11 August 2016
Hinchingbrooke Hospital is an established 289 bed general hospital, which provides healthcare services to North Cambridge and Peterborough. The trust provides a comprehensive range of acute and obstetrics services, but does not provide inpatient paediatric care, as this is provided within the location by a different trust. The trust has the traditional system of governance in NHS. The trust had previously been managed by a private provider. The ethos of empowerment of staff remained at the hospital and the “stop the line” initiative was still in use. This allowed anyone to raise issues immediately with the senior team. We found that this system was now working well within the hospital.
The average proportion of Black, Asian and minority ethnic (BAME) residents in Cambridgeshire (5.2%) is lower than that of England (14.6%). The deprivation index is lower than the national average, implying that this is not a deprived area. However, Peterborough has a higher BAME population and a higher deprivation index.
11 August 2016
The Care Quality Commission (CQC) carried out a comprehensive inspection between the 15 and 18 September 2014 at which the trust was rated as inadequate and placed into special measures. The CQC undertook a review of the areas rated as inadequate in January 2015 to ensure the safety of patients. At this inspection we rated most elements as requiring improvement although the urgent and emergency services were rated as inadequate. We undertook a focused inspection to review all areas identified as requiring improvement or inadequate in October 2015 to monitor the trusts progress. We returned on 10 May 2016 to monitor whether the improvements seen at the previous inspection were sustained.
Since 1 April 2015 the trust has a traditional management structure of an NHS trust. The trust has a trust board and with non-executive directors. The chief executive has now been in post for nearly 10 months. The changes that had been put in place were beginning to embed and staff were aware of the process for escalating issues to the senior team. The trust were aware of challenges and had plans in place to address these. We were aware of ongoing talks with a neighbouring trusts about efficient use of resources across the county.
The comprehensive inspections result in a trust being assigned a rating of ‘outstanding’, ‘good’, ‘requires improvement’ or ‘inadequate’. Each section of the service receives an individual rating, which, in turn, informs an overall trust rating. The inspection found that overall the trust has a rating of ‘Good’.
Our key findings were as follows:
- Most new systems and process were in place and these were embedded. Senior managers could articulate risks both internal and external to the organisation.
- Some new systems in processes in the emergency department such as triaging patients arriving by ambulance were yet to be embedded.
- There was an increased emphasis on incident reporting and disseminating learning to all areas of the trust though there were some delays in reporting incidents in surgery.
- Medicines were well managed across the trust with consistent processes to investigate concerns.
- Staff were caring and compassionate in their care of patients.
- Organisational development work had significantly impacted on the trusts development into a learning organisation.
- The emergency department continued to be under pressure through increasing volumes of attending patients and small numbers of emergency care consultants.
- The care of patients with a mental health condition was improved in the emergency department.
- There was an increased programme of audit including stroke audit though performance against some audits in the emergency department was below the England average.
- Referral to treatment times (RTT) were met for medical and surgical patients.
- There were clear visions for the services and visible leadership within the divisions.
- The trust and individual divisions were working with other providers and stakeholders on sustainability and transformation plans. Staff and managers had plans for improving care pathways though there was some anxiety amongst staff about collaborative working with other providers.
- There was a detailed end of life strategy in place which had received additional resourcing to meet the needs of patient and their relatives.
We saw several areas of outstanding practice including:
- The trust employed an Admiral nurse to support people living with dementia, their relatives and carers as well as staff. This was one of only five Admiral nurses in acute trusts in England.
- Staff worked with a local prison where consultants review patients that are at the end of their lives and work with prison and hospital staff to ensure that patients were safely admitted to the hospital or referred to the local hospice.
However, there were also areas of poor practice where the trust needs to make improvements.
Importantly, the trust must:
- Ensure that there are sufficient numbers of suitably qualified, skilled and experienced medical staff on duty in the emergency department. Also ensuring that there are robust contingency plans and which forecast shortages and ensure that sufficient cover is provided.
