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Bassetlaw District General Hospital Requires improvement

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

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.

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.

Maternity and gynaecology

Requires improvement

Updated 23 October 2015

Overall, maternity and gynaecology services required improvement. Systems were in place for reporting, investigating and acting on adverse events. There had been two clusters of stillbirths from January 2014 to January 2015. A still birth review had taken place and each case was assessed against the National Patient Safety Agency Stillbirth Toolkit. The action plan was due for completion shortly after our visit.

Midwifery staffing ratios were in line with the national recommended ratio of 1:28. Consultant cover at Bassetlaw maternity unit was 40 hours per week in line with the number of babies delivered on the unit per year. There was no dedicated emergency obstetric theatre team at Bassetlaw hospital during the mornings on weekdays. An emergency team was available at all other times. High rates of sickness were evident on the gynaecology ward.

Completion of mandatory training was at a good level for midwives, midwifery support workers and health care assistants. Mandatory training participation for medical staff was poor. There was a range of specialist midwives in post however neither the teenage pregnancy special midwife nor the substance- misuse specialist midwife had input into vulnerable women at Bassetlaw hospital. There was no specialist diabetes midwife in post. Good evidence of safeguarding vulnerable women was evident. There was limited awareness of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS).

On the labour ward there was no documentation evidence of wastage of controlled drugs used in epidural procedures.

Normal births were promoted. Since 2010 there had been a high percentage of non-elective neonatal readmissions within 28 days of birth. An action plan was in place and was being monitored. There were no designated scanning facilities in the EPAU at Bassetlaw; women had to go to the Ultrasound department with other ‘general’ users of the service. Maternity and nursing staff were caring. Patients and women spoke positively about their treatment by clinical staff and the standard of care they had received. There was good evidence of individualised maternity care. Hypnobirthing was available on delivery suite.

We found there was disconnection between ward staff and the board. Most staff were unaware of the vision for the service. We observed strong team working, with medical staff, nurses and midwives working cooperatively and with respect for each other’s roles. They told us that Bassetlaw was a ‘good place to work’. Most staff we spoke with were positive and enthusiastic.

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.

Urgent and emergency services (A&E)

