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Medway Maritime Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 30 April 2020

Medway Maritime Hospital provides acute and specialist services that serves a population of more than 424,000 people across Medway and Swale.

We conducted an inspection of: Emergency and urgent care, medical care, surgery, critical care, end of life care and services for children and young people. During our inspection, we spoke with 185 staff, 37 patients and 15 relatives. Prior to inspection we held focus groups, where staff shared their views of the organisation with us and we reviewed patients comment cards, which informed us of their experiences of their care.

Our rating of services stayed the same. We rated it them as requires improvement because:

  • We rated the trust as good for caring, requires improvement for safe, effective, responsive and well led as inadequate.
  • The trust did not have effective systems to control infection risk in line with best practice. We saw that staff did not always clean their hands or use personal protective equipment (such as gloves and aprons), in line with trust policy.
  • The risks to people were not always assessed and their safety monitored and maintained to support patient safety. We saw in some areas, basic observations were not taken or recorded routinely. Substances hazardous to health were not stored or managed in line with regulations.
  • Access and flow through the hospital continued to be a problem in the hospital, which negatively affected patients in all of the services we inspected.
  • Improvements were slow to be made, or in some cases not made, following our last inspection. As such there was little assurance that the leadership team had the capability or capacity to make and sustain any improvements in their organisation.
  • Not all leaders had the necessary experience, knowledge, capacity or capability to lead effectively. There was no stability in senior the leadership team, with regular turnover of senior leadership roles. Leaders were not always in touch with what was happening on the front line, and they could not identify or understand the risks and issues described by staff.

However,

  • The trust had implemented recruitment and training initiatives to address the lack of medical and nursing staff which meant staffing levels met national guidelines in most areas.
  • Generally, the service had enough nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix.
  • Staff generally treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Feedback from patients was very positive. Staff provided emotional support to patients, families and carers to minimise their distress. Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment.
  • There was an improvement in the incident reporting culture of the organisation, although there was a backlog in incidents at the time of inspection. Processes around serious incident management was still improving and learning from incidents was not shared consistently or across the organisation.

Inspection areas

Safe

Requires improvement

Updated 30 April 2020

Effective

Requires improvement

Updated 30 April 2020

Caring

Good

Updated 30 April 2020

Responsive

Requires improvement

Updated 30 April 2020

Well-led

Requires improvement

Updated 30 April 2020

Checks on specific services

Medical care (including older people’s care)

