Wexham Park Hospital

Wexham Park Hospital is a district general hospital serving a population of around 465,000 people with approximately 3,400 staff and around 700 beds. Since October 2014 it has formed part of Frimley Health NHS Foundation Trust (FT), when Frimley Health NHS FT acquired Heatherwood and Wexham Park Hospital. Wexham Park Hospital was the main acute site of the previous trust.

The previous Heatherwood and Wexham Park NHS FT was inspected by CQC in February 2014. The trust was rated as Inadequate. At that time 3 of the 8 core services at Wexham Park were individually rated as inadequate (Medicine, Surgery and Maternity) with a further 3 core services being rated as Requires Improvement (Urgent and Emergency Care, End of Life Care and Outpatients). Critical Care and Children’s and Young People’s services were the only services to be rated as good at that time. Consequently Heatherwood and Wexham Park NHS FT was placed in special measures.

Following the acquisition by Frimley Park special measures were lifted. This was because Frimley Park NHS FT had been rated as Outstanding in September 2014. This was the first trust in England to be rated as Outstanding with 5 of the 8 core services being individually rated as Outstanding and 3 of the 5 key questions being rated as Outstanding including the key question relating to the trust being Well Led. However, following the acquisition a number of requirement notices related to the Wexham Park location were issued in respect of aspects of care that had been of particular concern.

CQC reinspected the Wexham Park location in October 2015, just over a year after the acquisition and formation of Frimley Health NHS FT. This was a comprehensive inspection of the hospital/location to assess the current quality and safety of care. We did not reinspect the Heatherwood location as this had been rated as Good following the inspection in February 2014.

This report demonstrates that remarkable progress has been made since our previous inspection. Indeed this is undoubtedly the most impressive example of improvement that CQC has observed since our new approach to inspection started in September 2013.

All the external stakeholders we spoke with as part of this inspection were very positive about the progress that has been made over the past year. These included Monitor, NHS England, local CCGs, local HealthWatch and the Health Overview and Scrutiny Committee. We heard from staff working at Wexham Park that the culture in the hospital had improved markedly with a greater degree of openness at all levels. Governance had been completely revised, major improvements had been made with regard to handling of complaints and incident reporting. The number of student nurses who have opted to stay at Wexham Park Hospital following qualification has increased substantially over the past year.

Staff were much more positive about Wexham Park as a place to work than previously and a much higher proportion of staff would now recommend the hospital as a place to be treated. Key measures of performance such as the 4 hour A&E target, cancer waiting times targets and referral to treatment targets have improved markedly.

In relation to individual services, both the Urgent & Emergency Care service and Critical Care have now been rated as Outstanding with all other services being rated as Good. Three services were rated as Outstanding for being well led. This, together with the overall leadership at Wexham Park Hospital has resulted in the Well Led key question being rated as Outstanding for this location. This has been achieved by a team of experienced clinical leaders, mainly but not exclusively from Frimley Park, working with Wexham Park Hospital staff to deliver much better care for patients.

Our key findings were as follows:

Safe

There were effective and robust systems and protocols in place to protect patients from harm, and staff contributed positively to an incident-reporting culture that provided opportunities for continual learning. We found learning from incident investigations was disseminated to staff in a timely fashion and they were able to tell us in detail about improvements in practice that had occurred as a result.

A culture of openness was found in the trust. However, there was room for improvement with the policy and application of policy around Duty of Candour.

Staff contributed to the NHS Safety Thermometer programme. Information was collected on a weekly basis and clear, easy-to-read information was displayed for staff, patients and visitors across the hospital site.

The hospital was clean. However, the auditing of cleaning was not being managed in line with best practice guidance.

Medicines management had improved since our last inspection. Regular medicines audits took place; such as audits of the management of controlled drugs and antibiotic prescribing. Actions were taken where issues were identified such as a change in the antibiotic prescribing policy.

Staff attendance at mandatory training had improved since our last inspection. Mandatory training was monitored and all staff expected to attend on an annual basis. Staff told us that there was less ‘e-learning’ since joining with Frimley Heath NHS Trust and the quality of training had improved. They also told us they now received relevant training specific to their role.

Patients were protected from the risks associated with the unsafe use of equipment because staff maintained a reliable and documented programme of checks, including portable appliance testing (PAT).

The trust had identified that improvements in the management of deteriorating patients was a priority. A lead nurse for the management of deteriorating patients had recently been appointed and a work stream was in place to drive improvement across the trust. Actions included ensuring the availability of the resuscitation team, training for newly qualified staff and a review of early warning systems used across the NHS.

At this inspection we found nurse staffing had improved although there were still a number of staff vacancies. Providing safe staffing was an acknowledged risk for the hospital and there were appropriate action plans in place to monitor and address the risk on a daily basis.

Effective

Throughout our inspection we observed patient care carried out in accordance with national guidelines and best practice recommendations.

