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Great Western Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 21 December 2018

Our rating of services stayed the same. We rated them as requires improvement.

A summary of services at this hospital appears in the overall summary above.

Inspection areas

Safe

Requires improvement

Updated 21 December 2018

Effective

Good

Updated 21 December 2018

Caring

Good

Updated 21 December 2018

Responsive

Requires improvement

Updated 21 December 2018

Well-led

Good

Updated 21 December 2018

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 21 December 2018

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

  • Safe, effective, responsive and well led were rated as requires improvement.
  • There were insufficient staff on duty at all times to meet planned safe staffing levels.
  • The trust target for completion of mandatory training was not met by some staff in the unscheduled care division.
  • Infection control processes did not consistently promote the control of infection and protect patients from the risk of cross infection.
  • The unscheduled care division monitored risks at a local level and across the division. However, the risks associated with poor patient outcomes, identified through audit, were not always well managed. Patient outcomes, when benchmarked, did not always compare favourably with the England average. We were concerned that there had been a lack of significant improvement in stroke care, where performance had for some years been worse than the England average.
  • Services were not always planned and delivered to meet the needs of patients. The ability to provide patients with timely care and treatment was hampered by the flow throughout the hospital system.
  • Care and treatment was not consistently delivered, taking into account patients’ individual needs, including those in vulnerable circumstances.

However:

  • Caring was rated as good.
  • Staff safeguarded patients from the risk of abuse and medicines management kept people safe.
  • Patients’ needs were assessed, and care and treatment was delivered in line with legislation, standards and evidenced-based guidance.
  • Patients received a caring service from kind and empathetic staff.
  • An open culture was evident throughout the wards and departments and staff spoke well of their managers and the support they received.
  • Patients and staff were engaged and involved with the services provided.

Services for children & young people

Good

Updated 21 December 2018

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

  • Patient safety was a priority for this service. Staff numbers had been low but were improving and managers had a strategy to recruit and retain staff to the children’s service to create stability. Where there were gaps in rotas, these were filled with bank and agency staff.
  • Managers used trust governance processes to assess quality of care delivered and passed information to staff on areas needing improvement.
  • Staff followed infection control processes and monitoring showed infection rates were low.
  • Staff working in children’s specialty areas were trained to care for children. Support was provided for children and families when they left the hospital and outreach staff communicated well with community and children’s services colleagues.
  • Safeguarding processes were followed by staff and staff were knowledgeable about how to identify and manage potential abuse for children. Support was offered to staff with supervision and training.
  • There were enough medical staff to care for children in the hospital.
  • There was a noticeable change in culture, compared with our previous inspection. Staff felt supported, able to contribute ideas and voice concerns if they needed.
  • Leaders and managers were aware of the challenges to the service and that quality needed to be improved. They were using trust structures to monitor progress and using their own ideas to contribute to improvement.

However

  • Mandatory training modules did not always meet trust targets for staff attendance. This included medical staff in the children’s unit and some staff who cared for children in other parts of the hospital such as radiology, outpatients departments and surgical areas. There was, however a plan to improve this compliance.
  • A limited oversight of shift patterns meant that bank and agency staff could work long hours and shifts which did not give them enough rest.
  • Oxygen administration for children who needed it was not consistently prescribed.
  • GPs did not always receive discharge summaries about a child’s care in a timely way.
  • There was no non-executive lead to champion children’s services at the trust board.

Critical care

Good

Updated 4 August 2017

​We rated this service as good because:

  • There was a good incident reporting culture, learning was identified and staff received feedback from incidents.
  • There were safe nursing and medical staffing levels to deliver effective care and treatment.
  • The service provided care and treatment in line with evidence-based guidance.
  • There were experienced nursing and medical staff who received annual appraisals and were supported with training and professional development.
  • The service monitored patient outcomes and these were good when compared nationally and to other similar units.
  • Staff cared for patients with compassion and kindness. Staff treated patients with respect and dignity at all times.
  • The provision of the service met the needs of most people.
  • Patients’ individual needs were met wherever possible.
  • There were clear governance and risk management processes.
  • There was strong leadership and teamwork.

