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Royal Berkshire Hospital Outstanding

We are carrying out checks at Royal Berkshire Hospital using our new way of inspecting services. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Outstanding

Updated 15 February 2018

Our rating of services improved. We rated them as outstanding because:

Safe, effective, and well led domains were good, and caring and responsive domains were outstanding.

  • Urgent and emergency care remained rated as good overall. The question of safety stayed the same, effective was not rated the last time. Caring improved from good to outstanding, responsive improved from requires improvement to good, and the well led rating of good was unchanged. The integrated front door model was being used to improve both the efficiency of the service and respond better to patients immediate needs. The positive impact of the new service design was felt throughout the hospital.
  • Medicine (including older people’s care) improved from requires improvement to outstanding. Safety improved from requires improvement to good, caring improved from good to outstanding, responsive and well led moved from requires improvement to outstanding. Delivery of the service and outcomes for patients had improved. Patients’ needs were met and treatment was delivered by competent, knowledgeable and caring staff. Services were flexible and highly personalised to meet patients’ individual needs.
  • Surgery services improved from requires improvement to good overall. Safety improved from requires improvement to good. Effective and caring ratings stayed the same at good. Responsive and well led both improved from requires improvement to good.
  • Critical care improved from requires improvement to good overall. Safety and responsive improved from requires improvement to good. Effective stayed the same at good, and caring remained outstanding. Well led improved from requires improvement to good.
  • Outpatients improved from requires improvement to outstanding overall. (We did not inspect diagnostics as part of this inspection as it is now a different core service under the new methodology). Safe improved from requires improvement to good. Effective is not rated. Caring stayed the same at good, and responsive improved from requires improvement to outstanding.
  • On this inspection, we did not inspect maternity, services for children and young people, and end of life care. The ratings we gave to these services on the previous inspections in March 2014 and November 2015 are part of the overall rating awarded to the location this time.
  • Our decisions on overall ratings take into account, for example, the relative size of services and we use our professional judgement to reach a fair and balanced rating

Inspection areas

Safe

Good

Updated 15 February 2018

Effective

Good

Updated 15 February 2018

Caring

Outstanding

Updated 15 February 2018

Responsive

Outstanding

Updated 15 February 2018

Well-led

Good

Updated 15 February 2018

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 25 April 2016

Maternity and gynaecology services were rated good for providing caring, effective and well-led services. However, improvements were required for safe and responsiveness, which were rated as requires improvement.

At the previous inspection in March 2014 we rated safe as inadequate due to insufficient staffing levels particularly on Rushey ward and the impact on capacity and associated safety risks. We also found the ventilation system on the delivery suite did not meet the expected standards. The trust had developed an action plan to address the failings identified. During the inspection in November 2015 we found improvements had been made in staffing levels across the unit and the way in which capacity issues were escalated. However, further improvements were required.

All major obstetric haemorrhages were reported within the maternity governance dashboard and showedthe number of cases had significantly exceeded the trust goal of two per month between April to September 2015, with peaks of 13 and 14 in July and September respectively.Although there had been no corresponding increase in admissions to the intensive care unit or maternal mortality. The trust reported a review of all the cases of major obstetric haemorrhage which had occurred between August to October 2015 had taken place as part of a clinical audit and was due to be presented at the maternity unit’s March 2016 academic half day.

The trust goal was to have a midwife to birth ratio of 1:28 by April 2017 which is the national recommendation. The trust plan for 2015-16 was to have midwife to birth ratio of 1:30. Between April to September 2015 the service was consistently operating at a ratio of 1:30 or above and was 1:35 in September 2015. However, the service had been able to deliver one to one care for women in labour by redeploying midwives to the delivery suite and on occasions closing Rushey ward, the midwifery led unit.

