You are here

Hereford Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 3 November 2016

Wye Valley NHS Trust was established in April 2011 and provides hospital care and community services to a population of 186,000 people in Herefordshire and a population of more than 40,000 people in mid-Powys, Wales. The trust also provides a full range of district general hospital services to its local population, with some links to larger hospitals in Gloucestershire, Worcestershire and Birmingham. During this inspection we only inspected the services provided by Hereford Hospital. We did not inspect community services provided by the trust. Therefore, the overall rating for community services remains as requires improvement, as per the September 2015 inspection.

There are approximately 236 beds of which 208 are general and acute, 22 maternity and six critical care beds within Hereford Hospital. The trust employs 2,601 whole time equivalent staff as of June 2016.

We carried out this inspection as part of our comprehensive programme of re-visiting trusts which are in special measures. We undertook an announced inspection from 5 to 8 July 2016 and unannounced inspections on 11, 17 and 18 July 2016.

Overall, we rated Hereford Hospital as requires improvement with four of the five questions we ask, safe, effective, responsive and well led being judged as requiring improvement.

We rated caring as good. Patients were treated with kindness, dignity and respect and were provided the appropriate emotional support.

Our key findings were as follows:

Safe

  • There was a high vacancy rate which meant an increased use of agency and bank staff. The safer nurse staffing levels were planned in line with the national recommendations. The trust fill rate for registered nurses did not always meet the 95% target, ranging from 74.5% on Wye ward to 109.4% on Monnow ward for June 2016. The trust strategy was to cover unfilled registered nurse shifts with a health care assistant where appropriate, to help mitigate staffing level risk. For June 2016 the hospital health care assistant fill rate was 116% for day shifts and 122% for night shifts. We found actual staffing levels met planned staffing levels on most wards during our inspection. We found no incidents relating to staff shortages directly affecting patient care at ward level.
  • Mandatory and statutory training compliance for June 2016 was at 86% which although had improved from 78% in July 2015, did not meet the trust target of 90%.
  • Patients’ weight was not always recorded on patients’ prescription charts, which could potentially lead to the incorrect prescribing of the medicine.
  • In maternity, the anaesthetic room used as a second theatre on the delivery suite was not fit for purpose. This could lead to increased risk of infection for mother and baby. 

  • Staff were aware of their responsibilities regarding safeguarding procedures.
  • Staff understood the importance of reporting incidents and had awareness of the duty of candour process.
  • Staff understood their responsibility to report concerns and to record safety incidents and near misses. Staff received feedback on all incidents.
  • Ward and clinical areas were visibly clean and staff were observed following infection control procedures.
  • There were systems in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients.

Effective

  • The Summary Hospital-level Mortality Indicator (SHMI) and the Hospital Standardised Mortality Ratio (HSMR) indicated more patients were dying than would be expected. This had been reported to the trust board and an action plan was in place to understand and improve results.
  • The caesarean section rate was significantly higher (worse) than the national average and the deteriorating rate was not recorded on the risk register.
  • Most care was delivered in line with legislation, standards and evidence-based guidance. However, some trust guidelines needed updating.
  • The service had a series of care bundles in place, based on the appropriate guidance for the assessment and treatment of a series of medical conditions.
  • The trust had processes in place to monitor some patient outcomes and report findings through national and local audits and to the trust board. Performance in national audits had generally mixed results compared to the national average. Actions plans were in place to address areas needing improvement.
  • Staff were clear about their roles and responsibilities regarding the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

Caring

  • Staff were observed being polite and respectful during all contacts with patients and relatives. Staff protected patients’ privacy and dignity.
  • Patients felt involved in planning their care.

Responsive

  • The emergency department consistently failed to meet standards in terms of the amount of time patients spent in the department and waited for treatment.
  • Bed occupancy was consistently worse than the national average.
  • Patients were unable to access the majority of outpatient services in a timely way for initial assessments, diagnoses and/or treatment. The trust had put a system in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients on the waiting list.
  • The trust did not consistently meet all cancer targets for referral to treatment times.
  • Overall referral to treatment indicators within 18 weeks for admitted surgery patients was worse than the England average.
  • The percentage of patients that had cancelled operations was worse than the England average.
  • Delays in accessing beds in hospital were resulting in mixed sex occupancy breaches on the intensive care unit each month.
  • The trust did not have an electronic system in place to identify patients living with dementia or those that had a learning disability.
  • Staff adapted care and treatment to meet patient’s individual needs.
  • We saw examples of services planning and delivering care to meet the needs of patients.
  • Systems and processes were in place to provide advice to patients and relatives on how to make a complaint.

