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Inspection Summary


Overall summary & rating

Good

Updated 22 August 2019

Our rating of services improved. We rated it them as good because:

  • Generally, staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it. Staff we spoke with had a good understanding of who the safeguarding named lead was, and they could describe how to raise a concern or seek advice.
  • The hospital generally managed patient safety incidents well. Staff recognised and reported incidents and near misses.
  • The hospital had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank, agency and locum staff a full induction.
  • Staff consistently assessed, monitored and managed risks to patients who used their services. This had improved since our last inspection. Staff used a nationally recognised tool to identify deteriorating patients and escalated them appropriately. The trust had sepsis guidelines on how to screen for and manage sepsis.
  • The hospital provided care and treatment based on national guidance and evidence-based practice. Policies and procedures were available and accessible to staff via the trust intranet. Policies we viewed as part of our inspection were in date and in line with best practice and national guidelines. Clinical guidance was also available on the trust intranet.
  • Staff made sure patients had enough to eat and drink. Especially those with specialist nutrition and hydration needs. Specialist support from staff such as dieticians and speech and language therapists were available for patients who needed it.
  • Staff delivered kind and compassionate care to patients and their carers.
  • Staff provided emotional support to patients, families and carers to minimise their distress. They understood patients’ personal, cultural and religious needs.
  • The hospital planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care.
  • There were systems in place to aid the delivery of care to patients in need of additional support such as dementia or learning disabilities. The trust employed a learning disability liaison nurse and a dementia specialist nurse.
  • Peoples concerns, and complaints were listened and responded to. There were effective systems and processes to learn and improve from complaints.
  • Leaders had the integrity, skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the hospital for patients and staff. They supported staff to develop their skills and take on more senior roles.
  • There was good oversight of performance and leaders used the results to help improve care. All staff identified risks to good care and the service took action to eliminate or minimise risks.
  • Generally, staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear.

However:

  • The urgent and emergency care service did not mirror the general findings of the hospitals services. The leadership of the service did not have sufficient oversight of the quality and safety of the service provided.
  • In urgent and emergency care, the nursing leadership team lacked stability. Some staff did not feel engaged in the planning and delivery of services.

  • The urgent and emergency care service did not control infection risk well. Staff did not always keep equipment and the premises clean and they did not always use control measures to prevent the spread of infection.
  • In urgent and emergency care, patients did not always receive treatment within agreed time frames and national targets.
  • In urgent and emergency care, staff treated patients with compassion and kindness. However, because of the constraints of the physical environment, it was not always possible for staff to respect patients’ privacy and dignity and maintain their confidentiality.
  • The average length of stay for non-elective surgery at the trust was worse than the England average and showed little improvement since our last inspection.
  • There was poor compliance to safeguarding adults training for nursing and medical staff.
  • There was no Mental Capacity Act specific training at the time of the reporting period. The trust advised that a new course was introduced on 1 April 2019.
Inspection areas

Safe

Requires improvement

Updated 22 August 2019

Effective

Good

Updated 22 August 2019

Caring

Good

Updated 22 August 2019

Responsive

Good

Updated 22 August 2019

Well-led

Good

Updated 22 August 2019

Checks on specific services

Medical care (including older people’s care)

Good

Updated 22 August 2019

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

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it. Staff we spoke with had a good understanding of who the safeguarding named lead was, and they could describe how to raise a concern or seek advice.
  • The service-controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean. All ward areas we visited were visibly clean and tidy. We saw staff following national guidance on infection control.
  • The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service. Staff knew how to report incidents or near misses via the trust’s electronic reporting system. Staff we spoke with felt confident in raising an incident should they need to. They gave us examples of what they would report as an incident and how they would respond to the person involved.
  • The service provided care and treatment based on national guidance and evidence-based practice. Policies and procedures were available and accessible to staff via the trust intranet. Policies we viewed as part of our inspection were in date and in line with best practice and national guidelines. Clinical guidance was also available on the trust intranet.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and development. Managers used the appraisal process to identify staff learning and development needs. Staff told us they had regular one to one and team meetings and were supported with their continuous professional development.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. We saw all staff wearing name badges and we saw display boards informing patients and families of key staff on each ward. A poster displaying clinical staff grades and specialities by their uniforms was at the entrance to all wards we visited.
  • The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. We saw dementia friendly environments in all areas of the hospital. The dementia-friendly facilities on Ebony ward included a reminiscence room which provided a peaceful place for patients to spend time.
  • Pets as therapy dogs visited some wards twice weekly. We were told that this was welcomed by many patients and had positive feedback from both staff and patients.
  • It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff. The service included patients in the investigation of their complaint. The Patient Liaison and Advice service was available for patients to access, who supported patients with concerns and complaints and gave information about NHS services.
  • The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. Managers we spoke with were aware of the registers and knew the main risks and the actions needed to reduce the risks that had been found. We saw risk registers that had been reviewed with control measures in place and actions completed.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear.
  • Staff told us there was an open and honest culture and were aware of how to raise concerns in the workplace but reported that they did not have any. All wards were described as friendly and welcoming. The trust had a Freedom to Speak Up Guardian and had developed a freedom to speak up policy in 2018. The Director of Nursing was the designated Board member, with whom concerns about raising concerns could also be addressed.
  • Staff told us they were encouraged to learn. Nursing development opportunities were offered to staff throughout the wards and the practice development nurse supported staff with this.

