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Hereford Hospital Requires improvement

Reports


Inspection carried out on 5, 6, 7, 8, 11, 17, 18 July 2016

During a routine inspection

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 carried out on 22, 23, 24 and 25 September 2015

During a routine inspection

Wye Valley NHS Trust was established in April 2011 and provides hospital care and community services to a population of slightly more than 180,000 people in Herefordshire. The trust also provides urgent and elective care to a population of more than 40,000 people in mid-Powys, Wales. The trust provides a full range of district general hospital services to its local population, with some links to larger hospitals in Gloucestershire, Worcestershire and Birmingham

The trust’s catchment area is characterised by its remoteness and rural setting, with more than 80% of people who use the service living five miles or more from Hereford city or a market town.

Wye Valley NHS Trust provides services from Hereford Hospital and community healthcare settings. There are approximately 289 beds within the hospital.

We inspected the trust in June 2014 and gave an overall rating of ‘Inadequate’, with particular concerns about the provision of services in both A&E and medical care services. The inspection led to the trust being placed in special measures by the Trust Development Authority in October 2014.

We carried out an announced comprehensive inspection of the trust from 22 to 24 September 2015. We undertook one unannounced inspection on 1 October 2015 at Hereford Hospital and attended the trust board meeting. We held focus groups with a range of staff in the hospital, including nurses, junior doctors, consultants, midwives, student nurses, administrative and clerical staff, allied health professional, domestic staff and porters. We also spoke with staff individually.

Overall, we rated Hereford Hospital as inadequate with two of the five key questions which we always rate being inadequate (safe and responsive). Improvements were needed to ensure that services were safe and responsive to patient’s needs. We found that effectiveness and well led required improvement and the caring was good.

Five of the eight core services at Hereford Hospital were rated inadequate for safety.

The outpatient and diagnostic services at Hereford Hospital were rated overall as inadequate. All other services at Hereford Hospital were rated as requires improvement.

Our key findings were as follows:

  • Staff were kind and caring and treated people with dignity and respect.
  • Overall the hospital was clean, hygienic and well maintained.
  • In July 2015 there were 128 whole time equivalent (WTE) (14%) band 5 to 7 qualified nursing vacancies, 16 WTE (13%) consultant vacancies and 23 WTE (13%) other medical staffing vacancies within the trust. This was a high risk on the trusts risk register. A recruitment programme was ongoing and changes had been made to speed up the recruitment process. Oversees recruitment had taken place.
  • Nursing vacancies in some areas was very high and in excess of 40%, such as Lugg ward and the acute assessment unit.
  • There was an over reliance on bank nursing staff. Between January and May 2015 the average use of agency nurses across the trust was 13%, higher than the national average. There were occasions were temporary staff were more that 40% of the workforce on a ward.
  • The trust told us for August 2015 the use of agency nurses accounted for 17% of total nurse expenditure.
  • It is worth noting that at the Quality Oversight Review Group Meeting on 4 November 2015 the trust had a trajectory to reduce their nursing vacancies to 64 WTE by the end of 2015 and had established an internal agency that had reduced external agency use by over 50% (approximately 500 shifts). Subsequently, this had reduced expenditure.
  • In July 2015 there were 16 WTE consultant vacancies and 23 WTE other medical staffing vacancies. Between January and May 2015 the average use of locum medical staff across the hospital was 8.4%. The emergency department, radiology and medical services used over 25% locum medical staff.
  • Patient’s pain was well managed and women in labour received a choice of pain relief. Patients at the end of life were given adequate pain relief and anticipatory prescribing was used to manage symptoms.
  • Monitoring by the Care Quality Commission had identified areas where medical care was considered a statistical outlier when compared with other hospitals. The trust reported on their mortality indicators using the Summary Hospital-level Mortality Indicator (SHMI) and the Hospital Standardised Mortality Ratio (HSMR). These indicate if more patients are dying than would be expected. The SHMI indicator, which covered the 12 month period April 2014 to March 2015, showed mortality was above the expected range of 100 with a value of 114. However, the data for March 2015 reported a 12 month rolling figure of 117. The data for the trust was higher than expected and its overall level of HSMR for the 12 month period April 2014 to March 2015 was 132. This had been reported to the trust board. The trust had implemented a series of actions to address this concern including the introduction of regular mortality review meetings to identify any actions to improve overall patient care and treatment.
  • Like many trusts in England, Wye Valley NHS Trust was busy. Between July 2014 and March 2015, bed occupancy for the trust averaged 92%. This was above the level of 85% at which it is generally accepted that bed occupancy can start to affect the quality of care provided to patients and the orderly running of the hospital.
  • The trust were not consistently meeting the national targets set regarding patients access to treatment and they had failed to meet the 18 week target for access to treatment for many specialities.
  • The trust were not meeting the standard for patients being admitted, referred or discharged from the A&E department within four hours.
  • Staff generally felt they were well supported at their ward or department level.

