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Inspection Summary


Overall summary & rating

Good

Updated 14 February 2020

We rated effective caring, responsive and well led as good and safe as requires improvement.

Inspection areas

Safe

Good

Updated 14 February 2020

Effective

Good

Updated 14 February 2020

Caring

Good

Updated 14 February 2020

Responsive

Good

Updated 14 February 2020

Well-led

Good

Updated 14 February 2020

Checks on specific services

Medical care (including older people’s care)

Good

Updated 14 February 2020


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

  • Staff had training in key skills, understood how to protect patients from abuse, and managed safety 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 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,

  • The service did not always have enough staff to care for patients and keep them safe. There were occasions when the service did not control infection risk well. There were environment and equipment issues which presented potential risks to patient care. Patient risk assessments were not always carried out by staff and care records were not always secure. Medicines management was not consistently safe.
  • Outcomes for patients were not always good.
  • Not all services had a vision for what they wanted to achieve.

Services for children & young people

Good

Updated 14 February 2020

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

  • The service provided mandatory training in key skills to all staff and made sure everyone completed it.
  • Staff understood how to protect children and young people from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.
  • The service-controlled infection risk well. Staff used equipment and control measures to protect children, young people, themselves and others from infection. They kept equipment and the premises visibly clean.
  • The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave children, young people and their families honest information and suitable support.
  • The service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance. Staff protected the rights of children and young people subject to the Mental Health Act 1983.
  • Staff gave children and young people enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for children and young people’s religious, cultural and other needs.
  • Staff assessed and monitored children and young people regularly to see if they were in pain and gave pain relief in a timely way. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain.
  • Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for children and young people.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and provided support and development.
  • Doctors, nurses and other healthcare professionals worked together as a team to benefit children and young people. They supported each other to provide good care.
  • Staff treated children, young people and their families with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
  • Staff provided emotional support to children, young people, families and carers to minimise their distress.
  • Staff supported and involved children, young people and their families to understand their condition and make decisions about their care and treatment. They ensured a family centred approach.
  • The service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care.
  • Leaders had the integrity, skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for children, young people and staff. They supported staff to develop their skills and take on more senior roles.
  • Staff felt respected, supported and valued. They were focused on the needs of children, young people s receiving care. The service provided opportunities for career development. The service had an open culture where children, young people, their families and staff could raise concerns without fear.
  • Leaders overall operated effective governance processes, throughout the service and with partner organisations. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service.
  • Leaders and staff actively and openly engaged with children and young people, staff, equality groups, the public and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for children and young people and their families.
  • All staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them. Leaders encouraged innovation and participation in research.

However,

  • Staff did not always complete and update risk assessments for each child or young person to remove or minimise risks.
  • Staff did not always follow their own policy to identify children or young people at risk of malnutrition.
  • The service did not always meet nurse staffing standards on the neonatal unit. Managers regularly reviewed and adjusted staffing levels and skill mix.
  • Staff did not always keep accurate records of children and young peoples’ care and treatment.
  • Leaders were not required to routinely participate in audits relating to mental health and emotional wellbeing.
  • The electronic board behind the nurses’ station on the children’s’ ward displayed the names and ages of children and young people.
  • There was a low response rate for the Friends and Family Test on the neonatal unit.
  • Some of the equipment in the sensory room was not working.
  • Leaders and teams used systems to manage performance. However, they did not always identify relevant risks in relation to children and young people to reduce their impact.
  • We identified areas where oversight could be improved such as maintaining accurate and complete records. Gaps and errors in recording fell into areas such as observational charts, pain scores, the recording of children and young people’s height
  • There was no recent audit on how many children presenting at the paediatric assessment unit received an initial triage within 15 minutes although the 2017 audit showed poor compliance.

