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Inspection Summary


Overall summary & rating

Good

Updated 10 July 2019

We did not inspect all services at this inspection, but we combined previous inspection ratings for those not inspected to give an overall rating for the hospital. We inspected medical care, surgery, maternity and outpatients.

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

  • We rated safe and responsive as requires improvement. Effective, caring and well-led were rated as good.
  • Our rating for safe went down from good to requires improvement. This was because we found a decline in safety practices in maternity. Women who were identified as ‘high-risk’ were not always cared for in appropriate areas with access to appropriate staff and equipment. We were not assured that infection and prevention control measures were consistently applied in maternity.
  • Our rating of effective stayed the same and was rated as good. The trust continued to provide care and treatment based on national guidance and its effectiveness. Patient outcomes were monitored and actions plans were developed to address areas for improvement.
  • Our rating of caring stayed the same and was rated as good. Staff continued to treat patients with dignity and respect. Interactions between staff, patients and their loved ones was compassionate and empathetic.
  • Our rating of responsive went down and was rated as requires improvement. Referral to treatment times were below the England average in some specialities. This was of particular concern for patients awaiting cancer treatments and patients who had been waiting over 52 weeks for appointments. The trust had taken actions to improve performance; however, patients could not always access initial assessment and treatment in a timely manner.

Our rating of well-led stayed the same and was rated as good. Managers across the trust worked hard to promote a positive culture. Leaders were visible and approachable. Staff at all levels were aware of the trust vision and how they contributed to the delivery of the overall strategy. The trust had developed plans with external stakeholders for future provision of services in line with national objectives to achieve sustainable quality care.

Inspection areas

Safe

Requires improvement

Updated 10 July 2019

Effective

Good

Updated 10 July 2019

Caring

Good

Updated 10 July 2019

Responsive

Requires improvement

Updated 10 July 2019

Well-led

Good

Updated 10 July 2019

Checks on specific services

Medical care (including older people’s care)

Good

Updated 10 July 2019

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

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

  • Staff reported and managers investigated incidents and shared lessons learned with the whole team and the wider service.
  • The effectiveness of the service was good. Staff ensured that people received care and treatment that reflected current evidence-based guidance and achieved good outcomes. Where performance in national audits did not meet national standards, the service had plans to improve.
  • The care provided by staff remained good. People were treated with dignity and respect and were involved as partners in their care.
  • Patients and their families were involved in developing care plans and given information to help them understand choices available to them. Feedback from patients was generally positive about the caring attitude of staff.
  • The service was responsive to people’s needs. Vulnerable and local people had their needs met and there was good access to specialist staff and support services. Waiting times for referral to treatment were mostly in line with national averages.
  • Staff monitored patient flow well and understood the challenges to address delayed transfers of care and discharges and had systems and process to
  • There were innovative services to meet the needs of the population. Staff cared for patients with additional needs well and care for patients living with dementia had improved.
  • Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff were generally proud to work at the trust and felt valued for the contribution they made to patient care.
  • We found that the leadership, governance and culture generally supported the delivery of high-quality care. There were clear governance processes from ward level up to the trust board.

However:

  • Although most staff had received an up to date appraisal, and the relevant mandatory training, senior staff reported difficulty with monitoring training due to delayed updates on the electronic monitoring system. Staff were knowledgeable about how to protect patients from abuse and the service worked well with other agencies to do so, but we were not assured that all staff who required it had received the necessary level of adult safeguarding.
  • Systems and processes to keep people safe were not always followed when responding to patients with sepsis and medical records quality, storage and information governance was inconsistent.
  • Staff did not always understand their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. Staff did not always follow the trust policy and procedures when a patient needed a mental capacity assessment.
  • The trust mostly used a systematic approach to improve the quality of its services but there was inconsistency in the monitoring of performance and quality standards to ensure the creation of an environment in which clinical care would flourish.

Services for children & young people

Good

Updated 3 August 2015

We did not inspect services for children and young people during our inspection in March 2015.

In 2014 we found that services for children and young people provided by the hospital were good. There were good staffing levels; a strong skill mix had encouraged proactive teamwork to support a safe environment. There were arrangements in place to implement good practice, learning from any untoward incidents and an open culture to encourage a strong focus on child safety and risk management practices. Families told us they felt safe in the hands of the staff and staff said they felt supported by the trust in managing risk and keeping their patients safe.

