You are here

Hereford Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 17 October 2018

At this inspection, we inspected urgent and emergency care, surgery, outpatient, maternity, medicine and children and young people services. We did not inspect critical care or acute end of life care services at this inspection, but we combine the last inspection ratings to give the overall rating for the hospital.

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

  • Our rating for safe remained requires improvement overall. Not all services had staff with the right skills, experience and qualifications. Risks to patients were not always assessed.
  • Our rating for effective remained requires improvement overall. Not all guidance was up to date. Staff were competent for their roles and in most areas
  • Our rating for caring remained the same as good overall. Staff were cared for patients with respect and compassion and feedback from patients was positive. We rated children and young people services outstanding for caring.
  • Our rating for responsive improved. We rated it as requires improvement overall. We rated surgery as inadequate. Patients could not always access services when they needed and they were not meeting referral to treatment targets.
  • Our rating for well led improved. We rated it as good overall. Managers promoted a positive culture that supported and valued staff, to provide patient care and treatment.
Inspection areas

Safe

Requires improvement

Updated 17 October 2018

Effective

Requires improvement

Updated 17 October 2018

Caring

Good

Updated 17 October 2018

Responsive

Requires improvement

Updated 17 October 2018

Well-led

Good

Updated 17 October 2018

Checks on specific services

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.

Outpatients and diagnostic imaging

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.

Urgent and emergency services

Requires improvement

Updated 17 October 2018

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

  • Patients could not access the service when they needed it. The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the ED.
  • From April 2017 to March 2018 the trust consistently failed to meet the four-hour standard of 95% of patients being discharged or transferred, and with the exception of April 2017, performance was consistently worse than the England average. However: in March 2018, the department had five consecutive days of meeting this standard at 90% and above.
  • An average of 5% of patients left the trust before being seen compared to an England average of 3%. This had declined since the last inspection when 3.1% patient left without being seen.
  • Risks to most patients were assessed and their safety monitored and managed so they were supported to stay safe. However: the department were not meeting the 15-minute target for initial time to assessment.
  • Complaints were not managed in a timely manner.
  • There were 1.6 whole time equivalent permanent consultants for the department. However, the reduced number of permanent consultants was reflected on the services risk register.
  • There were two never events of the same type recorded in the department for May 2018.
  • They did not always meet the standards of the Royal College of Emergency Medicine audits, but did have action plans to deliver improvements.
  • Out of hours, there was no radiographer that could complete trauma CTs onsite, the superintendent of the radiology department was mitigating this risk, by ensuring that an appropriately trained radiographer was on the on-call list. This was on the risk register.
  • The hospital had no onsite security in place. The porters had undertaken training to support teams when responding to challenging behaviour.
  • Nursing and medical staff’s compliance with mandatory training had declined slightly since the last inspection in July 2016.

However:

  • The service had enough nursing staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment for the majority of shifts.
  • The department had processes in place to ensure adults and children in vulnerable circumstances were safeguarded from abuse and harm. There was an up to date policy and staff could access the safeguarding lead for the trust for advice.
  • 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 planned for emergencies and staff understood their roles if one should happen. Staff responded appropriately and identified changing risks to people who used the service.
  • The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. 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 a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff and key groups. For example, the local ambulance trusts. The service was committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation.
  • The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.
  • Staff from different disciplines worked together as a team to benefit patients. Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care.
  • The service prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time.
  • Staff recognised incidents and reported them appropriately. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • Patients pain was assessed and managed using pain assessment tools. Assessment of pain in patients with difficulties communicating was assessed using a specific pain management tool and managed well.

