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Queen Alexandra Hospital Requires improvement

We are carrying out checks at Queen Alexandra Hospital. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 5 October 2018

Our rating of services stayed the same. We rated it them as requires improvement because:

  • Within medical care, surgery, maternity and urgent and emergency services records of patients care and treatment did not always contain updated risk assessments and appropriate individualised care plans. Up to date records were therefore not always available to all staff that provided care.
  • Medicines were not managed safely in many of the core services we inspected. Medicines were not always stored securely, and medicine fridges were not consistently monitored to ensure medication was kept at required temperatures.
  • There were insufficient numbers of staff with the right qualifications, skills, training and experience to keep people safe and provide the right care and treatment in the medical care, children and young peoples and urgent and emergency services.
  • The design and layout of the emergency department (ED) did not keep people safe. The emergency department was frequently crowded and patients were queued in a corridor which became congested, sometimes hampering the movement of patients and equipment. People waited too long for initial assessment in ED and the flow through the department often impacted on the movement of patients into the hospital.
  • Within ED and surgical services infection prevention and control was not robust in some areas and some equipment and premises were not sufficiently clean. Within the surgical high dependency unit there was no facility to isolate patients and therefore there was a risk of the spread of infection.
  • Mandatory training rates in some areas fell short of the trust’s target meaning staff did not have the minimum training deemed essential for their roles.
  • Staff who worked in the surgery, urgent and emergency and medical care services did not fully understand their roles and responsibilities with regards to the Mental Capacity Act 2005 and associated Deprivation of Liberty Safeguards (DoLS). Where appropriate, people’s mental capacity and DoLS were not consistently assessed and recorded in line with legal requirements. This had been identified at previous inspections and the trust had not given sufficient priority to ensure staff were suitably trained, competent and fully understood their requirements under the legislation.
  • Within the maternity service, guidelines had not been reviewed and updated in line with current best practice or national guidance. There was no robust practice that ensured completed audits were acted upon to improve practices.
  • Staff did not always provide patients with compassionate or respectful care in the emergency department. We observed a number of nursing staff who did not behave in a way which was consistent with the trust’s stated values or desired practice. Staff did not always provide emotional support to patients and relatives to minimise their distress.
  • In both medical and urgent and emergency care staff did not always involve patients and those close to them in decisions about their care and treatment. Some patients and relatives told us there was little communication from staff and they were not kept well informed about what was happening
  • Within maternity, medical and urgent care, services were not consistently planned or delivered to meet the needs of the local population.
  • In urgent and emergency services patients were not always able to access care and treatment in a timely way and in the right setting. The trust was consistently failing to meet national standards in relation to the time patients spent in the emergency department, the time they waited for treatment to begin and the time they waited for an inpatient bed. Patients waited too long for their treatment to begin. Facilities and premises were not wholly appropriate for the services delivered and we observed patients queuing in non-clinical areas such as corridors where there was a lack of comfort and privacy. Patients sometimes waited on ambulances outside of the emergency department due to congestion.
  • Within maternity, services were not routinely planned to ensure women could always deliver their baby in the preferred place of birth.
  • There were shortfalls in how the needs and preferences of different patients were met in medical and urgent care. Staff did not fully consider the needs of individual patients living with dementia or who had a learning disability.
  • Although the medical service treated concerns and complaints seriously and investigated them, there was lack of process to ensure learning from complaints was communicated and shared across all staff groups.
  • During our inspection the trust was in the processes of re-designing both their risk and governance structures. While some new processes were in place these had not been fully embedded. There were systems in place to identify, manage and mitigate risks however risks had not been fully identified and risk registers had not been fully completed within the urgent and emergency, maternity, medical and surgery services.
  • Governance processes did not consistently provide an effective systematic approach which identified areas for improvements and there was no overarching governance structure in the outpatients service.
  • The trust had identified improvements were required to address some poor cultures across the hospital. On the whole staff told us managers promoted a positive culture that supported and valued staff creating a sense of common purpose. Managers had the skills and abilities to run a service which provided high quality sustainable care However we observed some poor behaviours exhibited by senior nurses within the urgent and emergency service. In the outpatients department there was a poor culture where staff concerns were not always taken seriously and there was low staff morale in some areas.
  • Information systems within urgent and emergency services, maternity and medical services did not support effective sharing of patient information or support comprehensive recording or analysis of data.

