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Inspection Summary


Overall summary & rating

Good

Updated 14 March 2018

Our rating of these services improved. We rated them as good.

A summary of services at this hospital appears in the overall summary above.

Inspection areas

Safe

Requires improvement

Updated 14 March 2018

Effective

Good

Updated 14 March 2018

Caring

Good

Updated 14 March 2018

Responsive

Good

Updated 14 March 2018

Well-led

Good

Updated 14 March 2018

Checks on specific services

Outpatients and diagnostic imaging

Good

Updated 13 January 2016

Barnsley Hospital NHS Foundation Trust outpatients and imaging departments was judged as good overall. The safe, caring and well-led domains were rated as good with the responsiveness domain found to be requiring improvement. We are currently not confident that we are collecting sufficient evidence to rate effectiveness for outpatients and diagnostic imaging.

Within the departments, patients received safe care and staff were aware of the actions they should take in case of a major incident. Incidents were reported, investigated appropriately and lessons learned were shared with all staff. The cleanliness and hygiene in the departments was within acceptable standards, however, there were some areas in need of re-decoration and a lack of appropriate seating for patients with different needs in some areas.

Staff were aware of the various policies designed to protect vulnerable adults and children and we saw good examples of actions taken to address identified concerns.Patients were protected from receiving unsafe treatment as medical records were available 99% of the time and electronic records of diagnostic results, x-ray images and reports and correspondence were also available. The records we looked at were in good order and entries were legible; however, some areas of record keeping practice required improvement.

Workload within outpatients was predictable due to the scheduling of clinics and availability of clinic lists in advance and nurse staffing levels were based on the number of clinics and expected number of patients. There were some vacant radiologist and radiographer posts; however, there were mitigations in place to ensure gaps in service were covered.

Care and treatment in outpatients and diagnostic imaging was evidence-based and performance targets consistently met. The staff working in outpatients and diagnostic imaging departments were competent, received an annual appraisal and there was evidence of multidisciplinary working across teams and local networks. Nursing, imaging, and medical staff understood their roles and responsibility regarding consent and the application of the Mental Capacity Act.

Staff undertook regular audits in imaging and pathology departments regarding quality assurance to check practice against national standards and action plans were put in place to make improvements when necessary. We found that some imaging reports contained mistakes due to the voice recognition system that generated the reports. We were told that no formal audit was in place to monitor these errors, but that clinicians highlighted errors in reports within their discrepancy audits.Outpatient clinics ran every weekday, occasionally at weekends and on Thursday evenings. Imaging services for inpatients were available seven days a week.

During the inspection, we saw and were told by patients that staff working in the outpatient and diagnostic imaging departments were kind, caring and compassionate at every stage of their journey. Patients told us they were given all of the information they needed, were given sufficient time and were encouraged to ask questions to ensure understanding. Patients were able to make informed decisions about the treatment they received and there were services in place to emotionally support patients and their families.

Confidentiality was maintained in all of the areas we visited.

Areas of good practice included mechanisms to ensure that services were able to meet the individual needs of patients such as for people living with dementia, a learning disability or physical disability, or those whose first language was not English. There were also systems in place to record concerns and complaints, review these and take action to improve patients’ experience.

Staff were focussed on delivering the best possible experience for all of their patients.

Staff and managers had a vision for the future of the departments and were aware of the risks and challenges. Managers at all levels were active, available and approachable to staff. Staff felt supported and were able to develop to improve their practice. Regular meetings took place where all staff participated and were confident to talk about ideas and sharing of good news as well as anticipated problems. There was an open and supportive culture where lessons were learnt and practice changes resulting from incidents and complaints were discussed.

The department was supportive of staff who wanted to work more efficiently, be innovative and try new services and treatments. Staff were centred on delivering a good patient experience, they said that they felt proud to work for the trust and that they provided a good service to patients.