Maternity

Good

Updated 17 October 2018

  • Staff cared for women and babies with compassion, dignity and respect. Women felt involved in their care and were given informed choice of where to give birth.
  • The service planned and reviewed staffing levels and skill mix to ensure that women and their babies received safe care, and at the time of our inspection, the service had enough staff to keep people safe from avoidable harm and abuse. The midwife to birth ratio was better than the national average and women always received one-to-one care in labour.
  • The maternity service worked closely with commissioners, clinical networks and other stakeholders to plan delivery of care and treatment for the local population. This collaborative working ensured future planning covered recommendations laid out by NHS England and the Department of Health.
  • The maternity service generally took account of women’s individual needs, including those who were in vulnerable circumstances or had complex needs. Bereavement care provision was in place to support families from their initial loss, throughout their time in hospital and return home.
  • The service had managers at all levels with the right skills and abilities to adequately run a service. They promoted a positive culture that supported and valued staff.
  • The service was committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation. We saw many examples of this during our inspection.
  • The service had a vision for what it wanted to achieve and workable plans to turn it into action. The vision and strategy was developed with involvement from staff, patients and key groups representing the local community.
  • The service worked collaboratively with a neighbouring trust, other stakeholders, and service users to establish a local maternity system (LMS), in response to national recommendations. We found there was good staff awareness of the LMS, and we saw workstreams had been developed to support its development and delivery.

However:

  • The service did not always have suitable premises. The second obstetric theatre was not compliant with national standards and the recovery area on delivery suite was not designed in a way that protected women’s privacy and dignity, and promoted a good patient experience.
  • Medical staff compliance with safeguarding children training was below the trust target.
  • Staff had not audited their sepsis management to assure themselves their care and delivery was effective and in line with trust and national guidance. Not all policies had been reviewed in a timely manner.
  • There was no process to monitor how frequently the staffing escalation policy was used.
  • The service had not yet established a systematic clinical audit programme, which adequately shared learning with staff.
  • Complaints were not always dealt with in a timely manner.
  • Pressure area risk assessments ,to identify women who were at risk of developing a pressure sore, were not consistently completed. We observed that staff did not introduce themselves to a woman in theatre, which was not in line with their adapted version of the World Health Organisation’s (WHO) surgical safety checklist. This meant that the team may not have known who to contact in the event of an emergency.

Outpatients

Requires improvement

Updated 17 October 2018

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

We rated it as requires improvement because:

  • From March 2017 to February 2018, the trust’s referral to treatment time (RTT) for non-admitted pathways had been worse than the England overall performance. Figures for February 2018, showed 83% of this group of patients were treated within 18 weeks versus the England average of 89%. In June 2018, the RTT on incomplete pathways within 18 weeks had dropped to 75% which was below England average of 87%.
  • We saw 13 out of 17 specialties were below the England average for non-admitted RTT within 18 weeks. The hospital’s action plan for reducing their waiting lists included running additional clinics to meet the demand for outpatient services.
  • The design and use of facilities and premises met patients’ needs. However, the maintenance and use of equipment did not always keep patients safe. Some equipment had not been serviced tested and out of date equipment was found in some areas. This meant that we could not be assured that all equipment was suitable for purpose. We raised this with senior staff who took immediate actions to get this equipment service tested.
  • Although there were processes in place to recognise and care for patients who became unwell within the outpatient’s department, not all staff were aware of where emergency equipment was located. We could not be assured that in the event of an emergency, staff would be able to locate emergency equipment required to keep patients safe.
  • Whilst systems were in place to manage the safe storage of medicines, there were intravenous fluids stored on resuscitation trolleys which were not secure. This contravened the Resuscitation Council November 2016 guidance. New tamper evident trolleys had been ordered.
  • We found that vision tests including blood pressure checks were administered on the corridor in vision lanes with no screens and there was no means of protecting patient’s privacy because the corridor was accessible to staff, patients and their relatives or friends. This meant that privacy and dignity of patients was not maintained. This had been highlighted during our last inspection.

However:

  • The service managed patient safety incidents well and staff were confident to report incidents.
  • Standards of cleanliness and hygiene were generally well maintained. Reliable systems were in place to prevent and protect people from a healthcare associated infection.
  • Medical staffing levels and skill mix was planned and reviewed so that patients received safe care and treatment in line with relevant tools and guidance.
  • Staff kept appropriate records of patients’ care and treatment. Records were clear and entries were dated, timed and signed. However not all patient records were stored securely, some trolleys were not locked.
  • Outpatient services delivered care and treatment in line with the National Institute for Health and Care Excellence (NICE) and national guidelines where appropriate.
  • Staff had opportunities for development and received an annual appraisal. Competency assessment frameworks were developed to ensure staff had the skills necessary to undertake their job role.
  • Staff received an annual appraisal that was constructive and provided a formal opportunity to review their progress and identify further training needs.
  • Patients were treated with compassion, kindness, dignity and respect.
  • Staff had good awareness of patients with specific needs and those patients who may require additional support should they display anxious or difficult behaviour during their visit to the service.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • The trust performed better than the 93% operational standard for people being seen within two weeks of an urgent GP referral.
  • Staff we spoke with said two-week waits were well managed and an increase in clinic capacity had made a big difference over the last few months.
  • Staff reported that leadership within the department was strong, with visible, supportive and approachable managers. Staff felt there was a positive working culture and in all areas we visited staff felt there was a good sense of teamwork.
  • Staff told us that local leadership was good and felt they could approach managers with concerns. Managers told us they had an ‘open door’ policy and they encouraged staff to share any issues, concerns or ideas they may have.