Inadequate

Updated 30 April 2020

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

  • The service did not have a culture in all areas that provided high-quality sustainable care. The service was not always focused on the needs of the patients receiving care. Most staff we spoke with felt respected, supported and valued.
  • Leaders were not always aware of the risks, issues and challenges in the service. However, leaders had the skills and abilities to run the service. Senior leaders could not demonstrate adequate systems and process to provide assurance that they had full oversight of the service in terms of risk, quality, safety and performance.
  • Although there were clear lines of accountability from the department to the board, through the directorate governance structure, it was not effective. There was a lack of oversight of the issues identified that were a risk to patient safety, which had not been identified or addressed by the leadership team until we raised them during our inspection. For example, lack of compliance with infection prevention and control policies, storage of control of substances hazardous to health and the issues we identified on Dickens ward.
  • Risks, issues and poor performance were not always dealt with quickly enough. The risk management approach was sometimes inconsistent or not linked effectively into planning processes. We identified a number of issues that were a risk to patient safety, which had not been identified or addressed by the leadership team until we raised them during our inspection. The approach to service delivery and improvement was reactive and focused on short term issues.
  • People could not always access the service when they needed it and receive the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not always in line with national standards.
  • Services were not always delivered in a way that focused on people’s holistic needs. There was some flexibility to take account of individual needs as they arise, but the service did not meet the needs of all the people who used it.
  • The service did not always plan and provide care in a way that met the needs of local people and the communities served.
  • Safeguarding was not given sufficient priority at all times. Staff we spoke with were able to tell us how they would identify and act on safeguarding concerns. But, the safety systems, processes and standard operating procedures were not always followed. Not all medical staff were up to date with their safeguarding training.
  • The service did not have effective systems to control infection risk in line with best practice. We saw that staff did not always clean their hands or use personal protective equipment (such as gloves and aprons), in line with trust policy.
  • The design, maintenance and use of facilities, premises and equipment did not always keep people safe. Staff managed clinical waste well.
  • The risks to people were not always assessed and their safety monitored and maintained to support patient safety.
  • The service did not always have sufficient numbers of suitably qualified permanent staff with the right qualifications, training and experience to keep people safe from avoidable harm and abuse.
  • Care and treatment did not always reflect the trust policies, current evidence-based guidance or best practice standards. Managers did not always check that staff followed guidance. Staff in all areas did not complete evidence-based recognised tools to keep patients safe and free from preventable harm.
  • Facilities and premises were not always appropriate for the services being delivered. For example, we saw that the cardiac department had areas across the whole hospital site. The cardiac catheter suite was at one end of the hospital and the coronary care unit, on the other.
  • Although staff supported patients with food and drink, it was unclear on the accuracy of the completion of food chart. They used special feeding and hydration techniques when necessary.
  • Outcomes for people who use services did not always meet expectations, compared with similar services.
  • Consent was not always obtained or recorded in line with relevant guidance and legislation. We saw staff did not ask patients for consent before undertaking care. Both nursing and medical staff were below the trust target for completion of Mental Capacity Act (MCA) and deprivation of liberty safeguards (DoLS) training.
  • Staff did not always deliver compassionate care to patients in medical areas. We saw staff did not always consider the privacy of patients and did not always introduce themselves to their patients.
  • The pressure to move patients around the hospital had a negative impact on their emotional wellbeing.
  • Staff did not always take the time to interact with patients and those close to them in a respectful and considerate way. We saw nursing staff attend patients and have discussions about them across their bed, referring to them as “he” or “she” and not addressing them by name.
  • Staff did not always introduce themselves to patients, explain what their role was or what they were about to do.
  • We found call bells were not always answered in a timely manner.
  • Staff did not always treat patients with dignity and respect. On Dickens ward we found multiple patients with their bed clothes off and exposing their underclothes, due to the heat. We observed one patient remain exposed for 10 minutes, whilst nursing staff walked past several times.

Services for children & young people

Requires improvement

Updated 30 April 2020

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

  • The service did not always provide mandatory training in key skills to all staff and made sure everyone completed it.
  • Not all medical staff were up to date with their safeguarding training. In medicine the 85% target was met for one of the three safeguarding training modules for which medical staff were eligible.
  • Staff did not always use the premises in a way that kept people safe. The doors to the kitchen on Dolphin ward was frequently left open.
  • Staff did not consistently keep appropriate records of patients’ care and treatment. Not all nursing assessments or care plans were up-to-date.
  • The children’s unit did not follow the Royal College of Nursing (RCN) guidance for Standards for assessing, measuring and monitoring vital signs in infants, children and young people (2017).
  • Although, Staff collected safety information, they did not share it with staff, children, young people, their families and visitors.
  • The children’s unit breached mixed sex accommodation standards. Senior staff told us that patients and parents were asked for consent before placing on a mixed sex ward. Staff were not concerned in regard to the breech and told us older children were more concerned about being on a ward with younger children or infants.
  • The hospital did not have a dedicated paediatric operating theatre or recovery area. We visited recovery and found the area was not ‘child friendly’. Children were placed in the same recovery area as adults with a curtain used as a partition.
  • The staff in recovery and theatre were not paediatric trained, in line with national guidance. The trust had not put in place any specific paediatric training for recovery or theatre staff.
  • Although there was a dedicated paediatric surgery list, there was not a designated operating theatre for children and young people. This is not in line with a review of organisational and clinical aspects of children’s surgery’ (2011) recommended hospitals that have a large caseload for children’s surgery should consider using designated operating theatres.
  • Children’s services did not use a nationally recognised tool to monitor children and young people at risk of malnutrition during our inspection and the service did not have access to dietetic support with no paediatric dieticians employed at the trust.
  • Outcomes for children and young people within children’s service were not always positive, consistent and did not meet the expected national standard for the paediatric diabetes audit and had worse than the England average for asthma, diabetes and epilepsy readmission rate.

However:

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.

  • The service-controlled infection risk well. Staff used equipment and control measures to protect children, young people, their families, themselves and others from infection. They kept equipment and the premises visibly clean.