Critical care

Good

Updated 14 February 2020

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

  • The service had enough medical and nursing 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 always treated patients with compassion and kindness. They truly respected patients’ privacy and dignity, and valued patients as individuals. There was a strong and visible patient-centred culture. Patients and relatives valued their relationships with the staff team and felt that staff often went ‘the extra mile’ for them when providing care and support. Staff helped patients understand their conditions and empowered patients and those close to them to have a voice, ensuring they were active partners when making decisions about their care and treatment. Staff always 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 supported staff to develop their skills. Staff were clear about their roles and accountabilities and were focused on the needs of patients receiving care. The service engaged well with patients and the community to plan and manage services and staff were committed to improving services continually.

However;

  • Governance systems were not always effective and leaders did not always have access to reliable information. Opportunities for leaders to meet, discuss and learn from the performance of the service had been limited. The service vision was not formally documented and the strategy to turn the vision into action was in development at the time of our inspection. Staff satisfaction was mixed and some staff felt unvalued and unappreciated.
  • The service was not fully compliant with the guidelines for the provision of intensive care services 2019. They did not have enough allied health professionals to care for patients and keep them safe at all times.

End of life care

Good

Updated 13 December 2016

Out of the 94 incidents reported to the palliative team, we saw eight were in relation to low staffing levels. We noted some resulted in palliative patients not being attended to or observed as often as they required and “Care was compromised”. Staff on surgical wards told us they would struggle to ensure end of life patients received the care that they needed. However, they told us that the palliative team were aware of their pressures and were very supportive.

The palliative team were not solely responsible for end of life patients but they supported the medical and nursing teams in providing specialist advice.

We reviewed 20 medication administration records across the wards and units inspected and found these were consistently well completed. Although improvement was needed to ensure that controlled medicines were safely and appropriately administered.

We reviewed medical and nursing paper care records and Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) records and saw these were well completed.

The palliative team worked across both New Cross Hospital and Cannock Chase Hospital so we found similarities across both sites. On both sites we found staff were well engaged with education and training programs around end of life care and it has taken a priority to ensure the care of patients and families is enhanced.

The palliative care team had introduced a staff survey, the results identified how approachable, supportive and informative members of the team were.

The palliative team were in the process of implementing the Swan Project at both hospital sites as a care planning tool and guidance for patients in the last few days of life. Staff adopted practices of the Salford Royal NHS Foundation Trust such as: the Swan logo being placed on the curtains or the door of the side room to alert staff to be mindful, relatives were given canvas bags with the Swan logo with their relative’s belongings as oppose to a plastic bag, staff offered families of end of life patients keepsakes such as photographs (of hands) and handprints, locks of hair (taken discreetly from behind the ear and presented in an organza bag not as previously in a brown envelope) , staff returned jewellery in a small box, they were given the choice of the deceased being clothed in their own clothes rather than a disposable paper shroud and the hospital renamed the mortuary the Swan Suite for discrete communication in public areas. Literature on both hospital sites had been updated and rebranded such as: the advanced care plan, the ‘practical information leaflet’ and the feedback survey was redesigned to have the Swan logo.

The rationale for the Swan logo was to trigger a compassionate response and kind communication. All staff at New Cross Hospital and Cannock Chase Hospital were aware of the project and had recently started the project for the past few patients. During the inspection we found the scheme to be in its infancy stages although all staff were fully aware of the project, what to do and how to implement it should they be caring for a dying patient.

We noted there was easy access to the palliative care team and they were responsive in supporting ward staff.

On both hospital sites the staff developed a ‘Rapid Home to Die Care Bundle’ which facilitated a rapid discharge. Staff told us they had used this bundle several times and were able to discharge a patient with a complex package of care within 24 hours.

For both hospital sites the palliative team had a clear vision for their service. The leadership, governance and culture promoted the delivery of high quality person centred care. The team displayed good engagement and attendance at national/international conferences and the West Midlands expert advisory group for palliative care.

The palliative team felt the trust were engaged with topics around end of life care and were supportive in their efforts to improve the service. They told us the board staff members were visible and were engaged in best practice.

We saw the culture was a positive energetic one.

