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Royal Hampshire County Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 26 September 2018

Our rating of services went down. We rated it as requires improvement because:

  • Patients were not always protected from avoidable harm. There were limited effective systems in place to assess and monitor the ongoing care and treatment to patients, including monitoring patients for signs of clinical deterioration.
  • Staffing levels and skill mix were not always sufficient to meet the needs of patients; as a result patients did not have their care and treatment carried out in a timely manner.
  • There were not effective systems in place for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
  • Risk assessments were not consistently completed to inform the development of individual care plans that included actions to mitigate identified risks and individual needs appropriately.
  • Staff did not always effectively support patients who lacked the capacity to make decisions about their care. This meant their individual wishes may not be considered.
  • The governance arrangements and culture at the hospital did not always support the delivery of high-quality person-centred care.
  • Medicines were not managed effectively and staff did not follow policies and procedures to ensure these were stored, administered and disposed of safely.
  • Emergency equipment was not consistently checked to ensure it was fit for purpose and available when needed.

However,

  • Staff did treat patients with dignity and respect. Patients felt supported and said staff cared for them well.
  • Safeguarding was seen as a priority by nursing staff, who understood how to protect patients from abuse.
  • Patients’ pain was regularly assessed and monitored. They received pain control as needed.
  • People who use services, carers and family members were involved and encouraged to be partners in their care and in making decisions, and received support they needed.
Inspection areas

Safe

Requires improvement

Updated 26 September 2018

Effective

Requires improvement

Updated 26 September 2018

Caring

Outstanding

Updated 26 September 2018

Responsive

Requires improvement

Updated 26 September 2018

Well-led

Requires improvement

Updated 26 September 2018

Checks on specific services

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.

Outpatients and diagnostic imaging

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.

Urgent and emergency services

Inadequate

Updated 26 September 2018

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

  • There were limited effective system(s) in place to assess and monitor the ongoing care and treatment to patients, including monitoring patients for signs of clinical deterioration.
  • Staffing levels and skill mix were not sufficient to meet the needs of patients as a result; patients did not have their care and treatment carried out in a timely manner. There was not a minimum of one children’s nurse present on each shift nor was there consultant presence in the department for 16 hours per day; both were not meeting national guidance.
  • Whilst the trust was assessing the most appropriate action to take, there was no viable long term solution to the challenges posed by the environment. A bid for additional money to assist with the redesign of the ED had been placed however no formal plans currently existed to describe how the department would be redesigned should the bid prove successful. Further, there was little regard and no holistic review of risk associated with environmental challenges such as those posed through the existence of ligature points. These unidentified risks had therefore not been sufficiently mitigated against.
  • Patients care, treatment and support did not always achieve good outcomes, promote a good quality of life and was not always based on the best available evidence. Audit participation was low during 2017. Where audit activity had occurred, results were not used to improve patient outcomes.
  • Sufficient priority was not given to patients’ pain needs.
  • There did not appear to be one individual taking overall responsibility for the day-to-day running of the department. Front line staff had not always felt supported, respected or valued by their immediate line manager(s); this was reflected in the 2017 NHS staff survey results in which the ED at Royal Hampshire County Hospital performed significantly worse in twenty-one questions when compared to the trust average.
  • There were not effective systems in place for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. The management of risks, issues and performance in the emergency department was not robust. Concerns identified by the inspection team such as the competency of the workforce and environmental risk factors were had not been recognised or managed appropriately leading to poor patient experience and the increased risk of avoidable harm being caused to patients.

However:

  • Feedback from patients we spoke with said staff treated them well and with kindness. Patients told us they had been given enough information about their condition and/or treatment in a way that they could understand.
  • Staff reported the morale within the department was good despite frustrations regarding a lack of long term strategy, staffing challenges and flow through the ED.

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)

Requires improvement

Updated 26 September 2018

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

  • There was limited assurance about safety which put patients at an increased risk of harm.
  • Staff did not always effectively support patients who lacked the capacity to make decisions about their care.
  • The service did not always meet people’s needs.
  • The governance and culture did not always support the delivery of high-quality person-centred care.

However,

  • The service treated patients with dignity and respect.

Surgery

Requires improvement

Updated 26 September 2018

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

  • There was limited assurance about safety processes and procedures.
  • Risk assessments were not consistently completed for care plans to be developed to manage the identified risks appropriately.
  • Staff did not follow policies and procedures to manage medicines safely. The service did not have effective processes to manage medicines safely.
  • Emergency equipment was not consistently checked to ensure it was fit for purpose and available when needed.
  • The process for protecting their privacy and dignity was not managed effectively.
  • Services were organised and delivered to meet the needs of the local population.
  • The leadership, governance and culture did not always support the delivery of high-quality person-centred care.

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.