Pages 1 and 2 of this report relate to the hospital and the overall ratings of that location. From page 3 the ratings and information relate to maternity services based at St George's University Hospital, Tooting.
We inspected the maternity service at St George's University Hospital as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.
We last carried out a comprehensive inspection of the maternity and gynaecology service in 2016. The service was judged to be good overall in 2016. We previously inspected maternity jointly with the gynaecology service, so we cannot compare our new ratings directly with previous ratings.
We will publish a report of our overall findings when we have completed the national inspection programme.
We carried out a short notice announced, focused inspection of the maternity service, looking only at the safe and well-led key questions.
Following this inspection, under Section 29A of the Health and Social Care Act 2008, we issued a warning notice to the provider. We took this urgent action as we believed a person would or may be exposed to the risk of harm if we had not done so.
- Our ratings of the maternity service did not change the ratings for the hospital location overall. The location remains rated as requires improvement overall.
- We rated maternity services safe as inadequate and maternity services well-led as inadequate, and maternity services overall as inadequate.
How we carried out the inspection
We inspected the service using a site visit where we observed care on the wards, spoke with staff, managers, and service users, and attended meetings. We interviewed leaders and members of the executive team remotely after the site visit. We looked at online feedback from staff and service users submitted via the CQC enquiries process. The service submitted data and evidence of their performance during the factual accuracy process which was analysed and reviewed for use in the report.
You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.
Our rating of services stayed the same. We rated them as requires improvement because:
- Staff did not always complete and update risk assessments for each patient. Documentation in patient files was inconsistent and not always completed; and in medical care, consent forms were not always completed in full.
- Some services did not keep detailed records of patients’ care and treatment. Some records were not clear, up-to-date, stored securely or easily available to staff providing care.
- Some services did not control infection risks well. Some staff did not use equipment and control measures to protect patients, themselves and others from infection. Some areas of the emergency department were not visibly clean.
- Some facilities and premises were not always ideal and in need of modernising or refurbishment. For example, some of the departments and wards were excessively hot in the summer months due to lack of air conditioning.
- There were gaps in management and support arrangements for staff, such as appraisal, supervision and professional development. The number of nursing staff who had received an annual appraisal was below the trust target in many wards and departments.
- People could not always access the service when they needed it and did not receive the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with national standards.
- Not all risks on some risk registers were completed thoroughly.
- Services provided mandatory training in key skills to all staff, however, not all staff had completed the training required.
- Staff had training in key skills and understood how to protect patients from abuse. Services managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve services.
- Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
- Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
- Services planned care to meet the needs of local people and took account of patients’ individual needs.
- In children and young people services, staff found innovative ways to enable children and young people to manage their own health and care when they could and to maintain independence as much as possible.
- Most services had enough staff to care for patients and keep them safe, despite there being vacancies in many areas.
- The trust scored highly in the Sentinel Stroke National Audit Programme (SSNAP). On a scale of A-E, where A is best, the trust achieved grade A in latest audit.
St George's University Hospitals NHS Foundation Trust is a combined acute and community health provider. The trust provides secondary and tertiary acute hospital services and community services to the local population. The trust employs over 8,000 WTE staff and serves a population of 1.3 million across South West London.
This is a report on a focused inspection we undertook of the cardiac surgery unit on 23 August, 13 and 14 September 2018. The purpose of this inspection was to follow up on concerns from the Bewick Report that the cardiac surgery unit was a mortality rate alert outlier, on other concerns raised in the Bewick Report published in July 2018, and on concerns raised to CQC.
The concerns focused on patient outcomes and mortality rates, culture, governance and leadership.
We found the cardiac surgery unit was going through a significant transition. Local governance and leadership were weak and were being revised to help improve the service. The culture was poor. Consultant surgeons mistrusted each other, as well as cardiologists, anaesthetists and senior leaders. Morale amongst several consultant surgeons was low and they told us they were under pressure and scrutiny, both internally and externally. There was a reduction in the number of patients accessing the service, as high-risk patients were diverted to other local hospitals and referrals were reduced. Monitoring and oversight by key stakeholders, meant that several measures had been put in place to assist and improve the service.
