Addenbrooke's and the Rosie Hospitals

Updated 4 September 2023

Pages 1 and 2 of this report relate to the hospital and the ratings of that location, from page 3 the ratings and information relate to maternity services based at Addenbrooke's and the Rosie Hospitals.

This location was last inspected under the maternity and gynaecology framework in 2017. Following a consultation process CQC split the assessment of maternity and gynaecology in 2018. As such the historical Maternity and Gynaecology rating is not comparable to the current maternity inspection and is therefore retired. This means that the resulting rating for Safe and Well-led from this inspection will be the first rating of maternity services for the location. This does not affect the overall Trust level rating.

We inspected the maternity service at the Rosie Hospital which is part of the Cambridge University Hospitals NHS Foundation Trust as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out an announced focused inspection of the Maternity service, looking only at the safe and well led key questions.

The Rosie Hospital is a purpose-built women's and maternity hospital which is located adjacent to Addenbrooke's Hospital in Cambridge. The Rosie hospital is a tertiary unit with a level 3 neonatal intensive care unit which accepts infants from 22+0 weeks gestation. The hospital serves the local population of Cambridgeshire, extending to parts of North Essex, East Hertfordshire, Suffolk and Bedfordshire, and specialist services in high-risk obstetrics and fetal and maternal medicine are provided to the whole of the Eastern region.

Maternity services include an early pregnancy unit, maternal and fetal medicine outpatient department, maternity assessment unit, antenatal ward (Sara ward), delivery suite, midwifery led birthing centre, two maternity theatres, postnatal ward (Lady Mary ward), an obstetric close observation area (OCOA), ultrasound department and an obstetric physiotherapy department. From April 2021 to March 2022 the total number of births was 5,573.

Our rating of this hospital stayed the same. We rated it as Good because:

• Our ratings of requires improvement for the maternity service did not change the ratings for the hospital overall. We rated safe as requires improvement and well-led as good and the hospital as good. Our reports are here:

Addenbrooke's and the Rosie Hospitals - https://www.cqc.org.uk/location/RGT01

How we carried out the inspection

This maternity thematic review was a focused inspection; we inspected the domains of safe and well-led using the CQC's specific key lines of enquiry designed to support the National Maternity Services Inspection Programme.

Inspectors visited maternity services on 11 May 2023. We spoke with 35 staff and reviewed six sets of maternity care records and prescription charts. We asked women and birthing people to share their experiences with us and we received 52 responses.

We requested and reviewed documentary evidence to support our judgements including training records, audits results, standard operating procedures, staff rosters, meeting minutes, recently reported incidents and quality improvement initiatives.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

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.

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.

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.

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).

Updated 4 September 2023

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.

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.

Updated 24 June 2022