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Diana Princess of Wales Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 7 February 2020

Our rating of services stayed the same. We rated it them as requires improvement because:

  • There had been little progress identified in this inspection and in some services a deterioration.
  • Within outpatients continued backlogs were identified and within diagnostic imaging there was also an increased backlog of patient awaiting diagnostic image services and the subsequent reporting of x-rays. There were unknown risks due to these backlogs.
  • There had been incidents where patients had come to harm due to delays in receiving appointments in both outpatients and diagnostic imaging. We had significant concerns regarding this and after the inspection, the Care Quality Commission completed a section 31 letter of intent to seek further clarification from the trust.
  • Within end of life we were concerned about the timeliness of pain relief given to patients and lack of documentation which would enable to trust to monitor the effectiveness of care and treatment and drive improvement.
  • Across most services there was still insufficient numbers of staff within the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
  • The service provided mandatory training in key skills to staff but had not ensured everyone had complete it. Across most services there were continued low levels of mandatory training.
  • We had ongoing concerns that patients with mental health conditions were not always cared for in a safe environment.
  • Within the emergency department there were significant numbers of black breaches and the department failed to meet the medium time to initial assessment.
  • Critical care services did not always manage infection control risks.
  • The services did not always provide care and treatment in line with national guidance and best practice. We found examples of this in some of the core services inspected.
  • The services did not ensure that staff were competent to carry out their roles and compliance with annual appraisals continued to be low.
  • Services were not always planned to meet the needs of local services. This was particularly so in end of life services.
  • Waiting times, referral to treatment and arrangements to admit, treat and discharge across a number of core services continued to be a challenge. People could not always access the services when they needed to.
  • Investigations of complaints were not managed in a timely way and in line with trust policy.
  • Across most services there continued to be a lack of clear strategies at this level.
  • Systems to manage performance were not consistently used to improve performance.
  • There continued to be changes in the governance structures and processes which had not become embedded and therefore there was limited oversight.
  • There was limited evidence of continuous improvement and innovation across most core services.

However:

  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
  • Overall staff felt respected, supported and valued.
  • Most services had an open culture where patients, their families and staff could raise concerns without fear.

Inspection areas

Safe

Inadequate

Updated 7 February 2020

Effective

Requires improvement

Updated 7 February 2020

Caring

Good

Updated 7 February 2020

Responsive

Requires improvement

Updated 7 February 2020

Well-led

Requires improvement

Updated 7 February 2020

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 7 February 2020

Our rating of this service stayed the same. We rated it as requires improvement because:

  • The service provided training in key skills to all staff but not all staff had completed it. We were not assured the service always had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Records were not always stored and disposed of securely. Medicines were not always managed safely.
  • Data submission and compliance with audits were sometimes poor. Annual appraisal compliance did not meet the trust’s target for all staff.
  • Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with national standards.
  • The strategy for the medical division was still in draft format. Concerns remained about the pace of change and improvement implementation. We were not assured about management oversight in some areas.

However:

  • The service-controlled infection risk well. Staff completed and updated risk assessments for patients and removed or minimised risks. The service managed patient safety incidents well.
  • The service provided care and treatment based on national guidance. Staff gave patients enough food and drink to meet their needs and improve their health. Staff assessed and monitored patients’ pain regularly and worked together to benefit patients. Staff supported patients to make informed decisions about their care and treatment.
  • 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.
  • The service took account of patients’ individual needs. It was easy for people to give feedback and raise concerns about care received.
  • Leaders had the skills and abilities to run the service. Staff mostly felt respected, supported and valued. The service had systems to identify risks.

Services for children & young people

Requires improvement

Updated 7 February 2020

  • We rated safe and well led as requires improvement. Effective, caring and responsive were rated as good.
  • Although the service had addressed some of the concerns from our last inspection, there were still areas where we told the trust they must improve that had not been actioned.
  • The service still did not have enough medical or nursing staff to meet national guidance. Nurse staffing on the paediatric assessment unit had not improved.
  • The service still did not ensure that young people with mental health concerns were risk assessed and cared for in a suitable environment. Although an assessment tool had been developed, this was not embedded into practice on the children’s ward and staff had not completed any mental health training. Environmental risk assessments had been completed, but no action taken.
  • We were not assured that the service always controlled infection risk well. Staff on the children’s ward did not always use control measures to protect children, young people, their families, themselves, and others from infection.
  • The service did not always record and store medicines safely.
  • Staff did not always keep detailed records of children and young people's care and treatment.
  • Although senior leaders had the skills and abilities to run the service, some ward/ department leaders required a high level of support.
  • There was no clear strategy for the service to achieve its vision.