Our key findings were as follows:
There was a lack of cohesion and poor working relationships between surgeons, although no direct evidence that this fed through to poor patient outcomes.
There was not a culture of learning from incidents, mortality and morbidity amongst consultants.
The quality of mortality and morbidity meetings were poor.
There were multiple patient record systems, which meant notes were not centrally recorded and there was a risk of information not being accessible or not being handed over adequately.
Morale amongst several consultant surgeons was low and they told us they were under pressure and scrutiny, both internally and externally.
There was a lack of ongoing and regular oversight of some aspects of the cardiac services.
There was a lack of understanding and insight of the performance within the team and the importance and role of national audits.
Not all staff understood the duty of candour, when it was clearly indicated.
Bed occupancy rates were being reduced, due to a reduction in referrals and high-risk cases being diverted to other local NHS trusts.
Comprehensive risk assessments of patients were carried out.
There was a hospital-wide standardised approach to the detection of deteriorating patients using the National Early Warning System (NEWS) scoring system and staff knew what action to take when the score went above four.
There were no immediate concerns with regards to patient safety and patients were well-prepared for surgery.
Latest available data showed the mortality rate for the unit had reduced to 2.7%.
Consent to care and treatment was sought in line with legislation and guidance.
There was ongoing external oversight and monitoring of the cardiac surgery unit by key stakeholders.
Multidisciplinary (MDT) team meetings, took place daily and involved neighbouring NHS Trusts.
An independent scrutiny panel for cardiac surgery, set up by NHS Improvement, was appointed to advise, challenge and support the trust.
Importantly, the trust must:
Review and improve governance systems and processes for the unit.
Review the quality of mortality and morbidity meetings and include evidence of learning and how this is shared.
Improve learning from incidents, mortality and morbidity amongst consultants.
Resolve issues relating to leadership structure and cohesion to support the service to change and improve.
Address cultural issues within the service to improve multi-disciplinary working and effective governance systems.
In addition, the trust should:
Review the multiple patient record systems in use, because there was a risk of information not being accessible or not being handed over adequately.
Ensure all medical staff understand their responsibilities to raise concerns, to record safety incidents, concerns and near misses and to report them internally and externally, where appropriate.
Ensure all staff understand and apply the Duty of candour procedure, when it is clearly indicated.
Support staff working in the unit, to improve morale and well-being.
Professor Ted Baker
Chief Inspector of Hospitals
Our rating of services stayed the same. We rated it as requires improvement because:
- The Department of Health and Social Care standard for 95% of patients in accident and emergency to be admitted, transferred or discharged within four hours, was consistently not met between January 2017 and December 2017.
- From quarter 3 of 2016/17 to quarter 2 of 2017/18, the trust consistently failed to meet the 93% operational standard for patients to be seen within two weeks of an urgent GP referral for suspected cancer.
- The environment in theatres remained a significant issue. Theatres were old and in need of significant improvement and maintenance. This presented an increased risk of infection as well as a risk of theatres becoming unusable due to urgent maintenance requirements.
- The trust was still not reporting Referral to Treatment Time (RTT) data. This meant the trust could not be fully assured that all patients had received their appointments nor could they identify what stage patients were at in their treatment pathway.
- There was a lack of recording of information about physical restraint and the administration rapid tranquillisation to patients. This meant the trust could not be assured that these practices were being reviewed and monitored or were in line with NICE guidance.
- Risks were not being dealt with in a timely way. For example, in accident and emergency, some risks entered on to the register in 2014, were still waiting to be resolved.
- There was low compliance in some mandatory training modules for most staff groups and staff appraisal rates were below the trust target.
- Medical records were not always held securely and were not completed consistently with gaps in documentation. There were three separate recording systems in place, which meant there could be difficulty in accessing records when patients were moved between wards. We found this was similar at the last inspection.
