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Royal Bournemouth Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 25 February 2016

Royal Bournemouth Hospital is the larger of two hospitals provided by The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust. The trust gained foundation status in 2005 and provides services, to a population of 550,000 in the Dorset, New Forest and south Wiltshire areas, which rises in the summer months due to an influx of visitors to the area.

We inspected the trust and Royal Bournemouth Hospital as part of our comprehensive inspection programme.

The Royal Bournemouth Hospital has approximately 600 inpatient beds and 123 day case beds. The hospital provides urgent and emergency care, medical care, surgery, critical care, end of life care, outpatient and diagnostic services. There is a limited maternity and gynaecology service, including a three bedded birthing unit and community midwife service. The children and young person’s service is limited to eye surgery and outpatients. The main centre for obstetrics and gynaecology and paediatric services is at a nearby NHS hospital in Poole.

We inspected eight core services at the hospital: urgent and emergency care, medical care, surgery, critical care, maternity and gynaecology, children and young people, end of life care, outpatient and diagnostic services. Detailed findings on children’s outpatient dermatology service is also included in this location report under children and young people’s core service.

We carried out an announced inspection visit to the hospital 20 -22 October 2015 and additional unannounced inspection visits 27 October, 4 and 9 November 2015. The inspection team included CQC managers, inspectors, and analysts. Doctors, nurses, allied healthcare professionals, senior NHS managers and ‘experts by experience’ were also part of the team.

We rated Royal Bournemouth Hospital as ‘requires improvement ’ overall and requires improvement for providing safe, effective, responsive and well led care. We rated urgent and emergency care, medical care, maternity and gynaecology services as requires improvement overall. We rated caring overall as good across most services and outstanding in children and young people services,  but as requires improvement in medical and older people services. We found surgery, critical care, services for children and young people, end of life care and outpatient and diagnostic imaging services were good overall.

Our key findings were as follows:

Are services safe?

  • Staff were encouraged to report incidents. However, this process was not embedded in all areas. Some staff did not always receive direct feedback. There was investigation and learning to improve the safety of services.
  • The rate of incidents (NRLS) per 100 admissions was below the England average with 98% of incidents being low or no harm incidents. There were 47 serious incidents in the 12 months to April 2015, of which four were Never Events. The rate of serious incidents was below the median of all trusts (2013/14). The majority of serious incidents were pressure ulcers and falls. In October 2015, the trust was at 91% for harm free care and not meeting its own targets (95%).
  • The initial clinical assessment of emergency patients arriving at the emergency department during the day was timely within the national standard of 15 minutes. However, at night the assessment was not timely or appropriately performed and this put some patients at risk.
  • Patients were assessed and monitored by nursing staff using electronic hand held devices. However, some staff did not always complete risk assessments in a timely and effective manner whilst getting used to the new nurse electronic risk assessment process.
  • The early warning score system needed to be used more consistently for the escalation of patients whose condition might deteriorate.
  • In some operating theatres, staff did not follow the five steps for surgical safety consistently or accurately, to minimise the risks of patient harm.
  • There was not an up-to-date protocol to remove a collapsed woman from a birthing pool in the event of unforeseen complications during labour or birth. Staff were not consistently able to describe emergency procedures in the birth centre.
  • Medicines were not consistently managed safely across the hospital. In some areas medicines were not stored securely, or stored safely at correct temperatures. Staff did not always follow trust policy when administering medication or destroying controlled drugs.
  • Staff generally adhered to infection control procedures, but there were some lapses in hand hygiene and some practices did not fully support effective infection control and prevention.
  • Some clinical areas such as emergency department and critical care unit were cramped. The corridor between Derwent Suite and the main hospital, used for transfers, was not suitable for patients. Most wards and clinical areas were clean but we found dust and cobwebs in some operating theatres.
  • Equipment was checked and stored appropriately in most areas but this needed to improve in the emergency department, critical care and some medical and surgical wards, specifically for emergency and transfer equipment.
  • Overall, staff had a good understanding of safeguarding adults and children
  • More staff needed to complete mandatory training, compliance was below the trust target in most areas.
  • Although there had been recruitment of nursing staff, vacancy levels were still high on some wards, and there was evidence that requests for additional staff to provide cover were not always met. On occasions there was a lack of consideration of the skill mix when agency and bank staff were covering vacant shifts. Wards that had a high number of temporary staff on duty did not have sufficient numbers of permanent staff to provide guidance to the temporary staff about meeting patient individual needs in a safe manner.
  • There was appropriate medical staffing levels in most areas, although consultants in emergency departments were not present in the department for 16 hours a day as recommended by the Royal College of Emergency medicine. The critical care unit was left without medical cover after 11pm if the one junior doctor was called for an emergency elsewhere.
  • In diagnostic imaging, staff were confident in reporting ionised radiation medical exposure (IR(ME)R) incidents and followed procedures to report incidents to the radiation protection team and the Care Quality Commission.
  • Senior clinical staff were aware of the Duty of Candour regulation and the importance of being open and transparent with patients and families. The considerations and documentation around this regulation needed to be happen in sexual health services, on one occasion.
  • The majority of do not attempt cardio pulmonary resuscitation (DNACPR) forms had been appropriate completed.

Are services effective?

