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Inspection Summary


Overall summary & rating

Good

Updated 1 March 2019

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

  • Staff treated people with the kindness, dignity and respect. Individualised, person centred care was delivered by a workforce who recognised and valued their responsibilities towards people using the hospital.
  • There was a strong culture of doing what was right for patients, for keeping them safe and involving them in decisions which affected their treatment and care. Patients and relatives spoke highly of staff and the standards and quality of care. They were informed of investigations and treatment plans, and how these would affect them.
  • Services were planned and arranged to meet the general and specific needs of local people. Staff carried out a range of risk assessments and safely managed these in line with national and professional guidance. The trusts safeguarding arrangements assisted in keeping vulnerable people safe and protected them from avoidable harm.
  • The systems and processes available to support staff in their clinical practices were well organised and structured. Professional guidance was easily accessible and used to inform decision making around patient needs.
  • The arrangements for reporting, investigating and learning from incidents was supported by a positive culture of improving patient care.
  • The hospital environment was generally visibly clean. Most staff followed infection prevention and control procedures and routine standards of cleanliness and hygiene were maintained.
  • Leaders had the skills, knowledge, experience to oversee services. We found improvements had been made in the leadership of the accident and emergency department and critical care services since the last inspection.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment. Staff were encouraged and supported to access training and development opportunities.
  • Departments planned and reviewed staffing levels and skill mix so people received safe care and treatment.
  • The trusts vision and values were understood by staff. Local service objectives had been developed and staff committed to achieving these.
  • There were effective governance arrangements within departments and information was communicated upwards through various committees to the board. Information was shared with staff in an open and transparent manner, which helped staff to feel valued and respected.
Inspection areas

Safe

Requires improvement

Updated 1 March 2019

Effective

Good

Updated 1 March 2019

Caring

Good

Updated 1 March 2019

Responsive

Good

Updated 1 March 2019

Well-led

Good

Updated 1 March 2019

Checks on specific services

Critical care

Outstanding

Updated 1 March 2019

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

  • During the 12 months preceding our inspection, the critical care team cared for five patients admitted to the unit via the emergency department with a condition later diagnosed as nerve agent poisoning. These admissions were categorised as major incidents, lasting 5 months in total. The team’s response to these major incidents was outstanding in terms of their commitment to provide effective care, their collaborative working and their focus on the safety and well-being of all staff and patients on the unit during this time. There was no precedent for treatment of nerve agent poisoning. Four of the five patients survived.
  • There were comprehensive systems to keep patients safe which took account of best practice. Rates of compliance with mandatory training now exceeded the trust target. The team had improved practices around infection prevention and control. There were now more effective systems for cleaning equipment and staff now used personal protective equipment consistently. Staff consistently checked safety equipment and recorded they had done so. All staff proactively anticipated and managed patient risks including the risk resulting from two bed-spaces that did not comply with best practice guidelines for critical care facilities. The service had improved patient records and nursing staffing numbers now met recommended staffing ratios. Mortality and morbidity reviews had embedded and were well attended.
  • Care and treatment was delivered in line with current best practice. Policies and procedures had been updated. The team had introduced care bundles and a new pain assessment tool. The pharmacist reviewed all patients daily in collaboration with the medical staff. Best practice in relation to consent to care and treatment was evident. The service had improved training around medical equipment. Nursing appraisal rates had improved and now exceeded the trust target.
  • The team still cared for patients with compassion and continued to involve patients and their loved ones in decisions about their care and treatment. The team had gone to extraordinary lengths to protect the privacy of patients during the period of the major incidents. The service included input from a psychologist.
  • The number of surgical operations that were cancelled due to a lack of an available bed in critical care had reduced (improved). The number of discharges form the unit that were delayed had reduced (improved). Staff made every effort to fulfil patient’ wishes and all decisions were centred on the patient experience and how it could be improved.
  • Governance arrangements had been recently reviewed. These now reflected best practice and mirrored the trust wide reporting protocols. The risk-register was updated and now included all evident risks. There was compassionate, inclusive and effective leadership at all levels. Staff at all levels were empowered and encouraged to be leaders. Staff engagement had improved. Monthly governance meetings were now well attended.