- Some staff had limited knowledge of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) and some staff did not always complete the required documentation fully or consistently. We found this was similar at the last inspection.
- Pain score tools were not consistently completed and records demonstrated that timely pain relief was not always administered to patients. We found this was similar at the last inspection.
- Some complaints were not investigated and closed in line with the trust policy of 85% of complaints being responded to within 25 working days of receipt.
- The hospital was in the bottom 25% of trusts in terms of the proportion of patients not developing pressure ulcers.
- The paediatric service was not meeting guidelines for consultants to review patients within 14 hours of admission.
- In the outpatients department, nasoendoscopes were occasionally decontaminated in a way that was not in line with best practice guidance, as a result of problems with formal sterilisation equipment. This meant there was a risk that a patient could have a procedure carried out with a nasoendoscope that had not been formally sterilised and this was not always reported as an incident.
- The emergency department (ED) was meeting the Royal College of Emergency Medicine (RCEM) recommendations that consultants should provide 24 hour, 7 days a week cover, as the hospital was a major trauma centre. I
- There was a good incident reporting culture and learning from incidents were shared across the hospital.
- There was effective multi-disciplinary team working in all areas.
- Staff cared for patients with compassion, involved them and those close to them in decisions about their care and took time to ensure patients and their families understood treatment. Feedback from patients we spoke with was overwhelmingly positive about the care they received.
- Paediatric ED nursing staff were interviewed by a children’s interview panel as well as going through a normal recruitment process. The children were usually service users who had been treated by the ED.
- The trust planned and provided services in a way that met the needs of local people and took account of patients’ individual needs ensuring people could access the service when they needed it. The trust had robust processes in place to manage flow through the hospital.
- There were effective systems in place to safeguard children and young people from harm. Children were monitored to identify any deterioration in their condition. Children and young people living with mental health challenges were cared for in an anti-ligature bay on Frederick Hewitt Ward.
- There was strong evidence of a good education and research culture, particularly within the cardiac investigation unit and the therapies department.
- The trust had introduced an automatic text or phone reminder system which had reduced the ‘Did Not Attend’ rate of appointments by approximately 7%.
- The hospital had improved the process to ensure there was a complete set of contemporaneous patient notes on site during clinic appointments through a scanning system and had tracked down 1,081 missing files since August 2017.
- In medical records, some patient notes were equipped with electronic stationery meaning they could be tracked on their journey throughout the hospital.
- In the therapies department, therapists could use software to send videos of exercises to send to their patients to complete, which staff told us had improved patient outcomes.
St George’s Hospital in Tooting, London, is the main hospital site of St George’s University Hospitals NHS Foundation Trust. The trust serves a population of 1.3 million across Southwest London. A large number of services, such as cardiothoracic medicine and surgery, neurosciences and renal transplantation are provided and the trust also covers significant populations from Surrey and Sussex, totalling around 3.5 million people.
As well as acute services, the trust also provides a full range of community services to patients of all ages following integration with community services in Wandsworth in 2010.
St George’s Hospital provides acute hospital services and specialist care for the most complex of injuries and illnesses, including trauma, neurology, cardiac care, renal transplantation, cancer care and stroke.
St George’s University Hospitals NHS Foundation Trust employs around 8,536 whole time equivalent (WTE) members of staff with approximately 3,259 working at St George’s Hospital. We carried out an announced inspection of St George’s Hospital between 21 and 23 June 2016. We also undertook unannounced visits to the hospital on 2, 7 and 11 July 2016.
Overall, this hospital is rated as require improvement. We rated outpatients and diagnostic imaging as inadequate. We rated the emergency department, medical care, surgery, services for children and young people and end of life care as requires improvement. We rated critical care and maternity and gynaecology as good.
We rated safe as inadequate. We rated effective, responsive and well led as requires improvement. We rated caring as good.
