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Addenbrooke's and the Rosie Hospitals Good

Reports


Inspection carried out on Date of inspection visit: 20th to 22nd September 2016 Unannounced inspection: 29th September 2016.

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

We carried out a full follow up inspection between 20th and 22nd September with an unannounced inspection on 29th September 2016. This inspection was to follow up our comprehensive inspection in April 2015 where the concerns identified by the inspection team had resulted in my recommending the trust for special measures. A smaller focussed inspection in February 2016 followed up our most serious concerns and those areas rated Inadequate.

At this inspection we saw significant improvement across most of the areas we inspected. This included outstanding effectiveness in the critical care units and improvements in safety and leadership in maternity services and outpatients which we have now rated as good. These had been rated inadequate in 2015. There were similar improvements in medical care, surgery and urgent and emergency services with all services now rated as good overall. The improvement was in line with the trusts improvement plan and was assisted by constructive challenge from stakeholders at regular meetings.

Cambridge University Hospitals NHS Foundation Trust is one of the largest in the UK with around 1400 beds. The trust provides a major trauma centre for the east of England and specialist services in immunology, fetal medicine, IVF, neurosurgery, ophthalmology, genetics and metabolic diseases, specialised paediatric, cancer and transplant services.

The trust also provides district general hospital services to patients predominantly coming from Cambridgeshire, Essex, Suffolk and Hertfordshire. The demographics vary during the year due to the large student population of approximately 24,488.

The clinical departments are clustered together into five divisions:

Division A: Musculoskeletal; Digestive Diseases and ICU/ Periops

Division B: Cancer; Laboratory services; Imaging and Clinical support

Division C: Acute Medicine; Inflammation/Infection; Transplant

Division D: Neuroscience; ENT/ Head and neck/ Plastics; Cardiovascular-Metabolic

Division E: Medical Paediatrics; Paediatric Critical Care and Paediatric Surgery; Obstetrics and Gynaecology

During this inspection we inspected all key questions in all of the eight core services. The organisation had been through a significant change in senior leadership in the preceding 12 months which had resulted in a number of governance changes within the organisation. The trust was continuing progress against an overarching improvement plan in response to concerns found at our previous inspections.

Our key findings were as follows:

  • The trust had received support from NHS Improvement since it was placed in special measures in September 2015 and had undertaken a review of governance structures across the organisation. This had included the implementation of the improvement plan and regular oversight of its implementation from regulators, commissioners and stakeholders.
  • There was improvement in the quality and safety of all services with the exception of children and young people’s services which found the demand on the service challenging. This improvement was in line with the trusts improvement plan.
  • There was improved learning from incidents across the divisions. Most staff we spoke with had a good understanding of the duty of candour.
  • There had been an increase in permanent staffing levels resulting in very low levels of agency nurse usage across the trust. There remained use of bank staff and some locum consultants.
  • The trust had developed a system of monitoring patient acuity on several occasions each day. This allowed senior managers and clinical staff to flex staffing levels to meet patient need.
  • There were ongoing capacity issues within the trust resulting in cancelled and delayed surgeries. Children’s services were also under pressure though the imminent opening of additional beds should alleviate some of this pressure.
  • Internal capacity issues were also seen in delayed discharges from the critical care units. There were also delays in transferring some patients from recovery post operatively to a ward for post-operative care.
  • There were ongoing capacity issues within maternity services meaning the unit diverted high risk deliveries on 17 occasions between December 2015 and July 2016.
  • Significant improvement had been made into reducing the numbers of patients waiting for outpatient appointments. However, further work was required to further reduce the waiting lists for appointments and some investigations.
  • The trust failed to achieve the national target for treating, admitting or discharging 95% of patients within four hours. In December 2015, the trust met the target, however performance began to fall in January 2016 and fell to 83% in May 2016
  • The revised governance systems were sufficient to ensure that the senior team had robust information on which to make decisions.
  • There was a large audit programme. However, we saw results in medicine were below the England average and the stroke national audit scored ‘D’ – the second lowest score. There was very limited audit in end of life care though the trust had identified this and were developing an audit plan.
  • The electronic patient record (Epic) had now been in place for some 2 years. Many of the concerns we had identified at previous inspections had been addressed and staff were more familiar with the system though care planning was not always individualised and personalised.
  • Staff were very caring and on some occasions went to great lengths to support and care for patients.
  • There was an open culture. Staff reported incidents and there was increased evidence of learning from incidents.
  • Staff spoke positively of local (divisional) management. Managers in all areas were well sighted on risks as well as developing new pathways and delivering care.
  • Patients spoke highly of the care they received. Friends and Family Test results were generally positive across the trust however, there were very poor response rates in some areas.