  • Mortality rates in the trust were within expected range. Mortality rates had improved (downward trend) over the last 18 months. There was no difference between weekend and weekday mortality rates. Seven day services in emergency medicine, acute medicine gastroenterology, cardiology, and critical care supported this positive trend
  • The treatment and care provided in most services took account of current evidence-based guidelines. However, evidence-based guidelines for the care and treatment of patients in the emergency department were not always followed.
  • The end of life care services had introduced personalised care plan for the last days of life (PCPDL). Wards we visited were aware of this documentation which was a replacement following the national withdrawal of the Liverpool Care Pathway in July 2014. The trust was piloting AMBER Care Bundle on some wards.
  • Most services participated in national and local audits which showed improving and good outcomes for patients. Emergency care patient outcomes varied and the results of audits were not always used to improve treatment techniques. The midwifery service did not collect information on patient outcomes and there was no programme of audits in place.
  • Pain relief, drinks and food were not always given in a timely manner in the emergency department. Patients received good pain relief and nutrition across all other services.
  • Most patients had access to services seven days a week and were cared for by a multi-disciplinary team working in a co-ordinated way. However the allocation of multidisciplinary support to the critical care unit, including pharmacy and physiotherapy, was lower that recommended. The wider multidisciplinary team did not attend the consultant led ward round on the unit.
  • The critical care unit was working with the Specialist Nurses in Organ Donation (SNODs)  to improve organ donation rate.
  • There was a low staff appraisal rate following the introduction of a new system, we found its use was improving and most staff completed training relevant to their roles. There was a comprehensive training programme for medical staff but little evidence of nursing staff competency training in the emergency department. Not all staff had access to clinical supervision
  • Access to information was mostly effective. In some services patient information was held in a variety of formats which meant it could sometimes be difficult to use and time consuming to find. Electronic patient records were recently implemented in outpatient clinics which staff were using. However, this was accompanied by increases in administrative time and difficulty in finding some records which did have an impact on timeliness of information access and potential for risks to patients. The trust had a plan to address staff concerns around this.
  • Staff followed consent procedures and had a good understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards which ensures that decisions are made in patients’ best interests.
  • Children and young people were consented appropriately and correctly.

Are services caring?

  • Across the hospital we found staff worked hard to ensure that patients were treated with dignity and respect, despite the challenges sometimes presented by the environment. However in medical and older people services, patients did not always receive care in a way that respected their privacy and dignity.
  • Patients were asked for their views and response rates were high, with a high proportion of patients recommending care and treatment.
  • Patients told us, and we observed, that staff were kind and compassionate, putting the patient at the centre of care.
  • Patients, relatives and families were kept informed of plans for care and treatment. They told us they felt involved in the decision-making process and had been given clear information about treatment options.
  • Patients and their families were supported by staff emotionally to reduce anxiety and concern. There was also support for carers, family and friends for example, from the chaplaincy, bereavement services for patients having end of live care, and counselling support where required.

Are services responsive?

  • Bed occupancy in Royal Bournemouth Hospital range between 90-95%. This was consistently above the England average. It is generally accepted that at 85% level, bed occupancy can start to affect the quality of care provided to patients, and the orderly running of the hospital.
  • Performance in meeting national emergency access target for 95% of patients to be admitted, transferred or discharged within 4 hours varied through the year. The target was not met for 36 of the 52 weeks to March 2015. The trust had achieved the target (95.3%) July-September 2015.
  • A lack of available beds in the hospital had resulted in delays in treatment for patients brought by ambulance and meant the emergency department was often full and this impacted on patient privacy.
  • The number of ambulances waiting more than an hour to hand over patients had reduced significantly since the introduction of a rapid assessment and treatment area (BREATH) but still averaged four per month.
  • There were long delays for patients with fractured hips to be transferred to Poole Hospital that treated trauma patients. The trust was taking action to introduce a formal pathway.
  • The acute medical unit (AMU) and Treatment Investigation Unit (TIU) had been set up to manage the increasing pressures on beds due to an increasing demand.
  • There were 55 medical outliers at the time of inspection. Their patients were appropriately assessed and followed by a team of medical consultant and junior doctors.
  • The hospital performed above the England national average for the referral to treatment standards for patients to wait less than 18 weeks (May to July 2015). Previously, it had not met this standard on any of the 12 months to April 2015.
  • Access to critical care beds within four hours was similar to comparable units. There were low rates of surgery cancellation due to lack of critical care beds. There was a higher than average number of delayed discharges, which resulted in mixed sex breaches, sometimes across several days. The service was performing better than similar services in avoiding out of hours discharges.
  • The hospital’s cancellation rate for operations was below the England average for all quarters in 2014/15
  • The trust was meeting national waiting times for diagnostic imaging within six weeks. However in October 2015 the percentage of patients Trust wide waiting over 6 weeks for all diagnostics was 6.2% compared to the England average of 2 – 2.5%. In diagnostic imaging no patients were waiting over 6 weeks in October 2015.
  • Outpatients referral to treatment for patients was meeting the standard to wait less than 18 weeks. The trust short notice cancellation rate for appointments were lower (better) than the England average.
  • Cancer waiting times for urgent referral appointments were below the national standard of two weeks (June 2014 – March 2015). However the trust was meeting the standard (April – June 2015). The trust was not meeting the standard for decision to treatment within 31 days (June 2014 – June 2015). The standard for 62-day cancer referral to treatment time was not met, specifically for urology and colorectal surgical treatments (June 2014 – June 2015). The trust was taking steps to reduce delays in these pathways.
  • Most patients were seen by the hospital palliative care team within 24 hours. The rapid discharge service for discharge to a preferred place of care was responsive to the needs of patients and families.
  • The hospital had implemented an improvement programme to reduce patient length of stay in hospital, and had identified specific barriers which they were addressing. There was a high number of delayed transfers of care. The main cause of delays was waiting for NHS non-acute care and patient and family choice, to meet patients’ ongoing needs. The provision of community services, especially care home and nursing home places, also caused delays.
  • The environment did not always support patient needs. Women on the urogynaecology ward had to walk past male patient bays to access toilet facilities. Not all wards had been refurbished to improve the environment for patients living with dementia, but this was planned.
  • Clinical staff knew how to access information to support them in meeting the needs of patients with a learning disability or living with dementia. They demonstrated an understanding of adjustments that could be made to support patients.
  • There was a robust complaints handling process and responses to complaints were detailed and considerate. Staff understood how to manage complaints and there was evidence of learning from concerns and complaints. However, complaints were not being responded in a timely manner, in July 2015, only 50% of complaints were responded to within the trust target of 25 days.