Well-led

  • The trust had governance oversight of incident reporting and management. Some local risks had not always been identified on risk registers.
  • Local leaders demonstrated good understanding of the risks, issues and priorities in human resource management. However, overcoming some of these issues, such as recruitment, remained a significant challenge.
  • The trust had a vision, their mission and their values. However, these were not fully embedded or understood by staff.
  • Following the trust being placed into special measures in October 2014, a comprehensive quality improvement plan was developed, which included a number of projects and actions at local level. We saw that the action plans were reviewed regularly, with monitoring of compliance against targets and details of completed actions.
  • There was a sense of pride amongst staff towards working in the hospital and they felt respected and valued.
  • The trust implemented a new structure in June 2016, with three service units reduced to two divisions, medical and surgical. Although staff felt the reconfiguration was positive and provided more support we were unable to assess the sustainability and effectiveness of the restructure as this had not yet been embedded into the trust.

We saw several areas of outstanding practice including:

  • Services for children and young people were supported by two play workers (one was on maternity leave at the time of inspection). The play workers regularly made arrangements for long term patients to have days out to different places, including soft play areas or bowling. An activity was arranged most months and the play workers sourced the activities from local businesses who donated their good and/ or services. This meant that patients with long term conditions could meet peers who also regularly visited the hospital. Patients found this valuable and liked the opportunity to meet patients who had shared experiences.
  • There was a children’s and young people’s ambassador group which was made up of patients who used or had used the service. We spoke with some members of the ambassador group who told us that they were involved in the service redesign when developments took place and improving the service for other patients.
  • The respiratory consultant lead for NIV had developed a pathway bundle, which was used for all patients requiring ventilator support. The pathway development was based on a five-year audit of all patients using the service and the identification that increased hospital admissions increased patient mortality. The information gathered directed the service to provide an increased level of care within the patient’s own home. Patients were provided with pre-set ventilators and were monitored remotely. Information was downloaded daily and information and advice feedback to patients by the medical team. This allowed treatments to be altered according to clinical needs. The development had achieved first prize in the trust quality improvement project 2016.
  • The newly introduced clinic for patients with epilepsy had enlisted the support of a patient with epilepsy; their views had helped the clinic develop so that the needs of patients were met.
  • Gilwern assessment unit was not identified as a dementia ward, however, this had been taken into consideration when planning the environment. The unit had been decorated with photographs of “old Hereford” which were used to help with patients reminiscing. Additional facilities included flooring that was sprung to reduced sound and risk of harm if patients fell, colour coded bays and wide corridors to allow assisted mobility. Memory boxes were available for relatives to place personal items and memory aids for patients with a history of dementia, and fiddle mittens provided as patient activities. The unit provided regular activities for patients, which included monthly tea parties and games.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • The trust must ensure that all staff receive safeguarding children training in line with national guidance, in particular in the emergency department.
  • The trust must ensure that enough staff are trained to perform middle cerebral arterial Doppler assessments, to ensure patient receive timely safe care and treatment.
  • The trust must ensure there are enough sharps bins available for safe and prompt disposal of used sharps.
  • The trust must ensure that patients’ weight is always recorded on patients’ prescription charts, to ensure the correct prescribing of the medicine.
  • The trust must ensure that medicine records clearly state the route a patient has received medicine, in particular, whether a patient has been given the paracetamol orally or intravenously.
  • The trust must ensure all medicines are stored in accordance with trust polices and national guidance, particularly in outpatients.
  • The trust must ensure that all patients receive effective management of pain and there are enough medicines on wards to do this.
  • The trust must ensure all staff have received their required mandatory training to ensure they are competent to fulfil their role.
  • The trust must ensure all staff are supported effectively via appropriate clinical and operational staff supervisions systems.
  • The trust must ensure staff receive appraisals which meet the trust target.
  • The trust must ensure that patients are able to access surgery, gynaecology and outpatient services in a timely way for initial assessments, diagnoses and/or treatment, with the aim of meeting trust and national targets.
  • The trust must continue to take action to address patient waiting times, and assess and monitor the risk to patients on the waiting list.
  • The trust must ensure the time taken to assess and triage patients within the emergency department are always recorded accurately.
  • The trust must ensure effective and timely governance oversight of incident reporting and management, particularly in children and young people’s services.
  • The trust must ensure all policies and procedures are up to date, and evidence based, including the major incident policy.

