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Bassetlaw District General Hospital Requires improvement

We are carrying out a review of quality at Bassetlaw District General Hospital. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 10 July 2018

Our rating of services stayed the same.

We rated the hospital as requires improvement because overall the domains of safe, effective and well led required improvement whilst caring and responsive we rated as good.

Inspection areas

Safe

Requires improvement

Updated 23 October 2015

Effective

Requires improvement

Updated 23 October 2015

Caring

Good

Updated 23 October 2015

Responsive

Requires improvement

Updated 23 October 2015

Well-led

Good

Updated 23 October 2015

Checks on specific services

Medical care (including older people’s care)

Good

Updated 10 July 2018

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

  • We rated safe, effective, caring, responsive and well- led as good.
  • Staff were aware of how and when to report incidents including safeguarding concerns. We saw that staff received feedback and lessons learned were shared.
  • All areas we visited were clean and well- maintained. Staff practiced safe infection control techniques and we saw predominantly positive audit results.
  • Staff assessed patients for risk of deterioration and escalated their care when necessary.
  • Record keeping was in line with staffs’ professional bodies, patients’ care plans were individualised, and patient centred.
  • We saw safe medical and nurse staffing levels in place.
  • We saw good examples of multidisciplinary working.
  • The trust performed better than the England average in a number of national audits.
  • Staff told us they were encouraged and supported to professionally develop.
  • We saw staff seeking patient consent before providing care and treatment. Most staff we spoke with had a clear understanding about what would constitute a deprivation of liberty and were aware of when they would apply for an urgent authorisation.
  • Patients, relatives and carers we spoke with gave consistently positive feedback.
  • Patients told us they felt safe on the wards and that staff were caring and compassionate.
  • We observed staff treating patients compassionately and with dignity and respect. Patients and their relatives told us that they were involved in planning their care and that communication with staff was good.
  • Staff were emotionally supportive to patients and their loved ones. Friends and family test responses were predominantly positive.
  • Services were planned to meet the needs of local people. The average length of stay was better than the England average.
  • Consultants were available seven days per week.
  • Care and treatment for vulnerable patients, such as those living with dementia or a learning disability, were seen as a priority. We saw numerous positive examples of initiatives in place for these patients.
  • There was a clear leadership structure. Staff told us that their line managers were visible, approachable and supportive. We saw positive leadership at ward and team level.
  • Staff were aware of the trust’s vision and values.
  • Local governance arrangements were robust. Ward managers attended care group governance meetings. Ward managers were aware of the risks to their service.
  • We saw numerous examples of improvements and innovation.

However:

  • There was low compliance in some mandatory training modules for medical staff.
  • The service did not ensure VTE assessments were routinely reviewed within 24 hours in line with NICE guidelines.
  • Two policies we reviewed were out of date and patient pathways did not have any references to nationally recognised, evidence-based, best-practice guidance.
  • The trusts performance was worse than the England average for the national heart failure audit and the national lung cancer audit.
  • Appraisal rates had improved since our inspection in 2015 however; they remained lower than the trust target on some wards.
  • The trust reported high numbers of delayed discharges and was not monitoring patient bed moves at night.

Services for children & young people

Good

Updated 10 July 2018

  • We rated safe, effective, caring, responsive and well led as good.
  • Care and treatment was based on national guidance and the service monitored the effectiveness of care and treatment.
  • Staff cared for patients with kindness and compassion, ensuring they involved patients and their families. Feedback we received about the services from patients and their families was positive.
  • The service was responsive to the needs of the individual children and young people who used it.
  • There were effective governance systems and processes in place. Regular review of the risk register took place.

