You are here

Inspection Summary


Overall summary & rating

Good

Updated 11 February 2020

Our rating of services improved. We rated it them as good because:

  • The safe key question improved to good.
  • Effective key question remained as good.
  • Caring key question remained as good.
  • Responsive remained as requires improvement.
  • Well led key question improved to good.
  • All eight core services are rated as good overall.
  • The additional service of neurosurgery was rated as requires improvement overall.
Inspection areas

Safe

Good

Updated 11 February 2020

Effective

Good

Updated 11 February 2020

Caring

Good

Updated 11 February 2020

Responsive

Requires improvement

Updated 11 February 2020

Well-led

Good

Updated 11 February 2020

Checks on specific services

Medical care (including older people’s care)

Good

Updated 11 February 2020

  • 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 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.
  • 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 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.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

Services for children & young people

Good

Updated 31 August 2018

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

  • Staff recognised incidents and reported them appropriately. Managers investigated incidents and provided feedback to staff. Lessons were learnt as a result of incidents and actions monitored.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service controlled infection risk well. The service had suitable premises and equipment and looked after them well. Equipment was checked at regular intervals to ensure it was safe for use. The service prescribed, gave, recorded and stored medicines well.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
  • The service monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them. Outcomes were generally better than the national average.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
  • Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They followed the trust policy and procedures when a patient could not give consent.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Staff provided emotional support to patients to minimise their distress. Staff were able to build relationships very quickly with children, young people, parents and their families. Staff involved parents and those close to them in decisions about their treatment.
  • The service took account of patients’ individual needs.
  • Patients could mainly access the service when they needed it. Waiting times from referral to treatment arrangements to admit, treat and discharge patients were in line with practice. There were delays in the provision of specialist mental health inpatient beds across the county and nationally. The service was maintaining patient safety and was meeting the needs of children and young people with mental health and self-harming behaviours.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with staff.
  • Managers at all levels in the service had the right skills and abilities to run a service providing high-quality sustainable care. There was strong local leadership within children’s services and staff spoke positively about team working and collaboration and being recognised for their contribution to the clinical team.
  • The service had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.
  • The service had effective systems for identifying risks, planning to eliminate or reduce them, coping with both the expected and the unexpected. The women and children’s clinical group had a divisional risk register which identified key risks and was regularly reviewed.
  • The service engaged with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.
  • The service was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.

However:

  • The service did not always have enough nursing staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. The service had carried out a staffing needs analysis and determined that they were not always meeting the recommended level of nurses in accordance with the Royal College of Nursing (RCN) safer staffing guidance. Patients’ needs were met during the inspection.
  • Due to the increase of clinical activity across children’s services in the last 12 months the service did not always have had enough medical staff with the right qualifications, skills and experience to keep people safe from avoidable harm and to provide the right care and treatment.
  • Staff kept detailed records of patients’ care and treatment but individual care records were not managed in a way that kept patients safe. Records were not kept secure.
  • There was low participation in the Friends and Family Test, the service was aware of this and was encouraging families to feedback about their care. Local surveys were held with respondents reporting a ‘mainly good experience’.

Critical care

Good

Updated 11 February 2020

  • 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 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.
  • 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 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.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

  • Risks around medical staffing being below planned levels, whilst recruitment is taking place, had not been reviewed.
  • Although staff had access to trust policies and procedures through the intranet, we identified some policies and procedures which were out of date and in need of renewal at the time of the core service inspection. This had been addressed by the time of the well led reivew.

End of life care

Good

Updated 31 August 2018

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

  • There were improvements to safety performance through the identification of and action against safety incidents, risks and patient assessment processes relating to end of life care.
  • There was improved recording of ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) decisions and discussions.
  • Care and treatment was delivered in line with evidence based national guidance such as National Institute for Health and Care Excellence (NICE) guidance.
  • Patient outcomes were monitored and improved through participation in the national care of the dying audit and subsequent internal audits relating to the individual plan of care for the dying person.
  • There were a range of training initiatives available for a variety of staff groups involved in end of life care so that staff had the skills, knowledge and experience to deliver effective care.
  • Patients at the end of life and those close to them were treated with kindness, respect and compassion. They were involved in making decisions about their care. Staff went the extra mile to meet patients’ individual needs and were supported by volunteer care of the dying champions.
  • There was a clear vision and strategy in place with identified priorities and monitoring of action taken by the end of life care committee. Governance structures around end of life care were in place to ensure continuous improvement.
  • There was a strong culture of quality end of life care across the trust, with active engagement, involvement, commitment and representation from a range of staff groups.
  • There were opportunities for and examples of innovation in end of life care, including the development of compassionate communities’ projects to improve end of life care for patients within the trust and the community.

