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Inspection Summary


Overall summary & rating

Good

Updated 8 November 2017

Northampton General Hospital (NGH) is an 800-bedded acute hospital. There are approximately 713 general and acute beds with 60 maternity beds, and 16 critical care beds. The trust employs 4,875 staff, including 531 doctors, 1,487 nursing staff and 2,857 other staff.

We carried out this inspection as part of our routine focused inspection programme. We completed a short notice focused inspection on the 25 to 27 July 2017and an unannounced inspection on 9 August 2017.

We determined the extent of this focused inspection following a review of information gathered and the findings from our previous inspection. This included an analysis of the trust’s performance and information from stakeholders. The hospital was previously inspected under our comprehensive methodology in January 2014, when the overall rating was requires improvement.

We found the trust has taken significant action to meet the concerns raised from the January 2014 inspection, particularly in establishing an inclusive and supportive staff culture with a clear focus on patient safety.

We rated the four core services we inspected (critical care, maternity and gynaecology, children and young people and outpatients and diagnostic imaging) as good overall. Combining these core service ratings with the ratings for the other four services we last inspected in February 2017, the overall rating for the hospital was good. All five key questions were rated as good (safe, effective, caring, responsive and well-led).

We found that:

  • Staff were friendly, professional, compassionate and helpful to patients in all interactions that we observed.
  • Patients told us that the staff had been caring towards them and all spoke positively about the staff in all areas inspected.
  • We observed care being delivered by nurses, play specialists, medical, therapy, and auxiliary staff that interacted with children and young people in a very positive and caring manner.
  • There was a positive culture towards reporting incidents and learning from these to improve patient safety in all areas inspected.
  • There were effective systems in place to ensure that standards of cleanliness and hygiene were maintained.
  • The design, maintenance, and use of facilities, premises, and equipment generally met all patients’ needs.
  • Improvements had been made in some areas in the outpatient environment, which included the expansion of the chemotherapy suite and new equipment in the diagnostic imaging department.
  • Medicines were generally stored and handled in line with the hospital’s medicines management policy.
  • There were generally effective processes in place to ensure that adults and children in vulnerable circumstances were safeguarded from abuse. Staff in all areas were aware of the processes to identify and respond to patient risk and there were systems in place to monitor and manage risks to patient safety.
  • Medical, nurse and midwife staffing levels met patients’ needs at the time of the inspection.
  • Patients’ outcomes were being measured and were generally in line with national average. Action plans were in place to drive improvements.
  • There was clear evidence and data upon which to base decisions and look for improvements and innovation. The unit participated in the Intensive Care National Audit and Research Centre (ICNARC) audit and performed better or as expected in six out of eight indicators.
  • The critical care outreach team provided 24 hour cover seven days a week and assisted with the monitoring and treatment planning of deteriorating patients throughout the hospital, ensuring risks were responded to appropriately.
  • Patients and their relatives were supported during their stay within critical care services and staff provided opportunities to discuss care and treatment. This was delivered in a way that promoted dignity and confidentiality at all times.
  • The maternity and gynaecology service completed the national maternity safety thermometer and monitored safety performance through clinical dashboards.
  • The children and young people’s service performed well in in a number of national audits including the National Neonatal Audit (2015) and the Epilepsy 12 audit (2014). Gosset ward was working towards achieving Bliss accreditation.
  • Policies were based on national guidance produced by National Institute for Health and Care Excellence (NICE) and the royal colleges.
  • Pain of individual patients was assessed and managed appropriately.
  • There were systems and processes in place to ensure that staff had the necessary qualifications, skills, knowledge and competencies to do their jobs.
  • Effective multidisciplinary working was clearly evident throughout the departments and services.
  • There were appropriate processes and systems in place to ensure that information needed to deliver care and treatment was available to relevant staff in a timely manner.
  • Patient’s consent was obtained in line with trust policy and statutory requirements.
  • Services had been planned to take into account the needs of different people, for example, on the grounds of age, disability, gender or religion.
  • Care and treatment was only cancelled or delayed when absolutely necessary.
  • Access to services was generally effective and timely.
  • Appointments were prioritised according to referral requests from GPs with urgent requests and cancer referrals booked within two weeks. The imaging department prioritised reporting higher risk examinations not seen by other clinicians.
  • The hospital consistently met the referral to treatment standards over time.
  • Waiting times for diagnostic procedures were better than England average.
  • The service managed complaints swiftly, openly and constructive as part of a co-ordinated patient feedback system.
  • The hospital staff worked with a variety of stakeholders and commissioners to plan delivery of care and treatment. There was a focus in providing integrated pathways of care, particularly for patients with multiple or complex needs.
  • The leadership teams were cohesive and inclusive and were focused on delivering safe, high quality care and treatment for all patients.
  • Staff felt there was a high level of staff engagement, which was positive and led to high levels of staff satisfaction.
  • Staff believed in the leadership of the hospital and were proud of the organisation and its culture.
  • Services had a clear vision, strategy, and objectives based on improving quality and safety in line with the overall trust vision.
  • Leadership in services was well established and there was a clear focus on improvements and patient safety.
  • Structured meetings were held throughout services to review all aspects of quality, risks and performance and high risks were escalated and monitored effectively.
  • Effective governance arrangements were in place. There were structured meetings to review all aspects of performance, quality and risks and high risks were escalated through the services.
  • Service risk registers reflected the risks within the service and there was evidence of ownership, mitigations having being implemented and ongoing monitoring.
  • Innovation throughout staff teams was encouraged.