However

  • In critical care, diagnostic imaging, outpatients and children and young people staff kept clear, up to date, detailed records of patients care and treatment.
  • Overall in critical care, children’s and young people, end of life, outpatients and diagnostic imaging services people were protected from abuse and avoidable harm.
  • We identified comprehensive systems where in place to keep people safe and risks were regularly assessed and updated.

  • The services controlled infection risk well and staff kept themselves and equipment clean.
  • Within critical care, end of life, outpatients and diagnostic imaging there were sufficient numbers of suitably trained and competent staff available to care for patients safely.
  • Staff in urgent and emergency, services for children and young people, end of life care, diagnostic imaging and critical care provided care and treatment based on national guidance. Managers checked to make sure staff followed guidance and audits were undertaken and acted upon to improve services. Staff, teams and services worked well together to provide effective care for patients.
  • We observed exceptional care in both children’s and young people’s services and critical care. We observed staff going ‘above and beyond’ to ensure patients and their relatives were supported and involved in treatment plans.
  • Overall in the services other than patients were treated with care and compassion. Patients and their relatives were complimentary about the care and treatment they received.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • Staff offered emotional support to patients and their relatives.
  • In most services we inspected we found people were able to access the service when they needed them. The services had been planned and provided in a way that met the needs of local people.
  • The services mostly took account of people’s needs and were flexible to encompass individual needs and preferences.
  • In critical care there was a proactive approach to understanding the needs and preferences of different groups of people and to delivering care in a way that met those needs, which was accessible and promoted equality.
  • Effective governance processes which monitored the quality of services provided were evident some services
  • Within critical care there was a fully embedded systematic approach to improvement. The service was forward looking, promoted training and clinical research and encouraged innovations. The service made effective use of internal and external reviews and learning was shared effectively and used to make improvements. There was a record of shared working locally, nationally and internationally.
  • Some services engaged well with patients, staff, and the public and local organisations to plan and manage appropriate services
Inspection areas

Safe

Requires improvement

Updated 5 October 2018

Effective

Requires improvement

Updated 5 October 2018

Caring

Requires improvement

Updated 5 October 2018

Responsive

Requires improvement

Updated 5 October 2018

Well-led

Requires improvement

Updated 5 October 2018

Checks on specific services

Critical care

Outstanding

Updated 5 October 2018

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

  • People were protected from abuse and avoidable harm by a strong comprehensive safety system, with a focus on openness, transparency and learning from when things went wrong.
  • People received excellent care, treatment and support which achieved good outcomes when compared with similar services, promoted a good quality of life based on the best evidence-based care and treatment.
  • People were treated with compassion, kindness, dignity and respect. They were truly respected and valued as individuals and were empowered as partners in care received, practically and emotionally, by an exceptional and distinctive service.
  • Services were tailored to meet the needs of individual people and were delivered in a way to ensure flexibility, choice and continuity of care.
  • The leadership, management and governance of the critical care unit assured the delivery of high-quality and person-centred care, supported learning and innovation and promoted an open and transparent culture.
  • The critical care unit had been rated as outstanding following our last inspection in 2015. However improvements had been made to the service since our last inspection. This included but not limited to: safety briefings increased to twice daily; a dedicated dietitian; increased physiotherapist staffing levels; new systems for improving patient flow; an improved and extended critical care outreach team that was now 24 hours a day seven days a week; an updated computer information system; introduced a relatives bleep system; and looked at ways to humanise the critical care environment to aid patient treatment and recovery.

Outpatients and diagnostic imaging

Good

Updated 19 June 2015

All outpatient and diagnostic imaging departments demonstrated good knowledge of reporting incidents and of learning from incidents. These were often shared with other outpatient specialities, but real learning only occurred within the speciality reporting the incident. All mandatory training, including safeguarding and infection control, was completed by all staff. Compliance for mandatory training was well monitored by senior staff members.