Are services well-led ?

  • The trust had published its vision, values, mission statement and objectives, and had taken action to assess and improve staff understanding of these. The trust had recently introduced values based appraisal and staff had better understanding of trust values if they had completed appraisal.
  • The trust described its five-year strategic plan for patient care, underpinned by six strategic objectives, taking into account the two possible outcomes of the clinical services review. The wider strategic direction of services was largely contingent on the ongoing outcome of the Dorset wide clinical services review. Service leads agreed with the trust’s preferred option to become the major emergency hospital in the area.
  • Most services had local strategic plans and were monitoring progress although this varied. The end of life care overarching strategy was produced in response the inspection, but had not been through consultation or approval by the board.
  • Most services had had effective clinical governance arrangements to monitor quality, risk and performance. However, governance processes in urgent and emergency care , maternity and gynaecology were not always effective in identifying issues and making improvements to safety and quality
  • Local risk registers did not always reflect all of the concerns described to us by staff, or provide sufficient detail on actions being taken. Information about risk and quality issues were not always shared with staff.
  • Staff were positive about the local leadership and the trust management focus on improving the hospital’s culture. However many staff noted a lack of visibility of the senior executive team.
  • Staff commented positively on local culture and teamwork. They said they would raise concerns about patient care if they witnessed poor practices.
  • Patient feedback was mainly through survey feedback or FFT, but there were some patent focus groups and the hospital had worked the local Healthwatch to obtain patient views.
  • Ideas to innovative and improve services were encouraged. There was participation in research and quality improvement projects
  • There was a cost improvement transformation group for every directorate in the trust. The service leads considered ‘safety and quality’ as a priority in the cost improvement plans (CIPs).

We saw areas of outstanding practice including:

  • The interventional radiology department had been awarded exemplar status by the British Society of Interventional Radiology for continuous audit, review and research in the unit, and improving patient experience. This award had been retained twice. The staff team were particularly proud of this achievement, particularly as they were not linked to a teaching hospital.
  • In Maternity and Gynaecology the Sunshine team offered support to women that were assessed as being vulnerable. They could be vulnerable due to mental illness or learning disability, but also from alcohol and substance misuse. The team worked with the local centre that cared for women who had been trafficked to Britain. The Sunshine team worked across health and social care and had excellent relationships with the police, education and the mental health. The service had been recognised by an all-party parliamentary group for its work with vulnerable women.

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

Importantly, the trust must ensure :

  • At all times, emergency department patients are assessed and treated according to nationally agreed standards, particularly those for sepsis and fractured neck of femur
  • Emergency department transfer equipment is checked regularly to ensure that it is always ready for use.
  • All incidents are reported using the trusts incident reporting process and staff receive feedback.
  • Pain relief, drinks and food are given in a timely manner .
  • All staff comply with good hand hygiene and infection control practices
  • Equipment is appropriately labelled, maintained, checked, cleaned and tested.
  • Equipment that poses a risk of cross contamination is disposed of promptly
  • That all premises and environments used by patients are clean, secure and safe for use including theatres and the corridor between Derwent suite and main hospital.
  • All emergency equipment is checked and maintained in working order
  • All medicines are stored securely, correctly and within a safe temperature range .
  • Patient medicines are checked and recorded to ensure they receive the correct medicines when admitted to hospital
  • Medicines are administered in a safe manner, following national guidance and trust procedures
  • Patient risks are assessed and documented in a timely manner and escalated appropriately
  • A policy, protocol and appropriate equipment is available to remove a collapsed woman from a birthing pool, and staff are trained in its use.
  • Sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed at all times. Including sufficient numbers of permanent staff to provide guidance to the temporary staff about meeting patient individual needs in a safe manner.
  • Staff receive appraisal annually in line with trust policy and procedures and access to clinical supervision improves .
  • Privacy and dignity of patents is protected during care and treatment.
  • The hospital escalation procedures are improved so that delays to ambulance patients are minimised
  • Delays in discharge are reviewed to prevent patient stay in an inappropriate location and mixed sex breaches, particularly in critical care services.
  • There are effective systems to identify, assess, monitor and improve the quality and safety and mitigate risks across departments, in particular maternity and gynaecology services and the emergency department .

