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Royal Hampshire County Hospital Good

Inspection Summary


Overall summary & rating

Good

Updated 12 November 2015

Hampshire Hospitals NHS Foundation Trust was established in January 2012 as a result of the acquisition by Basingstoke & North Hampshire NHS Foundation Trust of Winchester & Eastleigh Healthcare Trust.

The trust provides a full range of elective and emergency medical and surgical services to a local community of 600,000 patients in Basingstoke, Winchester, Andover and the surrounding areas in Hampshire and West Berkshire. It provides services from Andover War Memorial Hospital, Basingstoke and North Hampshire Hospital and the Royal Hampshire County Hospital. Outpatient and assessment services are provided from Alton, Bordon and Romsey Community hospitals, and the Velmore Centre in Eastleigh.

Royal Hampshire County Hospital (RHCH) is one of the acute district hospitals, and is based in the city of Winchester, Hampshire. The hospital has approximately 457 beds, and they had 44,273 emergency attendances in ED, and 211,418 outpatient attendances last year.

The RHCH provides a full range of general hospital services including accident and emergency, general and specialist surgery, general medicine, maternity and gynaecology, intensive care, rehabilitation, chemotherapy, diagnostic services, out-patient clinics and paediatric care.

The hospital employs approximately 654 clinical staff. They do not outsource for any contracted staff, and non-clinical staff are employed in all of the support functions such as portering, facilities management and catering provision.

We undertook this inspection of Hampshire Hospitals NHS Foundation Trust as part of our comprehensive inspection programme. The trust was in priority band 6 according to our Intelligent Monitoring system (with band 1 being the highest risk and band 6 being the lowest risk).

The inspection of RHCH took place on 28 to 31 July 2015. The full inspection team included CQC senior managers, county managers, inspectors and analysts. Doctors, nurses, allied healthcare professionals, ’experts by experience’ and senior NHS managers also joined this team.

We reviewed the following core services provided at RHCH: urgent and emergency care, medical (including older people’s) care, surgery, critical care, maternity and gynaecology services, children and young person’s services, end of life care, and outpatient and diagnostic services.

Overall, we rated RHCH as ‘good’. We rated it as ‘outstanding‘ for providing caring services, and good for safe, effective, responsive, well-led care.

We rated all services as RHCH as ‘good’ with end of life care as an ‘outstanding’ service.

Our key findings were as follows:

Are services safe?

  • Staff were encouraged to report incidents and there was learning from incidents to improve the safety of services locally and across the trust.
  • In diagnostic imaging, staff were confident in reporting ionised radiation medical exposure (IR(ME)R) incidents and followed procedures to report incidents to the radiation protection team and the care quality commission
  • Clinical areas, such as wards, theatres and clinics were visibly clean with appropriate cleaning schedules.
  • Staff followed infection control procedures and these were monitored. Staff in some areas were working to improve hand hygiene practices and environmental infection control standards, after having done audits.
  • Medicines were appropriately managed and stored. However, fridge temperatures were not being regularly checked and monitored on the surgical wards.
  • Anticipatory medicines (medicines prescribed for the key symptoms in the dying phase ie pain, agitation, excessive respiratory secretions, nausea, vomiting and breathlessness) were prescribed appropriately.
  • Equipment was checked and stored appropriately in most areas but this needed to improve in surgery and on some medical wards specifically for resuscitation equipment.
  • Overall, staff had a good understanding of safeguarding adults and children although more staff needed to attend training.
  • More staff needed to complete mandatory training.
  • Patients’ were assessed and monitored appropriately, for example, risk assessments were complete. However, the early warning score needed to be used consistently in surgery, and a tool was required for outpatients, for patients whose condition might deteriorate.

  • The hospital had a higher than expected number of avoidable harms (pressure ulcers and falls) against their own targets. The trust was taking action to improve this, for example, care bundles were introduced to appropriately assess and treat patients.

  • Critically ill children attending the emergency department were immediately referred to a paediatrician. There was a protocol for the transfer of critically ill children to a specialist care from the Southampton and Oxford retrieval team (SORT). The SORT team would provide specialist staff to support the child during the transfer.

  • Medical staffing levels across the hospital were appropriate. National recommendations were followed, for example, for consultant presence in the emergency department, maternity, critical care and end of life care. There was consultant presence in the hospital over seven days with the exception of surgical services; there was 24 hour consultant cover arrangements across all services. Consultants in children and young people services were working additional sessions because of vacancies with junior doctors at middle grade level. This additional working was not sustainable in the long term.

  • Nursing staffing levels were identified at trust level using an appropriate acuity tool. Planned staffing levels across all areas were higher than minimum recommendations. The hospital had a significant number of vacancies particularly in medical and older people’s care, surgery and children’s and young people’s services. Staffing levels were monitored and action was taken to fill vacancies from bank staff. Agency staff were not used. However, some medical and surgical wards did not always meet safe staffing levels. Nursing staff were coping by working longer hours, sharing staff or staff skills across shifts. Patients on these wards told us their needs were being met. The trust was implementing actions to mitigate and reduce the risks, for example, by developing skills in health care assistants and having ongoing recruitment campaigns, including employing staff from overseas.

  • Midwifery staffing levels did not meet national recommendations but staff worked flexibly and could provide one to one care for all women in labour.

