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Inspection Summary


Overall summary & rating

Good

Updated 15 August 2018

Our rating of services improved. We rated them as good.

A summary of this hospital appears in the overall summary above.

Inspection areas

Safe

Requires improvement

Updated 15 August 2018

Effective

Good

Updated 15 August 2018

Caring

Good

Updated 15 August 2018

Responsive

Good

Updated 15 August 2018

Well-led

Good

Updated 15 August 2018

Checks on specific services

Critical care

Requires improvement

Updated 20 October 2015

We rated the critical care service as requires improvement.

Patients were at risk of increased harm and not receiving effective care and treatment. Current evidence based guidance and standards were not always followed. Patients were not routinely assessed for delirium. Daily ward rounds did not always support or promote effective multidisciplinary working. Physiotherapy was not available for all patients at weekends. The critical outreach team was not available 24 hours a day, despite a demonstrated need for this.

The proportion of nursing staff attending mandatory training was well below the target of 90% for most of the required topics. Staff lacked awareness of the requirements of the Duty of Candour regulation. There was a lack of strategic overview and planning of critical care services Risks were not always identified and issues were not always dealt with in a timely way.

Patients were treated with kindness, dignity and respect. Patients and relatives were positive about how they were cared for and supported. Staff spent time with patients and relatives to ensure they understood the care and treatment and were involved in making decisions. Staff understood and fulfilled their responsibilities to report concerns and safety incidents. Lessons were learned and action was taken to improve safety. Cleanliness and infection control measures were generally appropriate and effective. The environment and equipment were mostly properly checked and maintained. Staffing levels in the critical care unit were in line with national standards.

Outpatients and diagnostic imaging

Requires improvement

Updated 9 November 2016

Urgent and emergency services

Good

Updated 15 August 2018

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

  • Improvements in meeting the four-hour waiting time target had been made and sustained with the department performing better than the national average.

  • Systems were in place for assessing all patients arriving in the emergency department to determine how quickly they should be reviewed: this included a clear streaming/triage process. Criteria were in place for staff to determine which patients could be signposted to the co-located primary care centre.
  • Patients waiting longer than the recommended time to be handed over from the care of ambulance staff to hospital staff had generally improved.
  • When concerns were raised or things went wrong, the approach to reviewing and investigating causes had improved. We saw evidence of wider learning from events or action taken to improve safety.
  • The leadership, management and governance of the department assured the delivery of high quality person-centred care. Risks and quality measures were regularly reviewed, responsibilities were clear and risks were understood and managed.
  • Clinical leadership had improved and was now consistent. There was compassionate, inclusive and effective leadership at all levels in the department. Leaders had the capacity and capability needed to deliver excellent care.
  • A divisional wide urgent and emergency care improvement plan was in place which included medical leadership. Significant issues that threatened the delivery of safe and effective care had been identified and appropriate action was taken to manage them.

Maternity

Good

Updated 15 August 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:

  • The service collected safety information, which was compared to national data. Staff used the information to improve the service.
  • Staff understood their roles and responsibilities regarding safeguarding vulnerable adults and children. Although consultants’ compliance with safeguarding training was lower than the trust target, most staff had received appropriate levels of safeguarding training and could tell us about examples of where they had identified and raised concerns.
  • Staff demonstrated good practice with regards to hand hygiene and infection control. We saw hand gel available in clinical areas and the environment and equipment were visibly clean. Equipment was regularly serviced and cleaned. Surgical site infections were below the national average.
  • There were effective processes for the reporting and management of incidents, Staff were aware of their responsibilities to report incidents and we saw learning from incidents was shared.
  • The service managed incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave women and families honest information and suitable support.
  • Staff kept appropriate records of women’s care and treatment. Handheld and inpatient records were clear, up-to-date and available to all staff providing care. Safeguarding records were up to date and easily accessible. Completion of cardiotography trace records was in line with trust policy.
  • The service provided care and treatment based on latest evidence and national guidance and maintained a quality dashboard to monitor outcomes. The normal birth rate was higher (better) than the national average and the total caesarean section rate was lower (better) than the national average.
  • Staff with different roles worked together as a team to benefit women. Midwives, doctors, nurses and other healthcare professionals supported each other to provide good care. Multidisciplinary teamwork was continuous and evident throughout the unit.
  • Staff gave patients enough food and drink to meet their needs and improve their health. Women had access to snacks and light meals as they required. Enhanced recovery programme supported early hydration and improved recovery.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care. Staff documented when consent for procedures and ensure records had been gained.
  • Staff actively promoted improving women’s health by encouraging women to stop smoking, and increasing skin to skin and breastfeeding.
  • Staff understood and respected the personal, cultural, social and religious needs of women and those important to them. Women and their relatives we spoke with told us without exception they were treated with dignity, kindness and respect.
  • Feedback from people who used the service, those who are close to them and stakeholders was positive about the way staff treated people. The trust performed amongst the best performing trusts for three out of 15 questions in the CQC maternity survey 2017.
  • Staff provided emotional support to patients to minimise their distress. Women, families and staff particularly valued the bereavement service. Excellent bereavement care was a priority for the service. Bereavement services and staff knowledge on supporting bereaved families ensured people received the physical and emotional care required.
  • People’s individual needs and preferences were central to the delivery of tailored services. Staff routinely involved women who used the services and those close to them in planning and making shared decisions about their care and treatment. Birthing partners were included and involved in the care of their partner and new-born baby.
  • We saw specific examples of innovative approaches to care particularly for women with complex needs. Staff from the multidisciplinary team worked collaboratively to provide care for women. Staff had a proactive approach to understanding the needs and preferences of different groups of people and delivered care in a way that met these needs. We saw staff going above and beyond to plan care for a woman with complex physical needs.
  • The trust planned and provided services in a way that met the needs of local people. There were a range of clinics for both high and low risk women.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff. Complaints were investigated and closed within the trust target timescales.
  • Service leads had the right skills and abilities to run a service providing high-quality sustainable care. The middle manager structure had just been implemented.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Matrons were visible and active in clinical areas. Predominantly staff felt valued for the work they did.
  • The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. The risk register was reviewed regularly and staff had an awareness of the risks throughout the unit.
  • The trust engaged well with women, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively. The service’s vision and strategy was in line with national priorities.

