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Inspection Summary


Overall summary & rating

Good

Updated 6 December 2018

  • The service did not meet the trust mandatory training compliance target (95%). One out of three medical staff (55%) had not attended five out of nine modules. Nurse staffing was 75% compliant. We raised this as a concern at the time of our last inspection.
  • The service did not meet the trust mandatory training compliance target for safeguarding training; four out of 16 nursing staff (25%) and one out of three medical staff (33%) had not received safeguarding adults training. This was worse than at our last inspection.
  • The trust employed one long term locum palliative care consultant. This meant the trust did not meet guidance from the Association for Palliative Medicine of Great Britain and Ireland, and the National Council for Palliative Care standard because the service had not been able to recruit a second substantive palliative care consultant. We raised this as a concern at the time of our last inspection.
  • Staff had not completed plan of care for the last days of life booklets in eight out of ten patient care records for patients who had recently died.
  • Patients could not access the specialist palliative care team (SPCT) directly without attending ED. Patients needed to be admitted via the emergency department (ED) for a referral to the SPCT to be triggered and the SPC service was not available 24/7, operating a telephone on call service out of hours and during the weekends.
  • We were concerned that medical staff in the emergency department (ED) were not able to access community patient care records which were stored electronically when palliative care patients presented in ED.
  • We were not assured that there was adequate identification and oversight of all risks within the organisation. We found that several risks that we identified on our inspection did not appear on the service’s risk register.
  • The service had a strategy which reflected the whole spectrum of end of life care. There were effective systems in place to support and monitor the implementation of the strategy. However some improvements identified from our previous inspections had not been made.

However,

  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. The service had reported no never events or serious incidents during the period May 2017 to April 2018.
  • The service had suitable premises and equipment and controlled infection risk well. Staff kept themselves, equipment and the premises clean.
  • The service prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time and staff kept clear, up to date and appropriate records of patients’ care and treatment.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005 and knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
  • The service provided care and treatment based on national guidance and planned for emergencies; staff understood their roles if one should happen
  • The service monitored the effectiveness of care and treatment. They compared local results with those of other services to learn from them. In the 2016 end of life care audit: dying in hospital the trust performed better than the England average for all three metrics considered.

  • Staff of different specialities worked together as a team to benefit patients. The trust planned and provided services in a way that met the needs of local people. The service made sure staff were competent for their roles. Managers appraised staff’s work performance.

  • The service took account of patients’ individual needs including, dietary, religious and cultural needs. The trust was the primary provider in palliative care for the geographical area and the specialist palliative care team (SPCT) consisted of both hospital and community nurses.

  • Nursing staff could access translation services for patients who did not speak English as a first language. The trust had facilities for family members to stay with their relative overnight and the mortuary had facilities for bariatric patients.

Inspection areas

Safe

Requires improvement

Updated 6 December 2018

Effective

Good

Updated 6 December 2018

Caring

Good

Updated 6 December 2018

Responsive

Good

Updated 6 December 2018

Well-led

Good

Updated 6 December 2018

Checks on specific services

Critical care

Good

Updated 12 November 2015

Overall, we have judged the intensive care service as good. The service was providing safe, effective, caring and responsive treatment and care to patients. There were, however, elements within some of these areas requiring improvement. The overall governance of the service required improvement.

The service was delivered safely. There was a good track-record on safety with lessons learned and improvements made when things went wrong or should be better. There were low rates of infection and avoidable harm to patients. Staff responded appropriately to changes in patients’ condition, although the intensive care outreach service (which provided support to staff caring for deteriorating patients elsewhere in the hospital) was not provided 24 hours a day. There were good levels of nursing and medical staff and agency nursing staff or locum cover was used infrequently. Patient records were clear and contemporaneous. Medicines were stored safely, were seen to be in date, and recorded accurately. The majority of staff mandatory update training compliance was high and most met trust targets.

The evidence of staff learning and sharing feedback from mortality and morbidity reviews was not well reported. There was insufficient cover to meet best-practice guidance from pharmacists and specifically physiotherapists. Some of the cover from the doctors at night did not meet the Faculty of Intensive Care Medicine (FICM) Core Standards guidance if the unit had a high number of patients.

Care was effective. The majority of treatment and care by all staff was delivered in accordance with legislation, standards, best practice and recognised national guidelines. There was a holistic, multidisciplinary professional approach to assessing and planning care and treatment, although insufficient input to patient treatment and recovery from the under-resourced physiotherapist and pharmacist teams. Patient-centred care was the focus for intensive care services. The intensive care unit achieved good outcomes for patients who were critically ill and/or with complex problems and multiple needs. There was a strong commitment to the successful programme of organ donation.

There was respected and high quality training and development in the intensive care unit for trainee doctors. There were not, however, enough nurses with a post-registration qualification in intensive care nursing, which is an expectation of the FICM Core Standards. There were also incomplete records in relation to competency in equipment use having been assessed for the nursing team.