Our key findings were as follows:
- Several areas of the hospital’s estate that was in a state of disrepair. There was water ingress during heavy rain to several clinical areas we visited. Work had commenced to repair some of the affected areas, but the significant maintenance huge backlog, meant that this would take some time.
- Heating and power failures which had previously affected one medical ward remained on the risk register and had not been fully addressed.
- Some theatres were not fit for purpose. Theatres were sometimes closed due to electrical faults or unsafe temperatures. Sixteen of the 51 theatres needed to be completely refurbished. Since the inspection, we have been told by the trust, that the refurbishment of theatres 5 and 6 had been completed.
- The ED environment was aged old and this meant that some areas looked dirty, despite regular cleaning. Many parts of the department were extremely hot and uncomfortable.
- Children and young people with mental health conditions were cared for on Frederick Hewitt Ward, but an environmental risk assessment had not been carried out to identify ligature points and other risks to their safety.
- The storage of equipment and fluids in the ED within the major incident cupboard was unclear and created confusion about what was training equipment and what was ‘live’ equipment.
- Many staff were trained in safeguarding adults and children and there were policies and processes in place for them to follow. However, 53% of medical staff working with children and young people had not completed level three safeguarding training, which is a requirement for all staff working with children. Safeguarding training was identified as a risk on the services risk register. Access to training was a problem; there was no dedicated trainer and no safeguarding supervision for staff.
- There was variable adherence to infection control procedures and some medical and surgical staff ignored challenges from colleagues, which had a high impact on infection prevention and control.
- Medicines were largely stored and managed appropriately, save for a few exceptions. For example, there were several examinations where radiographers gave contrast to patients despite PGDs not being in place.
- Mandatory training completion by staff was low in many areas.
- Records were well documented with fully completed care plans and legible entries that had been signed by the relevant staff member. However, there were instances where care records were not stored securely, increasing the risk of unauthorised access.
- Medical and nursing cover across the hospital was generally good, apart from in the paediatric wards.
- Most staff knew how to report incidents and there was evidence of learning from incidents being shared as well as changes to improve practice being made.
- There was a lack of formal mental capacity assessments and best interest decision making as required under the Mental Capacity Act, 2005 and some patients had decisions made for them that they were capable of making themselves.
- The Nursing Daily Evaluation Last Hour and Days of life document was a prompt sheet that was not backed up by either assessment or evaluation tools.
- Pain was assessed and patients told us their pain was managed well. However, pain relief was not always documented in records and there could be a delay to administration of analgesia when patients arrived within the emergency department.
- Information technology issues impacted on staff’s timely access to information and as a result records were fragmented in some areas.
- Evidence based guidance was available and care was provided in line with the guidance.
- We saw multiple examples of effective multi-disciplinary team working however there were shortfalls in some areas including MDT working for those at end of life or where patients required in out from both medicinal and surgical practitioners. .
- All areas participated in national clinical audits and patient outcomes were measured. Many clinical areas showed positive results, particularly maternity and surgery.
- Outcomes for renal patients in relation to survival rates and transplantation were excellent and were some of the best in the country.
- A strong obstetric team focused on effective intrapartum care and staff used innovative and pioneering approaches to care with excellent outcomes. The maternity service was achieving year on year reductions in emergency caesarean sections.
- The maternity unit was strong in fetal medicine and had done pioneering work in non-invasive testing.
- There had been improvements in the appraisal process for nursing staff, but there were limited opportunities for training and development.
- Staff delivered care in a kind and professional manner.
- Although we observed and received some very positive reports of staff’s kindness and caring attitude to patients, we also received some reports from patients about a lack of empathy from staff and poor communication.
- Patients were largely treated with dignity and respect.
- Most patients were positive about the care that they had received from staff and the way they had their treatment explained to them.
- Feedback from survey results showed high levels of satisfaction by patients and relatives with most of the services provided.
- There was sensitive support in place for bereaved parents of children.
- The trust had to temporarily cease national reporting of the RTT data. This was because, they could not guarantee the data they were reporting was robust and accurate.