However:

  • There had been improvements in mandatory training compliance and medical staff had improved their safeguarding level three compliance.
  • Staff provided care and treatment in line with national guidance. The service monitored the effectiveness of care and treatment through local and national audits.
  • Doctors, nurses and other healthcare professionals worked together as a team to benefit children, young people and their families. They supported each other to provide good care.
  • Staff treated children, young people and their families with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
  • People could access the service when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge children and young people were in line with national standards.

Critical care

Requires improvement

Updated 7 February 2020

Our rating of service stayed the same. We rated it as requires improvement because:

  • The service did not have enough nursing and support staff. Not all had the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Information provided by the trust showed that 37% of nurses in ICU had a post registration award in critical care nursing. Several staff we spoke with highlighted that whilst the number of staff on duty was appropriate, the mix of skills and competence was sometimes a concern.

  • The service did not have enough medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. We found the same situation with regards to medical staffing as at the previous inspection, in that it was not in line with Guidelines for the Provision of Intensive Care Services (GPICS) standards. Not all care was delivered by intensivists, and on call consultants had other areas of responsibility. In addition, the rota did not provide continuity of care for patients.
  • Staff did not always have measures in place to keep people free from infection. ICNARC data showed there had been six unit acquired infections between 1 April 2018 and 31 March 2019. This was higher compared to similar units (3.0 against 1.6 unit acquired infections in blood per 1000 patient bed days). Observations of hand hygiene frequency was variable between staff on the ICU. On three occasions, between January 2019 and September 2019, the hand hygiene audit dropped below the trust target of 85%. On one occasion compliance was 74%. Hand hygiene data for the HDU showed that there were two occasions between January 2019 and September 2019 when the compliance rate did not meet the target of 85%.

  • The service provided mandatory training in key skills to staff but had not ensured everyone had complete it. The 85% target was not met for three of the 10 mandatory training modules for which qualified nursing staff were eligible.  
  • Not all staff had training on how to recognise and report abuse. The 85% target was not met for two out of three safeguarding training modules for which qualified nursing staff and medical staff were eligible.  
  • Although, the service used systems and processes to safely prescribe, administer, and record medicines. We had concerns regarding the inappropriate storage of medicines on the ICU. All fluids were stored appropriately on HDU, however there were potassium based fluids stored alongside other IV fluids. This did not adhere to the trust policy.
  • Critical care services did not always provide care and treatment based on national guidance and evidence-based practice. Information from the July 2019 governance meeting minutes showed that the division were not meeting compliance against all the National Institute for Health and Care Excellence (NICE) guidance, with a few outstanding. However, the minutes were not specific to which NICE guidance this linked to.
  • Not all services were available seven days a week to support timely patient care. ICU medical team reviewed all patients at the weekend. Out of hours cover was provided by an anaesthetist on call or the medical out of hours team and not by an intensivist as per GPICS standards.
  • Doctors, nurses and other healthcare professionals did not always work together as a team to benefit patients. Multidisciplinary staffing was generally in line with GPICS recommendations; however, it did not meet the full recommendations. We observed that there was not always full attendance during multidisciplinary ward rounds.
  • People could not access the service in a timely way. For the intensive care unit there were also 4.2% had a non-clinical transfer out of the unit. Compared with other units, non-clinical transfers for this unit was worse than expected. Similar units had an average of 1.3% non-clinical transfers.