  • Radiographers worked alone overnight covering imaging services for the hospital and the emergency department. Radiographers reported a heavy workload and raised concerns over manual handling issues. Between 10.00pm and 8am, radiology was supported by an overnight outsourced radiologist service. Staff identified delays in the process to authorise request and provide advice on imaging which meant delays in the patient diagnosis.

  • The new regulation, Duty of Candour, states that providers should be open and transparent with people who use services. It sets out specific requirements when things go wrong with care and treatment, including informing people about the incident, providing reasonable support, giving truthful information and an apology. The trust monitored duty of candour through their online incident reporting system. Senior staff we spoke with were aware of duty of candour and talked about the importance of being open and transparent with patients and their families.                

 

 

      

                                    

                               

Are services effective?

  • Staff were providing care and treatment to patients based on national and best practice guidelines. In some areas guidelines had been unified across the trust for consistency of care.
  • Services were monitoring the standards of care and treatment. Patient outcomes were similar to or better than the England average. There were action plans to address where outcomes were worse when compared to the England average.
  • Patients who had suffered a stroke would be taken to the Royal Hampshire County Hospital as this was the designated receiving unit for the specialist treatment of stroke in Hampshire. For October 2014 to December 2014, the hospital performed better than other trusts for meeting standards for specialist assessments, thrombolysis and provision of physiotherapy and occupational therapy and discharge processes. The hospital was similar to other trusts for care on the stroke unit, multi-disciplinary working and standards of discharge standards. The hospital performed significantly worse than other trusts in providing speech and language therapy and scanning.
  • Patients received good pain relief across all services.
  • Patients, particularly older patients, were supported to ensure their hydration and nutrition needs were met.
  • Staff were supported to access training. Many staff had a high level of competency having undertaken specialty specific qualifications. There was evidence of regular staff appraisal, although clinical supervision varied.
  • Staff worked effectively in multidisciplinary teams to centre care around patients. This included working with GPs, community services, other hospitals. There were innovations in electronic records and the use of video conferencing in end of life care that enabled information to be shared about patient’s clinical needs and preferences across the trust, and with community and GP services. However, paediatric inpatient physiotherapy was not sufficient for children and young people with Cystic Fibrosis and this was of concern.
  • Seven-day services were well developed, particularly for emergency patients. There was support from therapists, pharmacy and diagnostic services was less well developed.

  • Staff had appropriate knowledge of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards to ensure that patients’ best interests were protected. Guidance was available for staff to follow on the action they should take if they considered that a person lacked mental capacity. Notification of Deprivation of Liberty Safeguards applications were correctly submitted to the Commission. However, capacity assessments were not always documented or regularly reviewed in patient care records.
  • ‘Do Not Attempt Cardio Pulmonary Resuscitation’ (DNACPR) forms were not always appropriately completed and did not include, for example, an assessment of the patient’s mental capacity.

Are services caring?

  • Staff were caring and compassionate and treated patients with dignity and respect. There was a culture in the hospital of understanding and responding to patient’s individual needs. This covered clinical and non-clinical staff such as porters who recognised the importance of their role in providing good quality care.
  • Patient feedback was overwhelming positive across all services.
  • We observed outstanding care for critical care patients, children and young people, patients having end of life care and patients attending outpatient and diagnostic imaging services. The staff had an ethos of providing person centred care and developed trusting relationship with patients and their families.
  • Staff maintained patient’s confidentiality, privacy and dignity in all areas, although the layout of bay areas in Victoria Ward may have compromised patient’s dignity at times
  • Patients and their relatives felt involved in their care and treatment, staff provided information and explanations in a way patients could understand. Patients felt that their views and considerations were listened to and acted upon.
  • Records of conversations were detailed on patient records. This meant staff always knew what explanations had been provided and reduced the risk of confusing or conflicting information being given to relatives and patients
  • Patients and their families were supported by staff emotionally to reduce anxiety and concern. There was also support for carers, family and friends for example, from the chaplaincy, bereavement services for patients having end of live care, and counselling support where required.
  • Data from the national surveys demonstrated that the hospital was similar to other trusts. Patients were very satisfied and would recommend the care they received.

Are services responsive?

  • Services were being planned to respond to increases in demand, staff capacity and patient needs. There was some innovation in models of care, for example, ambulatory care and early supported discharge. There was also joint work with partners, for example, to in-reach services for psychiatric assessment. Children’s and young people services had reduced the number of beds to respond to staffing issues. Other areas were working on how to increase capacity.

  • Bed occupancy in the hospital was below the England average of 88%, although this was higher on surgical wards. It is generally accepted that at 85% level, bed occupancy can start to affect the quality of care provided to patients, and the orderly running of the hospital.