However,

  • We were not assured that the trust’s safeguarding team were aware of all safeguarding cases. When practitioners made a referral to the local authority, the referral form stated that a copy should be sent to the safeguarding team. However the safeguarding team were unsure whether they were copied in to every safeguarding referral made to the local authority. There was a plan to introduce electronic referrals, which would automatically make a copy to the safeguarding team.
  • Staff had no training around mental health conditions and there were no individual risk assessment tools used to ensure the effective management of children and young people with mental health needs.
  • When GP trainees were on call they were responsible for covering gynaecology and obstetrics as well as paediatrics. This was identified on the risk register as it could create work pressures at times of high activity and not all consultants could be on site within 30 minutes. However, this was less of a risk than at our previous inspection, due to the closure of the paediatric inpatient ward overnight.
  • There appeared to be a disconnect between ward level staff and the service leads. Some staff told us they did not see the management team.
  • Although they were waiting for the outcome of a service review being undertaken with the integrated care system (ICS), there was no documented vision or strategy in the interim and staff were unaware of any vision for the children’s service.

Critical care

Good

Updated 23 October 2015

Overall critical care services at Bassetlaw District General Hospital were judged as good.

Within safety, concerns were identified with regard to the lack of pharmacy staff cover, there were no specifically trained intensivists working within the unit, and there was a lack of dedicated medical out of hours cover provided on the unit. We also identified concerns regarding a lack of delirium and sedation scoring and recording in patient records. However we did not identify any specific concerns regarding the levels of nursing staff on the unit, but some staff did comment that they were often moved to the critical care unit at Doncaster Royal Infirmary.

There were, however, many positive aspects to the unit. Caring was good, patients stated they were well cared for and surveys supported this. Care was effectively delivered by the multidisciplinary team utilising best practice. The service was well led locally, though as a relatively new care group unit, further focus was required on the development of the unit and its future use and links to the unit at Doncaster Royal Infirmary.

End of life care

Good

Updated 23 October 2015

We saw that end of life care services were safe, caring, responsive and well led. However, we saw that improvements were required in order for services to be effective. Mental capacity assessments were not being carried out on patients who were considered to be lacking capacity to be involved in discussions about DNACPR decisions. The trust needed to have a more systematic approach to recording mental capacity assessments in relation to DNACPR decisions where patients were unable to be involved in these discussions.

We observed specialist nurses and medical staff providing specialist support in a timely way that was aimed at developing the skills of non-specialist staff and ensuring the quality of end of life care. Specialist palliative care nurses provided a five day face to face assessment service which was different to the seven day face to face service available at Doncaster. While staff told us the Doncaster on-call nurse could see patients in Bassetlaw if required, this was not widely known by staff at Bassetlaw. There was an agreement by the trust’s corporate investment committee to recruit to a further two end of life care nurses to provide an improved service for patients at Bassetlaw District General Hospital. We were told that staff were caring and compassionate and we saw the service was responsive to patients’ needs. There were prompt referral responses from the specialist palliative care team and a good focus on preferred place of care and fast track discharge for patients at the end of life wishing to be at home.

Action had been taken against the issues identified in audits including the National Care of the Dying Audit. The implementation of the last days of life individual plan of care (IPOC) had been closely monitored by the end of life care coordinator with continuous reviews and feedback in place to develop this. A business case had been developed to increase the capacity of the end of life care/specialist palliative care service and the trust board had committed investment in improving the service as a result. The trust had a clear vision and strategy for end of life care services and participated in regional discussions and collaboration in relation to strategic planning and delivery of services to improve end of life care in the region.

Outpatients and diagnostic imaging

Requires improvement

Updated 23 October 2015

There is a legal requirement to protect the public from unnecessary radiation exposure. We saw that there were some doors with no signage that had unrestricted entry to x-ray controlled areas. This was raised with the trust and referred to the Health and Safety Executive. There were effective systems to report incidents. However, in some areas we were unable to identify clear systems and processes to evidence post incident feedback, shared learning and changes in practice resulting from incidents.

The percentage of staff that had undertaken mandatory training and received an annual appraisal was well below the trust compliance target of 85%, particularly within outpatients departments. It was unclear if this was a recording issue, but meant the trust could not be assured staff had the necessary training.