  • For the intensive care unit at there were 12.7% non-delayed, out-of-hours discharges to the ward. These are discharges which took place between 10:00pm and 6:59am. Compared with other units (4.4%), the unit’s performance was significantly worse. This did not meet the national standard.
  • For the high dependency unit at there were 12.7% non-delayed, out-of-hours discharges to the ward. Compared with other units (4.2%), the unit’s performance was significantly worse. This did not meet the national standard.
  • Investigations were not timely. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff. At the time of inspection, there were six complaints open and under investigation. Two complaints relating to Diana, Princess of Wales Hospital (DPoW) had been closed. Of these, the trust took an average of 82.5 working days to investigate and close.
  • From our observation and from speaking with staff, it was clear that staff lacked confidence in their immediate line managers leadership. We heard staff state that actions were not always followed up and that outcomes were slow. Nonetheless, all staff we spoke with felt able to escalate concerns. This was also highlighted on the previous inspection.
  • The HDU and ICU continued to function separately and there remained limited inter-unit working.
  • Staff at some levels were not clear about their roles and accountabilities.
  • There was limited improvement of leaders and staff engagement with patients and relatives. Limited work had been done to improve engagement with families and patients. However, the use of patient diaries was not embedded, and there was no support group for relatives.

  • There was limited learning and improvement of services. We were provided with limited examples of innovative working. We were not aware of any involvement or participation in research.

However:

  • The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • Staff completed and updated risk assessments for each patient and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration.
  • The critical care outreach team (CCOT) provided cover seven days a week from 8am to 8pm. Overnight cover was provided by the hospital out of hours team.
  • Managers appraised staff’s work performance and held supervision meetings with them to provide support and development. Data submitted at the time of inspection showed that nursing and medical staff working on HDU and ICU at Diana, Princess of Wales Hospital had achieved an appraisal rate of 100% against a trust target of 95%.
  • We found the processes for sepsis and delirium screening was undertaken in ICU and HDU.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
  • We saw evidence in patient records that care plans included assessment and interventions for any patients with additional needs. This information would be communicated to all staff during handovers.
  • Leadership of the service was in line with Guidelines for the Provision of Intensive Care Services (GPICS) standards. From discussions with the leadership team it was clear they understood the current challenges and pressures impacting on service delivery and patient care.

End of life care

Inadequate

Updated 7 February 2020

  • The service had not addressed many of the concerns from our last inspection, there were still areas where we told the trust they must improve that had not been actioned.
  • At the last inspection in 2018 we told the trust it must ensure that sufficient numbers of palliative care staff are employed to provide care and treatment. At this inspection the service still did not have enough nursing or medical staff with the right qualifications, skills, training and experience to meet national guidance. Managers did not regularly review and adjust staffing levels and skill mix.
  • The service did not have enough medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and provide the right care and treatment.  
  • Staff did not always keep detailed records of patients’ care and treatment. Records were not consistently clear and up-to-date or easily available to all staff providing care.
  • The service provided mandatory training in key skills however they did not ensure all staff had completed it.
  • The service did not always provide care and treatment based on national guidance and evidence-based practice.
  • There was very limited monitoring of patients care and treatment. Therefore, staff did not always monitor the effectiveness of care and treatment or use the findings to make improvements and achieve good outcomes for patients.
  • Preferred place of death was not consistently documented for all patients receiving end of life care.
  • Staff did not consistently assess and monitor patients regularly to see if they were in pain and did not give pain relief in a timely way. Staff did not always complete documentation specific to end of life and palliative care.
  • Staff did not support those unable to communicate using suitable assessment tools and give additional pain relief to ease pain.
  • The service did not make sure staff were competent for their roles. Managers did not appraise staff’s work performance and or hold supervision meetings with them to provide support and development.
  • At the last inspection in 2018 we saw the trust was not providing a seven-day service. Key services were still not available seven days a week to support timely patient care.
  • Staff did not consistently treat patients with compassion and kindness. Individuals privacy, dignity and their individual needs were not always taken in to account.
  • Staff did not always support and involve patients, families and carers to understand their condition and make decisions about their care and treatment.
  • The service did not always take account of patients’ individual needs and preferences. Multi faith facilities were not fully in place and access to chaplains was limited.
  • The service did not consistently monitor performance to enable improvements for people at the end of their life. This included rapid discharge arrangements to enable people to meet their preferred place of care and death and referral to treatment times
  • There had been no improvement in the complaint’s management for the service.
  • There were insufficient leaders with the skills and abilities to run the service. They did not understand or manage the priorities and issues the service faced. Due to the small numbers of staff their visibility was limited. There was no clear leadership of the service and lines of accountability were blurred.
  • Key senior management staff roles had been vacant for some time and remained unfilled at the time of inspection.
  • There was no current local strategy or vision for the service.
  • Staff working within the service told us they did not feel valued and respected. There was no sense that staff were fully engaged in making dying everyone’s responsibility.
  • There was a lack of governance structures in place with processes and systems of accountability to support a sustainable service.
  • There was little understanding or management of risk. There was no risk register to identify that there was oversight of the current risks or that these had been escalated. For example, the lack of audit completion and staff vacancies. Therefore, risks were not shared within this speciality
  • Leaders and staff undertook limited engagement with patients and staff to plan and manage services.
  • We saw limited evidence of any information to support learning, continuous improvement or innovation in the service.

