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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.

Reports


Inspection carried out on 14 Sept to 13 Oct 2017

During a routine inspection

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 carried out on 11 and 12 November 2015

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

The Royal Berkshire Hospital is the main hospital site of the Royal Berkshire NHS Foundation Trust. The hospital provides maternity and gynaecological services to the population of West Berkshire. Between April 2014 and April 2015 the trust reported there were 5681 births of which 161 were delivered outside the Royal Berkshire Hospital.

We carried out a comprehensive, unannounced inspection of the maternity and gynaecology services on the 11 and 12 November 2015, to check whether improvements had been made since the last comprehensive inspection in March 2014.

Overall we rated the service as requires improvement. We judged effective, caring and well led as good. Improvements were needed to ensure services were safe, and responsive.

Our key findings were as follows:

Safe

  • At the previous inspection in March 2014 we found there were insufficient staffing levels particularly on Rushey ward which had an impact on capacity and associated safety risks. We found improvements had been made in staffing levels across the maternity unit and capacity issues were escalated appropriately.
  • The number of major obstetric haemorrhages reported 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. A review of cases of major obstetric haemorrhage took place and was due to be presented at the maternity unit’s March 2016 academic half day.
  • The trust goal was to have midwife to birth ratio in line with Birthrate Plus of 1:28 by April 2017 and a 1:30 ratio in 2015-16. Between April to September 2015 the service was consistently operating at 1:30 or below and 1:35 in September 2015.
  • Staff work flexibly to consistently ensure women received one to one care in labour redeploying midwives to the delivery suite and on occasions closing Rushey ward, the midwifery led unit. Results were 100% for harm free care from May 2015.

  • Consultant cover remained below the recommended level of 168 hours per week. During the 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 March 2014 the ventilation system on the delivery suite did not meet the expected standards. The ventilation system used to remove used nitrous oxide from the air (produced when using entonox) 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, a pharmacist did not check prescription charts 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.
  • 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.

Effective

  • The normal delivery rate was comparable with the England average and the unassisted delivery rate was good when compared with the England average. Caesarean section rates were similar to the England average however instrumental delivery rates were slightly higher than the England average.
  • On the maternity and gynaecology wards 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. On the maternity unit, compliance was monitored and audited to ensure consistency of practice. There were some issues with accessing the policies and procedures on the gynaecology wards as the policies had been removed from the intranet whilst under review.
  • Breast feeding was encouraged and the midwifery services had achieved UNICEF ‘Baby Friendly’ status.
  • Staff had access to training and support to develop and maintain their competencies. New midwives were positive about the support they received through the preceptorship program. However, the supervisor to midwife ratio was 1:21 which was above national recommendation of 1:15, although 95.3% of midwives had a supervisor review in the preceding 12 months
  • When people received care from a range of different staff, teams or services, this was coordinated and staff worked collaboratively.
  • Staff were clear about their roles and responsibilities regarding the Mental Capacity Act (2005). Consent guidelines were followed appropriately.

Caring

  • Feedback from patients about their care and treatment was consistently positive. Patients were treated with kindness, compassion and dignity.
  • Women felt involved with their care, had their wishes respected and understood.
  • Staff helped people and those close to them to cope emotionally with their care and treatment.

Responsive

  • Between May 2015 to October 2015 the maternity unit was ‘on divert’ (closed) on 29 occasions for between 4 hours and 48 hours. The main reason for closure of the unit to new admissions was due to insufficient midwifery staff to maintain a safe service.
  • Women had access to gynaecological services within the maximum referral to treatment time period set by NHS England of 18 weeks.
  • 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. Improvements were made to the quality of care because of complaints and concerns. For example, additional staff training.

Well Led

  • A new strategy and vision for the maternity service was under development, which included moving the gynaecology service from the planned care directorate to sit with the maternity service in the urgent care directorate.
  • There were comprehensive risk, quality and governance processes in the maternity service.
  • Staff across the maternity service described an open culture and felt well supported by their managers.
  • There was a system in place for the monitoring of quality and the delivery of the gynaecology service as part of the planned care directorate. however, learning from incidents was not robust.

We saw several areas of outstanding practice including:

  • Breast feeding was encouraged and the midwifery services had achieved UNICEF ‘Baby Friendly’ status.
  • A pink patient wrist-band system had recently been introduced for patients who had undergone surgery and had a vaginal pack in situ. This was to ensure the pack was subsequently removed.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Review medicines management practices to ensure medicines are stored at the appropriate temperatures to protect patients from avoidable harm.

The trust should also:

  • Review the consultant obstetric cover to meet national recommendations.
  • Work towards reducing the number of times the midwifery service has to divert women to other centres.
  • Ensure confidential personal information, particularly that held electronically, is maintained securely to prevent unauthorised access.
  • Ensure systems are in place in the gynaecology service to allow staff to share learning from incidents.
  • Ensure staff have access to up to date policies and procedures relating to the gynaecology service.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 24-26 March 2014

During a routine inspection

Letter from the Chief Inspector of Hospitals

Royal Berkshire Hospital is the main acute hospital for the Royal Berkshire NHS Foundation Trust, which provides acute medical and surgical services to a population of 600,000 people across Reading, Wokingham and West Berkshire, and specialist services to a wider population across Berkshire and the surrounding borders. The Royal Berkshire Hospital is the only site that provides inpatient provision overnight. The trust also has five other sites including West Berkshire Community Hospital, Windsor Dialysis Unit, Prince Charles Eye Unit, Royal Berkshire Bracknall Clinic and Townlands Hospital Outpatients.

