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Inspection Summary


Overall summary & rating

Good

Updated 13 March 2019

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

  • We rated the hospital as good overall. We rated well led as outstanding, and safe, effective, caring and responsive 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 hospitalhad 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 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 in line with the duty of candour.

  • The service 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 service 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 receive one to one during labour.

Inspection areas

Safe

Good

Updated 13 March 2019

Effective

Good

Updated 13 March 2019

Caring

Good

Updated 13 March 2019

Responsive

Good

Updated 13 March 2019

Well-led

Outstanding

Updated 13 March 2019

Checks on specific services

Medical care (including older people’s care)

Good

Updated 2 February 2016

Overall we rated medical care (including elderly care) at Wexham Park Hospital 'Good' because:

We found medical care at the hospital was evidenced based and adhered to national and best practice guidance. The trust’s policies and guidance were readily available to staff through the trust’s intranet. The care delivered was routinely measured to ensure quality and adherence to national guidance and to improve quality and patient outcomes. The hospital was able to demonstrate that it mostly met national quality indicators.

Patients' medical outcomes were monitored and reviewed through formal national and local audits. Consultants led on patient care and there were arrangements for supporting the delivery of treatment and care through multidisciplinary teams and specialists. We found that training for staff was good with newly qualified staff being well supported. Staff caring for patients had undertaken training relevant to their roles and completed competence assessments to ensure patient safety.

The hospital was working towards offering a full seven-day service. Although some medical patients were treated in other areas of the hospital when beds were not available, systems had been put in place to ensure the consistent quality of their care. Staff responded to individual patient needs for those living with dementia.

The hospital had systems in place to allow patients to feedback their experience of care on the medical wards. The results of the surveys indicated the department provided excellent, compassionate care by friendly and approachable staff. Patients we spoke with during the inspection confirmed that staff were kind, considerate and respectful. Complaints processes had been improved since our last inspection. Complaints were acknowledged, investigated and responded to appropriately.

However, we found some areas had scope for improvement. We considered that existing mitigating strategies and the expertise of clinical staff meant that risks to patients were minimised.

We found some paper health records to be large in size and documentation was hard to locate in these records.

The electronic prescribing system used for patients requiring chemotherapy could not be accessed by staff working in Emergency Department (ED). Although staff had put in measures to mitigate this risk the trust may wish to reassess the risks associated with these measures.

There was an overdependence on agency staff to support permanent staff to ensure safe staffing levels during the delivery of chemotherapy.

Services for children & young people

Good

Updated 2 February 2016

Overall we rated services for children and young people at Wexham Park Hospital 'Good' because:

The treatment and care needs of children and infants were assessed and planned from referral to discharge, taking into account their individual needs. The health and wellbeing of children, young people and infants was monitored using recognised assessment tools. Arrangements were in place for looking after vulnerable children. Staff responded compassionately when children and young people needed help and supported them to meet their basic personal needs as and when required.

Children said that the staff were kind and caring and that they received information that helped them understand what treatment and care they were receiving. Staff helped children and young people and those close to them to cope emotionally with their care and treatment. Comprehensive safeguarding policies and procedures were in place. This included referral pathways for children’s safeguarding. The service had systems in place to ensure that incidents were reported and investigated appropriately.

Children and young people’s services were well-led by a very enthusiastic and committed staff team. The leadership, governance and culture promoted the delivery of high quality child-centred care. There was a clear statement of vision and values, driven by quality and safety, with defined objectives. Staff were aware of best practice guidance for the safe and effective care of children and infants. The service had experienced nursing staff shortages, but were actively recruiting nurses by advertising the vacancies.

Critical care

Outstanding

Updated 2 February 2016

Overall we rated the critical care unit (CCU) at Wexham Park Hospital as 'Outstanding' this was because:

We found significant areas of good practice through our review of clinical audits, staff training, patient notes, clinical outcomes and other indicators such as an exemplary programme to promote independence and person-centred care. Leadership in the unit was coherent, robust and respected by staff. This leadership contributed to a team that continually challenged existing practice to identify new and improved ways of working. Innovation was very much part of the culture in the unit and staff spoke positively about the development opportunities available to them as a result.

