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Inspection Summary


Overall summary & rating

Good

Updated 27 July 2015

Peterborough and Stamford Hospitals NHS Foundation Trust was one of the first wave of NHS trusts to be authorised as a foundation trust in April 2004. The trust has approximately 633 beds and over 3,500 staff spread across two sites, Peterborough City Hospital (611 beds) and Stamford Hospital (22 beds). Peterborough City Hospital is a new building funded under the private finance initiative (PFI); it became fully operational only in December 2010, combining services previously supported on three separate sites. It provides acute health services to patients in Peterborough, Cambridgeshire and Lincolnshire.

In addition, the trust provides a range of community services including community midwifery and Macmillan nursing as well as domiciliary visits undertaken by consultants. The trust provides rheumatology and neurology services at the City Care Centre and services in support of Sue Ryder in Peterborough, at HMP Peterborough and in local GP practices. We did not inspect these services during this inspection.

This was a follow up inspection to the comprehensive inspection of March 2014. This inspection was focused and specifically considered  the core services of urgent care and medicine and looked at all key questions and considered the responsiveness of children’s services as well as the effectiveness in end of life services. The inspection took place on the 18th and 19th May 2015.

Overall we found a trust that is improving and had addressed most of the issues we noted during our inspection in March 2014.

Our key findings were as follows:

  • There had been a recent improvement in the performance of the emergency department against the four hour wait and treatment target.
  • A new medical admissions unit had improved patient access and flow through the emergency department and the rest of the hospital whilst also reducing the numbers of outliers.
  • Safeguarding procedures in the emergency department were more robust with appropriate checks made by staff regarding children’s attendance in the department.
  • Medical and nursing staffing had improved across the clinical areas we inspected since our last inspection in 2014 but there remained shortfalls in some areas and there had been an acuity review during this period with an uplift in staff in some areas.
  • There were some concerns about storage of medicines in medical wards, specifically the monitoring of temperatures.
  • Whilst there was evidence of a learning culture, this was not embedded across the whole of the medical directorate.
  • Leadership was visible at trust and directorate level. Most staff felt valued and supported by their managers.
  • The majority of staff were caring and compassionate when providing care and treatment but we observed a small number of interactions that were not caring.
  • The service had made significant improvements in relation to the provision of same sex accommodation and services for adolescents. The service had engaged adolescents in service development and improvement. We saw a number of patient feedback stories from adolescents giving their opinions on the service, one of these had even been presented to the trust board.
  • The Amber Care Bundle had been successfully rolled out to all areas and there was a more consistent approach to managing pain relief in end of life care patients.

We saw several areas of outstanding practice including:

  • The trust had thoughtfully engaged with children and young people in the service development and improvement of children’s services.
  • A new transition projected had been agreed and was being supported by a CQUIN target for this year called “Ready Steady Go”. This project aimed to build confidence and the understanding of children, younger people and their families’ when transitioning into adult services.

  • The trust was now meeting face to face increasing numbers of patients to discuss concerns or complaints.
  • The Quality Assurance Committee was open to some external stakeholders including Healthwatch.

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

Importantly, the trust must:

  • Ensure records are accurate and updated to reflect the needs of patients and that care is given in line with records.

In addition the trust should:

  • Ensure that learning from incidents is disseminated consistently across the medical directorate.
  • Ensure that patients are adequately supported with nutritional needs on medical wards.
  • Ensure that medicines are stored correctly in all areas.
  • Ensure that call bells are answered in a timely way.

    • The trust should ensure that there are appropriate measures in place to further reduce falls and pressure ulcers.
    • The trust should ensure effective admission to the stroke unit for patients requiring specialist care.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 27 July 2015

Effective

Good

Updated 27 July 2015

Caring

Good

Updated 27 July 2015

Responsive

Good

Updated 27 July 2015

Well-led

Good

Updated 27 July 2015

Checks on specific services

Maternity and gynaecology

Good

Updated 16 May 2014

Women we spoke with were generally positive about their experiences. Each person said that they had been very well informed throughout their pregnancy and that staff had been attentive to their needs and demonstrated a caring attitude. There was, however, a small number of negative comments about how quickly staff responded to queries or questions people may have had. Staff we spoke with were positive about the running of the service and there were clear lines of responsibility.