Evidence based practice was being implemented and monitoring systems to measure performance were in place.

We saw good examples of care being provided with a compassionate and dignified approach. Children and young people were involved in planning their care and making decisions about the choices available in their care and treatment, including appropriate discharge planning.

The children and young people’s service understood the different needs of the communities it serves and acted on this to plan and design services. It was proactive in taking action to remove barriers that parents, children and young people face in accessing or using the service. There were good mechanisms for information sharing and willingness from staff for flexible working around responding to the needs of parent’s children and young people. The service had introduced several initiatives to encourage children, their relatives and those close to them to provide feedback about their care and were keen to learn from experience, concerns and complaints.

The service was well led, staff felt supported by senior management.

Critical care

Good

Updated 24 May 2016

We have rated the critical care service as good overall and noted that there has been a significant improvement to the service since our last inspection. Safety of critical care service was rated as good because there was a positive incident reporting and learning culture within the critical care unit. Staffing levels for nursing, medical and therapies staff had improved and were at a safe level. Mandatory training levels were in line with trust expectations for the critical care unit, except for the critical care outreach team where improvements in training rates were required. Critical care services were effective. Treatment and care was delivered in accordance with best practice and recognised national guidelines (ICNARC) NICE and care bundles. There was a multidisciplinary approach to assessing and planning care and treatment for patients. Critical care services were caring. Feedback from people using the service including patients and their families was very positive. Patients and their relatives were kept informed of their care and there was very clearly documented notes regarding the weekly meetings and communication that had taken place with them. Critical care services were responsive to patient’s needs. Whilst the number of delayed discharges and out of hours transfers remained high there were improvements in these areas, however more work was required to improve this further. The critical care outreach team provided support to patients on the wards where higher dependency care was required, avoiding critical care admissions. The process for the investigation and learning from complaints had improved since our previous inspection.

Critical care services were rated as good for being well-led locally.  There was a clear vision and strategy for the service. There was good evidence of ward to board leadership, communication and governance regarding the service. There had been notable improvements in the leadership of the critical care and outreach service. Morale and culture within the critical care and outreach service had improved significantly since our previous inspection.

End of life care

Good

Updated 3 August 2015

We did not inspect end of life care services during our inspection in March 2015.

In 2014 we found end of life care was safe, effective and responsive of patient’s needs. Care was delivered in line with current best practice and we saw very good care for those patients who chose to end their lives at home. The rapid discharge pathway enabled patients to leave the hospital within four hours.

All of the patients we spoke with told us that care was good. They were treated with respect and dignity and felt involved in their care and treatment. The trust had developed its own end of life care pathway which had replaced the Liverpool Care Pathway. This had yet to be evaluated but staff told us it was effective and working well.

We found that the way in which the hospital managed medication could be improved to make sure it was in date and stored securely. Improvements were needed to make sure all patients’ records in relation to ‘do not attempt to resuscitate’ decisions were completed.

For the deceased we found they were cared for by a team of dedicated staff who maintained patient’s dignity after death. Bereavement staff supported families effectively.

Surgery

Good

Updated 10 July 2019

  • Patients were protected from avoidable harm and there was a culture of learning from incidents. Staff recognised incidents and reported them appropriately. Lessons learned were shared with the surgical teams.
  • Staff in the operating theatres and day unit followed the World Health Organisation (WHO) surgical safety checklist and five steps to safer surgery and monitored to make sure this was completed accurately.
  • Records were appropriately completed, and their safety monitored and maintained.
  • There were robust processes to assess and escalate deteriorating patients.
  • Infection prevention and control policies and protocols were in place and regularly audited and surgical site infections were monitored.
  • Staff had a good understanding of safeguarding and awareness of their responsibilities in relation to safeguarding adults. The service worked with other agencies to share relevant safeguarding information.
  • The environment was visibly clean, tidy and well maintained.
  • The service had enough staff who had the skills, knowledge and experience to deliver effective care and treatment to patients.
  • Staff used external evidenced based standards and information to monitor and benchmark their practice. Patients care and treatment achieved good outcomes and was based on the best available evidence.
  • The service monitored the effectiveness of care and treatment through continuous local and national audits.
  • The service took part in national and international research programmes which supported the development of innovative and new ways of working and improving standards of care for patients.
  • Patients were at the centre of the service and the quality care was a priority for staff. Patients were involved in their care and treated with compassion, kindness, dignity and respect. Patients that we spoke with during this inspection were very complimentary about the level of care they had received.