  • The trust was not meeting the national emergency access target for 95% of patients to be admitted, transferred or discharged within 4 hours. Ambulance handovers over 30 minutes were often delayed and patients often had to wait in the emergency department for admissions.
  • Many medical patients were often on outlier wards (a ward that is not specialised in their care). However, this did not happen during the inspection and information demonstrates that these patients were regularly assessed.
  • Patient bed moves happened frequently, including at night. Staff were ensuring that patients with lower dependency needs were moved and patients had not expressed concern about their moves.
  • The trust was achieving the 31-day cancer waiting time diagnosis-to-treatment target and the 62-day referral-to-treatment target, although this had not been met in June 2015.
  • The hospital was achieving the 18-week referral-to-treatment time target for medical patients. The target had been met in surgery between April to December 2014 but was not being met between January to March 2015. The target was not being achieved in orthopaedics and ophthalmology.
  • The majority of patient who had cancelled surgical procedures for non-clinical reasons were re-booked for surgery within 28 days.
  • The trust was meeting national waiting times for diagnostic imaging within six weeks, outpatient appointments within 18 weeks and cancer waiting times for urgent referral appointments within 2 weeks and diagnosis at one month and treatment within two months.
  • The trust cancellation rate for appointments was 11%; the England average was 7%. Many of these clinic cancellations were at short notice. The reasons for this varied and included cancellation for staff sickness, training and annual leave. There was a plan to address this but this was in development. Patients were not appropriately monitored to ensure the timeliness of re-appointments.
  • Women were able to make choices about where they would like to deliver their babies. They had access early pregnancy assessment and their preferred ante-natal clinics. Women in the early stages of labour had access to telephone support.
  • Patient discharge was effectively supported. Patients were regularly reviewed and discharge coordinators worked to improve the discharge of patients with complex care needs. The hospital had problems with increasing delays transfer of care for community services and was working with partners to improve this.
  • Support for patients living with dementia was well developed, for example, there was specialist support, appropriate assessment, a sunflower symbol was used and staff had good awareness and training. Support for people with a learning disability needed further development. Although there was support for carers, the hospital needed a flagging system or passport to identify and support patients, and some staff identified the need for further training.
  • The trust offers a number of one stop clinics. The breast unit, for example, offers appointments to patients within two weeks following GP referral. The referrals were initially received into the central booking office and prioritised by consultants. Patients who attended the one stop clinics, would see a clinician, have a biopsy taken and see a radiologist if required. If a cancer diagnosis was suspected, patients were told before leaving the clinic and an appointment given to discuss the outcome and treatment options. This unit provided a responsive service for patients who were anxious in relation to a potential cancer diagnosis.
  • Patients having end of life care were identified by a Butterfly symbol so that staff were aware of their needs and those of their family.
  • There was a hospital at home service to deliver care to those patients identified as being in the last days or hours of life. The service was 24 hours and seven days a week. Multidisciplinary team working and innovations in electronic records and the use of video conferencing in end of life care also facilitated rapid assessment and access to equipment.
  • Patients having end of life care had multi-disciplinary care focused on their physical, mental, emotional and social needs. Patients could have a rapid discharge to home arranged within 24 hours. However, there were delays to the rapid and fast track discharge processes (within 48 hours) and processes were being improved to meet national standards.
  • All wards we visited provided care for patients in single sex accommodation bays, in line with Department of Health requirements.

  • Complaints were handled appropriately and there was evidence of improvements to services as a result. Some services, however, were not responding to complaints in a timely way.

Are services well-led?

  • All services identified the plans to build a new Critical Treatment Hospital as the overall strategy for the trust and there were in-depth plans towards this across services. However, some services did not have specific strategies and plans in the short and medium term to respond to priorities. Some consultants identified concerns with the plans for the new hospital.
  • Services had effective clinical governance arrangements to monitor quality, risk and performance. The Outpatients department needed better processes to manage risk and quality.
  • Most staff told us overall they had good support from the local clinical leaders and staff engagement was good.
  • Many staff identified the visibility and support of the chief executive of trust.
  • Joint working between Royal Hampshire County Hospital and Basingstoke and North Hampshire Hospital varied. This was important to improve standards, share good practice and develop efficient and effective services across the trust. This was well developed in the emergency department, critical care and end of life care.
  • The leadership for end of life care was outstanding. There were robust governance arrangements and an engaged staff culture all of which contributed to driving and improving the delivery of high quality person-centred care. This was an innovative service with a clear vision and supportive leadership and board structure.
  • Patient engagement was mainly through survey feedback however, there was some innovation, for example afternoon tea sessions with stroke patients and their families and ‘through your eyes’ a listening event to surgery.
  • The trust had a WOW Award scheme to recognise outstanding service. Staff could be nominated by patients or their colleagues. Recognition through the WOW Awards had led to high levels of staff satisfaction throughout the service

  • Ideas to innovative and improve services were encouraged. There was participation in research, quality improvement projects, and innovation in developing new roles for staff, such as the Majors practitioners, volunteers caring in dementia, and advanced critical care practitioners.

We saw several areas of outstanding practice including:

  • The trust was developing innovative new roles for staff, for example, majors practitioners in the emergency department and advanced critical care practitioners.
  • Every medical and care of elderly ward had an activity coordinator who planned and conducted different activities for patients after consulting them. The activities included range of things such as arts and craft, music, dance, group lunches and movie time.
  • ‘Afternoon tea’ session was held for patients and their relatives in the stroke wards. This gave patients an opportunity to share their experiences, peer support and education. The session was also attended by a member of stroke association team who delivered educational sessions related to care after stroke. Patients were also given information about support available in the community.
  • A nurse led eight bedded day unit in the admissions and discharge lounge for patients who required certain medical interventions: patients were referred to this service by the medical consultants and this service was helping to meet needs of patients who required medical intervention without prolonging their stay in the hospital. Patients were highly complimentary about this service.
  • When patients with complex needs on care of elderly wards were discharged to their new home, they were escorted by a member of nursing or therapy staff who spent up to an hour with patients in their new home. This had helped in offering elderly patients with emotional support.
  • The early supported discharge team helped stroke patients for up to six weeks following their discharge from the hospital. The staff felt that this gave continuity of care and supported the patients in achieving their goals following the discharge
  • Once a week the librarian attended the ward round in order to source relevant literature to assist the professional development of staff.
  • Critical care career pathways were developed to promote the development of the nursing team.
  • The critical care unit had Innovative grab sheets that detailed the essential equipment to care for each patient in the event the unit had to be evacuated. These included pictures of the essential equipment, so non-clinical staff such as portering staff could help collect the equipment ensuring medical and nursing care of patients was not interrupted.
  • Pregnant women were able to call Labour Line which was the first of its kind introduced in the country. This service involves midwives being based at the local ambulance operations centre. Women who called 999 could discuss their birth plan, make arrangements for their birth and ongoing care. The labour line midwives had information about the availability of midwives at each location and were able to discuss options with women and their partners. Labour Line midwives were able to prioritise ambulances to women in labour if they were considered an emergency. The continuity of care and the rapid discharge of ambulances when they are really needed, have been two of the main benefits to women in labour The Labour line had recently won the Royal College of Midwives Excellence in Maternity Care award for 2015 and they were also awarded second place in the Midwifery Service of the Year Award.
  • The breast care unit is a fully integrated multi-disciplinary unit that was pioneering intraoperative radiotherapy for breast cancer at the Royal Hampshire County Hospital.
  • The specialist palliative care team provided a comprehensive training programme for all staff involved in delivering end of life care.
  • The cardiac palliative care clinic identified and supported those patients with a non-cancer diagnosis who had been recognised as requiring end of life care.
  • The use of the butterfly initiative in end of life care promoted dignity and respect for the deceased and their relatives.
  • There was strong clinical leadership for the end of life service with an obvious commitment to improving and sustaining care delivery for those patients at the end of their lives.
  • All staff throughout the hospital were dedicated to providing compassionate end of life care.

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

Importantly, the trust must ensure:

  • Patients in the ED are admitted, transferred or discharged within national target times of four hours.
  • There is an appropriate system to identify patients with a learning disability.
  • Resuscitation equipment is appropriately checked and items are sealed or tagged.
  • Medicines are appropriately managed and stored in surgery
  • The early warning score is used consistently in surgery.
  • Venous thrombo-embolism assessment occurs on admission for surgical patients.
  • Staffing in radiology complies with guidance so that staff do not have heavy workloads and manual handling risks and staff have access to appropriate advice.
  • There is effective partnership working so that children and young people with mental health needs (CAMHS) have timely assessment and care reviews.
  • Children with cystic fibrosis are supported by appropriate paediatric physiotherapy.
  • The outsourced diagnostic imaging service is appropriately monitored and managed to reduce delays.
  • There are appropriate processes and monitoring arrangements to reduce the number of cancelled outpatient appointments, and ensure patients have timely and appropriate follow up.

In addition, the trust should ensure :

  • There is a named lead nurse for children in the ED as per Royal College of Paediatric and Child Health guidelines (2012)
  • Staff receive appropriate training and there is a formal process in place for staff to follow to meet requirements of the Duty of Candour.
  • Staff maintain Infection control procedures - peripheral cannula care and catheter care and hand hygiene - at all times.
  • Nurse staffing levels comply with safer staffing levels guidance.
  • Medicines are appropriate managed and stored in maternity and gynaecology.
  • Continued action to significantly reduce the incidence of pressure ulcer and falls.
  • Equipment in the Maternity unit and outpatients is appropriately checked.
  • The level of staff undertaking safeguarding adults and child training needs to meet trust targets.
  • The trust target of 80% for mandatory training is met.
  • The availability of medical notes for outpatient clinics continues to improve and this should be audited.
  • There is a formal method to identify patient’s whose condition might deteriorate in the outpatient clinic.
  • Clinical audit programmes continue to develop.
  • Nursing staff receive formal clinical supervision in line with professional standards.
  • Controlled drugs in liquid form are managed and stored appropriately in all the medical wards.
  • All staff have a clear understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards and mental capacity assessments are always documented or regularly reviewed in patient care records.
  • There is guidance around the frequency and timeliness of bed moves so that patients are not moved late at night and several times.
  • Review single sex bay arrangements on Victoria Ward to ensure patients privacy and dignity is not compromised.
  • Review the need for developing a Critical Care outreach service.
  • There is a critical care rehabilitation pathway.
  • Paediatric critical care guidelines are reviewed and updated.
  • There is a clear process and assurances for critical care staff who have been redeployed elsewhere in the hospital to return to the unit when a patient is admitted to the critical care unit.
  • Information for patients is available in accessible formats.
  • All DNACPR order forms are consistently completed accurately and in line with trust policy.
  • Review the process for ‘fast-track’ discharge to meet the standards for 90% standard to be discharged with the right level of care within 48 hours if there preferred place of death is home.
  • Safety Thermometer audits to allow staff, patients and their relatives to assess how the ward has performed in Maternity and gynaecology.
  • There is access to seven day week physiotherapy for children and young people with cystic fibrosis.
  • Complaints are responded to within the trust target of 25 days and there are formal methods to feedback complaints to staff.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 12 November 2015

Effective

Good

Updated 12 November 2015

Caring

Outstanding

Updated 12 November 2015

Responsive

Good

Updated 12 November 2015

Well-led

Good

Updated 12 November 2015

Checks on specific services

Maternity and gynaecology

Good

Updated 12 November 2015

Maternity and gynaecology services were rated ‘good’ for providing safe, effective, caring, responsive and well led services.