National Institute for Health and Care Excellence guidelines were followed in many departments and some excellent examples of practice was demonstrated. Staff were encouraged to develop professionally and regularly update their clinical skills. Rheumatology, dialysis and respiratory outpatient departments demonstrated outstanding practice and accomplishments.

Patients were positive about their experiences of care, including care that had been extended to relatives.

In ENT, patients were given access to a private room when they were being given difficult news or were distressed. A symbol on the door indicated to other staff not to enter the room. The privacy and dignity of patients was mostly adhered to. There were, however, some concerns about the building design affecting the privacy of patients in the dialysis unit on the Isle of Wight and in the ophthalmology department at Queen Alexandra Hospital. There were risks relating to infection control at the dialysis unit on the Isle of Wight.

Staff across outpatients and diagnostic imaging demonstrated a good understanding of how to make reasonable adjustments for patients living with dementia or those with a learning disability.

The waiting times for diagnostic imaging have historically been significantly higher than the national average up until July 2014. The Trust had met the waiting times for diagnostic imaging from September 2014, having extended the working day in the service to achieve this. In rheumatology, a rapid access clinic operated. Patients may receive an appointment that suits their existing commitments; often same-day appointments are available. It also provided innovative patient education and support conferences that are well attended by patients and have been nominated for awards.

The referral-to-treatment targets for most outpatient specialities were being met, although colorectal, back pain and the gastroenterology clinics had longer waits. The trust taking action to addressing this issue. Cancer urgent referral times for patients to be seen within two weeks were being met.

Ophthalmology had a high number of patients awaiting follow-up who were significantly delayed in receiving their follow-up appointment and were on the outpatients waiting list. This had been on the service risk register since 2009, as a result of a serious incident requiring investigation that occurred as a result of this backlog, it was escalated to the trust risk register In April 2013. This number had been reduced, but the number of patients waiting was still significant. The learning from this had improved how risks were escalated. Risks were being managed and waiting lists and service quality was monitored.

Renal outpatient letters were taking 35 days to be typed and sent to the patients’ GP. This was because the renal department had a separate IT system from the rest of the trust. It had caused significant delay in GPs receiving updated information regarding their patients’ treatment. An outpatients administration review was underway to improve services within the department.

