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The County Hospital Requires improvement

This service was previously managed by a different provider - see old profile

Inspection Summary


Overall summary & rating

Requires improvement

Updated 2 February 2018

  • There had been an improvement in the management of medicines from the last inspection.
  • The four-hour time to treatment waiting targets were consistently higher than the national average, at County Hospital ED and reached the target of 95% on occasions.
  • Staff treated patients with kindness and compassion. Patients were involved in the care they received.
  • The service had stopped using agency staff which improved the continuity of care patients received.
  • The Purple Bow scheme assisted staff to be responsive to patient and relative needs, and to provide a service over and above what is normally offered to patient visitors. This supported a positive experience for patients at the end of life, and their relatives.

Inspection areas

Safe

Requires improvement

Updated 2 February 2018

Effective

Good

Updated 2 February 2018

Caring

Good

Updated 2 February 2018

Responsive

Requires improvement

Updated 2 February 2018

Well-led

Requires improvement

Updated 2 February 2018

Checks on specific services

Outpatients and diagnostic imaging

Requires improvement

Updated 28 July 2015

Services were safe; there were sufficient staff who were trained and understood their responsibilities. Any incidents were followed up appropriately.

Patients’ needs were assessed and their care and treatment was delivered following local and national guidance for best practice. Consent to care and treatment was obtained in line with legislation and guidance. They were treated with dignity and respect.

There was potential risk for patients who require treatment at both sites, where records may be unavailable and we also observed that records were not consistently stored securely.

There is a clear vision for the service following the integration with Royal Stoke. Although it is still early days, most staff appeared to understand the vision and their role within it. Radiology staff did not feel engaged with integration and are unclear why some services have been moved.

Maternity and gynaecology

Good

Updated 28 July 2015

Overall we found the service good with one area that required improvement.

There were many good examples of safe processes including incident reporting systems, audits concerning safe practice and compliance with best practice in relation to care and treatment plans.

Policies were based on National Institute of Clinical Excellence (NICE) and Royal College of Obstetrics and Gynaecology (RCOG) guidelines. People received care and treatment that was planned in line with current evidence-based guidance, standards and best practice.

The birth to midwife ratio was 1:29. The named midwife model was in place. Midwives told us that they provided one to one care in labour.

Medical care

Requires improvement

Updated 28 July 2015

Medical care (including older people’s care)

Requires improvement

Updated 2 February 2018

  • Staff treated patients with kindness and compassion. Patients were involved in the care they received.
  • The service had improved how it stored medicines safely.
  • The service had stopped using agency staff which improved the continuity of care patients received.
  • There was good multidisciplinary working to treat the patient holistically.

Urgent and emergency services (A&E)

Good

Updated 2 February 2018

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

  • We observed good infection, prevention and control procedures throughout County Hospital emergency department.
  • There had been an improvement in the management of medicines from the last inspection.
  • The hospital had introduced a rotation process for staff to work across both emergency departments within the trust. This enabled staff to share experiences and best practice first hand.
  • Every patient or family member that we spoke to gave very positive feedback and said the care given was good. We saw staff treating patients with compassion and dignity.
  • The paediatric minor injuries unit was a good facility providing emergency care to children. The unit was well appointed with appropriate equipment and qualified, caring staff.
  • The four-hour time to treatment waiting targets were consistently higher than the national average, at County Hospital ED and reached the target of 95% on occasions.
  • There were always two ambulances available at the ED to facilitate swift transfers for patients to either Royal Stoke Hospital or another specialist hospital. This was an improvement in service provision from the last inspection.
  • Staff told us that managers were supportive and encouraged personal development. We saw that senior nurses mentored staff and nurtured a positive culture of leaning.
  • There was an overall positive culture within the department and staff told us that they were proud to be working at County Hospital as part of the emergency department.

However:

  • Some of the data we saw in the emergency department differed from the trustwide data that was available. We saw that, often the local data was more accurate and up to date.
  • Staff told us that they were not clear on the plans for the emergency department and were feeling detached from the process.
  • Despite there being good communication between staff, it was not always clear that learning from incidents was shared with staff that had submitted them.