The trust must ensure that all risks are identified on the risk register and appropriate mitigating actions taken.

In addition the trust should:

  • The trust should ensure all vacancies are recruited to.
  • The trust should continue to complete mortality reviews with the aim of reducing the overall Summary Hospital-level Mortality Indicator for the service.
  • The trust should ensure patient records are stored appropriately to protect confidential data.
  • The trust should ensure all patient records are fully completed, including stroke pathway documentation and communication detailing interactions and treatments provided within the care plan evaluation sheets.
  • The trust should ensure patients receive care and treatment in a timely way to enable the trust to consistently meet key national performance standards for emergency departments.
  • The trust should ensure delays in ambulance handover times are reduced to meet the national targets.
  • The trust should ensure initial patient treatment times are reduced to meet the national target for 95% of patients attending the emergency department to be admitted, discharged or transferred within four hours.
  • Ensure that each service has a local vision and strategy which is disseminated and understood by all staff so that it is embedded within the service.
  • The trust should ensure that systems and processes are in place to ensure cleanliness of equipment within the emergency department.
  • The trust should ensure that systems are in place to provide adequate nutrition and hydration to patients in the emergency department and clinical assessment unit.
  • The trust should ensure treatment bays in the emergency department resuscitation area protect patients’ privacy and dignity.
  • The trust should review staff safety and provision of an alarm call system in the rapid assessment area.
  • The trust should review its arrangements for transporting patients home if they need to travel on a stretcher, with emphasis on improving patient flow.
  • The trust should ensure that electronic discharge letters are completed in a timely manner to prevent delays in the preparation of patient’s medication to take home and delays in patient discharge.
  • The trust should ensure where possible, patients are placed in the most appropriate clinical area.
  • The trust should consider implementing a checklist for transferring patients between wards, to ensure transfer is appropriate and maintains patient safety.
  • The trust should consider implementing a risk assessment for the admission of medical patients to outlying wards, to ensure admission is appropriate and maintains patient safety.
  • The trust should ensure unnecessary patient moves are minimised at night.
  • The trust should continue to work with local stakeholders to improve the discharge pathway and facilitate timely patient discharge.
  • The trust should ensure mixed sex breaches are prevented.
  • The trust should consider employing a lead nurse for learning disabilities to support patients.
  • The trust should ensure that all staff are aware of the trust structure and who their managers are.
  • The trust should ensure that patents privacy and dignity is protected at all times, in particular during handover on Leadon ward.
  • The trust should ensure that there are action plans as a result of audits, to promote improvements.
  • The trust should ensure that cancelled operations are prevented; and if cancelling an operation is essential, patients are then treated within 28 days as per NHS England standard.
  • The trust should ensure staff are aware of the trust mission, vision, and strategic objectives.
  • The trust should consider a follow-up clinic for patients discharged home after an intensive care unit admission, as recommended in National Institute for Health and Care Excellence guidance.
  • The trust should ensure that flow is maintained throughout the hospital to ensure there is capacity to admit patients that required critical care services and discharge patient in a timely manner.
  • The trust should ensure there are systems and processes in place to keep patients safe, particularly in maternity services where, the anaesthetic room used as a second theatre on the delivery suite was not fit for purpose.
  • The trust should ensure there is clear oversight of outcomes and activity in maternity services.
  • The trust should ensure measures are in place to reduce the caesarean section rate.
  • The trust should ensure that meeting minutes clearly record recommendations and lessons learnt from incidents.
  • The trust should ensure that appropriate transition arrangements for children are clearly defined.
  • The trust should ensure there is an acuity tool to be used to determine patient dependency levels and staffing requirements in paediatrics.
  • The trust should ensure that there is oversight of the service arrangements for the mortuary team to ensure that staff training and supervision is in place.
  • The trust should ensure that effective information on the percentage of patients who were discharged to their preferred place within 24 hours is collected.
  • The trust should ensure that corridors where patients wait for their consultation and treatment in the Victoria Eye Unit do not pose a risk to patients with visual difficulties.
  • The trust should ensure there is signage on the doors to indicate if a compressed gas is stored in the room, in line with the Department of Health guidance (Medical gases. Health Technical Memorandum 02-01: Medical gas pipeline systems. Part B: Operational management, 2006).
  • The trust should ensure that complaints are responded to within the trust target of 25 days.
  • The trust should minimise the percentage of outpatient clinics cancelled.
  • The trust should ensure all equipment has safety and service checks in accordance with policy and manufacturer’ instructions and that the identified frequency is adhered to, particularly in outpatients, the emergency department and the intensive care unit.