In addition the trust should ensure:

  • There is always a band 7 nurse in charge of each shift in the Emergency Department
  • There is a consultant presence in Emergency Department for 16 hours each day.
  • Appropriate monitoring takes place check that changes in practice are effective
  • There is a robust competency framework in place for nursing staff in the Emergency Department.
  • Junior medical staffing levels on critical care are reviewed as there are at times when staff are called away from the unit to other wards.
  • All PDGs are up-to-date and available for staff to use, in particular midwives and sexual health staff
  • Oxygen cylinders are stored safely in theatre areas.
  • Improvements in safety and communication around the critical care patient handover.
  • Policies and procedures are comprehensive and up to date within theatres and critical care.
  • Critical care clinical guidelines are up to date and appropriately approved and monitored.
  • There is a checklist for all critical care patient transfers
  • Multi-disciplinary team working improves in critical care services to ensure patients receive care according to recommendations and there is effective communication centred around the patient.
  • Improved multi-disciplinary working with the SNODs to increase the organ donation rate
  • Records are accessible in a timely way and there are improvements to the electronic patient record system
  • Where relevant, mental capacity assessments are completed on DNACPR forms.
  • Patients are offered the opportunity to wash their hands before meal times.
  • There is consideration of the provision of eating utensils and how food is presented at meal times
  • The environment on wards is suitable for people living with dementia
  • Privacy is improved for patients in the major treatment area in the emergency department
  • The accommodation of medical patients on surgical wards is minimised.
  • Facilities for relatives of patients in critical care and end of life care are improved.
  • There are separate toilet and washing facilities of the urogynaecology ward, so that women do not have to walk past male patients to access these facilities.
  • There is awareness of the interpreter service throughout the hospital
  • Regular team meetings or forums are set up to encourage shared learning amongst paediatric staff; especially paediatric nurses across the trust.
  • There is a sustainability/succession plan in place for paediatric dermatology service
  • Feedback from patients improves in critical care services
  • Staff engagement improves on critical care services .
  • there is consultation on the overarching end of life strategy with internal and external stakeholders.
  • Patient information is available in an easy to read format, and in other languages than English
  • The general décor of the chapel is improved
  • Chaplaincy provision review and timelines of delivery of good quality pastoral, spiritual and religious care
  • Patient outcomes data is collected and used to improve services in maternity and gynaecology
  • Duty of candour is appropriately considered in all cases where there is harm, a potential for harm, including psychological harm.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Updated 18 December 2013

Prior to our inspection visit we reviewed a number of factors relating to patient safety at the hospital. These included rates of infections, reporting incidents, the occurrence of “never events” (errors in care that should never happen), reported deaths outside of expected limits. These indicated that that care provided at the hospital might not be as safe as needed for patients.

We found that care was not always safe; both doctors and nurses at times felt unsupported and under too much pressure due to staffing levels and skill mix within the areas where they worked. This meant that on some medical wards, including for frail older people, patients were at risk of harm for example from incidents, or lack of fluids and nutrition. On surgical wards the medical staffing level at night was not safe. In outpatients there were a risk of cross infection. However the services that were safe included maternity, critical care, children’s care and end of life care.

Effective

Updated 18 December 2013

Many parts of the hospital were effectively managed and applied recognised clinical guidelines or national standards. This meant that recognised best practice was used to deliver treatment that met patients’ needs. However the A&E and medical care services were not effective. Also there is a need to ensure greater external scrutiny of some measures, for example mortality rates.

Caring

Updated 18 December 2013

Patients, their relatives and staff told us about incidents where patients had not been treated with dignity and respect. Some aspects of care were not met in a timely manner. This was found to be inadequate on medical care Wards 3 and 26 in particular and, although to a lesser extent, across medical services as a whole. Some people in the medical care wards, including older frail people, were left in soiled beds. However, there were many positive examples of caring in areas that included maternity, critical care, children’s care, outpatients and end of life care.

Responsive

Updated 18 December 2013

Children’s care, critical care and end of life care were particularly responsive to people’s needs. However, improvements in one part of the hospital were not necessarily shared across all services. Services tended to work in isolation. We found people were able to raise concerns and make complaints. However some people felt that when they made a complaint, the trust was dismissive of their concerns. This meant that they either chose to have care elsewhere or continued to feel dissatisfied. A&E, medical services and outpatients were less responsive to the needs of patients.

Well-led

Updated 18 December 2013

Children’s care, maternity, critical care and end of life care were generally well-led. Many departments and wards had effective leadership. However the A& E department required improvements and medical care services in particular were inadequate in this regard.. While there was clear communication between the senior management and the trust’s Board, this was less apparent for other staff. This was affecting staff morale and individual professional accountability for some staff.

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 25 February 2016

Maternity and gynaecology required improvement in the effectiveness and leadership of services. The services were safe, caring and responsive.

Incidents were reported by staff, and these were investigated appropriately. However, learning from incidents was shared locally and not more widely. There were attempts to ensure governance processes were carried out robustly. However, the sharing of patients with Poole Hospital made this complex, it was not always clear who owned the actions around quality and risk from governance meetings.

