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Inspection Summary


Overall summary & rating

Good

Updated 10 August 2016

The Royal Bolton hospital is part of Bolton NHS Foundation Trust, which provides a range of hospital and community health services in the North West Sector of Greater Manchester, delivering services from the Royal Bolton Hospital (RBH) site in Farnworth, in the South West of Bolton, close to the boundaries of Salford, Wigan and Bury; and also providing a wide range of community services from locations within Bolton.

The Royal Bolton hospital site is situated in the town of Farnworth, near Bolton. For services, in particular patients requiring non-elective treatment, it is estimated to have a catchment population of 310-320,000, compared with a resident Bolton population of 270,000.

The Royal Bolton hospital provides a full range of acute and a number of specialist services including urgent and emergency care, general and specialist medicine, general and specialist surgery and full consultant led obstetric and paediatric service for women, children and babies,

including level three neonatal care and 24-hour paediatric and consultant-led obstetric services

.

Approximately 110,000 people

attend the trust for emergency treatment every year and 72,000 patients are admitted. Approximately 310,000 attend the outpatient departments for consultations. The Royal Bolton Hospital has approximately

740

beds and employs 5200 staff.

We visited the hospital on 21-24 March 2016. We also carried out an out-of-hours unannounced visit on 6 April 2016. During this inspection, the team inspected the following core services:

• Urgent and emergency services

• Medical care services

• Surgery

• Critical care

• Maternity and gynaecology

• Children and young people

• End of life

• Outpatients and diagnostic services

Overall, we rated Royal Bolton Hospital as good. We have judged the service as ‘good’ for effective, caring, responsive and well led. We found that compassionate, caring staff provided services and patients were treated with dignity and respect. However, improvements were needed to ensure that services were safe.

Our key findings were as follows:

Leadership and Management

  • There was a positive culture and a sense of pride throughout teams in the hospital, and staff were committed to being part of the trusts vision and strategy going forward.

  • There was effective teamwork and clear leadership and communication in services at a local level. Managers and leaders were visible and approachable. Staff felt supported by their managers and there was an open culture of transparency and communication in between teams.

  • The hospital was led and managed by an executive team that were approachable and visible. Staff knew the team and felt that they were listened to and concerns were acted upon.

Access and Flow

  • Access and flow remained a challenge, and the emergency department did not at times see, treat, admit or discharge patients within four hours. Between July 2014 and November 2015 the trust met the target to admit, transfer or discharge patients within four hours for six out of 17 months. However, the total average time spent in the emergency department between January 2013 and October 2015 was below the England average, ranging between 50 and 139 minutes.

  • Plans were in place to expand the emergency department in order to accommodate the increase in patient attendances, of which notable there had been an increase in patients attending from outside of Bolton and patients being brought in by ambulance.

  • There were some pressures with access and flow across the medical and surgical wards, including patients who were medically optimised for discharge, but awaiting further care arrangements to be agreed. Access and flow issues resulted in a number of patients being cared for on a ward outside of their speciality. Between August 2015 and November 2015, data showed there had been 208 medical outliers at the hospital. There were policies and procedures in place outlining the management of these patients to ensure that patients were seen by the appropriate medical teams at the right time.

  • The trust had put a number of initiatives in place, including theatre productivity initiatives and opening additional beds to support access and flow through the hospital. There were also established escalation procedures in place, which were supported through regular bed planning meetings.

  • The overall hospital-wide bed occupancy rate between

    July 2013 and December 2015

    ranged between

    80.8% and 88%, which rose to 91% on medical wards between January and March 2016.

  • In spite of pressures, we observed that the average length of stay for elective medicine at the hospital was shorter (better) than the England average at 2.9 days. The England average was 3.8 days. For non-elective (not planned) medicine, it was shorter (better) than the England average at 5.8 days. The England average was 6.8 days.

  • NHS England data showed the surgical and gynaecology services consistently performed better than the England average for 18-week referral to treatment standards for admitted (adjusted) patients between November 2014 and January 2016.

  • Records between April 2015 and January 2016 showed the surgical services also achieved the historical 90% standard for 18-week referral to treatment standards for admitted (adjusted) patients for general surgery, ENT, ophthalmology, urology and oral surgery during this period. However, the trauma and orthopaedics specialty (84.5%) and oral surgery (77.65) did not perform as well other specialties during this period.

  • Most patients were admitted to the intensive care unit within four hours of making the decision to admit them and a consultant assessed 100% of patients within 12 hours of admission.