During the inspection, in addition to the Royal Berkshire Hospital site, we visited West Berkshire Community Hospital (Day Surgery Unit and Outpatient services), Windsor Dialysis Satellite Unit and Prince Charles Eye Unit.

We carried out this comprehensive inspection because the Royal Berkshire Hospital NHS Foundation Trust was initially placed in a high risk band 1 in CQC’s Intelligent Monitoring system. However, when the latest Intelligent Monitoring bandings were updated the trust was placed in a low risk band 5. The inspection took place between 24 and 26 March 2014 and an unannounced inspection visit took place on 29 March and 2 April 2014.

Overall, this hospital requires improvement. We rated it ‘good’ for being caring and effective, but it requires improvement in providing safe care, being responsive to patients’ needs and being well-led.

We rated A&E, end of life care and services for children and young people as good, but we rated outpatients, medical, surgical, maternity and critical care as requiring improvement. Our key findings were as follows:

  • Staff were caring and compassionate and treated patients with dignity and respect.
  • The hospital was clean and well maintained, although there were some examples where cleanliness fell below expected standards.
  • The workforce were committed and we noted an open culture during the inspection.
  • Infection control rates in the hospital were similar to those of other trusts except the C.Difficile rates, which were higher than average and the trust was taking steps to make improvements.
  • Staffing levels were not always sufficient to meet the needs of patients on all ward areas, with a consequent reliance on bank and agency staff.
  • Medical records and the electronic patient record system and processes were not robust, which resulted in patient records not being available, reliance on temporary records and inability to access records as required in a timely manner, which impacted on the ability to deliver care.
  • Critical care capacity was insufficient and operations were going ahead when there had been a potential need for critical care post-surgery identified and no critical care bed was available.
  • The observation ward in A&E was a room with three beds but it was not included in the four-hour decision to discharge, admit or treat A&E target as it was used as a ward, although it did not have any shower facilities. There were concerns about appropriate use and care of patients in this observation area.
  • The major incident process associated with decontamination was not appropriate because of the distance and journey for patients through the hospital.
  • Safeguarding processes and knowledge of the Mental Capacity Act was not sufficient.
  • DNACPR forms were not consistently completed.
  • The end of life care team worked collaboratively with key stakeholders.
  • Paediatric care was generally positive.

We saw several areas of outstanding practice including:

  • Caring interventions and support for families in the Intensive Care Unit.
  • The Children’s A&E department.
  • Consultant geriatricians worked in the A&E department 8am to 8pm seven days a week.
  • The responsiveness of the Palliative Care team.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure that medical records are kept securely, and records can be located and accessed promptly when needed to appropriately inform the care and treatment of patients.
  • Maintain the privacy and dignity of patients placed in the observation bay in the A&E department.
  • Ensure that the design and layout of the emergency department protects patients and staff against the risks associated with unsafe or unsuitable premises.
  • Take appropriate steps to ensure that, at all times, there are sufficient numbers of suitably qualified, skilled and experienced staff employed to care for patients’ needs, and safeguard their health, safety and welfare.
  • Accurately complete ‘Do not attempt cardio-pulmonary resuscitation’ (DNA CPR) forms, and document the discussions about end of life care with patients.
  • Take proper steps to ensure that each patient is protected against the risks of receiving care or treatment that is inappropriate or unsafe by planning the delivery of care and appropriate treatment meet the patients’ individual needs and have procedures in place to deal with emergencies which are reasonably expected to arise.
  • Review the ICU capacity across the trust; employ suitably qualified, skilled and experienced staff; and have necessary equipment available to care for patients who require intensive or high dependency care.
  • Ensure that planning and delivery of care meets patients’ individual needs, and ensure the safety and welfare of all patients.
  • Increase staff knowledge of Deprivation of Liberty Safeguards (DOLs) and the Mental Capacity Act (MCA) through necessary training to improve safeguarding.
  • Improve contemporaneous record keeping by all staff to avoid misplacing records of care and observations.
  • Ensure the staffing levels and admission criteria in the Rushey Midwife-led unit is maintained to ensure safe care is provided to all women.
  • Ensure that at all times there is a sufficient number of suitably qualified, skilled and experienced staff employed to provide safe midwifery care in all areas.
  • Take action to improve the ventilation system on the delivery suite, to protect patients and others who may be at risk from the use of unsafe equipment.