We saw several areas of outstanding practice including:

  • The trust had established a young people’s ambassador group. This was run by a group of patients who had used the service or continued to use the service. The group met regularly and were consulted on changes on changes and developments, for example they had recently introduced a ‘Saturday club’ and had been involved in the ED Patient-Led Assessment of the Care Environment audit (PLACE) aiding the redesign of the children’s waiting area. We spoke with some representatives from the group who were very passionate about their role and welcomed the opportunity to make a difference.

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

Importantly, the trust must:

  • Ensure that where a person lacks capacity to make an informed decision or given consent, staff must act in accordance with the requirements of the Mental Capacity Act 2005 and associated code of practice.
  • The trust must ensure safeguarding referrals are made as appropriate.
  • The trust must ensure all staff have the appropriate level of safeguarding training.
  • 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 and appraisal to meet the appraisal target of 90% compliance.
  • The trust must ensure there are enough suitably qualified staff on duty within all services, in accordance with the agreed numbers set by the trust and taking into account national recommendations.
  • The trust must ensure there are the appropriate number of qualified paediatric staff in the ED to meet standards set by the Royal College of Paediatrics and Child Health 2012 or the Royal College of Nursing.
  • The trust must ensure consultant cover meets with the Royal College of Emergency Medicine’s (RCEMs) emergency medicine consultants workforce recommendations to provide consultant presence in the ED 16 hours a day, 7 days a week as a minimum.
  • The trust must ensure processes in place are adhered to for the induction of all agency staff.
  • The trust must ensure ligature points are identified and associated risks are mitigated to protect patients from harm.
  • The trust must ensure risk registers reflect the risks within the trust.
  • The trust must ensure all incidents are reported, including those associated with medicines.
  • The trust must ensure effective and timely governance oversight of incident reporting management, including categorisation of risk and harm, particularly in maternity services.
  • The trust must review the governance structure for all services at the hospital to have systems in place to report, monitor and investigate incidents and to share learning from incidents.
  • The trust must ensure that all trust policies and standard operating procedures are up to date and that they are consistently followed by staff.
  • The trust must ensure all medicines are prescribed and stored in accordance with trust procedures.
  • The trust must ensure patient records are stored appropriately to protect confidential data.
  • The trust must ensure patient records are accurate, complete and fit for purpose, including Do Not Attempt Cardio-Pulmonary Resuscitation forms and prescription charts.
  • The trust must ensure risk assessments are completed in a timely manner and used effectively to prevent avoidable harm, such as the development of pressure ulcers within ED and pain assessments for children.
  • The trust must ensure that mortality reviews are effective with the impact of reducing the overall Summary Hospital-level Mortality Indicator (SHMI) for the service.
  • The trust must ensure there are robust systems are in place to collect, monitor and meet national referral to treatment times within surgery and outpatient services.
  • The trust must ensure there are systems in place to monitor, manage and mitigate the risk to patients on surgical and outpatient waiting lists.
  • The trust must ensure staff check the “site” of the operation to ensure this is appropriately marked, prior to the operation; and ensure that the “site” of the operation is documented on the 5 Steps to Safer Surgery checklist.
  • The trust must ensure all incidents of pressure damage are fully investigated, particularly within ITU.
  • The trust must ensure there is a policy available to ensure safe and consistent practice for parents to administer medicines to their children.
  • The trust must ensure there is a system in place to recognise, assess and manage risks associated with the temperature of mortuary fridges.
  • The trust must ensure clinicians have access to all essential patient information, such as patients’ medical notes, to make informed judgements on the planned care and treatment of patients.
  • The trust must ensure outpatients patients are followed up within the time period recommended by clinicians.

In addition the trust should:

  • The trust should ensure all vacancies are recruited to.
  • The trust should ensure that complaints are responded to within the trust target of 25 days and lessons learnt shared.
  • 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.
  • The trust should ensure all equipment is portable appliance tested annually.
  • The trust should ensure there is an effective audit program and the required audits are undertaken by the services.
  • 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 EDs.
  • 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 ED to be admitted, discharged or transferred within four hours.
  • The trust should ensure re-attendance rates within ED are reduced to meet the target set by the Department of Health.
  • The trust should ensure the changes to manage overcrowding and patient safety in ED are sustainable.
  • The trust should ensure infection controls risks, associated with environmental damage within ED, are mitigated.
  • The trust should ensure changes continue to achieve adequate patient flow and capacity to accommodate emergency admissions in a timely way, ensure surgery cancellations are reduced and enable patients to be discharged from ITU in a timely way.
  • The trust should ensure patients privacy and dignity is maintained when cared for the in the ED corridor.
  • The trust should ensure the improvement of mental health service provisions within ED to prevent delays in specialist care.
  • The trust should ensure that the ED Escalation Management System (EMS) is used accurately and effectively to help the hospital identify the pressure within the ED and appropriate steps taken to reduce pressure as required.
  • The trust should ensure that appropriate plans in place regarding all patients being assessed and treated as requiring a deprivation of their liberty safeguard.
  • The trust should ensure unnecessary patient moves are minimised at night.
  • The trust should ensure all patients have person centred care plans that reflect their current needs and provide clear guidance for staff to follow.
  • Action should be taken to ensure that any chemicals are stored appropriately, and ‘out of bounds’ areas are appropriately secured.
  • The trust should ensure on the day surgical cancellations met the standard target.
  • The trust should consider a follow-up clinic for patients discharged home from after an ITU admission, as recommended in NICE guidance.
  • The trust should ensure the frequency of ward rounds on critical care meet core standards for critical care units.
  • The trust should consider the critical care outreach team providing 24-hour cover for the hospital as recommended in the Guidelines for the Provision of Intensive Care Services 2015.
  • The trust should ensure nutritional supplements are disposed of as per product guidance.
  • The trust should implement the use of the NHS Maternity Safety Thermometer, and ensure robust analysis.
  • The trust should ensure measures are in place to reduce the caesarean section rate.
  • The trust should consider developing an early warning tool for neonates.
  • The trust should ensure that all appropriate equipment is cleaned in line with trust policy to prevent the spread of infection.
  • The trust should ensure a policy on restraint or supportive holding is developed; and provide staff training in restraint
  • The trust should ensure that there is a system in acute paediatric services to check competencies of permanent staff.
  • The trust should ensure there are a suitable number of points for high flow oxygen on the paediatric ward to meet patient need.
  • The trust should ensure the trolley used for transporting bodies to the mortuary is fit for purpose.
  • The trust should ensure cancellation of outpatient appointments are reviewed and necessary steps taken to ensure that issues identified are addressed and cancellations are kept to a minimum.
  • The trust should ensure a suitable digital archiving system for cardiology department is provided.

Following the inspection we issued Hereford Hospital with a warning notice under section 29a of the Health and Social Care Act 2008.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 4 and 5 June 2014

During a routine inspection

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 carried out on 10, 11, 17 October 2013

During a routine inspection

We carried out this inspection under our powers in conjunction with a review conducted by colleagues from NHS England.

During this inspection we visited five wards and spoke with sixteen patients. We spoke individually with 13 clinical, nursing and care staff and attended a focus group of 20 nurses to hear their views. We also spoke with the Director of Nursing and Quality and the Chief Executive of the trust.

During this inspection we intended to focus on pressure area care. In most areas of the hospital we inspected, we found that patients received care that met their needs in this area. We received positive comments about the nursing staff around the hospital. Such comments included: "The staff here are great. Nothing's too much trouble for them," and "The nurses have been brilliant, really patient."

However, when we inspected the Day Surgery Unit we found other concerns. The unit was in use as an inpatient ward to provide additional bed space at the hospital. The layout of the ward and the number of patients in it meant that people's privacy and dignity were significantly compromised.

The care needs of patients on this ward were not fully met, and instances of patients' conditions deteriorating were not identified and responded to in line with their treatment plans.

Staff were not fully supported to meet the needs of the patients receiving care on this ward.

The trust's processes to assess and monitor the quality of its services were not effective, particularly in relation to the operation of the Day Surgery Unit.

Inspection carried out on 26 November 2012

During a routine inspection

A team of four inspectors carried out an unannounced visit to Hereford hospital. We spent time on four wards at the hospital, where we observed the care and support that people received from staff. We spoke with seventeen people using the service and with two relatives who were visiting. We also spoke with staff and we reviewed records.

People were very positive about the staff at the hospital, describing them as, “very cheerful and friendly” and, “very good at asking if I need anything”. We saw that staff were attentive to people's needs and spent time making sure that people had what they needed and were comfortable.

People told us that they felt safe and well cared for at the hospital. One person said, “I feel privileged to have received the treatment I’ve had”. We saw staff providing care and support to people in accordance with their care plans.

Staff had a good understanding and knowledge of people's individual needs. They showed empathy and sensitivity when talking with people. Staff received the training they needed to carry out their roles.

At our previous inspection in March 2012, we had concerns about some aspects of record keeping at the hospital. The trust had sent us a detailed action plan to tell us how they would make the necessary improvements. At this inspection, we found that there were effective systems in place to ensure that records were accurate and fit for purpose.

Inspection carried out on 20 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 3 February and 15 April 2011

During a themed inspection looking at Dignity and Nutrition

People told us that nursing and care staff generally treated them with dignity and respect, but some people felt that medical staff talked about them rather than to them. One person said “You’re just told that things are happening, there’s no explanation” and another told us “the doctors don’t tell you what’s going on”.

Almost everyone we spoke to told us that they enjoyed the food provided by the hospital, and that there was plenty of choice. People told us that they could choose the portion size they wanted, although some people said that they would have preferred larger portions. People did not like the fact that the main course and puddings are served at the same time, and people told us “pudding can get cold if you don’t eat your first course quickly” and “hot puddings go cold and ice cream starts to melt, as it’s all served at the same time”.