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Inspection carried out on 16th and 17th August 2016

During a routine inspection

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 carried out on 11th, 12th and 13th August 2015

During a routine inspection

We carried out a comprehensive inspection between 11 and 13 August 2015 as part of our regular inspection programme. In May 2015 James Paget University Hospitals NHS Foundation Trust had been identified as having only one elevated risk and one risk on our Intelligent Monitoring system. This showed a decreasing pattern since October 2013.

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.

We have rated this location as Good overall. We found that the staff were exceptionally caring and that they went the extra mile for their patients.

Our key findings were as follows:

  • All staff were caring and compassionate. They treated patients, relatives and carers with respect and dignity.
  • The trusts referral to treatment times (RTT) and four hour performance in the emergency department had improved since worse performance over the winter.
  • There was mostly enough nursing and medical staff to care for patients and protect them from the risk of avoidable harm though it did not always follow national guidance in relation to the care of children.
  • A number of medical vacancies had been identified, such as for consultant geriatricians which the trust had been unsuccessful in recruiting to.
  • There was an effective recruitment and retention strategy in place for nursing and medical staff with gaps in nursing staff acknowledged in medicine.
  • Clinical areas were visibly clean and we saw mostly good infection control practices. Infection control rates were low in the hospital.
  • The environment in some clinical areas including theatres and recovery was dated. A comprehensive estates strategy was in place to address these issues.
  • A new, purpose built day surgery unit opened during the course of our inspection which will enable more patients to be seen as day cases and potentially offer new pathways and services.
  • The emergency department made excellent use of technology and pathways, including for stroke, to effectively manage the care of patients.
  • For a number of clinical audits, the hospital performed in line with or better than the England average.
  • The vast majority of staff felt supported in their work, had received training and appraisals and most were aware of the trust vision and values.
  • Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) was not always consistently recorded or a care plan in place for patients receiving end of life care.

We saw several areas of outstanding practice including:

  • Care of patients requiring thrombolysis in the emergency department, with trained consultants and telemedicine access to a consultant neurologist.
  • Patient pathways for GP referrals that resulted in 97% of GP referrals not requiring services of the emergency department.
  • Spinal injuries nursing and state of the art equipment for patients with spinal cord injury was excellent.
  • A charity funded Eye Clinic Liaison Officer raised awareness about support for patients with macular degeneration.
  • The trust had been awarded integration status, with other health partners and social care to pioneer seven-day services. This included an Out of Hospital Team chaired by the clinical commissioning group involving social care, the mental health trust and the hospital to identify ways to avoid crises in communities leading to hospital attendance. Data was showing a reduction in admissions.
  • The neonatal unit had developed a breastfeeding pack to encourage new mums whose babies were on the neonatal unit to hand express their breast milk. The pack contained information and tips on hand expressing along with a personal expressing log.

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

Importantly, the trust must:

  • Ensure that all equipment is checked at a frequency as per trust policy including, but not limited to emergency resuscitation equipment.
  • Ensure that all patient records are up to date and reflective of patient’s needs.
  • Ensure a named Non Executive Director for end of life care in line with Department of Health Guidance.
  • Ensure that all Do Not Attempt Cardio Pulmonary Resuscitation forms are completed fully and in line with national guidance.
  • Accelerate the implementation of the approved replacement for the Liverpool Care Pathway for people receiving end of life care

In addition the trust should:

  • Review the application of the assessment under the Mental Capacity Act 2005 in end of life care.
  • Review the storage of medicines in theatres to ensure that temperatures are consistent with trust policy.
  • Review approach to the care of older people and the provision of senior medical staff in care of the elderly.
  • Review audits in end of life care to ensure good practice is followed.
  • Review staffing in children’s services to ensure it meets national guidance.
  • Review the environment within the outpatient area for gynaecology and paediatric patients to ensure that this meets their individual needs.
  • The hospital trust should review the level of physiotherapists and pharmacists provided to the intensive care service as staff levels did not meet recommended levels of the Faculty of Intensive Care Medicine Core Standards for allied health professional staffing.
  • Mortality and morbidity reviews within intensive care should be recorded in order to demonstrate lessons from any reviews are learned and these can be shared throughout the trust.
  • The cover from specialist trainee/registrar doctors in the intensive care unit should be reviewed to ensure this meets recommended safe levels at all times.
  • Intensive care should review the use of dementia-specific care plans for patients living with this condition. The trust should also review the provision of mental health support given to patients and their families who are or have been patients in the intensive care unit.
  • The hospital trust should review and risk-assess the provision of the intensive care Outreach team service which was not being provided for 24 hours a day in line with national guidance.
  • The intensive care team should review the governance within the unit and formalise the structure and meetings.