- Ensure that the time to treatment from a clinician in the emergency department is reviewed and times to treatment are improved.
- Ensure that the triage process for ambulance arrivals is received to ensure that the pathway for patients is safely and times of assessment accurately recorded.
- Ensure that infection control practices within the emergency department are improved.
- Ensure that the processes for the checking of equipment, particularly blood glucose and anaphylaxis boxes, in the emergency department is improved and safe for patients.
In addition, the trust should:
- Review the observation and seating arrangements for the children’s area to ensure parents and children only sit in this areas.
- Should ensure that fridge temperatures are routinely checked.
- Should allow staff to attend and receive updated mandatory training.
- Review the need to monitor the culture of staff within the emergency department.
- Review the environment and provision of children’s services and where children are treated.
- Ensure that records are used in a consistent way across wards, that they are contemporaneous; reflect patient needs and appropriate actions taken following risk assessment.
- Review the relative risk of readmission for surgery patients as data shows this to be significantly above the England average.
- Review the complaints process and the time taken to provide people who complain with a full response.
- Should ensure that audits are undertaken locally within the emergency department to improve quality measurement and assurance.
- Should ensure a consistent monitoring of preferred place of death for patients receiving end of life care.
- Should ensure that there is a clear target for fast track discharge of patients requiring end of life care and ensure consistent monitoring of the timeliness of these discharges.
Based on the findings of this inspection I would recommend the trust be removed from special measures. However I would recommend that ongoing support continue during this period of transition.
Professor Sir Mike Richards
Chief Inspector of Hospitals
11 August 2016
We rated medical services as Good overall.
Learning from incidents was consistently shared with staff across the division and formal mortality and morbidity meetings had been introduced and we observed good infection control practices in relation to hand hygiene and the use of personal protective equipment. All patients had their allergies recorded on their medicines chart and medicines were stored securely though prescription charts were not completed fully for time critical medications such as paracetamol though the trust informed us they would be using new charts in the near future. Staff had a good understanding of safeguarding principles and how to make safeguarding referrals and mandatory training had improved compliance across the division. However, records and risk assessments were mainly correct however they did not always reflect the needs of patients and were not updated to reflect changing care or needs.
Patient outcomes were now measured including the reinstatement of stroke audit data. Local audits plans were comprehensive and had lead clinicians identified. Patient care and pathways followed national guidance and best practice and staff had good knowledge of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. However, several patients had been identified as being at risk of malnutrition but we could not see that steps had been taken to address this.
We observed staff interacting in caring and compassionate ways with patients and relatives. Friends and Family Test (FFT) response rates were higher than the England Average and most wards scored highly on the test. Patients we spoke with told us that staff were caring and had kept them involved and up to date with their care and treatment.
The division was meeting referral to treatment times (RTT) and was actively engaging with sustainability and transformation plans and was working collaboratively with neighbouring trusts around the provision of some care including stroke care. There was now a speech and language therapist for patients suffering stroke and other service level agreements for therapy staff providing stroke care and patients had their individual needs met and we saw good practice in relation to dementia care on one ward. However, complaints and concerns were addressed locally. More staff were aware of learning from complaints but half of those we spoke with were unclear on this.
A number of changes in ward leadership and the introduction of a quality matron had become embedded since our last inspection. Governance and risk had been addressed with the implementation of mortality and morbidity meetings and that the findings of root cause analysis was more widely shared. The division was actively engaging with sustainability and transformation plans and collaborative working with other providers. However, we were concerned about the sustainability of some services due to a lack of key staff. Whilst locum staff were in place permanent recruitment had been difficult. The division was aware of these concerns and a review of some specialty care was underway.
22 April 2015
11 August 2016
End of life care was good at Hinchingbrooke Hospital as patients received safe, effective, and responsive care that met their individual needs and protected them from avoidable harm.