However, we also found:

  • The critical care service was aware of the shortfall in band 8a specialist pharmacist support and was providing cover with a band 7 pharmacist. A business case had been put forward, which if successful, would ensure standards were being met.
  • Medicines were not always stored safely behind locked doors or in restricted areas in critical care. We raised this with the trust and this was rectified immediately by the trust.
  • There was effective working relationships and commitment to critical care between members of the multidisciplinary team. However, the trust was not meeting the national core standards for employment of allied professionals within critical care services.
  • The critical care unit did not comply with the Department of Health’s Health Building Note 04-02 critical care unit’s standards; however, this had been risk assessed and was under review. Refurbishment plans were in place to address this.
  • Not all medical staff in critical care had completed the required mandatory training.
  • Hospital wide bed capacity affected the ability of the service to discharge patients to wards at the most appropriate time. Over eight hour delayed discharges were higher than the national average, however, action had been taken and improvement observed for patients waiting 24 to 48 hours.
  • Single sex accommodation in critical care was not always maintained due to hospital wide bed pressures. Action was taken to protect patient’s dignity at all times.
  • Not all doctors, nurse and midwives had had annual refresher training for safeguarding adults at level two in the maternity and gynaecology service. Action plans were in place to address this.
  • The maternity service had had higher than expected caesarean rates and perinatal mortality rates over time. Whilst actions and mitigating actions had been taken, these had not always improved outcomes. The service continued to monitor and assess these potential risks to patients.
  • There were not always effective systems in place regarding the storage and handling of medicines in the children’s outpatient department. The trust took immediate action to address this once we raised it as an urgent concern.
  • Children or young people on Paddington ward could access the corridor to the delivery suite. This was a risk particularly for patients who may be at risk of self-harm or suicide. The trust took immediate action to address this once we raised it as an urgent concern.
  • The pathway for patients who needed to cross the road between buildings had not been reassessed to ensure opportunities to prevent or minimise further harm were not missed. The trust took immediate action to address this once we raised it as an urgent concern.
  • The child abduction policy was in draft and awareness was lacking in some areas of the service. The trust took immediate action to address this once we raised it as an urgent concern.
  • Paediatric wards did not have the appropriate facilities to care for the increasing number of patients with mental health issues who could be at risk of self-harm or suicide.
  • We found concerns about the fire exit in the fracture clinic. This had been addressed by the unannounced inspection and we found the service had also reviewed all fire exits throughout the service.
  • Not all staff were compliant with infection prevention and control measures in the blood taking unit. We raised this with the service, and immediate actions were taken to review infection control precautions to mitigate risk. This had been addressed by the unannounced inspection.
  • Not all staff had had the required frequency of mandatory training, including safeguarding.
  • The controlled drugs cupboard in the pain relief clinic contained a variety of non-controlled drugs. This was not in line with medicines storage guidelines. We raised this with the service and this had been rectified by the time of our unannounced inspection.
  • We observed poor infection control practices in both the blood-taking unit and the pain relief clinic. We raised this with the service and this had been rectified by the time of our unannounced inspection.
  • Some staff in the diagnostic imaging department had limited understanding of the ionizing radiation (medical exposure) regulations (IR(ME)R) regulations themselves and five members of staff we spoke to were unable to locate where the employers’ procedures were kept. We raised this with the service and senior staff took immediate action to address this.