Clinical practice was benchmarked against national guidance from organisations such as the National Institute for Health and Care Excellence (NICE), the Royal College of Physicians and the Intensive Care Society (ICS). Such guidance was embedded into the work culture and staff used it to evaluate and improve their practice. For example, an extensive programme of audits was used to update policies and procedures. Staff contributed to national audits compiled by the Intensive Care National Audit and Research Centre (ICNARC). They then used the national audit results alongside local studies to inform the planning of staff study days. The CCU team had access to multidisciplinary specialists who contributed to decision-making and ward rounds to ensure best care for patients. An established critical care outreach team supported patients across the hospital and provided bereavement and emotional support.

The CCU appeared clean, hygienic and well maintained. Staff demonstrated good infection control practices but there was room for improvement in some areas of housekeeping. Equipment was serviced regularly and staff were competent in its use with regular training updates. We found one area of non-compliance with the trust’s medication management policy but there were safeguards in place to ensure that this would not affect patient safety.

A robust incident reporting system was in place that staff confidently used to investigate incidents and errors. There was evidence that learning from investigations had taken place consistently with an effective system in place to ensure all staff were aware of updates to practice. These measures contributed to an environment in which safety was prioritised and patients received individualised care.

We observed numerous instances of significant commitment to personalised care. Staff were competent, passionate and driven, and their efforts included supporting a patient to return home safely to their garden during an extended CCU stay and a programme to promote independence in patients' in the middle of their recovery. Staff were active in clinical research and were supported in this by a senior team of nurses and doctors who understood the need for continued innovation in care and treatment. One relative told us, “I am overwhelmed by the attention of all of the people looking after [relative].”

Staffing levels were reviewed continually using an established nursing acuity tool and there were enough staff to provide care and treatment in accordance with Royal College of Nursing (RCN) guidance. The use of agency staff was consistently below the maximum acceptable level set by the trust and temporary staff underwent stringent induction and background checks before working on the unit. Without exception staff told us they were supported and valued by the senior team and they felt proud to work in the unit.

At our last inspection of Wexham Park Hospital, we found critical care services for responsiveness to require improvement. This was because admissions and discharges were often delayed and patients were sometimes transferred out of hours because of a lack of capacity elsewhere in the hospital. At this inspection we found a significant and sustained improvement in these areas, with an acute commitment from the senior team to improve the unit's responsiveness to patient needs that had been highly successful. In areas we previously found to be good, staff had worked hard to build on their existing practice and explore innovation in patient care and treatment.

End of life care

Good

Updated 2 February 2016

Overall we rated the EOLC services at Wexham Park Hospital as 'Good' this was because:

National guidance determines precisely what end of life care (EOLC) should look like for adults diagnosed with a life limiting condition in all care settings. EOLC is defined as a patient with less than 12 months to live no matter what the diagnosis.

Overall we found the EOLC service provided by Wexham Park Hospital was good. The duty of the inspection was to determine if the hospital had policies, guidelines and training in place to ensure that all staff delivered suitable care and treatment for a patient in the last year of their life. The hospital provided mandatory EOLC training for staff which was attended, a current End of Life Care Policy was evident and a steering group met regularly to ensure that a multidisciplinary approach was maintained.

Staff at Wexham Park Hospital provided focused care for dying and deceased patients and their relatives. Facilities were provided for relatives of patients and patient's cultural, religious and spiritual needs were respected. Further supplies of syringe drivers were purchased to enable a dying patient to receive prompt, adequate and appropriate medication.

The palliative care team had a high level of evidence based specialist knowledge. They worked well with the local hospice and other departments involved in providing EOLC. The team were well thought of throughout the hospital. They supported, trained and gave advice to other staff.

There was evidence that systems were in place for the referral of patients to the palliative care team for assessment and review to ensure patients received appropriate care and support. Through education and acknowledgement of national guidance the number of referrals to the palliative care team had increased since the last inspection and these referrals were seen and acted upon within 24 hours.

At our last inspection of Wexham Park Hospital we found the EOLC service to require improvement. This was because the service relied on the drive and vision of the EOLC team and not through any trust wide strategy. EOLC did not appear to be a priority for the trust.