  • The design, and maintenance facilities, premises and equipment kept children, young people and their families safe. Staff managed clinical waste well.
  • The service used systems and processes to safely prescribe, administer, record and store medicines.
  • The service mostly provided care and treatment based on national guidance and best practice. Managers checked to make sure staff followed guidance. Staff protected the rights of children and young people subject to the Mental Health Act 1983.
  • Staff supported children, young people and their families to make informed decisions about their care and treatment. They knew how to support children, young people and families who lacked capacity to make their own decisions or were experiencing mental ill health.
  • Staff monitored the effectiveness of care and treatment. They used the findings to make improvements but did not always achieve good outcomes for patients.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and development.
  • Doctors, nurses and other healthcare professionals worked together well as a team to benefit children, young people and their families. They supported each other to provide good care.
  • Staff treated children, young people and their families with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
  • Families told us staff treated them well and with kindness. The majority of the feedback we received was positive, with a number of the comments saying staff were kind and friendly.
  • Staff provided emotional support to children, young people and their families to minimise their distress. They understood children and young people’s personal, cultural and religious needs.
  • 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.
  • The service was inclusive and took account of children, young people and their family’s individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers.
  • People 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 children and young people were in line with national standards.
  • Leaders had the integrity, 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.
  • The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. The vision and strategy were focused on sustainability of services and aligned to local plans within the wider health economy. Leaders and staff understood and knew how to apply them and monitor progress.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear.
  • Leaders operated effective governance processes, throughout the service and with partner organisations. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service.

Critical care

Outstanding

Updated 30 April 2020

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

  • The service had made significant improvements to the findings from the last inspection in areas such as nursing and medical staffing, pharmacy support and nursing patients in recovery area. Nursing staff cover now met national guidance, there was no agency nursing staff use and minimal nursing of patients in recovery beds. The service had also taken steps to address the medical cover shortage gaps.
  • There was now an embedded positive culture to making sure leaders and staff provided high-quality care. Staff understood the senior leadership structure and said the team were always accessible and visible. They felt there was now stability at middle management level. This had improved from what we found in the last inspection.
  • Medical and nursing staff compliance to mandatory training had improved and showed better compliance than the trust target and was better than at the last inspection.
  • The service leadership was compassionate, inclusive and effective. Leaders at all levels demonstrated the high levels of experience, capacity and capability needed to deliver excellent and sustainable care. Leaders had the skills, knowledge and experience to perform their roles.
  • Leaders and staff had a clear understanding of issues, challenges, priorities and vision for their service. The service places patients’ safety and individual needs at the core of its strategy.
  • There was strong and collective collaboration, team work and support across all functions and a shared focus on improving the quality, safety and sustainability of care.
  • Staff were proud of the service as a place to work and spoke highly of the culture. Staff at all levels were actively encouraged to speak up and raise concerns.
  • There was a strong visible person-centred culture to providing care across the service. Staff always treated patients with dignity and respect. Staff were highly motivated, passionate and dedicated to make sure patients received the best individualised patient-centred care.
  • Staff understood the impact that a person’s care, treatment or condition had on their wellbeing and on those close to them, both emotionally and socially. Staff saw people's emotional and social needs were equally important as their physical needs.
  • Staff involved patients and those close to them in making decisions about their care and treatment.
  • All staff actively engaged in activities to monitor and improve quality of care. Leaders and staff proactively pursued opportunities to participate in benchmarking and peer review are proactively pursued, including participation in approved accreditation schemes and research.
  • The continual development of staff skills, competence and knowledge was recognised as integral to providing high-quality care. Managers proactively supported and encouraged staff to acquire new skills, use their transferable skills and share best practice. Managers made sure staff received specialist training for their role.
  • Staff worked collaboratively and found innovative and efficient ways to deliver more joined-up care to people who use services.
  • The service was inclusive and took account of patients’ individual needs and preferences. There was a proactive approach to understand the needs and preferences of different groups of people and to deliver care in a way that meets these needs, which was accessible and promoted equality. This included people with protected characteristics under the Equality Act, people who may be approaching the end of their life, and people who were in vulnerable circumstances or who have complex needs.
  • Governance arrangements were proactively reviewed and reflected best practice. The service took a systematic approach to work with other organisations to improve quality of care.
  • The service managed patient safety incidents well. Staff recognised incidents and near misses and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
  • Openness, honesty and transparency were the norm.
  • The service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix.
  • Staff understood their responsibilities and knew the steps to take to protect patients from abuse. They had training to recognise and report abuse and knew how to apply it.