Cleanliness and Infection control

  • Clinical areas at the point of care were visibly clean and trust had infection prevention and control policies in place, which were accessible to staff and staff were knowledgeable on preventing infection.

  • There was enough personal protective equipment available, which was accessible for staff and staff used this appropriately.

  • Staff followed good practice guidance in relation to the control and prevention of infection in line with trust policies and procedures.

  • Between April 2015 and December 2015, the trust reported 19 cases of Clostridium difficile, 4 cases of Methicillin-resistant staphylococcus aureus (MRSA) and 18 cases of Methicillin-susceptible staphylococcus aureus (MSSA).

  • Lessons from all cases were disseminated to staff for learning across directorates

    .

  • There were established audit programmes in place related to the prevention of cross infection, which included

    hand hygiene, infections within a central line (a long, thin, flexible tube used to give medicines, fluids, nutrients, or blood products) and

    methicillin-resistant Staphylococcus Aureus

    (MRSA).

Nurse staffing

  • The trust undertook biannual nurse staffing establishment reviews as part of mandatory requirements. As part of this, key objectives were set though this work to support safer staffing.

  • The trust was in the process of implementing a daily acuity tool to further support safer staffing levels based on patients acuity.

  • There were processes in place to ensure ward staffing levels were monitored on a daily basis. Senior nurses and matrons met each week to discuss nurse staffing levels across services to ensure that that there were sufficient numbers of staff. Staffing on a day-to-day basis was reviewed as part of the trust bed management meetings.

  • However, nurse staffing levels remained a challenge, particularly in emergency, medical and the paediatric department. Nursing staffing was identified on both operational and corporate risk registers. At the time of this inspection there were 50 nursing staff vacancies across the trust and additional posts had been made available in order to support the increased requirements across the across the hospital.

  • Staffing levels were maintained by staff regularly working extra shifts and with the use of bank or agency staff. Inductions were in place for new staff in order to mitigate the risk of using staff that were not familiar with the hospital.

Medical staffing

  • Whilst most areas had sufficient numbers of medical staff to meet patients needs, which included the use of agency staff, there were pressures within the emergency department due to increased demand.

  • Increased activity in the emergency department had meant that emergency department consultants were regularly working in place of middle grade staff to ensure the department continued to function with safe medical staffing levels. We observed that medical staff were committed to maintaining patient safety and ensuring that rotas were covered.

  • A recent review by the Royal College of Emergency Medicine had recommended an increase in establishment of consultants of 6.5 WTE, which was being considered at the time of this inspection. In addition, it had been recommended to increase medical middle grade staffing by five WTE. Whilst the shifts we reviewed showed that staffing levels were safe, we were concerned that the current use of consultants to fill middle grade shifts may not be sustainable in the long term.

  • Locum doctors were also used to boost medical staffing levels, particularly in the emergency department. Between May 2014 and March 2015, the average rate of locum use in this area was high at 21.5%.

  • The trust board had recently authorised recruitment for two middle grade doctors and relaxed the cap on locum use to assist with staffing. However, managers described difficulties recruiting due to the high volume of patients attending the ED compared with other EDs.

Mortality rates

  • Mortality and morbidity reviews were held in accordance with trust policies and were underpinned by policies and procedures. All cases were reviewed and appropriate changes made to help to promote the safety of patients. Key learning Information was cascaded to staff appropriately. Monitoring arrangements were in place at board level to ensure that any findings were acted upon.

  • The Summary Hospital-level Mortality Indicator (SHMI) is a set of data indicators, which is used to measure mortality outcomes at trust level across the NHS in England using a standard and transparent methodology. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die based on average England figures, given the characteristics of the patients treated at the hospital. The risk score is the ratio between the actual and expected number of adverse outcomes. A score of 100 would mean that the number of adverse outcomes is as expected compared to England. A score of over 100 means more adverse (worse) outcomes than expected and a score of less than 100 means less adverse (better) outcomes than expected. In November 2015, the trust score was 104.

  • The sentinel stroke national audit programme (SSNAP) is a programme of work that aims to improve the quality of stroke care by auditing stroke services against evidence-based standards. The latest audit results rated the hospital overall as a grade ‘D’ which was an improvement from the previous audit results when the hospital was rated as the ‘E’. The trust had put in place actions to improve the audit results. These included a dedicated social worker on the stroke unit and further training for staff.

Nutrition and Hydration

  • Patients and people close to them attending departments had access to food and drink whilst visiting this hospital, including a café that was open out of hours and vending machines in areas such as the emergency department.