Since the hospital's acquisition by Frimley Health  NHS Foundation Trust the service had board representation and a dedicated clinical lead. This had resulted in a well led trust wide service that had a clear vision and strategy.

Outpatients and diagnostic imaging

Good

Updated 2 February 2016

Overall we rated the outpatients and diagnostic imaging departments at Wexham Park Hospital as 'Good' this was because:

The hospital consistently met waiting and treatment times in line with national standards. Professional staff treated patients with kindness, dignity and respect. The outpatient and radiology departments followed best practise guidelines and there were regular audits taking place to maintain quality.

The booking centres had processes to ensure patients received appointments within the appropriate timeframe. There were fail-safes in place and medical staff assisted management if required. Medical record management enabled clinicians in outpatients to have access to patients’ records more than 99% of the time. The radiology department had worked to reduce waiting times in the past year.

Staff were competent , professional and treated patients with dignity and respect. The outpatient and diagnostic imaging department appeared clean and well maintained. Staff demonstrated good infection control practices . Equipment was serviced and maintained regularly.

Every member of every team contributed positively to patient care. All staff shared the vision and values of the hospital and good leadership was visible at all levels. Staff worked hard to deliver improvements in their departments. They were proud of their achievements and had the vision and energy to continue with improvements and develop services further.

Surgery

Good

Updated 13 March 2019

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

  • Security of theatre had improved; all areas had been secured and access was restricted. Checking of the blood fridge had improved and was consistently completed and recorded.

  • The service had improved on how it carried out the safe surgery checklist and undertook audit to ensure compliance. Further development of the debriefing process was underway to ensure the process remained robust.

  • The service provided mandatory training in key skills to all staff. Mangers made sure staff had the right skills to perform their role. There were practice development nurses in all areas and departments who supported staff training within a positive learning environment.

  • Staff understood how to protect patients from abuse. staff had training on how to recognise and report abuse and they knew how to apply it.

  • The service controlled infection risk well and had suitable premises and equipment and looked after them well.

  • Staff completed and updated risk assessments for each patient. Patient safety information was collected and safety monitoring results were used to drive improvements in practice.

  • The service managed patient safety incidents well. Staff knew what incidents to report, how to report, investigate and lessons learnt were shared. They identified any themes and monitored improvements in practice.

  • The service provided care and treatment based on national guidance and evidence of effectiveness. Patient outcomes were monitored and staff used findings to improve them. They compared local results with those of other services to learn from them.

  • Doctors, nurses, other healthcare professionals and all other staff worked together to benefit patients and supported each other to provide good care.

  • A consultant-led seven days a week service was in place. It was being further developed in a two-year plan to provide full service delivery in line with National Health Service Improvements (NHSI), seven-day service in the NHS.

  • Staff understood their roles in gaining valid consent. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.

  • Staff cared for patients with compassion, treating them with dignity and respect. Staff were passionate about delivering high standards of care and took account of patient feedback. Patient feedback was overwhelmingly positive and confirmed that staff were helpful and positive and treated patients with kindness.

  • The service planned and provided services in a way that met the needs of local people. They could generally access the service when they needed it. Patients’ individual needs were taken into account. There were specialist nursing and medical practitioners available to support patients and staff.

  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results and shared these with staff. Managers had the skills, knowledge and experience to manage the service. Managers demonstrated the ability to understand the challenges they faced and developed plans to deal with these challenges. Governance and performance management arrangements are proactively reviewed and reflect best practice.

  • There were high levels of staff satisfaction across all staff groups. Staff were proud of the organisation as a place to work, and they spoke highly of the culture.

However:

  • The service did not currently achieve its target of 85% of all staff to complete mandatory training.
  • There was a lack of consistency in how the change of the theatre list was managed on two consecutive days. Practice should be consistent to protect the safety of the patient.
  • Feedback from junior doctors was that rotas were not always planned in a timely way and there was no guardian of safe working hours in post, as there was a gap between retirement of the post holder and another taking up the post.
  • Fridge and room temperatures where medicines were stored were recorded daily but we were not sure that staff always took appropriate action when temperatures were outside the required range.
  • The corridor to pre-assessment had a fire door open to give ventilation to the area. This should be addressed to maintain safety.
  • The service did not currently achieve its target of 85% of all staff to receive an appraisal.
  • Complaints were not always responded to in a timely way; the service did not achieve the target of 25 days for a response to complaints.

