You are here

Inspection Summary


Overall summary & rating

Outstanding

Updated 13 March 2019

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

  • We rated the hospital as outstanding overall. We rated caring, responsive and well led as outstanding and, effective and safe as good. In aggregating ratings we took account of the ratings from 2014 for the six services we did not inspect at this time.
  • On this occasion we rated both surgery and maternity as good in effective, caring, responsive and well led. For safe we rated surgery as good and maternity as requires improvement.
  • 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 they knew how to apply it.

  • The hospital controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection. The hospital had suitable premises and equipment and looked after them well.

  • The hospital followed best practice when prescribing, giving, recording and storing medicines. Patients received the right medication at the right dose at the right time.

  • Generally, the hospital had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.

  • The hospital 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 in line with the duty of candour.

  • The hospital provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance and monitored the effectiveness of care and treatment and used the findings to improve them.

  • Staff gave patients enough food and drink to meet their needs and improve their health. The hospital made adjustments for patients’ religious, cultural and other preferences.

  • Staff assessed and monitored patients regularly to see if they were in pain. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain.

  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.

  • The trust planned and provided services in a way that met the needs of local people and took account of patients’ individual needs. The trust was a leader in the Frimley Integrated Care System and collaborated well with partners.

  • The hospital treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff. However, the trust did not always meet its own standard in response timeliness.

  • Managers at all levels in the hospital had the right skills and abilities to run a service providing high-quality sustainable care.

  • The trust had a vision for what it wanted to achieve and workable plans to turn it into action. This was underpinned by a set of values that staff at the hospital understood.

However:

  • Although the trust provided mandatory training in key skills to all staff the trust was not achieving its completion target of 85% in all topics.

  • Although there were systems for managers to appraise staff’s work performance not all staff had received an up to date appraisal.

  • Midwifery staffing did not always meet national guidance. Women did not always

Inspection areas

Safe

Good

Updated 13 March 2019

Effective

Good

Updated 13 March 2019

Caring

Outstanding

Updated 13 March 2019

Responsive

Outstanding

Updated 13 March 2019

Well-led

Outstanding

Updated 13 March 2019

Checks on specific services

Medical care (including older people’s care)

Outstanding

Updated 26 September 2014

Overall we rated medical care as outstanding.  Medical care provided at Frimley Park Hospital was rated as good for safety, as patients were protected from avoidable harm and abuse. Incidents were reported, learned from and in general fed back to staff. The trust was aware of areas in which it needed to improve (such as falls) and there were established work streams to improve harm free care. The department was clean and there was an active infection control and prevention team who audited practices regularly. The trust used its own early warning score (known as the Medical Emergency Team (MET) score) which again was well audited, and, as well as a Critical Care Outreach Team (CCOT), staff could call the Medical Emergency Team if they had concerns regarding a patient’s condition. With the exception of one ward, all wards were well staffed and frontline staff told us they felt confident that they could increase their numbers if their acuity or dependency changed and that this would be supported by their senior managers. There was increasing consultant presence on site from 8am to 12 midnight seven days a week and the number of junior doctors on the wards out of hours had been increased in response to the increased number of medical patients within the hospital.

Medical care services at Frimley Park were rated as good in terms of delivering effective care. There was evidence of easily accessible guidelines on the trust intranet and specific audit checklists had been developed for two conditions which have been raised nationally as a potential area in which care needs to improve. The Summary Hospital-level Mortality Indicator (SHMI) for the trust remains within expected levels and its readmission rate is better than the national average. National audits were contributed to as expected, and we were given evidence of changes made by specialities in response to their outcomes. We witnessed strong and respectful multidisciplinary team working during our inspection and this was corroborated by feedback from all disciplines spoken with. Enhancing seven-day services was demonstrated to be a priority for the medical directorate and, although this was not yet fully in place at present there was a clear and achievable business case in progress.

We rated the medical care services outstanding for caring. This was because a caring culture was felt to be fully embedded throughout the medical directorate and throughout our inspection we witnessed exemplary patient centred care being given. Wards felt calm despite some being very busy and the nursing staff were seen to be relaxed and cheerful whilst undertaking their work, taking the time to consider individual patient’s needs.  We heard very few buzzers sounding throughout our visit, and those we did were answered very quickly. Interactions between staff and patients appeared natural and easy-going - communication was respectful but friendly. All relatives we spoke with praised the staff and the standard of care that their relative had received.  