We saw how the service identified, responded to and acted upon things that had gone wrong to ensure that the service remained safe.

Effective practices were in place and these were continually monitored and reviewed to ensure that the service met the needs of the women it cared for. The service was staffed in line with recommended ratios; however, concerns were raised about the level of staffing within the antenatal clinic.

While overall the service was well led, we found that there was confusion within the senior team about how and where the staff should report quality issues. Also, there was no clear strategy or vision for the maternity service. We found that the service had not analysed information to determine how it could improve the running of the available maternity helpline.

Medical care

Requires improvement

Updated 27 July 2015

Medical care (including older people’s care)

Updated 27 July 2015

In 2015 we returned to this service to follow up on issues identified at our last inspection. In 2014 the service was found to require improvement in relation to all five domains. In 2015 we found that whilst some improvements had been made to focus on aspects such as falls prevention, pressure ulcer care and patient flow there still remained areas of concern which resulted in the service still requiring improvement in all areas. Incidents remained high, with learning not widespread, records, documentation and medicine storage required improvement. Timely admission to the stroke unit remained an issue as did consultant staffing and auditing within the respiratory service. There were also some incidences of poor interactions between staff groups and staff and patients.

Urgent and emergency services (A&E)

Good

Updated 27 July 2015

At our previous visit in March 2014 we found some areas of urgent care that required improvement. This inspection was to review and report on those issues.

In 2015 the trust was  meeting the four hour waiting time target for treatment and discharge from emergency department (ED). The performance on this target was improved due to the implementation of a medical admissions unit two weeks prior to our visit. In the quarter January to March 2015 the Trust had seen 84% of the 21,867 patients within four hours against the target of 95%. The Trust had improved patient flow through the hospital to achieve the target in the weeks prior to our visit. Activity was recorded in detail and showed approximately 7% increase on the previous year at the time of our visit.

Medical and nurse staffing had been improved since our last visit. A review had been undertaken to revise the nurse staff complement. There was still much use made of agency nursing staff but this was to ensure safe staffing. Locum cover for consultants was minimal due to effective recruitment into senior posts.

Arrangements to care for children had been improved since our last visit. There was a designated paediatric area. This was closed after 9:30pm with children moving to main ED bays. There was only two paediatric registered nursing staff in the ED however, other staff received additional training to mitigate the risk. There were checks made of children under five attending against social services risk databases.

Staff working within the department generally felt well supported by management and thought that they worked in an open and transparent environment.

Surgery

Good

Updated 16 May 2014

Services in the surgical department were safe for patients. Services were provided in a clean and hygienic environment in line with recognised guidance, which helped protect patients from the risk of infection, including hospital-acquired infections.

We saw staff who were caring; the patients we spoke with complimented staff on their caring approach and professionalism.

Shortages of beds resulted in some patients being admitted to an inappropriate environment, particularly in the planned surgery orthopaedic ward. Patients’ operations were often cancelled or delayed due to lack of capacity. The operating theatre time available, due to cancelled elective surgery, was utilised by performing emergency surgery and thus minimising the need to attend to cases out of hours. Gaps in staffing were met using bank (overtime) and agency staff, but such staff were not always available. The trust has a recruitment programme; however, staff reported to us that there were delays recruiting and replacing staff.

Action plans were written as a result of reported incidents; however, there was no robust system in place to facilitate learning from incidents or complaints. We saw that appropriate equipment checks and maintenance were carried out. However, there was a lack of storage space throughout all the surgical wards.

Most of the staff we spoke with felt supported by their managers. A minority reported to us that they would be afraid to raise concerns and they feared being victimised. However, most staff we spoke with said that they would challenge a senior member of staff for wrongdoing, either directly or via a senior colleague. Staff training and appraisals were carried out to ensure that staff were competent and had knowledge of best practice to effectively care for and treat patients. A clinical governance framework was also in place.

We found that staff were responsive to people’s individual needs; however, staff told us that there were often delays in patients’ discharge from the hospital.