  • Review awareness of the risk register process

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 11 September 2014

During an inspection to make sure that the improvements required had been made

We ask five key questions of services we inspect. Are they safe, are they effective, are they caring, are they responsive and are they well-led? Because this was a follow up inspection we focused on two of those five questions; are they safe, are they effective.

At our inspection on 27 and 28 November 2013 we found the service did not always protect people against the risks from unsafe management of medications. People were at risk from unsafe or inappropriate care and treatment because accurate and appropriate records were not always maintained.

Is the service safe?

At this inspection we found that the service was safe as medications management had been improved. Records of medication showed that medical, pharmacy and nursing staff communicated effectively about as required medication. Pharmacy and ward managers audited the management of medications and fedback to staff to monitor and improve safety.

Is the service effective?

We found that care was effective as records of care and key documents were completed appropriately. Patient care records included comprehensive assessment of risks and of the care provided. There were appropriate records showing that patients and relatives had been included in discussions about care.

Inspection carried out on 27, 28 November 2013

During a routine inspection

During our inspection we spoke with 38 people who used the service and with 15 people visiting family or friends who were using the service on the two days we spent carrying out our inspection. During our inspection we visited a number of wards the accident and emergency unit and an outpatient’s clinic. We also spoke with the members of the hospital board, the Chairman of the board of governors, the medical director and director of nursing and with 38 staff members.

People who used the service told us that they had been involved in their care and we saw that staff ensured people had consented before starting any care or treatment. We observed one staff member who asked "Could I check your skin," and another who asked for consent to help a person into their chair so that they could bring them food.

People were mostly happy with their care and treatment. One person told us, "It’s really excellent, they are most caring." Another person we spoke with said, "My treatment has been pretty good, they are looking after me and feeding me well" and another person said that, "It’s been nothing but a positive experience."

We identified some concerns over gaps in records and the ways in which medication was administered and recorded and have asked the provider to tell us how these issues will be resolved. We found that measures were in place to assess and maintain the quality of the service provided and to analyse and resolve any complaints or issues that arose.

Inspection carried out on 1 February 2013

During a routine inspection

During the inspection we spoke with 23 people who used the service, eight visitors and 23 staff members. We spent time in nine wards or clinics and looked at 15 sets of records relating to people's care and treatment.

People we spoke with told us they were well looked after. One person said "It’s the best hospital ever. I have been in quite a few, this is certainly the best one." Another told us that, "Staff are kind and caring and very respectful." We were told by another person that, "All the staff are very professional, from the doctors through to the cleaners."

Care records we looked at showed that people's needs had been assessed either before they were admitted or on admission and people we spoke with told us they received nutritious food. Supplements were available where people had an identified risk of malnutrition.

We looked at infection control and prevention measures in place. We found that staff were committed to carrying out care in a safe manner and that risk assessments and procedures were in place to prevent or manage the risk of infection or contamination.

We spoke with 23 staff who told us about the training they received. We were also given copies of planned training for the coming year. Although we were told that there were staff shortages on some of the wards we visited during the inspection, we were assured by the provider that a full review of staffing was underway to ensure that adequate staffing was in place.

Inspection carried out on 30 July 2012

During an inspection to make sure that the improvements required had been made

We spoke with people using the services but their feedback did not relate directly to this to this standard. However, we looked at people’s records and crosschecked these with what people told us about their care and treatment and with what we observed.

Inspection carried out on 12 June 2012

During an inspection to make sure that the improvements required had been made

One visitor told us that the “standards of care vary”. They said that hygiene standards on the wards was not always as good as it could be. They also said that staff did not always understand how to meet some people’s needs. Another visitor told us that the care had been very good and that their relative had everything they needed. One patient told us that they “could not complain” everything was alright and they had been looked after.

