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Bassetlaw District General Hospital Good

Inspection Summary


Overall summary & rating

Good

Updated 19 February 2020

Our rating of services improved. We rated them as good because overall the domains of effective, caring, responsive and well led were good and safe required improvement. Effective and well-led had improved one rating overall.

Inspection areas

Safe

Requires improvement

Updated 19 February 2020

Effective

Good

Updated 19 February 2020

Caring

Good

Updated 19 February 2020

Responsive

Good

Updated 19 February 2020

Well-led

Good

Updated 19 February 2020

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.

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

Good

Updated 19 February 2020

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

  • The domains of effective and well-led had each improved one rating since the previous inspection.
  • Leaders had the 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 service for patients and staff. They supported staff to develop their skills and take on more senior roles.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Feedback from patients and their relatives and carers was consistently positive.
  • There had been significant improvement in the transfer of paediatric patients. Although some staff had concerns about long waits being experienced by surgical patients, senior managers were in the process of addressing the transport issues and a dedicated surgical transfer ambulance had been in place since March 2019.
  • Staff identified and acted quickly in response to patients at risk of deterioration. A structured process was applied for patients diagnosed with sepsis.

•Patients could access the service when they needed it and received the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were in line with national standards.

•Staff were aware of their responsibilities as to safeguarding both adult and paediatric patients. The hospital had protocols in place to identify and manage adults and children at risk.

  • Staff supported patients to make informed decisions about their care and treatment and supported patients who lacked capacity to make their own decisions or were experiencing mental ill health. Staff assessed and monitored patients regularly to see if they were in pain and gave pain relief in a timely way. Patients were given enough food and drink to meet their needs.

•Staff had access to the electronic patient records system and up-to-date, accurate and comprehensive information on patients’ care and treatment was readily available. A patient tracker had been developed for the medical division.

•Clinical guidelines were easy for staff to access and staff were familiar with the clinical guidelines available in the emergency department. The hospital participated in national audits to enable it to benchmark practice.

•Mental health services were located in the emergency department and this arrangement had substantially improved the service for patients. Patient feedback was very positive.

•It was easy for patients 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 appointment of a matron for the emergency department at Bassetlaw had positively impacted the department and senior nursing staff in the department were visible and supportive. Staff expressed a positive culture and the departmental team worked well together

However:

•Whilst the medical staffing had substantially improved since our previous inspection, some significant issues remained with senior medical staff, consultants and middle grade doctors.

•Although paediatric nurse cover had improved it was not achieving the Royal College of Paediatrics and Child Health (RCPCH) (2018) guidance and night cover remained a challenge.

•Managers did not consistently appraise work performance to ensure staff were competent for their roles. We found a lack of training for middle grade doctors and a lack of structured teaching of junior doctors.

•At peaks times the department could experience crowding with patients waiting in the corridor. The escalation arrangements in place to mitigate crowding were unclear, particularly for specialty referral standards, ambulatory care, frailty pathways, or cancer care.

•Staff had received little training in providing support for patients with dementia or mental health needs.

•Information about the communication needs of patients with a disability or sensory loss or of the needs of patients who frequently attended the emergency department was not routinely recorded in patient records.

•For patients requiring mental health services, mental health were required to provide an initial response within one hour of referral but the service were achieving only 50% of this standard.

•The hospital took an average of 46.1 days to investigate and close complaints, this was not in line with the trust complaints policy, which stated complaints should be completed in 40 days.

•The room used for assessment of patients with mental health needs had been recently updated but was unfurnished and not yet open for patients at the time of our visit. Patients were being assessed in the relatives’ room and although this was temporary it was unsuitable for the purpose.

Diagnostic imaging

Requires improvement

Updated 19 February 2020

We previously inspected diagnostic imaging jointly with outpatients, so we cannot compare our new ratings directly with previous ratings.

We rated it as requires improvement because:

•There had been a lack of senior leadership in post as the due to long term sick leave and staff vacancy, there had been no head of service post since March 2019. Because of this a number of outstanding actions had not been fulfilled, such as recruitment of a permanent radiation protection supervisor (RPS) and actions from the previous CQC inspection. A new head of service had now been recruited and they were due to commence their role in October 2019.

•Senior managers and directors had collated all the outstanding actions into a plan for the new head of service to accomplish, however very little progress had been made on the issues identified during the previous inspection.

•The service did not provide evidence that radiation protection supervisors (RPS) had completed appropriate training or had been formally appointed. Local rules had been recently updated but were not available in every scan room and had not been signed by all staff.