After moving to the new electronic patient record system in October 2014, the trust had identified in June 2015 that 23,557 patients were being held on a review list and who may not have been provided with follow up appointments. Immediate validation of the list reduced this to 7,980 patients overdue an appointment to end August 2015. Due to the change in processing the trust was carrying a backlog of about 2,000 outpatient outcomes per month; these were all reconciled by the end of each month. A further 9,613 patients appeared to have an open patient pathway, however these patients were discovered to have multiple pathways opened in error and the duplicates were removed from the system early into the validation process. Work was underway to ensure all relevant patients were offered a review appointment by 30th November with all patients seen by 31 January 2016; however, this was rated as a red risk by the trust, which indicated the potential patient safety risk associated with missed appointments. It was unknown at the time of inspection whether any harm had occurred to patients as a result of this situation, however, there was a risk that there may have been delayed treatment or diagnosis.

There were relatively high rates of cancelled clinic appointments and patients who did not attend their appointments.

Maternity and gynaecology

Good

Updated 13 January 2016

Staff were encouraged to report incidents and systems were in place following investigation to help rapidly disseminate learning. Both nursing and medical staffing levels were in line with national guidelines. The service was 90% compliant for mandatory training overall and this was in line with the trust target. We saw evidence of how they had recently addressed non- compliance in safeguarding supervision training, and although there were some areas which did not meet the trust target, they had identified further training days to address these shortfalls. We found an unlocked cupboard of diaries which contained confidential information. This was brought to the attention of the trust who acted immediately and addressed the situation.

Women received care according to professional best practice clinical guidelines. The unit provided individualised care to people using the service and they were treated with privacy, dignity and respect. The trust had a specialist midwives in bereavement who provided support, compassion and care for women and their families in time of bereavement.

The trust dashboard showed they were not always meeting their key performance indicators (KPI’s) for antenatal bookings for women to be seen before 10 and 12 weeks of pregnancy. The trust target was 90% and the information showed, between April 2014 and February 2015, the bookings for women to be seen before 10 weeks ranged between 53.3% and 81.2%. Women booking before 12 weeks ranged between 72.4% and 96.9%. Trust managers had identified that there were data extraction issues following implementation of the new maternity information system. A manual audit showed the target was met for the 12 week bookings, but not the 10 week antenatal bookings. An action plan had been written to address the issues which included a review and completion dates. A supervisor of midwives was available for all women using the service and feedback/debriefing was offered to patients who had not followed their choice of care pathway.

The service was managed by a cohesive team who understood the challenges of providing good, quality care. They were aware of their shortfalls and had taken steps to address them. Staff were encouraged to drive service improvement and used creative and innovative ways to try to ensure they met the needs of women who used the service and the organisation.

Medical care (including older people’s care)

Good

Updated 14 March 2018

However:

  • There were issues with the access and flow of patients through this service.

Urgent and emergency services (A&E)

Good

Updated 14 March 2018

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

The service had addressed previous recommendations, namely:

  • Patients that did not attend ED by ambulance now had an initial assessment undertaken by a suitably qualified healthcare professional in accordance with national guidance.
  • The department had increased the number of registered sick children’s nurses (RSCN) from three to nine nurses. RSCN’s worked from 7am to midnight. At other times, paediatric patients were assessed and triaged by adult registered nurses. The trust was aware that it was not meeting the Royal College of Emergency Medicine Guidelines which states that one RSCN should be in place per shift.
  • A bid submitted by the trust had been accepted to co-locate the paediatric ED department and children’s assessment unit together where staffing would be reviewed. No timescales were provided by the trust for when this will be commenced.
  • A process was in place to review mandatory training for nurses.There had been improvements to the percentages of staff complying with training. However, further work was required to ensure that medical staff completed mandatory training.
  • A process was in place for the recording of verbal consent in a patient’s clinical record when requiring minor surgery in the department.
  • The department had reviewed sign language interpretation availability and a database was accessible for staff to use. The trust was also engaging with the deaf community to use a video link interpreting tool.

