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Norfolk and Norwich University Hospital Inadequate

We are carrying out checks at Norfolk and Norwich University Hospital. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Inadequate

Updated 19 June 2018

  • Diagnostic imaging staff were not always trained to the appropriate level for safeguarding children and there was low compliance in some areas of mandatory training.
  • Equipment was ageing and there was no capital replacement programme in place. Specialised personal protective equipment was not always being checked on a regular basis. Resuscitation trolleys were not always being checked on a regular basis.
  • Security and access to controlled areas was not consistent.
  • Contrast media was not stored appropriately, in a temperature monitored and secure area, within the diagnostic imaging service areas.
  • The emergency call bell system within nuclear medicine had not been fit for purpose since 2015.
  • The diagnostic imaging service was not always meeting NHS England Seven Day Services Clinical Standards.

  • Recommended changes to practice as a result of audit findings did not always identify the individual responsible for implementing changes or the date by which the change should have been implemented.
  • Written consent for radiological procedures was not consistently undertaken in line with the trust’s standard operating procedure.
  • The diagnostic imaging environment did not always afford patients with privacy and dignity.
  • Friends and Family Test scores were below the national average, and there were low response rates.
  • Reporting times were not meeting targets in the majority of diagnostic imaging areas.
  • Managers had not identified or put in place actions to address a number of the concerns that were identified during our inspection and action had not been taken to address some of the concerns identified at our previous inspection. Risks were not always resolved or acted upon in a timely manner and the risk register did not reflect all of the risks identified during this inspection.

However:

  • There had been improvements in staff understanding of the incident process and training provided for those undertaking incident investigation and root cause analysis..
  • Progress had been made in the recruitment of new staff to address previously high vacancy levels.
  • Appraisal rates were in line with trust targets and the service offered staff the opportunity for development and progression in their roles.
  • The service was regularly reviewing the effectiveness of care and treatment through a comprehensive range of audits.
  • Staff cared for patients with compassion, involved patients in decisions and provided emotional support to minimise distress. Feedback from patients confirmed that staff treated them well and with kindness.
  • The service took account of patients’ individual needs and offered out of hours, walk-in and one stop services to provide flexibility and choice. The service gathered the views of patients to ensure that services were being provided in a way that met their needs.
  • Staff said that they felt proud to work in the organisation and described supportive relationships with colleagues. Staff said that their managers were approachable and supportive. None of the staff spoken to on this inspection raised concerns about bullying or harassment.

Inspection areas

Safe

Inadequate

Updated 19 June 2018

Effective

Requires improvement

Updated 19 June 2018

Caring

Good

Updated 19 June 2018

Responsive

Requires improvement

Updated 19 June 2018

Well-led

Inadequate

Updated 19 June 2018

Checks on specific services

Outpatients and diagnostic imaging

Requires improvement

Updated 16 March 2016

Outpatient and diagnostic services were rated as requires improvement with caring, and well led rated as good, but safety and responsive were rated as requires improvement, which gives a rating of requires improvement overall.

Incident reporting and correct identification of harm were not robust in either outpatients or radiology services. There had been three ophthalmic never events in the trust in last three years and two in dermatology in the last two years. The consistency of incident reporting was not robust; there was a limited number of staff trained to undertake root cause analysis; and reporting responsibility sat with senior staff members, with little individual feedback or learning. Incidents were not always classified correctly which resulted in under-reporting. There had been three dermatology incidents that we raised with the trust as potentially meeting the never event criteria. The trust held a serious incident meeting at the end of November 2015 to review the incidents and two were raised retrospectively as never events.

The trust was not meeting two of its referral to treatment targets for cancer patients.

The Cromer site was potentially underutilised given the appointment waiting lists at the main Norwich site.

There was effective patient focused care provided by ‘one-stop clinics’ and innovative nurse led clinics. The venous-thromboembolism (VTE) clinic had been recognised nationally winning the British Nursing Journal award for 2015.

Patients and relatives gave high praise for the care received within the trust. Clinics collected patient feedback to improve services. Initiatives were trialled, audited and monitored to improve the safety and experience of patients.

It was evident that there was a strong teamwork ethos with a large number of staff employed for many years within the trust. Staff were very passionate and proud of the services they offered to patients.

