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Addenbrooke's and the Rosie Hospitals Good

Inspection Summary


Overall summary & rating

Good

Updated 26 February 2019

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

Inspection areas

Safe

Good

Updated 26 February 2019

Effective

Good

Updated 26 February 2019

Caring

Outstanding

Updated 26 February 2019

Responsive

Requires improvement

Updated 26 February 2019

Well-led

Outstanding

Updated 26 February 2019

Checks on specific services

Medical care (including older people’s care)

Good

Updated 26 February 2019

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

  • Medicines management and records management practices were implemented effectively.
  • Most staff had received an up to date appraisal, and the relevant mandatory, safeguarding, and Mental Capacity Act training for them to fulfil their role.
  • Staff reported and managers investigated incidents and shared lessons learned with the whole team and the wider service. Staff kept themselves, equipment and the premises clean.
  • Patients and their families were involved in developing care plans and given information to help them understand choices available to them. Feedback from patients was uniformly positive about the caring attitude of staff.
  • The service was responsive to people’s needs. Vulnerable and local people had their needs met and there was good access to specialist staff and support services. Waiting times for referral to treatment were in line with national averages.
  • Senior managers promoted a positive and open culture amongst staff and managers had the necessary skills and experience to achieve the service objectives and vision.
  • However,
  • Staff continued to be moved between wards to cover for staff absences and vacancies within their divisions.
  • The trust continued to experience challenges with delayed transfers of care (DTOC) and patient flow in the hospital. Staff understood the challenges and were taking action to address shortfalls, which were mainly affected by external pressures of domiciliary care capacity.

Services for children & young people

Good

Updated 18 January 2017

We rated this service as good because:

  • The service managed safety well. Staff knew how to report patient safety incidents and what should be reported as an incident. Managers investigated when things went wrong and shared lessons to be learnt with all staff to help prevent further similar incidents.
  • Medical and nursing staff knew that when things went wrong with care and treatment they needed to inform patients honestly, give them support and apologise to them verbally and in writing. This process is known as duty of candour.
  • Duty of candour training and knowledge was good across medical and nursing staff.
  • Equipment servicing was up to date and equipment checked was safety tested.
  • Clinical areas were visibly clean.
  • The service had enough staff to keep patients safe and to provide the care they needed. Staffing levels for senior doctors, nurses and healthcare assistants consistently met demand.
  • We found good transitional care services at Addenbrooke’s Hospital for patients transferring from children’s services to adult services.
  • The hospital had good systems in place to continually improve the quality of their services and protect high standards of care.
  • The divisional leadership team were knowledgeable about the service and understood the constraints within which the service was working.
  • There was a strong culture of openness and transparency within children and young people’s services.
  • Staff provided kind compassionate care to patients and families in all areas we visited.
  • Patients and relatives felt informed and included in the decisions being made about their care.

However:

  • Staff on adult wards caring for young people aged 16 and 17 did not undertake children’s safeguarding level three training in line with the Intercollegiate Role Framework.
  • Staff management of controlled drugs in children’s intensive care was a concern. Staff left controlled drugs keys unattended and hung on portable workstations.
  • Senior management raised concerns about the lack of acute paediatric beds available across children’s services.
  • The children’s divisional management team told us that 250 scheduled admissions were cancelled between January 2016 and August 2016 due to a lack of beds.
  • Between September 2015 and August 2016, the trust cancelled 132 procedures for children and young people. Of these 121 were rebooked within 28 days of the procedure being cancelled and 11 patients waited longer than 28 days to be rebooked.
  • Staff did not receive training in how to take patient’s consent for treatment. Staff delegated the task of consent should have completed a consent competency package according to the trust consent to examination, treatment and post mortem policy. However, the trust provided no detail on completion of this.

Critical care

Good

Updated 18 January 2017

We rated the critical care services provided at Addenbrooke’s hospital as good overall, with caring and effective as outstanding.