However:

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. There had been improvements in medical staff safeguarding training compliance.
  • Systems had been introduced since the last inspection to improve systems within the mortuary such as cleaning and fridge temperate monitoring.

Surgery

Requires improvement

Updated 7 February 2020

  • The division did not move with enough pace to address the issues from the previous inspection. We were not able to see the impact of change on all areas we raised at the last inspection.
  • The service did not always have enough medical staff to care for patients and keep them safe. The service provided staff with training in key skills but did not have effective systems and processes to ensure this was completed; compliance was particularly poor for medical staff and safeguarding training compliance was below the trust target. Records were poorly organised, not always completed and version control was poor. The service did always respond to safety incidents well or in a timely way.
  • The service did not always provide care and treatment in line with national guidance and best practice. We found examples of patients being fasted for longer than the recommended time and malnutrition universal screening tool (MUST) scores were not recorded in line with policy. Appraisal rates did not meet the trust target.
  • 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.
  • In the service, we found that patients whose operations were cancelled were not always treated within 28 days and some patients were still waiting more than 52 week waits for surgical treatment. Medical outliers did not always receive timely medical reviews and the trust continued to breach mixed sex accommodation in the high observation bay (HOBs) area. The trust had a backlog of complaints and the average complaints response took 119.8 working days; the trust policy is 60 working days
  • Systems to manage performance were not consistently used to improve performance. We saw limited evidence of identifying and escalating relevant risks and issues and identified actions to reduce their impact. We did not see governance, performance or risk issues escalated and discussed in an effective way. The governance structure internally within the division and externally within the trust needed strengthening to show evidence of risk and performance discussion. We saw limited evidence that the draft vision and strategy had been developed with all relevant stakeholders.

However:

  • Staff 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. They managed medicines well. Staff recognised and reported some incidents and near misses and managers investigated incidents appropriately and shared lessons learned.
  • Staff provided good 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.
  • 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.
  • Leaders and teams had systems to manage performance. The service had a vision for what it wanted to achieve and had developed a draft strategy to turn it into action. The culture in the division had improved and staff were focused on the needs of patients receiving care.

Urgent and emergency services

Requires improvement

Updated 7 February 2020

Our rating of this service stayed the same. We rated it as requires improvement because:

  • Whilst the service provided mandatory training in key skills including the highest level of life support training, staff in the department had not all completed the training. This included basic and advanced life support training for children and adults and safeguarding training.
  • The design of the department did not meet the requirements to keep all patients safe. We had ongoing concerns that the design of the department was not psychiatric liaison accreditation network (PLAN compliant).
  • The time from arrival to initial assessment was worse than the overall England median in all months over the 12-month period from April 2018 to March 2019. From June 2018 and May 2019 there was an upward trend of ambulances handovers of more than 30 minutes however following our inspection information provided by the trust showed that from April 2019 to November 2019 there had been improvement in this metric. There had been 1,410 black breaches from June 2018 to May 2019.
  • We found oxygen was not always prescribed before being administered in line with the trusts policy.
  • The service did not have enough substantive medical or nursing staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment, however bank, agency and locum staffing was used to fill most roster gaps. At the previous inspection the department had insufficient numbers of nursing and medical staff.
  • There was not enough registered sick children’s nurses (RSCNs) to meet the intercollegiate emergency standard.
  • At the previous inspection we found that the department was not in line with the Royal College of Emergency Medicine (RCEM) guidance of providing 16-hour consultant covert this inspection we saw that this was still not being met.
  • At our inspection in 2018, we found the department did not meet the RCEM audit standards 2016/17 for moderate and acute severe asthma, consultant sign off and severe sepsis and septic shock. At this inspection we found the service had completed internal audits to monitor progress against the RCEM audit standards. We found some improvement against some standards, but this was not consistent across all the required standards.
  • The service did not always make sure staff were competent for their roles. Appraisal of staffs work performance was not in line with the trusts target for medical or nursing staff.
  • The trust was not meeting the time of arrival to receiving treatment of less than one hour. The trust did not meet the standard for 11 months over the 12-month period from April 2018 to March 2019.
  • The national standard for emergency departments of 95% of patients being admitted, transferred or discharged within four hours of arrival was not met and data demonstrated a deteriorating picture up to September 2019 with an overall performance of 78.4% of patients meeting the four-hour target.
  • Whilst the service treated concerns and complaints seriously, the time taken to investigate, share lessons learned with staff and feedback to the complainant was not in line with the trusts policy. The time taken to investigate, complaints and share lessons learned with all staff and provide feedback to the complainant was not in line with the trusts policy.
  • Whilst the service leaders understood the priorities and issues the service faced there had been limited improvements made since our last inspection.
  • The service had a vision for what it wanted to achieve, however the strategy to turn it into action was not yet in place despite this being identified as a concern at our previous inspection.
  • We saw limited evidence that leaders and teams used systems to manage performance effectively. Whilst some risks and issues were identified and escalated, there was limited evidence to show actions to reduce their impact and not all of the identified risks were on the risk register.
  • There was limited examples of learning, continuous improvement and innovation.

However:

  • The service controlled infection risk well. They kept equipment and the premises visibly clean.
  • The service managed patient safety incidents well.
  • The service provided care and treatment based on national guidance and evidence-based practice.
  • Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for patients’ religious, cultural and other needs.
  • Staff assessed and monitored patients regularly to see if they were in pain and gave pain relief in a timely way.
  • Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent.
  • 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, and took account of their individual needs.
  • 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.

Diagnostic imaging

Inadequate

Updated 7 February 2020

Our rating of this service went down. We rated it as inadequate because:

  • Patients could not always access the service when they needed it. Waiting and result reporting times were not in line with national standards.
  • There had been incidents where patients had come to harm due to delays in reporting results. We had significant concerns regarding this and after the inspection, the Care Quality Commission completed a section 31 letter of intent to seek further clarification from the trust.
  • Safety was not a sufficient priority. Although there was measurement and monitoring of safety performance, there was a limited response leading to unacceptable levels of incidents and potential harm.
  • There had been a lack of pace to address the backlogs and therefore there were concerns that incidents and near misses were not recognised which had caused harm and put patients at risk of harm or potential harm.

  • Safety was not a sufficient priority. Although there was measurement and monitoring of safety performance, there was a limited response leading to unacceptable levels of incidents and potential harm.
  • From May 2018 to April 2019, the percentage of patients waiting more than six weeks to see a clinician (12%) was higher than the England average (3%).
  • Substantial, ongoing and frequent staff shortages increased risks to people who used services.
  • Although, the trust had systems for identifying risks in place, opportunities to prevent and minimise harm were missed.
  • Since our last inspection in 2018, the backlog in unreported results had increased from 5,364 examinations (3,686 patients) to 10,701 examinations (7,045 patients) in July 2019.
  • The contract with the external reporting company to address the backlog had been put in place in August 2019. This delay increased the potential risk of harm to patients.
  • At the time of inspection, the overall backlog in unreported results across all modalities was 7,942 delays (4,719 patients).
  • Following inspection, the initial trajectory for clearing the backlog in unreported results had changed and extended, increasing the risk of potential and actual harm to patients still within the backlog of unreported and delayed results.
  • There were trust wide shortages of radiologists. This impacted on reporting rates across the trust, including Diana, Princess of Wales Hospital.
  • Although there was some resistance from existing radiologists to supporting the long-term development of radiographers’ capacity to report on results, the expansion of plain film reporting to chest and abdomen was supported and the trust had also put in place other initiatives to improve their reporting capacity.
  • From June 2018 to June 2019, the trust received 19 complaints in relation to diagnostic imaging (3.9% of total complaints received by the trust). Nine complaints were still open and under investigation or partially upheld with no closed date. Of the closed complaints, the trust took an average of 67.8 working days to investigate and close. This was not in line with their complaints policy, which states complaints should be completed within 60 working days.
  • There was inconsistency of record keeping at the hospital. Of the records we checked over half were missing key documents such as recording of consent to treatment.
  • A finalised divisional strategy was not in place and had been developed to draft stage only.