In addition the trust should:

  • Ensure patient flow and discharge enables patients in the A&E to be admitted to wards without undue delay.
  • Ensure patients are supported with access to information in a language that meets their needs throughout the hospital.
  • Ensure that staff are appropriately trained to care for patients with dementia.
  • Improve the visibility of the executive team throughout the hospital and be open with the workforce regarding the strategic direction for the trust.
  • Ensure that all equipment is properly checked, maintained and documented with sufficient equipment available to meet needs of all patients.
  • Utilise the Intensive National Audit and Research Centre Case Mix programme (ICNARC data) to drive improvements and meet standards of care.
  • Ensure a regular programme for changing disposable curtains.
  • Ensure that appropriate risk assessments are undertaken where patients remain in the A&E department for a prolonged period.
  • Ensure that shift lead handovers in A&E take place without interruptions to ensure prompt communication.
  • Ensure that access to CAMHS services are timely and meet the needs of patients.
  • Ensure that access to equipment for use in chemical biological or hazardous incidents is easily accessible.
  • Ensure all staff are aware of the process to raise concerns in accordance with trust policy.
  • Ensure that communication to GPs following a consultation or inpatient stay is consistently documented and sent in a timely way.
  • Review transition processes for young people with all long term chronic conditions.

There were also areas of practice where the trust should take action which are identified in the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 14 August 2012

During a themed inspection looking at Dignity and Nutrition

People told us what it was like to be a patient at the Royal Berkshire NHS Hospital and described how they were treated by staff and their involvement in making choices about their care and treatment. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people in hospitals were treated with dignity and respect and whether their nutritional needs were met.

The inspection team was led by a Care Quality Commission (CQC) inspector, with a supporting inspector, a practicing professional and an Expert by Experience (people who have experience of using services and who can provide that perspective).

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of patients who could not talk with us.

This inspection focused on two wards providing care to elderly patients. On the day of our visit there were 28 patients on one of the wards, which provided care to female patients. The other ward was providing care to 22 male patients. We spoke with 16 patients and 11 relatives or other visitors during our visit. We also spoke with eight staff members and looked at six patients' records.

All the patients we spoke with said they were treated kindly and with respect. Most said the doctors had discussed their treatment with them. A couple of patients said they would like to be addressed by their preferred name, not the name on their records.

One visitor told us their relative came back from having tests done and was found in wet clothing. Staff had not informed them their relative's catheter was leaking. The visitor said sometimes when they arrived their relative needed to be washed. They said staff attended to the person immediately when requested.

Another visitor said they thought the care was ''OK'' for their relative. A further visitor told us their relative ''was being looked after well.'' A patient told us the care she received was excellent. She said ''I couldn’t be treated any better if I was the Queen.''

Patients said the meals were ''good'' or ''very good.'' They said they had different options to choose from and were served their preferences. They said portion sizes were sufficient.

All patients said there was a good variety of food and it was hot when delivered to them. One patient said only cold food options were offered if a meal was missed (staff told us meals could not be re-heated, for food safety reasons).

Most patients thought there were enough staff but said they were always busy. One said there were not enough staff on duty later in the day and they had to wait for the call bells to be answered. Patients told us the weekends were much quieter, which gave staff more time to spend with them.

Inspection carried out on 23, 30 March 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 9 November 2011

During an inspection in response to concerns

Patients we spoke with were generally happy with the quality of care provided by the hospital. They told us that staff maintained their dignity and privacy at all times by ensuring that the screens were always pulled around the bed when care and treatment were provided. They told us that staff were patient, kind and helpful and were quick to respond to calls for assistance. They told us that staff provided them with sufficient information about their care and offered them appropriate choices in relation to their treatment.

Patients and relatives that we spoke with on Burghfield Ward felt that staff were "doing their best" and that "the quality of care was good". Patients told us they were offered pain relief when they needed it and felt "well cared for". When asked if they were receiving the care that they needed one patient said " excellent, can't fault it". They said that the ward was always busy however; they were "able to get good nights sleep".

The patients we spoke with on Castle Ward said that they had been well cared for. They said the ward was “lovely and quiet at night”. They were generally happy with the care they received and felt that staff responded to calls for assistance in a timely manner.

Patients on the Clinical Decision Unit were in the main happy with their care. However, relatives of one patient felt that the start of treatment had been delayed due to waiting for a bed on the ward. As a result they felt that their relative had become "more poorly". Most patients felt that their care and treatment had been appropriate and timely. They told us that they had been referred to appropriate specialists and received the treatment they needed in timely way. One patient was waiting to be discharged. They told us that their experience on the unit had been "very good". Staff had been quick to diagnose their illness and provide treatment "so they could get back home".

Inspection carried out on 7 December 2010 and 7 January and 9 March 2011

During a routine inspection

During our visit on 7 December 2010, we interviewed 24 patients, 5 relatives and 2 visitors at the Royal Berkshire Hospital. Generally, patients expressed high satisfaction rates with staff and trust services. Most patients felt well informed and involved in making decisions about their care. In general, patients felt that staff treated them with dignity and respect.

Patients expressed some concerns regarding the hospital’s accident and emergency unit. They told us about waiting a long time to be seen, not having enough privacy, and feeling that staff did not always share information about their care and treatment with one another. While patients rated staff attitude and behaviour highly overall, some patients reported concerns regarding staff attitude, particularly towards elderly patients at night. Patients also told us that staff do not always fully explain to them the advantages and risks of taking medication.