Importantly, the trust must:

  • Ensure medicines including controlled medicines are securely stored at all times.
  • Ensure that end of life care is properly audited (such as preferred place of death and DNACPR) and actions taken in response to those audits.
  • Ensure that complaints are responded to in a timely way wherever possible.
  • Ensure resuscitation decisions are always documented legibly and completed fully in accordance with the trusts own policy and the legal framework of the Mental Capacity Act 2005.

In addition the trust should:

  • Ensure it improves the environment for children in the ED to ensure children’s safety at all times.
  • Review staffing in the emergency department with respect registered nurses (child branch) to ensure children’s needs and national guidance are met.
  • Review staffing of the specialist palliative care team against national guidance.
  • The trust should ensure that all staff complete mandatory training and safeguarding training to ensure it complies with the 90% compliance target.
  • Continue to work to improve delayed discharges and discharges that occur between the hours of 10pm and 7am in the critical care and intensive care units.
  • The trust should ensure the actions from the safeguarding review they have conducted for level three training for staff in adult areas caring for patients under the age of 18 years are implemented.
  • The trust should review the level of children’s safeguarding training healthcare assistants undertake to ensure it is in line with the Intercollegiate Role Framework for Looked After Children and the trusts own Safeguarding Children’s Policy.
  • Review consultant hours in maternity in line with national guidance.
  • Continue to improve referral to treatment time performance including for cancer services and reduce the number of cancelled operations.
  • Consider improvements to the response rate for the Friends and Family Test which are poor across the trust.
  • Ensure that systems are in place to reduce the risk of confidential information leaks.
  • Work to reduce the number of diversions of high risk deliveries in maternity services.
  • Continue to reduce the time for end of life patients to be discharged to their preferred place of care.
  • Ensure that all equipment is appropriately checked and safety tested where required.

We saw areas of outstanding practice including:

  • Ward J2 ran weekly ‘music and movement’ classes to help meet the holistic needs of patients during their long-term recovery. A volunteer specialising in music and movement ran the classes and staff encouraged patients and their relatives to attend. This had received excellent feedback from patients and relatives.
  • The teenage cancer unit provided outstanding facilities for young people diagnosed with cancer and receiving treatment for cancer. The teenage cancer unit provided a welcoming, age appropriate environment for young people to receive treatment, but also meet other young people and relax and socialise.

  • The ED team had developed a mobile phone application called “Choose Well.” The application offered guidance on waiting times and hospital services across Cambridge in order to improve the patient experience and offer choices in health care.
  • The emergency department had secured £100,000 of funding from the Small Business Research Initiative (SBRI) to support the development of a crowd prediction modelling tool to enable the trust to understand and map patient flow through the department.
  • The charitable trust was in the process of setting up a trauma ICU centre in Burma in which a number of the ICU/NCCU staff were involved, as well as the Burma nurse specialist visiting later on in the year.
  • The initiative for ‘Family Facetime’ proposed the purchase of two technology tablets to enable mums on the Obstetric Close Observation Area (OCOA) who are too unwell to visit their baby on the neonatal intensive care unit to receive a video link via Facetime with their baby.
  • The bereavement follow up scheme saw a reduction in complaints of approximately 50%.