However:

  • Although there was no evidence of impact on the care women received, there were gaps in the junior doctors’ rota which were being filled by staff working flexibly and covering additional shifts. This had an impact on individuals’ morale and ability to access training.

Outpatients

Good

Updated 15 August 2018

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings.

We rated it as good because:

  • Our rating of this service improved. We rated it as good because:
  • There was a positive incident reporting culture with evidence of learning and sharing following incident investigations.
  • Mandatory training and appraisal rates exceeded the trust target.
  • Staffing levels showed minimum vacancies and a low staff turnover rate.
  • Staff complied with infection prevention guidelines.
  • There was efficient medical records management with over 98% availability for all outpatient clinics.
  • Medicines were stored in line with local and national guidance.
  • Policies, protocols and patient pathways were based on national guidance.
  • Staff were suitably qualified and trained to carry out their roles within the outpatient environment.
  • Appraisal rates were 100% throughout the department.
  • Specialities were involved in local networks for sharing best practice,
  • We saw evidence of multidisciplinary working.
  • We received consistently positive feedback from patients
  • We observed positive interactions between staff and patients.
  • There were opportunities for patients to receive psychological support when receiving bad news.
  • There was an ethos of open leadership with senior management becoming more visible throughout the trust.
  • Local management had a strong influence, enabling staff make comments and suggestions for improvement.
  • Medical records had undergone a reorganisation over the previous two years resulting in over 98% records availability across the trust.
  • There was a clear vision and strategy.
  • Governance practices were cascaded down throughout the department with information shared at all levels.
  • There had been positive engagement with staff, reflected in the staff survey response rate and outcomes.

Maternity and gynaecology

Requires improvement

Updated 9 November 2016

Medical care (including older people’s care)

Good

Updated 15 August 2018

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

  • The service had improved in relation to sharing learning from incidents. We found a culture which encouraged the sharing of learning from incidents.
  • The service had improved in relation to staffing levels for level two patients in ward 43. There was increased staffing provision in comparison to the staffing arrangements at the time of our 2015 inspection.
  • Patient risk assessments were routinely completed and nursing records were clear and comprehensive.
  • The service monitored the effectiveness of care and treatment by participating in national and local audits and used the findings to drive improvements.
  • There was an effective multidisciplinary team (MDT) working environment within medical services with the involvement of external partners (such as mental health service providers) to support patients’ health and wellbeing.
  • Consent was well managed and staff understood their responsibilities in relation to the Mental Capacity Act and associated Deprivation of Liberties Safeguards (DoLs).
  • Staff demonstrated a kind and caring approach towards patients and their families. It was obvious that staff had positive relationships with patients and we saw them spend time talking to patients and their families and friends.
  • Staff took their time to respond to the individual needs of patients, including those living with a cognitive impairment such as dementia and those living with a learning disability.
  • Services were in place to support patients with spiritual and cultural needs.
  • All staff we spoke with were enthusiastic and passionate about the work they did.
  • There was evidence of clinical governance procedures and quality measurement processes. It was evident that risks were identified, mitigated (where possible), reviewed and escalated through different committees.

