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Andover War Memorial Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

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.

Andover War Memorial Hospital (AWMH) was opened in 1926. The hospital provides inpatient rehabilitation, day hospital services and a minor injuries unit, and a new outpatient unit opened in 2010. The site also houses the Countess of Brecknock Hospice, which provides six inpatient beds, day care, and a base for Macmillan Nurses.

We inspected the hospital as part of our comprehensive inspection programme. We inspected six core services at this hospital: Urgent care services, medical (including older people) services, surgical services, maternity and gynaecology, end of life care and outpatient services. The hospital did not have critical care or services for children and young people.

There were 60 staff employed at the hospital.

The inspection of AWMH took place on 28 and 30 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 rated AWMH as overall as ‘requires improvement’. We rated it as good for providing safe, caring, responsive services. However, MIU was rated as requires improvement for effective and well led services.

We rated the hospital’s services for end of life care as ‘outstanding’; for medical care, maternity and outpatients and diagnostics as ‘good’ and for the minor injuries unit and surgery as ‘requires improvement’.

Our key findings were as follows:

Are services safe?

  • Staff were encouraged to report incidents and learning from incidents to improve the safety of services locally and across the trust. However, in the Minor Injuries Unit (MIU) and in surgery, learning was not being effectively shared across the trust’s services.
  • 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.
  • Patient clinical areas were visibly clean and staff followed good infection control procedures.
  • Staffing levels were appropriate in all areas.
  • Overall, staff had a good understanding of safeguarding adults and children. In the MIU there were pathways for children with non-accidental injury. However, safeguarding checks had not been consistently recorded in patient notes.
  • Medicines were appropriately managed and stored. Action was being taken in areas where there were some concerns. The Patient Group Directions, which allows trained nurses to prescribe and administer drugs, were out of date in the MIU.
  • Equipment was checked and stored appropriately in most areas but this needed to improve in the MIU, specifically for resuscitation equipment.
  • More staff needed to complete mandatory training.
  • Patients’ were assessed and monitored appropriately. However, the early warning score needed to be used in surgery, and a scoring tool was required for outpatients, for patients whose condition might deteriorate. There also needed to be a clear hospital protocol for responding to a collapsed patient.
  • The trust did not employ site security for the hospital. MIU staff were concerned about the number of recorded incidents of abuse from patients attending the MIU towards staff.
  • 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. However, the MIU did not have clear guidelines or protocols for the management of common conditions. Staff in surgery did not all know how to access the trust’s guidelines and protocols and some policies they were using were out of date.
  • Most services were not monitoring the standards of care and treatment. Patient outcomes, where available, were similar to the England average or within expected range.
  • Patients received good pain relief in the MIU, after surgery and in end of life care. The Maternity Centre used hypnotherapy-birthing techniques to support women in pain during labour.
  • Patients, particularly older patients, were supported to ensure their hydration and nutrition needs were met.
  • Staff were supported to access training and there was evidence of staff appraisal and supervision. Nursing and midwifery staff were autonomous, experienced and competent practitioners. However, staff in the MIU were not supported to keep their clinical skills up to date through supervision or developmental training, and day surgery staff did not have regular and up to date competency assessments. Midwifery staff told us they did have opportunities for professional development.
  • Staff worked effectively in multidisciplinary teams to centre care around patients. 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.
  • Seven-day services varied. These were developed in the MIU, the Maternity Centre and the hospice. However, day surgery occurred Monday to Friday and medical patients did not receive therapy input for rehabilitation over the weekends. There were a high number of repeat attenders to the MIU because there was no radiology at the weekend.
  • 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, the capacity assessments were not always documented or regularly reviewed in patient care records.
  • ‘Do Not Attempt Cardio Pulmonary Resuscitation’ (DNACPR) forms had been fully completed.

Are services caring?