However:

  • Provision for therapy services did not meet national guidelines. There was not sufficient physiotherapy and dietitian support, and limited support from other therapies.
  • There was a slightly higher than national average of delayed discharges for patients. However, this did not result in any significant delays in admitting new patients.
  • There was only one junior doctor in the unit at night, when standards recommended a unit of this size should be covered by two at all times.
  • Junior medical staff were not all ‘airway competent’ with skills in advanced airway techniques.
  • Patients were occasionally transferred to general wards at night, which was not optimal for their care.

End of life care

Good

Updated 19 January 2016

We judged the overall service provision of end of life care as good. We found the service to be safe, effective, caring, responsive and well-led.

End of life care was seen as a priority for the trust. There was a clear overarching strategy for the service and plans to improve the delivery of care had already begun to take place with good results Education programmes had been developed and delivered, new documentation had been successfully introduced to the trust improving the pathway for patients although there was also some , yet to be fully embedded.

Staff, patients and relatives spoke in high regard for the specialist palliative care team; they were seen as responsive to the needs of both patients and staff. Out of hours there were good resources for staff to access including a 24 hour advice line managed by specialist palliative care nurses at a local hospice.

End of life care was responsive to the needs of patients and relatives. The end of life service was flexible and provided choice and accommodated individual needs for the patient and carers.

The specialist palliative care team had been involved in looking at complaints and incidents, as part of a wider team, and were keen to ensure training and teaching sessions were tailored and disseminated to ensure future complaints were minimised and care of patients was enhanced.

The specialist palliative care team were dedicated members of a cohesive team working to deliver effective care and treatment plans for patients, offering advice and acting as a resource for clinical teams.

Maternity and gynaecology

Good

Updated 19 January 2016

Overall, we have judged the maternity and gynaecology services to be good for responsive, effective, caring and well-led services. Overall, we have judged safety in the maternity service requires improvement.

Care in both the gynaecology and maternity wards and central delivery suite was consultant led. Patients had risk assessments completed and reviewed regularly. There were established and thorough safeguarding procedures in place. Systems were in place which ensured women who required emergency obstetrics and gynaecology treatment and care were seen promptly by specialist nurses and consultants at all times. Clinical procedures were provided in line with national guidance and policy.

Safety improvements were required to the maternity services. The midwifery staffing levels did not comply with the Health and Social Care Act (2008) Code of Practice on staffing. The midwife to patient ratio exceeded (was worse than) recommended levels and one to one care for women in established labour was not achieved 100% of the time.

The maternity services were responsive to the needs of local women and those living outside of the locality of the hospital. The majority of patients were satisfied with the care and treatment they received and would recommend services. We saw records documenting patient’s choices and preferences. Additional specialist counselling was available to patients as required. Access and flow through the gynaecology inpatient service had been affected by intense trust wide service pressures.

At departmental levels there were effective, risk, quality and governance structures in place. Incidents, audits and other risk and quality measures were reviewed for service improvements and actions taken. Improvements were required to risk management processes at a senior level to ensure a complete overview of all serious issues and actions was maintained, and escalated to the board.

At departmental levels, systems were in place to effectively share information and learning. There was a positive culture and staff were proud of the patient care they provided and spoke of good and productive team working practices. Consultant, nursing and midwifery leadership was described as good, junior staff were well supported and departmental senior managers were visible and approachable. There was strong evidence from the midwives and consultant obstetricians of innovations completed to improve treatment, care and outcomes for patients.

Surgery

Requires improvement

Updated 21 December 2018

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

  • We were not assured the service was always meeting requirements to provide safe care.
  • We were not assured cleanliness and infection control procedures were always followed. Nursing documentation and risk assessments were not always managed in a way that protected patients from avoidable harm
  • Although effective care was rated as good, the service did not achieve all of the intended patient outcomes. There was inconsistent engagement with board rounds. There were not enough radiographers allocated to work in the operating theatres.
  • Although caring was rated as good, patients’ privacy and dignity were not always maintained.
  • The service was not meeting the demand and facilities did not always meet patients’ needs. There were not sufficient surgical inpatient beds to meet demands of some specialities. Patients did not always receive timely care and treatment in the right setting.
  • Although we rated well-led as good, there were some gaps in assurance frameworks.