Spinal injuries

Requires improvement

Updated 1 March 2019

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

  • There are workforce challenges across the Spinal Centre, specifically within nursing due to vacancies. However, the teams had been proactive and innovative to rectifying this and mitigating against risks. Medical staffing levels were met for consultants but despite innovative development of roles not fully for training grade doctors. Staffing levels for nursing, therapy and psychology staff did not meet the NHS standard contract for specialised rehabilitation services. here were vacancies across the directorate workforce that despite conventional and creative recruitment attempts were not all filled. This had created additional pressures for staff on the spinal unit, this was particularly evident for therapy staff.
  • The room temperatures for areas where medicines were stored were not monitored to ensure they were at the correct temperature to store medicines safely. However, the hospital takes a pragmatic risk based approach for monitoring clinic room temperatures when a problem is identified based on national guidelines.
  • The spinal treatment centre had contributed to a national database for data collection and analysis purposes. The spinal treatment centre measured their service to standards and national data collection which could be measured against other centres. The data provided was a measurement of activity and not an indicator of quality of service.
  • Quality dashboards indicated that in some areas the unit performed well, for example, reduction in delay to admission and face-to face outreach visits. However other areas for example, length of stay and delayed discharges further work was needed. However, there was evidence of work already undertaken and in progress to address under performance.
  • The maintenance and use of facilities, premises, and equipment generally kept people safe. There was evidence to demonstrate that the pool environment was monitored for safety, however we saw areas which required further attention to prevent any risk of cross infection.
  • Where possible, a flexible approach was taken to the care, treatment and therapy of individual patients, allowing them a voice in their plan for the day; however, one patient we spoke with commented that the nurses struggled to get patients ready for rehabilitation in the mornings and staff confirmed that this was sometimes the case. We observed that some patients were still waiting to get washed and prepared for the day at lunchtime.

However:

  • Since our last inspection in 2015 and subsequent ongoing engagement with the trust, the spinal unit has demonstrated significant improvements to its management of patients and recruitment and management of staff. This includes the management of outpatient waiting times and the development of care pathways to improve patient experience.
  • Systems, processes and practices were used to keep patients safe and these were understood by staff. Mandatory training targets were met by nursing and therapy staff and the service the service to control any risks of infection.
  • Staff completed a holistic assessment of patients. Risk assessments were carried out and nursing and therapy care plans were completed to meet each identified area of need. Staff completed patient written records well and were seen to be legible, signed and dated.
  • There was a strong incident reporting culture in the spinal treatment centre. The safety thermometer was used by ward staff to identify safe care and treatment. The management of medicines was safe.
  • Policies and guidelines had been developed in line with national policy including the
  • National Institute for Health and Care Excellence (NICE) guidelines. All patients had their nutrition needs and hydration needs met and staff assessed and managed patients’ pain effectively.
  • Staff had the right skills and knowledge to provide safe care and treatment for patients. Clinical education was used to support staff and patients.
  • Staff worked collaboratively with other health professionals and across health care disciplines to ensure continuity of specialist and individualised care for patients.
  • Medical and health cover was available to support patient care; however, seven-day services were not available in all areas.
  • Staff had a good understanding of consent, mental capacity act and deprivation of liberty safeguards and had access to them through the intranet.
  • Staff were kind and supportive to patients and their relatives. We observed staff providing emotional support to patients on many levels. Patients told us that they felt involved and included in decisions about their care. The spinal treatment centre was responsive to patient’s individual needs. Therapy staff tailored the therapy to the patient and goals set each week were updated and staff were responsive to patient’s suggestions.
  • Medical and health cover was available to support patient care; however, access each day varied over the seven-day period.
  • The spinal treatment service was responsive to patient’s admission but some discharge delays were seen to be beyond the discharge teams control. The outpatient department staff confirmed that there was no waiting list for outpatient appointments.
  • Learning from complaints were shared on wards through staff safety briefs and an overview of complaints was reviewed through the medical services governance board.
  • Leadership at ward level was considered by staff to be supportive and effective.
  • Staff felt the spinal treatment centre had a voice at board level. Ward staff were aware of the trust values and the values of the spinal treatment centre. While managers had been involved in the vision for the spinal treatment centre, ward staff had not,
  • Staff told us that they were proud of their teamwork and considered the team was working together to provide good patient care. They felt that the team was the whole ward from cleaners to consultants.
  • Processes were used to look at risks and manage issues and performance.
  • Overarching monitoring of the service and governance processes took place, there was evidence that responsibilities, quality, performance and risks are managed and understood.
  • There was engagement with patients, volunteers and local charities and external support providers. Staff were actively involved in the development of these service.