  • Patients were able to choose from a wide range of meals, which took account of their individual preferences, including religious and cultural requirements. Most patients felt that the quality of food offered was of a good quality.

  • We found that there were policies and procedures in place to support patients nutritional and hydration needs and staff across the hospital knew how to access them.

  • The hospital used part of the malnutrition universal screening tool (MUST) to assess patient’s nutritional needs. An audit of the completion of the tool was undertaken as part of the food standards assessment and the trust scored an amber rating. Nutrition champions are now in place who undertake regular audits of nutrition and hydration standards.

  • We found that patients nutritional needs were risk assessed and results were acted upon appropriately, however on some medical wards, fluid balance charts and nutrition charts had not been completed promptly.

  • There was a system in place to identify patient in needs of assistance with eating and drinking. We found that most patients received assistance with eating and drinking as needed.

  • Staff and patients had access to specialist nutritional advice from the dietician team who responded promptly to patient referrals.

  • Breast feeding support was available for mothers after discharge. Post-natal support for breast-feeding was provided by peer support workers.

We saw several areas of outstanding practice including:

  • The emergency department had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicine.

  • The emergency department offered bereavement meetings were offered to those who had lost a loved one, to help them understand what had happened.

  • Emergency department Consultants were regularly working in place of middle grade staff to ensure the department continued to function with safe medical staffing levels.

  • The radiology department had a managed equipment programme in place. This meant that equipment was serviced, repaired and replaced as part of the contract in a timely way, minimising disruption to services and reducing the need for costly and time consuming business cases when equipment needed replacing. This was an innovative way of managing high cost equipment.

  • The trust were early adopters of the neonatal behaviour evaluation scale (NBES). The scale represents a guide that helps parents, health care providers and researchers understand the newborn’s language.

  • The neonatal unit were early adopters of volume ventilation.

  • The neonatal unit introduced ‘Matching Michigan’, a two-year programme designed to reduce infections in central lines, before it was rolled out as best practice. The service was nominated for an award from the Health Service Journal (HSJ) for this.

  • The neonatal unit introduced the ‘fresh eyes initiative’, which is where nursing staff look at other nurses’ patients at 1am and 1pm to promote things not being missed.

  • There was a visible person-centred culture with caring, compassionate staff who considered the needs of patients nearing their final days or hours and their families. There were systems in place to support this, including the butterfly logo. This was embedded throughout the organisation so that any staff coming into contact with bereaved families could offer care and support where this may be needed.

  • The trust had adopted the ‘butterfly symbol’, which made staff aware of a family in need (identified by the symbol). This ensured that during difficult times families were supported (for example by staff offering drinks etc.). The scheme also ensured that the deceased’s property was put into a special bag (with the butterfly symbol on). Relatives were offered a fingerprint, lock of hair and photo (from medical illustration) of the deceased patient.

  • We observed nurse interaction with patients living with dementia on the bluebell ward, using a variety of dementia friendly strategies. Staff used aids, for example dolls, computers, karaoke and a piano. Interaction was approached in a caring way, and tailored to support each patients individual needs.

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

Importantly, the trust must:

  • Complete mental health assessment forms in the emergency department as soon as practicable and ensure these are distributed and used where appropriate.

  • Improve appraisal rates in the emergency department.

  • In the emergency department, Improve the focus on audits, ensuring clear action plans are formulated and progress regularly tracked to improve outcomes

  • Ensure that robust information is collected, analysed, and recorded to support clinical and operational practice in medical services.

  • Must ensure that there are sufficient staff with the appropriate skills on wards.

  • Must ensure that records are kept secure at all times so that they are only accessed and amended by staff.

  • The trust must ensure that staff are up to date with appraisals and mandatory training in medical wards.

  • The trust must ensure that paper and electronic records are stored securely and are complete in outpatients areas.

  • The trust must ensure that essential safety checks are completed and records of checks are maintained to provide assurance that all steps are being taken to maintain patient safety in outpatients.

In addition the trust should:

In urgent and emergency care services :

  • Ensure building work continues at a suitable pace.

  • Improve staffing levels in the emergency department with an aim to reducing agency and locum rates.

  • Review the security arrangements for both paediatric entrances to ensure the trust is satisfied the risk is mitigated as far as possible.

  • Consider the addition of facilities appropriate for adolescents in the paediatric area

  • Review the number of computer terminals in the clinical areas to ensure this meets the needs of staff during peak periods.

  • Continue to work to improve figures in relation to Department of Health targets.