Inspection carried out on 21 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 12 March 2012

During an inspection to make sure that the improvements required had been made

People we spoke with who had been admitted to the hospital were generally complimentary about their treatment, how their medicines were managed and had no complaints. People said that they were provided information about medicines in a way that was useful to them. People told us they were provided pain relief when they needed it without delay.

Inspection carried out on 1 March 2012

During an inspection to make sure that the improvements required had been made

One person told us that the staff were very good. They said they had been informed about their care and what arrangements were being made for them to move from the hospital. We were told the person had received a form about the possible arrangements for their discharge and how this was to be managed. They confirmed that they had received support from the therapy team to help improve their mobility and had been given a different walking frame from the one they used at home. They said this was more stable and they felt more confident with it.

Another four people told us that they were happy with their care and treatment. They thought there were enough staff on duty and had not had to wait unacceptable lengths of time for support. They had been kept informed about their treatment.

We were told by another person that they had been asked about their pain and given tablets to control this when they needed them. We heard staff asking people whether they were comfortable and explaining what they were doing to try and ensure people were involved and clear about what was happening.

We observed that, when people were receiving care, their dignity and privacy was sometimes compromised. For example, one person was receiving attention from two staff present at their bedside. Their clothes were elevated over the thigh and the curtains around their bed had not been closed.

Another person with a catheter in situ was being assisted with mobility from their bedside chair to the centre of the bay where their bed was. The person’s ‘flies’ were not covered in any way to prevent any accidental exposure.

Inspection carried out on 7 December 2011

During an inspection to make sure that the improvements required had been made

People with whom we spoke told us that they were happy with the service they received. One person said that the meals look, smell and taste good. Another person said that they were “excellent”. Several people said that staff asked them frequently if they were alright or if they needed anything more. One person said they had observed staff assisting people with their meals without rushing them.

People told us that they received the meals they had asked for and that they were suitable. They also said that staff supported them with hand wiping and to use the facilities when needed.

One person told us that staff assisted them into a comfortable position prior to their meal and “are always coming round with drinks”

A relative told us that they had been asked for information about their relatives needs because they were unable to clearly state these for themselves.

People with whom we spoke who were admitted to the hospital were generally complimentary about how their medicines were managed. However, we identified that some people experienced poor outcomes in relation to how their medicines are managed by the service.

Inspection carried out on 14 October 2011

During an inspection to make sure that the improvements required had been made

People with whom we spoke were complimentary about the food they had received. They told us that there was sufficient choice and that the meals were appetising, served at the correct temperature and tasty. One person told us that their relative did not always receive the amount of fluid that they should have and the food was not always suitable for the persons needs.

We were told by one person that they received “first class treatment”. Another person said that they felt well cared for. A relative told us that they did not always feel that their relative’s needs were being met.

In addition to checking if the trust had met the requirements of the warning notice issued in respect of meeting people's nutritional needs, we checked how well the trust were meeting the requirements under outcome areas: 04, Care and Welfare of people who use services; 016, Assessing and Monitoring the quality of service provision and 021, Records. During this visit, we did not check if the service was complying with the compliance action made following the last inspection in respect of 09, Management of Medicines. We will check this at the next inspection.

Inspection carried out on 1 September 2011

During an inspection to make sure that the improvements required had been made

People with whom we spoke told us that they felt well informed about any treatment and care that was provided. People said that they had been involved in decisions about them and knew what would happen when they were discharged from the hospital. When we asked one person about how staff promote their dignity, they said staff made efforts to make sure they were covered up during personal care, they appreciated the same sex wards and though staff had not asked them how they preferred to be addressed, they called them by their first name and that made them feel more relaxed. People told us that their care had been very good. They said things like “Everything has been spot on”, “Absolutely fantastic” and “We have a laugh with the staff.” One person said “They couldn’t have been nicer.”

People in the maternity unit said they were provided with lots of information that helped them to make informed decisions about how they wished to give birth and about the way they wished to feed their new born baby. The people with whom we spoke were all satisfied with the advice and support given in this respect. One person said "All the staff have been very good, they have always told me everything and answered questions." Another person said that “staff don’t use jargon”.