There were appropriate numbers of appropriately trained staff on the maternity unit and gynaecology service. There was a high midwife to birth ratio in the maternity service.

The storage and management of medicines was mostly safe. However, medicines that required to be stored in a refrigerator were not stored consistently at the correct temperature.

There was no up-to-date protocol to remove a collapsed woman from a birthing pool in the event of unforeseen complications during labour or birth. 

Staff participated in mandatory training, but completion of some courses was low against the trust target. Good infection control and prevention measures were seen. Action was taken when audits showed that hand hygiene was not satisfactory at the birth centre.

Good infection control and prevention measures were seen. Action was taken when audits showed that hand hygiene was not satisfactory at the birth centre.

The service provided a caring and supportive environment for women in pregnancy and those undergoing gynaecological surgery. Women were happy with the care they received from the services and this was consistently demonstrated by patient feedback.

The service did not collect outcomes from patients to allow them to monitor progress against targets and ensure that the service was providing effective care and treatment. Although there was a programme of audits in place, no results from them were available. The service was not collating sufficient assurance that evidence based care was being provided.

The service was responsive to the needs of women with access to the midwife led birth unit available across 24 hours. Community midwives provided antenatal care and support in GP surgeries and in children’s centres. Community midwives were able to support women with a low risk of complications, to give birth at home if that was the woman’s wish. Midwives provided effective coordination of a woman’s care through pregnancy, birth and the post-natal period. There was a designated team of midwives to support women that were vulnerable.

Appointments for investigations required in gynaecology were available at times to suit patients. There was emotional support available for women and their families.

The trust had identified that there were potential risk associated with the changes to leadership for maternity service.

Medical care (including older people’s care)

Requires improvement

Updated 25 February 2016

There were areas of good and innovative practice in most areas of medical and older people services. But we found medical and older people services overall, required improvement.

Safety of the service needed to improve as there were risks for patients posed by some practices and staffing numbers and skill mix. Staff knew how to report incidents, but not all incidents were reported. Medicines were not consistently managed in a safe and effective manner. Medicines were signed as administered without observing whether the patient had taken the medicines. In some areas were not stored in a secure manner. Inaccurate monitoring of medicine drug fridges meant it was not assured refrigerated medicines were stored at correct temperatures.

The electronic risk assessment process did not always support staff to complete risk assessments in a timely and effective manner. For some patients there was no current record of identified risks or plan of actions to mitigate risks, as risk assessments were overdue by up to three days.

Although staff adhered to infection control practices in relation to hand hygiene and personal protective equipment, other practices did not fully support effective infection control and prevention practices. Patients were not consistently offered the opportunity to wash their hands prior to meals and on one ward there were dirty clinical items (blood stained gauze and sharps bins and trays) left next to patient’s bedside which posed risk of cross infection.

There were vacancies of nursing staff on all the medical and older people wards. During the unannounced inspection we saw patient’s wellbeing was put at risk because there a lack of consideration was paid to the skill mix when agency and bank staff were covering vacant shifts. Poor compliance with mandatory training and appraisal rates meant patients were at risk of being cared and treated by staff who lacked updated knowledge and skills.

Patients did not consistently receive care that respected their privacy and dignity. We observed patients were left exposing the lower half of their body, a patient was administered an injection without pulling curtains around them, lifting their gown up for the injection in view of patients and staff. Patients were left in nightwear on the wards, when they preferred to wear their own clothes. A patient said they had to pass urine in a pad, rather than be supported to use the toilet, because staff took so long to answer call bells.

The treatment and care provided followed current evidence-based guidelines. Medical services participated in national and local audits which showed improving and good outcomes for patients. Patients had access to services seven days a week and were cared for by a multi-disciplinary team working in a co-ordinated way. Patients told us they felt involved in decision making about their care. Where patients lacked capacity to make decisions for themselves, staff acted in accordance with legal requirements.

Services were developed to meet the needs of the local population. The trust was working with partners to decrease delayed patient discharges, and was also working to improve its internal processes to ensure daily discharge targets could be met.

Innovative and new working practices supported the trust to improve patient flow and patient experience. A GP led ward for older patients medically fit for discharge, but whose discharge was delayed, released acute beds in the hospital for unwell patients to be admitted and treated by the hospital medical staff.

There were new services that worked in a multidisciplinary manner, including working with community services, which improved outcomes for patients and reduced their length of stay in hospital. This included the heart failure service and working in partnership with Dorset Adult Integrated Respiratory Service. with provided a holistic and multidisciplinary service for patients with heart failure which had result in improved outcomes and reduced length of stay in hospital for patients with heart failure. Employment of an Acute Kidney Injury (AKI) nurse specialist, providing education, outreach bleep service Monday to Friday and development of care pathways resulted in reduced length of stay and reduced mortality rates for patients with AKI. New pharmacy working practices on ward 26, which included two pharmacists embedded into the multidisciplinary team, resulted in improved effectiveness and outcomes for patients.

Governance processes promoted reviews of the service provision and identified areas for improvement. However, risk registers at department and trust level did not identify all risks posed to the service and patients. The culture within medical services was caring and supportive. Staff were actively engaged and the division supported innovation and learning.