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 17 October 2018

  • Mortality rates were higher (worse) than expected, however the trust had a number of areas of work in progress to reduce this.
  • The trust did not have an active dementia strategy at the time of inspection and ward environments, other than Gilwern ward, were not dementia or disability friendly.
  • The service provided mandatory training in key skills to all staff but did not ensure it was completed by everyone.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. However, not all staff had training on how to recognise and report abuse.
  • Confidential patient information was not always secure. Medical notes trolleys were often left unlocked and on occasions left open with notes displayed, records for patients who had been discharged, were stored on desks on the ward.
  • A number of trust produced guidance documents on the intranet that could be accessed by staff that of out of date or passed time for review.
  • Seven day services were not always available. Medical consultants were not completing a minimum of three daily ward rounds at weekends, on all wards, which was not in line with London Quality Standards
  • Waiting times for treatment were longer than the England average. However, improvements to arrangements to admit, treat and discharge patients were in line with good practice.
  • Concerns and complaints response was not always in line with their complaints policy timescales. The trust took an average of 50 working days to investigate and close complaints.

However:

  • Staff cared for patients with compassion. Patients and their relatives were treated well and with kindness. Staff provided emotional support to patients to minimise their distress.
  • Despite the high vacancy rates, the service manged staffing to ensure they 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.
  • Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
  • Patients we spoke with confirmed that they had received pain relief medication when they required it.
  • 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 of different kinds worked together as a team to benefit patients.
  • Staff generally understood their roles and responsibilities under the Mental Health Act (MCA)1983 and the Mental Capacity Act 2005.
  • Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • The risks present on the register reflected the views of the staff we spoke to at all levels.

Surgery

Requires improvement

Updated 17 October 2018

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

  • Patients could not access the service when they needed it. The average referral to treatment performance 2017/18 for England admitted pathways against the standard target of 90% of patients being seen within 18 weeks from referral, was 59.2%. At the end of May 2018 161 patients had waited for more than 52 weeks from referral to treatment.
  • Staff assessed most risks to patients and monitored their condition. However, risk assessments to assess patient’s risk of developing blood clots after surgery and risk of sepsis were not always completed and a timely response to the identified risks was not always achieved. Criteria developed to keep people safe in times of pressure, were not always followed.
  • The service did not always have enough nursing and theatre 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. Ward staffing levels were reviewed and agreed, but these were not always achieved.
  • The service did not always have enough medical 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 but did not always use the findings to improve. There was variable performance in national audits and most did not have an action plan to drive improvements. This had not improved since our inspection in July 2016 when we identified similar issues.
  • Systems and processes were in place to prevent and control infection but they were not always followed. The service monitored staff adherence to most infection prevention and control procedures through audits, although actions taken to address lack of adherence were not effective.
  • The trust did not use a systematic approach to continually improving the quality of its services and safeguarding high standards of care. Governance processes were in place although further development and consistency of approach was required.
  • Increased numbers of medical and surgical emergency patients impacted on access to elective surgery and resulted in patients not being placed in the wards most suitable for them.
  • Records were not always stored securely. Medical records were observed to be stored in areas accessible to the public on the wards. Staff did not always have access to up to date policies and guidance and they were difficult to locate.
  • The trust had systems for identifying and reviewing risks, and coping with both the expected and unexpected. However, some of the risks on the risk register had remained there for a number of years. There were delays in obtaining pressure relieving equipment in busy periods and outside office hours.
  • Staff sometimes felt they were not listened to and were overridden by the wider site management teams. The service had vacancies for some management posts impacting on their management capacity to drive forward improvements.
  • Complaints were not dealt with in the timescales set out by the trust and there was no evidence of discussion of themes from complaints at surgical governance meetings.
  • Some patients were without food and drink prior to their operation for longer periods than necessary.