Surgery

Good

Updated 14 March 2018

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

  • We rated safe, effective, caring, responsive and well-led as good.
  • We saw evidence that the service investigated serious incidents thoroughly and monitored the impact of recommendations for improvement by following-up on each action.
  • A review of 10 medical records demonstrated oxygen being prescribed in line with national guidance and that medication reconciliation was achieved within 24 hours for the majority of patients.
  • Observation of records and practice in theatres and local audit outcomes demonstrated that compliance with completing the five steps to safer surgery had improved to 99%.
  • The environment was visibly clean in all areas inspected and infection prevention and control practices had improved for clinical stock management.
  • Laparoscopic colorectal surgery was made available to suitable patients in accordance with National Institute of Clinical Excellence (NICE) guidance. Since the last inspection, the trust had recruited two new colorectal surgeons and was in the process of recruiting a third surgeon to extend the service.
  • Compliance with national emergency laparotomy audit requirements had improved.
  • The trust had reconfigured the bed base in general surgery and introduced a new system to centralise preparation of patients for theatre. This had improved the care pathway for surgical patients.
  • A clinical lead for surgical services had been appointed and the clinical business unit leadership team demonstrated a cohesive approach to achieving their strategic aims.

Intensive/critical care

Good

Updated 13 January 2016

We rated the care delivered by the intensive therapy (ITU) and the surgical high dependency (SHDU) units as good.

Staff used the trust policies and procedures when reporting incidents. Details of incidents and the lessons learnt were shared among staff and action was taken to prevent or minimise the occurrence of similar incidents. There was a multidisciplinary team (MDT) approach to reviews of incidents, morbidity and mortality. Staff attended organisational inductions, mandatory training which included safeguarding and infection prevention and control.

The Safety Thermometer results between April and June 2015 showed the unit had performed better than the nationally expected targets. The units had sufficient supplies of equipment and cleaning products to maintain safety. Equipment was cleaned in line with the department of health infection control policy. Staff we spoke with were aware of the major incident policy and their role in managing it.

An outreach team made up of a consultant, a nurse, a physiotherapist and a healthcare assistant supported patients when they were transferred from ITU or SHDU to wards. They also assessed deteriorating patients within the hospital and decided whether patients would be appropriately cared for in either SHDU or ITU.An outreach team supported patients when they were transferred from ITU or SHDU to wards. They also assessed deteriorating patients within the hospital and decided whether patients would be appropriately cared for in either SHDU or ITU. A multidisciplinary team approach meant care was delivered in a more co-ordinated and consistent way which had a positive impact on patient progress and the length of time spent on the unit.

The computerised system used by nursing staff was seen as onerous, time consuming and unreliable. Access to information for bank and agency professionals was available after appropriate training. Management told us that there was a system in place to provide agency nurses with their own unique access login. However to maintain safety this automatically expired after 30 days.There was good understanding of the Mental Capacity Act and its application.

Patients and relatives we spoke with told us that they would recommend this service to others. We observed examples of good compassionate care and treatment practices by staff. Staff had implemented the use of ‘patient’s diaries’ on ITU. Relatives had access to a bereavement service and enquiries about organ donation were attended to by a specialist nurse.

The ITU and SHDU services worked collaboratively with the surrounding NHS providers to meet the needs of the local population. Patients discharged from ITU and SHDU had access to a follow-up clinic. Staff were proud to work at the Barnsley hospital and they understood the priorities.

There was a clear structure within the unit for doctors, nurses and the multidisciplinary staff. They demonstrated their roles and their specific responsibilities during our inspection so that patients received consistent care.

We found that 24 hour intensivist cover was not provided for ITU in accordance with Core Standards for Intensive Care Units guidance (2013), however plans were in place to address this. On six occasions over two weeks the lead nurse and the clinical educator were counted in the numbers to ensure safe staffing levels. The fill rate of shifts for registered nurses was 80-85% during days and 93 -97% at nights over the previous three months.