Some people were critical about their experience, saying that the visiting times were too long. “You sometimes need a rest” and “It is a long day without radio or television”. One person told us that they had become partially sighted as a result of a recent stroke and were unable to read or see the clock. When asked they told us that staff did not seem to be aware of their difficulties. One visitor told us that when they had telephoned the ward on the morning of our visit they were given some information about their relative that led them to be very concerned. When they had called again an hour later they had discovered that the information they had been given was about a different person. However, they confirmed that apart from this one incident they had been kept well informed at a difficult time.

One person using the service told us that their medicine record had recently been mislaid on two separate occasions and in each case this had contributed to significant delays in them receiving the pain relief they required. They told us that on the first occasion they had been in considerable pain for three hours during the night and had been told by staff that they could not have any medication because they had an epidural in place. Staff subsequently found that the epidural was not working but the person had been in pain without medication in the interim. On the second occasion they had been in pain for two hours before medication was given and they told us that they had missed a dose of painkiller.

Some people expressed the view that there were not enough staff on the wards, saying “They are worked off their feet” and “They do their best”. One person told us that the day before our visit, the ward had been chaotic and that, as a result they felt under pressure to fit in with the ward routine, rather than express their wishes regarding their care. A visitor of another person who had been an inpatient for six weeks said that some of the “general” wards were very short staffed.

People gave us mixed feedback about their mealtime experience. One person said "The food is OK, a bit bland but OK and enough of it". Another person told us that the food was very good and they were looking forward to tea.

We were told on the maternity ward that the meals are good with one person saying they thought they were ‘better than expected’. We were told that choices are given on a list the day before and that ‘there is always a lighter diet or soup if we are not too hungry’. We noted the drinks trolley being offered mid morning with choices available.

We spoke with a person who visits every day and who is present to support their relative at both lunch and teatime. They told us that their relative requires a pureed diet but on the previous day were provided with a full un-pureed lunch time meal. The member of staff took this away and brought back an omelette which was still unsuitable. This relative also said the teatime meal was also inappropriate, as a jacket potato was offered. This person only had soup on the day. The relative was concerned that, if they had not been present all day, the incorrect food would have been offered and could place the person at risk of choking. A visitor told us that there were no offers of support with hand washing before lunch. Hand wipes are supplied on the meal trays but “staff don't always have time to help people to use them”. Another visitor also told us that they had bought special cutlery to help their relative to eat independently. Staff then told her that they had some on the ward but this had not been offered.

In addition to checking if the trust had made improvements in respect of outcomes areas 01 and 05 we checked how well the trust was meeting the standards in outcome areas 04, 07, 13 and 16. During our visit to the hospital we also identified concerns in outcome area 09, management of medicines and our findings have been included in this report.

Inspection carried out on 5 April 2011

During a themed inspection looking at Dignity and Nutrition

People with whom we spoke told us that they were satisfied with the service they had received. Those people who had been admitted for surgery told us that they had been made fully aware of what was involved with the surgery and that the procedure had been fully explained to them. When asked the question, are you happy with the way staff care for you, one person replied “Absolutely brilliant”. When asked the same question, another person replied “No complaints at all, everything absolutely wonderful”. People told us that on the whole staff treated them with respect and they were consulted about the way in which they received care and treatment. However, one person told us they had asked a member of staff who came to take some blood, what the blood test was for but the member of staff said they did not know. We asked people about how well they felt their needs were met. They told us that staff respond to their needs as quickly as they can. One person said “it is obvious that staff are very busy and might not respond at once”. This person said they had received excellent care from night staff when they needed prompt assistance.

People with whom we spoke were reasonably independent and able to express their needs and preferences to staff on the ward. They told us that they were offered a choice of meals that were of a good standard. Two people told us that they had been asked about what they like to eat and a menu was provided everyday. One person told us that they had an allergy to an ingredient used in various foods and that they had informed staff of this repeatedly. However, staff were not able to tell the person which foods contained the ingredient that the person was allergic to and this person said they managed their own diet by omitting foods that were most likely to contain it. Other people told us that staff had spoken with them about what they like to eat and what level of support they needed. Apart from the above, nobody expressed any concerns about the way in which they were supported to maintain a good nutritional intake. When we asked people if they were given the opportunity to wash their hands before and after their meal, they told us that hand washing had not been offered. One person told us that they had brought in their own hand wipes.