Urgent and emergency services

Requires improvement

Updated 5 October 2018

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

  • The emergency department was frequently crowded. Patients were not always handed over promptly by ambulance staff on arrival in the emergency department and some patients waited too long for their initial assessment and for their treatment to begin. Crowding in emergency departments is associated with an increase in mortality and impacts on patients’ experience.
  • Patients were not always able to access care and treatment in a timely way and in the right setting. Patients spent too long in the emergency department. The service consistently failed to meet the national standard which requires that 95% of patients are admitted, transferred or discharged within four hours of arrival in the department and performance was consistently below the England average.
  • Poor patient flow within the hospital and the health and social care system meant that patients in the emergency department, who required admission, frequently experienced long waits for a bed. From April 2017 to March 2018, the trust’s monthly percentage of patients waiting more than four hours from the decision to admit until being admitted was consistently higher (worse) than the England average. In the same period 307 patients waited more than 12 hours. This is known as a ‘black breach’.
  • There was a lack of assurance with regard to the ongoing monitoring of patients’ safety and the identification of patients at risk of harm or deterioration, particularly where patients experienced extended waits. During our inspection we found that patients’ records were not consistently completed so as to provide assurance that regular checks on patients’ safety had taken place. Although daily audits of completion rates were taking place, a comprehensive audit tool had not yet been developed to provide assurance that this risk assessment tool was being used consistently and effectively to ensure safe care.
  • There were insufficient risk assessments documented to provide assurance that patients who were at risk of falls or developing pressure ulcers were identified and appropriately managed. The service had not taken prompt action in response to two serious incidents where patients had fallen in the emergency department and sustained a serious injury.
  • Facilities were not wholly appropriate for the services delivered. Demand often outstripped the availability of clinical spaces in the emergency department to assess, treat and care for patients. Patients frequently queued in the corridor where their safety, privacy, dignity and comfort was compromised.
  • The service provided mandatory training in key skills but not all staff had completed it.
  • Staff did not always comply with systems to control and prevent the spread of infection Staff did not always demonstrate good hand hygiene practice or ensure the safe disposal of sharps. Systems to isolate infectious patients were not effective.
  • There were significant numbers of registered nurse vacancies and heavy reliance on temporary staff. There were frequent shortages of medical staff at night.
  • Staff did not always understand or comply with the relevant consent and decision-making requirements of legislation, including the Mental Capacity Act, 2005.
  • Not all staff received regular supervision or performance appraisal so the service could not be assured of staff competence in their roles.
  • Nursing staff did not always provide compassionate and respectful care. We witnessed a nurse shout at a patient and treat them in a disrespectful way. We witnessed staff talking over patients as if they were not there.
  • Staff did not always provide emotional support to patients and relatives. We witnessed a number of occasions where nursing staff did not respond promptly to patients or relatives who were distressed.
  • Staff did not always involve patients and those close to them in decisions about their care and treatment. A number of patients and relatives told us there was little communication from nursing staff, especially on arrival in the emergency department.
  • There was limited use of tools and strategy in the emergency department to support patients living with dementia.
  • Assurance systems around risk and performance were not fully developed or embedded. Risks on the risk register did not fully align with those staff told us were on their ‘worry list’ and there were notable omissions. The safety risks associated with delayed ambulance handover, delayed initial assessment, delayed time to treatment, and prolonged waits for a bed (12 hour breaches were the most common cause of a serious incident) were not captured. The safety risks associated with poor record keeping (failure to consistently complete safety checklists) and falls (two serious incidents had occurred) had also not been captured.

However:

  • Staff knew how to protect patients from abuse, had received training and knew where to seek support.
  • Medicines were prescribed and given well but some fridge temperature checks had not been completed.
  • The service provided care and treatment in accordance with evidence-based guidance.
  • Patients were given enough food and drink to meet their needs. However, this was not always documented.
  • The service collected and monitored data about clinical outcomes and this was used to improve practice.
  • The service provided regular training and development opportunities for staff.
  • Staff in the emergency department felt well supported by the rest of the hospital. There were some good examples of multidisciplinary working. The department was well supported by the mental health liaison team and the frailty and interface team.
  • The service was working towards providing a range of services over seven days a week.
  • The department had improved services for patients with mental health needs. There was a registered mental health nurse employed to support people with mental health needs and a child and adolescent mental health service (CAMHS) practitioner was employed in the children’s emergency department to support children and young people with mental health needs.
  • Patients were encouraged to report concerns and complaints; these were treated seriously, investigated and lessons learnt.
  • Leaders were visible and accessible in the emergency department; staff respected the local management team and felt well supported by them. Staff who had previously felt they and their service were undervalued and under-invested in now felt that the executive management team understood the challenges they faced and were focussed on implementing system-wide change by holding all partners to account.
  • There was good managerial oversight of complaints and incidents and evidence of learning from them.
  • There was a vision for the service and preparatory work was underway to develop an urgent care floor or a ‘one stop shop’ for all unscheduled care. There was a system-wide accident and emergency (A&E) delivery board providing strategic and operational leadership and a number of work streams had been developed, supported by external consultants to drive improved performance and to set out what needed to change in preparation for next winter.
  • There were a number of quality improvement projects underway. This included the development of a nurse training programme in advanced sepsis care, for which external funding had been sourced.