Nursing and midwifery staff were encouraged to report incidents and robust systems were in place to ensure lessons information and learning was disseminated trust wide.

Midwives followed comprehensive risk assessment processes from the initial booking appointment through to post-natal care. Identified risks were recorded and acted upon across both services.

All areas of the service we visited were visibly clean and systems were in place to ensure nurses, midwives and domestic staff adhered to trust infection control policies and procedures.

The gynaecology ward participated in the NHS Safety Thermometer. The NHS Safety Thermometer is a local improvement tool for measuring, monitoring and analysing patient harms and 'harm free' care. The ward conducted monthly audits in respect to patient falls, pressure ulcers, catheters and urinary tract infections. However, information about the audits was not displayed. It is considered to be best practice to display the results of the Safety Thermometer audits to allow staff, patients and their relatives to assess how the ward has performed.

Care and treatment was delivered in line with current legislation and nationally recognised evidence based guidance.

Policies and guidelines were developed in line with the Royal college of Obstetricians and Gynaecologists (RCOG), Safer childbirth (2007) and National Institute for Health and Care Excellence (NICE) guidelines. The guidelines had been unified across the trust for the maternity service to ensure all services worked to the same guidelines. Staff received further training and support in order for them to develop and maintain their competencies.

The supervisor to midwife ratio was 1:15.

The funded mid-wife to birth ratio was on average 1:30 which met the trust national and local benchmark. However, there were times during April 2014 to April 2015 when the midwife to birth ratio was 1:32-34. The England average was 1:29. Shortfalls in midwifery staff were due to maternity leave and sickness. Midwives had consistently been able to deliver one to one care in labour and there was no evidence to support harm had occurred to women when there had been a shortfall in midwifery staffing levels. The 103 hours dedicated consultant cover exceeded the recommendation of RCOG, Safer Childbirth (2007).

Women throughout the service consistently gave us positive feedback about the care and treatment they had received. We observed women were treated with dignity and respect and were included in decision making about their care. They were able to make choices about where they would like to deliver their babies. Women and families had access to sufficient emotional support if required.

The gynaecological service met the referral to treatment time target for women to be treated within of 18 weeks.

Translation services were available, and some midwives had undergone further specialist training to support women with additional needs such as learning disabilities and drug and alcohol addictions.

There was vision and strategy for the service which was focussed around plans for the development of a new hospital. Staff and the members of the community had been consulted about the changes to service provision and had been involved in the architectural design of the new building. Short term strategies had been developed to ensure staff were ready for the move to a new hospital and guidelines were embedded across the sites. However there had not been short and medium term plans for the service development.

There were comprehensive risk, quality and governance structures and systems were in place to share information and learning. Staff across the service described an open culture and felt well supported by their managers. Staff continually told us they felt “proud” to work for the trust and that their successes had been acknowledged and praised by the trust board.

Medical care (including older people’s care)

Good

Updated 12 November 2015

We found that medical care (including older people’s care) was ‘good’ for safe, effective, caring, responsive and well led.

Process and procedures were followed to report incidents and monitor risks. Staff were encouraged to report incidents. Themes from incidents were discussed at ward meetings to share learning. The environment was clean and equipment was well maintained. Staff had good access to equipment needed for pressure area care. They were able to order bariatric equipment within 24hours. Infection control practices were followed although needed to improve on some wards. Staff across all services described anticipated risks and how these were dealt with.

Patients whose condition deteriorated were appropriately escalated. The incidence of pressure ulcers and falls was higher than expected. Action was being taken on ensuring harm free care

Safeguarding protocols were in place and staff were familiar with these.

Medical staffing, across the medical services, was appropriate and covered medical outliers well. There was a significant shortage of nursing staff on the medical and care of elderly wards. The trust was using bank nurses where shortages were identified. However, we found that safer staffing levels at night were not always met on the care of the elderly ward, Freshfield and Victoria medical ward. The trust was implementing actions to mitigate and reduce the risks.

There were appropriate procedures to provide effective care. Staff provided care to patients based on national guidance, such as National Institute for Clinical Excellence (NICE) guidelines. Patient outcomes overall were similar to or better than England average for stroke care, diabetes care and heart attack. Were outcomes were worse than the England average, there was an action plan to address areas where improvements.

Arrangements were in place to ensure that staff had the necessary skills and competence to look after patients. Patients had access to services seven days a week and were cared for by a multidisciplinary team working in a coordinated way. When patients lacked capacity to make decisions for themselves, staff acted in accordance with legal requirements. However, the capacity assessments were not always documented or regularly reviewed in patient care records.

Staff had received statutory and mandatory training, and described good access to professional development opportunities.

Patients received compassionate care that respected their privacy and dignity. They told

us they felt involved in decision making about their care. We found staff were caring and

compassionate. Without exception, patients we spoke with praised staff for their empathy,

kindness and caring.

Bed occupancy in the trust was below the England average It is generally accepted that at 85% level, bed occupancy can start to affect the quality of care provided to patients, and the orderly running of the hospital. There were no medical outliers at the time of our inspection. Hospital data demonstrated the hospital routinely had medical outliers. Staff told us these patients were regularly assessed and followed by a team of medical consultant and junior doctors. Patient bed moves happened frequently, including at night. Staff were ensuring that patients with lower dependency needs were moved and patients had not expressed concern about their moves.