The trust was placed into special measures in October 2014. Due to the improvements seen at this inspection, I have recommended to NHS Improvement that the special measures are lifted.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 3 November 2016

Effective

Requires improvement

Updated 3 November 2016

Caring

Good

Updated 3 November 2016

Responsive

Inadequate

Updated 3 November 2016

Well-led

Requires improvement

Updated 3 November 2016

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 3 November 2016

We rated maternity and gynaecology services as requires improvement overall. We rated maternity and gynaecology services as requires improvement for safe, effective, responsive and well-led. We rated the service as good for caring.

We found:

  • Systems and processes in maternity were not always reliable or appropriate to keep patients safe. The anaesthetic room used as a second theatre on the delivery suite was not fit for purpose. This could lead to increased risk of infection for mother and baby, and injury to staff from moving and handling within a small space. the trust had implemented mitigating actions to reduce the risk. However, the environment did not meet patient demand and could impact on patient care. 

  • The caesarean section rate for 2015/16 was 30.3% which was worse than the national average of 26.5%. The caesarean section rate had risen to 42.9% in April 2016. This was worse than the caesarean section rate in the two previous years. The deteriorating caesarean section rate was not recorded on the risk register.
  • The midwife-to-birth ratio was 1:30 (one midwife to 30 births).
  • 95% of women received one to one care in labour.
  • Root cause analysis demonstrated detailed investigations of incidents. Recommendations and lessons learnt were recorded within the documentation. However, we did not see evidence of these always being followed up.
  • There were gynaecology patients on surgical wards due to lack of gynaecology beds. This meant that gynaecology patients were not always cared for on the most appropriate ward.
  • 39 operations were cancelled on the day of surgery between March 2015 and April 2016, 18 of those were due to lack of beds.
  • Lack of medical staffing resources to deliver the gynaecology cancer pathway meant there was a number of women breaching referral to treatment times.
  • There was no dedicated bereavement room.
  • Compliance with mandatory training did not meet the trust target.
  • Two documents were used to monitor outcomes: the quality report obtained from the maternity information system and the dashboard. This meant there was no clear oversight of outcomes and activity.
  • Although staff we spoke with understand their role and responsibilities regarding the Mental Capacity Act 2005. The trust did not provide data to demonstrate that staff had the appropriate skills to care for patients under the Mental Capacity Act 2005 or Deprivation of Liberty Safeguards.

However, we also found:

  • Patients, partners and relatives felt involved in their care and were happy that they had received sufficient information to make informed decisions about their care.
  • Women’s privacy and dignity were protected.
  • Staff were aware of their roles and responsibilities in the management and escalation of incidents.
  • Staff were aware of their responsibilities regarding the duty of candour and we saw those involved in incidents were offered an apology.
  • Staff we spoke with demonstrated an understanding of the arrangements in place to safeguard adults and babies from abuse, harm and neglect and reflected up to date safeguarding legislation and local policy.
  • The gynaecology ward displayed quality data that demonstrated the ward had been free for pressure ulcers, falls and MRSA bacterium for over 1000 days.
  • The planned and actual staffing levels were displayed and met on the gynaecology ward.
  • All areas of the service were visibly clean and well maintained with display boards detailing cleanliness and safety information.
  • Equipment was maintained and was safe for use.
  • Staff had access to and used evidence-based guidelines to support the delivery of effective treatment and care.
  • Women we spoke with felt that their pain and analgesia administration had been well managed.
  • Staff had appropriate skills to manage patients care and treatment with systems in place to develop staff, monitor competence and support new staff.
  • Appraisal rates met the trust target.
  • There was a statement of vision and strategy.
  • There was an active women’s forum that met regularly and provided input into projects in the maternity services.

Medical care (including older people’s care)

Requires improvement

Updated 3 November 2016

Spinal Injuries Centre

Not sufficient evidence to rate

Updated 3 November 2016

Urgent and emergency services (A&E)

Requires improvement

Updated 3 November 2016

We rated urgent and emergency services as requires improvement overall. We found urgent and emergency services required improvement to be safe and responsive. However, it was good for being effective, caring and well led.