On the basis of this inspection I am recommending that Cambridge University Hospitals NHS Foundation Trust is removed from special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 9th and 10th February. Unannounced inspection 23rd February.

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

We carried out a focussed follow up inspection on 9th and 10th February with an unannounced inspection on 23rd February. This inspection was to follow up specific concerns in surgery, maternity and gynaecology and outpatient and diagnostic services that were identified at our inspection in April 2015.

Cambridge University Hospitals NHS Foundation Trust is one of the largest in the UK with around 1100 beds. The trust provides a major trauma centre for the east of England and specialist services in immunology, foetal medicine, IVF, neurosurgery, ophthalmology, genetics and metabolic diseases, specialised paediatric, cancer and transplant services.

The trust also provides district general hospital services to patients predominantly coming from Cambridgeshire, Essex, Suffolk and Hertfordshire. The demographics vary during the year due to the large student population of approximately 24,488.

The clinical departments are clustered together into five divisions:

Division A: Musculoskeletal; Digestive Diseases and ICU/ Periops

Division B: Cancer; Laboratory services; Imaging and Clinical support

Division C: Acute Medicine; Inflammation/Infection; Transplant

Division D: Neuroscience; ENT/ Head and neck/ Plastics; Cardiovascular-Metabolic

Division E: Medical Paediatrics; Paediatric Critical Care and Paediatric Surgery; Obstetrics and Gynaecology

During this inspection we inspected all key questions in maternity and gynaecology, outpatients and diagnostic imaging and the responsive question only in surgery. We found improvement in each area we inspected compared to our previous inspection in April 2015 with a particular focus on leadership and safety. The organisation had been through a significant change in senior leadership which had resulted in a number of governance changes within the organisation. However, the trust was continuing the implementation of an improvement plan in response to concerns found at our previous inspections.

Our key findings were as follows:

  • Nitrous oxide scavenging systems had been installed and monitoring had shown them to be effective at reducing environmental nitrous oxide. Other equipment within the unit was all serviced and had been appropriately maintained.

  • There had been a review of midwifery staffing which had led to an increase of nine midwifes and six health care support workers in the unit.

  • Governance in maternity had improved with clear view of the unit’s risks and key performance data now being collected. However, there was no long term plan in maternity to manage capacity and demands on services.

  • Neonatal early warning scores were still not being consistently completed or recorded.

  • The outpatients department had risk assessed and reviewed all patients records with an outstanding appointment to ensure patients were seen in a timely way based on relative clinical risk. However, there continued to be a backlog of appointments within outpatients.

  • There was a general improvement in referral to treatment times (RTT) and against other waiting time standards. However the trust was still failing to meet agreed RTT, some diagnostic test waiting times and was just below the national standard on one measure of cancer waiting times.

  • New leadership within the outpatients department had a clear view of the risks within the department and a strategy for addressing these. A new governance and management structure gave full oversight of the trusts improvement plan.

  • There was on-going cancelled surgery though the number was on a downward trajectory and represented improved performance since our last inspection in April 2015.

Importantly, the trust must:

  • Ensure that staff in maternity are compliant with mandatory training including safeguarding
  • Ensure that neonatal early warning observations are completed, recorded and responded to according to protocol and clinical need.
  • Ensure that all staff receive feedback on incidents in their area or relevant to them in their work.
  • Ensure all staff are aware of their responsibilities under Duty of Candour.

In addition the trust should:

  • Review the provision of information technology for the community midwifery teams.
  • Review the provision of consultant hours on the delivery suite in relation to national guidance.
  • Ensure that data in relation to delayed induction of labour is collected and acted on.

This inspection was to gain assurance that Cambridge University Hospitals NHS Foundation Trust had taken action to address our most serious concerns identified at our inspection of April 2015 and was not to determine if the trust should be removed from special measures. A full follow up inspection has been announced for September 2016.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 21- 24 April 2015 and 7 May 2015

During a routine inspection

We carried out a comprehensive inspection between 21 and 24 April 2015 as part of our regular inspection programme. In December 2014 Cambridge University Hospitals NHS Foundation Trust had been identified as having only two elevated risks and one risk on our Intelligent Monitoring system. However, in May 2015 the system showed that there were five elevated risks and four risks.

