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Inspection Summary


Overall summary & rating

Good

Updated 4 December 2019

  • We inspected two core services: urgent and emergency care and medical care. We rated both as outstanding overall.
  • Caring for medical care was rated as outstanding.
  • Responsive for urgent and emergency care was rated as outstanding.
  • Well led was rated as outstanding for both core services.
  • The hospital had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided great care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. 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 great 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 delivering care and support in a holistic, person centred way.
  • The hospital planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Experienced and strong leaders at the hospital ran services well using reliable information systems and supported staff to develop their skills. Staff fully understood the service’s vision and values, and how to apply them in their work. All staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were very clear about their roles and accountabilities.

However,

Inspection areas

Safe

Good

Updated 4 December 2019

Effective

Good

Updated 4 December 2019

Caring

Good

Updated 4 December 2019

Responsive

Requires improvement

Updated 4 December 2019

Well-led

Good

Updated 4 December 2019

Checks on specific services

Medical care (including older people’s care)

Outstanding

Updated 4 December 2019

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided great care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. 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 great 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 delivering care and support in a holistic, person centred way.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Experienced and strong leaders ran services well using reliable information systems and supported staff to develop their skills. Staff fully understood the service’s vision and values, and how to apply them in their work. All staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were very clear about their roles and accountabilities. The service engaged fully with patients and the community to plan and manage services and all staff were committed to improving services continually in a very proactive way.

Services for children & young people

Good

Updated 28 March 2017

Children and young people were treated with dignity, respect and kindness. Feedback from parents and children were positive. Parents felt supported and told us staff cared about them and their children.

Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. We found evidence sharing learning and changing practice as a result of incidents.

Services were clean and staff adhered to infection control policies and protocols. Equipment was checked daily, cleaned and documented.

The service used a comprehensive prescription and medication administration record card which facilitated the safe administration of medicine.

Patient records we looked at were comprehensive.

Medical ward rounds and nursing handovers took place three times a day across the service and were well attended.

The risks associated with anticipated events and emergency situations were recognised, assessed and managed.

Staff received training on the duty of candour.

Staff understood their roles and responsibilities for safeguarding children. Although mandatory training was generally well attended, safeguarding children training at level three was not in accordance with the intercollegiate guidance 2014 document published by the Royal College of Paediatrics and Child Health (RCPCH), ‘safeguarding children and young people roles and competences for health care staff, 2014’. This meant there was a risk that staff may not have the level of competence to respond appropriately to safeguarding concerns.

Although nursing staffing levels did not always meet RCN and Toolkit for High Quality Neonatal Services 2009 recommendations; and the service did not comply with RCPCH standards for having 10 consultants to cover, we found mitigating actions were in place and there was no evidence of a negative impact on the care and treatment children and young children received.

Children and young people’s care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation. This was monitored to ensure consistency of practice.

Staff were proactively supported to acquire new skills and share best practice and staff were competent to carry out the care of children and young people.

Services were planned and delivered in a way that was meeting the needs of the local population. The individual needs of children and young people were generally met.

Waiting times, delays and cancellations were minimal and managed appropriately.

The service was part of the integrated paediatric strategy (2014-2019) that included both acute and community provision of services. The vision, values and strategy had been developed through a structured planning process with regular engagement from internal and external stakeholders, commissioners and others.

Staff in all areas knew and understood the vision and values. Staff felt well supported and felt they were well managed.

The arrangements for governance and performance management did not always operate effectively. Governance arrangements were fragmented with no one person responsible for children and young people’s services.

Not all risks we identified on the risk register.

It was unclear who had the overall oversight of care for neonates, children and young people. After the inspection the trust told us that the Head of Midwifery had oversight of the service in the hospital.

We found limited evidence of public engagement.

Mandatory training compliance levels did not always meet the trust target. This meant that there was a risk that staff did not have the necessary skills to carry out their role.

There was no recognised early warning score tool for babies on SCBU and no audit for the use of a local tracker and trigger system on Macgregor ward within the last 12 months. This meant that there was a risk that any deterioration of a child’s condition may not always be recognised. However, we saw no evidence of this in practice.

There were no formal pain tools used on SCBU.

Critical care

Good

Updated 28 March 2017

The service demonstrated a good track record on safety with low rates of infection and avoidable harm to patients.

Patient outcomes reported within ICNARC showed the service performed as expected, or better than expected for most outcomes when compared to other similar critical care services.

Staff understood and spoke positively about the safety reporting system in place, and felt that openness and transparency about safety was encouraged.

Staffing levels were compliant with Guidelines for the provision of intensive care services, 2015 ( (the core standards) with staffing levels and skill mix planned, implemented and reviewed to keep people safe at all times.

There were clear policies, procedures and training in place to enable staff to keep people safe and safeguarded from abuse.

The environment was clean and well organised, and we saw good compliance with infection prevention and control practices.