Medical care provided at Frimley Park Hospital was responsive to patients’ needs. In common with all acute trusts, Frimley Park Hospital struggled with the management of flow through the hospital due to the significant rise in emergency attendances and subsequent admissions. Consistent with the national picture, this was largely felt in the medical division. Significant work had been undertaken to reduce the number of unnecessary admissions in terms of developing robust ambulatory pathways and providing geriatrician input to the Emergency Department (ED). Achievement of the four-hour target was seen as much as the responsibility of the medical teams as the ED and joint admission proformas had been developed to allow flex in the admission pathway when either team was particularly stretched. Equally extensive work had been undertaken to improve discharge planning from both a medical and allied health professional standpoint seven days a week. There were still ongoing issues with the number of patient moves (and those occurring out of hours), and patient outliers; both of these were escalated to the chief nurse on a weekly basis. Following a previous inspection by CQC, there was increased visibility of the work being undertaken to improve the experience of patients admitted who were living with dementia.

We rated medical care services outstanding in terms of being well-led. There was a clear vision and strategy for the service, which, despite the potential for uncertainty regarding the acquisition, was well developed and well understood throughout the department. The behaviours and actions of staff working in the division mirrored the trust values of ‘Committed to Excellence, Working Together, Facing the Future’ of which we saw multiple examples of during our inspection. There was evident ownership of services and patient-centred care was clearly a priority. Risks (and potential risks) were identified early and discussed openly and there was a governance structure in place that allowed formal escalation where appropriate. The trust (and therefore directorate) welcomed views and input from staff and the local community allowing for a real sense of engagement and therefore empowerment from those involved in the services to improve the quality of care being provided.

Services for children & young people

Good

Updated 26 September 2014

Overall we rated the services for children and young people as good.  We found children’s services to be generally safe. However, we had concerns about nursing staffing levels and skill mix. For example, it had been identified as part of the annual clinical governance review that during periods of limited staffing, there had been an increase in medication incidents.

There were procedures in place to manage the deteriorating patient although the trust had identified that additional work was required to ensure that staff had the necessary skills to both identify and manage the deteriorating child.

Children’s services followed national evidence-based care and treatment and carried out local audit activity to ensure compliance.

Children and those close to them, such as their parents or carers, were involved in the planning of care and treatment and were able to make individual choices on the care they wished to receive. Leadership within the service was strong with a mostly cohesive culture. There was evidence of public and staff engagement as well as innovation within the service.

Services for children and young people followed the trust’s incident reporting system and demonstrated that learning from incidents that took place there. Perinatal and clinical governance meetings were held and staff were able to demonstrate that learning from these meetings was taking place.

The children and young people’s service was provided in a clean environment. Emergency equipment was checked in line with trust policy and was readily accessible and available.

Critical care

Outstanding

Updated 26 September 2014

Overall we rated critical care services outstanding. Patients we spoke with told us of the “good reputation” the service had in the locality and also that they felt “very safe” when using its facilities.

Patients had access to a bereavement service and annual memorial service to remember their loved ones. The unit had implemented the use of patient diaries and a psychology service was provided. Relatives of patients who remained on the unit for more than one week had a meeting with the matron of their service to ensure any concerns they had would be addressed.

The unit delivered a consultant-led service with two consultants providing medical cover. One consultant was solely dedicated to being on the unit from 8am until 10pm daily. Another consultant provided support to the critical care outreach team and covered the unit on an on-call basis from 10pm until 8am. There were resident facilities provided for consultants who lived more than the recommended 30 minutes away from the hospital. There was nine hours of on-site consultant cover provided at weekends. The unit did not use locum doctors to cover unexpected vacancies. Medical oversight of the MADU was primarily by respiratory consultants with support from their intensive care colleagues when required.

Use of agency nursing staff was below the acceptable minimum rate set by the trust, and all agency staff were subject to a strict recruitment and induction process which mirrored the trust’s own recruitment policy. The unit had also rolled out an advanced Critical Care Practitioner training programme, one of very few nationally and the first regionally.

All aspects of care delivered in the unit were audited and reviewed to enable continuous improvements. The unit had implemented extra quality and safety measures to ensure it was delivering a high quality service in line with national guidance. The unit could demonstrate that it was achieving low mortality rates and good patient outcomes when compared to other units of a similar size. We found an open and transparent approach to incident management and a real focus on learning from these events through root cause analysis and peer review processes. There were continuous data submissions to national audits and participation in research programmes on the unit.

The unit was innovative. For example, it had implemented cardio pulmonary exercising testing and Intra-aortic balloon pumps. It regularly contributed to the CCN (Critical Care Network), RCN (Royal College of Nursing) and BACCU (British Association of Critical Care Units).