However:

  • Consent to care and treatment was sought in line with legislation and guidance. However, some patient records of mental capacity assessments relating to decisions regarding ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) were not always maintained.

  • Mandatory training achievement fell below trust targets in a number of areas.
  • Facilities for having difficult conversations with relatives were limited, although this had been identified by the trust and was being incorporated into work plans.
  • Activity data relating to the responsiveness of the specialist palliative care team was incomplete which meant monitoring of response times to referrals was limited.
  • The trust did not provide a seven-day face to face service to support the care of patients at the end of life.

Surgery

Good

Updated 31 August 2018

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

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • Managers investigated incidents and there were procedures in place to share lessons learned with the whole team and the wider service.
  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • The service monitored the effectiveness of care and treatment and consistently used the findings to improve them.
  • Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care.
  • The service managed patients’ pain effectively and provided or offered pain relief regularly.
  • Staff provided patients with enough food and drink to meet their needs and improve their health.
  • Staff worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Lessons learned from complaints were shared with all staff members effectively.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff provided emotional support to patients to minimise their distress.
  • The trust generally planned and provided services in a way that met the needs of local people.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • The service had managers with the right skills and abilities to run a service providing high-quality sustainable care.
  • The service had an embedded systematic approach to continually monitor the quality of its services.
  • Continuous improvement, and learning from when things go wrong was not evident across all areas.

However:

  • The service generally controlled infecting risk well. However, not all staff followed the trust’s infection control guidance to ensure patients were kept safe from the spread of infection.
  • The service provided mandatory training in key skills but did not ensure all nursing and medical staff completed it. However, there was an action plan in place to address this.
  • Most staff had not received training in the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards. Staff generally understood their roles and responsibilities under the Mental Health Act 1983 and the MCA.
  • Records were not always stored appropriately to maintain patient confidentiality.
  • Patients could not access the service when they needed it. Waiting times for treatment were not in line with good practice. The number of cancelled operations for non-clinical reasons was worse than the England average. However, the service had implemented an action plan to review patient harm and monitor those waiting over 18 weeks.

Urgent and emergency services

Good

Updated 11 February 2020

  • 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. Staff identified and quickly acted upon patients at risk of deterioration. 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 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.
  • 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 planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However,

  • Some areas of the emergency department were unsuitable for patients especially those with mental health needs. Staff did not always remove or minimise risks and update the risk assessment relating to mental health. Records were not always accurate regarding the patients’ care and treatment. Records were not always stored securely.
  • While leaders audited fluid balance charts, we found gaps in the completion of fluid balance chart recordings. The service had a higher than expected risk of re-attendance than the national standard and the England average. Staff did not always know how to support patients who were experiencing mental ill health or who lacked capacity to make their own decisions. Improved interagency working was needed to support patients with mental health needs with their discharge from the observation ward.
  • Better communication and understanding were needed to inform patients of their rights under the Mental Health Act.
  • Patients could not always access the service when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not always in line with national standards.

