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Inspection Summary


Overall summary & rating

Good

Updated 20 December 2016

The James Paget University Hospitals NHS Foundation is a university hospital providing the care to a population of 230,000 residents across Great Yarmouth, Lowestoft and Waveney, as well as to the many visitors who come to this part of East Anglia. The main trust site is in Gorleston and is supported by services at Lowestoft Hospital, the Newberry Clinic and other outreach clinics in the local area.

The James Paget Hospital officially opened on 21 July 1982, was established as a third wave NHS Trust in 1 April 1993 and became a Foundation Trust on 1st August 2006.

The trust has 458 inpatient beds and 26 day case beds located on the James Paget University Hospital. The trust provides critical, intensive and high dependency care, general and orthopaedic surgery and medicine, maternity, paediatrics and neonatal services.

In August 2015 James Paget University Hospitals NHS Foundation Trust was inspected under our comprehensive inspection programme and rated as good overall. However, the safe key question was rated as requires improvement because medical care, surgery, maternity and gynaecology, children and young people and end of life care were all rated as requiring improvement in this area. End of life care was also rated as requires improvement under the effective and well led key questions with surgery also being rated as requires improvement under the responsive key question.

We therefore carried out a focused inspection between 16 and 17 August 2016 to review the areas which were rated as requires improvement at our inspection in August 2015.

We found that improvements had been made in safety across children and young people, maternity services and surgery. Although medical services had improved in areas which were found to be unsafe in August 2015, during this inspection we found that areas were not being staffed with sufficient numbers of staff. This meant the services rating for safe remained as requires improvement. 

We undertook a full review of end of life services and surgery services due to there being more than one area of requires improvement following our previous inspection. End of life services demonstrated improvements which meant their overall rating changed from requires improvement to good with all but the safe key question achieving a good rating. Safe had not improved enough to achieve a revised rating.

Surgery services had also demonstrated improvement enough to receive a revised rating of good. All key questions received a good rating.

Our key findings were as follows:

  • There was a culture or reporting and learning from incidents. We found that staff were aware of their responsibilities in relation to reporting incidents, managers undertook incident analyses and investigations to determine any areas of improvement and staff were provided with feedback.
  • All staff we spoke with regards to duty of candour correctly understood this to be the regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that person. We were provided examples of this working in practice which included patients being contacted when there had been a serious incident in relation to the care or treatment provided to them.
  • There were effective safeguarding procedures in place for both adults and children. Staff had received appropriate training, there were clear examples on interagency working and lessons were shared to ensure people were safeguarded when they used services at this hospital.
  • Improvements had been made to the checking of equipment. We found that relevant checks had been undertaken and documented. This meant the provider had complied with a requirement notice issued following our last inspection under regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.
  • Improvements had been made within children and young peoples’ services to ensure that patients having a mental health crisis were appropriately assessed to ensure their needs could be met.
  • A new children’s outpatient department had been opened. Following concerns about infection control raised at our last inspection this department had been moved from next to the antenatal clinic meaning that pregnant women attending antenatal appointments were not exposed to children with potentially infectious conditions, such as chickenpox.
  • A new end of life care strategy had been developed which outlined the five priorities of end of life care as determined by the Leadership Alliance for Care of Dying People. Each priority had trust actions, these were realistic and some had already been implemented, such as providing additional training to staff. These priorities also aligned to the trusts own visions and values.
  • A non-executive director had also been appointed to oversee and provide advice on the delivery of end of life services in line with Department of Health guidance.
  • Medical care services had implemented a new care pathway for older people. This pathway allowed staff to monitor the care and treatment being received by older people across the 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 had been an improvement in referral to treatment times and the hospital was looking at increasing the services it provided as day case surgery.
  • However, we had concerns with staffing levels and training completion within medical services. There were not enough nursing staff employed to meet planned shift ratios. For example, for the period May to July 2016 the nurse fill rate for day shifts on ward 16 averaged 64.75% and the short stay medical unit filled an average of 79.32%. We also found that only 77% of medical grade staff had completed their mandatory training.
  • In children and young people’s services only 68% of staff had completed paediatric intermediate life support training against a target of 95%. We did however note dates had been booked to provide this training to those staff which required it.
  • We found that staff were shared between the neonatal unit and paediatric department in periods of high demand or short staff. However, the service could not confirm this sharing of staff to ensure safe staffing was maintained because records were not kept.
  • In maternity services the birth to midwife ratio was not consistently being met however, 18 new midwives had been appointed to improve this.
  • The palliative care team was also understaffed and were not commissioned to provide a seven day service. Nursing and medical staffing for palliative care did not meet national recommendations.
  • Across services we found that medicine management procedures were not being appropriately monitored. We saw medicines in stock which had passed their use by dates, the signing of prescription charts was inconsistent and often illegible and fridge temperature monitoring was poor.