Staff were caring and compassionate. Patients were respected, valued and understood as individuals. Feedback from people who had used the service, including patients and their families, had been exceptionally positive. Staff delivered care with kindness, dignity, respect and compassion. Patient’s cultural, religious, social and personal needs were respected and those close to them were involved with their care.

The intensive care service responded well to patient needs. The intensive care team were organised, flexible and ensured patients who needed a bed were admitted. Some patients were delayed on discharge from the unit or discharged at night, when this was recognised as less than optimal for patient wellbeing. There were good facilities in the intensive care unit for patients, visitors and staff, and these met the modern intensive care building standards.

Although there was good leadership and attention to a safe, effective, caring and responsive service, there was a lack of straightforward formal governance. There was no regular governance meeting for the whole intensive care service looking at a programme of audit; receiving and reviewing reports; developing shared action plans; and onward representation at key divisional governance meetings. The risks on the unit were mostly understood, but not being locally managed, or addressed by the board.

Intensive care staff were committed to their patients and their unit with a shared purpose. A high level of staff satisfaction was found throughout the services. Many spoke highly of the positive culture and levels of constructive engagement, support and encouragement. There was a committed leadership from the consultants and the nursing team. The nurses were supported by an experienced matron who did, however, have extensive responsibilities beyond the intensive care unit.

Outpatients and diagnostic imaging

Good

Updated 12 November 2015

Overall we rated the outpatients and diagnostic imaging services as good. Medicines storage and management was safe and robust in outpatients and diagnostic imaging services, clinical environments were visibly clean with regular auditing of cleanliness. Nursing staffing levels were well maintained to provide the level of care required. The reporting, managing and learning from incidents was well embedded and supported by an electronic system that was easily accessible for all relevant staff.

The auditing of equipment and clinical practice was well embedded across outpatients and diagnostic imaging services with sharing of learning happening at both local and senior level. Patients felt well cared for and respected in the outpatients and diagnostic imaging services, with patient’s privacy and dignity being maintained by staff.

Referral to treatment times (RTT) were better than the England average for outpatients and diagnostic imaging services and the waiting time for patients with suspected cancers was exceptionally good and there was dedicated provision for people with dementia in outpatients and diagnostic imaging services.

Local leadership was good within the outpatients and diagnostic imaging services. Staff were aware of the trust’s values and there was good clinical governance monitoring and escalation, and there were service-level strategies for forward planning over the next three to five years. Outpatients and diagnostic imaging staff felt proud to work at this trust.

The use of both paper and electronic medical records introduced a risk of information being misplaced or not available within outpatients and diagnostic imaging services. The use of several different electronic systems for items such as medical records, investigations, reporting, patient note tracking, and cancer pathways was confusing and not robust. Systems were not joined up with each other which meant that all information regarding a patient may not be on one system or always accessible.

Staff compliance levels for mandatory training were on track to reach the trusts target level by March 2016. Auditing of clinical guidelines was not robust across all departments, meaning that good practice was not always being shared.

Some clinical areas were cramped due to the increased demand on services, which impacted on maintaining patient’s privacy and dignity. However this was due to be addressed as outlined in a new estates strategy. Although some departments with outpatients and diagnostic imaging services had service development plans in place, this was not consistent across all departments.

The monitoring of complaints was done at local level and senior level, however the reporting of complaints was confusing and contradictory at times meaning that departments may not always be able to improve practice when complaints data is not robust. The senior executive team were visible to local leaders who knew how and when to contact them. However, senior executive visibility was not always present for front line staff.

Urgent and emergency services

Good

Updated 12 November 2015

Overall, we have rated the accident and emergency department at James Paget hospital as good with an outstanding leadership team. The department ensured that people were protected from abuse and avoidable harm. Staff provided good care with outstanding elements for its effectiveness, which included patient care pathways and use of technology with evidence-based techniques and technologies, used to support the delivery of high quality care.

We heard from our discussions with staff a genuine open and transparent culture in the department. All staff use an incident reporting system. Incidents investigated were impartial with an ethos placed on quality and learning and improvement to the service offered to people.

We observed the leadership of the department, which was co-ordinated and was very well organised within the teams. Experienced leaders encouraged positive clear open communication and in particular, when the department was under pressure. There was a recurring theme of staff engagement within the department and between managers, which had a good impact on patient care, and staff morale. We saw outstanding evidence of a well led accident and emergency department and the Emergency Assessment and Discharge Unit (EADU) by the management team.

We looked at equipment within the entire department, which was clean, serviced and suitable. Maintenance of equipment to the manufacturer’s recommendations with service labels advising when the next service is due was evident. The environment was clean and designed to assist people with a disability.

We reviewed evidence that the department made full use of guidelines with over seventy guidelines in use that were available to all staff electronically. All staff within varied discipline levels was involved with local and national audits and staff leads ensured that education from audits took place across all teams.

There were minimal nurse vacancies within the accident and emergency department and Emergency Assessment and Discharge Unit (EADU). We observed during our inspection that nurses and doctors demonstrated an understanding of individual patient needs centred on the patient.

