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University Hospital Requires improvement

The rating for ‘Outpatients and diagnostic imaging’ shown on this page does not reflect our latest judgement of services at University Hospital. We now inspect Outpatients and diagnostic imaging services separately.

At our latest inspection, in August 2018, we rated the Outpatients and diagnostic imaging separately as good.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 31 August 2018

We inspected eight core services and two additional services (neurosurgery and diagnostic imaging) at this hospital. Whilst we rate additional services, we do not include them in the overall aggregation of ratings for a hospital, or at trust level.

Our rating of core services stayed the same. We rated the hospital as requires improvement overall because:

  • Our rating for safe stayed as required improvement. Urgent and emergency care and maternity were rated as requires improvement. Medical care, surgery, critical care, services for children and young people, end life care and outpatients were all rated as good, showing improvements from the last inspection overall.
  • Our rating for effective improved to good overall. Critical care was rated as requires improvement. Urgent and emergency care, medical care, surgery, maternity, children and young people and end of life care were all rated as good, showing improvements from the last inspection overall. We inspect but do not rate effective for outpatients.
  • Our rating for caring stayed as good. All services were rated as good, apart from end of life care, which was rated as outstanding.
  • Our rating for responsive stayed as required improvement. Urgent and emergency care, surgery and outpatients were rated as requires improvement. Medical care, critical care, maternity, children and young people and end of life care were all rated as good, showing improvements from the last inspection overall.
  • Our rating for well led improved and was rated as good. Urgent and emergency care, medical care, surgery, maternity, children and young people, end of life care and outpatients were rated as good showing improvements from the last inspection overall. Critical care was rated as requires improvement.

Our ratings of the additional services were:

  • Overall, neurosurgery was rated as requires improvement. Safe, effective, responsive and well led were rated as requires improvement. Caring was rated as good.
  • Overall, diagnostic imaging was rated as good. Safe, caring, responsive and well led were rated as good. We inspect but do not rate effective for this service.
Inspection areas

Safe

Requires improvement

Updated 31 August 2018

Effective

Good

Updated 31 August 2018

Caring

Good

Updated 31 August 2018

Responsive

Requires improvement

Updated 31 August 2018

Well-led

Good

Updated 31 August 2018

Checks on specific services

Critical care

Requires improvement

Updated 31 August 2018

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

  • Records in CTCC were of a mixed quality, some were illegible and medical notes were out of sequence and upside down. This made it difficult to see at a glance a coherent plan of care.
  • Multidisciplinary working was not always fully effective. We did not see a dietetic, microbiologist or speech and language therapists (SALT) at MDTs; nor did these services work seven days a week. We also observed MDT meetings in CTCC and found they did not always have daily input from SALT and dietetics.
  • There was a delay in reporting to ICNARC which meant that a similar benchmarking comparison with other critical care units and the effectiveness of care provided could not be made for cardiothoracic critical care. This meant that assurance could not be made that the unit performed favourably with other critical care units. This had not improved since our last inspection three years ago.
  • Staff we spoke with said that the two units did not currently function as one and that there was the risk of staff leaving if rotation was mandated. In critical care staff spoke of conflict between the intensivist consultants and cardiothoracic consultants. Staff we spoke with said that nursing staff had to intervene in disagreements and calm situation. This had not improved since our last inspection three years ago.

However:

  • There was a dedicated training and development team in place. Arrangements were in place to provide annual mandatory training to all members of staff. Staff we spoke with understood how to protect patients from abuse. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • Staff used care bundles to ensure the delivery of the minimum standard of care and staff had dietetic support to support patients effectively. Staff were trained to assess a patient’s experience of pain, which was a crucial component in providing effective pain management. Staff were suitably skilled, qualified, and knowledgeable to work safely and effectively with the patient group. All staff had a trust-wide and local induction programme. All staff received a trust wide and local induction, the local induction being in the form of boot camps ran by MDT staff.
  • We saw a person-centred approach with specific needs of the individual kept in mind. Staff understood the impact of the critical care environment on patients and relatives, and delivered emotional support and care in often changing conditions. Relatives and patients, we spoke with said that they had received good information about their care and treatment and had been involved in decisions about their care.
  • The service was well-staffed for the acuity of patients and level of activity. Staff had been apportioned into teams to sit within designated areas with a supernumerary co-ordinator overseeing that area. Patients and visitors’ individual needs were considered throughout the service. The service worked with external parties to access the best support and advice for both patients and staff.
  • Critical care services were consultant led and supported well by dedicated matrons. The senior team were well established and staff told us they were approachable and accessible. There was evidence of professional management development and routes to clinical progression within critical care. Local managers promoted a positive culture that supported and valued nursing staff. Staff told us that there was considerable commitment and passion in the teams. All staff we spoke with said they felt proud to work for the service and that the individual team working was excellent. Staff were self-motivated, supported and encouraged to make improvements and changes to the service.

Outpatients and diagnostic imaging

Requires improvement

Updated 12 January 2017

Overall, we rated the outpatient and diagnostic imaging service as requires improvement because:

  • Staff were aware of their responsibilities and understood the need to raise concerns and report incidents. However, we did find that in some areas incidents were not always reported in line with trust policy.
  • Learning and feedback from incidents was inconsistent. The action taken as a result of some incidents did not always address the cause of the incident.
  • Governance systems were in place to monitor and assess risk, but these were not always accurately recorded.
  • In ophthalmology there were medicines that were not securely stored.
  • Systems in place to prevent and protect people from a healthcare associated infection were not always followed.
  • There was inconsistent handover of inpatients when they arrived and waited for their radiology investigation or procedure.
  • Patients were not always kept informed about how long they were expected to wait to be seen in clinic. Some patients arriving for their appointments waited a considerable time to be seen. In ophthalmology patients left the clinic without being seen due to the long waits.
  • We identified areas in radiology where there was insufficient action taken to maintain patient privacy and dignity.

However, we also found that:

  • Patients were treated with compassion, kindness, dignity and respect.
  • Patients we spoke with felt well informed about their care and treatment.
  • The trust was generally meeting referral to treatment times.
  • There were facilities to meet the needs of patients with complex conditions.
  • Staff described when the duty of candour applied and demonstrated an understanding of when it should be implemented.
  • Arrangements were in place to safeguard adults and children from abuse.
  • Staffing levels and skill mix were planned and reviewed so that patients received safe care and treatment. Where there had been staff shortages, we saw no evidence of patients coming directly to harm.
  • There was a systematic programme of clinical and internal audit.
  • Staff were encouraged to suggest improvements.
  • Most staff felt that managers were visible, supportive and approachable.
  • Staff were proud to work at the hospital and passionate about the care they provided.

Urgent and emergency services

Requires improvement

Updated 31 August 2018

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

  • The service provided mandatory training in key skills but not everyone completed it. Staff told us that high levels of clinical demand meant that staff could not always be spared to attend training.
  • There had been recent improvements in risk management of adult patients but we could not be sure that they were fully embedded. Risk assessments for children were inconsistent with delays for initial assessment and no system for identifying clinical deterioration. Once we raised this with the trust, immediate action was taken.
  • The service did always not have enough nursing staff, with the right mix of qualification and skills, to keep patients safe and provide the right care and treatment. Records showed that not all shifts were filled and there was a high reliance on temporary staff. Patients’ needs were met at the time of inspection.
  • Staff in the children’s ED did not assess and monitor patients regularly to see if they were in pain. They did not support those unable to communicate using suitable assessment tools.