Outpatients

Requires improvement

Updated 19 June 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

A summary of our findings about this service appears in the Overall summary.

Maternity and gynaecology

Requires improvement

Updated 10 August 2017

We rated this service as requires improvement because:

  • Incidents were not always classified in line with trust policy.
  • Controlled medicines were not always checked and stored safely.
  • Patient records were not stored securely and records audits indicated continued poor compliance in some areas.
  • Resuscitation equipment was not always checked regularly in line with trust policy. 
  • Mandatory and safeguarding training were below the trust targets.
  • Electronic discharge letters were not always sent within 24 hours meaning women’s general practitioners were not informed of their hospital stay and outcome.
  • Community midwives did not have access to information technology, although this was in the process of being addressed there was no time schedule yet.
  • Patient outcomes were similar to the England average, but maternity dashboard outcomes such as the percentage of women breastfeeding at discharge, readmissions within 30 days and admissions to critical care unit consistently failed to meet targets.
  • The gynaecology service did not meet its referral to treatment (RTTs) waiting times. There were 2543 patients on the gynaecology 18 week RTT incomplete waiting list and a backlog of 617 patients waiting up to 45 weeks for treatment.
  • There was a lack of ownership at ward management level of issues such as checking resuscitation equipment, ward cleaning and medication checking.

However:

  • There have been significant improvements in the investigation of incidents with staff given training and protected time to investigate.
  • Midwifery staffing had improved since the previous inspection, and hospital midwifery staff were over establishment to accommodate leave.
  • Staff provided care according to national guidance and evidence based practice and where they were not using guidance they risk assessed, reviewed and worked towards compliance.
  • Staff contributed to a number of national audits and performed a range of local audits to improve women’s care and shared results.
  • Women we spoke with were very positive about their treatment by all clinical staff and the standard of care they had received.
  • Women were involved in their choice of birth at booking and throughout the antenatal period. In antenatal clinics, women were given information regarding different birthing settings early on in their pregnancy, including the benefits and risks of home birth.
  • Services were planned, delivered and co-ordinated to take account of women with complex needs, there was access to specialist support and expertise from medical and nursing and midwifery staff.
  • There was strong leadership demonstrated from the senior management team, with a clear vision and strategy for the maternity service.
  • The senior management had oversight of clinical risks and there was evidence that risks were regularly reviewed and updated with named ownership of risks.
  • There was a strong drive to improve and develop with multiple innovations including the development of the IT system, and the Baby University scheme.

Medical care (including older people’s care)

Updated 10 August 2017

  • Medicines were not always stored safely in line with trust policy and the temperature of medication requiring refrigeration was not always checked.
  • Staff did not carry out routine checks on resuscitation equipment.
  • Staff compliance with mandatory training, including safeguarding was below the trust target.
  • Most of the wards we visited had vacancies for either registered nurses (RN) or health care assistants (HCA). The vacancy rate across medical wards was 14%. .
  • Staff raised concerns regarding the length of time the trust had been operating with two doctors in training positions rather than three within the medicine division. The trust informed us that the establishment was for two with a third booked to support. The third position was to become permanent in August 2017.
  • We spoke with a number of junior doctors, who were unhappy with the working shift rota and working hours.
  • For medical non-elective patients, the average length of stay was 7.2 days, which is higher than England average of 6.7 days.
  • The following specialties were above the England average for admitted Referral to Treatment Times (RTT) (percentage within 18 weeks), neurology, geriatric Medicine, rheumatology, and dermatology.
  • The majority of staff we spoke with on the wards were unaware of any local vision or strategy held by the trust in relation to the medical division.
  • Some staff felt there was a lack of senior leadership within the medical division.
  • The majority of staff we spoke with said they hardly ever saw the directors on the ward areas. Some staff said they saw them infrequently at bed meetings, but most agreed that the senior team members were not visible.
  • Not all medical and nursing staff we spoke with during our inspection knew medical division risks were held on the electronic system.
  • Some staff felt there was unnecessary pressure placed on them to take and discharge patients from the wards and that at times this was uncomfortable for them to manage.