We saw areas of outstanding practice including:

  • Staff within end of live services going above and beyond to show compassion to the patients they were caring for in the last days and weeks of life. We heard of occasions where staff had facilitated and contributed to helping people fulfil their last wishes such as seeing their pets or being supported to take trips.
  • The deep sedation list for patients for whom endoscopy procedures may be traumatic such as those who have mental health issues or learning disabilities.

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

The trust should also:

  • Review its registered nurse staffing across the emergency and medical divisions to ensure sufficient numbers of registered nurses are on duty to ensure the delivery of safe care.
  • Review medical and dental staff participation in mandatory training and increase compliance with required training.

  • Ensure all staff have the appropriate up to date paediatric and or neonatal life support training.
  • Consider reviewing their medicines management practice to ensure medications are appropriately stock checked so that out of date medicines are disposed of and action is taken when fridge temperatures are recorded outside of accepted ranges.
  • Consider reviewing prescription recording to ensure that signatures on prescription charts are legible.
  • Consider improving the recording of shared staffing across ward 10 and the neonatal unit to prove safe staffing standards are maintained.
  • Consider reviewing infection control arrangements within the children and young people’s service to ensure effective hand hygiene and equipment cleaning.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 20 December 2016

Effective

Good

Updated 20 December 2016

Caring

Good

Updated 20 December 2016

Responsive

Good

Updated 20 December 2016

Well-led

Good

Updated 20 December 2016

Checks on specific services

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 20 December 2016

Overall the medical care service has received a rating of 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 inspection findings from August 2016 demonstrated that although key improvements had been made, there were other concerns highlighted which meant the rating of requires improvement for safety remained. This was because:

Registered nurse staffing across medical wards was a concern, with one ward filling an average of 64% of its registered nurse shifts in May, June and July 2016. This was worse than the previous inspection in August 2015 when the lowest fill rate was 74% for any medical ward. We also found that only 77% of medical staff had completed their mandatory training.

During the August 2015 inspection, medication was stored appropriately however, during the current inspection, we found medication that had not been stored appropriately.

However:

Staff knew how to report safety incidents and gave examples of incidents that should be reported. Ward managers investigated safety incidents and did root cause analyses.

Staff complied with infection control practices, including using personal protective equipment and washing their hands. We checked 17 pieces of equipment and all were within their service dates.

Staff checked medication fridge temperatures daily. We saw records of daily checks and actions taken if the fridge temperatures exceeded the recommended range. This practice ensured medicines were not damaged by being stored at too high or too low a temperature.

Medical and nursing staff kept detailed records and updated them regularly. Nurses assessed risks to patients and took appropriate actions to reduce or remove the risks.

The trust had implemented a frail elderly pathway and could monitor the location and progression of all frail elderly patients across the trust.

Urgent and emergency services (A&E)

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.

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.

Intensive/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.

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

Good

Updated 20 December 2016

We undertook a full review of end of life care which was rated good overall. The safe key question was rated as requires improvement which had not improved from our previous inspection in August 2015 but the effective and well-led key questions had improved from requires improvement to good and responsive remained as good. Caring was rated as outstanding. This was because:

Staff were proud of the service they provided and patients gave high praise of the caring support they received. We saw examples of the hospital’s teams going beyond their normal duties to be compassionate and supportive and Staff took into account personal preferences to provide outstanding personalised care.

The mortuary and chaplaincy had well embedded procedures to go the extra step to provide person centred care and offered a 24 hour service. The hospital had access to the Louise Hamilton centre which provided support and resources to cancer and palliative patients.

There was an improvement in the percentage of patients receiving individualised care and this was above the England average. The hospital provided a fast track discharge and in 2015 73% patients wishing to die at home were discharged. There was a much more unified care plan for dying patients and this was well-referenced and accessible to staff

There was now an end of life care strategy for end of life services that reflected the trusts vision and values. The leadership structure was clear and following recommendations there was now a clinical lead and a non-executive director for end of life care and we found board level staff to have an understanding of the service and the areas of concern and risk.

However:

The palliative care team were understaffed and were not commissioned to provide a seven day nursing service. Ward staff had difficulty accessing all palliative care records as a different computer system was used.

The service had implemented new Clinically Agreed Plans (CAPs) to replace the previously used Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms. However, key areas of CAPs were not understood by front line staff and internal audits in March 2016 found that they were not always completed. Re- audit in late summer 2016 had shown improvement in the completion of the CAP. 

Outpatients

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.