- Children shared ward areas with other children of a different gender or age group. Parents were asked to sign a disclaimer confirming their acceptance that their child could share an area with children of a different age or gender.
- People were not able to access services for assessment, diagnosis or treatment when they needed to. The trust was not meeting national waiting times for diagnostic imaging within six weeks and outpatient appointments within 18 weeks for the incomplete pathways.
- The trust was not meeting the urgent two week referral target for patients with suspected cancer and cancer waiting times on the whole were variable across the targets.
- Follow up appointments were not always made in a timely manner and ‘Did Not Attend’ rates were higher than the England average.
- Theatres were unable to meet demand. Cancellation of operations were frequent and some of these were not rebooked within 28 days.
- Bed occupancy levels in surgical wards were higher than the England average, with a steady increase over 2015.
- Patients sometimes had to wait for tests because of demand on ultrasound and MRI scanners.
- There were a significant number of patient moves at night, between the hours of 10pm and 6am, which caused disruption and anxiety to some patients.
- Although a hospital passport had been completed for patients with a learning disability, their care plans were not adapted to take account of their individual needs.
- Care of people living with dementia was variable. The butterfly scheme existed but the Dalby Ward environment had not adapted to meet the needs of people living with dementia.
- The ED was not large enough for the current throughput of patients and did not meet modern standards, which meant that in some areas, privacy and dignity of patients was compromised.
- There was not always a systematic approach to the management of actions and learning from complaints.
- Interpreters were sometimes used when patients were consenting to treatment and did not understand English, but at other times staff relied on relatives to interpret.
- Not all women currently received continuity of midwife care.
- There had been delays in access to some gynaecology clinics and procedures, although reductions in waiting times had been achieved over the previous three months by running extra clinics.
- curtains used to screen the beds on at least four of the medical wards did not preserve people’s privacy.
- Some patients were unhappy with having to use of disposable utensils and plastic beakers.
- Parents were informed via text, when the child came out of theatre following surgery.
- Leadership across several departments was weak, with many longstanding problems failing to be addressed within a timely manner. There was a lack of strategic direction for some of the services from the top of the organisation.
- We found a reactive rather than proactive approach to risk and environmental safety.
- Whilst there were named executive and non-executive directors, staff working within the palliative care team considered ttere was lack of executive strategic direction for the provision of palliative care. for the top of the organisation. The lack of multidisciplinary team meetings (MDT) with colleagues from medical and surgical departments and other allied health professionals was an area of concern.
- An external review of Referral To Treatment (RTT) data quality at St George’s University Hospitals NHS Trust (June 2016) found that due to a high number of unknown start times of a patient’s referral journey, patients were prevented from being treated in chronological order. The trust was also inconsistent in achieving their two week targets for patients with suspected cancer.
- Following the inspection, the trust wrote to NHS Improvement and NHS England, to confirm their intention to temporarily cease national reporting of our RTT data. This was because, they could not guarantee the data they were reporting was robust and accurate.
- The risk register in several divisions, did not fully document all risks identified across the departments and mitigating actions were not always sufficient to address risks. Actions taken to mitigate the risks were insufficient and timescales to fully address the risks were unclear.
- Some staff felt able to approach their senior management team and felt well supported by their senior clinical staff. However, staff working with children and young people did not receive feedback from their appraisals and felt support was inconsistent.
- There was no evidence that a vision and strategy for maternity was being jointly developed with midwives and obstetricians.
- There was low morale among theatre staff and consultant surgeons. Some consultant surgeons were not working with a multidisciplinary approach and were not engaged in the divisional objectives.
- Black and minority ethnic staff felt that they were not given the opportunities that less experienced white staff had in some areas.
- Engagement of patients and the public in the improvement of services was evident.
- There were examples of the development of services and the introduction of new practices to take the service forward.
- We saw innovation across some areas, including participation in research, journal publication and use of social media to disseminate key information to staff.