We found that:

  • Systems, equipment and standard operating procedures were not always reliable or appropriate to keep patients and staff safe. For example, there was not an effective system in place for staff to identify deteriorating patients in the waiting room.
  • Waiting times for ambulance handovers were worse than the England average, with over one hour ‘black breaches’ being reported most weeks.
  • Patients were unable to access services in a timely manner for assessment, diagnosis or treatment. Action to address this was not always timely or effective. Lack of available capacity caused overcrowding in the emergency department (ED).
  • The trust was not meeting the 95% Department of Health target for patients being seen within four hours of arriving in ED.
  • The times patients were assessed by a triage nurse were not always recorded accurately.
  • Systems and processes were not always in place to ensure cleanliness of equipment within the ED.
  • In ED’s resuscitation area we saw two instances of unsafe management of used sharps.
  • Staff were aware of their responsibilities regarding safeguarding procedures however, the trust did not meet intercollegiate guidance for safeguarding training, which states all doctors and qualified nurses should be trained to level 3. Only 71% of nursing staff and 63% of medical staff in ED had completed level 3 safeguarding children training.
  • We saw incidents reported in ED related to nursing staff shortages. However, none resulted in impact to patient care.
  • Triage times were not always recorded correctly so data about how long patients waited to be seen by a nurse could not be assessed accurately.
  • Patients who could take fluids orally did not always have a drink within reach in the emergency department and staff reported that meals in the clinical assessment unit were often cold when served to patients.
  • Nursing appraisal rates did not meet the trust target. However, medical staff appraisal rates did meet the trust target.
  • The trust did not provide evidence to show that a nurse trained in paediatric immediate life support was on shift at all times.
  • Treatment bays in the ED resuscitation area did not have effective screens or curtains to protect patients’ privacy and dignity.
  • There was no divisional strategy in place.

However, we also saw:

  • Openness and transparency about safety was encouraged. Staff understood their responsibilities to raise concerns and report incidents and near misses; they were fully supported when they did so.
  • Medications were stored and administered safely.
  • Patient risk assessments were generally well completed.
  • Staff had awareness of major incident planning.
  • A freestanding hand wash station had been installed in the ambulance corridor in response to an area for improvement identified in our September 2015 inspection.
  • The trust had systems in place to meet patient’s individual needs. Particularly for paediatric patients.
  • Patients, their relatives and carers told us staff treated them with dignity and respect, and involved them in decisions about their care.
  • Patient’s care and treatment was planned and delivered in line with current evidence-based guidance, standards and best practice. This was monitored to ensure consistency of practice.
  • Most medical and nursing staff had appropriate skills to manage patients care and treatment with systems in place to develop staff, monitor competence and support new staff.
  • Consent to care and treatment from patients aged 16 and over was obtained appropriately under the Mental Capacity Act 2005 and by making a Gillick competency assessment of children.
  • The trust had systems in place to identify and monitor risks. Performance issues were escalated to relevant senior managers through clear structures and processes.
  • Managers were knowledgeable about quality issues and priorities, understood the service’s challenges and took action to address them.
  • The division had a robust audit calendar, which was used to monitor services and compliance against national and local standards.
  • There was a children’s and young people’s ambassador group that had assisted the redesign of the paediatric ED area.

Surgery

Requires improvement

Updated 3 November 2016

We rated surgery services as requires improvement overall. We rated the service requires improvement for effective and well-led; inadequate for responsive; and good for safe and caring because:

  • Between March 2015 and February 2016, the overall referral to treatment (RTT) within 18 was significantly worse than the England average.
  • There was an electronic system to monitor and record waiting times for treatment. It was unclear what measures the trust were taking to reduce waiting times. We asked the trust to provide evidence of measures taken but this was not provided.
  • Capacity was an issue at the hospital.
  • Most staff we spoke with were unaware of the trust’s vision and mission.
  • There was a strategy for delivering care to patients. The strategy mirrored national performance targets. However, the trust acknowledged within the strategy that demand was outweighing capacity and there were insufficient clinicians to meet this demand.
  • There was a new governance structure. However, staff were unaware of the structure and who their line managers were.