Urgent and emergency services (A&E)

Requires improvement

Updated 25 February 2016

We rated the service in the emergency department as requires improvement for safe, effective, responsive and well-led services. Care of patients was good.

Learning from incidents was not always embedded in practice.  Initial clinical assessment of patients during the day was quick and, on the whole, effective. However, at night assessment was not timely or appropriate and this put patients at risk. Much of the department was cramped and poorly ventilated. Some staff did not follow appropriate hand hygiene procedures and medicines were not always stored correctly. Patient records were fragmented and some were poorly completed.

The department had appropriate medical staffing levels although consultants were not present in the department for 16 hours a day. There were good nurse staffing levels and skill mix. There was active recruitment to existing vacancies. There was a lead children’s nurse and a qualified children’s nurse on each shift. The requirements for safeguarding of children, young people and vulnerable adults were understood and implemented by staff.

Although there were easily accessible evidence-based guidelines for the care and treatment of patients these were not always followed. There were occasions when staff did not follow professional standards for the treatment of sepsis and fractured neck of femur. Pain relief, drinks and food were not always given in a timely manner. Patient outcomes varied and the results of audits were not always used to improve treatment techniques.

There was a comprehensive training programme for medical staff but we could find little evidence of nursing staff competency training. There was good multi-disciplinary working and access to radiology and pharmacy was available 24 hours a day, seven days a week. Access to mental health services was limited out of hours.

Staff provided compassionate care and worked hard to ensure that patients were treated with dignity and respect despite the challenges sometimes produced by a crowded department. There were good results from the national emergency department patient survey. Patients that we spoke with were positive about the care they received, and the attitude of motivated and considerate staff. Patients, relatives and families were kept informed of plans for care and treatment. They told us they felt involved in the decision-making process and had been given clear information about treatment options.

Delays in admitting patients to a hospital bed meant that the emergency department was often full and could not immediately treat new patients. The number of ambulances waiting more than an hour to hand over patients had reduced significantly since the introduction of the rapid assessment and treatment area (BREATH). An ambulatory emergency centre had been developed by the hospital but we could see little evidence that it had improved treatment for ED patients.

The treatment of patients with complex needs lacked focus. Response to complaints was timely, comprehensive and considerate.

Governance and quality monitoring processes were not always effective and the risk register did not reflect all of the concerns related to us by staff. Departmental leaders were described as having the knowledge, skills and integrity to carry out their roles. There was a good sense of teamwork and staff felt supported by their colleagues and managers. A number of improvements had been made to the service in order to enhance the treatment of patients.

Surgery

Good

Updated 25 February 2016

This core service was rated as good. We rated safe as requires improvement and found effective, caring, responsive and well led were good.

We rated safe as requires improvement because of shortfalls in areas of medicines management, cleaning, the environment and equipment, surgical checklist compliance and staffing levels. For example, staff were not always monitoring medicine storage temperatures or following trust policy when destroying controlled drugs. We found dust and cobwebs in some theatre areas, although ward areas were visibly clean. The routes for patients to move from the main hospital wards to the Derwent unit were not suitable for patients, and some items of equipment were not stored safely or were not accessible. Although there had been recruitment of nursing staff, vacancy levels were still high in some areas, and there was evidence that requests for additional staff to provide cover were not always met. We found that in some theatres, staff did not follow the five steps for surgical safety accurately. There were systems in place to assess and respond to patient risks however, and records were generally legible and comprehensive. If they were completed electronically, they were automatically monitored for compliance.

Staff commented that access to information was not always effective. Patient information was held in a variety of formats which meant it could sometimes be difficult to use and time consuming to find.

Patients received care and treatment that followed national clinical guidelines and staff used care pathways based on evidence-based research. Staff audited patient treatment and care, and used the findings to improve outcomes for patients. Patients commented positively about the skills of staff, the quality of food and the provision of pain relief. Reports showed appraisal rates were improving following the introduction of a new system. Staff completed training relevant to their roles, but overall their compliance with mandatory training was below the trust target.

There was effective team working within and across different staff groups. This included multi-disciplinary working to provide person centred care. Staff commented that local leadership was good and there were opportunities for personal and professional development. Some staff, however, felt isolated and disconnected from the senior management team. This was mainly theatre staff.

Patients told us that staff provided care in a kind and compassionate manner and they were involved in decisions about their care. They were asked for their views and response rates were high, with a high proportion of patients recommending treatment. Results of patient feedback, as well as quality and safety data, were displayed for patients and visitors to view on ward areas.

There was an effective governance structure to review performance and there was evidence of formal reviews of risks, incidents, deaths, complaints and audits. Performance data showed the hospital was achieving the referral to treatment times and its cancellation rate for operations was below the England national average. Medical patients were frequently allocated beds on surgical wards however, and this presented a risk to patient experience and care. Staff worked hard to minimise this risk by working to admission criteria and re-allocating staff to reflect patient needs.

Intensive/critical care

Good

Updated 25 February 2016

We rated critical care services as good overall, the service required improvement for responsiveness. There was a higher than average number of delayed discharges, which at times resulted in mixed sex breaches, sometimes across several days.

There was a culture of reporting and learning from incidents, the majority of staff received feedback from reported incidents. There was a low rate of hospital acquired infections, but infection control practices were not always adhered to.