  • Staff were caring and compassionate and treated patients with dignity and respect. Patient feedback was positive across all services. The Countess of Brecknock Hospice provided outstanding care with patients and relatives providing examples where staff had gone “above and beyond” and developed trusting relationships to provide personalised care and support to patients and their families.
  • Staff maintained patient’s confidentiality, privacy and dignity in all areas.
  • Patients and their relatives felt involved in their care and treatment, staff provided explanations in the way patients could understand. Patients felt that their views and considerations were listened to and acted upon.
  • Patients and their families were supported emotionally to reduce anxiety and concern, particularly for example, in preparation for surgery, or for women during labour. There was support for carers, family and friends from the chaplaincy and bereavement services for patients having end of life care.
  • Data from the NHS Friends and Family Test demonstrated that patients were very satisfied and would recommend the care they received.

Are services responsive?

  • The MIU service saw and treated patients within the national emergency access target of four hours.
  • Medical patients did not have to wait for access to the Kingfisher ward and there was active therapy input to commenced rehabilitation immediately. Discharge planning was supported but there were delayed transfers of care.
  • The trust 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 rebooked for surgery within 28 days. Some operations and procedures were being cancelled because of absent medical records.
  • Patients did not have staggered admission times for all procedures as recommended, to limit fasting and waiting times on the day of surgery.
  • Women were able to make choices about where they would like to deliver their babies. They had access to their preferred ante-natal clinics and women in the early stages of labour had access to telephone support.
  • There were one stop gynaecology, cataract and orthopaedic clinics.
  • The trust was meeting national waiting times for diagnostic imaging within six week, 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 13%; 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.
  • Some patients had long waiting times whilst waiting in clinic for diagnostic imaging, and there could be delays of up to an hour.

  • Support for patients living with dementia or a learning disability was well developed for medical care, but was not consistent for patients undergoing surgery.

  • There was access to the breast unit at Winchester, which offered access to one stop clinics. Appointments were offered 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 about a potential cancer diagnosis.
  • 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.
  • Complaints were handled appropriately and there was evidence of improvements to services as a result.

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, the individual services did not have specific strategies and plans in the short and medium term for their development. Priorities were identified to increase capacity and staffing.
  • Clinical governance arrangements varied across the hospital. The Kingfisher Ward (medical care), Maternity Centre and Countess of Brecknock Hospice had effective arrangements to assess and manage the quality of service provision. However, the MIU, day care unit for surgery and outpatient department required more robust arrangements to effectively monitor the quality of the service, clinical standards and to mitigate risks.
  • Many staff told us overall they had good support from the local clinical leaders, for example ward managers and clinical leads.
  • Staff engagement also varied and was good in some areas, but there was a disconnect with the trust’s working arrangements in the MIU, Day Care Unit and outpatient department, and staff did not feel part of the wider trust.
  • Many staff identified the visibility, approachability and support of the chief executive of the trust.
  • 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, although the Maternity Centre also used social media.
  • Innovative ideas and approaches to care varied. This was being encouraged and supported on the Kingfisher Ward (medical care), in maternity and end of life care, and there were good examples of innovations in care. This was less evident in the MIU, the day care unit for surgery, and outpatient and diagnostic imaging services.
  • The non-clinical site manager was a highly-valued member of staff.

We saw several areas of outstanding practice including:

  • Kingfisher ward had activity coordinators who planned and conducted different activities for patients after consulting them. There was a range of activities offered, including arts and crafts, music, dance, group lunches and movie time.

  • Pregnant women were able to call Labour Line which was the first of its kind introduced in the country. This services involved midwives 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 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 hospice at home service was proactive in supporting patients in their own home.
  • The use of the butterfly initiative 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 Countess of Brecknock Hospice 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:

  • MIU staff have access to up- to-date approved Patient Group Directions (PGDs).
  • MIU staff must all have received update mandatory training in basic life support and infection control
  • Safeguarding checks are consistently completed and recorded.
  • Resuscitation equipment is appropriately checked and equipment is sealed and tagged.
  • There is a clear hospital protocol for responding to a collapsed patient in an emergency.
  • There is appropriate security on site for the protection of staff and patients in the MIU.
  • The lead consultant for ED should regularly monitor and maintain clinical standards in the MIU
  • There are appropriate processes and monitoring arrangements to reduce the number of cancelled outpatient appointments and ensure patients have timely and appropriate follow up.
  • There is an effective system to identify, assess, monitor and improve the quality and safety of the MIU, the day care unit and outpatient services