Cambridge University Hospitals NHS Foundation Trust is one of the largest in the UK with around 1100 beds. The trust provides a major trauma centre for the east of England and specialist services in immunology, foetal medicine, IVF, neurosurgery, ophthalmology, genetics and metabolic diseases, specialised paediatric, cancer and transplant services. These services, as provided at Addenbrooke’s Hospital and the Rosie Hospital were inspected as part of the core services within this report. The trust also provides district general hospital services to patients predominantly coming from Cambridgeshire, Essex, Suffolk and Hertfordshire. The demographics vary during the year due to the large student population of approximately 24,488.

The clinical departments are clustered together into five divisions:

Division A: Musculoskeletal; Digestive Diseases and ICU/Periops

Division B: Cancer; Laboratory services; Imaging and Clinical support

Division C: Acute Medicine; Inflammation/Infection; Transplant

Division D: Neuroscience; ENT/ Head and neck/ Plastics; Cardiovascular-Metabolic

Division E: Medical Paediatrics; Paediatric Critical Care and Paediatric Surgery; Obstetrics and Gynaecology

Whilst we inspect core services, these crossed divisions. We were able to disaggregate some of the performance information for the trust across our core services.

During this inspection we found that the trust had significant capacity issues and was having to reassess bed capacity at least three times a day. This pressure on beds meant that a number of routine surgery admissions were cancelled as there were no beds available. We found that staff shortages meant that wards were struggling to cope with the numbers of patients and that the adult critical care areas were not staffed in line with national guidance. We reported this to the hospital trust management immediately and undertook enforcement action to place a condition on the trust’s registration in relation to Addenbrooke’s Hospital to ensure that there were sufficient staff in place to care for critically ill patients. We have since been assured by the trust that there are systems now in place to ensure that staffing in this area is in line with national guidance and we have removed this condition form the trusts registration.

We have rated this location as inadequate overall due to significant concerns in safety, responsiveness and the disconnect between ward staff and the divisional leaders. We found that the staff were exceptionally caring and that they went the extra mile for their patients..

Our key findings were:

  • There was a significant shortfall of staff in a number of areas, including critical care services and those caring for unwell patients. This often resulted in staff being moved from one area of a service to another to make up staff numbers. Although gaps left by staff moving were back-filled with bank or agency staff, this meant that services often had staff with an inappropriate skills mix and patients were being cared for by staff without training relating to their health needs .Despite this patients received excellent care.
  • Pressure on surgical services meant routine operations were frequently cancelled and patients were waiting longer than the 18-week referral to treatment target for operations. Pressure on the outpatients department meant long delays for some specialties and not all patients being followed up appropriately, particularly in ophthalmology and dermatology. There were some outstanding maternity services but significant pressures led to regular closures and a midwife to birth ratio worse than the recommended level.
  • Disconnected governance arrangements meant that important messages from the clinical divisions were not highlighted at trust board level.
  • Introducing the new EPIC IT system for clinical records had affected the trust’s ability to report, highlight and take action on data collected on the system. Although it was beginning to be embedded into practice, it was still having an impact on patient care and relationships with external professionals.
  • Medicines were not always prescribed correctly due to limitations of EPIC, although we were assured this was being remedied.

However, we also found:

  • Caring staff who did everything they could for patients in their care.
  • Effective and robust multidisciplinary working across the trust.
  • The emergency department and major trauma centre were efficient and effective.

There were areas of poor practice where the trust needs to make improvements.