Intensive/critical care

Good

Updated 16 May 2014

Critical care patients received safe, responsive and effective care services. The service was provided by sufficient specialist staff in a spacious and clean environment. Admissions to the unit were organised so that they were appropriate and took place without delay.

We saw that people received care and treatment according to national guidelines. There were always sufficient staffing numbers to meet patient needs. Consultant-led one-to-one nursing, or two-to-one nursing, was provided according to each patient’s assessed level of need. The staffing ratio was planned so that it was sufficient to meet the needs of critical care patients.

Staff training and appraisals were carried out to ensure that staff were competent, were aware of best practice, and were effective in caring for and treating patients. Care delivered within the unit and to patients on other wards by the outreach team was observed to be person-centred and compassionate.

Patients were supported to make decisions about their care where possible, and relatives were included in their family member’s care planning. There was an unacceptable level of delayed discharges from the critical care unit. There was effective leadership at all levels within the critical care service.

Services for children & young people

Good

Updated 27 July 2015

In 2014 we found that children’s and young people’s services were provided in a clean and hygienic environment in line with recognised guidance, which helped protect patients from the risk of infection, including hospital-acquired infections.Children’s care and treatment followed best practice guidance and monthly audits were carried out regarding patient safety, patient experience and the environment. Parents we spoke with told us that they felt that their child received good-quality care and that they were informed about any treatment required.

In 2014 we found that staff were responsive to people’s individual needs; however, staff were unaware of the trusts guidance for staff on the ward areas when they needed to make a decision concerning same-sex accommodation. There was also limited support from the child and adolescent mental health services out of hours. There was leadership at all levels within children’s and young people’s services and staff felt well supported well supported by their managers. A clinical governance frame was also in place.

In 2015 we returned to the service to assess whether or not improvements had been made in relation to the responsive domain where in 2014 the service was found to require improvement. This was specifically in relation adolescent service provision and the use of single sex accommodation. It was also identified that improvements were needed in relation to joint working with child and adolescent mental health services (CAMHS). We found that these improvements had been made and that the service had worked extremely hard to develop and progress projects and plans to meet the needs of the children and young people using this service.

End of life care

Good

Updated 27 July 2015

In 2014 we found that the trust had a strong focus on end of life care. The trust had used CQUINs (Commissioning for Quality and Innovation targets agreed with the local commissioning groups) to develop and improve the service provided to patients at the end of their life.

The trust was clear with regard to the actions required to review and replace the Liverpool Care Pathway. The Amber Care Bundle was being piloted on two wards. The action plan demonstrated that it would then be rolled out across the trust to meet the Department of Health’s guideline timeframe of July 2014.

The palliative care team was very committed and provided a service seven days a week. The team was alerted immediately to any admission of a terminally ill patient. There was very good multi-agency working and close working with both the community team and the local hospice.

Staff were clear about ‘do not resuscitate’ policies and documents viewed were appropriately signed. Equipment was available and clean, appropriate checks had been made and staff understood how to use the equipment.

The care provided to those who had died was excellent and led by a very passionate bereavement centre manager. In addition, the chaplaincy service and the faith centre provided support to both patients, their families and friends and staff of all faiths and cultural backgrounds.

The purpose of our follow up inspection in May 2015 was to check that the Amber Care Bundle had been rolled out throughout the trust, that pain management was being prescribed and administered effectively and communication over the preferred place of death had been improved. We found that a new lead for palliative care had been put in place and that they had supported and empowered the palliative care team to drive forward improvements and positive change. This meant that the effective domain had gone from requiring improvement to being rated as good.

Outpatients

Good

Updated 16 May 2014

Outpatients services were safe, and staff were well trained and knowledgeable. All staff understood the principles of safeguarding for children and adults and knew how to refer concerns.

The trust had responded positively to concerns about the booking office and call centre. A review of these departments had resulted in more staff being employed and systems refined; this has led to a more effective service. The trust has had 12 patients wait longer than the 13 week target, however this is in proportion to 103,152 new attendances in the year to date. Some outpatient clinics run over but ‘did not attend’ rates have dramatically decreased as a result of the appointment ‘chase and alert’ system.