Maternity

Requires improvement

Updated 5 October 2018

Our rating of this service went down. We rated it it as requires improvement because:

  • There were gaps in the service’s safety systems, such as monitoring training for obstetric medical staff, monitoring infection control, monitoring competency using equipment and monitoring medicines management.
  • Staff created records which were not consistently person-centred and with some omissions
  • Staff did not always receive feedback when reporting incidents and some felt discouraged from reporting.
  • In theatres, staff did not consistently follow the World Health Organisation (WHO) guidelines and the five steps to safer surgery.
  • Some of the protocols and guidelines for the service had not been reviewed and updated against best practice and national guidance.
  • The service did not use audit effectively to ensure the service delivered care in line with practices and implemented improvements where necessary.
  • The leadership structures and processes were relatively new and there was not an embedded culture of effective teamwork across different disciplines.
  • Women could not always give birth in the place of their choosing.
  • The maternity IT system did not support comprehensive recording and analysis of data.

However

  • Staff demonstrated care and compassion when caring for women.
  • There was effective engagement with the local community and the wider health economy in developing services
  • Women could access maternity services when they needed it, with access to 24/7 telephone guidance and prompt responses.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results.
  • The service had good systems for training staff and was working towards providing improved arrangements for sharing learning.

Outpatients

Good

Updated 5 October 2018

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

  • People were protected from avoidable harm and abuse.
  • People had good outcomes because they received effective care and treatment.
  • People were supported, treated with dignity and respect and involved in their care.
  • People’s needs were met through the way the service was organised and delivered.

However:

  • The governance and culture did not always support the delivery of high-quality person centred care

Maternity and gynaecology

Good

Updated 19 June 2015

Patients who used the maternity and gynaecology services were protected from avoidable harm.

The trust took action in response to reported incidents and feedback was provided to staff to ensure learning from previous incidents was achieved. When something went wrong there was an investigation, carried out by appropriate staff. Patients were included in discussions and feedback about their care.

Systems and processes were in place to promote the control of infection and ensure equipment in use was safe by servicing, maintenance and keeping it clean. Safeguarding women and babies was given high priority by the staff who were proactive in identifying and liaising with a multidisciplinary team to ensure the involvement of appropriate staff.

Systems were in place to review staffing levels to ensure they were safe. The staffing levels and skill mix on both the consultant-led obstetric unit and the gynaecology ward was discussed at handover and arrangements were made, if necessary, to risk assess and manage the staffing of each area. The consultant presence on the consultant-led obstetric unit had been measured against guidelines in Royal College of Obstetricians and Gynaecologists (RCOG) Safer Childbirth (2007). As the level of cover was lower than that recommended, this had been placed on the risk register and a business plan was being developed to obtain increased consultant cover. The safety of women was promoted by consultants attending the unit over the weekends in their on-call rota time.

The care and treatment provided to patients was effective in that patients experienced care, treatment and support that provided good outcomes for them.

The integrated model which the trust maternity service runs (Nurture programme) allowed flexible use of staff to maintain 1:1 care in labour. This had kept women’s denied choice of place of birth to a minimum. However, the access and flow of women through the maternity unit had affected where staff were required to work and on rare occasions affected the choices women could make on where they delivered their baby. Because of pressures on medical beds, some medical patients were transferred to the gynaecology ward, which had increased the numbers of cancelled gynaecology operations. An action plan was in place to reduce the waiting time for women whose operation had previously been cancelled.

Patients’ care and treatment was provided in line with current evidenced-based guidance, national recommendations and legislation. Care and treatment was updated following changes in best practice guidance and legislation. The trust monitored the care and treatment provided to women; the data showed women received an effective service when compared with women in other parts of England.

Patients received an outstanding caring service because staff involved and treated patients with compassion, kindness, dignity and respect. Relationships between the staff and patients were strong, caring and trusting. Patients and their representatives were encouraged to make choices and were involved in their care and treatment. Staff took patients personal, cultural, social and religious needs into account when providing care and treatment.

Patients were actively encouraged to complete quality monitoring surveys and participated in the national NHS Friends and Family Test quality surveys, from which positive responses had been received.

Patients received a responsive service because the service provided was organised to meet the needs of women in their local areas. For example, antenatal and postnatal clinics and the midwife-led birthing units. Additional gynaecology clinics and appropriately trained staff had been put in place to meet the increased demand of newly referred patients. Women were informed on how to make a complaint and complaints were acted on and monitored effectively by the women’s and children governance and quality committee.