However:

  • The service provided mandatory training in key skills to all staff and made sure everyone completed it.
  • The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use equipment.
  • Staff we spoke with were aware of their responsibilities in relation to duty of candour.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
  • Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
  • In August 2019, 80% of people who completed the Friends and Family Test (FFT) were extremely likely or likely to recommend this service to their family and friends.
  • The service planned and provided care in a way that met the needs of local people and the communities served.
  • The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services.

Maternity

Requires improvement

Updated 7 February 2020

Our rating of this service went down. We rated it as requires improvement because:

  • Not all staff were up to date with key mandatory training; including obstetric emergency, resuscitation, adults safeguarding, and Mental Capacity training. The service had not provided quarterly ‘live’ (unannounced) emergency skills and drills training, in line with trust policy. The use of band three (healthcare assistant) scrub practitioners in theatres was not compliant with national guidance. The appraisal rate for medical staff was low and did not meet trust target.
  • Leaders and senior staff had the necessary experience and knowledge to lead effectively. Whilst, there had been instability within the team since our previous inspection, some of the leaders had worked in the service for many years. Staff did express concerns about leadership stability and the implementation of new models of care; and said morale within the service had wavered. The service did not have an agreed vision for what it wanted to achieve and the strategy to turn it into action was in draft. In addition, the divisional strategy was also in draft.

  • We were not assured leaders had oversight of clear and reliable midwifery and nurse staffing data; and we saw sickness rates and use of bank staff were high. Community caseloads, allowing for some changes in allowances and changes in NICE Guidance since 2009, exceeded the recommended ratio of 96 to 98 cases per WTE midwife. A high proportion of community clinics had been cancelled in the 12 months prior to inspection.
  • Leaders did not always operate effective governance processes or manage performance effectively. The service did not always collect and collate reliable data; for example, we were not assured NICE red flag data was valid and reliable, and we observed some inaccuracies in other key data we reviewed. The frequency of perinatal morbidity and mortality meetings was not compliant with trust policy, the quality of women’s and children’s divisional meeting minutes varied, and action plans were not always sufficiently robust.
  • The time taken to investigate, and close complaints was not in line with the trust’s complaints policy.

However:

  • The service provided care and treatment based on national guidance and best practice. Staff completed and updated risk assessments for each woman and took action to remove or minimise risks. Staff identified and quickly acted upon women at risk of deterioration. The service used systems and processes to safely prescribe, administer, record and store medicines.
  • The design, maintenance and use of facilities, premises and equipment kept people safe. Staff carried out daily and weekly safety checks of specialist and emergency equipment, and the service controlled infection risk well.
  • Staff treated women with compassion and kindness, provided emotional support, respected their privacy and dignity, and took account of their individual needs. Staff supported women to make informed decisions about their care and treatment and followed national guidance to gain patients’ consent. Staff understood how to protect women and children from abuse and the service worked well with other agencies to do so.
  • The service had an open culture where patients, their families and staff could raise concerns without fear. The service treated concerns and complaints seriously, investigated them and shared lessons learned with staff.