Risks to people who used the service were assessed, monitored and managed on a day-to day basis.

Care and treatment was delivered in accordance with best practice and recognised guidance and standards.

There was collaborative working amongst the multi-disciplinary team, and with other services and providers.

Staff had the right qualifications, skills, knowledge and experience to do their job and were supported through appraisal, supervision, training and revalidation.

Patients and those close to them spoke positively about their care and treatment, and felt supported and cared for by staff.

There were clear processes in place for people to raise concerns or complain; these were low in number and managed in a timely manner.

The nursing leadership team were knowledgeable about quality issues and priorities, and took action to address the challenges; there was alignment between the recorded risks and concerns raised by staff.

Staff satisfaction was high and staff felt engaged with the service leaders.

End of life care

Good

Updated 8 March 2018

Our rating of this service improved. We rated it as good because:

  • There had been a focus on continuous improvement across the service since our last inspection. There was now improved governance in end of life care, with a clear structure of accountability and audits and outcome measures in place.
  • There was a new governance structure in place that was understood by staff. There was an end of life care steering group that had trust wide representation and received regular audits and updates from various ongoing work streams.
  • Appropriate measures were in place to keep patients safe from avoidable harm. Incidents and safety monitoring results were collated and shared to improve the service.
  • Risk assessments and care planning for patients at the end of life had improved since the last inspection.
  • Medicines were managed and prescribed appropriately and equipment was available to patients at the end of their life and equipment was well maintained.
  • There was good team working across the service. Local managers supported their staff in their roles, with chances for professional development offered. Staff received the right additional training and support to care for patients at the end of life.
  • Patients were provided with compassionate and person centred care, which took account of their individual differences and needs. Relatives and friends were involved in care planning wherever appropriate and recognised as part of the caring team.

However:

  • There was a variable approach on the wards to the criteria for making referrals to the specialist palliative care and end of life team. Not all patients referred to the team met the criteria for assessment by the specialist palliative care team.
  • There was no specialist palliative care consultant based at the hospital, which did not meet national guidelines. The trust was in the process of recruiting a specialist consultant to the post.

Maternity and gynaecology

Good

Updated 8 March 2018

We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings.

We rated it as good because:

  • Women were overwhelmingly positive about their care and treatment. They were treated with kindness, compassion, dignity and respect. Women felt involved in their care and were given an informed choice of where to give birth. Actions were taken to improve service provision in response to complaints and feedback received.
  • Staff had real-time access to women’s electronic maternity records, and could make informed decisions on patient care, management and treatment. The service received national recognition for their implementation and use of electronic maternity records. We found records were stored securely and patient confidentiality was protected.
  • All staff understood their responsibilities to safeguard patients from abuse and neglect, and had appropriate training and support. The service worked well with other healthcare professionals and agencies to ensure the needs of vulnerable women were met.
  • Staff understood their responsibilities to raise concerns and report patient safety incidents. There was a robust governance and risk management framework in place to ensure incidents were investigated and reviewed in a timely way. Learning from incidents was shared with staff and changes were made to the delivery of care because of lessons learned.
  • Women’s care and treatment was planned and delivered in line with current evidence-based guidance. There was an effective system in place to ensure staff were aware of updated guidelines. National and local audits were carried out and actions were taken to improve care and treatment when needed. The service performed better than the national average for perinatal mortality rates and neonatal audit standards.
  • The service managed medicines and women’s pain well. They met the national standards for obstetric anaesthesia. Women were encouraged to self-administer medicines where appropriate, and were empowered and supported to manage their own health, care and wellbeing.
  • Managers appraised staff’s work performance and held supervision meetings with them to provide support and encourage improvement. The service received national recognition for its partnership model of midwifery supervision.
  • Service provision met the needs of local people. They worked closely with commissioners, clinical networks and service users to plan and improve the delivery of care and treatment for the local population.
  • Leadership was strong, supportive and visible. The leadership team understood the challenges to service provision and actions needed to address them. There was a positive culture, which was focused on improving patient outcomes and experience. Staff were committed and proud to work at the trust.
  • The service had a vision of what it wanted to achieve and clear objectives to ensure it was met. The vision and strategy was developed with involvement from staff and patients and reflected national recommendations for maternity care provision.

However:

  • We found ‘fresh eye’ cardiotocography trace reviews, safer surgery checklists and swab counts were not always completed in line with national recommendations and trust policies.
  • Midwifery specific training compliance was generally below the trust target, particularly for medical staff and blood transfusion training.
  • Midwifery staffing levels generally did not meet patient acuity levels within the service. The midwifery to birth ratio was worse than the trust threshold and national recommendations. Women did not always receive one-to-one care in established labour. We reported these concerns following our previous inspection in March 2016. We also found the labour ward coordinator was generally not supernumerary. The trust was taking action to address midwifery staffing levels.
  • There were inconsistencies in the monitoring of emergency equipment to ensure it was safe and effective for patient use.
  • Women who attended the maternity assessment suite were not always reviewed in a timely manner.