The service was well led because the leadership, management and governance of the organisation assured the delivery of high-quality person-centred care and promoted an open and fair culture.

Staff were positive about the management of their services and the accessibility to their line and senior managers. Innovative practice was encouraged and in evidence within the trust, including the development of an application to be used on smart phones and tablets enabling women to access information to make choices and decisions regarding their birth. Student midwives had support from experienced community midwives to run a postnatal clinic to increase their knowledge and competencies.

Medical care (including older people’s care)

Requires improvement

Updated 5 October 2018

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

  • The service did not consistently provide safe or effective care and treatment. Staff did not always identify risks to patients, and where staff identified risks there was often lack of guidance about how to lessen the risk. Patient records were not held securely and often had missing information. The records did not demonstrate staff always followed evidence based care pathways.
  • Nursing and allied health care professional shortages increased the risk of patients receiving unsafe or inadequate care and treatment. There was a lack of assurance that staff had the necessary skill set to carry out their roles. There was a low rate of medical staff compliance with mandatory training and annual appraisals were below the trust target.
  • Across staff groups there was a lack of understanding and application of the Mental Capacity Act 2005 and associated Deprivation of Liberty Safeguards.
  • The service was not fully developed to meet the needs of the local population. The individual needs of patients with dementia were not fully considered. Some staff did not consider involving people, carers and their families as an important part of care.
  • Staff did not consistently monitor and manage risks to patient safety and governance arrangements to identify shortfalls in performance and areas for improvement were not fully effective.
  • Staff and managers had not developed and implemented a strong vision and strategy for the service.

However:

  • The medical services used national audits to monitor and improve their services.
  • Staff understanding about safeguarding vulnerable people had improved.
  • There were some good examples of multidisciplinary working, on many of the medical wards.
  • Staff commented that the new trust leadership team were visible. There was increased confidence in the trust leadership team.

Diagnostic imaging

Good

Updated 5 October 2018

  • Staff had completed training which allowed them to undertake their role effectively. Further training opportunities were provided by the trust to allow staff to expand their skills and professional knowledge.
  • Staff took appropriate action to minimise the risk of cross infection between patients.
  • Staff followed professional guidance and working practices during investigation to keep patients safe.
  • Risk to patient safety due to the type of investigation being undertaken were identified and managed appropriately
  • Patients received care from staff who treated them as individuals and ensured their physical and emotional wellbeing needs were met
  • Waiting times for investigation were similar or better than the national average identifying patients received the right investigation at the right time.
  • Staff felt valued and supported in their role enabling them to provide high quality care. Patient feedback confirmed this was happening.
  • Innovative practice was supported and promoted by staff who took responsibility to explore options to increase the quality of patient care

However

  • The trust did not consistently meet the national and trust target of 48% of patients entering the emergency department with a suspected stroke receiving a CT scan within an hour of arrival.
  • The Queen Alexandra Hospital environment did not fully support patients to move around the hospital independently. Environmental design did not always support those with a sensory loss such as vision impairments to negotiate the hospital whilst transferring between departments.
  • Steps taken by staff to ensure a patient’s individual needs could be met appropriately were not always followed consistently. Information about particular additional needs or patient support was not always passed between teams to ensure these needs could be met prior to investigation.
  • The investigation of complaints did not take place in a timely way leading to delays in responding to the complainant. The service did not complete investigation of, respond to, and close complaints within agreed timescales

Surgery

Requires improvement

Updated 5 October 2018

  • Safe was rated as “requires improvement” as there were areas of poor practice in respect of infection prevention, assessing and responding to patient risk, records and medicines management.
  • Effective was rated as “requires improvement” which is down one rating from that given in 2015. This is largely due to poor practice in respect of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) and Mental Capacity Assessment (MCA) assessments and recording which still required improvement in decision making and in recording as required from the 2015 report.
  • Caring was rated as “good” which was an improvement on its previous rating of “requires improvement”. This was because the service was meeting the standards expected.
  • Responsive was rated as “good” which was an improvement on its previous rating of “requires improvement”. This was because the service was meeting the standards expected.
  • For Well-led, while there were good systems observed, the fact remained that many of the policies, processes and procedures were in the course of being revised and introduced hence its rating as “requires improvement”.