  • The service took account of patients’ individual needs but was not always able to meet them. The observation ward did not provide the therapeutic environment required by patients with serious mental health problems.
  • People could not access the service when they needed it. Patients waiting for admission to a ward spent longer in the emergency department than in most other hospitals in England.
  • There was no clear management oversight of the children’s ED.
  • The department had a vision for what it wanted to achieve and initial plans to turn it into action developed with involvement from staff and patients. However, means of achieving it lacked detail and there was no reference to the emergency needs of children.

However:

  • 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.
  • Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care.
  • The service followed best practice when prescribing, giving, recording and storing medicines. Patients received the right medication at the right dose at the right time.
  • 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.
  • The trust planned and provided services in a way that met the needs of local people.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.
  • Managers at all levels in the emergency department had the right skills and abilities to run a service providing high-quality sustainable care.
  • There were effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
  • The department engaged well with patients, staff and the public to plan and manage appropriate services, and collaborated with most partner organisations effectively.

Maternity

Good

Updated 31 August 2018

We previously inspected the maternity department at University Hospital jointly with gynaecology. Therefore, we cannot compare our new ratings for this inspection of maternity services directly with the previous ratings.

We rated this service as good overall because:

  • The service had suitable premises and equipment and looked after them well. The labour ward was located close to the obstetric theatres and neonatal unit in the event of patients requiring transfer.
  • The service managed patient safety incidents well. Staff recognised incidents and knew how to report them. Managers investigated incidents quickly and shared lessons learned and changes in practice with staff. When things went wrong, staff apologised, provided patients with honest information, and gave them suitable support.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, midwives and other healthcare professionals supported each other to provide good care. Staff respected their colleagues’ opinions and staff at all levels could contribute to the discussion and were prepared to challenge each other.
  • Staff assessed and managed women’s pain effectively and regularly. Patients had medicated pain relief methods available such as epidurals and natural pain relief options such as labouring in water such as birthing pools.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff provided appropriate information and timely emotional support to patients to minimise their distress. Bereavement midwives provided patients and those close to them with specialist bereavement support during and following a pregnancy loss or neonatal death for as long as they needed it.
  • Staff involved patients and those close to them in decisions about their care and treatment. Feedback from patients and those close to them was consistently positive about the level of tailored support staff provided.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff. Staff aimed to alleviate patient concerns before they became formal complaints. However, they were not always responded to in a timely way.
  • The trust had a clear 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 recently recruited Head of Midwifery (HoM) already had a well-defined vision and strategy for the service.
  • The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively. Maternity staff recognised colleagues’ contribution for going the extra mile in their roles. The service was involved in the trust’s employee of the month award and appreciation cards scheme.
  • The trust was committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation. The service had opened a Tommy's National Centre for Miscarriage Research in April 2016. This was the first world-class research centre to be opened dedicated to researching the causes of early miscarriage.

However:

  • The service did not always have 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 midwife to birth ratio was not in line with national recommendations. Even using bank staff did not mean they had enough staff on each shift with the right skills and experience. Patients’ needs were being met at the time of the inspection.
  • Managers did not ensure all staff had completed their mandatory training and skills drills training. Staff training compliance for the Neonatal Life Support (NLS) Update was below the trust target of 95% at 82%.
  • The service had systems in place to ensure the safety of patients; however, they were not always followed. Cardiotocography (CTG) monitoring was not always carried out in line with trust procedures.
  • The service did not collect information to provide assurance that they could improve care in response to data collated. For example, the service did not record delays in patients receiving some pain relief.
  • Some staff morale was low. A number of staff told us they were “burnt out and tired” due to the staffing shortages the department was experiencing.
  • People could access the service when they needed it. However, patients told us it could take a number of hours to complete their antenatal appointments. The trust could not provide us with accurate bed occupancy levels and were therefore not assured they had full oversight of their bed occupancy levels.

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.

Maternity and gynaecology

Good

Updated 6 August 2015

Overall, we found the service to be good, but with the ‘safe’ domain requiring improvement. Ward storage of medication, handling of medication by community midwives, checking of resuscitation equipment on the labour ward, and elements of infection control and prevention practice were found to be in need of improvement.