Importantly, the trust must ensure that:

  • All patients awaiting an outpatient’s appointment are assessed for clinical risk and prioritised as to clinical need.
  • Effective governance and management arrangements are put in place in outpatients.
  • Systems or processes must be established and operated effectively to enable the outpatients department to assess, monitor and improve the quality and safety of services.
  • Services around end of life are reviewed to allow for fast track or rapid discharges to be undertaken in a timely way.
  • Patient dependency in the intensive care unit is reviewed and staffing monitored against this on a day to day basis to ensure compliance with the Faculty of Intensive Care Medicine / Intensive Care Society core standards for ICU (Ed1) 2013.
  • There is adequate staffing to provide safe care for patients requiring non-invasive ventilation.
  • Data collection for the ICNARC case mix programme is monitored and that data collected is reliable, accurate and representative of the functioning of both critical care units.
  • Patients are discharged from critical care units to the wards in a timely manner and minimises the number of patients being discharged after 10pm.
  • It encourages collaborative working and sharing of clinical governance data between the general critical care unit and the Neuro Critical Care Unit.
  • Medicines are managed in line with national guidance and the law.
  • All patients who may lack capacity have a mental capacity assessment and, if appropriate, a deprivation of liberty safeguards (DoLS) assessment and that patients’ consent is properly sought before treatment.
  • All emergency equipment is checked in line with policy.
  • Risk assessments are completed and correctly recorded.
  • All environments are safe and that high levels of nitrous oxide in delivery suites are addressed.
  • Consistent foetal heart rate monitoring is provided in maternity services.

In addition, the trust should:

  • The impact of high bed occupancy on the admission of emergency patients and the provision of emergency surgical services at Addenbrooke’s Hospital is reviewed.
  • Review the provision of end of life care to consider providing cover over seven days a week.
  • Ensure that focus is given to drive improvement and delivery of the end of life care service, including community engagement and investment in the service.
  • Ensure the estates department is staffed with enough appropriately trained people to facilitate a more timely response to maintenance requests to help improve the environment, infection control and health and safety for patients and staff.
  • Improve the skill mix across critical care to ensure that 50% of staff complete their certificate in critical care in line with best practice standards.
  • Staff on the wards should be clear who has a DNACPR in place at all times to minimise the likelihood of incidents where patients may be resuscitated against their expressed wishes.
  • Ensure access to dedicated physiotherapy and clinical pharmacy services seven days a week.
  • Ensure that there are arrangements in place with clear management plans for the merging of two mortuaries in Cambridgeshire.
  • Review the arrangements for patients undergoing termination of pregnancy for foetal anomalies on the labour ward.
  • Ensure that medical and surgical patients are cared for in an appropriate ward.
  • Reduce the number of cancelled surgery admissions.
  • Consider the use of pain assessment tools for patients who require additional assistance in communicating their needs.

We saw areas of outstanding practice including:

  • The allergy clinic had a one-stop allergy service that provided diagnosis and management of a wide range of allergic disorders. This clinic was dynamic and comprehensive.
  • Virtual clinics had been set up in a number of areas, each consisting of a multidisciplinary team of staff including nursing and consultant grade staff. The purpose of the clinic was to review patient diagnostic tests and notes to make treatment decisions without the need for the patient to attend an appointment. Patients were then called and treatment options explained over the phone.
  • The chaplaincy and bereavement service offered a one-stop appointment where bereaved relatives could see all trust staff that they needed to see in one visit. Bereaved relatives were also invited back six weeks after the death to enable staff to provide emotional support and answer any questions. The six-week follow-up had been devised at Addenbrooke’s and rolled out nationally.
  • The specialist palliative care consultants at Addenbrooke’s had won National and International recognition as an area of excellence in palliative care for their work in developing the “Breathlessness Intervention Service”.
  • The online educational resource – cambridgecriticalcare.net – developed by the neurological critical care team is a repository of educational resources aimed not only at local trainees, but trainees nationally and internationally.
  • Patients previously treated within critical care were invited to a twice-yearly focus group to help drive service improvement. Through this focus group, real change had been implemented, including improving the transition of care from the critical care area to the ward, establishment of a quiet/interview room for doctors to speak to relatives on the critical care unit, and the re-design of the relatives’ room.
  • On the general critical care unit, a junior doctor jointly with the IT department developed an application for a mobile tablet called “My ICU Voice” to enable patients who had a tracheostomy to communicate with staff.
  • Team working in the critical care unit was outstanding. Given the limited resources, all members of the multidisciplinary team worked collaboratively to ensure patients received kind and compassionate care. Nursing staff were observed doing everything they could to ensure patients’ carers were well informed of their loved ones’ condition.
  • There was well-managed and coordinated medical handover and follow-up of patients following admission, with all specialties being represented for effective care management planning.
  • The “supervisor of midwives” network at the trust was outstanding and was an important contact for patients and staff. The purpose of supervision of midwives is to protect women and babies by actively promoting safe standards of midwifery practice.
  • The Birthing Unit in The Rosie Hospital had facilities that were outstanding and state of the art. They included 10 birthing rooms, all with en-suite bathrooms, mood lighting and music systems, a fold-down double bed, birthing balls, slings, birthing stools, floor mats and comfortable seating and access to a sensory garden.
  • The Neonatal Intensive Care Unit is at the forefront for provision of care for babies. The neonatal transfer team (ANTS) was the first such team to formally and consistently enable parents to travel with their sick babies.
  • The ACTIVE Children and Young People’s Board enabled current and former young patients, and any other children who were interested, to meet and share ideas. The ACTIVE Children and Young People's Board was involved in producing child-friendly information and in projects such as Teens in Hospital, which was looking at ways of improving the experience of young people, especially those on adult wards.

On the basis of this inspection, I have recommended that the trust be placed into special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 7 January 2014

During a themed inspection looking at Dementia Services

To help us assess the quality of care and service patients living with dementia experienced we visited the emergency department, the short stay acute medicine for older people unit, a specialist ward for patients living with dementia which also provided services for patients experiencing delirium and a general medical older person's ward. We identified patients who were living with dementia in all of these areas.

We spoke with 18 patients living with dementia, observed five other patients who were living with dementia, spoke with eight people who cared for people living with dementia, some of these were care staff from care homes accompanying people. We also spoke with 20 staff. We looked at 11 sets of records, and we looked at the care and treatment pathway for these patients to ensure patients' needs were met.

Most patients told us they received good quality care and were involved in decisions about care and treatment, this meant care was planned and delivered in a way which was intended to meet patient’s individual needs.

Patients had access to a range of services to ensure their overall needs were met. The hospital staff worked hard to make sure they had the information they needed on admission to meet patients' needs effectively and to ensure an appropriate and safe discharge from hospital.

There were a number of systems in place to enable the trust to assess and monitor the quality of the service which were in line with national guidance on developing dementia care services.

Inspection carried out on 10 December 2012

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

During this inspection on the 10 December 2012 we visited three wards and spoke with several staff who were working on these wards. We visited two operating theatres and although we did not speak with people who were receiving care and treatment, we spoke with nursing staff, surgeons and consultants involved in the surgical procedures that were being undertaken during our inspection.

We found clear evidence of an improvement in the application of the World Health Organisation (WHO) checklist within operating theatres. We found staff were enthusiastic and focussed on maintaining people’s safety through the improved use of the WHO checklist. We found significant improvements in the completion and retention of specific surgical safety records relating to the individual responsibilities, which has led to greater safety for people and improved quality assurance.

Safeguarding arrangements for children and for vulnerable adults were inspected on the three wards that we visited and found to be fit for purpose. We found that staff knowledge about safeguarding was robust on the children’s ward we visited and that appropriate safeguarding arrangements were in place on older people’s wards.

The initiation of an extended and improved system of safety checks at each stage of the WHO checklist had ensured better safety for people in operating theatres. Quality assurance monitoring and auditing processes showed that continuous improvements in theatre safety had been achieved.

Inspection carried out on 25 April 2012

During an inspection in response to concerns

During this review, we visited two ward areas, several theatres and spoke with eight people who were receiving treatment and one relative. Overall, they were complimentary about the care and treatment they had received and felt they had received sufficient levels of information from staff about their health issues.