However:

  • Staff knew how to report incidents and deal with complaints and there was a learning culture within the medicine division.
  • There were clear procedures for managing and referring safeguarding concerns in relation to children and adults who may be at risk of abuse. Staff we spoke with knew how to make a referral and who to refer their concerns to within the trust.
  • We reviewed 21 patient records and found all risk assessments were completed, early warning scores (EWS) and risk assessments clearly documented.
  • Staff adhered to the trust hand hygiene and ‘bare below the elbow’ policy, and wore personal protective equipment such as gloves and aprons during care.
  • Staff used early warning scores (EWS) on the medical wards to monitor and identify any deteriorating patients. All records we reviewed showed that staff routinely completed EWS and alerted senior staff to any patient that may be deteriorating.
  • Between November 2015 and October 2016, the average length of stay for medical elective patients at the trust was 2.9 days, which is lower than England average of 4.1 days.
  • We saw significant improvements in the Acute Medical Unit Men (AMUM) and Acute Medical Unit Ladies (AMUL) performance due to changes in the physical environment.
  • Patients living with dementia and those who had suffered a stroke had “This is me.” documentation in place. The division had a dementia strategy and delirium strategy in place and supported by a dedicated dementia team.
  • The speech and language therapy (SaLT) team saw patients who had had a stroke promptly to reduce the time patients spent nil by mouth.
  • If patients had complex needs or required additional family support, staff made special arrangements regarding visiting and access to patients outside of normal visiting hours
  • The trust had significantly invested in the recruitment of discharge co-coordinators who worked across the wards to promote the safe and timely discharge of patients.
  • All staff we spoke with knew how to report a complaint and that feedback from complaints would be shared on a one-to-one basis where necessary or via team meetings.
  • There were several established systems to ensure good clinical governance and monitor performance.
  • The majority of staff we spoke with felt supported and valued by their direct line manager.
  • Junior nurses we spoke with told us that the medical division was a good place to start their career.

Diagnostic imaging

Requires improvement

Updated 19 June 2018

Urgent and emergency services (A&E)

Inadequate

Updated 19 June 2018

Our rating of this service went down. We rated it as inadequate because:

A summary of our findings about this service appears in the Overall summary.

Surgery

Inadequate

Updated 19 June 2018

Our overall rating of this service went down. We rated it as inadequate.

A summary of our findings about this service appears in the Overall summary.

Intensive/critical care

Good

Updated 16 March 2016

The safety of critical care at Norfolk and Norwich University Hospital required improvement. The effective, caring, responsive and well-led domains were good.

Patients and their relatives were treated with respect and dignity by competent staff who were passionate and provided treatment in line with national standards and benchmarks. Staff were proactive in reporting incidents and senior staff on the unit conducted thorough investigations that had led to improvements in practice. The critical care complex (CCC) was clean and well-maintained and staff demonstrated an acute understanding of how to provide person-centred care that met the treatment needs of individuals and also considered their wellbeing and social needs.

The mortality rate of the CCC was consistently lower than the national average for similar units, at 15%. Staff used care bundles appropriately and audited these regularly. Multidisciplinary input into patient treatment plans was available but significant short staffing meant that the unit did not have a full time pharmacist and that the presence of physiotherapists and microbiologists on ward rounds was inconsistent.

Medical staffing out of hours did not meet the requirements of the Intensive Care Society (ICS). Nurse staffing levels did not meet the recommended requirements of the Royal College of Nursing (RCN) or the Faculty of Intensive Care Medicine (FICM), with each shift regularly short of up to four nurses. A supernumerary senior nurse coordinator was not always available out of hours on the intensive care unit.

In 2014/15, 63.6% of patients experienced a delayed discharge of four hours or more. Introduction of a more robust escalation process had started to reduce delayed discharges through more effective clinical and operational governance. Staff were encouraged to contribute to the development and improvement of the service.

Staff were not always listened to or engaged with appropriately by the trust’s senior leadership team when they had escalated areas of concern or risk.

In the year prior to our inspection the unit had experienced significant disruption to its staff team, including the departure of two matrons. We found that staff had established a coherent, mutually supportive working environment and culture and were positive about the changes that had been implemented by a new matron and operational manager.