However:

  • The high dependency unit did not meet the minimum bed space dimensions as recommended in national guidance.
  • Staff did not always keep control of substances hazardous to health (COSHH) secure.
  • Patient flow throughout the hospital resulted in delayed discharges and very high occupancy rates. This continued to have a significant impact on discharges from the medical and surgical high dependency units. This delay in discharge also contributed to the majority of mixed sex accommodation breaches the trust reported.
  • Out of hours critical care discharges to ward between 10pm and 7am remained a challenge and were worse than the national average. The service relied on the availability of ward beds throughout the hospital and its performance was similar to the last inspection.

End of life care

Good

Updated 30 April 2020

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

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well.
  • The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines in line with best practice. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment and gave patients enough to eat and drink. Managers monitored the effectiveness of the service and made sure staff were competent.
  • Staff consistently monitored and managed patient’s pain to ensure they remained as comfortable as possible
  • Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Patients and relatives said staff go above and beyond and the care received exceeded their expectations. Staff truly respected and valued patients as individuals. They treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. They were clear about their roles and accountabilities.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

  • The service did not have a specialist palliative care consultant.
  • The service did not consistently have capacity to deliver end of life care training to staff across the trust.
  • The trust did not ensure staff had time to attend end of life care training.
  • The service did not keep their risk register fully up to date when they reviewed risks.

Maternity and gynaecology

Good

Updated 17 March 2017

At our previous inspection in 2015 we rated the service as good. On this inspection we maintained a rating of good as the overall quality of care for patients had been maintained.

At this inspection, overall we rated maternity and gynaecology services as good. This was because:

  • People were being protected from avoidable harm and abuse.

  • Openness and transparency about safety was encouraged. Staff understood their responsibilities in relation to incident reporting. Incidents were investigated appropriately by staff with the necessary clinical knowledge who had received training in leading such investigations. We were given examples of where changes to practice had been made following incidents.

  • Overall, medicines practice met practice guidelines. However, we found two areas where medicines were not stored appropriately.

  • The services, wards and departments were clean and, overall, staff adhered to infection control policies and protocols. However, we found some areas that had not been cleaned appropriately following spillages, and areas which were not cleaned to required standards. We also found that staff were not always washing their hands in line with trust policy.

  • Performance demonstrated a consistent track record and steady improvements in safety. Record keeping was comprehensive and audited on a regular basis.

  • Decision making about the care and treatment of patients was clearly documented. The service used systems of observation to drive improvement in the timely identification of patients at risk of unexpected deterioration. It had allowed for oversight of patients with elevated risk and concerns were escalated for review by the medical teams.

  • Treatment and care was generally provided in accordance with the National Institute of Health and Care Excellence (NICE) and Royal College of Obstetricians and Gynaecologists (RCOG) evidence-based national guidelines. Maternity and gynaecology had an MDT approach in the care of women and babies.

  • There was a range of national and local audits with action plans. In response to audit results action plans were reviewed and monitored providing evidence of good outcomes for children and young people.

  • Leadership was good and staff told us about being supported and enjoyed being part of a team. There was evidence of multi-disciplinary working with staff working together to problem solve and develop child-centred evidence based services which improved outcomes for children and young people.

  • Development opportunities and clinical training was accessible and there was evidence of staff being supported and developed in order to improve services provided to women.

  • Feedback from women and their families was continually positive about the way staff treated people. We saw staff treated women with dignity, respect and kindness during all interactions. Women and families told us they felt safe, supported and cared for by staff.

  • There was an embedded culture of caring, which was demonstrated by the team winning the Johnson’s Excellence in maternity care award at the annual RCM national awards. Staff listened and responded to women's needs as shown by the introduction of the 'Induction of Labour Team' and the 'Patient Satisfaction Following Emergency Caesarean Section' project.

However:

  • The maternity service was not meeting it ratio of staff to patients every month.

  • There were no guidelines in place in regards to babies’ identification.

  • The maternity unit had closed on seven occasions between April 2015 and July 2016 due to the neonatal unit (NNU) being closed. However, the service had followed trust procedures in regards to unit closures.