The trust was achieving the 31-day cancer waiting time diagnosis-to-treatment target and the 62-day referral-to-treatment target, although this had not been met in June 2015. The medical services were consistently achieving the 18-week referral-to-treatment time target against a national target 90%.

Patient discharges were discussed by medical teams daily. Discharge arrangements were supported by discharge coordinators. The hospital had an increasing number of delayed transfers of care to community services. The trust was working with its partners to improve this

Support was available for patients living with dementia and patients with a learning disability. We were given examples of the trust working closely with other local mental health NHS teams to meet the needs of patients in vulnerable circumstances.

The medical service had identified a long-term strategy and priorities around improving the services. There were effective governance arrangements and staff felt supported by service and trust management. Lessons from incidents and complaints were usually shared within the staff.

The culture within medical services was caring and supportive. Staff were actively engaged and innovation and learning was supported. There was good local leadership at ward level. Staff were focused on achieving key outcomes and these were linked to the trust’s vision and strategy.

Urgent and emergency services (A&E)

Good

Updated 12 November 2015

The emergency department (ED) was rated good for providing safe, effective, caring and well-led services. The responsiveness of the service ‘required improvement’.

The department had a culture of safety where incidents were reported. Learning was shared and changes made as a result of this. The department was visibly clean and hygienic. Medicines were appropriately managed and stored. Staff adherent to infection control procedures, but were working to improve hand hygiene compliance after carrying out their own audits. Equipment was available, fit for purpose and clean.

The department had appropriate medical staffing levels that included a consultant present for 16 hours a day. There were a low number of nursing vacancies within the department. Agency staff were seldom used as staff worked flexibly to provide appropriate skill mix and staffing levels. Recruitment for the small number of vacancies was ongoing. Safeguarding requirements for children, young people and vulnerable adults were understood, and there were appropriate checks and monitoring in place. There were effective procedures to assess and stream patients in the department and escalate patients whose condition might deteriorate.

The department provided effective care that followed national guidance and this was delivered to a high standard. Pain relief was offered appropriately and the effectiveness of this was checked. Multi-disciplinary work was in evidence and the department ran its services seven days a week. Patients gave positive comments about the care they received, and the attitude of the staff. Patients and relatives told us they were treated with compassion, dignity and respect.

The service had some improvement to make in terms of its responsiveness. The hospital was not meeting the national emergency access target of 95% of patients who required hospital admission to be transferred to a ward or discharged from ED within four hours. Patients were however, assessed and treated within standard times. Patients were, at times, waiting longer than expected for ambulance handovers and could have long waits in the ED on a trolley. However, risks to these patients were managed. There was good support for patients with a mental health condition and patients living with dementia.

The ED was well led by senior nurses and doctors, and the departmental strategy and vision was recognised by staff. The culture within the department was one of accessible leadership with mutual trust and respect.

Surgery

Good

Updated 12 November 2015

Surgery services were rated as ‘requires improvement’ for providing safe care and ‘good’ for being effective, caring, responsive and well led.

Procedures to ensure safe care required improvement. Resuscitation equipment and the storage of medicines in fridges needed to be appropriately checked in line with trust policy. Patient risks assessments for potential blood clots had not been done for patients within 48 hours of admission. The early warning score was not consistently being used to identify patients whose condition might deteriorate. There were not always adequate numbers of nursing staff to meet the assessed needs of patients, particularly at night on some wards.

Incidents were reported and appropriately investigated and action plans were developed to improve staff learning and services. Compliance with the Five Steps to Safer Surgical checklist was 94% and there were actions plans to improve this. Surgical staffing levels were appropriate.

Care and treatment was provided based on national guidelines. The surgical directorate took part in a number of local and national audits and outcomes in surgery were similar to or better than the England average. Patients received appropriate pain relief and nutritional support.

There was good multi-disciplinary team working to centre care around patients. Staff had good access to training and received clinical supervision and annual appraisals. Seven day services were developing. Consultant led care was provided with 24 hour cover arrangements. Some multidisciplinary support was available form therapist for colorectal and orthopaedic patients over the weekend.

Patients were consented appropriately and correctly. Staff were clear about their roles and responsibilities regarding the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

The surgical services provided care in a caring and compassionate way. Patients and their relatives told us staff understood their needs and treated them with sensitivity. Patients told us they were involved in their care and treatment and staff provided information in a way they could understand.

The hospital was achieving the referral to treatment time target of 18 weeks in some specialities; the target was not being achieved in orthopaedic and ophthalmology. Most patients who had their surgery cancelled on the day were rebooked for surgery within 28 days. The service was reviewing its capacity to identify ways in which service demands could be better managed

Support was available for patients living with dementia and patients with a learning disability. The service was taking part in a campaign in raising awareness and promoting better care for people living with dementia.

Complaints were handled in line with the trust’s policy although many were not dealt with in a timely manner. Information about complaints was not displayed in ward areas

There were good leadership at all a local level. Staff felt supported by the multi-disciplinary team, joint working and strong clinical leadership. Staff felt supported by managers who were considered to be visible, approachable and knowledgeable and were highly respected by their staff.

There was an effective governance structure to manage risk and quality. Staff were passionate to deliver quality care and an excellent patient experience.