Surgery

Good

Updated 27 June 2018

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

  • Staff were aware of how to report incidents; learning from trust wide incidents was shared via meetings and updates. Following never events that had occurred within the surgery directorate, actions had been put into place to prevent reoccurrence Staff were aware of the never events and spoke about changes made following these.
  • Staff understood how to protect patients from abuse. Staff were aware of safeguarding adults and children arrangements and provided examples of measures put into place to safeguard patients from harm.
  • In the main, infection prevention and control was to a good standard. Staff wore appropriate personal protective equipment and patient areas were visibly clean. However, we did notice on a small number of occasions, staff who did not wash or gel their hands upon entering ward areas.
  • Audit results showing patient outcomes were varied. Many measures showed the trust were in line with the England average for outcomes following specific surgery; however, the trust were worse than the England average in some standards.
  • Staff followed best practice and followed National Institute of Health Care Excellence (NICE) guidelines. Guidelines, policies and standards were available for staff to refer to when providing patient care and treatment.
  • Staff worked together well as a multidisciplinary team; referrals were made to appropriate professionals who ensured they shared relevant information within patient records and during ward rounds.
  • Staff treated patients with dignity and respect. Patients were cared for with compassion. Staff made effort to ensure patients were emotionally supported and kept informed of their treatment and care.
  • Patients individual needs were responded to; staff were aware of how to support patients with additional needs such as sourcing interpreters, and liaising with specialist teams within the trust.
  • The number of cancelled operations had reduced since 2016. During this time, all cancelled patients were re-booked within 28 days as per national standards.
  • During the inspection, we saw a positive culture of teamwork and support that mirrored the trust’s vision and values. Local leadership enabled shared learning and development; and encouraged an open approach to reporting incidents.
  • The surgical directorate were involved in a range of research and innovative projects with the aim of improving patient outcomes.

However, we saw areas in which the service needed to improve:

  • We noted some specific areas where the theatre department did not meet infection prevention and control standards. For example, we saw damage to the walls and floors and cleaning logs were not consistently completed.
  • Although the World Health Organisation (WHO) safer surgery checklist was generally completed to a good standard, we saw one occasion whereby one part (‘sign out’) was not completed. Auditing of the safer surgery checklist showed deterioration in compliance.
  • Mandatory training compliance, particularly for medical staff, did not meet trust targets for several modules. However, the target for compliance was set high at 95% and compliance levels were high in most subjects.
  • The risk of readmission following surgical procedures at New Cross Hospital was higher than the national average for elective admissions.
  • We saw on one occasion; an assessment of a patient’s capacity to consent to treatment had not been accurately assessed.
  • From December 2016 to November 2017 the trust’s referral to treatment time (RTT) for admitted pathways for surgery was consistently worse than the England average.

We observed some patient identifiable information was unsecured within ward areas.

Urgent and emergency services

Good

Updated 14 February 2020

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

  • The service had enough staff to care for patients and keep them safe. Nursing staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff mostly assessed risks to patients, acted on them. They managed medicines well. The service managed safety incidents well and learned lessons from them.
  • 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,

  • Not all patient records contained information to keep patients safe. This was a breach of the Health and Social Care Act: Regulation 12.
  • Staff did not document how they decided that a patient may lack capacity to consent to care or treatment; or document what assessment process had taken place. This was a breach of the Health and Social Care Act: Regulation 11.
  • It was not always immediately clear when medical staff had prescribed medicines on discharge.
  • Not all medical staff had training on how to recognise and report abuse. Not all documentation pertaining to safeguarding children and young people was completed.
  • We found that falls assessments were not specifically completed on arrival to ED, despite this being identified as an area of concern for the trust.

Outpatients

Good

Updated 14 February 2020

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

  • 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. 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 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

  • Some of the areas that had previously been identified as underperforming for referral to treatment times at our last inspection continued to do so at this inspection.
  • In the main outpatient department information on how to make a complaint was not clearly displayed.
  • The service did not have information leaflets available in languages other than English.