Neurosurgery

Requires improvement

Updated 11 February 2020

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

  • Medical staff were not compliant with mandatory training requirements. Medical staff were also not fully compliant with safeguarding training requirements. The service did not consistently control infection risk well. Not all the equipment and the premises were visibly clean. The design, maintenance and use of facilities, premises and equipment was not always in line with national guidance.
  • Not all patients had their clinical observations reviewed in line with required timescales.
  • The service did not have 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. We found not all record keeping followed national guidance.
  • Non-medical staff did not apply the Mental Capacity Act effectively prior to undertaking routine care and treatment where applicable to support patients who lacked capacity to make their own decisions. Staff understanding about when to assess capacity was varied.
  • Key services were not always available seven days a week to support timely patient care.
  • Not all facilities and premises were appropriate for the services being delivered. Not all patients were provided with an interpreter in a timely manner. Patients could not all access the service when they needed it and did not always receive the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were in not line with national standards; although improvements were noted.
  • Staff did not all feel respected, supported and valued. The service did not have an open culture where patients, their families and staff could raise concerns without fear. Leaders did not consistently operate effective governance processes, throughout the service. Whilst governance was clear from the ward; within theatres this was not embedded or clear. Some staff at management levels were not clear about their roles and accountabilities. Although leaders and teams used systems to manage performance, not all responsible individuals were reporting concerns or adverse incidents transparently or openly.

However,

  • Nursing staff had training in key skills, understood how to protect patients from abuse, and managed safety well. Staff assessed risks to patients and acted on them. 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 mostly provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers 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.
  • Staff treated patients with compassion and kindness, mostly 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 planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
  • Leaders mostly ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff were focused on the needs of patients receiving care. The service engaged well with patients and the community to plan and manage services.

Maternity

Good

Updated 11 February 2020

  • 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 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.
  • 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 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.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

Diagnostic imaging

Good

Updated 31 August 2018

We previously inspected diagnostic imaging jointly with outpatients so we cannot compare our new ratings directly with previous ratings. As this is an additional service, we do not include this service’s ratings in our aggregation of core services ratings at this hospital.

We rated it as good because:

  • Changes had been made to strengthen the management and governance structure in this core service, which had led to a culture of continuous assessment of risk and focus of improving performance. There had been progress made to the majority of areas noted for improvement found during our previous inspection.
  • The service shared lessons learned from reported incidents and complaints. There was effective use of daily safety huddles meetings to communicate with teams.
  • The service monitored its performance including turnaround times. The team were proud that they had been delivering their diagnostic targets since 2015.
  • The service developed their staff in order to deliver appropriate care and treatment. They ensured staff attended mandatory training and received an appraisal of their development needs.

However:

  • Only medical staff received safeguarding children training to level 3.
  • The design of the building did not always lend itself to providing appropriate waiting areas or segregation of male and female patients. The service had made improvements in order to provide facilities to protect patent’s privacy and dignity, although the solutions were not always reliable.
  • There was minimal evidence of engagement with patients and the public to ensure services reflected local needs.

Outpatients

Good

Updated 31 August 2018

We cannot compare ratings to previous inspections as we inspected outpatients with diagnostic imaging previously. We rated it as good because:

  • The service provided mandatory training in key skills to staff. Most staff had completed mandatory training in line with trust policy
  • The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
  • The service had enough staff with the right qualifications, skills, training, and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
  • Staff gave patients enough food and drink to meet their needs and improve their health. The service adjusted for patients’ religious, cultural, and other preferences.
  • The service monitored the effectiveness of care and treatment and used the findings to improve them.
  • Generally, the service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
  • Staff in different teams worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • The service took account of patients’ individual needs.
  • The service had managers at all levels with the right skills and abilities to run a service working to provide high-quality sustainable care.
  • The service used a systematic approach to continually improve the quality of its services and safeguarding high standards of care by aiming to create an environment in which excellence in clinical care would flourish.
  • The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
  • The trust was committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation.

However, we also found:

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had basic training on how to recognise and report abuse and they knew how to apply it. Some medical staff had not completed the appropriate level of safeguarding training required by the trust and some nursing staff had not received the required level of safeguarding recommended by national guidance.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act (MCA) 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care. However, not all staff received specific training in MCA or Deprivation of Liberty Standards (DoLS).
  • People could not always access the service when they needed it. Waiting times for treatment were not in line with good practice. There were still large numbers of patients waiting to be seen in the outpatient department.
  • The service sometimes collected, analysed, managed and used information to support its activities, using secure electronic systems with security safeguards. However, some patient notes and referrals had gone missing or not been available for clinic appointments.