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Inspection Summary


Overall summary & rating

Good

Updated 18 June 2018

  • Across the trust, we found the services we inspected to be safe, effective, caring, responsive and well led. We rated safe, effective, caring and responsive as good overall and well led to be outstanding.
  • The trust had made significant improvements in all the areas we inspected. Trust leaders had taken a cultural approach to improving services, ensuring that quality improvement and continuous improvement were integral to the everyday workings of the trust.
  • Patient safety was afforded sufficient priority. Staff kept patients safe from avoidable harm and abuse. When patient safety incidents occurred, the trust took a robust and systematic approach to ensuring that learning was identified and practices improved where appropriate.
  • Staff followed best practice and evidence based guidance to ensure patient outcomes were good. Patient outcomes were mostly better or similar to other acute trusts when compared nationally.
  • There were sufficient numbers of suitably skilled and trained staff to deliver effective care and treatment.
  • Equipment and premises were fit for purpose, clean and managed well. Medicines were safely managed.
  • Staff, including senior leaders, worked together and followed clear escalation protocols when the hospital was reaching capacity to ensure patient care was not unduly compromised.
  • Patients were treated with dignity and respect throughout the trust and trust leaders promoted a person centred culture. Patients and their relatives gave consistently positive feedback about the care they received.
  • The trust was responsive to individual needs and made good provision for patients with mental health conditions and/or a learning disability.
  • Services were planned in a way that ensured patients could access care and treatment in a timely way.
  • The trust was ranked first (highest performing) when compared against acute trusts nationally in the NHS staff survey of 2017.
  • Senior leaders at the trust provided exemplary leadership to staff, ensuring staff had the right tools in place to drive improvements and innovate in their everyday work.
  • Trust leaders had developed a clear mission, strategy, vision for the trust underpinned by clearly understood strategic objectives and key priorities.
  • Robust governance arrangements and risk management ensured the trust could deliver against its strategic objectives.
  • The trust were working collaboratively with system partners towards the transformation of services across Dorset.
  • The relationship between the board and the Council of Governors had improved and board members were more responsive to challenges and concerns raised by governors.
Inspection areas

Safe

Good

Updated 18 June 2018

Effective

Good

Updated 18 June 2018

Caring

Good

Updated 18 June 2018

Responsive

Good

Updated 18 June 2018

Well-led

Outstanding

Updated 18 June 2018

Checks on specific services

Outpatients and diagnostic imaging

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.

Maternity

Good

Updated 18 June 2018

  • People, including vulnerable women, were protected from harm and abuse. Staff understood and worked with other agencies to ensure expectant women were protected from abuse and poor care.
  • Where incidents occurred, lessons were learned and communicated widely, including with system partners, to support improvement.
  • The service controlled and prevented the spread of infection well.
  • The service had suitable premises and equipment and looked after them well.
  • Staff were competent for their roles. Managers regularly appraised staff, and held regular meetings to support them.
  • Women had good birthing outcomes because they received effective care and treatment that met their needs. Up to date information about patient outcomes and audit results were shared, and used to improve care and treatment outcomes.
  • Women and their families received care in a compassionate manner by staff that displayed kindness and respect in their interactions.
  • Women and their families were overwhelmingly positive about the care and treatment they had received.
  • Leaders at every level were visible and approachable and highly regarded by staff at all levels. Leaders were working in a highly collaborative way with system partners to ensure outcomes for women were positive.
  • The leadership, governance and culture promoted the delivery of high quality person-centred care.

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)