In medical care services :

  • The trust should ensure that hazardous chemicals are stored appropriately in a locked cupboard when not in use.

  • The trust should ensure that patient is discharged as soon as they are fit to do so.

  • The trust should wherever possible ensure that patients are cared for on a ward suited to meet their needs.

  • The trust should ensure that patients’ privacy and dignity is maintained at all times

  • The trust should ensure that equipment and facilities in the endoscopy mobile unit are fit for purpose

  • The trust should ensure that procedures and assessments in place to provide safe care are completed correctly. Especially comfort round and fluid and nutrition charts and assessments.

In surgical services :

  • Take appropriate actions to minimise the occurrence of never events.

  • Take appropriate actions to improve staff appraisal rates.

In Maternity and Gynaecology

:

  • Consider improving the electronic patient management systems.

Children and young people’s services

:

  • Review the door exit systems on the paediatric and neonatal unit to improve security.
  • Ensure all staff working with children and young people have level three safeguarding training.
  • Ensure that there is a trained Advanced Paediatric Life Support or European Paediatric Life Support nurse on each shift.
  • Ensure there is sufficient staff to match patient acuity on the paediatric unit,
  • Ensure that all paediatric staff have a good working understanding of the Mental Capacity Act and how it works in practice.
  • Ensure the risk register highlight all risks and controls that are in place and is periodically reviewed.
  • Ensure that neonatal practitioners all have current NLS training certification

In end of life services:

In relation to DNA CPR:

  • In all cases assess and record patients’ mental capacity as part of the DNA CPR assessment.
  • Document a summary of communication with the patient, welfare attorney and/or next of kin (NOK).
  • Document consent.
  • Ensure private rooms are available to break bad news to bereaved family and friends of a deceased patient

In outpatients and diagnostic imaging services :

  • The trust should ensure that medical gases are stored safely and securely.

  • The trust should ensure that letters are provided to GPs in a timely way.

  • The trust should ensure that patients are kept informed about any delays in outpatient and diagnostic imaging services and should monitor how long patients wait to be seen.

  • The trust should ensure that the recovery plan for breast screening is completed within agreed timeframes.

  • The trust should consider participating in the Imaging Services Accreditation Scheme (ISAS) and the Improving Quality in Physiological Services (IQIPS) accreditation scheme.

  • The trust should consider how to meet the need to see patients in the TIA clinic with 24 hours over weekend and bank holiday periods.

  • The trust should consider how the privacy and dignity of inpatients can be maintained in the main radiology department.

  • The trust should consider how to manage environmental capacity in the eye unit and breast unit.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 10 August 2016

Effective

Good

Updated 10 August 2016

Caring

Good

Updated 10 August 2016

Responsive

Good

Updated 10 August 2016

Well-led

Good

Updated 10 August 2016

Checks on specific services

Maternity and gynaecology

Good

Updated 10 August 2016

Medical care (including older people’s care)

Good

Updated 10 August 2016

We rated medical services as good because :

  • Clinical staff had access to information they required, for example diagnostic tests and risk assessments.

  • Staff were clear about the procedures in relation to assessing patients for capacity and in the completion of capacity assessments and deprivation of liberty forms.

  • The hospital had implemented appropriate schemes to help meet individual patient needs.For example those living with dementia.

  • Care was provided in line with national best practice guidance and the level ofpain patients were in was monitored effectively

  • Staff were committed to delivering good, compassionate care and were motivated to work at the hospital.

  • There were systems in place to keep people safe and staff were aware of how to ensure patients’ were safeguarded from abuse. The hospital was relatively clean and staff followed good hygiene practices.

  • Best practice guidance in relation to care and treatment was usually followed and medical services participated in national and local audits. Action plans were in place if standards were not being met.

  • We observed care and found this to be compassionate from all grades of support and clinical staff and patients were involved in their care and treatment and could access emotional support if they needed to.

  • The hospital had implemented a number of schemes to help meet people’s individual needs, such as the forget-me-not sticker for people living with dementia or a cognitive impairment and a red symbol to indicate that a patient was frail or elderly. This helped alert staff to people’s needs.Medical services had access to psychiatric liaison services to help support patients who had dementia or a cognitive impairment and who had challenging behaviour

  • Medical services captured views of people who used the services with changes made following feedback.A survey showed that people would recommend the hospital to friends or a relative.

  • All staff knew the trust vision and behavioural framework and said they felt supported and that morale was good.All staff were committed to delivering good, compassionate care and were motivated to work at the hospital.