The trust has continued to develop their engagement with patients including initiatives such as ‘through your eyes’ listening event’, which was developed by the division and introduced across the trust. The service took part in research and national projects and innovative practice.

Intensive/critical care

Good

Updated 12 November 2015

We rated critical care services as ‘good’ for providing safe, effective, responsive and well-led services. The service was outstanding for caring.

There were areas of good, outstanding and innovative practice in the critical care services. Once a week the librarian attended the ward round in order to source relevant literature to assist the professional development of staff. To promote the development of the nursing team the senior nursing team and clinical educator had taken the initiative to develop a critical care career pathway for grades 5, 6 and & 7. The nursing team was split into four teams. Each team had a team away day every two months during which they had time allocated to complete mandatory training. In response to difficulties recruiting middle grade (registrar) doctors the unit had developed a two year course in Advanced Critical Care Practice (ACCP), in conjunction with Southampton University. The ward manager’s assistant had developed spread sheets that accurately monitored staff annual leave and mandatory training in a timely way and had introduced an automated text system to alert staff of shifts that needed filling. Innovative grab sheets on the unit that detailed required essential equipment needed to care for patients if the unit had to be evacuated. These included pictures of the essential equipment, so non-clinical staff such as portering staff could help collect the equipment ensuring medical and nursing care of patients was not interrupted.

There were effective risk management processes in place with processes to ensure learning from incidents was shared across the critical care units at both RHCH and BNHH.

Staffing levels and qualifications were in line with national guidance. This meant patients received care and treatment from staff who had the necessary specialist skills and experience.

Treatment and care followed current evidence-based guidelines with the exception of outreach services and critical care rehabilitation services. The risk to patients associated with not having these services was being monitored and action was being taken to try to introduce these services. The critical care services participated in national and local audits and there were good outcomes for patients. Staff had effective training, supervision and appraisal and there was good multidisciplinary working to ensure that patients’ needs were met.

Data showed that outcomes for patients were comparable with those of similar critical care units.

There was strong leadership of the critical care service across the trust and in the unit at RHCH.

There was a culture of mutual support and respect, with staff willing to help the unit at BNHH when they were short staffed. Innovative ideas and approaches to care were encouraged and supported.

Services for children & young people

Good

Updated 12 November 2015

We rated services for children and young people services as ‘good’ for providing safe, effective, responsive and well-led services. The service was outstanding for caring.

Incidents were reported and appropriately investigated. Lessons were learnt to support improvements. Staff had an understanding to be open and transparent when things go wrong and the new regulation of Duty of Candour was being followed. Clinical areas were visibly clean and staff were following infection control procedures. Medicines were appropriately managed and stored and equipment was available and regularly tested to be fit for use.

Staff took steps to safeguard children. Children’s risks were appropriately assessed and procedures were followed to identified if their condition might deteriorate. Children with mental health problems were, however, not being assessed and supported by mental health professionals in a timely way.

Action was being taken to ensure safe nurse staffing levels. Consultants were covering middle grade doctor vacancies but this practice was not sustainable in the long term

Care and treatment was based on national guidance and evidence based practice. The services was monitoring clinical standards and participated in local and national audits. The trust scored better than the England average for diabetes and asthma outcomes.

Children and young people had good pain relief, nutrition and hydration. The hospital had received the level 3 “Baby Friendly” Accreditation in the neonatal unit in 23 July 2015 which supports parents to be partners in care.

Staff had appropriate training and were highly competent. Staff worked effectively in multi-disciplinary teams and with external providers to provide a holistic approach to care. The hospital, however, did not have sufficient inpatient paediatric physiotherapists to effectively support patients with cystic fibrosis.

Seven day services had developed for medical staff and consultants were available seven days a week.

Staff were providing a compassionate and caring service. Feedback from people who use the service, those who are close to them, was overwhelmingly positive. Children and their parents spoke of staff going “above and beyond” to provide care and keep them well informed, and of an “excellent” service. Children and their parents were involved in their care and treatment. Play leaders supported children to understand their care and reduce anxiety.

The service was being planned around managing service demands and responding to the needs and preferences of children, young people and their families. There was good access to the service, with open access for children with chronic conditions and those who had recently been discharged. There were good link with the community child health team, based in the hospital, leading to continuity and an integrated care approach. The service was meeting the needs of children with long-term chronic and life-limiting conditions by working in collaboration with other hospitals and hospices.

The trust needed to work with its partners to ensure there was a service level agreement for children and young people with mental health needs. There was support for children with a learning disability.

Governance processes appropriately managed quality and risks issues, although we did not see how risks were being escalated to the trust board. Staff were positive about the local leadership of services and demonstrated they were passionate and committed to delivering high quality, patient focused care.

There was evidence of cross site working, for example, to streamline services and share good practice although it was acknowledged that more work was required to develop consistent service across the trust.

Children and young people were encouraged to feedback ideas to improve the service

End of life care

Outstanding

Updated 12 November 2015

End of life care at this hospital was “outstanding”. We rated it ‘good’ for safe, effective and responsive services and outstanding for caring and well-led services.

End of life care at this hospital was safe and people were protected from avoidable harm and abuse. Reliable systems and process were in place to ensure the delivery of safe care.

Care and treatment was delivered in line with local and national guidance and there was a clear holistic patient-centred approach.

Staff involved and treated people with compassion, kindness, dignity and respect. Feedback from patients and their families was mostly positive and we observed many examples of outstanding compassionate care.