Services for children & young people

Good

Updated 5 October 2018

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

  • Staff were clear about their safeguarding responsibilities and if there was a concern about a child’s wellbeing staff understood and followed safeguarding procedures. All staff we spoke with had completed the appropriate level of training in safeguarding, apart from the medical and dental staff who had not yet achieved above 85% training in levels two and three.
  • There was openness and transparency about safety, and continual learning was encouraged. Staff were supported to report incidents, including near misses. Both units were secured both day and night.
  • The service controlled infection control well.
  • Staff used a paediatric early warning system for the early detection of any deterioration in a child’s condition, and we observed children and young people’s pain effectively assessed and treated.
  • Services were provided seven days a week by medical and nursing staff. There was good multidisciplinary working evident across both units.
  • Inpatient services were tailored to meet the needs of individual children and young people. Access and flow through all departments was very good and complaints were dealt with in a timely manner. Staff listened to feedback and complaints and responded to them in a timely manner.
  • Staff planned and delivered care in line with evidence-based guidance, standards and best practice and met the individual needs of the child and family through the careful care planning. Staff followed care pathways on electronic, multidisciplinary patient records to support practice.
  • Staff received annual appraisals and new staff were supported when completing their competency assessments, helping to maintain and further develop their skills and experience.
  • Parents and children gave feedback about the care and kindness received from staff, which was positive. All children and their carers we spoke with were happy with the care and support provided by staff. We observed staff treated children, young people and their families with compassion, kindness, dignity and respect. Staff worked in partnership with children, young people and families in their care.
  • Play staff ensured that children and their families were supported during their hospital stay and their interventions during procedures reduced the anxiety and worry for the children for example during blood tests.
  • The children’s unit had its own radiology department which provided specific ‘child friendly’ environments for children to wait and undergo investigations and worked closely with the play therapist team to reduce stress and anxiety during those procedures.

However:

  • There was not enough nursing staff on the neonatal unit and medical staff on the children’s unit with the right skill mix to provide safe care. The trust had reviewed staffing levels, and identified a shortage of medical and nursing staff. Recruitment to vacant posts was ongoing at the time of inspection. Nursing levels on the neonatal unit did not conform to the British Association of Perinatal Medicine (BAPM) standards and the medical staffing on the children’s unit did not conform to the Royal College of Children’s and Child Health (RCPCH).
  • There was a risk children would be distressed in the maxillo facial (Max Fax) outpatient’s clinics as they were treated alongside adult patients Mandatory training rates for both medical and nursing staff were below the trusts target of 85% for nine mandatory training modules.

  • The Children and Adolescent mental health service (CAMHS) did not cover weekend and evenings, therefore children requiring a review before discharge would have extended stays in hospital.
  • Adult trained nurses who had not completed child specific competencies worked with children and young people in the children’s fracture clinic and ophthalmology clinic.

End of life care

Good

Updated 5 October 2018

  • The service provided mandatory training in key skills to all staff and made sure everyone completed it.
  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.

  • Staff assessed and monitored patients regularly to see if they were in pain. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain.

  • Managers monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them.

  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff provided emotional support to patients to minimise their distress.
  • The service mostly took account of patients’ individual needs.
  • People could access the service when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were in line with good practice.

  • Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care.
  • The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
  • The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.

However,

  • Not all staff had received an annual appraisal of their work, although the trust had plans to address this.
  • The trust was not able to provide a seven day service. This was due to some long term sickness within the nursing team. Actions had been taken to mitigate the impact of this, freeing up nurses for clinical time on the ward. Cover arrangements had been put in place for out of hours. Patients received consistent end of life care because care was provided on the wards by staff across the trust.