However:

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Although staff training levels did not meet trust targets, staff we spoke with had a good working knowledge of safeguarding issues and they were able to provide examples of safeguarding referrals or concerns they had reported.
  • Staff kept appropriate records of patients’ care and treatment. The service mostly managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Staff were able to identify learning from incidents. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • Staff gave patients enough food and drink to meet their needs. They assessed their nutritional risk and when necessary monitored the amount they ate and drank.
  • The service managed patient’s pain well. Patients told us they received pain relief promptly and staff monitored its effectiveness.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and provided training to enable them to develop their skills.
  • Staff worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Staff understood their roles and responsibilities in relation to consent for surgical procedures. Knowledge of the Mental Health Act 1983 and the Mental Capacity Act 2005 was variable amongst nursing staff; however they had access to advice from the trust lead nurses.
  • Staff cared for patients with compassion and kindness. Patients, praised staff, saying they were friendly, reassuring and respectful. Staff provided emotional support to patients to minimise their distress.
  • Staff involved patients and those close to them in decisions about their care and treatment. Patients felt in control of the decisions and listened to by staff.
  • The trust had a newly developed clinical strategy which provided a clear direction for the future provision of surgical services. The surgical division had identified objectives for the current year. The premises and environment were generally maintained to provide a safe environment and plans were in place to develop a new surgical block.

Services for children & young people

Good

Updated 17 October 2018

Our overall rating of this service has improved since our July 2016 inspection when we rated it requires improvement. At this inspection in June 2018, we rated the service good because:

  • There was a strong, visible patient- and family-centred culture. Staff were highly motivated and inspired to provide care and treatment that was kind, compassionate and promoted patients’ dignity, and respected the totality of people’s needs.
  • Patient’s emotional and social needs were seen as being as important as their physical needs. Staff were fully committed to working in partnership with patients and their families, and empowered them to have a voice.
  • Leadership was strong, supportive and visible. The leadership team understood the challenges to service provision and actions needed to address them. Staff were committed to providing the best possible care for children, young people and their families. Staff felt ownership for the service and were proud to be part of the children’s service.
  • The service had a vision of what it wanted to achieve and clear objectives to ensure the vision was met. The vision and strategy was developed with involvement from staff, patients, and key groups within the local community.
  • Staff understood their responsibilities to raise concerns and report patient safety incidents. There was an effective governance and risk management framework in place to ensure incidents were investigated and reviewed in a timely way. Learning from incidents was shared with staff and changes were made to the delivery of care because of lessons learned.
  • The service made sure staff were competent for their roles. Mandatory training in key skills was provided to all staff and the service made sure everyone completed it. Staff were encouraged to develop their knowledge, skills and practice. The number of staff who had received an annual appraisal exceeded the trust target.
  • Service provision met the needs of local people. They worked closely with commissioners, clinical networks, stakeholders and service users to plan and improve the delivery of care and treatment for the local population.
  • The service generally provided care and treatment based on national guidance and evidence of its effectiveness. Local and national audits were completed and actions were taken to improve care and treatment when indicated.
  • The children’s unit was imaginatively decorated, and equipment and toys were used creatively to create a fun, warm and child-friendly environment. Play was seen as an essential part of children’s care. There was a wide range of age appropriate toys, games and books for children and young people, including a separate teenage room for adolescents and outside play area. Play therapists supported the care and treatment of children and young people and arranged special activities and days out for long-term patients.
  • The service met and generally exceeded national standards in relation to paediatric consultant availability. Patients could generally access the service when they needed it and waiting times for treatment were similar to the England average.

However:

  • We found that many policies and guidance had expired their review date. At the time of our inspection (June 2018), 39% of paediatric guidelines were under review. We found expired guidelines had not been included on the service’s risk register.
  • We found multidisciplinary attendance at perinatal mortality and morbidity meetings was variable. We also found specialty meeting minutes often lacked detail.
  • Nurse staffing levels did not always meet planned levels or national recommendations. However, we found there was generally enough staff to keep people safe from avoidable harm and to provide the right care and treatment.
  • The service’s most recent audit results showed that sepsis screening tools were not always completed in line with trust guidance.

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.