Surgery

Good

Updated 28 July 2015

Patients received compassionate care and staff were kind and caring. Patients’ privacy and dignity were respected and outcomes for patients were above the England national average. The standard of cleanliness was good and infection control procedures were followed. There were standardised protocols for elective surgery which were followed and included the five steps to safer surgery checklist. Incidents were reported and learning from these was shared with staff.

Access and flow was not well managed and resources at the County were not optimised. Beds and theatre were not being fully utilised.

Senior clinicians and nurses told us they had good multi- disciplinary working at the County and they felt supported in their roles. Staff did not feel part of the wider trust. They said senior trust management was not visible.

Intensive/critical care

Requires improvement

Updated 28 July 2015

The changes to critical care services had been in place for three weeks at the time of the inspection. As a result of this it was difficult to assess an accurate picture of the responsiveness of the service.

An intensive care consultant was on site Monday to Friday. Medical cover was mainly provided from early afternoon, evening and throughout the night by anaesthetic middle grade doctors with anaesthetic consultants on call from home. This does not meet intensive care core standards.

Staff morale was low and they were concerned about the future of the unit and their on-going employment.

Critical care staff were caring and compassionate. There were sufficient, highly experienced nursing staff available within the critical care unit and within the outreach team at the time of our inspection.

People received effective care, treatment and support that met their needs and achieved good outcomes, promoted a good quality of life and was based on the best available evidence.

Services for children & young people

Requires improvement

Updated 28 July 2015

Inpatient care for children transferred to the Royal Stoke site in May 2015. We saw robust plans in place to facilitate the move and staff were involved.

We found some parents were confused over the plans and did not know what services the hospital was planning to provide. Although, we noted there had been several efforts to engage with the public around the closure of the inpatient ward.

Care plans and risks assessments were not adequately maintained and contained insufficient detail to care for patients. Parents made comments that the medical staff did not always keep them informed but the nursing staff did. We saw there were a number of issues in maintaining patient and staff safety. There was a lack of correct storage of medicines and hazardous cleaning products were not safely stored.

We saw elements of compassionate care and were told staff had taken the children on days out. Parents told us they felt emotionally supported by staff. Staffing levels were found to be of a safe standard.

End of life care

Good

Updated 2 February 2018

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

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

  • Documentation had improved since our previous inspection in 2015. We saw improvements with the recording of Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) decisions.
  • We saw that there had been improvements with the prescribing of anticipatory medicines for patients since the last inspection.
  • End of life care training formed part of staff mandatory training; ensuring staff were familiar with the processes to follow for the identification and care of patients at the end of life.
  • Staff were aware of how to report incidents and provided examples of incidents they would report. We saw changes to practice had occurred following incident investigations.
  • Specific equipment regularly used with patients at the end of life, such as syringe drivers, was readily available which was an improvement since the previous CQC inspection.
  • Staffing within the specialist palliative care team, mortuary team and bereavement teams was sufficient to meet the needs of patients.
  • We saw the trust had improved their results within the National Care of the Dying Audit for Hospitals (NCDHA); and had action plans to address areas where performance indicators had not been met.
  • The end of life care service followed guidelines set by the National Institute of Health and Care Excellence (NICE) regarding end of life care.
  • Staff were caring and compassionate in their approach to patients and relatives. Staff made effort to protect privacy and dignity, even when patients were located within a ward bay rather than a side room.
  • The Purple Bow scheme assisted staff to be responsive to patient and relative needs, and to provide a service over and above what is normally offered to patient visitors. This supported a positive experience for patients at the end of life, and their relatives.
  • The end of life care service was recognised at trust board level, and had a trust strategy to support its delivery. Staff were aware of the end of life care objectives and sought to achieve these within their day to day roles.

However:

  • We saw that staff did not undertake Mental Capacity Act assessments with patients who were identified as potentially lacking capacity when completing Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms.
  • We saw that the trust failed to meet four out of five clinical indicators as part of the ‘End of life care: Dying in hospital’ audit, 2016.
  • We saw variable completion of individual care records for end of life patients.
  • The trust did not monitor patients achieving their preferred place of care, or patients achieving rapid discharge.
  • There was no local risk register for the end of life care service; instead one risk was identified for the service on a corporate register.