•The service did not have an effective equipment quality assurance programme in all areas. For example, we did not see evidence of patient data collection to review doses for plain film or mobile x-ray and ultrasound checks were inconsistent.

•At department level, staff told us that, although managers were supportive, they needed to be more visible by coming on to the department and talking to staff rather than spending large amounts of time in their offices.

•The service had ongoing challenges with staffing levels across all disciplines within the department. This had been identified on the departmental risk register with risks rated as extreme for breast screening administrative staff to high risk for radiographers, abdominal aortic aneurysm screening, mammographers and interventional radiographers. Some of the staffing risks had been on the departmental risk register since January 2017, categorised as high risk, with no recent updates on progress of reducing or minimising risk.

•Overall mandatory training compliance for allied health professionals, medical and nursing staff was 69.5% against a trust target of 90%. For medical staff, the 90% target was met for only five of the 11 mandatory training modules for which medical staff were eligible.

•Medical staff had not kept up to date with safeguarding training specific for their role; for example, only 53.3% of medical staff had completed safeguarding adults and children level 2 compared with the trust’s completion rate of 90%.

•Staff recognised and reported incidents and near misses. However, there was limited evidence of lessons learned from incidents being shared with staff across the wider service.

•From April 2018 to March 2019, 71.3% of required staff in diagnostic imaging had received an appraisal compared to the trust target of 90% although the trust had recently reviewed its process and all appraisals were now undertaken between April and June each year.

•At our previous inspection, we had concerns about a lack of diagnostic reference levels (DRLs) audits. At this inspection, we found that the service had conducted some audits of doses against DRLs across the trust. This showed that five rooms across the service, including the x-ray room at Retford hospital was producing higher doses, due to older computed tomography (CR) equipment. However, we saw no evidence that these rooms had been subject to proactive optimisation or more frequent testing to mitigate this.

However;

•Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.

•Staff clearly described how they would report incidents using an online tool. Feedback from incident reporting was via email or staff meetings. Staff told us they talked openly about incidents and operated a no blame culture. Staff understood the duty of candour and what needed to be done when things went wrong.

•Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Staff provided emotional support to patients to minimise their distress. Staff involved patients and those close to them in decisions about their care and treatment.

•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. Most patients we spoke with told us that they had been told how to raise a complaint or they would know how to raise a complaint.

Maternity

Requires improvement

Updated 19 February 2020

Our rating of this service went down. We rated it as requires improvement because:

•The service did not make sure all staff completed mandatory and safeguarding training in key skills. The number of staff who completed it did not meet trust targets and managers had not appraised all staff’s work performance during 2018/19 to provide support and development. Current staff appraisal statistics for Bassetlaw maternity ranged from 0% (community midwifes) to 68.18% (labour ward).

•Staff we spoke with did not demonstrate a good understanding of mental capacity, best interest and deprivation of liberty.

•The service did not have enough nursing staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. The highest staffing vacancies were in the community midwifery service and ward A2 the antenatal/postnatal ward.

•Monitoring of surgical safety checklists was not in place.

  • Although, the trust confirmed that monitoring of neonatal early warning scores and women’s maternity early obstetric warning scores were in place we were unable to ascertain whether scores were being escalated appropriately and whether patient outcomes had improved through this monitoring process.

•Shortfalls in monitoring, calibration and servicing of some equipment was found. Some single use equipment was found to be out of date and still in use.

•Not all staff had received training in the use of hoists and written guidance was not available for staff on use of the hoist.

•The current pool cleaning guidance did not reflect current practice. The hoses used to fill the pool were not disinfected/replaced after each use and both hoses looked old and were yellowing in appearance. Trust guidance stated that hoses should be disinfected after use and new hoses attached to the taps.

•Flushing of taps helped control legionella in hot and cold-water systems. Trust records confirmed that legionella testing dates were from 10 August 2016 to 24 February 2017. No other legionella testing dates were provided for the Bassetlaw District General Hospital site.

•Gaps were observed in authorisation processes of the supporting documentation for patient group directions.

•The must action from the trusts previous inspection in 2017 identified that the trust must ensure that all policies are up to date and in line with current professional guidance. Four evidence-based guidelines were either seen to be out of date or had dated references.

However:

•Staff treated women with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Staff supported and involved women in their care and treatment decisions.

•In 2018/19 the trust completed an organisational restructure. This meant the trust went from six care groups which encompassed most of the acute provider services to four divisions. Obstetrics was within the children and family’s division. A new management structure was put in place and a new head of midwifery appointed following the retirement of their successor. Leaders understood and had started to manage the priorities and issues the service faced.