In addition, the trust should ensure:

  • Staff receive appropriate training, and there is a formal process in place for staff to follow to meet requirements of the Duty of Candour.
  • The availability of medical notes for outpatient clinics continues to improve and this should be audited.
  • There is a formal method to identify patients whose condition might deteriorate in the outpatient clinic.
  • Patients receive better access to therapy services to continue rehabilitation over weekends.
  • Clean equipment is clearly identified for use and is appropriately separated from dirty equipment.
  • Bariatric equipment is available when required.
  • Continue to recruit to support radiographers, and assess the impact of vacancies on staff.
  • All staff have appropriate clinical supervision.
  • The Maternity Centre has better access to defibrillator equipment.
  • Medicines are appropriately stored in the Maternity Centre.
  • Clinical audit programmes are developed in all services.
  • Information is being measured, monitored and recorded regarding outcomes for women.
  • Theatre capacity is reviewed and patients are not waiting longer than 18 weeks for surgery.
  • Patient have staggered admissions for day surgery.
  • Patient operations are not cancelled on the day of surgery for non-clinical reasons.
  • Patient’s privacy and dignity is maintained on the day care unit by reviewing same sex arrangements.
  • There is service continuity with local funeral directors to collect deceased bodies from the Countess of Brecknock Hospice, to reduce the risk of any services being withdrawn.
  • The process for ‘fast-track’ discharge for end of life care is reviewed so that the standard is met.
  • Improve staff engagement in the MIU, day surgery unit and outpatients.
  • There are formal methods to feedback complaints to staff.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 12 November 2015

Effective

Requires improvement

Updated 12 November 2015

Caring

Good

Updated 12 November 2015

Responsive

Good

Updated 12 November 2015

Well-led

Requires improvement

Updated 12 November 2015

Checks on specific services

Maternity and gynaecology

Good

Updated 12 November 2015

We found maternity services were good for providing safe, effective, caring, responsive and well led services.

Our key findings are:

Midwifery staff were encouraged to report incidents and robust systems were in place to ensure lessons information and learning was disseminated trust wide.Procedures to protect people from abuse and avoidable harm were being followed. Midwife staffing levels were appropriate to provide one to one care.

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 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.

Although patient outcomes were recorded on the trust wide maternity dashboard, outcomes appropriate for a midwifery led centre were not being measured and recorded. This needed further development.

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. Women 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.

There was a strategy and vision for the service which was focused towards the development of a new hospital. However, there was not a specific strategy or plans for the maternity centre in the short and medium term. The overall plan was for the service to remain open to increase choice for women but the plans to increase birth rates or expand and develop the service were not developed.

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.

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 services.

Our key findings are:

Process and procedures were followed to report incidents and monitor risks. Staff were encouraged to report incidents and the learning from incidents was used to improve the service. The ward environment was clean and equipment was available and well maintained. Patients whose condition deteriorated were appropriately escalated and action was taken to ensure harm free care. Safeguarding protocols were in place and staff were familiar with these. Nursing staffing levels were appropriate; junior doctors were present during weekdays and there were arrangements for on call medical cover at the weekend.

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.

Patients were cared for by a multidisciplinary team working in a co-ordinated way and staff had good access to training. There were effective arrangements to ensure that staff had the necessary skills and competence to care for patients; staff had good access to training and professional development opportunities. When patients lacked capacity to make decisions for themselves, staff acted in accordance with legal requirements. However, the capacity assessments were not always documented in patient care records.

Patients received compassionate care from staff that respected their privacy and dignity. Patients told us they felt involved in decision making about their care. We found staff were caring and compassionate. Patients we spoke with praised staff for their empathy, kindness and caring. There was support available for patients living with dementia or who had a learning disability, and for staff caring for these patient groups.

Patients were not waiting for access to rehabilitation to Kingfisher ward and once admitted rehabilitation was commenced immediately with active therapy input. Patients who were medically declared fit and needing further rehabilitation input were transferred from RHCH and BNHH to Kingfisher ward. Occasionally patients were also admitted from other acute NHS trust hospitals in the locality or referred by GP’s. Patients regularly received medical input and were regularly seen by the therapists who assisted the patients to work towards their rehabilitation goals. The ward based social worker supported ward staff in planning complex discharges and carried out specialist assessments such as those for NHS funded continuing care.