We saw several areas of outstanding practice including:

  • The trust had a duty of candour sticker that would be placed into the patient’s notes when the duty of candour had been applied. This included, for example, staff name, date, name of person/patient receiving information, account of incident, details of incident and if an apology was offered.
  • Two members of the critical care team had been nominated for the ‘Best Possible Care’ Awards. Patients and those close to them, as well as work colleagues, voted for staff members who had gone above and beyond to exceed expectations and had made a real difference to patient care.
  • The ‘Chit Chat’ group was set up by the maternity service in 2016 to facilitate antenatal education, parenting advice and peer support for women with additional needs, including learning disabilities or anxiety. Staff said these meetings were two weekly and very well attended. This group meeting initiative had been nominated for two national awards and had won one at the time of the inspection.
  • The maternity service reviewed and evaluated the provision of multi-disciplinary training when the service was chosen as one of the 10 pilot sites for enhancing patient safety. As part of the pilot, the service chose to concentrate on the fetal monitoring and team working and skills drills sections with the outcome that the service was able to deliver these training programmes completely internally (including Practical Obstetrics Multi-professional Training (PROMPT).
  • Gosset ward was working towards achieving Bliss accreditation. This means the ward had undertaken exceptional work through the involvement of parents to encourage bonding with these very special babies which has helped to build the evidence for Bliss accreditation.
  • Staff had developed an assessment tool to improve the monitoring and assessment of baby’s skin on Gosset ward. The ward was working with neonatal services from across the world (Canada and Turkey) to further develop the tool.
  • The recruitment of 1.7 WTE advanced neonatal nurse practitioners (ANNP) onto the medical neonatal rota was helping to address recruitment issues in relation to junior doctors.
  • The superintendent sonographer was very passionate about their service and had developed an excellent team which provided image quality assurance and peer review. They were able to detect team members’ weaknesses and pair them with other sonographers to help them develop. The ultrasound department conducted many audits and fed these back to ultrasound community in England.

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

The trust should:

  • Review pharmacy provision to meet the needs of the critical care service and be in line with national guidance.
  • Continue to review and monitor over eight hour delayed discharges in critical care and report incidents and mixed sex breaches using the electronic reporting system.
  • Monitor staff mandatory training to ensure compliance with the trust’s target including annual refresher training for safeguarding adults at level two and safeguarding children level two and three.
  • Continue to monitor caesarean rates and perinatal mortality rates in the maternity and gynaecology service.
  • Review multidisciplinary support to critical care services to ensure national best practice is following, in relation to therapy support.
  • To monitor allergy testing ampules ensuring use within their recommended expiry dates.
  • The trust should consider improving the facilities for parents to stay overnight on paediatric wards.
  • Continue to monitor and review the impact of patients admitted to paediatric wards with mental health issues.
  • Continue to monitor and review the effect on children’s services due to the limited availability of psychologist support, particularly for children with long term conditions.
  • Continue to monitor controlled drugs are effectively stored in outpatient areas.
  • Continue to monitor fire exits are accessible at all times.

Professor Edward Baker

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 8 November 2017

Effective

Good

Updated 8 November 2017

Caring

Good

Updated 8 November 2017

Responsive

Good

Updated 8 November 2017

Well-led

Good

Updated 8 November 2017

Checks on specific services

Maternity and gynaecology

Good

Updated 8 November 2017

We rated this service as good because:

  • The service completed the national maternity safety thermometer and monitored safety performance through clinical dashboards.
  • The design, maintenance and use of facilities and premises met all patients’ needs. There were systems and processes in place to ensure that the maintenance and use of equipment kept patients safe.
  • Medicines were stored and handled in line with the hospital’s medicines management policy. Individual care records were written in a way that kept patients safe.
  • Effective systems were in place to assess risks to patients and to recognise deterioration, including the use of early warning score assessments.
  • Medical, midwife and nurse staffing levels, skill mix and caseloads were planned and reviewed so that patients received safe care and treatment at all times, in line with relevant tools and guidance.
  • Policies were based on national guidance produced by National Institute for Health and Care Excellence (NICE) and the royal colleges.
  • Patients’ outcomes were being measured and were generally in line with national average. Action plans were in place to drive improvements.
  • The service leadership team was cohesive and inclusive and was focused on delivering safe, high quality care and treatment for all patients.
  • The trust had a clear and effective vision for maternity and gynaecology services to deliver high quality person-centred care, which staff were committed to.
  • The focus on safe patient care was clearly evident in all areas and from all staff.
  • There were effective and clear governance systems in place to escalate issues and risks to the service leaders and to the trust board.
  • The service risk register reflected the risks within the service and there was evidence of ownership, mitigations being implemented and ongoing monitoring.
  • Staff believed in the leadership of the service and were proud of the organisation and its culture.