However,

  • We found records were left unsecured on a number of wards we visited and there was a risk that personal information was available to members of the public.

  • There were standards for record keeping that required improvement but records did include a treatment plan for each patient.

  • Oxygen was not being stored in line with guidance and resuscitation equipment was not always being checked. We found occasions where the temperature of fridges used to store medications were not always checked.However, there was good management of safe administration and prescribing of medication.

  • There were concerns in relation to nursing staffing on some of the wards especially at night and there had been a reliance on agency or bank nurses as well as locum doctors.

  • We found there was insufficient bed capacity on occasions to meet the needs of people within the hospital but there where systems in place to ensure they were reviewed by the medical team.

  • We observed care and found this to be compassionate, however, privacy and dignity was not always being maintained on the discharge lounge.

  • There were governance structures in place which included a risk register. Some actions on the register had still not been completed despite being past the target date for completion.

Urgent and emergency services (A&E)

Requires improvement

Updated 10 August 2016

  • The Emergency Department (ED) regularly saw more patients than the infrastructure was built to accommodate. Building work was in progress to expand the ED.
  • There was no assigned room for mental health patients to stay whilst in the department and no formal environmental risk assessments to record risks associated with mental health patients or the environment they were placed in. A room was under construction which would reduce the risks posed to patients.
  • One of two entrances to the paediatric ED was via an unlocked door, which posed a risk of unauthorised access. There was no area designed for adolescents.
  • Patient outcomes were measured through audits at both national and local level. Improvements were evident in audit results relating to sepsis care. However we were less assured about the work done to improve all other national audit results given that the trust had no formal action plans in place.
  • Staff described a limited number of computer terminals causing delays during busy periods.
  • Whilst some training was up to date, we were less assured about advanced life support training for nurses and competencies for reception staff.
  • Annual appraisal rates were below the trust target of 85%.
  • Access and flow remained a problem and despite efforts to address this, the ED missed the target to see, treat, admit or discharge patients within four hours over the last two winter seasons. Additionally, the number of patients waiting between four and 12 hours following a decision to admit was above the England average.
  • Staff felt supported by leaders in the department. Senior staff felt supported by the trust executive team but reported it had taken some time to establish this.
  • Despite these issues, the department was visibly very clean and tidy.
  • Fridges storing medicines requiring low storage were within the correct temperature range and checked regularly. Equipment was stored in an organised way, within expiry date for portable appliance testing.
  • A central safeguarding team and safeguarding link nurses with specialist knowledge worked within the ED.
  • Records were legible, and included the correct details
  • Major incident equipment was in place and equipment for patients suffering viral haemorrhagic fever such as Ebola was fit for purpose and regularly checked. Practice educators worked in the department to ensure other staff competencies were maintained.
  • Staff cared for patients using national and local guidelines, policies, protocols and pathways. Pain was checked and managed for patients where necessary. Patients were offered food and refreshment whilst in the department.
  • Staff worked together to provide services. These included doctors, nurses, physiotherapists, the safeguarding team, police, the rapid assessment interface discharge (RAID) team, Age UK and other NHS trust’s emergency planning teams.
  • Staff worked under the principle of implied consent when caring for and treating patients. They knew who to contact to organise assessments of patients under the Mental Capacity Act 2005.
  • Patients spoke highly of the care they received, describing staff as friendly, calm and caring, introducing themselves and taking time to listen and explain care.
  • Staff invited people who had lost a loved one back to the ED to meet with staff and answer any questions about what happened, to help with the grieving process.
  • Staff were familiar with local people and their needs. Language interpretation was available for patients or loved ones and Hearing loops were available for people with hearing problems. Loved ones were able to access quiet rooms if they wished.
  • Complaints were dealt with at the time they occurred, if possible. Formal complaints were referred to the trust’s patient advice and liaison team.
  • Staff were aware of the vision and values held by the trust and plans to expand the ED in the future.
  • Governance, risk and quality was measured and recorded appropriately.
  • Innovative work to assist bereaved relatives took place and the department focused on the new build and community supportive strategies to ensure future sustainability.

