in their care and were given informed choice of where to give birth. Staff of all disciplines worked together as a team to benefit patients.
  • The maternity service worked closely with commissioners and other stakeholders to plan delivery of care and treatment for the local population. This collaborative working ensured future planning covered recommendations laid out by NHS England and the Department of Health.
  • The service took account of women’s individual needs, including those who were in vulnerable circumstances or had complex needs. Bereavement care provision was in place to support families from their initial loss, throughout their time in hospital and return home.
  • Appropriate systems were in place to assess risk, recognise and respond to deteriorating women and babies within the service. Systems were in place to appropriately assess and manage women with mental health concerns.
  • Since our last inspection, the service had implemented a process to ensure women and their babies were kept together following obstetric surgery in the recovery area. This has had a positive impact on breast feeding, skin to skin bonding and had been shown to result in a lower rate of admissions to the neonatal unit.
  • The service used current evidence-based guidance and quality standards to inform the delivery of care and treatment. Staff monitored its effectiveness and used the findings to improve practice and the care provided.
  • Women’s and babies’ nutrition and hydration needs were identified, monitored, and met. There was access to an infant feeding specialist to assist women and babies when needed, and the trust’s breastfeeding initiation rate was better than the national average.
  • Staff understood their responsibilities to raise concerns and report patient safety incidents. There was an effective governance and risk management framework in place to ensure incidents were investigated and reviewed in a timely way. Learning from incidents was shared with staff and changes were made to delivery of care because of lessons learned.
  • The service made sure staff were competent for their roles. Mandatory and role specific training in key skills was provided to all staff and the service made sure most staff completed it. Staff were encouraged to develop their knowledge, skills and practice.
  • The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. There was strong local leadership within maternity services and staff spoke positively about their senior management team and ward managers.
  • The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.
  • There was a culture of continuous learning, improvement and innovation across maternity services and managers encouraged staff to look at different ways to improve their service.

However:

  • Although staff understood how to protect patients from abuse and the service worked well with other agencies to do so, not all medical and midwifery staff in maternity had up-to-date safeguarding adults and children training. Compliance for adults and children safeguarding training was variable and slightly below the trust target of 90% in some areas.
  • There were some gaps in the flushing logs where there was no evidence that taps had been run to ensure legionella was not present in water
  • The processes in place to ensure emergency equipment was checked daily, was not always adhered to by staff.
  • Fridge temperature and ambient room temperatures were not always documented.
  • While the service provided care and treatment based on current-evidence based guidance and quality standard, some policies and guidance had expired their review date.
  • We saw there were limited facilities for partners staying overnight to rest comfortably on the postnatal ward. This was raised as a concern at the Maternity Voices Partnership (MVP) group and the service were planning on taking some action to improve provisions for partners.
  • The service took longer than the trust target to investigate and close complaints.