However:

  • Not all doctors, nurse and midwives had received annual refresher training for safeguarding adults at level two. Action plans were in place to address this.
  • The service had had higher than expected caesarean rates and perinatal mortality rates over time. Whilst actions and mitigating actions had been taken, these had not always improved outcomes. The service continued to monitor and assess these potential risks to patients.

Medical care (including older people’s care)

Good

Updated 23 May 2017

We rated the medical care service as good overall. Despite significant bed capacity and patient flow pressures, staff worked positively and effectively to minimise the risk and discomfort for patients. Patient outcomes were generally better than the national average, notably the service’s performance for stroke care. Staffing levels met patients’ needs including in the escalation areas used. Senior managers had clear oversight of the pressures and risks in the service and were taking actions to improve all aspects of patient care and treatment.

Urgent and emergency services (A&E)

Good

Updated 23 May 2017

We rated the emergency department as good overall and outstanding for the well-led key question. There was a strong, team-centred approach to ensuring all patients were provided with safe care and treatment. The culture and drive for improvement within the staff team was positive, coupled with a focus on providing evidence based care and benchmarking from national audits to drive improvements in the service.  

Surgery

Good

Updated 23 May 2017

We rated the service as good overall. Many patient outcomes were better than the national average and a strong safety culture was prevalent in wards and theatres. Staff delivered safe, effective care and treatment with compassion and respect. 

Intensive/critical care

Good

Updated 8 November 2017

We rated this service as good because:

  • There was a strong culture of reporting, investigating and learning from incidents. Learning was shared throughout the team.
  • Adequate medical and nursing staff was provided to meet the recommended staff to patient ratio, as defined in the core standards for intensive care units.
  • There were effective systems in place to protect patients from avoidable harm and improve compliance with standards on a continuous basis. The principles of the duty of candour were well understood by all staff.
  • There was clear evidence and data upon which to base decisions and look for improvements and innovation. The unit participated in the Intensive Care National Audit and Research Centre (ICNARC) audit and performed better or as expected in six out of eight indicators.
  • The critical care outreach team provided 24 hour cover seven days a week cover and assisted with the monitoring and treatment planning of deteriorating patients throughout the hospital, ensuring risks were responded to appropriately.
  • Staff were very caring and kind and provided emotional support for patients and relatives, for example, through the use of patient diaries.
  • Leadership was well established and there was a clear focus on improvements and patient safety.
  • Structured meetings were held throughout the directorate to review all aspects of quality, risks and performance and high risks were escalated and monitored effectively.
  • Effective governance arrangements were in place. There were structured meetings to review all aspects of performance, quality and risks and high risks were escalated through the directorate. Innovation throughout the staff team was encouraged.

However:

  • The pharmacy team were aware of the shortfall in band 8a specialist pharmacist support and were providing cover with a band 7 pharmacist. A business case had been put forward, which if successful, would ensure standards were being met.
  • Medicines were not always stored safely behind locked doors or in restricted areas. We raised this with the trust and this was rectified immediately by the trust.
  • The unit did not comply with the Department of Health’s Health Building Note 04-02 critical care unit’s standards; however, this had been risk assessed and was under review. Refurbishment plans were in place to address this.
  • Not all medical staff had completed the required mandatory training.
  • Hospital wide bed capacity affected the ability of the service to discharge patients to wards at the most appropriate time. Over eight hour delayed discharges were higher than the national average, however, action had been taken and improvement observed for patients waiting 24 to 48 hours.

Services for children & young people

Good

Updated 8 November 2017

We rated this service as good because:

  • There was a well-embedded culture of incident reporting and staff said they received feedback and learning from incidents.
  • Safety thermometer data from the last 12 months reported 100% of “harm free” care in the child health directorate.
  • There were clear arrangements in place to safeguard children and young people from abuse, which reflected relevant legislation and local requirements. The majority of staff had undertaken the required level of safeguarding training.
  • The service performed well in a number of national audits including the National Neonatal Audit (2015) and the epilepsy 12 audit (2014). Gosset ward was working towards achieving Bliss accreditation.
  • Staff had the clinical skills, knowledge, and experience they needed to carry out their roles effectively. Mandatory training and appraisal levels were above trust targets.
  • Actual nurse staffing levels met planned rotas during our inspection and patient’s needs were met. Medical staffing was appropriate and there was an effective level of cover to meet patients’ needs.
  • Feedback from children and parents was consistently positive and parents told they were treated with dignity and respect.
  • Services were responsive to the needs of patients, parents and families and were working towards delivering sustainable seven-day services.
  • Staff felt that local leadership was strong with visible supportive and approachable managers.
  • The child health directorate was continually developing patient services to ensure innovation, improvement, and sustainability.