The Royal College of Obstetricians and Gynaecologists good practice guidelines 2010 states the recommended consultant cover for a maternity unit which delivers more than 5000 births a year should be 168 hours a week. At the previous inspection in March 2014 the consultant cover was identified as between 68 to 91 hours per week, the trust had appointed two new consultants and was currently consistently achieving 91 hours a week of cover. In 2016, further recruitment of consultant obstetricians as well as combined consultant posts with resident commitments will improve hours of consultant presence, working toward the target of 168 hours per week.

At the previous inspection in March 2014 we found the labour ward had an insufficient scavenging system to remove used nitrous oxide from the air (produced when using entonox). This had been addressed and was no longer on the service risk register. This had been replaced with a unit that met expected standards.

All clinical areas were appropriately equipped to provide safe care and were visibly clean. Time to effect equipment and maintenance repairs had improved since the last inspection due to closer monitoring and follow up.

Medicines management in the gynaecology service was not robust as there had not been a dedicated pharmacy service on the gynaecology ward since December 2014. For example, prescription charts were not checked by a pharmacist and medicines management was recognised as a risk on the service risk register. However, all the control measures in place were not strictly adhered to.

At the previous inspection we rated effective as requires improvement. This was due to the way the service performed in comparison to national and local benchmarks. For example, instrumental and caesarean section rates were higher than expected and there were a high number of delayed inductions of labour. During this inspection we found performance had improved and instrumental and caesarean section rates were comparable to the national average.

The gynaecology ward participated in the NHS Safety Thermometer.The NHS Safety Thermometer is a local improvement tool for measuring, monitoring and analysing patient harms and 'harm free' care. Results were 100% since May 2015 except for August 2015 and September 2015 when results were 91% and 94% respectively.

Care and treatment was delivered in line with current legislation and nationally recognised evidence based guidance. Policies and guidelines were developed to reflect national guidance. They were monitored and audited to ensure consistent practice within the maternity service.

Maternity and gynaecology services had performance dashboards which recorded a range of service and patient outcomes. For example, the maternity dashboard showed the numbers and types of births, delivery methods and maternal and neonate morbidity. Between April 2014 to March 2015 the normal delivery rate and caesarean section rate was comparable to the England average. Between April to September 2015 the trust performed slightly below their goal for spontaneous vaginal delivery and the total caesarean section rate was slightly higher than the trust target of 23% at 26.5% but was similar to the England average of 26.7%. Between April to September 2015, the service performed well in relation to the number of patients experiencing third or fourth degree perineal tears, between six to 13, average of nine against a target of 14. However, over the same time period the service consistently failed to meet its target of 80% of patients to have suturing commenced within one hour of delivery, achieving between 44% to 75% and an overall average of 59.5%.

A range of equipment and medicines were available to provide pain relief in labour and for patients on the gynaecological ward. Women received appropriate pain relief and were able to self-administer if required.

Breast feeding was encouraged and the midwifery services had achieved full stage 3 accreditation of UNICEF ‘Baby Friendly’ status.

Staff had access to training and support to develop and maintain their competencies. However, the supervisor to midwife ratio was 1:21 which was above national recommendation of 1:15. The higher ratio increased the workload on the supervisors of midwives.

When women received care from a range of different staff, teams or services, this was coordinated. All relevant staff, teams and services worked together and assessed, planned and delivered peoples care and treatment collaboratively.

Staff were clear about their roles and responsibilities regarding the Mental Capacity Act (2005). Consent guidelines were followed appropriately.

Staff had limited access to the policies and guidelines relating specifically to the gynaecology services. Generic trust-wide nursing guidelines were available on the trust intranet. Specific clinical guidelines relating to gynaecology were not available (other than for colposcopy) as these reference documents had been removed from the trust intranet. The policies were under review and this was recorded as a risk on the service risk register.

Feedback from women about their care and treatment was consistently positive. We observed women were treated with kindness, compassion and dignity. Women told us they felt involved with their care, had their wishes respected and understood. Midwives were trained to provide emotional support, for example, for women who may have suffered bereavement. There were also specialist support and counselling services available.