Infection, prevention, promotion, and control was good and patients benefitted from visibly clean environments that were routinely audited and cleaned. Staff knew how to respond to safeguarding concerns and reported these appropriately. Staff reported incidents using the trust electronic incident reporting system and learning from incidents was shared across the staff teams.
Equipment was appropriate for the patient’s needs and the bereavement, mortuary, and chaplaincy team made use of a number of key environments to enable relatives and families to access private areas for reflection and practice their religion or belief. The mortuary team provided a caring and empathetic approach and created a homely and comforting environment for families to see their deceased loved ones.
The trust ensured staff were trained, appraised, and supervised appropriately. Improvements were seen in end of life training for all staff, particularly junior doctors, and the number of staff completing the Quality End of Life Care for All (QUELCA) training had increased. Patients were cared for using best practice guidance, for example, National Institute for Health and Care Excellence (NICE), and individual care planning promoted patient nutrition, hydration, and the effective use of pain relief to manage patients’ symptoms.
Patient records were of a very high standard, reflected the patient’s individual needs and choices, and demonstrated multidisciplinary (MDT) working to support patient outcomes. There had been improvements in the way do not attempt cardiopulmonary resuscitation (DNACPR) was recorded and the trust carried out audit activity to ensure quality was measured in key areas of its services. Patients were referred to the specialist palliative care team in a timely and professional way, this meant that patients accessed last days of life care and treatment that met their individual needs.
Patients and their families were cared for with high levels of dignity, compassion, and respect throughout our inspection. Staff gave examples of good practice that enhanced patients’ physical, psychological, and emotional wellbeing. Families were offered a wide range of information to help them deal with death and dying and the trust collaborated effectively with external providers, for example, funeral homes, counselling services and patient advice services.
The trust had a clear strategy and vision in place for end of life care with staff roles and responsibilities clearly set out within it. The culture across the service was one of support and mutual respect amongst the staff team and there was a significant focus on improving staff knowledge and competence in end of life care.
22 April 2015
22 April 2015
11 August 2016
Surgery services were rated as good overall.
Staff had access to an electronic incident reporting system and knew how to report incidents.
Scrutiny of mortality cases was regular and robust, with all cases being presented at dedicated meetings and actions for improvement being set. There was no increased risk of death for this surgery services at this trust, as the trust performed as expected in the two surgery specific mortality indicators, death in the low-risk diagnosis group and death after surgery. Good hand hygiene techniques and the use of personal and protective equipment such as aprons and gloves was consistent amongst all staff. Surgical site infection rates were low, with two cases being reported for large bowel surgery between April 2015 and December 2015 and zero cases being reported for other surgical specialties. Equipment was regularly safety tested and all equipment checked on our inspection was within date for the next safety check. Resuscitation trolleys were consistently checked with no omissions noted for the time period we checked (January 2016 to May 2016). Medicines were stored securely across surgical wards and access was limited to nursing staff. Learning from medicine related incidents was evident. For example, an insulin-related incident had led to a ward manager completing a course on insulin safety and cascading that learning to their team.
World Health Organisation (WHO) surgical checklists were consistently used by the service and their use was audited. Overall training compliance for Mental Capacity Act and Deprivation of Liberty Safeguards was 92% for surgical services which was above the trust target of 90%. The service comprehensively audited its performance each year, including both local and national audits. There was an established pain team and provision was in place for this support to be provided out of hours. The trust performed in line with, or better than the England average in the national hip fracture audit, the national lung cancer audit, and the patient reported outcomes measures for groin hernia, hip and knee replacement and varicose vein surgeries. With the exception of theatres, staff appraisal rates were better than the trust average across the surgery services.
Friends and family responses were positive for surgery services, indicating that between 93% and 100% of respondents would recommend the service to their family and friends. Patients were involved and informed about their care, with a range of patient information leaflets and a hip and knee club for patient undergoing joint replacement surgery. Emotional support was available from an Admiral nurse (a specialist dementia nurse). The Admiral nurse was observed to provide dedicated care to a person living with dementia, ensuring they were settled and had their privacy and dignity respected. The service provided care within 18 weeks of referral in the majority of cases (90% of the time or more). Cancer treatment targets were consistently met or exceeded and the trust was amending cancer pathways with a view to bringing cancer targets down.