Surgery

Requires improvement

Updated 30 April 2020

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

  • While the service improved in some areas since the last inspection, it stayed the same or became worse in others.
  • While staff had training in key skills, the service did not always ensure everyone completed them.
  • The service did not control infection risk well and staff did not consistently follow infection prevention and control policies. The design, maintenance and use of facilities, premises and equipment did not always keep people safe. Records were not always stored securely.
  • While the service had improved staff recruitment, there remained significant challenges within theatres. This caused high reliance on bank and agency staff. This issue was identified at the last inspection and continued to require improvement.
  • Staff collected safety information but did not display it for patients and visitors to see.
  • Not all staff felt respected, supported and valued and staff morale was low in theatres.
  • The service did not ensure patients must ensure that all reasonable steps were being taken to improve the quality of service, specifically in relation to access to treatment and waiting times.
  • The service did not ensure products deemed as hazardous to health were stored securely.
  • The trust was not meeting the Department of Health and Social Care’s standard on eliminating mixed sex accommodation in the recovery area of theatres.
  • Patients were still spending longer than they needed to in recovery awaiting placement in the hospital. Patients staying in recovery for an extended time or overnight had their privacy and dignity compromised.
  • The leadership, governance and culture did not always support the delivery of high-quality person-centred care.
  • In main theatres staff had not been engaged and morale in the department was low and there was frustrations around leadership, low staffing and capacity and flow issues.
  • There was a lack of clarity from managers in theatres on whether staffing was maintained in line with national guidelines.
  • There was not an effective, structured review and judgement process for mortality and morbidity meetings.
  • The trust was still challenged with getting patients who had a fractured neck of femur to theatre within 36 hours of admission. Performance against this was poor.

However:

  • Staff understood how to protect patients from abuse, staff assessed risks to patients, acted on these and kept good care records. They managed medicines well.
  • Staff gave patients enough to eat and drink and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent.
  • Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff delivered compassionate care and treated patients and their loved ones with respect and dignity. They provided emotional support to patients, families and carers.
  • The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.
  • Staff were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities.

Urgent and emergency services

Requires improvement

Updated 30 April 2020

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

  • The emergency department did not meet the recommendations of the Royal College of Emergency Medicine guidelines of consultant cover. These state that consultant cover must be provided a minimum of 16 hours a day. This remained unchanged since our previous inspection.
  • Data provided for mandatory training compliance did not meet the trust target of 85%. However, this had improved at the time of inspection for nursing staff.
  • Compliance in Mental Capacity Act training amongst medical staff was 68% and 80% for nursing staff, which did not meet the trust target of 85%. However, staff demonstrated a good understanding of the Mental Capacity Act and safeguarding of vulnerable people.
  • The trust performed worse than the England average for the decision to admit until being admitted. Over the 12 months from October 2018 to September 2019, 124 patients waited more than 12 hours from the decision to admit until being admitted.
  • Patients and visitors were able to access all areas of the adult emergency department, as access was not restricted to staff only.
  • There was poor flow and capacity through the department. This meant patients waited many hours in the majors waiting area. Patients experienced significant delays whilst awaiting specialist review or to be placed in a bed on a ward.
  • The department consistently failed to meet the four-hour NHS constitution 4hour standard. The standard stipulates that 95% of patients be admitted, transferred or discharged within four hours. The trust did not meet the standard and performed worse than the England average.
  • The Patient Friends and Family Test asked patients whether they would recommend the services they have used based on their experiences of care and treatment. The trust scored between 72.0% and 81.8% from September 2017 to August 2019.This was consistently worse than the England average from January 2017 to December 2017.
  • There was not enough specialist provision for the assessment and treatment of patients attending with a mental health illness, which ensured they were kept safe. Risk assessments of patients attending with a mental health illness were completed but patients had long stays in the department waiting for mental health care.

However:

  • Staff were professional and cared for patients in a kind and compassionate manner. Feedback from patients and relatives was positive.
  • The leadership team supported staff and provided new staff with an individual induction plan and educational plans to ensure the skills they brought to the team were recognised along with identifying training needs.
  • There was consistent recording of information within the patient records we reviewed. This included good completion of risk assessments and pain scores.
  • Care provided to patients suffering with sepsis (infection) was in accordance with National Institute for Health and Care Excellence guidelines. This was an improvement since our last inspection. Local audits showed good compliance with adherence to national guidelines in the management of sepsis.
  • Staff were aware of the escalation processes used in times of increased demand on the service. This was an improvement since our last inspection.
  • The streaming of patients aimed to make care more efficient and take pressure away from emergency departments by having a healthcare professional, triage patients coming through hospital doors.
  • Staff monitored patients who were at risk of deteriorating appropriately. Early warning scores were in use in both adult and paediatric areas.
  • The department was staffed by a team of people who wanted to improve care and constantly sought ways of innovating and making changes for the better.