•The service had enough medical staff with the right qualifications, skills and experience to keep women and babies safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix and gave locum staff a full induction.

•Mitigation strategies were in place in respect of midwifery staffing shortfalls.

  • Following inspection, the maternity service confirmed that the whole service had a budgeted establishment to meet 1:28. At the time of inspection vacancies existed and the trust had offered 20 whole time equivalent new midwives positions and were waiting for them to commence employment on the 21 October 2019 once their NMC PIN Numbers had been received. The additional midwives would improve the ratio of births to midwives from 1:32 to 1:27.4 in line with RCM recommendations.

•The service provided care and treatment based on national guidance and evidence of its effectiveness. Joint policies, guidelines and procedures were in use across the service.

•The service 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.

Outpatients

Good

Updated 19 February 2020

  • The service provided mandatory training to all staff and controlled infection risk well. Equipment and the premises were visibly clean. Staff managed clinical waste well. There were enough staff to keep patients safe and provide the right care and treatment.
  • Staff kept records of patients’ care and treatment. Records were up to date and easily available to staff providing care. The service prescribed, administered, recorded and stored medicines safely.
  • Staff recognised incidents and reported them appropriately. Managers shared lessons learned locally with the team.
  • The service based care and treatment on national guidance and individual specialities managed NICE guidance compliance rates within departments. Medical staff prescribed and administered pain relief for minor procedures.
  • Staff worked together as a team to benefit patients and provide good care and were competent for their roles. All staff had completed their appraisal. Staff knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health.
  • The service provided outpatient clinics between 9am and 5pm, Monday to Friday. Some clinics were provided in the evenings to meet demand. People could access food and drink. The service had relevant information promoting healthy lifestyles and support.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
  • Staff provided emotional support to patients, families and carers to minimise their distress.
  • Staff supported patients, families and carers to understand their condition.
  • The service planned and provided care to meet the needs of local people. The service was inclusive and took account of patients’ individual needs and preferences.
  • People could access the service when they needed it. Although some specialties struggled to meet demand, most waiting times from referral to treatment and arrangements to admit, treat and discharge patients were in line with national standards. Staff treated concerns seriously, investigated them and managers shared lessons learned with staff.
  • Local managers were visible and approachable for patients and staff. They supported staff across the department. The service and senior leaders had a vision for what it wanted to achieve and a strategy to turn it into action.
  • Staff felt respected, supported and valued, and focused on the needs of patients. The service provided opportunities for career development with an open culture where staff could raise concerns without fear.
  • Although the ‘did not attend’ rate was higher than the England average at all of the trust’s sites, a new text reminder and respond system had been implemented. Managers and booking centre staff told us the trust had been able to reduce the rate significantly over two full months prior to our inspection.
  • Leaders operated effective governance processes. Managers worked with partner organisations. Staff at all levels were clear about their roles.
  • Leaders managed performance effectively. Environmental risks were identified and recorded.
  • The service collected data to understand performance, make decisions and improvements. The information systems were integrated and secure.
  • Leaders and staff engaged with patients, staff, and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients.
  • Leaders encouraged innovation and participation in research.

However:

  • Cleaning checklists were not always completed.
  • Records were not always clear, and staff did not always adhere to professional record keeping standards.
  • Learning from never events was not shared widely across different outpatients departments at the trust although staff in ophthalmology were aware of the events and actions taken as a result of investigation and reporting within the specialty.
  • The trust did not display information for patients on how to make a complaint.
  • There was a waiting list for review patients in ophthalmology and an incident had occurred where a patient had not received the right care promptly. Patient review appointments were managed centrally by the trust bookings team and managers said their processes were robust and would not allow a backlog of review appointments. However, the incident investigation had identified over 700 patients in ophthalmology had no review appointments. Following the inspection, staff told us the trust, with the CCG, had commissioned an external review of all waiting lists. They told us all ophthalmology patients on the review list had their appointments brought forward.
  • Information provided by the trust prior to our inspection showed no clinics were cancelled. However, they later provided information to show 20% of all outpatient clinics were cancelled.
  • Some staff were unaware who executive leaders were.
  • Although staff were aware of departmental plans relevant to their own area, not all staff were aware of how they linked in with the overarching trust strategy.
  • Risk registers did not include all risks and reviews of actions taken were not documented.
  • Senior leadership operated at directorate level and outpatients departments worked separately from each other. It was not clear if leaders had an overview of the outpatients department as a whole.