Surgery

Good

Updated 10 August 2016

We gave the surgical services at the Royal Bolton Hospital an overall rating of good. This was because: -

  • Patient safety was monitored and incidents were investigated to assist learning and improve care. Patients received care in visibly clean and appropriately maintained premises. Medicines were stored safely and given to patients in a timely manner.
  • Most staff had completed their statutory and mandatory training and the hospitals internal targets for training completion were achieved. The staffing levels and skills mix was sufficient to meet patients needs.
  • The surgical services reported four never events between January 2015 and January 2016. A never event is a serious, largely preventable patient safety incident that should not occur if the available preventative measures have been implemented by healthcare providers.
  • Remedial actions were taken to learn from these never events and to minimise the risk of reoccurrence. Most remedial actions had been completed and staff were working to implement the remaining actions. There were clear timelines in place for the completion of these actions.
  • The services provided effective care and treatment that followed national clinical guidelines and staff used care pathways effectively. The services performed in line with the England average for most safety and clinical performance measures.
  • Patients received care and treatment by trained, competent staff that worked well as part of a multidisciplinary team. The majority of staff had completed their annual appraisals. However, the hospitals internal target of 85% appraisal completion had not been achieved across all the surgical specialties.
  • Patients and their relatives spoke positively about the care and treatment they received. They told us they were kept fully involved in their care and the staff supported them with their emotional and spiritual needs. Patient feedback from the NHS Friends and Family Test showed that most patients were positive about recommending the surgical wards to friends and family.
  • Services were planned and delivered to meet the needs of local people. The surgical services achieved the 18 week referral to treatment standards across most specialties.
  • The proportion of elective operations cancelled at the hospital was either similar to or slightly worse than the England average from April 2013 to December 2015. However, the services performed better than the England average for the number of patients whose operations were cancelled and were treated within the 28 days.
  • Actions taken to improve patient access and flow by opening an additional ward to increase capacity for day surgery and elective admissions. A theatre productivity and safety project was also in place to improve theatre efficiency.
  • There were systems in place to support vulnerable patients. The majority of complaints about the services were resolved within the expected time frames and complaints were shared with staff to aid learning.
  • The hospitals vision and values had been cascaded across the surgical services. Key risks to the services, audit findings and performance was monitored though routine departmental and divisional governance and integrated performance meetings.
  • There was effective teamwork and clearly visible leadership within the services. Staff were positive about the culture within the surgical services and the level of support they received from their managers.

Intensive/critical care

Good

Updated 10 August 2016

We gave the critical care services at the Royal Bolton Hospital an overall rating of good. This was because: -

  • Patient safety was monitored and incidents were investigated to assist learning and improve care. Patients received care in safe, clean and suitably maintained premises.
  • There were plans to build a combined critical care unit by 2019. In the interim, risk assessments had been carried out minimise the risk to patients. The control measures included visible prompts and floor markings, additional infection control training and monitoring of staff compliance and restricting visitors to a maximum of two per bed.
  • Most staff had completed their mandatory training and the hospitals internal targets for training completion were achieved. The staffing levels and skills mix was sufficient to meet patients needs and staff assessed and responded to patients risks.
  • The critical care services provided care and treatment that followed national clinical guidelines and staff used care pathways effectively. The service performed in line with expected levels for most performance measures in the Intensive Care National Audit and Research Centre (ICNARC) audit.
  • Patients received care and treatment by multidisciplinary staff that worked well as a team. Staff understood the legal requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.
  • Patients and their relatives spoke positively about the care and treatment they received. They were supported with their emotional and spiritual needs. Feedback from surveys showed patients or their relatives were positive about recommending the services to friends and family. There were systems in place to support vulnerable patients.
  • There was sufficient capacity to ensure patients could be admitted promptly and receive the right level of care. Bed occupancy levels were similar to or slightly lower than the England average between March 2015 and February 2016. Most patients were admitted to the ICU within four hours of making the decision to admit and assessed by a consultant within 12 hours of admission.
  • Remedial actions were being taken to reduce delayed discharges, including increased consultant presence on the HDU and analysing admission data to predict capacity issues. Staff also took appropriate steps to minimise the impact to patients privacy and dignity.
  • The hospitals vision and values had been cascaded across the critical care services. Key risks monitored though routine departmental and governance meetings. There was effective teamwork and clearly visible leadership within the services.
  • Staff were positive about the culture within the critical care services and the level of support they received from their managers. The services participated in a safety culture survey during 2015, which showed staff were positive about morale, training and overall safety culture.
  • The ICU team received the team of the year award in 2015 following their work on patient diaries, ICU follow up and for their work to facilitate the discharge of three patients that expressed a preference to die in their own home.