National clinical audits were completed. Mortality and morbidity trends were monitored monthly through SHIMI (Summary Hospital-level Mortality Indicator) and CRAB (Copeland's Risk Adjusted Barometer) scores. Reviews of mortality and morbidity took place at local, speciality and directorate level within a quality dashboard framework to highlight concerns and actions to resolve issues.

There was a consistent and standardised approach to multidisciplinary meetings and morbidity and mortality meetings trust-wide. The trust told us that attendance was good and learning identified with monthly updates and reports to the Trust’s Quality Committee. The trust had considered the results from national reviews such as the review into mortality and morbidity, and action had been taken to implement the findings and recommendations.

The trust had a range of clinical governance groups who were responsible for reviewing best practice guidelines and changes to legislation. Audits took place against national guidelines with changes to practice shared where appropriate.

The trust identified that not all policies and procedures at Wexham Park Hospital were in date or reflected current best practice. An action plan was in place to prioritise the policies to be updated and the resources required to undertake this. In the meantime the chiefs of service were reviewing policies and procedures to make sure patients were safeguarded. Staff were able to access national and local guidelines through the trust’s intranet, which was readily available to all staff.

Caring

Patients' told us that they were treated with dignity and respect and had their care needs met by caring and compassionate staff. We also received positive feedback from patients who had received care at Wexham Park Hospital over the past few months. This positive feedback was reflected in the Family and Friends feedback and patient survey results.

During our inspection we observed patients being treated in a professional and considerate manner by staff. All staff we were enthusiastic about the service they provided and gave examples of ‘going the extra mile’ to ensure patients received good-quality care that they would want their own families to receive.

Responsive

There had been an improvement in patient flow through all departments of the hospital. The Emergency Department (ED) had re-designed the service to improve patient flow through the department. Wards and departments across all directorates had also made improvements in patient flow through the hospital. Improvements were reflected in data throughout the hospital and the in the ED despite an increased number of people accessing the service the proportion of patients being seen within four hours had improved from 93% to 95% (meeting the national standard) and was being sustained consistently.

At the last inspection, we found complaints were not dealt with in a timely fashion and a backlog had developed. These had now been dealt with and any new complaints were being managed more effectively. Specialist staff were now managing complaints centrally.

We heard of the positive initiatives in place to support patients living with dementia. Dementia Leads were reviewing the care of patients living with dementia across all the trust’s sites against the trust’s Dementia Strategy.

Staff had access to resource folders for patients admitted with special needs such as a learning disability. There was an email ‘in-box’ for staff to raise any queries, referrals or concerns.

Well led

Following the acquisition of Wexham Park Hospital by Frimley Health NHS Foundation Trust in 2014, the trust’s values, vision and strategic plan were reviewed and revised.

At this inspection we spoke with a positive and ambitious workforce. Staff told us that they felt valued and felt able to put excellent patient care and experience at the heart of their work.

Staff across the hospital told us how the trust’s values were now embedded throughout their directorates and were monitored through local work and the appraisal system.

Since the last inspection the executive team had taken action to ensure they were visible on the wards and in the departments and ensured they engaged with front line staff, listening to feedback and acting promptly on any concerns raised. Senior staff walkabouts were undertaken to engage with staff and obtain direct feedback.

The trust implemented a new governance and committee structure with Board level quality assurance informed by new quality committees. Clinical governance was now embedded at local level with structured standard agendas complete with minutes and action logs. The local groups reported to the quality committee and to the Board via the Trust’s Clinical Governance Committee.

Since the last inspection the trust had established a clear set of values together with the expected standards of behaviour expected from all staff employed by the trust. Direct action had been taken to address the behaviour of individuals who did not demonstrate the professional standards of behaviour expected.

The quarterly Family and Friends Test included additional questions regarding values and leadership. The most recent results (April 2014 to September 2015) showed improvements in staff recommending the Trust as a place to work up 17% to 57% and in staff recommending the trust as a place to have treatment up 25% to 69%.

New central directorates had been established to manage complaints, patient safety and quality assurance.

The Family and Friends Test had been expanded to include questions, which gave a baseline on the patient safety culture within the trust.

A Patient Safety Committee had been established at Wexham Park Hospital and met monthly to share outcomes and take pro-active actions taken to improve safety.