  • There was a good reporting and learning ethos throughout the unit. Staff told us that there was a “no blame culture”. Duty of candour was understood and discharged appropriately by staff. Morbidity and Mortality meetings were open to all staff which contributed to a positive learning and open culture across all disciplines of staff.
  • Since the previous inspection in 2014, there had been significant improvements made in relation to nurse staffing levels, meaning that nurse staffing levels were sufficient to meet with the Faculty of Intensive Medicine Standards.
  • There had been a dedicated supervisor introduced. Staffing levels, as well as patient acuity and dependency were reviewed five times per day to ensure that staffing levels remained safe and that patients were receiving high quality care.
  • The previous inspection in 2014 had identified that data collection and upload to the Intensive Care National Audit and Research Centre (ICNARC) had been stopped, meaning that data had not been submitted for two years.
  • However we found on this inspection that there was a dedicated team for ICNARC data collection, consultant engagement for review and accuracy check, mid-month review of any trends and themes, and training provided to staff, which included other staff being able to input data. Data had been submitted since quarter four 2015.
  • There were numerous examples of outstanding team work across medical, nursing and allied health professionals. Staff worked collaboratively to provide the highest possible care for patients. Feedback from patients and relatives during our inspection was very positive. We saw examples of innovations from the focus groups, which were recorded and logged onto an action plan.
  • The critical care Rapid Response Team (RRT), provided outreach services into wards, proactively identifying patients who would benefit from closer monitoring. The team also ran bed side teaching as well as delivered on a number of internal courses, providing support and education to ward teams.
  • There was a strong culture of service improvements and research. There were a number of research studies ran by the National Institute of Heath Research (NIHR) studies, which the critical care unit were involved in. We saw poster presentation that had been presented at National conferences in 2016.

However:

  • Data from the East of England critical care network showed that between April 2015 and March 2016 there were 776 delayed discharges (discharges delayed between 4-24 hours).It was recognized that the critical care unit was working hard to improve this by early identification of patients that could be discharged and escalating to the control and command centre. Bed capacity throughout the hospital contributed to these delays.
  • The result of these delays meant that 32 patients in September 2015 across critical care, were transferred between 10pm and 7am.However, it was noted that numbers had been declining since the early months of 2015 to the latter months. This was due to actions, such as early identification of patients ready for discharge in the day and escalation to the control room.
  • During August 2016, seven patients had been identified as requiring level one care, but remained on the unit. We were not assured that mixed sex breaches were being robustly reported, as we were told that only those delayed “overnight” were reported internally but not declared externally.

End of life care

Outstanding

Updated 26 February 2019

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

  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately.
  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • The nurse staffing for the specialist palliative care team (SPCT) was in line with national guidance.
  • The trust had suitable premises and equipment and looked after them.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness, where the organisation did not meet clinical indicators there were actions from audits in place.
  • Staff in the SPCT informally monitored their response times, discussion of preferred place of death and preferred place of care, and audited this data.
  • Staff treated patients with compassion, dignity and respect. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff involved patients and those close to them in decisions about their care and treatment. The service had open visiting hours, enabling relatives and carers to stay overnight and made arrangements to meet the individual needs of each patient.
  • Staff provided emotional support for patients to minimise their distress. The trust gave patients and carers information on what to expect following the death of a loved one, and sign posted families to relevant information and support, including counselling services provided by external providers.
  • The trust planned and provided services in a way that met the needs of local people. The trust had a system in place to highlight patients who were at the end of their life by placing a swan magnet around their bed space and on the ward white board for ease of identification and discussion at board round.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff. All complaints relating to end of life care were reviewed by the SPCT and discussed at the end of life steering group meeting. Staff were aware of themes in complaints around end of life care and could identify areas of learning.
  • The trust had compassionate, inclusive, and effective leadership at all levels. Leaders at all levels demonstrated high levels of experience, capacity, and capability needed to deliver excellent and sustainable care.
  • Comprehensive and successful leadership strategies were in place to ensure and sustain service delivery and to develop the desired culture. Leaders had a deep understanding of issues, challenges, and priorities in their service, and beyond.
  • The end of life care service had a strong, visible person-centred culture. Staff were highly motivated and inspired to offer care that was kind and promoted people’s dignity. We found strong caring, respectful and supportive relationships between people who used the service, those close to them and staff.

However:

  • Fast track discharge did not meet the NHS England recommended time of 48 hours and on some occasions, was much longer than this. The median time to discharge was eight days, which suggests that the trust was performing worse than the last inspection, where the average time to discharge was 3.8 days for patients living in Cambridge and 4.7 days for patients living outside Cambridge.
  • The trust did not audit what percentage of patients achieved their preferred place of death (PPD).