Services for children & young people

Updated 10 August 2017

  • Patient care records were clear, detailed, and contained all necessary information.
  • Additional security measures had been introduced throughout the children and young people’s service. All areas were found to be secure during our inspection. This addressed concerns raised during our previous inspection.
  • Staff were knowledgeable about the incident reporting process. There was evidence of learning and communication to staff regarding outcomes of investigations.
  • Staff across the children and young people’s service were knowledgeable about the complaints process. Staff gave us examples of complaints that had led to changes in practice.
  • The service was planned and delivered to meet the needs of local people. For example, accommodation was available for parents to stay on the neonatal unit and an outreach team supported the discharge process.
  • The service met the individual needs of patients, including those in vulnerable circumstances. For example, there were support groups and a family care coordinator for parents on the neonatal unit.
  • An electronic bed booking system had been introduced on the children’s day ward to improve list utilisation.
  • A paediatric flow coordinator role was introduced in April 2017. This role would support patient flow throughout the children and young people’s service.
  • A child and adolescent mental health service (CAMHS) was introduced in April 2017 and was available seven days a week, meaning that children and young people suffering from mental health problems could be assessed on the same day as their admission.
  • Staff described a positive and open culture with approachable and visible local leadership in the children and young people’s service.
  • The majority of staff demonstrated an awareness of the trust vision and values.
  • Action had been taken to address some of the concerns that were identified on our last inspection. For example, additional security measures had been introduced across the service, cytotoxic waste was now being segregated and disposed of appropriately, and a bank healthcare assistant was being used on the children’s day ward.
  • Senior leaders were well sighted on the risks in the division. There was a clear strategy in place for the development of services.
  • There were regular governance and quality meetings within the division with good attendance form staff.
  • Staff were increasingly given an opportunity to contribute to the direction and strategy of the division.

However:

  • Only 16% of incidents were reported to the National Reporting and Learning System (NRLS) within 60 days.
  • Checks of resuscitation equipment were inconsistent.
  • Mandatory training compliance was below the trust target of 95% in February 2017. Compliance rates for medical staff (67.1%) were much lower than for nursing staff (86.9%).
  • Registered nursing staffing levels regularly fell below basic levels on Buxton ward and healthcare assistants were used to increase staffing numbers when this occurred.
  • There were insufficient numbers of qualified staff to fill the rota to the recommended levels for the four paediatric high dependency unit (HDU) beds on Buxton ward. In the interim, practice educators, the ward sister and staff with relevant experience but no HDU qualification were used to support the rota.
  • Consultant cover in the children’s assessment unit did not meet national guidance. However, consultant cover had been increased from previous levels and a CAU improvement project was underway at the time of our inspection, which included a review of the level of consultant cover.
  • Cohort nursing, where infectious patients are treated together in one area away from other patients, was practiced on the children’s assessment unit due to the lack of side room availability. This presented an increased risk of cross infection. However, an integrated performance report showed that daily audits were undertaken as a monitoring precaution.
  • Paediatric surgery and neonatal mortality and morbidity meeting minutes lacked detail and this limited the opportunity for shared learning with those unable to attend. It was not clear who attended meetings as only initials were recorded and the minutes for the February 2017 surgery meeting appeared to indicate that only one person was in attendance.
  • The children and young people’s service had lost access to four transitional beds for young people aged 16 to 18.
  • There were increased admission times on the children’s assessment unit (CAU) due to an increasing number of attendees with no increase in bed spaces.
  • Referral to treatment time (RTT) was not met consistently across all sub-specialties, meaning that children were not always treated within 18 weeks of referral.
  • Staff said that they rarely or never saw the director of nursing or the executive team.
  • Staff said that there was a lack of out-of-hours management support on Buxton ward.
  • The risk register did not reflect all of the risks identified on our inspection. For example, the inconsistent checks of resuscitation equipment and children being admitted onto non-paediatric wards where staff were not always appropriately trained in safeguarding or paediatric resuscitation.
  • A number of the concerns identified during our previous inspection had not been addressed. For example, mandatory training compliance levels, inconsistent checks of emergency resuscitation equipment, and nursing staffing levels.

End of life care

Requires improvement

Updated 19 June 2018

A summary of our findings about this service appears in the Overall summary.