We saw several areas of outstanding practice including:

• Leadership in the trust had inspired a culture shift since our last inspection that was evident across the hospital in all of the staff groups we spoke with. Staff were proud to work in the hospital, and were committed to delivering care that met with the trusts values and vision.
• The improvements to patient flow through the ED  meant that patients being seen within four hours had improved from 93% to 95% (meeting the national standard) and was being sustained consistently despite an increased number of people accessing the service.
• In critical care staff showed considerable innovation in meeting the individual needs of patients under exceptional circumstances.
• Staff engagement throughout outpatients and diagnostic imaging departments was outstanding. All staff were working towards common values, both clinicians, administrative and support staff, at all levels.
• The achievement of the radiology department to reduce and maintain their waiting times, in view of reduced staffing levels and equipment issues showed an outstanding commitment to improve patient experience.
• The improved booking centre processes in outpatients and radiology which involved multidisciplinary team members and ensured patients got the right appointment at the right time.
• Medical records were available more than 99% of the time, over the past 12 months.
• The roles of the five practice and development midwives were split between 50% clinical work and 50% administration and teaching workshops. One midwife worked every day in the labour ward to provide on the spot guidance and support to midwives.
• We observed outstanding prompt, appropriate and sensitive care and treatment provided for a woman in the labour ward who had complex and sensitive needs. Staff adhered to the comprehensive care plan they had developed to ensure the woman did not experience unnecessary distress.
• The hospital had comprehensive guidelines for staff in regards to female genital mutilation (FGM). The trust’s safeguarding children annual report 2014/15 recorded that the identification of FGM had been an area of development for the trust. The trust had a policy of addressing FGM when booking women for maternity care.
• The hospital had a Deputy Director for Clinical Education who had developed a comprehensive preceptorship programme for newly qualified nurses. This was a structured period of transition for the newly qualified nurses when they started their employment at the hospital. We viewed comments from newly qualified nurses’ evaluation forms from their learning and found these to be consistently positive.
• The matron on children and young people’s ward had received a trust recognition award for leadership.
• A senior nurse in critical care had been seconded into a research post for the year before returning to full time clinical duties. They had contributed to the application of the good clinical practice (GCP) guidance of the NIHR Clinical Research Network, which had been used to prepare a research working book for other nurses to use as a benchmark for research processes, from screening to final data analysis. The research was quality assessed by Monitor through site visits to check that research protocols adhered to gold standard clinical and ethical requirements. The lead research nurse had attended a GCP training course and had successfully been certified against national standards including ethics, legislation and application of the Mental Capacity Act (2005).
• One of the key research projects, VANISH (Vasopressin versus Noradrenaline as Initial therapy in Septic shock), had resulted in specialised one-to-one training packages for staff and an invitation for staff to present their findings at the European Intensive Care Society Conference in 2015. The study had looked at the avoidance of acute kidney injury through the use of steroids with inotropes and the results were presented to staff in the unit on completion of the study. Other projects included a study of the effectiveness of emergency laparotomies and a study of the translocation of bacteria in abdominal sepsis to consider specific antibiotic therapy. The impact on nurses had been very positive and for three consecutive years, research-active staff had attended the European Intensive Care Society Meeting as recognition of their efforts towards establishing an active programme of testing best practice and treatment.

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

• The cleanliness of the hospital must be audited in line with standards set out in the national specifications for cleanliness in the NHS (NSC). This includes the correct classification of high risk and very high risk areas and the frequency of auditing in these areas. Audit processes should include a re-audit where areas are found to be less than 100% compliant. If the hospital chooses not to audit to NSC standards they must provide evidence of an equally robust auditing programme.
• Ensure their policy around Candour (DoC) includes incidents resulting in ‘psychological harm’. The provider must also ensure the policy is followed when managing incidents that come under this regulation.
• Continue with its delivery and the risk priorities associated with the backlog program. Fire risks associated with backlog need to be addressed as a priority.
• Improve Estates governance and ensure that up to date and approved policies and standard operating procedures (SOP’s) are in place.
• Ensure that monitoring of weekly medicine stock checks in critical care is consistently applied and must ensure that the system in place to make sure out of date medicine is disposed of is audited.
• Ensure that resuscitation equipment is always checked according to the trust policy. The auditing system must include a visual check of the expiry dates of batteries.
• Cleaning and storage materials in critical care must be stored in locked facilities and the lock for the cleaning cupboard must be replaced.
• Recruit to the three vacant consultant posts in ED. Although consultant cover in ED had improved since our last inspection the department still fell short of national standards.
• Ensure that all oxygen cylinders have an expiry date displayed, and system in place for staff to check that cylinders are within date.
• Continue to improve staffing recruitment and retention. 

In addition the trust should:

• Ensure all staff in outpatients have development opportunities and training as agreed in their personal development plans.
• Ensure that regular and routine checks are made of the temperature of medication fridges.
• Consider plans for an additional CT scanner and integrated x-ray within the new emergency centre development planned for 2016.
• Improve pharmacy support for the emergency department and the decision unit (EDDU) in particular.
• Explore an effective means of explaining to patients why they have to wait to be treated in the ED.
• Consider testing the major incident plan which had recently been re-written.
• Consider the size and organisation of paper health records.
• Ensure the audit trail of medications delivered to wards is completed including the signature of the staff member receiving the medications on the ward. 
• Consider the safety of Aria e prescribing system which is not available to staff in the ED and the patient risks associated with this.

Professor Sir Mike Richards

Chief Inspector of Hospitals