At the previous inspection we rated responsive as requires improvement. This was due to the number of times the midwifery led unit (Rushey ward) was closed due to lack of staff or unit capacity, at least once a month and the number of times the unit was put on divert. This meant that women had to travel to neighbouring organisations in order to deliver their babies. Although the trust had made improvements in the way it managed its capacity to ensure safe delivery of care, we rated responsive as requires improvement for this inspection. Between May 2015 to October 2015 the unit was ‘on divert’ (closed) on 29 occasions for between 4 hours and 48 hours. Mostly due to insufficient midwifery staff. During those times 61 women were diverted to other units. Women had a choice where to receive antenatal care. However, staffing and capacity issues meant the maternity unit was not always able to provide the service to local people.

The majority of women had access to gynaecological services within the maximum referral to treatment period set by the NHS England of 18 weeks.

Patients undergoing investigations in gynaecology were offered appointment times that were suitable to them. There was an early pregnancy assessment unit that provided rapid care for women.

Translation services were available, and a specialist team of midwives supported women with additional needs such as homelessness and substance abuse through pregnancy and child birth.

Complaints and concerns were taken seriously, and listened to. Improvements were made to the quality of care as a result of complaints and concerns

At the previous inspection we rated well-led as requires improvement. This was due to the lack of robust governance and risk management processes. We found improvements had been made in maternity services.

Maternity services were part of the urgent care directorate and gynaecology services were part of planned care group directorate; the governance processes in place were different for the two directorates.

Since the last inspection the maternity service had undergone a service review and an improvement programme was implemented. A new strategy and vision for the maternity service was due to be launched.

There were comprehensive risk, quality and governance processes in the maternity service to ensure issues were reported and escalated for action and learning. Staff across the service described an open culture and felt well supported by their managers.

Medical care (including older people’s care)

Outstanding

Updated 15 February 2018

A summary of our findings about this service appears in the Overall summary

Urgent and emergency services (A&E)

Good

Updated 15 February 2018

A summary of this service appears in the Overall summary.

Surgery

Good

Updated 15 February 2018

A summary of this service appears in the Overall summary.

Intensive/critical care

Good

Updated 15 February 2018

A summary of this service appears in the Overall summary.

Services for children & young people

Good

Updated 24 June 2014

Babies, children and young people were cared for in wards and departments that were clean. Infection control practices were adhered to. There were sufficient nursing and medical staff across all areas. Staff used recognised early warning systems for both neonates and paediatric patients. Staff reported incidents, and learning was shared across the area to prevent the likelihood of a reoccurrence. Security for patients and staff in the neonatal and paediatric areas was good. Access to mandatory and additional training was available to staff, to allow them to develop additional skills.

Care and treatment was delivered in line with national guidelines. Outcomes were reviewed, and there was active participation in research and audit. Care plans and pathways were in use. Multidisciplinary team working was good in all areas.

Staff provided care in a kind and compassionate manner. Parents were involved in both decision-making and the delivery of care and were given appropriate emotional support. There was a highly visible leadership team and an open and supportive culture.

End of life care

Good

Updated 24 June 2014

The palliative care team was available seven days a week, with the hospice providing out-of-hours cover. Medicines were provided in line with guidelines for end of life care. DNACPR forms were not consistently completed in accordance with policy and there were no standardised processes for completing mental capacity assessments.

Training relating to end of life care was provided at induction and study days were arranged for palliative care link nurses from wards. Leadership of the palliative care team was good and quality and patient experience was seen as a priority.

All patients requiring end of life care could access the palliative care team. Viewing times in the mortuary were limited, which impacted on patients’ families being able to view their relative. There was a multidisciplinary team (MDT) approach to facilitate the rapid discharge of patients to their preferred place of care.

Relatives of patients receiving end of life care were provided with meal vouchers and free car parking. Patients were cared for with dignity and respect and received compassionate care. The ‘End of Life Care Plan’ was the pathway patients were placed on in the last few days of life.

Outpatients

Outstanding

Updated 15 February 2018

A summary of this service appears in the Overall summary.