However;

  • Patients’ medical records were not always stored safely to maintain the privacy of patients.
  • Some risks on the risk register were past their review date and some didn’t have a review date at all.

Diagnostic imaging

Good

Updated 15 August 2018

We previously inspected diagnostic imaging jointly with outpatients so we cannot compare our new ratings directly with previous ratings. We rated it as good because:

  • The radiology department was well supported through a service level agreement by a team of medical physics experts who monitored radiation levels received by staff and patients as well as auditing of compliance against national radiation regulations.
  • The radiology department conducted audits of clinical practise as well as operational performance against national standards where available and benchmarked themselves against other trusts locally and nationally.
  • Role development of radiographers and sonographers was actively encouraged and well supported by radiologists.
  • The management team in radiology was effectively managing staffing vacancies, and had managed to attract staff despite the national occupational shortages.
  • Performance and operations were well monitored in the radiology department. Senior staff were aware of up to date statistics via regular meetings, scorecards and weekly emails.

However:

  • Radiographers did not consistently check pregnancy status of women of child bearing age as per local procedures.
  • Inpatients attending the radiology department for examinations did not always have their notes transported with them. This meant that staff would not be aware of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order or falls risk assessment.
  • The MRI department was only seeing up to 40% of suspected cancer patients within the trust’s target of seven days.
  • X-ray images were having to be outsourced to a tele-radiology company as the department was struggling to meet their key performance indicators.
  • Document control in the x-ray departments was poor, and we found outdated or old versions of documents which staff were referring to. This was because the shared computer drive which held the most up to date policies and procedures was difficult to navigate.

Surgery

Good

Updated 20 October 2015

We rated the surgical services as good.

Arrangements to minimise risks to patients were in place with a full range of risk assessments on admission, and the early identification of patient deterioration following a surgical procedure. However, in the 12 months April 2014 to March 2015, two thirds of patients with sepsis, a potentially life-threatening condition triggered by infection, did not receive safe and timely treatment.

Care and treatment was planned and delivered in line with national guidance and NICE (National Institute of Clinical Excellence) quality standards. Patient outcomes were generally in line with or better than the England average, although some standards were not being met. Some allied health professional support was only available four days a week, which resulted in delays in patients receiving assessments and treatment.

People’s individual needs and preferences were considered when planning care. The service achieved the required referral to treatment time (RTT) of 18 weeks and cancellation rates had been improved by 50% over the last twelve months.

There was good leadership at departmental level. Staff were enthusiastic and supportive of each other. There was a good governance structure with regular, well attended meetings, with sharing and learning from incidents and complaints. However, there was a lack of clear vision and strategy for the future development of surgical services.

Services for children & young people

Good

Updated 20 October 2015

We rated the children and young peoples service as good.

Although risks to patients were assessed and managed, staff had not consistently monitored the emergency resuscitation equipment. Medication monitoring practices were not effective as we found some out of date medications.

Patients received evidenced based care and there was good multi-disciplinary working between the children’s services and the child and adolescent mental health team. However, there was no written guidance on how to manage risks for children and young people who presented with mental health concerns.

In adult outpatient clinics staff tried to accommodate children’s needs, but the clinic environments were not child friendly, and some patients had excessive waiting times. Staff in adult outpatient areas where children and young people were seen had not received adequate child safeguarding training.

Staff were caring, compassionate and respectful. Staff were positive about working in the service and there was a culture of openness, flexibility and commitment. Arrangements were in place to minimise risks to children and young people receiving care, and there was effective monitoring of quality and outcomes.

End of life care

Good

Updated 15 August 2018

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

  • Staff understood their roles and responsibilities regarding the safeguarding of vulnerable adults and children. All staff we spoke with had received appropriate levels of safeguarding and could describe what safeguarding was and the process to refer alerts.
  • There were comprehensive risk assessments completed in the medical and nursing notes. These were commenced on admission and there was evidence that risk assessments continued throughout the patient’s stay in hospital.
  • We saw good examples of multidisciplinary working and involvement of other agencies and support services.
  • There was good team working between the specialist palliative care team, the bereavement service and the chaplaincy service. The chaplaincy team was an integrated part of the overall delivery of care to the dying patient.
  • Patients and their relatives told us they were fully included in discussions around their plan of care.
  • Data provided by the trust showed that there were no complaints related to end of life care between January 2017 and December 2017.
  • There was a newly appointed non-executive director for end of life care at board level.

However;

  • Some of the Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders known as Allow a natural death forms (AND) we viewed were not completed properly and did not reflect the information included in the patient’s mental capacity assessment.