Requires improvement

Updated 10 July 2018

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

  • At the time of the inspection there were extended waits to initial assessment for both patients who walked into the department and those who arrived by ambulance. We were told this was because the department was busy; however, we looked at footfall over a period of three months including our inspection days and found that attendance on these days was not exceptionally high. We found these long waits for initial assessment were a potential risk to patient safety.
  • There were delays in patients booking into the department, we witnessed patients arriving by ambulance and waiting in the corridor if the ambulance assessment bay was full. Ambulance staff could not book the patients in until they had handed over the patient to the nurse. All patients should be booked in as soon as they arrive at the hospital.
  • Ambulance turnaround times should be within 30 minutes, allowing ambulance staff to handover the patients to the hospital staff and be available for further emergency and urgent calls. From November 2017 to October 2017, there was 45-65% of journeys turnaround times over 30 minutes at Bassetlaw District General Hospital.
  • At the previous inspection, we found nurse staffing was insufficient for the safe operation of the service. During this inspection, we found the service did not always have enough nursing staff of the right level to keep patients safe from avoidable harm.
  • The previous inspection highlighted the shortage of medical staff and during this inspection; we found the service did not always have enough medical staff of the right level to keep patients safe from avoidable harm. There were no substantive consultants in post at BDH. Two consultants from DRI work part-time at Bassetlaw, the rest of the shifts were covered by locum consultants.
  • In the previous inspection, staff were not up to date with mandatory training. During this inspection, we found not all medical and nursing staff was up to date with mandatory training, including safeguarding. Staff had not received any specific training regarding caring for patients with mental health conditions, learning disabilities, autism or dementia.
  • The previous inspection highlighted that in ED medical staff were not up to date with adult and paediatric life support training. At this inspection we found that this had not changed. We had concerns about safety because nursing and medical staff were not up to date with advanced life support skills. Data from the trust showed that 64% of nursing staff had not undertaken intermediate life support training, 69% of nursing staff had not received advanced life support training and 83% of medical staff had not received advanced life support training.
  • Compliance was low for paediatric immediate life support; there was 48% (49 out of 103) nurses trained and for paediatric advanced life support there were 56% (6 out of 16) nursing staff trained. There was only 22.5% (6 out of 40) medical staff compliant for paediatric advanced life support training.
  • During our previous inspection, we found the standard of cleanliness and adherence to hygiene procedures was variable. We found areas and equipment that were dusty and dirty.
  • The service did not always manage medicines well.
  • Although the service had a separate room to assess patients with mental health needs, it did not conform to the Psychiatric Liaison Accreditation Network (PLAN) standards. None of the risks in the rooms were considered or recognised by the staff.
  • We found staff were not always able to identify and respond appropriately to patients who were at risk of deterioration.
  • From October 2016 to September 2017, the trust reported no never events and one serious incidents between October 2016 to September 2017 at BGH. We found there was a backlog of incidents within the emergency care group that required reviewing; this had a risk to patient safety, as actions to prevent these incidents happening again could be delayed.
  • We found that some areas in the department were cluttered, as there was not adequate storage space for equipment. The majority of mattresses were damaged which posed an infection risk.
  • We found none of the pathways had review dates.
  • The emergency department had participated in a number of audits to benchmark their performance against the Royal College of Emergency Medicine (RCEM) standards. The trust was failing to meet many of the standards.
  • Staff did not understand their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • From April 2016 to March 2017, 51% of staff within urgent and emergency care at the trust had received an appraisal compared to a trust target of 90%.
  • From October 2016 and September 2017, the trust’s unplanned re-attendance rate to A&E within seven days was consistently worse than the national standard of 5% but generally better than the England average.
  • The environment of the emergency department was not conducive to maintaining the patient’s privacy, dignity and confidentiality in all circumstances. We witnessed patients who arrived by ambulance queuing in the corridor.
  • The service did not meet the Department of Health’s target of 95% of patients admitted, transferred, or discharged within four hours of arrival at the department. The trust did not meet the standard from November 2016 to October 2017.
  • From October 2016 to September 2017, the trust’s monthly median total time in A&E for all patients was consistently worse than the England average.
  • The risks on the risk register did not match all the risks identified during the inspection.
  • From September 2016 to August 2017, there were 101 complaints about urgent and emergency care services. The trust took an average of 61 working days to investigate and close complaints; this is not in line with their complaints policy.

However:

  • Staff kept patients safe from harm and abuse. They understood and followed procedures to protect vulnerable adults or children.
  • Staff worked together as a team for the benefit of patients. We saw good multidisciplinary team working.
  • Staff cared for patients with compassion and respect. We received positive feedback from patients and carers.
  • The data for the median time from arrival in ED to initial assessment was better than the overall England median across the entire 12-month period from October 2016 to September 2017 although this data may not have been accurate as the time measured started at the point the patient spoke with the nurse at reception and did not take account of the time they had waited in the queue before being registered and assessed. This may have affected the accuracy of other quality standards.

  • From November 2016 to October 2017, the Trust’s monthly percentage of patients waiting between four and 12 hours from the decision to admit until being admitted was better than the England average. Over the 12 months from November 2016 and October 2017, no patients waited more than 12 hours from the decision to admit until being admitted.
  • The department had strong links with the community mental health teams, community learning disability team and the child adolescent mental health teams.
  • The local nursing leadership was strong, supportive and staff felt they were listened to and felt valued. We found the culture of the department open and inclusive.
  • The trust had developed a three-year Strategic Plan for Urgent and Emergency care services.
  • The trust had effective structures in place and each care group had their own governance meetings, from which each department meeting fed into.

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.

Intensive/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.

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.

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.