However, we also found that: -

  • The intensive care unit (ICU) and one bay in the high dependency unit (HDU) did not have sufficient bed space of a minimum of 25.5M2 as outlined in the Department of Health Health Building Note HBN 04-02 (critical care units) guidelines.
  • There were 60 delayed discharges over four hours on the ICU between September 2015 and February 2016. However, there were 246 delayed discharges over four hours on the HDU during this period. The delayed discharges were mainly due to a lack of available ward beds across the hospital.
  • The presence of patients with delayed discharges meant there were three mixed sex breaches on the ICU between January 2015 and March 2016. However, there were 40 mixed sex breaches in the HDU during this period; 25 of these breaches occurred between January 2016 and March 2016.

Services for children & young people

Good

Updated 10 August 2016

Overall we rated children and young people’s services at Bolton NHS Foundation Trust as good. This was because:

  • Processes were in place to use available evidence to achieve good outcomes for children and young people.

  • Guidelines were based on national standards of best practice and audits were undertaken to identify compliance with action plans for improvements.

  • Systems were in place to support children and young people and their families to provide informed consent to procedures.

  • Staff were kind and compassionate in their communications with parents and their children. They were given information in a way they could understand.

  • Children and young people felt informed and involved in their treatment options. Regard was given to emotional health and support was provided to promote independence when the child was discharged.

  • Children and young people were involved in their care and were aware of their treatment options.

  • Feedback from children and young people who used the service and their families was positive with quotes that the service was ‘excellent’ and that parents were ‘very pleased with the care and the explanations given.’

  • Individual needs were considered and needs met wherever possible in a way that did not single people out as different.

  • There were strong links with community resources which helped provide continuity of care for patients when they were discharged from hospital.

  • Senior staff were represented at trust board level and felt children’s services were listened to and action was taken, where necessary.

  • Partnership working and engaging with patients and staff was a priority for the management team.

  • Innovation and improvement was encouraged and implemented.

However, there were some concerns, particularly within the safe domain:

  • Paediatric nurse staffing did not meet Royal College of Nursing (RCN) guidance in terms of patient to staff ratios in 41 out of 87 shifts (47.1%) over one month that we reviewed.

  • Paediatric nurse staffing did not meet RCN guidance in terms of the Advanced Paediatric Life Support (APLS) or European Paediatric Advanced Life Support (EPALS) requirements as there was no suitably trained nurse on shift in 36% of the shifts we reviewed.

  • Neonatal nurse staffing was not compliant with British Association of Perinatal Medicine (BAPM) guidance in terms of the patient to staff ratio. Over a three month period the figures varied from 95.4% to 82.9% compliant.

End of life care

Good

Updated 10 August 2016

We rated End of Life Care as ‘Good’ overall. This was because:

  • There were no ‘Never Events’ or serious incidents in the year prior to our inspection, processes were in place to ensure that learning from incidents took place and duty of candour was undertaken when required.

  • End of Life staff were 100% compliant with mandatory training.

  • A rapid discharge pathway checklist enabled Pharmacists to process prescriptions quickly.

  • The Specialist Palliative Care Team (SPCT) responded promptly when required and worked in line with best practice and national guidelines.

  • The partook in the National Care of the Dying Audit and the results showed that they scored above the England average for the majority of indicators.

  • There was a proactive and comprehensive end of life care training programme in place.

  • There was good evidence of multidisciplinary team working across the hospital and in community settings.

  • There was a visible person-centred culture with caring, compassionate staff who considered the needs of patients nearing their final days or hours and their families.

  • There was a co-ordinated approach to meeting the needs of the local population and involving other organisations.

  • There was a clear work plan in place for end of life care that showed measurable progress.

  • There was good leadership with a clear view of strategy.

  • Staff told us that the management team worked well together and that they were proud of the service that they provided.

  • The mortuary staff had won the ‘Non-clinical Team of the Year Award’ in 2015 and were very proud of this.

However:

  • Consultant cover at the hospital was not at establishment and there was long-term Consultant locum cover at the hospice.

  • There was no electronic patient record system in general use in the hospital and patient transfer between services relied on paper-based records.

  • The ‘Care After Death’ Audit revealed that ward notes did not reveal the trust’s bereavement nursing and chaplaincy services being routinely offered to bereaved families or carers.

  • The Bereavement Team was being restructured at the time of our inspection and the support offered by them was expected to be undertaken by staff on the wards, overseen by a Band 7 Bereavement Nurse. Staff did not feel supported throughout the consultation period for this and were unclear on what the service would look like going forward.

  • There was a lack of private rooms available to break bad news to families and friends.

Outpatients

Good

Updated 10 August 2016

We rated safe as good because,

  • Staff were encouraged to report incidents and lessons were learnt and shared.