However, we found that:

  • We saw that all policies were current and followed the appropriate guidelines, such as National Institute for Health and Care Excellence (NICE).
  • Staff understood the importance of reporting incidents and had awareness of the duty of candour process. The team meeting minutes identified shared learning from incidents.
  • The environment was visibly clean and staff followed infection control policies.
  • Patient notes had documented risk assessments undertaken.
  • The surgical team used the Five Steps to Safer Surgery checklist. The hospital audited and monitored the checklist to ensure any harm caused to patients was avoidable.
  • The service assessed the nursing staffing numbers using the national safer nursing tool in order to identify the planned staffing levels.
  • There were competency frameworks for staff in all surgical areas.
  • Patients told us staff requested their consent to procedures and records seen demonstrated clear evidence of informed consent.
  • Staff were clear about their roles and responsibilities around the Mental Capacity Act 2005 and had an awareness of the Deprivation of Liberty Safeguards.
  • Staff were caring and compassionate to patients needs and treated patients with dignity and respect.
  • The hospital had a nurse led pre-assessment clinic, which provided choice to patients regarding their appointments.
  • Length of stay was better than the national average for elective and non-elective general surgery, urology, non-elective upper gastrointestinal surgery, and trauma and orthopaedics. However, elective trauma and orthopaedic length of stay was worse than the England average.
  • There was a sense of pride amongst staff working in the hospital.
  • The hospital recognised the views of patients and carers.
  • Staff working within the service felt supported.
  • Ward sisters had access to leadership programmes.

Intensive/critical care

Good

Updated 3 November 2016

We rated critical care services as good overall. We rated critical care services good for safety, effective, caring and well-led and requires improvement for responsive.

We found:

  • We found an active patient safety incident reporting culture and evidence of learning from incidents.
  • There were low infection rates and good adherence to infection prevention and control policies and use of handwashing and personal protective equipment.
  • Patients’ pain was regularly assessed and pain relief was provided.
  • Staff acted in accordance with the Mental Capacity Act 2005 when treating patients on the ICU and requested Deprivation of Liberty Safeguards authorisations when necessary.
  • Patients were treated with dignity, respect and kindness during interactions with staff.
  • Staff responded compassionately when patients needed support and helped them to meet their personal needs.
  • During the inspection, patient's privacy and confidentiality was respected at all times.
  • The unit worked hard to meet individual patients’ needs and accommodate preferences.
  • The staff accessed use of translation services appropriately during our inspection.
  • The service had a low formal complaint rate.
  • Members of the multidisciplinary team worked well together on the unit.
  • The overall mandatory training compliance met the trust target (90%).
  • 60% of trained nursing staff on the ICU held a post registration award in critical care nursing, which met guidelines for the provision of intensive care services (GPICS) 2015.
  • The ICU was performing as, or better than expected (compared to other similar services) in seven out of eight indicators used in the ICNARC report (2015/16).
  • There was an improvement in the minutes of mortality and morbidity meetings, with ongoing actions to improve care.
  • We found evidence that staff regularly discussed new guidance and presented patients clinical cases in meetings, which resulted in recommendations and changes in practice.
  • The unit engaged in the hospital bed capacity meetings.
  • Leadership of the unit was in line with guidelines for the provision of intensive care services (GPICS) 2015.
  • The unit had a risk register which contained relevant risks. There was evidence of frequent discussions and reviews of the risks and leaders were all aware of them.
  • There were regular meetings including at unit and clinical leader level. The minutes of these demonstrated that quality, risks, incidents, mortality and morbidity were discussed and ongoing actions were monitored.
  • The intensive care unit (ICU) team had been nominated by theatre staff to receive the trust’s ‘going the extra mile’ award for their dedication and hard work.

However, we also found:

  • The Intensive Care National Audit and Research Centre (ICNARC) 2015/16 report showed that the unit was performing worse than expected for transferring patients out of hours to a ward and this had increased from the previous year.
  • There was no follow-up clinic for intensive care unit (ICU) patients following discharge home from hospital, which was recommended in National Institute for Health and Care Excellence (NICE) guidance and guidelines for the provision of intensive care services (GPICS) 2015.
  • Delays in accessing beds in hospital were resulting in mixed sex occupancy breaches each month. There were 27 instances of mixed sex occupancy reported from January to June 2016.
  • There had been 22 cancellations of on the day of surgery due to lack of ICU beds in 2015/16, which was significantly worse than the previous year.
  • In the six months ending April 2016, there were 14 critical care patients who were ventilated outside the unit and eight patients transferred to another hospital for non-clinical reasons (in the three months ending April 2016) due to bed pressures.
  • NHS Safety Thermometer data was not on display and staff were unaware of the results.
  • Antibiotic stewardship audits showed that improvements were required in documenting when an antibiotic prescription required review.
  • We found there were many local policies and guidance that were beyond review date.
  • There was not always a consultant anaesthetist that specialised in intensive care covering the ICU because the on call rota was split between critical care and anaesthetics.
  • The ICU nursing staff appraisal rate was 76% and did not meet the trust target of 90%. However, this was an improvement from the September 2015 inspection when 50% of staff had an annual review.
  • There was unclear understanding of a vision and strategy for critical care services.