However:

  • The service did not achieve their trust completion rate targets for all mandatory training modules.
  • Safeguarding and Mental Capacity act training rates did not achieve trust completion rate targets. We heard this was because training in these modules had been restructured and training rates were being monitored since these were introduced.
  • There was no Mental Capacity Act specific training at the time of the reporting period. The trust advised that a new course was introduced on the 1st of April 2019 but staff we spoke with had not yet attended it.
  • The service did not always develop and establish action plans and strategies in a timely way from their audits. As an example, the lung cancer audit did not identify any actions to improve or sustain their results.
  • Not all staff received an appraisal. Appraisal rates were not meeting trust completion targets for several staffing groups.
  • There was no formal action plan to minimise the number of night ward moves. This data was however discussed through senior members of the medicine clinical group and the executive team.

Services for children & young people

Good

Updated 2 July 2014

In the main children’s department parents told us that staff were responsive to their needs and that they listened to them. They were included in decisions about the care and treatment of their children. They said staff responded quickly to requests for assistance. Patients received safe and effective care and treatment. The environment was well maintained and engaging for young people. There were sufficient numbers of staff on the wards and in the outpatient area, and there was a system for the management of staffing levels and skill mix to ensure children were cared for safely.

This was not the case in the A&E department where there was an insufficient number of nurses qualified in the care of children. We also found in the A&E department that national guidance was not being followed in relation to the management of pain in children.

The trust was monitoring the quality of the service and making changes were they were needed. The views of children and families were being used to inform the service provision in the main children’s department. There was a team in place to monitor and address any safeguarding concerns, and the trust had planned further developments.

Critical care

Good

Updated 2 July 2014

We found that the intensive care and critical care service was safe and effective, performing within expectations for a unit of its size according to the Intensive Care National Audit and Research Centre data. It was responsive to the needs of patients and had caring and attentive staff. We found that the unit was well led. Pressure was placed on the unit when transfer of patients was delayed due to bed occupancy challenges faced by the trust. Though the unit coped with the situation, these patients were cared for in a mixed sex environment and had to use the bathroom and toilet facilities in the adjacent ward.

End of life care

Good

Updated 2 July 2014

We found that end of life care provided at the trust was safe, effective, caring, responsive and well led. The trust no longer used the Liverpool Care Pathway and was in the process of reviewing its end of life pathway. The palliative care team worked closely with staff on wards to ensure that patients had individualised end of life care provided in a positive, supportive environment. The team also had close links to community services. Patients and their families were involved in decisions about care and treatment in a dignified, respectful manner. Staff spoke positively about the support they received from the team. They felt this improved the patient experience and ensured patients received choices regarding end of life care and treatment.

Maternity and gynaecology

Good

Updated 2 July 2014

We found that the midwifery unit provided safe and effective care for women. Feedback from women using the service was positive. They told us that staff were kind and sensitive to their needs and that they were given effective advice and support in their chosen method of feeding their babies. The service was well led with clear shared goals and objectives which were known to all staff we spoke with. Women said they had been well supported throughout their stay in the maternity services.

Outpatients and diagnostic imaging

Good

Updated 2 July 2014

The main outpatients department was a large area, with good access and seating for patients. Patients received effective treatment and information and felt happy with the care they received. The trust was monitoring appointment targets for waiting times and clinic start and finish times. It had sought the views of patients, and we saw that it had listened and responded to patient feedback by changing the layout of the department. Clinics were well managed and organised. When unavoidable delays occurred and clinics ran late, staff kept patients informed and provided them with information. Staff told us that they received training and supervision to enable them to provide effective care. All staff we spoke with told us that outpatients was a positive environment to work in.

Surgery

Good

Updated 22 August 2019

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

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients and acted on them. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

Urgent and emergency services

Requires improvement

Updated 22 August 2019

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

  • There was poor compliance to safeguarding children and adults training for nursing and medical staff.
  • The service did not control infection risk well.
  • Staff did not always complete daily safety checks of equipment, they did not always dispose of clinical waste safely and fire safety measures were inadequate.
  • The service did not always store medicines well.
  • The service did not perform well in national clinical audits. The trust could not demonstrate effective local audit, to act on the national audit results.
  • Staff treated patients with compassion and kindness. However, because of the constraints of the physical environment, it was not always possible for staff to respect patients’ privacy and dignity and maintain their confidentiality.
  • The chair patients on Cypress ward shared mixed sex accommodation. This area lacked space at busy times which meant patients dignity and respect and confidentiality was not maintained.
  • The service did not meet the needs of all the people who used it and patients did not always receive treatment within agreed time frames and national targets
  • The nursing leadership team lacked stability. Some staff did not feel engaged in the planning and delivery of services.