However:

  • There were not always effective systems in place regarding the storage and handling of medicines in the children’s outpatient department. The trust took immediate action to address this once we raised it as an urgent concern.
  • Children or young people on Paddington ward could access the corridor to the delivery suite. This was a risk particularly for patients who may be at risk of self-harm or suicide. The trust took immediate action to address this once we raised it as an urgent concern.

  • The pathway for patients who needed to cross the road between buildings had not been reassessed to ensure opportunities to prevent or minimise further harm were not missed. The trust took immediate action to address this once we raised it as an urgent concern.
  • The child abduction policy was in draft and awareness was lacking in some areas of the service. The trust took immediate action to address this once we raised it as an urgent concern.

End of life care

Good

Updated 23 May 2017

We rated the service as good overall. Many improvements had been made to raise the profile for the end of life care service in the trust and this had led to improvements in the way patients received safe, compassionate care in their last days. However, more work was required to collect performance information about the service and ensure that mental capacity assessments underpinning decisions about cardiopulmonary resuscitation were being evidenced in patients’ records.

Outpatients

Good

Updated 8 November 2017

Overall, we rated outpatients and diagnostics as good. We inspected but did not rate the effectiveness of the service, as we are currently not confident that we are collecting sufficient evidence to rate this key question for outpatients and diagnostic imaging. We rated this service as good because:

  • Staff were aware of their responsibilities and understood the need to raise concerns and report incidents. Staff told us they felt fully supported when raising concerns.
  • Generally, the design, maintenance, and use of facilities and premises met patients’ needs. The maintenance and use of equipment kept patients safe from avoidable harm. Improvements had been made in some areas in the outpatient environment, which included the expansion of the chemotherapy suite and new equipment in the diagnostic imaging department.
  • Appointments were prioritised according to referral requests from GPs with urgent requests and cancer referrals booked within two weeks. The imaging department prioritised reporting higher risk examinations not seen by other clinicians.
  • We found that medical and nursing staffing levels and skill mix were planned and reviewed so that patients received safe care and treatment.
  • Care and treatment was delivered in line with national guidelines. Staff within the service had the appropriate skills, qualifications, and knowledge to complete their roles safely.
  • All teams reported effective multidisciplinary working.
  • Patients were treated with compassion, dignity, and respect.
  • Feedback from patients and those close to them was positive about the way they were treated.
  • Staff made patients’ appointments according to the needs of the individual. This included moving them to allow work and other appointments to take place.
  • The service consistently met the referral to treatment standards over time. Waiting times for diagnostic procedures was lower than England average. The service was meeting cancer targets for referral to treatment times at the time of the inspection.
  • The "did not attend" (DNA) rate for the trust from June 2016 to May 2017 was 7% and this was same as the England average of 7%.
  • Outpatient specialties ran additional evening and weekend clinic lists to reduce the length of time patients were waiting. The radiology department offered a walk in service for all plain film examinations.
  • Services were tailored to meet the needs of individuals and offered flexibility in choice with appointments being flexed across a seven day service within the diagnostic imaging department.
  • The service had a challenging and innovative strategy that supported the trust vision. This included redesign of departments, introduction of support systems to improve performance and repatriation of services to improve patient experience.
  • Staff had awareness of the trust vision and strategy. Staff were aware of the risks within their departments. Staff were proud to work at the hospital and passionate about the care they provided.
  • The service had leadership, governance and a culture which were used to drive and improve the delivery of quality person-centred care.
  • Staff felt that managers were visible, supportive and approachable. Specialties were focused on developing services to improve patient care.

However, we also found that:

  • We found concerns about the fire exit in the fracture clinic. This had been addressed by the unannounced inspection and we found the service had also reviewed all fire exits throughout the service.
  • We observed poor infection control practices in both the blood-taking unit and the pain relief clinic. We raised this with the service, and immediate actions were taken to review infection control precautions to mitigate risk. This had been addressed by the unannounced inspection.
  • We found issues with the storage of controlled drugs in the pain relief clinic. However, when we raised this with the service, senior managers took immediate action to address storage of these drugs. This had been addressed by the unannounced inspection.
  • Not all staff had received the required frequency of mandatory training, including safeguarding. Plans were in place to address this.
  • We observed poor infection control practices in both the blood-taking unit and the pain relief clinic. We raised this with the service and this had been rectified by the time of our unannounced inspection.