Services for children & young people

Requires improvement

Updated 3 November 2016

We rated services for children and young people as requires improvement. We rated the service requires improvement for effective and well-led. We rated the service as good for being safe, caring and responsive.

We rated the service as requires improvement because:

  • There was not always effective and timely incident reporting and management.
  • Lessons learned from incidents were not always shared and understood by staff.
  • Not all risks were identified on the risk register, such as ligature risk. However, mitigating actions had been taken.
  • The trust’s mandatory training target of 90% had not been achieved although there had been some improvement since the September 2015 inspection.
  • The trust did not use an acuity tool to assess whether additional staff were required depending on the acuity and age of patients present on the ward. However, we saw staffing levels met patient need.
  • Procedures and guidance available to staff were not always up-to date. This had been identified in September 2015 but action had not been taken.
  • Audits were undertaken to monitor compliance. Audit aims and objectives were clearly defined. However, audit plans did not define clear timescales, were not always assigned to a lead, actions and recommendations were not always documented and there was no evidence of discussion around the audit findings.
  • Intended Patient outcomes were either in line with the national average or worse than the national average. The trust had developed action plans to make improvements.
  • The transition arrangements for conditions, with the exception of diabetes, were not clearly defined.
  • The service did not have a clear vision.
  • Objectives in the business plan had been set but were not supported by actions, timescales or accountability.
  • Some risks we identified during our inspection had not been included on the risk register, we also highlighted this in the September 2015 inspection.
  • Risks were overdue their review date.
  • Governance processes were not in place to assess and review policies and care pathways.

However, we also found:

  • Patients and stakeholders were involved in service development, including a children’s and young people’s ambassador group.
  • Play workers arranged activities for patients, to provide patients with the opportunity to meet peers who had similar patient experiences.
  • Patients and / or their relatives were informed when things went wrong.
  • Good standards of cleanliness and hygiene were maintained on the paediatric ward and special care baby unit (SCBU) which was an improvement since September 2015.
  • There was adequate equipment to meet the needs of patients.
  • There were suitable arrangements in place for management of medicines which included the safe ordering, prescribing, dispensing, recording, handling and storage of medicines.
  • Patient’s individual medical records were written and managed in a way that kept patients safe.
  • Staff were clear about their roles and responsibilities around the safeguarding children.
  • Patient risks were managed appropriately and their risks were assessed on admission; observations were made in line with their risk assessment.
  • Medical staffing levels and skill mix were planned so that patients received safe care and treatment.
  • Staff understood the relevant consent and decision making requirements of legislation and guidance and consent was obtained in line with legislation.
  • Most staff had the right qualifications and experience to carry out their role.
  • Staff interactions with patients were positive and patients were treated with dignity and respect
  • Patients told us that staff were helpful and that they explained things to them in a manner patients could understand.
  • There were facilities to engage and occupy young children and teenagers admitted to the ward.
  • There were overnight facilities for parents to stay on both the paediatric ward and SCBU.
  • Leaders were visible and approachable; ward managers understood the challenges at a local level.
  • Staff felt well supported and listened to, there was a strong culture of putting the patient first.

End of life care

Good

Updated 3 November 2016

We rated end of life care services as good. The service was safe, effective, caring, responsive and well led because:

  • Care records were maintained in line with trust policy.
  • Medicines were provided in line with national guidance. We saw good practice in prescribing anticipatory medicines for patients who were at the end of their life.
  • The trust had a replacement for the Liverpool Care Pathway (LCP) called the multidisciplinary care record for adults for the last days of life (MCR). The use of this document was embedded in practice on all of the wards. The MCR was also used in community based care homes in the area.
  • Do not attempt cardio-pulmonary resuscitation (DNACPR) records we reviewed had been signed and dated by appropriate senior medical staff. There was a clear documented reason for the decision recorded. This included relevant clinical information.
  • Policies and procedures were accessible and based on national guidance. We saw improvements since the September 2015 inspection, with regard to only one DNACPR policy being accessible to staff on the intranet.