Women we spoke with were mostly happy with the care they had received, and we heard staff offering compassionate care and clear explanations. Ward staff told us they felt well informed about the trust, and that they regularly met and spoke with senior management. Community staff had recently been based at the hospital to improve their integration with hospital staff and management.

Medical care (including older people’s care)

Good

Updated 31 August 2018

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

  • There had been progress made to the majority of areas noted for improvement found during our previous inspection. Infection prevention and control practices had improved. Leadership had been strengthened, middle management were more visible and this had a positive impact on staff morale and culture.
  • The service shared lessons learned from reported incidents and complaints. There had been a decrease in the number of serious incidents that had been reported and there was effective use of daily safety huddles meetings to communicate with teams.
  • Patient outcomes were monitored and different specialty teams worked together to ensure action was taken to improve outcomes for patients.
  • Patient’s individual needs were met and there was an excellent holistic approach to caring for people living with dementia.

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.

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.

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’.

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.

Neurosurgery

Requires improvement

Updated 31 August 2018

We rated it as requires improvement because:

  • Staff did not always keep appropriate records of patients’ care and treatment and record were not stored securely.
  • Not all eligible staff had completed mandatory training.
  • Eligible medical staff in neurosurgery had not met the 95% target met for any of the three safeguarding modules.
  • The service did not have an interventional radiologist. This meant patients were at risk of coming to avoidable harm because their urgent health needs were not addressed in a timely manner.
  • The service did not have a dedicated emergency theatre. We found that elective surgeries were cancelled to accommodate emergency cases. This increased the risk of harm to patients on the waiting list for surgery.
  • The service did not monitor the effectiveness of care and treatment and use the findings to improve them. They did not compare local results with those of other services to learn from them.
  • Consultants did not contribute to Spinal Outcome Registries. This meant there was a lack of reliable data on volume of patients, procedures undertaken and outcomes for this main patient group.
  • The pre-operative assessment room did not afford patients and significant others privacy and dignity.
  • People could not always access the service when they needed it. Waiting times from treatment and arrangements to admit, treat and discharge patients were not line with good practice.
  • From January to December 2017, University Hospital’s referral to treatment time (RTT) for admitted pathways for neurosurgery was consistently worse than the England average.
  • Theatre Utilisation was 65% at the time of our inspection and just under 19% of patients’ surgery was cancelled on the day.
  • We found consultant staff did not feel respected and valued.
  • Management and teams did not work collaboratively to resolve conflict quickly and constructively.
  • There was no clarity about the consultant’s roles and what they were personally accountable for. This meant there were no clear lines of responsibility.
  • There was no robust systematic programme of clinical and internal audit to monitor quality of consultant’s work.
  • The service did not use a systematic approach to continually improving the quality of its services and safeguarding high standards of care.
  • There was limited seven day working and limited access to support services.

However:

  • The service managed patient safety incidents well and when. When went wrong, staff apologised and gave patients honest information and suitable support.
  • The service used safety monitoring results well.The service used information to improve the service.

  • The service controlled infection risk well and had suitable premises and equipment.
  • The service prescribed, gave, recorded and stored medicines well.
  • Staff were trained in safeguarding and understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • The service had enough competent staff with the right qualifications, skills, training and experience to keep people safe.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness.
  • Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques and planned for patients’ religious, cultural and other preferences.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Staff always had access to up-to-date, accurate and comprehensive information on patients’ care and treatment.
  • Staff knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care, cared for all patients with compassion and kindness and provided emotional support to patients to minimise their distress.
  • The service planned and provided services in a way that met the needs of local people and took account of patients’ individual needs.
  • The service treated concerns and complaints seriously.
  • The service had systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
  • The service collected, analysed, managed and used information well to support some of its activities, using secure electronic systems with security safeguards.
  • 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 go well and when they go wrong, promoting training, research and innovation.