We found there was a real commitment to delivering multidisciplinary care and the nursing staff worked flexibly to ensure that a quality service could be delivered safely during busy times. Staff felt valued and supported by their teams and by senior management. They told us they received appropriate training to enable them to meet people’s individual care needs. Staff discussed the continuous learning culture on the unit and how they felt supported to engage in continuous personal development.

Staffing levels were continuously reviewed using the unit’s staffing acuity tool and we found the staffing levels to be adequate to deliver the service.

The environment was cleaned to a high standard and the trust’s infection control policy was being complied with. The unit demonstrated safe medication management and we saw adequate supplies of equipment to meet patients’ care needs.

End of life care

Outstanding

Updated 26 September 2014

Overall we rated end of life care as outstanding.  We found that Frimley Park Hospital was providing an exemplary quality of care to people approaching the end of their life. The few areas where there was potential for improvement had been identified and we saw evidence that work was in progress to make the service even better.

The trust’s End of Life Care (EOLC) Steering Group, which was responsible for the overall monitoring of the provision of EOLC, was established in 2008. It had developed policies and procedures to support end of life care and had a diverse multi-disciplinary membership from both the trust and local community. The EOLC Steering Group was chaired by the Clinical Director for Surgical Services, which meant that the trust strategy for end of life care was disseminated well across all services and we found that there was good ‘buy in’ to the end of life policies from staff working outside the SPCT.

The hospital’s palliative care team saw approximately 1,028 patients in 2013/14. Of these, 51% were non- cancer patients, which showed a good balance between cancer and non-cancer patients being provided with the specialist services of the palliative care team. We were told that 45% of patients who died at the trust were referred to the specialist palliative care team, which compares well with the national average of fewer than 40%. Where people received specialist palliative care input, less than a quarter (23.9%) died in hospital compared to national data for all deaths that showed 51.5% of people died in hospital nationally. This means that the good access to the expertise of the SPCT, coupled with a robust discharge policy, allowed more people to die where they wanted and reduced both the length and frequency of admissions for end of life care.  The first national VOICES survey of the bereaved (2012) found that 71% of people wanted to die at home and the trust’s staff talked with enthusiasm about their proactive stance in getting people home to die if at all possible. This was supported by a strong rapid discharge policy that was sufficiently resourced to make it workable. A strong culture of enabling rapid discharge supports people and their families in their desire to die in their home surrounded by the people they love and within a familiar environment that they retain more control over. We were told that the shortest recorded discharge was just 45 minutes but that this was not the norm; a one-day target for making the necessary arrangements for a safe discharge was more usual.

The trust had implemented the AMBER care bundle system, which provided a systematic approach to manage the care of hospital patients who were facing an uncertain recovery and who are were at risk of dying in the next one to two months.

A review of the data showed that the trust had robust policies and monitoring systems in place to ensure that it delivered good end of life care. However, it was the direct observation and conversations with staff, relatives and patients that made us judge the care outstanding. Individual stories and observed interaction provided assurance that staff of all grades and disciplines were very committed to the proactive end of life care agenda set by the board. One healthcare support worker said, “Is it odd that I enjoy caring for people at the end? I don’t mean I want them to die, because I have usually got to know them and care about them and their families, but I am really proud of the good care we give and how comfortable we make people. It is nice knowing you couldn’t possibly do any more for them.”

A porter told us that all his team treated the people who had recently passed away on the wards as if they were “our own nan or mum. We make sure we look after their dignity and that they are comfortable. Most of us talk to them about where they are going and explain what the mortuary will be like and that their fridge will be cold. It makes our job better if we do it properly and kindly”.

We spoke with many people who were approaching the end of their life and some of their relatives. All were extremely positive about the care and support they received at Frimley Park Hospital. People told us their symptoms were very well managed and that nothing was too much trouble for staff. We observed kind and gentle interactions between staff and patients and could see that the people we visited in their rooms were clean, comfortable and hydrated. We sat with one elderly person who was being cared for in bed, in a single room, as they were expected to die shortly. This person slid their hand out of the covers to hold our hand and said they weren’t really frightened as everyone was so kind to them. They said their grandchildren had visited and bought them lovely presents that were displayed around the room. Then they showed us the bright nail polish that they said one of the night nurses had used when they gave them a manicure. They said, “I used to like dancing and parties and my nails make me smile and remember those days”.