Diagnostic imaging

Good

Updated 27 June 2018

  • Safeguarding policies and procedures were in place. There was good compliance with safeguarding training and staff knew how and when to make a safeguarding referral.
  • Processes were in place to ensure patients received the correct scans. Staff followed “The Ionising Radiation (Medical Exposure) Regulations 2017”.
  • All areas were visibly clean. There were hand gel dispensers in place, staff wore personal protective equipment and were arms bare below the elbow.
  • Equipment was serviced in line with recommendations. Handover sheets were completed when equipment was out of action; staff had a good understanding of reporting faults.
  • Risk assessments were in place and contained relevant information. There was signage and information to advise patients and staff where radiation exposure took place. There were radiation protection advisors in post.
  • Processes were in place for women who were pregnant; the processes ensured that staff were aware.
  • Staff understood their responsibilities to raise incidents. There was evidence of a learning culture in relation to incidents; incidents were discussed in meetings and managers provided feedback to staff.
  • Root Cause Analysis investigations were completed when an incident met the threshold.
  • There were processes in place for the safe disposal of radiopharmaceuticals. Radiopharmaceuticals were kept secure. Staff monitored fridge temperatures.
  • The department audited conformity with “The National Institute for Health and Care Excellence” (NICE) guidelines, 2017. Local audits also took place such as hand hygiene and audits of radiology checklists.
  • Clinical support workers were multi skilled, rotating to other areas of the department as required.
  • Staff had opportunities to complete training and updates. Continuing professional development sessions were held in lunch hours. We heard of several examples of career progression.
  • There were systems in place for GPs to make a referral to the service electronically.
  • Staff gained patients consent before any procedure was completed. Consent was audited on a trust wide basis.
  • Staff had an awareness of the Mental Capacity Act 2005. Staff had a fob which contained information on DoLS.
  • Staff were caring, polite and considerate to patients. We saw that they protected patients’ confidentiality and treated them with dignity and respect.
  • Staff provided us with several examples of how they reassured patients who were anxious about having a diagnostic test.
  • Most facilities were suitable for use by bariatric patients.
  • A porter service was available to transport patients to and from ward areas. Additional porters were in place at busy times.
  • Staff understood and respected patient’s personal, cultural, social and religious needs. The hospital had an interpretation service.
  • An external company had been brought in to help reduce some of the backlogs; this had been successful.
  • The department investigated complaints quicker than in the trust policy. Patients received updates on their complaints and apologies. Complaints were discussed in staff meetings and staff could give examples of how practice had changed due to a complaint.
  • Leaders were knowledgeable. Staff felt informed and supported by their leaders, they felt that leaders were visible and approachable.
  • Leaders could identify challenges and plans were in place when challenges were identified.
  • There was a five-year plan in place to address how the department would achieve its priorities in 2015-2020.
  • There was a clear governance structure in place. Staff knew what they were accountable for.
  • The department had a risk register, risks were discussed at monthly clinical governance meetings; the meetings were well attended by key staff.

However

  • Not all staff were trained to level 3 in safeguarding children. Staff told us that when a child was due for a procedure a level 3 trained person is in attendance. However, in an emergency or out of hours we not assured that suitably trained staff would be available.
  • At the time of the inspection, the department had not signed up to the Imaging Service Accreditation Service (ISAS).
  • Mandatory training compliance rates for medical staff were low.
  • Handwashing amongst staff appeared inconsistent.
  • A dirty utility area was being used to store clean items such as sharps bins and cardboard patient bowls due to lack of storage.
  • Some consumable items had expired and this had not been recognised by staff.
  • Some policies and procedures needed to be updated.
  • There was a high number of radiographer vacancies within the department; however, the department were actively recruiting.
  • There was nothing specific in place to support patients with dementia or a learning disability and staff often relied on information provided by the referrer.
  • There were no processes or pathways for urgent referrals. Staff would mostly use their discretion or common sense.