However:

  • Safety was good in some key areas. Ward and departments appeared visibly clean. Equipment was checked and serviced daily. Staff monitored patients and took appropriate actions if patients’ conditions deteriorated. Staffing levels were adequate to deliver safe care. Medicines were mostly managed well and there was a good incident reporting culture.
  • Effective care was provided in line with evidence-based guidance. National audit results varied when benchmarked against national metrics but actions had been taken to improve. Staff were competent to deliver care. Patients’ pain was managed well. All relevant staff, including those working in different teams, were involved in assessing, planning and delivering care and treatment.
  • Caring was rated as good as staff demonstrated compassion. Staff showed an encouraging, sensitive and supportive attitude to patients and their relatives. Staff took time to interact with patients and their relatives in a respectful and considerate manner.
  • Although responsive was rated as requires improvement, some areas were good. The length of stay for patients meant they were not staying in hospital longer than they needed to. Patients were treated as individuals with tailored care. Patients’ concerns and complaints were used to improve the quality of care and the services provided.
  • Well-led was rated as good. The leadership team of the planned care division had the knowledge and integrity to lead the service. There were clear lines of responsibility from board to service level. Leadership staff were visible and approachable. There was a good structure for governance. Innovation and improvement was encouraged.

Urgent and emergency services

Requires improvement

Updated 21 December 2018

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

  • Some areas of concern raised at our last inspection had not been addressed. For example, there was continuing poor compliance with mandatory training for medical staff, and in subjects that affected the care and treatment of children. Staff working on the observation unit continued to feel isolated and unsafe and did not feel adequately supported to care for patients with acute mental health needs. Patients continued to wait too long to have their healthcare needs assessed, and crowding in the emergency department remained a significant challenge.
  • There was a significant lack of physical space in the emergency department. Although this had improved since our last inspection, at times there were two patients per cubicle and staff had to care for patients in the corridor most of the time, which affected patients’ privacy, dignity and comfort.
  • There were delays for emergency patients at all stages of their care and treatment. Patients were not consistently assessed within 15 minutes of arrival, and too many patients experienced delays in their ongoing care and treatment. Two percent of patients spent longer than 16 hours in the department.

However:

  • Treatment pathways were effective and based on latest evidence and national guidance and best practice. Staff had the skills to deliver safe care and the department monitored the care given to identify areas that could be improved.
  • Kind and compassionate care was delivered to patients and relatives. Even when they were busy, staff were focused on the needs of patients, informed them of what was happening and took time to make them as comfortable as possible.
  • The department met the individual needs of patients, including those with specific or complex needs such as those with dementia, learning disabilities, sensory impairment or those who may be vulnerable. Staff included those close to patients in their care and provided 1:1 support when it was needed.
  • The leadership of the department had the skills and experience to lead effectively. Working partnerships were well-managed and there was regular review and improvement of services in response to changes in legislation or service requirements. Risks were well-managed and there was a culture whereby improvements were sought out in response to incidents, risks and feedback.