Outpatients and diagnostic imaging

Good

Updated 28 March 2017

Performance data showed a good track record in safety.

Clinical areas were generally clean and well-organised. Medical records were maintained accurately and securely, and there was an effective records tracking and location system.

Infection control procedures were followed and the service conducted regular audits.

There were robust systems in place to ensure that patients and staff were protected by adherence to national guidelines relating to ionising radiation and diagnostic imaging.

The service had a system in place to recognise and respond to changes in patient’s health.

There was evidence that patients were told when things went wrong and offered an apology.

There were systems in place to ensure the right patient received the correct diagnostic procedure.

Staff were recognising, resolving and discussing incidents but not always recording them in line with trust policy, this meant that learning from incidents was not always shared.

Not all staff had the appropriate level of training for safeguarding children.

Surgery

Good

Updated 28 March 2017

There was a culture of incident reporting and staff said they received feedback and learning from serious incidents. However, some staff did not always receive feedback on all clinical incidents. Staff were able to speak openly about issues and serious incidents.

The environment was visibly clean and generally staff followed the trust policy on infection control, although, we saw no evidence of domestic staff using cleaning checklists.

Medical staffing was appropriate and there were good emergency cover arrangements. Consultant-led, seven-day services had been developed and were embedded into the service.

Staffing levels were planned and reviewed to ensure that patients received safe care and treatment. Agency and bank staff were used and sometimes staff worked additional hours to cover shifts but this was well managed and patients’ needs were met at the time of the inspection.

Treatment and care were provided in accordance with evidence-based national guidelines. There was good practice, for example, assessments of patient needs, monitoring of nutrition and falls risk assessments. Multidisciplinary working was effective.

Patients outcomes were generally good but not all staff were aware of patients’ outcomes relating to national audits or performance measures.

Most staff had received annual appraisals and support systems for staff development were effective, however there were areas of poor compliance with mandatory training.

Staff had awareness of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) procedures to keep people safe.

The consent process commenced in outpatients, there were specific consent clinics and consent was reconfirmed at the time of admission.

Patients told us that staff treated them in a caring way, and they were kept informed and involved in the treatment received. We saw patients being treated with dignity and respect.

Patient care records were appropriately completed with sufficient detail and kept securely.

The service had an effective complaints system in place and learning was evident.

There was support for people with a learning disability and reasonable adjustments were made to the service. However information leaflets and consent forms were not available in other languages. An interpreting service was available and used.

Surgical services were well-led. Senior staff were visible on the wards and theatre areas and staff appreciated this support. There was generally a good awareness amongst staff of the trust’s values.

Urgent and emergency services

Outstanding

Updated 4 December 2019

Our rating of this service improved. We rated it as outstanding because:

  • Leaders had the integrity, skills and abilities to run the service. They fully understood and managed the priorities and issues the service faced. They were highly visible and approachable in the service for patients and staff. They fully supported staff to develop their skills and take on more senior roles.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Staff were discreet and responsive when caring for patients. Staff took time to interact with patients and those close to them in a respectful and considerate way.
  • All staff were fully committed to continually learning and improving services. They had a strong and clear understanding of quality improvement methods and the skills to use them. Leaders encouraged innovation and participation in research.
  • The service provided care and treatment based on national guidance and evidence-based practice. Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients.
  • People could access the service when they needed it and received the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were in line with national standards and better than the England average. For ambulance handovers in the period from April 2018 to March 2019 the trust performance was better than the England average. For the Department of Health’s standard for emergency departments of 95% of patients should be admitted, From June 2018 to May 2019, the trust performed better than the England average and exceeded the standard for several months of the year. transferred or discharged within four hours of arrival in the emergency department. Over the 12 months from June 2018 to May 2019, zero patients waited more than 12 hours from the decision to admit until being admitted. From April 2018 to March 2019, the monthly percentage of patients that left the trust’s urgent and emergency care services before being seen for treatment was better than the England average.
  • Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide the best possible care.
  • The service managed patient safety incidents well. The service used monitoring results well to improve safety. Staff collected safety information and shared it with staff, patients and visitors. The service continually monitored safety performance.
  • Staff completed risk assessments for each patient swiftly. They removed or minimised risks and updated the assessments. Staff identified and quickly acted upon patients at risk of deterioration.

However,

  • Not all equipment was checked in line with trust policy and some chemicals were not stored safely.
  • Consultant hours in the ED did not meet national guidance.
  • Staff did not always store and manage medicines in line with the provider’s policy.
  • Clinical support workers (CSWs) providing 1:1 observation to patients experiencing acute mental health problems did not have mental health competencies to give them the confidence to carry out this role.