We saw several areas of outstanding practice including:
- Outcomes for renal patients in relation to survival rates and transplantation were excellent and some of the best in the country.
- The outcomes achieved by the specialist medical and surgical services provided by the hospital.
- The effectiveness of maternity care delivered by the hospital.
- The responsiveness of the neonatal unit to parents whilst their baby was on the unit and the support provided by the outreach nurse.
- The involvement of children of varying ages on the interview panel as part of the recruitment process for ED paediatric nurses.
However, there were also areas of poor practice where the trust needs to make improvements.
Importantly, the trust must:
- Ensure all premises and facilities are safe, well-maintained and fit for purpose.
- Ensure all care is delivered in accordance with the Mental Capacity Act, 2005, when appropriate.
- Review Improve all its governance processes, so that patients receive safe and effective care.
- Ensure the RTT data is robust and accurate so that patients are given appointments and treatment based on their needs and within national targets.
- Ensure serial numbers of prescriptions (FP10s) for prescribers are always monitored for use.
- Ensure staff radiographers only administer medication (contrast media) where appropriately authorised Patient Group Directions (PGDs) or valid prescriptions are in place.
- Ensure the fit and proper persons’ requirement regulations for directors is are always complied with.
- Ensure the paediatric ward environment, staffing and training requirements are suitable for treating and caring for children and young people with mental health conditions.
- Ensure medicines are stored in an appropriate manner, by keeping cupboards locked when not in use.
- Ensure the process for decontamination of nasoendoscopes is always compliant with guidance.
In addition, the trust should:
- Maintain patient privacy, dignity and confidentiality at all times.
- Review the fluid storage within the ED major incident cupboard to ensure that training equipment is not stored with ‘live’ equipment.
- Ensure staff consistently follow guidance related to the prevention of healthcare associated infections with specific regard to hand hygiene.
- Ensure the equipment stored on Pinckney Ward is cleaned and there are systems in place for monitoring the cleanliness of equipment returned to the ward.
- Ensure all staff caring for children receive level 3 safeguarding training.
- Ensure the process for investigating serious incidents is timely and undertaken by people trained in investigation so they understand the root causes of an incident and identify measurable action.
- Minimise the cancellation of operations and when this cannot be avoided, they are rescheduled within 28 days.
- Reduce the moves of patients to wards that are not appropriate.
- Ensure there are robust arrangements in place, which staff are conversant with, in relation to the recognition and escalation of deteriorating patients.
- Ensure divisional and trust priorities are shared by personnel of all grades and professions who work together to promote the quality and safety of patient care.
- Address the low morale among theatre staff and consultant surgeons.
- Replace damaged furniture in patient/clinical areas so that they can be thoroughly cleaned.
- Ensure that all patients within the ED ‘streaming’ area are assessed within a private area.
- Ensure staff can observe the patients whilst they are waiting in their outpatient departments.
- Ensure patient electronic records are not easily visible or their paper records are not easily accessible by the public.
- Improve the percentage of telephone calls answered by staff in the outpatient department are within the service level agreement targets.
- Communicate effectively with patients when outpatient clinics overrun.
- Ensure there is sufficient diagnostic equipment (including cystoscopes) to supply day surgery, main theatres and endoscopy.
- Ensure staff are appropriately inducted to the clinical areas to which they are employed to work.
Professor Sir Mike Richards
Chief Inspector of Hospitals
St George's Healthcare NHS Trust a large hospital and community health service provider. With nearly 8,000 staff and around 1,000 beds on the St George’s site, the trust serves a population of 1.3 million across South West London. A significant proportion of services are offered to the populations from Surrey and Sussex, totalling about 3.5 million people. St George's Hospital, Tooting site, is situated in the London Borough of Wandsworth. It is one of the country’s principal teaching hospitals and is shared with St George’s, University of London, which trains medical students and carries out advanced medical research. The hospital also hosts the St George’s, University of London and Kingston University Faculty of Health, Social Care and Education, which is responsible for training a wide range of healthcare professionals from across the region.