Diagnostic imaging

Requires improvement

Updated 26 July 2018

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:

  • Systems, processes and practices did not always keep people safe and safeguarded from abuse because;

Cleaning of ultrasound probes did not meet guidance presenting an infection risk.

Resuscitation equipment was not adequately monitored.

Turnover, vacancy and sickness rates were higher than the trust target.

Safety huddles were not sufficiently recorded.

  • The provider had not ensured the proper and safe use of medicines because;

Fridge temperatures were not monitored in line with trust policy.

Contrast injections used within CT were not checked by a second registered person as required by local policy and national guidance.

However,

Following inspection, the trust provided us with assurance these issues had been dealt with and would continue to be monitored.

  • Waiting times for scans were worse than the national averages in some areas including MRI, CT, ultrasound and dexa scanning.
  • Report turnaround times for general imaging was longer than the trust target of five days. The average time from imaging to report taking seven days.
  • Changes to the process for obtaining porters to transport inpatients had resulted in delays and waits for patients.
  • There was limited space in some areas of the department for patients in wheelchairs.
  • There was no formal strategy for diagnostic imaging at the time of inspection. Although the management team had developed a draft strategy it had not been agreed or implemented.
  • There were four vacant leadership posts within diagnostic imaging. There good local leadership within the imaging department with staff consistently telling us that imaging department managers were approachable. However, staff said senior trust and directorate leaders were not visible in the department. They felt that changes were implemented without their involvement, consultation or their concerns being listened to.
  • IT systems did not support the monitoring of demand, activity and capacity across the modalities within the department.

However;

  • The completion of mandatory training was better than the trust target overall.
  • There were quality assurance systems to monitor the safety of equipment within the department.
  • There was appropriate safety signage within the department.
  • Environmental cleaning audit results were consistently good.
  • Patient safety incidents were investigated and action was taken to monitor and improve safety. Radiation incidents were reported and monitored in line with legislation.
  • A radiation protection advisor, radiation protection supervisors and local rules were present in each modality in diagnostic imaging.
  • Chaperones were available patients were receiving care and support from a member of the opposite sex.
  • Staff demonstrated understanding of the needs of patients who were vulnerable and those who might be frightened, confused or phobic. Where patients were anxious about the process of the scan, staff made arrangements for them to visit the department prior to their appointment so they were familiar with the process and the equipment in use.
  • Staff provided patients with information leaflets and allowed time for discussion prior to procedures.
  • Volunteers were available to support patients and we observed them doing so with kindness and respect.
  • The diagnostic imaging department conducted their own patient satisfaction survey every six months. Results from the most recent survey showed that 99% of patients felt that their privacy and dignity was respected.
  • There were governance procedures in place with sufficient contact and advice for the provision of radiation protection supervisor services. There were regular radiation protection committee meetings and governance meetings and in place.

Outpatients

Good

Updated 26 July 2018

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

  • There was no way of monitoring how many medical staff in outpatients were compliant with mandatory training.
  • Referral to treatment targets remained consistently worse than the national average on most pathways.
  • The response time for outpatient complaints was worse than the hospital’s target.
  • The outpatient pharmacy department could not provide assurance that turnaround times were being accurately monitored following issues with the electronic system used to track outpatient prescriptions.
  • Signage for the outpatient pharmacy was non-existent.
  • The outpatient department did not have oversight of how many medical staff had completed their mandatory training as these staff were managed by their individual speciality.

However:

  • The service managed patient safety incidents well.
  • The trust monitored patients who could be at risk of harm from a long wait to see a clinician.
  • Staff were competent to perform their roles and received regular appraisals.
  • Staff cared for patients with compassion and feedback from patients regarding their care was continually positive.
  • Risks for the service had been identified at a service level, but wider risks such as the referral to treatment targets were not identified.
  • Staff knew and understood the hospital vision and values and told us the culture of the department was positive.
  • Staff told us their line managers and senior managers were visible and supportive.