The unit was built before specific building regulations, it was cramped and cluttered. There were safety systems for management of medicines, records and equipment. However, there was not always evidence that equipment was checked and ready to use.

There were processes for identifying and responding to risks and deteriorating patients on the unit.

The unit was consultant led and staffing levels met national guidelines, however the one doctor on duty at night was sometimes called away to the wards. The number of staff completing mandatory training was below trust target.

The critical outreach team was available 24 hours a day to respond to respond to requests to assess deteriorating patients across the hospital. The team followed up all patients discharged from the unit.

The treatment and care provided was evidence based. National and local audits and data showed there were good outcomes for patients. A number of critical care policies and clinical protocols were in the process of being reviewed.

There was access to multi-disciplinary services seven days a week. The wider multidisciplinary team did not attend the consultant led ward round the ward round. The allocation of multidisciplinary support to the unit, including pharmacy and physiotherapy, was lower that recommended.

Nurses were competent and trained in critical care nursing, with access university validated training. There was a low staff appraisal rate since introduction of a new process.

There was evidence of innovation and three research nurses undertook trials which aimed to improve patients care and outcomes. The critical care unit had won an award for developing a patient transfer course.

There was timely access to the unit and low rates of cancellation of operations due to lack of beds. The service was performing better than similar services in avoiding out of hours discharges.

Staff understood how to manage complaints and there was evidence of learning from concerns and complaints. Processes for formally obtaining patient and relative feedback were limited to the family and friends test on discharge.

Governance processes promoted reviews of the service quality and identified areas for improvement. Staff reported a strong consultant centred hierarchical culture on the unit and this was limiting delegation and multi-disciplinary team working.

Staff were caring and patients were treated with dignity and respect, staff tried to anticipate their needs and to enhance their experience on the unit. Patients and relatives gave positive feedback about the care they received and confirmed they had been informed and involved in the decision making regarding care and treatment. Staff offered on going emotional and psychological support to bereaved families.

The critical care unit was working to improve organ donation rate.

Services for children & young people

Good

Updated 25 February 2016

Children and young people received compassionate care that respected their privacy and dignity. They told us they felt involved in decision making about their care. We found staff were caring and compassionate. Without exception, parents of the children we spoke with praised staff for their empathy, kindness and caring. Children’s emotional needs were highly valued by staff and were embedded in their care and treatment.

Process and procedure was followed to report incidents and monitor risks. Staff were encouraged to report incidents. The environment was clean and equipment was well maintained. The children’s eye ward provided a ‘child-friendly’ environment with a variety of age appropriate toys and play equipment and access to play areas. Staff across all services described anticipated risks and how these were dealt with. Safeguarding protocols were in place and staff were familiar with these.

Infection control practices were followed. Staff regularly washed their hands in between patients, used personal protective equipment such as gloves and aprons, and adhered to the trust’s ‘bare below the elbows’ policy.

Children whose condition deteriorated were appropriately escalated and action was taken to ensure harm-free care. The five steps to safer surgery checklists were completed for children and young people undergoing surgery.

Nursing staffing on the children’s eye ward and outpatient clinics was adequate. There were three ophthalmology consultants with a paediatric specialist interest who operated on children for eye surgery. The trust employed two paediatric anaesthetic consultants to provide anaesthetic and analgesic advice in the eye theatre. The children in dermatology unit were seen by dermatology consultants with a paediatric specialist interest.

Staff provided care to patients based on national guidance, such as National Institute for Health and Care Excellence (NICE) guidelines. The trust did not participate in any national audits related to children and young people.

Arrangements were in place to ensure that staff had the necessary skills and competence to look after patients. The acute referral eye unit at the Royal Bournemouth Hospital (RBH) offered a seven-day service for children and young people suffering with acute eye problems. The unit was open between 8am and 6pm every day of the week. Staff received statutory and mandatory training, and described good access to professional development opportunities.

Children and young people were consented appropriately and correctly. Young people were presumed to be able to give consent depending on their maturity and the nature of the decision. Staff undertook competency assessment and, when a patient was found not competent, only a person with parental responsibility was able to give consent.

There was clear guidance for staff on ‘which patients to accept for eye surgery’ at the eye unit at RBH. Children aged less than one year of age and those with multiple comorbidities and traumatic eye injury were referred to Poole hospital or Southampton hospital for treatment.

Complaints were handled appropriately in line with trust policy and these were reviewed to improve the service.

There was no documented vision or strategy for services provided for children and young people. Staff were aware of the trust’s strategy and described high quality patient care as key components of the trust’s vision. There were effective governance arrangements and staff felt supported by service and trust management.

The culture within children and young people services was caring and supportive. Staff were actively engaged and innovation and learning was supported. There was good local leadership at ward level.

End of life care

Good

Updated 25 February 2016

There was a good track record and steady improvements in safety. Staff were aware of their responsibilities to report incidents and they received feedback on these incidents. Learning from incidents had taken place. Improvements to safety were made and the resulting changes monitored.