Maternity and gynaecology

Good

Updated 18 January 2017

We rated this service overall as good with findings in the following:

  • The service had robust systems in place to report incidents and the number of serious incidents reported was 16, with no never events reported between January and September 2016.
  • Throughout maternity and gynaecology services we saw the “NHS Safety Thermometer” displayed in public areas. We saw completed essential patient risk assessments including venous thromboembolism (VTE) and early warning score (EWS) assessment outcomes.
  • Staff confirmed to us that the maternity record system was improved with smart text filters in place but there was still a combination of electronic and paper records in place. Smart text is similar to a predictive text with the most used status or treatment descriptors featuring first on the system.
  • All equipment checked was safety tested and was on the pre-planned maintenance programme.
  • Staffing shortages within the delivery suite were seen each day but we were informed of clear plans to fill those vacancies with staff already recruited to start in October 2016.
  • Policies and procedures in place were based on up-to-date evidence-based guidance which had been followed: for example; fetal heart monitoring (FHR) monitoring, vascular thromboembolism (VTE) and early warning score guidelines.
  • All staff were competent and understood the guidelines they were required to follow.
  • Outcomes of women’s care and treatment were robustly collected and monitored. For example, a maternity dashboard was available.
  • Staff also confirmed that electronic hospital (Epic) coordination between electronic and paper-based systems had developed and they were able to show a thorough history for patients including risk factors. Although day case risks were not all completed on our initial review.
  • We observed good practice in terms of audit, effective multidisciplinary team working and that staff consistently had the right skills, qualifications and knowledge for their role.

  • All staff observed were extremely caring and we found that people were treated with dignity, kindness and respect throughout the directorate. There were also exceptionally good support systems in place to meet people’s emotional needs, which included support following bereavement.
  • The service consistently received more compliments than complaints.
  • Women undergoing termination of pregnancy were cared for in a dedicated area that was accessed through a double door into soundproofed side rooms within labour ward but well away from labouring women or crying babies.
  • Information had been provided in ways that the women could understand and which promoted women in being involved in making informed decisions about their own care and the delivery arrangements. Overall maternity and gynaecology services feedback received indicated that staff had a caring and compassionate approach. Women reported being treated with respect and dignity and having their privacy respected and dealt with in a sensitive manner across this service.

  • Women could access and be discharged from the service in a timely way.
  • The gynaecology referral to treatment time (RTT) had maintained at 95% (trust target 92%) from the previous inspection in February 2016. There had been no national standard for RTT since October 2015.
  • Service planning across the directorate was seen with workforce planning addressed. The demand on the service was addressed when patient acuity or staffing could not meet the needs of the women. The maternity unit had 17 diversions between Dec 2015 and July 2016 mainly due to a lack of capacity or insufficient staffing numbers.
  • Senior managers had responded appropriately since the last inspection.
  • Risk registers were up-to-date with clear ownership and actions completed or in progress.
  • Key performance data was collected and analysed which meant that responsibilities were clear and that quality, performance and risk were fully understood and managed.
  • The introduction of electronic hospital (Epic) caused problems with not meeting the needs of the service; for example, with data collection. Four out of six staff confirmed that improvements with the system had been a priority. ” We are still on the journey but have moved forward since last year”.
  • There was an improvement with the completion of the neonatal early warning scores.
  • All staff told us that senior managers were approachable and encouraged them to be open and transparent. Senior managers and staff confirmed their commitment and spoke about “the honour in being able to provide the best care possible to women and their families”. Staff dedication and passion for delivering high-quality care was inspiring and there were numerous examples of outstanding practice in relation to innovation, improvement and sustainability.

Outpatients and diagnostic imaging

Good

Updated 18 January 2017

Overall, we rated the outpatient and diagnostic imaging service as good. We rated outpatient and diagnostic imaging as good for safe, caring and well led. We rated responsiveness as requires improvement and although effectiveness of the service was inspected, we did not rate it. We found:

  • The trust had taken action to ensure that patients awaiting appointments were being risk assessed to enable appointments to be booked in order of clinical priority.
  • There had been improvements with appointment slot issues (ASIs) and did not attend (DNA) rates since our inspection in February 2016.
  • Staff received feedback about incidents that happened in their area and there was evidence of learning.
  • Staff received appraisals and there was effective multidisciplinary working within the department.
  • Staff were caring and patients and carers spoke positively about the care and compassion shown by all clinic staff. Friends and family test (FFT) data showed 93.8% of patients would recommend the service although this was based on a low response rate.
  • Medical staff planned and delivered patient care and treatment in line with current evidence-based guidance, standards, best practice and legislation.
  • The board and other levels of governance within the trust worked effectively together and interacted with each other regularly. Structures, processes and systems of accountability were clearly set out, understood and effective.