Urgent and emergency services

Outstanding

Updated 2 February 2016

Overall we rated the emergency service at Wexham Park hospital as 'Outstanding' because:

Since our last inspection in 2014, a new leadership structure had been developed. Consultant medical staff now provided leadership for some aspects of the service, such as clinical safety and patient experience, clinical governance, education and training. There had also been changes to the senior nursing team with the appointment of matrons who now oversaw the quality of the service being provided in the department on a daily basis, ensuring patients were being well cared for. We found these changes had resulted in sustained improvements in the quality of care patients received.

At our last inspection we were concerned that some patients spent a long time in the ED waiting to be seen. The service had difficulty meeting the national quality standard for 95% of patients being seen in less than four hours. At this inspection, we found the trust had met the four hour quality standard since February 2015. Patients were assessed quickly and the service had met the national quality standard for 95% of patients being seen in less than four hours since February 2015.

Consultant medical staff provided effective leadership of the service such as clinical safety and patient experience, clinical governance, education and training.

Senior nurses took responsibility for the quality of the service being provided in the department on a daily basis, ensuring patients were being well cared for.

The service was well co-ordinated through board rounds held four times a day and clinical practice was audited against the standards set by the College of Emergency Medicine (CEM). Guidelines were accessible and followed by staff.

The ED audited clinical practice against the standards set by the College of Emergency Medicine (CEM). The college of emergency medicine is a body which sets national standards for emergency services. The department was also part of the Thames Valley Trauma Network, which aimed to develop high-quality trauma care across all the hospitals in the area. This involves the ED service being reviewed against a set of national quality standards and undergoing a quality review by clinicians providing similar services in other hospitals.

The ED had a system in place for monitoring changes in a patient’s condition. The Detection of Deterioration (EDOD) scoring system was used when patients were first assessed and to monitor their condition during their stay in the ED. Similar systems were in place for both adults and children. Staff monitored each patient’s condition and were able to reduce the risk of unsafe care if they deteriorated.

When we last visited the hospital we found the number of patients waiting between four and 12 hours and longer than 12 hours for admission was much worse than the England average. At this inspection we found that the number of people waiting longer than 12 hours for admission had reduced steadily from 23 in April 2015 to five in June 2015. This reduction may reflect a difference between the seasons with fewer admissions required during the summer months. However, the hospital had also been working on a range of ways of improving the movement of patients from the ED to other departments which had contributed to this reduction.

At our previous inspection we found that patients who were waiting a long time for admission did not have the condition of their skin checked and were not offered anything to eat or drink, both of which are good practice. At this inspection we found staff had improved the care provided and now monitored the condition of patient’s skin and provided food and drink to those waiting.

Staff delivered care based on best practice national guidelines. At our last inspection we found staff had good knowledge about the guidelines and audits in place, but were less clear about how improvements were going to be implemented. At this inspection we found the hospital had strengthened the structures for overseeing the implementation of guidelines and there were effective, clear written information accessible on the computer for all staff working in the department.

Staff spoke positively about the considerable changes that had taken place over the last 12 months and the pace at which this had been achieved. They told us the leadership of the department provided clarity about the vision for the service and senior medical and nursing staff provided support and direction. Consultant medical staff had highly visible leadership responsibilities for improving the quality of service which staff believed was making a positive difference. Staff told us they felt more motivated, supported and energised. They were proud to work in the ED because the leadership and culture had improved.

The ED had worked with other departments to reduce the length of time patients waited to be admitted. Three additional consultants had been appointed, which enabled senior staff to have a greater presence in overseeing the work of the department. Senior nursing staff also spent more time supervising the quality of patient care.

However, we found some areas had scope for improvement. We considered that existing mitigating strategies and the expertise of clinical staff meant that risks to patients were minimised.