Outpatients

Good

Updated 21 December 2018

  • We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings.
  • We rated it as good because:
  • Staff understood how to protect patients from abuse; there were clear processes for reporting safeguarding concerns and staff knew how to access support to do this.
  • There were systems and processes in place to protect patients and visitors from the risk of infection.
  • There were systems in place for managing the planned maintenance of equipment and when faults were identified.
  • Staff could identify and respond to a deteriorating patient within the outpatient environment, including medical emergencies.
  • Patient records were accessible and staff had the information they needed to make informed assessments of care needs.
  • Medicines and prescription pads were appropriately managed to keep people safe in line with national guidance and legal requirements.
  • Staff understood their responsibilities to report near misses, patient safety concerns and incidents.
  • The physical, mental, and social needs of patients were holistically assessed. The care and treatment provided was underpinned by the relevant standards, legislation and evidence-based guidance.
  • Nutrition and hydration was considered as part of the patient assessment. Refreshments were also available to patients in the outpatient setting.
  • There was an established audit programme to monitor the outcomes of patients’ care and treatment within the outpatient setting.
  • Staff had the qualifications, knowledge and skills to be able to assess and meet the care needs of patients. Staff were encouraged to develop through accredited learning and training programmes developed by the organisation.
  • Professions worked together to provide seamless patient care, including when care was provided across different specialisms.
  • Patients were treated with compassion, kindness, dignity and respect throughout their visits to outpatient services.
  • Clinical consultations and conversations regarding people’s health and well-being needs were conducted within clinical areas with the door or curtain closed to maintain confidentiality.
  • Patients with mental health needs were treated with compassion and without judgement.
  • Staff provided emotional support to patients to minimise their distress including when a life-changing diagnosis was given.
  • Patients were signposted to sources of further information, including other providers and community services that could support their care.
  • When patients were finding decisions difficult, staff supported them to understand the complex information about their condition.
  • Those close to the patient were made to feel part of the conversations and able to contribute to discussions regarding health needs and care plans.
  • The services provided reflected the needs of the local population by offering choice, flexibility and continuity of care.
  • The trust was performing better than the operational standard for people being seen within two weeks of an urgent GP referral, to receive treatment within 31 days of diagnosis and the standard for patients to receive their first treatment within 62 days of GP referral.
  • The trust had instigated an outpatient transformation programme, which aimed to improve the services delivered to the local population. This included offering additional clinics and establishing more efficient ways of working.
  • The trust identified where a system-wide approach was needed to meet the needs of the local population. Within endocrinology, rheumatology and dermatology, work was ongoing with commissioners and partners in primary care to find solutions to the demand for services.
  • Staff supported patients with additional needs such as patients living with dementia. An alert was placed on patients’ records and early appointment times allocated to reduce anxiety.
  • Translation services were available for patients whose first language was not English.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.
  • There was a clear strategy for outpatient services to deliver a transformation programme. Staff were highly engaged with this and understood their role in delivering the vision.
  • There was generally a positive culture within outpatient services, except for one area reporting low morale. Many staff, of all grades, told us they felt part of a team and described a supportive and respectful working environment.
  • The board and other levels of governance in the organisation functioned effectively. There were clear lines of accountability and information was shared effectively.
  • Senior nurses had joined together to create an outpatient nursing forum with representation from specialities across the organisation. The purpose of the group was to establish more uniform ways of working across divisions to improve quality and efficiency.
  • From speciality to board level, risks and issues were recorded, reviewed, escalated and managed to reduce the likelihood of patient harm.
  • Information was used as part of decision-making and to monitor performance. A divisional dashboard had been developed to provide an overview of service provision and monitor potential issues.
  • Senior staff had taken steps to improve staff engagement. An outpatient forum had been set up for staff nurses to attend.
  • There was a focus on learning, improvement and innovation throughout outpatient services, driven by the outpatient transformation project.
  • However:
  • Not all nursing and medical staff were up to date with their required mandatory training, including safeguarding.
  • Lack of space was identified as an issue in several areas we visited, including the Coate Water Unit, oncology/ haematology clinics, endoscopy, cardiology, and the breast clinic.
  • We found unattended patient records in an unlocked room in the orthopaedic clinic and Wren Unit.
  • We did not observe the use of ‘I am clean’ stickers or a similar system to notify staff that equipment was cleaned and ready for use.
  • We were not assured that all staff could identify if equipment was fit for clinical use. Servicing labels did not contain the next service date and the responsibility for maintenance of specialist equipment was not clearly understood by staff.
  • Seven-day services were not routinely offered to outpatients due to a lack of resources to extend services beyond the working week.
  • We raised concerns that privacy was not maintained within the blood test clinic, where doors were left open and curtains were not used to hide patients from the view of others.
  • Waiting times meant people did not always have timely access to an initial assessment or treatment. The trust had developed processes for managing the risk and prioritising patients.
  • Despite improvements made through a space utilisation programme, the premises were not sufficient to deliver the number of appointments required to meet demand.
  • Complaints were not always investigated within national time frames. At the time of our inspection 17 investigations regarding complaints were overdue.
  • We raised concerns a long-term sustainable plan for outpatient services had not yet been developed. The trust was evaluating the ability of demand predication tools to capture both new and follow-up appointments.
  • Governance meetings were not consistently organised to follow a set template, the detail of discussion was not always captured in the minutes to allow retrospective comparison.
  • Patient feedback was not consistently engaged or reviewed to measure level so satisfaction.
Other CQC inspections of services

Community & mental health inspection reports for Great Western Hospital can be found at Great Western Hospitals NHS Foundation Trust.