Outpatients

Inadequate

Updated 7 February 2020

  • The trust had identified incidents in 2018 and 2019 where patients had come to harm due to delays in receiving appointments in out-patients.  We had significant concerns regarding this and requested further information from the trust on what it was doing to limit risk in a section 31 “letter of intent to seek further clarification from the trust”. The trust provided a response to this. CQC continue to have concerns about the risks of harm and potential harm to patients when waiting times remain lengthy. However, we were assured that the trust had put in place oversight mechanisms and processes to limit the risks.
  • Following the inspection, the trust provided more information which showed they had revised the inclusion criteria for patients to be added to the clinical harm review in ophthalmology to include any delay that exceeded the speciality/department risk stratification criteria. For example, in September 2019, this new risk stratification criteria had identified 83 patients to be added to the clinical harm review. Of these 83 patients, 37 patients had been seen and assessed for harm and the trust highlighted there was no harm in 24 of these patients, there was low harm in ten patients and one moderate harm and two severe harm. Out of the 83 patients identified, the remaining 46 patients were due to have a clinical harm review in November 2019.
  • Whilst the trust had implemented clinical validation to help ensure patients were seen in order of clinical need, there remained risk in some waiting lists due to the volume of patients on the waiting list and the service not meeting the operational standard for patients receiving their first treatment within 62 days of an urgent GP referral for a suspected cancer diagnosis. This was an ongoing concern since our previous inspection. The trust provided information after the inspection stating they were taking steps to address the challenges with cancer performance in accordance with the trust’s performance management framework.
  • We did not see evidence of safety checklists being used in any areas other than in ophthalmology.
  • Staff did not consistently tell us they had received shared learning from incidents.
  • Although records were now stored securely, which was an improvement since our last inspection, records were not always timed or signed by staff, and staff did not always provide their role or designation. Written notes were not consistently legible. These concerns were ongoing since our previous inspection.
  • Although the oversight of waiting lists and backlogs had improved, the July 2019 board papers showed there remained 33,673 overdue outpatient review appointments in May 2019. Overall there had been improvements with the referral to treatment indicators, however there remained specialties which did not always achieve the referral to treatment indicators.
  • From June 2018 to May 2019 the trust’s referral to treatment time (RTT) for non-admitted pathways has been worse than the England overall performance. The latest figures for May 2019, showed 78.7% of this group of patients were treated within 18 weeks versus the England average of 87.6%.
  • From June 2018 to May 2019 the trust’s referral to treatment time (RTT) for incomplete pathways has been worse the England overall performance, although there has been an improving trend from January to May 2019. The latest figures for May 2019 showed 77.8% of patients still waiting for treatment had been waiting for less than 18 weeks, versus the England average of 86.4%.
  • From June 2018 to June 2019, the trust received 134 complaints in relation to outpatients at the trust (27.6% of total complaints received by the trust). 66 complaints were still open and under investigation or partially upheld with no closed date. Of the 68 complaints that were closed, the trust took an average of 82.2 working days to investigate and close complaints. This was not in line with their complaints policy, which states complaints should be closed within 60 working days.
  • From March 2018 to February 2019, the ‘did not attend’ rate for Diana, Princess of Wales Hospital was higher (worse) than the England average.
  • Leaders were not always visible in the outpatient department. Staff did not always feel respected, supported and valued. At the previous inspection, there was no strategy in place and although the trust had developed a strategy and provided the draft strategy for outpatients, this was still a draft version.

However, we also found:

  • The service provided mandatory training in key skills to all staff and made sure everyone completed it. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • The service controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean. Staff managed clinical waste well.
  • The service had enough nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed staffing levels and skill mix and gave bank staff a full induction. The service used systems and processes to safely prescribe, administer, record and store medicines.
  • Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care. Staff gave patients practical support and advice to lead healthier lives. Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Staff provided emotional support to patients, families and carers to minimise their distress. Patients were given contact details for specialist nurses to contact with any worries or questions.
  • Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment. Patients we spoke with gave positive feedback about their care and treatment in outpatients at this hospital.
  • The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. Leaders and teams used systems to manage performance.
  • There had been improvement in some areas and improved oversight and governance regarding the challenges across outpatient services. The services had implemented procedures to support the work regarding the challenges in outpatients, for example outpatient leaders monitored performance through performance reports and regular meetings.
Other CQC inspections of services

Community & mental health inspection reports for Diana Princess of Wales Hospital can be found at Northern Lincolnshire and Goole NHS Foundation Trust.