Surgery

Good

Updated 1 March 2019

  • The service had made a number of improvements in response to the concerns we raised at our last inspection.
  • Staff made sure that equipment needed for emergency situations were checked frequently as per trust policy and records made to demonstrate this.
  • Changes had been implemented to sterile drapes on equipment used in theatre to reduce the risk of damage and to prevent cancelled operations. Whilst these risks had not been totally eradicated, arrangements were in place to continually monitor and review the situation.
  • The service had improved compliance with The World Health Organisation (WHO) surgical safety checklist. Recent audits demonstrated that compliance for the general theatres was running at 100%.
  • Staffing levels had improved following several initiatives which had been introduced to help aid recruitment of registered nurses across all wards. Recruitment was ongoing and additional staff had been recruited from different disciplines to support registered nurses.
  • The service provided effective care, with patients receiving evidence-based care and treatment. Staff from different services, both internal and external, worked well together. Staff were competent in meeting the assessed needs of patients.
  • The trust participated in national audits to monitor patients’ care and treatment outcomes, and to compare with other similar services. Reviewing data from audits, the trust was generally performing well or as expected, when benchmarked nationally.
  • Staff took the time to interact with patients, and those close to them, in a respectful, compassionate and considerate way. Patients and their relatives/carers, where required, were actively involved in their treatment and care.
  • The service had taken steps to improve the experience of patients discharged home following surgery by reconfiguring facilities.
  • The service had improved patient flow in order to prevent unnecessary cancelled operations. Since the last inspection the trust had completely re configured its wards creating a short stay surgery unit, along with a chaired area for patients pre discharge. In addition, the trust had also changed its theatre timetable to maximise throughput for patients. These were components of larger Patient Flow and Theatre transformation programs. These actions had seen the number of elective cancellations due to bed pressures reduce dramatically and discharges from recovery, which was highlighted at the last inspection, no longer occur. Patients mostly received care and treatment when they needed it. Referral to treatment times were mostly in line with the England average. The percentage of cancelled operations was similar to the England average and all cancelled operations were rearranged within the required 28 days, which was better than the England average.
  • Leaders had the right skills and commitment to improve the quality of the service. The culture was centred around the needs and experience of patients. There were structures, processes and systems of accountability to support the delivery of good quality services.

However:

  • Storage of some equipment in the day surgery unit on the floor and fabric chairs in several areas were potential infection control risks.
  • Rooms where medications were being stored were not routinely having the temperature monitored to make sure they were being stored at the manufacturers recommended temperature.
  • There was some confusion about the resources available to staff when caring for patients with a learning disability.

Urgent and emergency services

Good

Updated 1 March 2019

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

  • Staff had the right skills and knowledge to provide safe care and treatment for patients. Clinical education was used to support staff and patients.
  • Policies and guidelines had been developed in line with national policy including the

National Institute for Health and Care Excellence (NICE) guidelines.

  • All patients had their nutrition needs and hydration needs met and staff assessed and managed patients’ pain effectively.
  • Staff had a good understanding of consent, mental capacity act and deprivation of liberty safeguards and had access to guidance through the intranet.
  • Doctors, nurses and allied healthcare professionals supported one another to provide holistic care to patients.
  • The service supported patients by promoting healthier lifestyles. The service had managers at all levels with the right skills and abilities to run the service, providing high-quality sustainable care.
  • The service had a vision for what it wanted to achieve and we saw evidence of actions to achieve it.
  • Managers promoted a positive culture that supported and valued staff, free from bullying, harassment or discrimination, creating a sense of common purpose based on shared values.
  • The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
  • Staff were kind and supportive to patients and their relatives. We observed staff providing emotional support to patients on many levels. Patients told us that they felt involved and included in decisions about their care.
  • Learning from complaints were shared across the emergency department through daily safety huddles and regular team meetings. Complaints were reviewed through the emergency department governance meetings.
  • Leadership at departmental level was considered by staff to be supportive and effective.
  • Departmental staff were aware of the departments values and the values of the trust.
  • There were assurance systems implemented to ensure the identification and management of risks was undertaken and appropriate action taken.

However:

  • There were not always sufficient numbers of staff employed by the service. This had contributed to a sense of low morale within the department.
  • Staffing challenges meant dedicated areas of the department designed for children and young people could not be opened. This resulted in children being treated in the main emergency department which may not always promote the best experience for children.
  • A lack of a standard operating procedure for the short stay emergency unit meant there was ambiguity over who should be referred to the unit.