However:

  • Staffing levels and skill mix were planned and reviewed so patients received safe care and treatment in line with relevant national guidance.

  • Generally, managers investigated incidents and communicated lessons learned.
  • The service provided care and treatment based on national guidance and best practice. They now participated in relevant national clinical audits including the trauma audit and research network.
  • Staff treated patients with compassion and kindness, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.

Maternity

Good

Updated 28 March 2018

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

  • Overall, medicines were managed. The pharmacist visited daily and checked drugs and administration charts.
  • Incidents were discussed at handovers and morning meetings.
  • All staff we spoke to were aware of their responsibilities relating to Duty of Candour under the Health and Social Care Act (Regulated Activities Regulations) 2014.
  • Overall, care was being provided in line with the National Institute for Health and Care Excellence quality standards. We saw evidence that all guidance and policies within maternity services had been reviewed and were based upon current guidance.
  • The trust had achieved level three United Nations Children's Fund Baby Friendly accreditation in January 2018. The Baby Friendly Initiative is based on a global accreditation programme of United Nations Children's Fund and the World Health Organisation.
  • The maternity services key performance indicator dashboard recorded the service were consistently better than the trust’s target rate of 5% for third and fourth degree perineal tears during labour. (A perineal tear is a laceration of the skin and other soft tissue structures that, in women, separate the vagina from the anus).
  • Between April 2016 and March 2017, the total number of caesarean sections was as expected. The standardised caesarean section rates for elective sections as expected and rates for emergency sections were as expected.
  • There were comprehensive training and education opportunities available to staff. The trust employed two dedicated maternity education lead midwives. New midwives joining the trust completed a comprehensive preceptorship programme.

  • All supervisors of midwives were transferring to the professional maternity advocate role. Professional maternity advocate are experienced practising midwives trained to support and guide midwives to deliver care developed nationally and locally.
  • The October 2017 maternity newsletter informed staff of a new pathway for the mother and infant mental health service and gave staff guidance on how to refer to the service. Maternity services had recently been allocated a consultant psychiatrist for one day a week. The service also had a lead mental health midwife.
  • There had been no maternity unit closures between September 2016 and October 2017.
  • Complaints were responded to and closed in less than 25 workdays.
  • The antenatal unit was midwife led. Staff were committed to providing and promoting normal birth. Most women we spoke with told us they felt involved in planning and making decisions about their care.
  • We found a positive culture in maternity services. Staff reported that they felt supported by their immediate line management and that they had good working relationships with other specialties in the hospital.
  • Maternity had a dashboard that was used to monitor key performance indicators. The service’s strategic goals were monitored via the clinical solutions meeting. The meeting looked at maternity key performance indicators’ and decided strategy to meet or improve the Key Performance Indicators.
  • The maternity service had completed actions to meet the requirements of the ‘saving babies lives’ care bundle, with the aim of reducing stillbirths, neonatal deaths, and intrapartum brain injuries.

However:

  • The maternity education department specific database was not aligned to the trust’s mandatory training spreadsheet.
  • The ‘strategic and operational cleaning plan’ was out of date and overdue for review.
  • There was a lack of obstetric theatre nurses and operating department practitioners, 24 hours a day seven days a week, to support the anaesthetist if required. The service audited the use of theatre two between February and October 2017. The audit found in theatre two it was predominantly midwives scrubbing (86%), with most of these midwives (77%) coming from the delivery suite. In 23% of cases, midwives had to be utilised from other ward areas.
  • The midwife to birth ratio was 1:36, (this means there was 36 births to one midwife), this was identified on the trust’s risk register. The risk register acknowledged the midwife to patient ratio was not at the agreed level according to Birthrate Plus. The risk register also recorded that increasing case complexity and a high midwife to birth ratio increased risks to women and babies; the risk register also recorded that only one part time scrub nurse was available on the delivery suite. Following our inspection the trust informed us there were processes in place to mitigate the risk from the midwife to birth staffing ratio.
  • In June 2017, the proportion of consultant staff reported to be working at the trust was lower than the England average. The proportion of junior, foundation years one and two, staff was higher than the England average.
  • A never event involving a retained swab had occurred at the weekend, in October 2016. However, this followed a previous incident involving a retained gauze ball in August 2016 which was downgraded from a never event to serious incident. The service showed us evidence of the learning being communicated to staff following the retained swab event. However, learning from the October 2016 event had not been timely.
  • The trust was in the process of moving to electronic records. Staff told us there were issues with records being scanned onto women’s electronic health records, and records sometimes went missing for up to two weeks during transit to scanning.
  • The risk register did not contain timescales for when identified actions should be completed.