There were clearly defined and embedded systems to keep people safe. Arrangements to minimise risks to patients were in place including measures to prevent falls, and pressure ulcers. Patients had comprehensive assessments of their needs and were appropriately monitored. Staff demonstrated a good understanding of the early identification of a patients whose condition might deteriorate. The mortuary was appropriately clean. . All wards had documentation of the new care plan that the trust had introduced in July 2014 to replace the Liverpool Care Pathway

People’s care and treatment was planned and delivered based on current national and evidence-based guidance. There were local guidelines for the management of the five key symptoms at the end of life. The end of life care team had successfully introduced personalised care plan for the last days of life (PCPDL). Wards we visited were aware of this documentation which was a replacement following the national withdrawal of the Liverpool Care Pathway in July 2014. The trust was piloting AMBER Care Bundle on some wards. This was in response to an overarching vision and six ambitions identified in the National Framework of Ambition for Palliative and End of Life Care, 2015-2020.

There was participation in relevant local and national clinical audits. The trust participated in the National care of the dying audit for hospitals (NCDAH) 2013/14 and performed worse than average for six out of seven organisational indicators. However, a trust audit in August 2015 demonstrated that the trust had achieved progress in five out of seven indicators and there were ongoing plans for improvement.

Feedback from people who use the service was consistently positive about the way staff treat people. Patients were cared for by compassionate and caring staff and we observed patients being treated with dignity and respect.

Patients told us they were well informed in their treatment and care. For example staff spent time talking to people to discuss and allay their fears.

There was a clear statement of vision of end of life care. This vision was based on promoting quality of care and a culture of patient safety. The trust, after our visit, produced a document with an overarching strategy for end of life care based on existing strategic objectives and actions to meet national guidance and standards. This had not been subject to consultation or consideration by the trust board.

A consultant in palliative care was the clinical lead who championed end of life care and palliative care, and the associate medical director provided leadership and support. There was a steering group to monitor performance against national standards. Strategic objectives were supported by quantifiable and measurable outcomes, which were cascaded throughout the organisation.

The end of life steering group met regularly and had identified an audit programme to monitor the quality of the service. The end of life care team had developed their own performance dashboard based on national standards and local guidance. This was presented to the trust board on a monthly basis, for discussion.

Outpatients

Good

Updated 25 February 2016

The outpatient and diagnostics imaging departments provided good safe, caring, responsive and well led services for patients.

Staff were encouraged to report incidents and the learning was shared to improve services. In diagnostic imaging, staff were confident in reporting ionised radiation medical exposure (IR(ME)R) incidents. They followed procedures to report incidents to the radiation protection team and the Care Quality Commission where necessary. The Duty of Candour was understood by senior staff, but it was not appropriately documented and considered. There was not however, a clear breach of the regulation.

The environments were visibly clean and staff followed infection control procedures. Equipment was maintained regularly and medicines were appropriately managed and stored. However, in sexual health services the patient group directions for administration of medicines had expired.

Electronic patient records were used in outpatient clinics; this had been a recent implementation. Staff felt they were using the system well but there was concern about the increases in administrative time on clinic staff and the management of records information to reduce risk to patients.

Patients were assessed and observations were performed, where appropriate. However, there was no assessment tool available to identify patient’s whose condition might deteriorate in outpatients.

Nurse staffing levels were appropriate and there were few vacancies. Radiographer vacancies were higher but recruitment was underway, some candidates had recently been appointed.

People’s care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation. This was monitored to ensure consistency of practice. There were local audit programmes to monitor clinical standards. Staff had access to training and had annual appraisal but did not have formal clinical supervision.

Staff followed consent procedures and had a good understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards which ensures that decisions are made in patients’ best interests.

Patients consistently told us that they had experienced a good standard of care from staff across outpatients and diagnostic imaging services. We observed compassionate, caring interactions from nursing, medical and radiography staff. Patients and relatives told us that they were included in the decision making process regarding their care and treatment. Staff recognised when a patient required extra support to be able to be included in understanding their treatment plans.

There was good evidence of service planning to meet people’s needs. For example, the breast clinics within the Jigsaw building offered access to one stop clinics, patients were able to see a clinician, have a biopsy and see a radiologist if required. Ophthalmology patients had access to a one stop cataract clinic. National waiting times were met for outpatient appointments and cancer referrals. There were some clinics cancelled at short notice, but this was lower than the England average. The waiting times for diagnostic imaging within six weeks met national targets on average over the year. However, In October 2015 the percentage of patients waiting over 6 weeks for diagnostics was 6.2% compared to the England average of 2 – 2.5%.

There was good support for patients with a learning disability or living with dementia. Clinicians had access to translation services and most staff knew how to access the service if required. The service received very few complaints and concerns were resolved locally. Staff were not aware of complaints across the trust or the learning from complaints.

The outpatient department had a strategy and were developing a plan to improve new patient referral waiting times. There were plans to deliver advice and guidance via telephone clinics, to assess where follow up care should be provided. There were various one stop and nurse led clinics already in place. Staff were not aware of how the strategy would develop for the future within their own departments. In diagnostic imaging they were working toward the ‘2020 strategy’ with staff representatives who were assisting to move the strategy forward.

Governance processes to monitor risk and quality were well developed within the outpatient departments and in diagnostic imaging.

Some staff were clear about the overall vision and values of the trust. Nurses and radiographers spoke highly of their immediate line managers and told us they worked in caring, supportive teams which they valued.

There were good examples of local innovation and improvement to services. Particularly in ophthalmology, diabetes and endocrine services and in respiratory medicine.