During our inspection, the department assessed patients’ at periods of busy times arriving by ambulance within fifteen minutes of arrival. We noted that the ambulance median to initial assessment time to handover was consistently below the England average. There were only 197 ambulance handover delays over thirty minutes during the winter period of November 2014 to March 2015.

Maternity

Good

Updated 6 December 2018

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

A summary of our findings about this service appears in the Overall summary.

Maternity and gynaecology

Good

Updated 20 December 2016

Overall maternity and gynaecology service were rated as good. In August 2015 the effective, caring, responsive and well-led key questions were all rated as good. We returned to the hospital to undertake a focused inspection of the safe key question only as in August 2015 safety was rated as requires improvement. Our findings at this inspection demonstrated that improvement had been made and the safe key question was rated as good. This was because:

Managers had moved the paediatric clinic away from the antenatal clinic in response to concerns about infection control raised at our last inspection. This meant that pregnant women attending antenatal appointments were not exposed to children with potentially infectious conditions, such as chickenpox.

Staff consistently completed safety checks for emergency equipment in the maternity and gynaecology services and medicines were stored securely across the maternity and gynaecology services.

All clinical areas and equipment we saw were visibly clean and managers had responded to midwifery staffing shortages and had recruited 18 midwives to start work from June to September 2016.

However:

We found three medications that were out of date on the maternity ward. This meant that the efficacy of these medications could not be assured if they were given to women.

The midwife to birth ratio was consistently higher than the ratio of 1:29 recommended by the Birthrate plus staffing tool. However, senior staff had recruited 18 new midwives due to start work from June to September 2016 in order to improve this.

There were no processes in place for gynaecology services to monitor safety outcomes for patients and staff signatures on prescription charts were not always legible. The provider took action to mitigate this by introducing electronic prescribing shortly after our inspection. The safety checklist for the resuscitation trolley on the maternity ward was not easy to read. This meant that there was a risk of staff not documenting safety checks accurately.

Medical care (including older people’s care)

Good

Updated 6 December 2018

A summary of our findings about this service appears in the Overall summary.

Surgery

Good

Updated 20 December 2016

We undertook a full review of surgery services which has been rated as good overall. All key questions achieved a rating of good which was an improvement from our August 2015 inspection. Both safety and responsiveness had improved from requires improvement to good. Surgery services were rates as good overall because:

The environment was clean, tidy and areas of concern identified at our last inspection had been addressed. We reviewed five sets of notes and found that documentation was complete and accurate. Staff reported patient safety incidents and there were clear examples of lessons learnt. Completion of the surgical safety checklist was embedded in practice.

Evidence based care and treatment was in place throughout the division and national audit data showed the trust to be similar to the national average.

There was good multidisciplinary working and staff applied the Mental Capacity Act correctly. Pain relief was administered in a way best suited to patients need.

The friends and family test (FFT) for the surgical wards was very positive, with high percentages of patients saying they would recommend the ward they were received care on. We observed examples of kind, compassionate and respectful care during the inspection. ‘Dementia radio’ was used on a ward with elderly patients, to provide familiar music and aid anxiousness.

A new day surgery unit had opened in August 2015 which allowed patients to be treated without requiring them to stay in hospital. The trust had opened an emergency theatre in line with national guidance, which meant that emergency surgery did not impact upon surgical patient lists. There was good evidence of learning from complaints and concerns.

However:

Some patients reported frustration with internal and external communication and whilst staff said they had a good relationship with the executive team and felt listened to, they felt concerns were not always acted upon.

An area identified for improvement within the August 2015 comprehensive inspection report was for a review of awareness of the risk register. Our August 2016 inspection findings showed staff’s concerns were not reflective of high grade risks on the divisional risk register.

Services for children & young people

Good

Updated 20 December 2016

Overall children and young people’s services were rated as good. In August 2015 the effective, caring, responsive and well-led key questions were all rated as good. We returned to the hospital to undertake a focused inspection of the safe key question only as in August 2015 safety was rated as requires improvement. Our findings at this inspection demonstrated that improvement had been made and the safe key question was rated as good. This was because:

The trust has made significant changes to the children’s outpatient service, which now has a new dedicated children and young people’s outpatient clinic, no longer sharing space with the maternity service.

The trust has developed a standard operating procedure (SOP) to ensure a senior (band 6 or above) paediatric nurse was available at all times via a rota as per Royal College of Nursing best practice guidance (2013) in relation to nurse staffing levels for children’s and young people’s services.

Resuscitation equipment was checked and recorded daily, with full checks undertaken weekly as per trust policy. There was also a new children and young person flowchart to risk assess those with mental health crises needing a place of safety and safeguarding training had improved with all but one staff trained to level three.

However:

The paediatric immediate life support refresher training was below trust requirements but we did see evidence of booked dates to rectify this.

Ward 10 and the NNU had not produced regular data for the hand hygiene and personal protection equipment audit. Medicines were not stored appropriately on the NNU with poor management of medicine fridge temperatures and out of date medicine in drug cupboards.

End of life care

Requires improvement

Updated 6 December 2018

A summary of our findings about this service appears in the Overall summary.