The data provided by the trust demonstrated there were an increasing number of delayed transfers of care (January 2015 to May 2015). We were told by the social worker and nursing staff on the ward that the main cause of delays was the provision of community services, especially care home placement, to meet patients’ on-going needs.

The medical services had a long-term strategy and priorities around improving the services this included improving the pathway for frail elderly patients. There were not however, specific plans for the development of the service in Andover. 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 on the Kingfisher ward was caring and supportive. Staff were actively engaged and innovation and learning was supported. There was good local leadership at ward level. The service was forward looking, encouraging innovations to ensure improvement and sustainability of the service.

Urgent and emergency services (A&E)

Requires improvement

Updated 12 November 2015

We found the minor injury unit (MIU) was good for caring and responsive services but required improvements to provide safe, effective and well-led care.

There were insufficient processes for identifying, assessing and managing risks in the service. Staff did not have access to up to date guidance and protocols and were not supported through clinical supervision. The clinical standards of the service were not monitored in line with the MIU service specification. Staff did not have regular contact with the consultant lead for the service and most staff could not name the consultant lead. There was a disconnect between the operation of the unit and the senior governance processes in the trust. Staff did not feel their concerns were managed effectively and this had impacted on staff morale. The trust had recently recognised the leadership issues within the MIU service and was in the process of reviewing the current arrangements to ensure better and closer liaison with the ED’s at the other two sites.

Processes to protect patients from risks were not always followed. Learning from incidents was not consistently shared between the MIU and trust’s main emergency departments. There was no record of the daily check of resuscitation equipment, and we found some items in the resuscitation trolley were out of date. Not all staff were up to date with mandatory training or had completed updated training in basic life support. The MIU reference file of Patient Group Directions (PGDs) contained some which were out of date with different versions of the same PGDs, which increased the risk of error.

However, the MIU was organised and equipment was visibly clean. Medicines were appropriately managed and stored. Staff were adherent to infection control procedures, We observed caring and compassionate interactions between staff and patients. There was one vacancy for an emergency nurse practitioner and low rates of staff sickness. There was a supportive team culture within the ENPs and clinical nurse assistants. Safeguarding requirements for children, young people and vulnerable adults were understood, and there were appropriate checks and monitoring in place.

Patients’ presenting to MIU were assessed and in case of deteriorating conditions, appropriate action was taken. However, staff said they were not clear about the hospital protocol for responding to a collapsed patient elsewhere on the site.

Staff provided compassionate care and ensured that patients were treated with dignity and respect. We observed patient’s privacy and dignity was maintained at all times. The results of the NHS Friends and Family Test (FFT) showed that a higher than average number of patients would recommend the department, although this was based on a low response rate. Patients were fully involved in the assessment and treatment process.

The service met the national emergency access target for 95% of patients to be admitted, transferred or discharged from the MIU within four hours.

Staff described the chief executive as accessible and approachable through her monthly visits to the hospital.

Surgery

Requires improvement

Updated 12 November 2015

We found that surgery was good for safe and caring services. We rated effective, responsive and well-led services as requiring improvement.

Our key findings are:

Incidents were reported on the trust electronic system and actions were taken at local level, although staff did not always share lessons learnt across the trust. The day care unit was clean and well maintained and infection control procedures were followed. Emergency equipment, such as a resuscitation trolley was available and checked regularly to ensure it was fit for purpose.

The service used the Five Steps to Safer Surgery checklist although this was not audited locally. Patients were risks assessed and monitored. However, an early warning score was not used as a formal process to monitor and escalate patients whose condition might deteriorate. Staffing levels were appropriate to the needs of patients.

Staff provided care to patients based on national guidance and evidence based practice. However, standards of care and patient outcomes were not being monitored through a clinical audit programme. Patient outcomes were measured for cataract surgery and the complication rate was low. Patient’s pain was appropriately assessed and treated.