The service performed better than the England average in rebooking cancelled operations within 28 days. One theatre was available 24 hours a day, seven days a week for emergency or life threatening surgeries, in line with National Confidential Enquiry into Patient Outcome and Death (NCEPOD) guidelines. There was awareness at ward level of complaints and learning, with ward managers able to give examples of improvements made to their ward areas as a result of learning from complaints.
A clear plan was in place for the development of a surgery strategy that was linked directly to the development of the new trust values. The development of the strategy involved staff and was based on the results of the staff survey. There was good ward level understanding of risk; however the recording of scrutiny of risk and other clinical governance issues was inconsistent across surgical specialties. Almost half of incidents were not reported within 14 days of their occurrence. The acute trauma and surgery unit and Juniper ward consistently performed below trust targets for various infection control and patient safety measures.
The length of stay for elective trauma and orthopaedics was 1.5 days over the national average, and the overall risk of re-admission for elective patients was much higher than the England average at a score of 158 compared to an average score of 100.The service had not appropriately managed an increase in medical outliers. This had led to the displacement of emergency and elective surgical patients and ultimately the cancellation of joint surgeries at the time of our inspection, due to elective and emergency (or patients swabbed for Methicillin resistant staphylococcus aureus (MRSA) and those not swabbed) being placed in bays together.
11 August 2016
The emergency department was rated as requires improvement for being safe because there remained concerns regarding staff hand hygiene techniques, and use of PPE. The boxes which monitor the blood glucose of a patient, known as a BM box, and the anaphylaxis boxes were not checked daily as required. Time to see a clinical decision maker to receive treatment was consistently above 60 minutes. The process for triage of ambulance patient was not yet fully embedded and therefore this could place patients at risk through a lack of monitoring. However we also found that medicines management was safe, items were stored securely and dispose of appropriately. The care and treatment of patients with a mental health condition had much improved since our previous inspection. This included staff awareness on the importance of care for those with mental health conditions. The environment for the children’s waiting area had improved since our last inspection.
The service was rated as requires improvement for being effective because the service performed worse than expected on the RCEM Asthma audit, and severe sepsis and septic shock audit. Some of the national audits were from 2013; however there was a lack of local audits being undertaken. The service could not demonstrate if any of their key patient outcomes had improved. Fluid rounds and drinks provision for patients had not increased despite the warm temperatures in the department. However we also found that there was a clear protocol for staff to follow with regards to the management of stroke and sepsis. Pathways were written in line with the national institute for health and care excellence (NICE) and RCEM guidelines. Management of pain and administration of pain relief had improved since our last inspection.
The service was rated as good for caring because the feedback received from service users was positive. The friends and family test results were consistently above the England average. We observed positive and caring interactions between staff and patients throughout the inspection. Staff were caring and compassionate when they spent time with patients. However we also received comments from three patients and relatives on comment cards where they felt the service was not good.
The service required improvement for being responsive because the trust was not consistently meeting the four hour standard. On review we found that this was not only affected by reduced bed capacity but in addition, delays in decision to admit times. The average time spent in the department was much longer than the England average. However we also found that the service has significantly improved the working relationship and pathways, assessment and treatment for adults and children with mental health conditions. The waiting area had an improved paediatrics waiting area including a separated play zone for children.
The service required improvement for being well led because the risk register, identification or risk and management of risk was not yet embedded within the service. The risk register provided did not detail any emergency department specific risks despite concerns about medical staffing being raised by the trust as a risk. There was a lack of medical leadership within the department due to staffing shortages. However we also found that the nursing staff had been provided with some training in leadership, and the leadership and governance for the children’s emergency department had sustained good practice which had further improved the children’s service.