However:

  • The service provided protected time for mandatory training for staff but had not achieved the trust target.
  • We saw trust wide policies that had last been reviewed 5 years ago and did not reflect the most recent guidance.
  • The referral to treatment (RTT) was poor but we saw that plans were in place with improved outcomes.

Urgent and emergency services

Good

Updated 3 August 2015

In 2014 the department did not have enough consultants to provide care ‘on site’ all of the time, but there was a system of on call duty that did provide staff with access to a consultant at any time on the day. The hospital had an active recruitment programme in place to improve this situation. The hospital needed to improve the observation of patients in the waiting area prior to entering the A&E department. In 2015 we found that service had improved the observation of patients in the waiting room and the trust had taken action to ensure that there was adequate medical cover provided to the A&E department. The service was continuing their work on recruitment and safe staffing levels in the department. We noted that work was on going to improve the development and training of staff internally with progression routes to consultant level which was positive.”

Patients were treated with compassion and respect throughout their stay in the accident and emergency. Staff made sure patients were involved in discussions about their care and understood what was happening to them.

The services in A&E were responsive. In 2014 the department had improved the patient flow through the system because of the greater numbers of patients attending. As a result patients were seen and treated in a timely way upon their arrival in the department.

In 2014 it was evident that the culture of the department had changed in the past 12 months. We found complaints were investigated in line with the trust policy and senior staff made sure that all staff learnt lessons from this process in order to improve patient experience.

There had previously been concerns about the effectiveness of the leadership within the department that affected its performance. In 2015 we found there was good clinical leadership and that staff continued to work well as a team and were motivated and positive about working for the trust and in A&E. Staff were well supported by clinical leads and senior management.

We however identified new concerns regarding the Clinical Decision Unit (CDU). We found that there was not enough registered nurses to provide safe care and that the CDU admission protocol was not followed as the trust was on black alert.

Maternity

Requires improvement

Updated 10 July 2019

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

  • Mandatory and safeguarding training rates did not consistently meet trust target compliance levels.
  • We found records for women were inconsistently completed. These included records of foetal movement, recording of the date and time of the observations and signatures of the member staff undertaking the review.
  • The service did not assess, monitor or manage women with high risk pregnancies in the correct environment with the support of medical staff. This meant that if risks were identified there was a delay in transferring women to the obstetric led unit.
  • The service did not have a Non-Executive Director Champion.
  • The trust did not have robust systems to identify risks, plans to eliminate or reduce them, and cope with both the expected and unexpected.
  • The Head of Midwifery (HOM) and clinical lead did not have direct access to the board to present to them regularly, although they did meet monthly with the chief nursing officer, this was not in line with recommendations from ‘Spotlight on Maternity’ 2016.
  • The service did not store medications in line with good practice.
  • Midwifery handovers were not completed in line with best practice or trust policy.

However:

  • Staff were kind, caring and considerate and women were happy with the care they were receiving.
  • Staff were competent and were supported to develop their skills and knowledge.
  • Staff thought local management was good and they felt supported by the local managers.

Outpatients

Good

Updated 10 July 2019

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings.

We rated it as good overall because:

  • The service provided mandatory training in key skills but not everyone completed the training in line with the trust’s target.
  • The service generally had suitable premises and equipment was well looked after.
  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately.
  • The service planned for emergencies and staff understood their roles if one should happen
  • Staff assessed and managed patients to see if they were in pain
  • Staff worked together as a team to benefit patients.
  • Staff understood their roles and responsibilities under the Mental Capacity Act 2005. Patients were asked for their consent prior to procedures or examinations taking place.
  • Patients were supported emotionally and staff made efforts to minimise their distress.
  • Staff involved patients and those close to them in decisions about their care.
  • The service took account of patients’ individual needs.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.
  • Matrons and managers were visible and supportive.
  • Managers promoted a positive culture that supported and valued staff.
  • The service collected, analysed, managed, and used information well to support its activities to continually improve. Staff stored records securely.
  • The leadership team for the service were passionate about continuous improvement.

However:

  • Referral to treatment times were not meeting national standards or the England average. This meant that patients could not always access initial assessments and treatment in a timely manner.