St George's Hospital, Tooting, offers district general hospital services and specialist care for the most complex of injuries and illnesses, including trauma, neurology, cardiac care, renal transplantation, cancer care and stroke.
St George’s Hospital has been inspected on five occasions since registration in April 2010. It was not fully compliant for all the outcomes inspected on two out of five occasions. The last inspection took place in October 2013 and the hospital was found to be non-compliant in respect of Outcome 9, management of medicines, Outcome 13 (R22) staffing and Outcome 21 (R20) records. During this inspection we reviewed the actions the trust had taken to address these issues and found that they had been rectified, apart from the staffing levels on Trevor Howell Day Unit. We found that staffing levels on this ward were maintained using bank (overtime) and agency staffing, but that this did not impact on the care experienced by patients.
Key findings from this inspection include:
This trust, like many others, experiences difficulty in recruiting enough nurses to cope with the increasing demands on the service and the complexity of patients admitted to the ward areas. We held a number of staff focus groups where staff stated that they had actively chosen to work at St George’s hospital as they enjoyed the culture of the organisation and felt that they were able to deliver a good service to their patients. However, we noted on some wards and areas that there were significant issues with shortages of staff which impacted on patients and the care they received.
Cleanliness and infection control
Overall, the hospital was found to be clean and good infection prevention and control systems were in place. We noted that there were some issues of cleanliness within the mortuary and the day assessment unit. However, most ward areas and departments were clean and clutter-free. The chief nurse and director of operations was the lead for infection prevention and control and this ensured that this issue had board-level commitment.
End of life care
End of life care occurred throughout the hospital and more frequently on the oncology wards. There was a palliative care team who worked well for patients who are recognised as being at the end of their life. However, this is not replicated throughout the hospital where patients who have a terminal illness are cared for but may have medium to longer-term life expectancy. End of life care in the maternity department was exceptional.
Most of the patients and relatives we spoke with felt they were given enough information and were involved in decisions about their care. We saw that patients were in general being treated with respect but we identified that the dignity and privacy of patients on the Trevor Howell Ward and Day Unit was not always being respected.
We saw that most of the areas we visited were visibly clean and improvements had been made since our previous visit.
During our inspection, we saw that the medication records we checked were up to date but we identified concerns with the monitoring of the temperature of fridges and medication storage areas on some wards.
The trust provided us with evidence that they had identified these issues before our inspection, and had a plan in place to address them. As the action plan had not been fully implemented, the lack of effective temperature monitoring of medication storage areas on some wards had the potential to impact on the safety of relevant medicines to patients.
On the majority of wards we visited the care plans were current and patient focused but on Caroline ward we identified issues with the individualisation of the plans.
The majority of patients we spoke with were happy with the food being provided and we saw that systems were in place to identify patients who needed additional support during mealtimes.
We saw that in most wards there were adequate levels of staff but we identified concerns regarding staffing levels on the Thomas Howell Ward and Day Unit.
During our visit we saw that the trust had suitable systems in place to assess and monitor the quality of care being provided.
We saw when we visited the wards that the records on Brodie Ward and Caroline Ward were incomplete and did not protect patients from the risks of unsafe or inappropriate care and treatment.
People we spoke with told us they felt they were treated well and they were kept informed about their care. People commented that "Although we have been waiting awhile, they keep us informed and check we are OK and the treatment was very good".
When asked about staff, a patient in A&E said "They can't do enough for us, even though you can see how busy they are". The women we spoke with on Maternity were pleased with their care and spoke very highly of the midwives in particular.
People identified issues with the choice of food provided and we noted others with the cleanliness of some wards and departments, the attitude of staff in a care of the elderly ward and staffing levels in a paediatric ward.
People who were staying at the hospital said that they liked the food. They told us that they were given choices and that their special preferences were catered for. Some people said that they would like more help from staff to understand menu choices and others told us that sometimes food and drinks were not served at the right temperature.