The leadership for end of life care was strong. There were robust governance arrangements and an engaged staff culture all of which contributed to driving and improving the delivery of high quality person-centred care.

This was an innovative service with a clear vision and a strong focus on patient centred care which was supported by a board structure that believed in the importance of good end of life care for the local population.

There was good multidisciplinary working, staff were appropriately qualified and had good access to a comprehensive training programme dedicated to end of life care. However we were concerned about the uptake of mandatory training by the specialist palliative care team.

Patient outcomes were routinely monitored and where these were lower than expected comprehensive plans had been put in place to improve. However, ‘Do Not Attempt Cardio Pulmonary Resuscitation’ (DNACPR) decisions were not always made appropriately and in line with national guidance.

Patient’s needs were mostly met through the way end of life care was organised and delivered. However, the rapid discharge of those patients expressing a wish to die at home did not always happen in a timely way. The specialist palliative care team identified rapid discharge as a challenge. We saw where recommendations and actions to address these audit results had been made and results had been discussed at board level.

Outpatients

Requires improvement

Updated 12 November 2015

We found the outpatients and diagnostic departments at RHCH were outstanding for caring and good for responsive services. The service required improvements to provide safe and well-led services.

Staff were encouraged to report incidents and the learning was shared to improve services. There had, however, been one serious incident requiring investigation of a patient lost to follow up in outpatients where clear actions had not been taken to mitigate future risks. Some of the equipment used in outpatients had not been regularly tested to ensure it was safe to use.

Staff compliance with mandatory training was good in diagnostic imaging but more outpatient staff needed to complete mandatory training.

Radiographers worked alone overnight and was responsible for covering all plain film X-rays for the main hospital and the emergency department as well as basic computerised tomography (CT) scans. Radiographers reported a heavy workload and raised manual handling issues. Between 10.00pm and 8am, radiology was supported by an overnight outsourced radiologist service. Staff identified delays in the process to authorise request and provide advice on imaging which meant delays in the patient diagnosis.

In diagnostic imaging, staff were confident in reporting ionised radiation medical exposure (IR(ME)R) incidents and followed procedures to report incidents to the radiation protection team and the care quality commission.

The environments were visibly clean and staff followed infection control procedures. Medicines were appropriately managed and stored. Patients were assessed although, Most records were available for clinics and, if not available, temporary files and test results from the electronic patient record were used. Patients were assessed and observations were performed, where appropriate. However, there was not a tool in use to identify patient’s whose condition might deteriorate. In interventional radiology there was evidence of the WHO checklist being completed and patient protocols in place

Nurse staffing levels were appropriate as there were few vacancies. There was an ongoing recruitment plan for nurses and radiographers.

There was evidence of National Institute for Health and Care Excellence (NICE) guidelines being adhered to in rheumatology and ophthalmology. However, there was not a local audit programme to monitor clinical standards. Staff had access to training and had annual supervision but did not have formal clinical supervision.

Staff followed consent procedures but did not have an understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards which ensures that decisions are made in patients’ best interests.

Staff provided outstandingly good, compassionate care, and ensured patients and relatives were well-supported whilst in the department. We were informed of some exceptional compassionate care for patients, with nurses and radiography staff going the extra mile and far above and beyond of that expected. Patients were well-informed and routinely involved in the planning of their care and treatment. Staff recognised when a patient required extra support to be able to be included in understanding their treatment plans. The feedback from patients and relatives we spoke with was overwhelmingly positive, within very detailed conversations.

There was some evidence of service planning to meet people’s needs. For example, the breast unit offered access to one stop clinics where patients could see a clinician, have a biopsy and see a radiologist if required. National waiting times were met for outpatient appointments, cancer referrals and treatment and diagnostic imaging. However, the trust had a higher number of cancelled clinics, many of which were at short notice. The reasons for this varied and included cancellation for staff sickness, training and annual leave. There was a plan to address this but this was in development. Patients were not appropriately monitored to ensure the timeliness of re-appointments.

‘There was good support for patients with a learning disability or living with dementia. Patients whose first language might not be English had access to interpreters although some staff were not aware of how to access this service. The service received very few complaints and concerns were resolved locally. Staff were not aware of complaints across the trust or the learning from complaints.

The outpatient department had a strategy in development. There were plans to deliver, local consultant led services, including more one stop, nurse led and complex procedure clinics for outpatient services. Staff were not aware of how the strategy would develop in their departments and there were no immediate plans to tackle capacity issues and clinic cancellations. In diagnostic imaging there was an action plan planned to increase the skill mix of staff, the capacity of services and service integration across sites. This had had yet to be considered at divisional and trust board levels and interim actions were not specified.

Governance processes required further development in the outpatient and diagnostic department to monitor risks and quality.

Staff were not clear about the overall vision and values of the trust but told us that the patient experience and the provision of high quality care was their main concern. Nursing staff did not identify a strong leadership presence in the outpatient department and did not feel well supported. Radiographers felt well supported by their immediate line managers. They told us that they felt well supported and valued. Staff said they enjoyed working for the trust due to the strong team support from colleagues.

There were however, few examples of local innovation and improvement to services. In diagnostic imaging, a staff representative role was being introduced following to support and implement positive changes within the department that staff members themselves had recommended. Public and patient engagement occurred through feedback such as surveys and comment cards.