Patients for endoscopy were admitted at varying intervals during the day. However, patients undergoing orthopaedic and cataracts procedures did not have staggered admissions which is recommended to limit fasting and waiting times.

Staff had access to training to maintain their skill. However, their competencies were not regularly assessed. Staff worked in a multi-disciplinary way to provide care. GPs received discharge summaries in a timely way and there was a service level agreement for transfer of patients within the trust.

Patients received care and treatment from staff who were caring and in a compassionate way. Staff across the day care unit treated patients with kindness and respect. Patients were involved in their care and treatment. Procedures had been fully explained and options discussed. Patients received emotional needs, were supported, and they felt prepared for their surgical procedures.

There was no evidence of service planning to meet local needs and the service was currently using less than 50% of its theatre capacity. Some referral to treatment times were not being met in orthopaedic surgery and ophthalmology and patients were waiting over 18 weeks for surgery. Treatment times were being met in dermatology, gynaecology and urology. Patient operations and procedures were being cancelled on the day of surgery because patient records were not always available. This was not being monitored and improvements had not occurred. The service had one stop clinics and was developing a bowel diagnostic service.

Support for patients living with dementia or who had a learning disability was not consistently being accessed or used by staff. The day care unit did not provide separate or same sex facility as care was provided in an open unit which may compromise patients’ privacy and dignity.

The day care unit service at Andover hospital did not have a specific strategy for development. Staff were engaged, and felt connected to the trust, via the chief executive visits to the hospital. However, they were less engaged with the trust and their own surgical division. They did not, for example, participate in governance meetings or were aware of governance matters which may affect the service.

Governance processes were at divisional level and were underdeveloped in the unit. There was limited evidence of local audit or monitoring of the service quality and risks.

Staff were positive about the local leadership of the service and felt supported by their immediate managers and worked well together. Patient feedback, via the Friends and Family test was used to improve the service.

End of life care

Outstanding

Updated 12 November 2015

End of life care at this hospice was “outstanding”. We rated the service good for safe, effective and responsive care and outstanding for caring and well-led care.

Our key findings are:

People were protected from avoidable harm and abuse. There were reliable systems and processes were to ensure the delivery of safe care.

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

There was good multidisciplinary working, staff were appropriately qualified and had good access to a comprehensive training programme dedicated to end of life care.

Patient outcomes were routinely monitored and where these were lower than expected, comprehensive plans had been put in place to improve. ‘Do Not Attempt Cardio Pulmonary Resuscitation’ (DNACPR) forms had been completed.

Staff treated people with compassion, kindness, dignity and respect and feedback from patients and their families were consistently positive.

People’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. Where delays to discharge had occurred, these were mostly subject to circumstances outside the control of the trust.

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 and was supported by a board structure that believed in the importance of good end of life care for the local population

Outpatients

Good

Updated 12 November 2015

Outpatients and diagnostic imaging services were good for providing safe, caring, responsive services, but required improvement to provide well-led services.

Staff were encouraged to report incidents and the learning was shared to improve services. 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. Equipment was well maintained and medicines were appropriately managed and stored. 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 an assessment tool in use to identify patient’s whose condition might deteriorate.

Nurse staffing levels were appropriate as there were few vacancies. Radiographer vacancies were higher and they reported a heavy workload. There was an ongoing recruitment plan.

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.

Patients consistently told us that they had experienced a good standard of care from staff across outpatients and diagnostic imaging services. We observed compassionate, caring interactions from nursing and radiography staff. Patients told us that they were included in the decision making regarding their care and treatment and staff recognised when a patient required extra support to be able to be included in understanding their treatment plans.

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. Some patients had long waiting times whilst waiting in clinic for diagnostic imaging, and there could be delays of up to an hour.

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 department to monitor risks and quality although these were well developed in diagnostic imaging.

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. Staff identified a disconnect with local services and the wider trust. Many staff in outpatients did not see their service leads frequently and said that trust board members did not have a visible presence.

Nurses and radiographers spoke highly of their immediate line managers and told us they worked in strong, supportive teams which they valued. There were however, few examples of local innovation and improvement to services. In diagnostic imaging, a staff representative role was being introduced 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.