We asked numerous staff about the care and support they received when people died. Many acknowledged that it could be emotionally difficult when caring for people in their last days and hours, but all said they had excellent support and told us who they could turn to at these times. Staff mentioned their teams supporting each other, approachable and supportive ward colleagues, input from clinical nurse specialists and senior managers and the chaplaincy team. One junior nurse told us about a recent traumatic death where she had been upset after caring for the patient. They said, “One of the consultants took me to the quiet room and sat with me for ages explaining why the person suffered the symptoms they did and that they would not have been aware of the symptoms. He spent ages answering all my questions and making sure I was OK”. Good staff support is essential to enable the staff to provide effective end of life care. Well cared-for staff meant that they felt strong enough to provide good care in difficult circumstances and we found that the good staff support available enabled them to provide effective end of life care.

Staff across the hospital were justifiably proud of the quality of end of life care they provided; all the staff smiled easily as they went about their work. They talked about, “Loving their work” and “Really enjoying caring for elderly people”. Senior managers were effusive in their praise of the whole staff group and this had enabled ownership of care quality by the whole hospital staff team.

Outpatients and diagnostic imaging

Good

Updated 26 September 2014

Overall we rated outpatients as good.  Patients attending for outpatient appointments at Frimley Park Hospital and other clinic sites provided by the trust received good care. The premises were, with the exception of the fracture clinic, appropriate for the service they were providing. Where issues around capacity had been identified, the trust had responded to reduce the impact on patients.

We did identify some minor shortcomings in care practice by individual staff members, but this was not widespread.

Staff were kind, attentive and spent time ensuring patients understood what their appointment involved and what their treatment plan was. Where necessary, people were assisted to make follow-up appointments and to access the hospital transport.

The trust generally compared favourably with other trusts nationally in meeting waiting time and treatment targets, and in ophthalmology was a market leader, having been presented with an award as Clinical Service of the Year by the Macular Society. There was scope for a more consistent and sustained level of achievement in meeting targets and delivering an above average service.

Leadership at all levels was visible and engaged with operational staff. Staff reported feeling supported and encouraged to innovate. There was some uncertainty in response to our questions by the nurse in charge of the main outpatients department, but we accepted they had been thrust into the position by the death of a senior colleague a very short while before the inspection. The impact of the loss of a close colleague was clearly felt throughout the department but this did not impact significantly on the delivery of patient care.

The Head of Nursing for the outpatients department said, “We put patients first. We work as a team. The patient pathway through the outpatients department links with so many departments and we communicate well with them. We always look ahead and we always deliver a level of care we would expect our families to receive”.  Our observations found this to be true.

Surgery

Good

Updated 13 March 2019

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

  • Patients were assessed, treated and cared for in line with professional guidance. Staff completed risk assessments for clinical risks including falls, pressure ulcers and venous thromboembolism (VTE).
  • We observed multidisciplinary participation in all patient care. Patient records demonstrated input from allied health professionals, medical and nursing staff. All staff spoke of good working relationships.
  • Staff understood their responsibilities to report incidents, including safeguarding concerns. We saw staff received feedback and lessons learned were shared.
  • Local governance arrangements were robust, and the service leaders were aware of the risks to their service. The concerns staff told us about, were reflected in the risk register.
  • There was a clear leadership structure and strategy for surgical services. Staff told us that leaders were visible, approachable and supportive.

However:

  • During our inspection we found access to store rooms was not correctly restricted, allowing access to unauthorised persons.

Urgent and emergency services

Outstanding

Updated 26 September 2014

Overall, we rated the Emergency Department (ED) as outstanding. The culture of the team working within the department was one of cohesiveness, with staff displaying a very high level of professionalism and enthusiasm for the work they did.

Our discussions with staff, and a review of over 150 individual pieces of evidence, revealed that there was an open and transparent culture within the department with regard to the management of risk. Staff were prepared to report incidents and accidents; incidents were investigated impartially, with a high emphasis placed on quality and service improvement.

Although patients were waiting marginally longer to be seen by a clinical decision maker when compared to College of Emergency Medicine standards, the ED at Frimley Park Hospital was one of only a small number of hospitals to consistently achieve the government’s 95% target for admitting, transferring or discharging patients within four hours of their arrival in the ED during each quarter for the previous two years. Furthermore, staff spoke positively about having the opportunity to recommend new ways of working to help improve the overall effectiveness of the department. Staff had recognised that the current process of streaming was not perhaps as effective as it could be. We found evidence that suggestions had been made by junior members of the team which would further reduce the time it took for patients to be assessed and to be seen by a clinical decision maker.

