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Inspection Summary


Overall summary & rating

Good

Updated 11 April 2019

Our rating of services stayed the same. We rated it them as good because:

  • We rated safe, effective, caring and well led as good.
  • All services were rated as good overall.
  • The only rating of requires improvement is in children and young people’s services for safe which we did not inspect at this inspection.
  • The caring domain in medicine was rated as outstanding.
Inspection areas

Safe

Good

Updated 11 April 2019

Effective

Good

Updated 11 April 2019

Caring

Good

Updated 11 April 2019

Responsive

Good

Updated 11 April 2019

Well-led

Good

Updated 11 April 2019

Checks on specific services

Medical care (including older people’s care)

Good

Updated 11 April 2019

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

  • The service ensured that there were enough staff in the right areas to keep people safe. Staff had received mandatory training, knew what to do to protect patients from abuse and how to report an incident if things went wrong.
  • The service had suitable premises and equipment and looked after them well. Wards were visibly clean and tidy and staff had access to equipment they needed.
  • Staff completed and updated risk assessments for patients and kept clear records of their care. Records were stored securely which was an improvement since the last inspection.
  • The service managed medicines well and adhered to antimicrobial prescribing policies. We saw that oxygen storage was secure and had improved.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers monitored the effectiveness of care and treatment and used the findings to improve them. The service had seen an increase in the sentinel stroke national audit programme results.
  • The service assessed and monitored patients’ nutritional and pain needs effectively.
  • Staff of different kinds worked together as a team to benefit patients. We saw good examples of multidisciplinary and cross sector working.
  • The culture within the service supported and encouraged staff to provide the best care for patients. All staff had a strong patient centred approach to patients and cared for them with compassion. Patients spoke highly of the care they received.
  • Staff provided emotional support to patients to minimise their distress and recognised that their emotional needs were as important as their physical needs. They involved patients and those close to them in decisions about their care and treatment and encouraged them to become active partners in their care.
  • The service planned and provided services in a way that met the needs of local people and took account of patients’ individual needs.
  • People could access the service when they needed it. Referral to treatment times were good and better than the England average.
  • Managers at all levels in the service had the right skills and abilities to run a service providing high-quality sustainable care. There was a vision for what it wanted to achieve and workable plans to turn it into action with a focus on staff development.
  • Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff were proud to work for the service.
  • The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. Staff felt empowered to develop, influence change and be involved in improvement projects.

However

  • Medical staff had a low compliance rate for safeguarding training, against the trust target of 95%
  • There was a high use of bank and agency staff for nursing and medical roles, the service acknowledged shortages in the workforce and this was recorded on the divisional risk register.
  • The service had an inconsistent approach to the temperature monitoring of stored medication.
  • Staff sometimes recorded lack of capacity as the reason for not discussing do not resuscitate decisions with the patient. In these cases, staff did not always document a formal capacity assessment or review of capacity.
  • The service had actions on the risk register that were breaching their completion date which was identified as a concern at the last inspection. However, there was a focus to improve this.

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.

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.

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 and diagnostic imaging

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.

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.

Urgent and emergency services

Good

Updated 11 April 2019

Our rating of this service improved. We rated it as good because:

  • We rated all five domains (safe, effective, caring, responsive and well led) as good.
  • The service had made improvements following our previous inspection.
  • The infrastructure had been expanded to increase capacity in the department which increased flow and reduced the issues we identified with privacy and dignity.
  • The department better met the needs of individual patients, with areas now specifically designed for adolescents and those living with dementia. There was now a room assigned for mental health patients which met national quality standards.
  • Risk assessments were now being routinely completed for mental health patients.
  • The service had enough staff with the right qualifications, skills, training and experience to keep people free from avoidable harm and provide the right care and treatment. Where previously we had concerns that consultants were having to backfill shortfalls in middle grade medical staffing numbers, this was no longer an issue.
  • The service measured patient outcomes through audits and acted to improve practice and re audit to measure change. A consultant was now in charge of audits in the department.
  • Computer terminals had been added and staff confirmed they had enough of these to provide timely care to patients.
  • Training records now provided assurance that compliance levels for life support training were good.
  • Staff appraisal rates were now in line with the trust target.
  • Whilst access and flow remained challenging, the department had taken steps to improve this and results were proving successful when compared to the previous inspection.
  • The culture was positive and supportive with a strong emphasis on training each other using collective skills and taking a team approach to making the department as effective as possible for patients and staff.

However:

  • Issues we identified with paediatric entry and exit doors were only just being rectified with controlled access being fitted the week after our inspection.
  • We were not assured that room temperatures in areas where medicines were being stored, were checked as often as they should be.

Maternity

Good

Updated 11 April 2019

We previously inspected maternity jointly with gynaecology so we cannot compare our ratings directly with the previous ratings. We rated it as good because:

  • The trust provided mandatory training for staff and managers ensured staff completed this.
  • Staff were aware of safeguarding issues, following trust procedures when these were identified.
  • The service controlled infection risk well. Staff kept themselves, equipment and the premises clean and implemented control measures to prevent the spread of infection.

  • Managers monitored staffing levels to ensure sufficient midwives were available to keep women safe and provide the right care.
  • Staff kept appropriate records of care and treatment.
  • Clinical staff followed systems for medicines management appropriately.
  • Staff reported incidents when these arose and there were established systems for managers to share any learning with staff.
  • Managers made sure staff were competent for their roles and completed staff appraisals.
  • The service used audits to benchmark against other services and identify improvements.
  • Staff worked well together in a multidisciplinary team approach.
  • Midwives were automatically focussed on the needs of women and provided holistic care.
  • Women and their partners were supported to be fully involved in decisions about their treatment and care.
  • The service received positive feedback; complaints were responded to and information used to improve the service.
  • The trust collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards. Managers had access to data to monitor performance and identify improvements.
  • Managers had the skills and abilities to deliver services providing high-quality sustainable care.
  • Staff had a positive outlook in the service and the culture was open and supportive.
  • The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively. The Ingleside midwife led birth centre participated in wide community engagement.

However:

  • The service did not always have enough staff available with the right qualifications, skills, training and experience although there were processes in place and staff worked together effectively to ensure women received safe care and treatment.
  • Some policies and guidelines we reviewed were not in date.