Paediatric resuscitation equipment was contained within the adult trolleys within the CT and main radiology department. Staff were unaware of this which posed a potential risk. We saw patient personal information and medical records were mostly managed safely and securely. Evidence-based guidance was available however there was limited evidence of audit to demonstrate effectiveness. This included IR(ME)R related audits.

All of the patients we spoke with across the department told us they were very happy with the services provided.

The management team were in the process of reviewing capacity and demand for outpatient clinics and recognised the need to address the rate of clinic cancellations by the hospital. Trust-wide data showed 16.8% of patients waited more than 30 minutes to be seen. Most referral to treatment targets were met including all cancer related targets. Medical imaging was not meeting the 6 week target referral to treatment target; however improvements had been made.

There was no centrally held list of all patients requiring a review or follow-up appointment.

An outpatient’s services strategy had been drafted in December 2014. However, this lacked detail. A review of outpatient services had started to audit the current outpatient service delivery and clinical work streams but this was not yet completed. There were limited key performance indicators for outpatients. Radiology discrepancy and peer review meetings were inconsistent with the Royal College of Radiology (RCR) Standards.

Surgery

Good

Updated 23 October 2015

We found that surgical services were safe. However, staff in the main operating theatres told us there were no pre-planned maintenance and deep cleaning schedules. We also found that the theatres’ sterile supply room had not been adequately cleaned.

We found that surgical services were effective although we had concerns about the level of mandatory training, with the service not meeting the trust target that 85% of all staff should have received mandatory training.

We found that the service was caring, responsive and well-led. Patient access and flow compliance with the ‘referral to treatment’ (RTT) targets were affected by the numbers of medical patients admitted to surgical wards.

Urgent and emergency services

Requires improvement

Updated 14 March 2019

We rated this service as requires improvement. Safe, effective and well led were rated as requires improvement. Caring and responsive were rated as good.

Maternity

Good

Updated 10 July 2018

We rated the service as good because:

  • Risk assessments and records were completed. Learning from incidents and investigations was shared with staff at team meetings and individually with their managers. The trust produced a monthly staff update, which included learning from incidents.
  • External audits take place and these included the National Maternity and Perinatal audit. This was in response to an escalation of third and fourth degree tears; an action plan was produced and a working party of matrons and obstetricians were working to address the actions identified.
  • To help meet women’s needs, specialist midwives were employed by the service. These included specialists for teenage pregnancies, antenatal screening, safeguarding, bereavement, diabetes and infant feeding. Specialist support was also available through the learning disabilities specialist nurses and perinatal mental health consultant.
  • Although staff were not up to date with safeguarding training, procedures were in place to refer and safeguard adults and children from abuse. Staff were aware of the procedure to follow. This included referral to the mental health team.
  • Consultant cover on labour ward was in line with current guidance and the ratio of midwife to birth ratio was slightly better than the national average.
  • In November and December 2017, women received 1:1 care in labour 91% of the time compared to the trust target of 90%.
  • All staff spoke positively and were proud of the quality of care they delivered. We observed good team working, with midwives working collaboratively and with respect for each other’s roles.

However:

  • When we inspected in 2015, staff told us they had not had an appraisal in the preceding 12 months. At this inspection, we found the trust continued not to meet its appraisal target of 90% compliance for nursing and medical staff.
  • At the previous inspection, a large number of staff had not received mandatory training in a number of subjects. At this inspection, we found medical staff continued to be non-compliant for mandatory training.
  • Nursing staff we spoke with told us that the induction of labour procedures varied depending on the doctor who saw the patient, this meant the induction of labour policy was not followed consistently on both sites at the time of our inspection. Following our inspection the Trust introduced an audit process.Both medical and midwifery staff were not meeting the target for safeguarding training.
  • We found several policies were past their date of review and this included the induction of labour policy. Managers were aware of this and taken steps to quickly address this.
  • Some staff felt senior managers had not engaged with them sufficiently about proposed changes; including staffing, ward and location rotation.