The need to improve access to CT scanning. There is currently only one scanner on site. Patients were diverted to another hospital when the CT scanner was out of action. The trust planned to provide a second scanner when the new emergency department is built, however the trust should seek to ensure all patients requiring a CT scan were able to receive one, at the earliest opportunity.

Pharmacy support for the department was limited to 16 hours a week. Patients in emergency department decision unit (EDDU) needed their medicines reviewed before they could return home, the lack of pharmacy support sometimes led to delays in patients being discharged.

A new major incident plan had been developed but not all staff were aware of it. The plan had not yet been rehearsed or tested but a simulation was planned.

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 women and children 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 service controlled infection risk well. Staff kept themselves, equipment and the premises clean.
  • The service had suitable premises and equipment and looked after them well.
  • The service assessed a comprehensive range of risks in pregnant women, including diabetes, pre-eclampsia and mental health. We saw the service responded promptly to a range of risks to keep women and babies safe.
  • Staff kept clear and up-to-date records of patients’ care and treatment.
  • The service managed medicines safely and effectively.
  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Senior staff 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 provided care and treatment based on national guidance and evidence of its effectiveness.
  • Staff gave women enough food and drink to meet their needs and improve their health. Trained staff provided plenty of support to women with infant feeding and the service had Level One Unicef UK Baby Friendly Initiative accreditation. The accreditation helped ensure a high standard of care for pregnant women and breastfeeding babies and mothers in hospital.
  • Women and babies using maternity services at Wexham Park Hospital had similar outcomes to the national averages for other maternity units in England. National audit findings showed the service’s performance was as expected. The trust performed better than expected in the 2017 Maternal, New-born and Infant Clinical Outcome Review Programme (MBRRACE UK Audit).
  • The service monitored the effectiveness of care and treatment through local audits and used the findings to improve them.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, midwives and other healthcare professionals supported each other to provide good care.
  • The service obtained and recorded women’s consent in line with General Medical Council (GMC) and Nursing and Midwifery Council (NMC) guidance.
  • The service made sure staff were competent for their roles.
  • Staff cared for women and their babies with compassion. Women we spoke with confirmed staff treated them well and with kindness.
  • Staff provided emotional support to women and their families and comfort in times of distress. Dedicated pregnancy loss midwives provided support to women and their partners who had lost their babies.
  • Staff involved women and their partners in decisions about their care and treatment.
  • The trust planned and provided services in a way that met the needs of local people. This included specialist clinics and dedicated midwives for perinatal mental health, bereavement and diabetes.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with relevant staff.
  • The service had specialist staff and facilities to meet women’s individual needs, including those in vulnerable circumstances, bereaved women and families and those with complex needs.
  • The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • The service had effective systems for identifying risks and working to eliminate or reduce them.
  • The service had a vision for what it wanted to achieve and workable plans to turn it into action.
  • The service engaged well with patients, staff, the public and local organisations to plan and deliver maternity services.
  • The service used a systematic approach to maintain high standards of quality and there was a focus on continuous learning and improvement.

However:

  • The service did not have sufficient numbers of midwifery staff on all shifts. 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. Midwives described the impact of short-staffing, including midwives feeling “exhausted” from working extra shifts. Trust data showed staff reported 71 incidents of short staffing across the maternity service at Wexham Park Hospital between October 2017 and September 2018.
  • We saw some gaps in the daily checking of key equipment, including the neonatal resuscitation trolleys on Labour Ward and the adult resuscitation trolley on Ward 22 (postnatal ward). Midwives we spoke with told us checks were sometimes missed because of short-staffing.
  • Mandatory training rates were worse than the trust target for five out of 18 courses for midwifery and nursing staff, and 16 out of 17 modules for doctors between August 2017 and August 2018.
  • Midwives reported pharmacy were sometimes slow to collect out-of-date controlled drugs for secure disposal. We saw some out of date controlled drugs awaiting collection by pharmacy. These were stored securely while awaiting collection and disposal.
  • Eleven of the 14 policies we reviewed for Wexham Park Hospital were outside their review date and under review at the time of our visit.
  • Appraisal rates for nursing and midwifery staff did not meet the trust target of 85% between August 2017 and July 2018.
  • Access and flow through inpatient areas of the service was sometimes a concern.