  • Staff gave us numerous examples of innovations and improvements which had been introduced across OPD and DI as well as plans to improve sustainability.

However, we found:

  • There were still appointment backlogs in some specialties.
  • The trust was failing to meet referral to treatment time in six of the 18 specialties. However, this was an improving performance since our last inspection.
  • There were waits of longer than six weeks for some diagnostic tests.
  • FFT response rates were low.

Surgery

Good

Updated 26 February 2019

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

  • Compliance with mandatory training was good.
  • Staff were aware of processes and standard procedures to keep people safe from abuse, and received training to assess, recognise and report abuse.
  • There were reliable systems to ensure standards of cleanliness were maintained and prevent and control the risk of infection
  • The environment and equipment was generally suitable to treat patients safely, although there were some environmental and equipment risks. Service leads knew about these risks and were taking steps to improve and manage them.
  • The service responded appropriately to changing risks to patients who used the services
  • Nurse and medical staffing levels were planned and reviewed to ensure patients received safe care and treatment.
  • Records were well managed, clear, up-to-date and easily available to all staff providing care.
  • There were systems in place to ensure the proper and safe use of medicines.
  • The service used national guidance, best practice and local policy to deliver effective care and treatment.
  • Patients’ nutrition and hydration and pain management needs were clearly documented and met.
  • There were examples of better than average patient outcomes, for example patients had a lower than expected risk of readmission for non-elective admissions.
  • Staff had the appropriate skills, training and knowledge to carry out their roles and there were opportunities to develop additional competencies or learning. Staff received regular appraisals.
  • There was effective multi-disciplinary team (MDT) working throughout the service to maximise patient experience and outcomes.
  • Staff obtained consent to care and treatment in line with legislation.
  • Staff treated patients with compassion, dignity and respect, and patients consistently reported that staff were caring and that they were happy with their experience.
  • Staff supported patients’ emotional and holistic needs.
  • Despite the challenges with access and flow, there was evidence of significant mitigating actions to manage it as best as possible, including strong links between wards and the bed management team and discharge planning coordinators.
  • Services were planned with a focus on meeting the individual needs of patients. For example, there were initiatives to meet the needs of patients living with dementia or learning disabilities, particularly anxious patients or patients with mobility difficulties.
  • Neurosurgery was performing above the England average for RTT rates (percentage within 18 weeks).
  • The trust was performing positively against the national requirement for the total elective surgical waiting list to be lower in March 2019 than March 2018. Staff could explain the process for when patients wanted to raise a complaint and there were examples of changes in practice or sharing of feedback resulting from complaints.
  • There was strong, effective leadership to help deliver care to patients and support staff.
  • Staff spoke highly of the leadership and support provided at matron level and we saw matrons had a strong presence on the wards.
  • There was a trust strategy which staff were aware of and engaged in, and service specific strategies within surgery to develop and improve the service.
  • Morale was generally high, and there was a positive, open and team-based culture. Staff spoke highly of their teams and felt proud to work in the service.
  • There were effective structures, processes and systems of governance and accountability
  • There were systems and processes to ensure risks were monitored and mitigated wherever possible, and performance was monitored.
  • Staff were engaged in their work and there were examples of where initiatives from staff had been used to develop and improve the service.
  • Surgical services had several ongoing innovative initiatives to develop services and maximise patient experience.

However:

  • We had concerns around the checking and escalation arrangements for medication fridge temperatures to ensure medicines were stored at a safe temperature.
  • We had concerns that learning from incidents was not always shared between different divisions. Most staff did not show awareness of the serious incidents around breaches of confidential information or the never event of a retained foreign object following surgery.
  • Some patients felt that they were not always kept informed by medical staff about their care and treatment plans.
  • Access, flow and capacity were a significant challenge for the service, and delayed discharges were a frequent concern.
  • The service overall referral to treatment time (RTT) for admitted pathways for surgery was worse than the England average.
  • Between 2016 and 2018, the percentage of cancelled operations for elective procedures due to non-clinical reasons was higher than the England average in all quarters apart from the most recent one (April to June 2018)
  • Overnight intensive recovery (OIR) was intended to only be a 22-hour stay before patients were transferred to an appropriate ward, but there were frequent delayed discharges from OIR and main recovery to wards and the intermediate dependency area. The environment in OIR was not well suited for this.
  • There had been three serious incidents in relation to confidentiality breaches, due to staff not always following information management procedures.