Maternity

Good

Updated 27 June 2018

  • The service maintained good standards of cleanliness and hygiene. We observed all areas were visibly clean and clutter free and staff followed regular cleaning schedules.
  • There was a good hand washing culture in the department; hand cleansing gels were readily available and were regularly used by staff and visitors.
  • The service had an electronic incident reporting system. Staff received feedback from incidents they had reported and lessons had been learned.
  • Staff at all levels demonstrated a thorough understanding of the Duty of Candour. The Duty of Candour regulation requires health service bodies to act in an open and transparent manner when things go wrong.
  • Staff at all levels were knowledgeable about how to recognise abuse in children and adults and understood how to escalate concerns.
  • The service treated patients in accordance with National Institute for Health and Care Excellence (NICE) quality standards and guidelines for maternity services.
  • Staff had the necessary qualifications and experience to conduct their role effectively.
  • New staff were well supported by more senior colleagues.
  • We observed close multidisciplinary (MDT) relationships between all staff groups in the maternity department.
  • Trained staff supported patients and their families to cope emotionally with their care and treatment. Feedback from patients, those close to them and stakeholders was consistently positive about the level of tailored support staff provided.
  • Staff ensured patients and partners were actively involved in decisions about their care and treatment.
  • There was a well-embedded culture in maternity services to put patient care at the centre of everything staff did.
  • Staff were considerate regarding the individual needs of patients and provided support to minimise the distress of patients and those close to them.
  • Bereavement midwives provided patients with specialist support during and after a pregnancy loss or neonatal death in hospital and following discharge home.
  • Staff were highly motivated to offer patients the best possible compassionate and emotional care and showed determination to achieve this.
  • Staff were responsive to the individual needs of patients. Translation services were readily available for patients whose first language was not English.
  • A range of specialist support was available to patients with complex needs. For example, bereavement midwives and vulnerable women midwives, which included responsibility for providing teenage pregnancies.
  • The service also provided dedicated clinics for long-term conditions such as diabetes.
  • The maternity service held a Supportive Training Offering Reassurance and Knowledge (STORK) programme, which taught parents basic life support, choking management, Sudden Infant Death advice in addition to breastfeeding, diet and smoking cessation.
  • Maternity services had not received high levels of complaints from people using their services. The service took complaints seriously.
  • Staff understood and felt engaged with the strategy for the maternity unit. Leaders of the took into account the maternity challenges the Black Country was currently experiencing.
  • The maternity service was well represented at the trust board. The board had oversight of the challenges the department faced.
  • The department was working collaboratively with maternity units and commissioners in the Black County region to develop and implement a local vision for improved maternity services and outcomes.
  • The maternity service’s risk register included the main risks to the service.
  • The service continued to strengthen involvement of the local community by engaging with patients and families as part of the Maternity Voices partnership.
  • The trust set a high target for mandatory training of 95% and although this was not met on all occasions, in maternity services, 88% or more was achieved in all training modules, with some attaining 100%.

However:

  • As at November 2018, the midwife to birth ratio was lower than the England average. However, a recent staffing acuity assessment had been conducted to review staffing establishment requirements. The service demonstrated all patients received one-to-one care when in labour.
  • Between September 2016 to August 2017, maternity staff had not met the trust target of 95% for either Mental Capacity Act (MCA) training or Deprivation of Liberty Safeguards (DoLS) training. However, the service had addressed this and as of February 2018, staff training compliance was above the trust target at 95.2%.
  • Medical staff were not trained to level 3 in children’s safeguarding. We found several examples where junior doctors had not completed the training and data provided indicated an overall compliance for level 3 safeguarding was at 0%. Following the inspection, the trust provided information assuring us they were taking urgent action to address this.
  • In the 2017 Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE) audit, the maternity departments stabilised and risk-adjusted extended perinatal mortality rate (per 1,000 births) at 7.11 was worse than their comparator group rate at 6.44.