  • Diagnostic imagining services had established systems and practices in place to protect patients and staff from radiation and radioactive substances.

  • Infection control practices were good and audits were completed.

  • Nursing, medical and allied health professional staffing was good with few vacancies. Bank or locum staff received appropriate inductions to departments.

  • Procedures in relation to safeguarding adults and children were in place and understood and training rates were high.

However,

  • In the eye unit, audit systems did not provide assurance that safety checks were being carried out following a serious patient safety incident.

  • Medical gases were not always stored safely and securely.

  • Records were not always stored securely and IT systems were sometimes left logged on and unattended. They were not always well organised or contained minimum patient identifiers and 38% of incidents reported for outpatients and diagnostic imaging related to issues with records.

  • In interventional radiology, the most recent audit of the use of the safer surgery checklist showed this had only been completed in 47% of cases.

We are currently not confident that we are collecting sufficient evidence to rate effectiveness for Outpatients & Diagnostic Imaging.

  • Services followed national and local guidelines based on evidence based practice.

  • Local audits were completed to monitor performance against local guidelines and patient outcomes.

  • Pain relief was discussed and provided when this was needed, for example interventional radiology and in fracture clinic.

  • Appraisal rates were high and staff were supported to develop extended knowledge and skills.

  • Ninety-nine per cent of patient records were supplied by health records for outpatient clinics, however, we noted that this figure was based on notes available at the end of clinic rather than at the time of the appointment.

  • The diagnostic imaging service was not participating in the Imaging Services Accreditation Scheme (ISAS) or the Improving Quality in Physiological Services (IQIPS) accreditation scheme.

  • Only 73% of clinic letters were sent within 5 days of the appointment and for some specialities this was as low as 36%.

We rated caring as good because:

  • Patients were treated with dignity and respect. Staff were caring, compassionate and kind.

  • Patient feedback about staff was positive. High numbers of patients would recommend outpatient and diagnostic imaging services to their friends and family.

  • Patients and their families were involved in their care and treatment. Information was provided in a way that patients could understand and patients had time to ask questions about their care.

  • Clinical nurse specialists for a range of health conditions were available to provide additional emotional support. Psychologists provided additional emotional support to patients on the breast unit and Churchill Unit.

We rated responsive as good because:

  • There were a number of rapid access and one stop shop clinics. Emergency referrals could be seen on the same day in the eye clinic. Services had been planned to meet the needs of local people.

  • Diagnostic waiting times had been consistently better than the England average between January 2014 and November 2015.

  • Overall, the 95% 18-week target for non-admitted patients was met each month between April 2015 and December 2015.

  • The trust had performed consistently better than the England indicators for incomplete pathways referral to treatment times within 18 weeks.

  • Individual needs were understood and considered when delivering care and treatment. Adjustments were made to remove barriers to people accessing services.

However,

  • Clinics in outpatients often ran late and patients were not always informed of delays. The trust did not gather sufficient data to monitor whether patients were seen on time.

  • The breast screening service was not meeting national targets in relation to the recall of women for mammography. Nearly half of all patients did not receive a timely breast screening service. National targets had been extended locally to allow a recovery plan.

  • Diagnostic imaging reporting turnarounds did not meet locally agreed targets.

  • The 18-week target for non-admitted colorectal and trauma and orthopaedic patients was missed in each month between April and December 2015.

  • In the main radiology department, there was no separate area for inpatients to wait. This meant that inpatients on trolleys or in beds, usually in nightwear or gowns, waited in the same area as outpatients.

  • Some services had outgrown the clinical space available, meaning that areas were frequently overcrowded or additional clinic capacity could not be accommodated.

We rated well-led as good because:

  • Governance systems were in place to support the delivery of high quality care.

  • Objectives were aligned with the trust aims and had clear, measureable outcomes.

  • Risks were understood and managed to reduce any impact upon the quality of service deliver. Risk registers were reviewed and updated regularly.

  • Performance dashboards were comprehensive and shared widely with staff to provide feedback on how services were doing.

  • Leaders at all levels were described as supportive. Staff were supported to develop leadership skills.

  • Services planned to maintain sustainability in the future and continue to deliver service improvement.

However,

  • In the eye unit, staff felt they were not supported to be innovative. A new business manager was in place following a recent practice review and this change needed further time to embed and provide leadership.
Other CQC inspections of services

Community & mental health inspection reports for Royal Bolton Hospital can be found at Bolton NHS Foundation Trust.