One person in theatres said “Staff have been very kind and reassuring. I find all these checks good, I’ve never been asked my name and date of birth so much.”

Another person in the treatment centre said they had felt, "Claustrophobic" when the curtains were drawn around the bed spaces. Two other people made comments about the confined space around each bed although they felt staff did their best to help maintain privacy and confidentiality.

Inspection carried out on 21 March and 13 August 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 6 September 2011

During an inspection in response to concerns

We spoke with several women and their partner's about their experiences of the care and support received at the Rosie Maternity Hospital. Overall people were complimentary about the service, they advised that they had received relevant and timely information and felt well supported by staff.

However, one woman was not happy about the care and support she received during treatment after labour and another person advised that staffing levels, "Varied from shift to shift."

Inspection carried out on 29 June 2011

During a routine inspection

During our visit to Addenbrooke's and the Rosie Maternity Hospitals people told us they were very satisfied with the care and treatment they had received. People who required surgery or a diagnostic test were given a full explanation of the procedure and felt they had given their informed consent.

The people that we spoke with told us they had no need to make a complaint about their care experience, but knew how to make a complaint should they feel it were necessary.

One person told us, “Staff here are fantastic, gold star, they are always helpful and explain what’s happening”.

People that we spoke with were not aware of how to raise any concerns about abuse or safeguarding issues and had not seen any information about the hospitals procedures to support them.

Inspection carried out on 23 March 2011

During a themed inspection looking at Dignity and Nutrition

We visited two wards and spoke with eight members of staff and six patients who were receiving care and treatment. We also used information provided by patients on the NHS Choices website and patient survey results. The survey results were generally good, although people who completed the outpatient survey felt they were not receiving sufficient information about how to receive test results.

We found that most people were happy with the way staff cared for them and felt respected by them. They told us that staff explain what they need to do and ask them if it is alright to help them first. Most people told us they had been given the opportunity to say how they wanted to be treated and had never felt embarrassed or uncomfortable during their stay.

On both wards we visited, people felt that staff did not respond to their needs quickly enough and one person said she can wait for up to an hour to have her call bell answered. One person said, “I don’t think they can respond quickly, they have so much to do, they do their best”.

All the people that we spoke with felt they had not received enough information from staff about one or more of the following: care options including the risks and benefits, the facilities available, or what will happen when they leave hospital.

Most people that we spoke with had not been asked for feedback about their care experiences.

Overall people told us the standard of food was good and they got their choice of meal most of the time. They were aware that snacks and drinks are available any time of day although two people had made requests that were not received. Some people had missed a meal because they were away from the ward and were able to order a ‘late’ meal. One person said they are not routinely offered an evening drink although they could request one. The next routine hot drink is offered to people at breakfast time and she felt it was unacceptable to wait for over twelve hours.

People told us that they are offered hand wipes before meals and the tables are wiped down if they are visibly dirty. Most people had not talked to someone about what they liked to eat and any support they needed with their diet. They are not always asked if they have had enough to eat and drink.

Inspection carried out on 29 December 2010

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

We spoke with a total of 31 people during our visit to the accident and emergency department. These people were present because they required treatment or they were there to accompany someone. This includes friends, parents, other relatives and paramedic teams.

Overall people who were being treated in the accident and emergency department told us that their experience was positive. They found that staff were attentive, approachable and informative. Most people were very satisfied with their treatment and the experience of being a patient in the department.

Some people who were waiting realised they had been delayed so that staff could treat people with more immediate needs first.

People told us that staff treated them with respect and dignity and provided them with an appropriate level of information. However, some people in the main waiting areas felt they were not informed about how long they would need to wait before being treated.

Four people who had already been assessed informed us that they were waiting for results of blood tests and they felt this was an unnecessary delay to their treatment or discharge. They indicated tests had been taken between one and four hours previously.

One person commented that plain English could be used by staff as they were not sure of the meaning of some of the terms and language used by clinicians.