The clinical effectiveness of the emergency department varied depending on the presenting complaint of patients. Where the service was seen to be performing in low to median quartiles when compared nationally, the department was working to improve its overall performance. We reviewed evidence which demonstrated that the department had improved its management of neutropenic septic patients during 2014. However, where improvements had been made in specific areas such as pain management, we noted that these improvements had not always been sustained; this had already been acknowledged by the trust and action plans were in place to resolve these issues.

Feedback from patients and their relatives regarding the care they received while using the service was consistently positive. Where people had cause to complain, the senior management team had processes in place for meeting with complainants to address their concerns and to offer resolutions, as well as ensuring improvements were made to the overall service. Staff were observed to engage with patients in a compassionate and caring manner.

There were distinct subtleties with regards to the way staff considered their patients. For example, despite the fact that the majority of patients using the ED were only present in the department for no more than four hours, staff were seen to provide holistic care to people; people were referred to by name and not by condition or cubicle number. Examples of comments made by patients included “It is not possible to put a value on what was done for me in A&E”, “They [nurses and doctors] listened and were 100% professional yet still personal and friendly” and “Your complete emergency department were not only extremely efficient but caring, empathetic, reassuring and speedy. The care I received was exemplary… Every single person that we came across in this hospital has given us outstanding customer care. They are all an enormous credit to you [Chief Executive] and to the NHS”.

Careful consideration had been given to the design and layout of the ED during a refurbishment in 2012. Senior members of the ED team reviewed a range of existing EDs and incorporated innovative designs and ideas as part of their refurbishment plan. Staff visited internationally renowned trauma EDs in an attempt to learn and introduce new ways of working, with the ultimate goal of improving the overall quality of care patients could expect to receive when they visited the ED at Frimley Park Hospital.

Consideration had been given to the ageing population to which Frimley Park Hospital serves. Examples included the design of two majors cubicles so that they were “dementia friendly”. A bariatric cubicle was included in the re-design on the ED to meet the anticipated and evolving obesity epidemic. Patients presenting with gynaecology complaints could be cared for and receive treatment in a cubicle that was suitably designed so as to protect people’s privacy and dignity.

Maternity

Good

Updated 13 March 2019

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

  • Staff understood how to protect patients from abuse. Staff had training on how to recognise and report abuse and data provided to us showed that midwifery staff performed better than the target, however medical staff performed worse than the target in both adults and children safeguarding.
  • The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. Control measures were used to prevent the spread of infection and staff had infection control training as part of their mandatory training.
  • Some safety thermometer information was displayed on each ward area for patients and visitors to the ward to see. Falls and pressure damage were displayed on boards but rates of catheter-associated urinary tract infections and venous-thromboembolism (VTE, or blood clots in veins) were not. However, we saw data that confirmed that the maternity service had 100% harm free care over the last 12 months.
  • Information about patient’s care and treatment and their outcomes was routinely collected and monitored and care and treatment was based on national guidance.
  • Consent to care and treatment was gained in line with legislation and guidance, including the Mental Capacity Act 2005. People were supported to make decisions and where appropriate their mental capacity was assessed and recorded.
  • Staff cared for patients with kindness and compassion.
  • People who used the services and those close to them were involved and encouraged to be partners in their care and in making decisions, and received support they needed.
  • The trust planned and provided services in a way that met the needs of the local people. The importance of flexibility, informed choice and continuity of care was reflected in the services.
  • People could access the service when they needed it. Access to care was managed to take account of people’s needs, including those with urgent needs.
  • Leaders of the service were visible and approachable. They were knowledgeable about the issues and priorities for the quality and sustainability of the service, understood the challenges and how to address them.

However:

  • The service provided mandatory training in key skills, however not all staff completed it. Medical staff met or exceeded the trust training target for only two out of 17 mandatory training modules and only 71% of medical staff had received level two safeguarding children training. Midwifery staff met or exceeded the trust training for only 11 out of 17 modules.
  • The service did not have sufficient numbers of midwifery staff on all shifts. Data for April to June 2018 showed that the trust did not meet its target for one to one care in labour.
  • The trust’s ratio of one midwife to every 31.7 births was worse than the England average of one midwife to every 25.7 births. Midwifery staffing levels often did not meet the expected levels determined by the nationally-recognised acuity tool the trust used.
  • Appraisal rates for nursing and midwifery staff did not meet the trust target. Compliance ranged between 57% to 68% which was worse than the 85% target.
  • Printed copies of the fire policy and evacuation plans in business continuity folders seen on the departments were out of date.