Good

Updated 18 June 2018

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

  • People were protected from harm and abuse. Staff understood and worked with other agencies to ensure patients were protected from abuse and poor care.
  • Where incidents occurred, lessons were learned and communicated widely to support improvement in other areas where appropriate.
  • The service mostly controlled and prevented the spread of infection well. There were effective dirty and clean flow areas in endoscopy, and a clear process for the decontamination and sterilisation of endoscopes.
  • The service had suitable premises and equipment and looked after them well.
  • The service made sure staff were competent for their roles. Managers regularly appraised staff, and held regular meetings to support them.
  • People had good outcomes because they received effective care and treatment that met their needs. Up to date information about patient outcomes and audit results were shared, and used to improve care and treatment and people’s outcomes.
  • People were supported, treated with care, dignity and respect and were involved as partners in their care. People received care in a compassionate manner and we observed they were treated with kindness during all interactions with staff.
  • Patients were overwhelmingly positive about the care and treatment they had received.
  • People’s needs were met through the way services were organised and delivered. Reasonable adjustments were made and action taken to remove barriers when people found it hard to access or use services.
  • Leaders at every level were visible and approachable. Compassionate, inclusive and effective leadership was evident in the medical care service. The trust had effective recruitment, deployment, support processes for staff and succession planning.
  • The leadership, governance and culture promoted the delivery of high quality person-centred care. Quantifiable and measurable outcomes supported strategic objectives, which were cascaded throughout the organisation.

However

  • Whilst the service overall was provided safe care, there were some inconsistency with measures to control and prevent infection, medicines management, the completion of patient risk assessments in a timely way and storage of patient records.
  • Staff compliance with screening patients’ nutritional needs using a national tool was 84% against a trust target of 100%.
  • Staff demonstrated some variation in how and when to assess whether a patient had the capacity to make decisions about their care.
  • A proportion of patients did experience a delay when medically fit with their transfer from hospital. The trust’s greatest concern was delays in transfers to community hospitals, services and packages of care.

Urgent and emergency services (A&E)

Good

Updated 18 June 2018

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

  • We previously undertook a comprehensive inspection of urgent and emergency care in October 2015. At that time we rated the service in the emergency department as requires improvement for safe, effective, responsive and well-led services. Care of patients was rated as good.
  • We observed impressive escalation protocols in action that served to protect patients from avoidable harm whilst the trust was at the highest escalation level. Similarly, staff morale remained high and care did not appear to be compromised.
  • The environment was safe and staff ensured that equipment was looked after and used control measures to reduce the spread of infection.
  • Staff knew how to safeguard patients from avoidable harm and abuse. Staff showed good understanding of MCA and DoLS legislation.
  • The department had sufficient numbers of staff to provide safe care and treatment. Staff were observed to be competent and skilled within their roles. A wide variety of staff worked effectively together for the benefit of patients.
  • Records were stored securely and completed accurately. Medicines were stored and administered safely.
  • Care and treatment was evidence based, followed national guidance and mostly produced positive outcomes for patients.
  • Staff worked in a person-centred way, demonstrating kindness and compassion to patients and their loved ones.
  • The trust planned and provided services in a way that met the needs of local people. Staff worked hard to meet national waiting time targets and ensure patients were treated in a timely and responsive way.
  • The service took account of patients’ individual needs. Staff made suitable adjustments where needed for patients with individual or complex needs.
  • The directorate had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. Governance processes were robust and we saw clear reporting lines from ward to board.
  • Risks were identified, escalated and mitigated where possible. When incidents, including deaths, occurred these were reported, investigated and learning shared.

Surgery

Good

Updated 18 June 2018

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

  • The surgical services had improved overall since the last inspection; active staff recruitment had taken place with innovative methods to increase staff retention in theatres. Staffing levels were regularly reviewed by senior staff with a method for escalation of red flag shifts to the board. Patients were risk assessed for safety regularly with reviews and reassessments on line.
  • The patients’ care and treatment was broadly based on current national guidance, audits and monitoring took place internally and nationally to monitor effectiveness and to improve patient outcomes.
  • Care was delivered in line with the Mental Health Act 1983 and Mental Capacity Act 2005, staff were aware of their responsibilities to safeguard their patients from harm.
  • Patients told us of the compassionate care they received, with respect for their privacy and dignity. They felt supported with information to make decisions about their care.
  • Patients could access surgical services that were planned around their needs. Most surgical services met or were better than the national access targets.
  • Complaints or concerns were dealt with appropriately with any learning shared across the trust.
  • The service had engaged with staff and created a vision that reflected the trust values.

However,

  • Recent never events did not illustrate that learning from a previous incident had been embedded.
  • Clinical cleaning compliance was inconsistent.
  • There was no reference to online risk assessments in the paper based nursing documentation including care plans.
  • Fluid charts were not consistently totalled to give an accurate 24-hour balance. Food charts were not always fully completed.

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.