Urgent and emergency services

Good

Updated 26 February 2019

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

  • Staff received safeguarding training and were aware how to recognise and report safeguarding concerns. They took steps to prevent abuse and worked effectively with other professionals.
  • Staffing levels and skill mix were planned, implemented and reviewed throughout the day. Unexpected shortages were responded to quickly and adequately.
  • The emergency department (ED) provided care and treatment that was planned and delivered in line with current evidence based guidance. Patients received comprehensive assessments of their needs including pain relief, mental health, physical health and wellbeing and nutrition and hydration.
  • Patients subject to the Mental Health Act 1983 (MHA) had their rights protected, staff received training and complied with the MHA code of practice.
  • Information about patient’s care and treatment and outcomes were routinely collected and monitored. The information was used by the emergency department to improve patient experience and care. Outcomes were mainly positive and consistent.
  • Feedback from patients and relatives was overwhelmingly positive about the way staff provided care and treatment.
  • Staff treated patients with kindness respect and went the extra mile and exceeded patient expectations. Staff considered patients personal, cultural, social and religious needs into account when planning care.
  • Staff were highly motivated and inspired to offer care that was kind and promoted patient dignity, patient’s emotional needs were seen to be as important as their physical needs.
  • There was a patient centred culture within the emergency department, we observed strong caring respectful interactions between staff and patients and their relatives.
  • Patients and people close to them were involved in their care. Staff were fully committed to working in partnership with patients to empower them to make informed decisions regarding their care and treatment.
  • Staff communicated with patients and relatives in a way they could understand their care, treatment and advice.
  • Patients’ privacy and dignity was consistently embedded in practice by all roles of staff working within the department.
  • Without exception patients and relatives, we spoke with or feedback we reviewed said staff were always kind, caring and respectful even during busy times.
  • Staff within the ED took a pro-active approach to understanding the needs of different patient groups and planned care in a way that met those needs Care was person cantered and promoted equality, including patients approaching the end of their life, vulnerable patients and patients with complex needs.
  • Care and treatment was coordinated with other agencies and services to ensure the needs of patients were assessed and treatment planned according to the individual’s needs. We observed detailed assessments and care plans in all of the records we reviewed.
  • Patients could access services to receive the right care at the right time. Access to care was managed by staff to take into account patients with urgent needs. Patients could access services and follow on appointments in a way that suited them.
  • There was compassionate inclusive and effective leadership at all levels. Leaders demonstrated high levels of experience and capability needed to deliver excellent sustainable care.
  • The ED prioritised leadership development and succession planning to ensure the service continued to have effective leaders within the department.
  • The leadership team set out a vision for the service where the effectiveness of care in ED was reflected across other services such as mental health, medical care, surgical care, children and young person’s care and end of life care.
  • All staff we spoke with were aware of the trust’s vision and could describe the vision. There was a systematic approach to monitoring, reviewing and tracking progress within the department.
  • Leaders had an inspiring shared purpose and strove to deliver and motivate staff to succeed. There were high levels of satisfaction across staff groups within the department.
  • Governance arrangements were proactively reviewed and reflected best practice. A systematic approach had been implemented to enable staff to work with other organisations to improve patient experiences and outcomes.
  • There was a commitment to best practice performance and risk management processes. The department reviewed how they functioned and ensured all staff had the skills and knowledge to use systems effectively.
  • The electronic patient systems provided real time information to enable staff to provide effective care and treatment. Information was shared across services within the trust to coordinate patient care.
  • Leaders consistently involved staff, considered public feedback and welcomed stakeholder challenge to develop the department.
  • There was a commitment from all staff to seek and embed new ways of working to improve care and services for patients.

However:

  • The Royal College of Emergency Medicine recommends that the time patients with should wait from time of arrival to receiving treatment should be no more than one hour. The trust did not meet the standard in eight months over the 12 month period from August 2017 to July 2018.
  • The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the emergency department. From October 2017 to September 2018 the trust consistently failed to meet the standard.
  • Initial access to the dedicated paediatric waiting area had been made partially secure, but patients already in minors area of the ED were still able to access the paediatric waiting and treatment area. Staff were not able to see the paediatric waiting area and there was no closed-circuit television to observe the children and relatives. The trust had detailed plans to further reduce access and address the audio-visual concerns within the paediatric waiting area.
  • Observations were not always documented for patients with mental health conditions who were required to be observed every 15 minutes.