  • We found the trust had addressed maintenance issues affecting the mortuary body storage units (fridges), that we had identified on the September 2015 inspection. We also saw a new governance structure in place. The mortuary staff had a clear reporting structure.

  • Patients were happy with the care they had received. Relatives were happy with the care their relatives had received.
  • Patients were involved in making decisions about their care. Staff carried out care in a respectful and careful manner.
  • Care and treatment was coordinated with other services and other providers. The specialist palliative care team (SPCT) had good working relationships with their community colleagues, which ensured when patients were discharged, their care was coordinated.
  • 100% of patients were seen by the SPCT within 24 hours of referral.
  • The trust had an executive and a non-executive director on the trust board with a responsibility for end of life care.
  • The risks regarding the mortuary were identified on the support services risk register.
  • Risk associated with SPCT were on the divisional risk register. The staff had taken action to mitigate against risks.

However:

  • The acute SPCT were not collecting information on percentage of patients that had been discharged to their preferred place of death within 24 hours. Without this information, the service was unable to monitor if they were able to honour patients’ wishes and assess if they needed to improve on this. This had not improved since the inspection in 2015.
  • We did not see evidence of a hand hygiene audit being completed in the mortuary.
  • The mortuary team did not have oversight of the service arrangements for mortuary equipment so were unable to assure us that this was completed in a timely manner.
  • The facilities management company provided staff training, while it did not specifically include safeguarding training. However, it identified the need to raise any concerns about the treatment or condition of deceased patients to the mortuary staff and their line manager.
  • The service did not provide face-to-face access to specialist palliative care for at least 9am to 5pm, Monday to Sunday. This did not meet the recommendation from the National Institute for Health and Care Excellence (NICE) guidelines for ‘End of life care for adults’.
  • Medical staffing did not meet the NICE guidance for end of life care staffing, that recommends there is one whole time equivalent consultant/associate specialist in palliative medicine per 250 hospital beds. However, in addition to the hospital based medical cover, an out of hours consultant led palliative care advice service was available through the local hospice 24 hours a day, seven days per week.

Outpatients

Requires improvement

Updated 3 November 2016

Overall, we rated the outpatients and diagnostic imaging services as requires improvement. We rated the service inadequate for being responsive, requires improvement for being safe and well-led, and good for caring. CQC do not have the methodology to rate the effective domain. The service was judged to be requires improvement overall because:

We found:

  • There were long waiting lists for the majority of specialities and the trust had not met all cancer targets for referral to treatment times.
  • Although the trust had taken action to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients on the waiting list, we saw there were approximately 28,000 open patient pathways still to review. Therefore, there continued to be a risk that the trust did not have full oversight of the risk to patients on open pathways.
  • Mandatory and safeguarding training levels did not always meet the trust’s target and not all staff had received an annual appraisal.
  • We could not be assured that learning from incidents was cascaded to all staff within the outpatient department.
  • Patient records were not always stored securely in some areas of outpatients.
  • Whilst the formal complaint rate for outpatients was low, complaints were not always responded to in a timely way.
  • The outpatients department had been restructured within the surgical division and whilst governance systems were in place to monitor and manage risks identified within the department, these were not yet established within the new structure.
  • The trust had developed a comprehensive quality improvement plan in order to improve the patient experience and reduce waiting times. However, the trust had not yet met the majority of objectives and actions it had set and had fallen behind the completion schedule.
  • There were effective systems in place for the management of medicines throughout the outpatient department, although not all medicines were stored in accordance with trust polices and national guidance.

However, we also found:

  • Staff were aware of their responsibilities and understood the need to raise concerns and report incidents. Incidents were investigated and patients were informed when things went wrong. This had improved since our September 2015 inspection.
  • The trust had taken action to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients on the waiting list.
  • All clinical areas we visited were clean and there was good adherence to infection control policies and personal protective equipment.
  • Patient records were generally stored securely and effective systems were in place to ensure clinicians had access to appropriate and up to date patient information.
  • The diagnostic and imaging service had systems in place to ensure the safe administration of ionising radiation for staff and patients and these systems were regularly audited and reviewed.
  • We saw effective multidisciplinary working across outpatient and diagnostic services.
  • Patients were treated with kindness, dignity and respect and spoke positively about the care they had received.
  • Some departments had developed services, such as one-stop clinics, in order to better meet the needs of patients and improve service provision.
  • The outpatient department was well represented at board level and leadership within the department was strong, supportive and visible. Staff felt confident to report concerns to senior management.