Services for children & young people

Requires improvement

Updated 14 March 2018

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

  • We rated safe and well led as requires improvement. Effective, caring and responsive were rated as good.
  • Although staff told us they understood their responsibilities in relation to safeguarding children and young people and could tell us the process for making a referral to the local authority, we were not assured that vulnerable children, particularly those with a mental health condition, would be identified by the trust in a timely or robust way. Staff were not consistently following the safeguarding children policy.
  • Staff had not had any training to ensure effective support for children and young people with mental health conditions and there were no risk assessments or care plans to ensure the effective management of children and young people with mental health needs.
  • National guidance was not followed to determine staffing ratios on the children’s ward and the trust had not used an acuity tool to assess staffing needs since October 2016.
  • There was no specific documented pathway in place for paediatric sepsis at the time of the inspection. Documentation did not include all the red flags or have variation for different ages. However, following our inspection the trust produced a paediatric policy and pathway that now needs to be embedded in practice.
  • We were not assured that the leadership team had enough focus on ensuring appropriate safeguarding processes were in place for the children and young people admitted to the trust.
  • Risks associated with staff having had no mental health training had not been identified on the risk register.

However:

  • Premises and equipment were well looked after and clean. Control measures were in place to prevent the spread of infection.
  • Care and treatment was based on national guidance and the service monitored the effectiveness of care and treatment.
  • We saw evidence of effective multidisciplinary working. Staff supported each other to provide good care.
  • Staff cared for patients with kindness and compassion, ensuring they involved patients and their families. Feedback we received about the services from patients and their families was positive.
  • Services were planned and provided in a way that met the needs of local people. Waiting times were in line with good practice.
  • The service had a clear vision and strategy that all staff were aware of. The service vision and strategy aligned with the trust vision and strategy.
  • There were effective governance systems and processes in place. Regular review of the risk register took place.

End of life care

Good

Updated 13 January 2016

We rated end of life care services at Barnsley hospital as good. There were some outstanding examples of compassionate care. There were areas where there was potential for improvement and these had been identified by the trust. We saw evidence that work was in progress to further improve the service.

The end of life service was led by committed leaders. There was good visibility of senior staff and end of life care was high on the agenda of the trust. The trust’s end of life steering group, which was responsible for providing clinical leadership and implementation of the service, told us they provided assurance to the trust. Procedures had been developed to support a smooth transition of care from hospital to the community. There were strong links with community teams.

There had been 550 referrals to the specialist palliative care team from April 2014 to March 2015. This had increased from 480 referrals the year before. We saw 100% of the referrals made to the team from April to June 2015 were seen within 24 hours. Most of the referrals (85%) were for cancer related diagnosis and the palliative care team were aiming to address the imbalance by working with other services to reach end stage heart and respiratory failure patients. The AMBER care bundle had been implemented using a rolling programme across medical wards at Barnsley hospital since May 2013. There was a dedicated AMBER care pathway facilitator. The AMBER care bundle is an approach used in hospitals when clinicians are uncertain whether a patient may recover and are concerned that they may only have a few months left to live.

We saw outstanding compassion for patients at the end of life and their families, particularly from the porters, mortuary staff and bereavement officers. Porters told us they looked after deceased patients as if they were their own parents and were committed to caring for them in a dignified manner. The mortuary team provided training to a wide range of staff from inside and outside the trust. There were comfortable, sensitively decorated areas for bereaved families; we found that a number of staff in a variety of roles supported them.

During our inspection we found that oxygen was rarely prescribed. The National Patient Safety Agency (NPSA) indicates oxygen should always be prescribed except in emergencies, as there is a potential for serious harm if it is not administered and managed appropriately. We pointed this out to senior managers at the time and immediate action was taken to address this.

We found that advance care planning was rare. If patients brought in a preferred place of care folder into hospital from the community, hospital staff thought it was not relevant, as it was a ‘community document’. Senior nurses and doctors told us they did not understand the concept of advance care planning; they thought this could only be done in the community. Some staff told us it was often too late to have care planning discussion with patients by the time it was recognised they were dying. This was reflected when we found three patients on the respiratory ward had become too poorly to be transferred. We found that advance care planning would have prevented these situations and enabled patients to achieve their preferred place of care at the end of life.