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St James's University Hospital Requires improvement

We are carrying out checks at St James's University Hospital. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 15 February 2019

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

  • We found that nurse staffing did not always meet the minimum levels to ensure patients received safe care and treatment and there was a high turnover of nursing staff. This was observed in multiple services at the hospital
  • We found that mandatory training compliance in multiple services was below the trust target of 80%
  • We observed that effective infection prevention and control protocols were not consistently followed on all wards and theatres and we had concerns about the number of healthcare acquired infections in surgical services at the hospital
  • We observed that substances hazardous to health such as cleaning solutions and alcohol gels were not always stored securely and in some cases were accessible to patients
  • We observed that the mental health assessment room did not meet recommended standards and that staff understanding of mental capacity and consent was variable
  • We had concerns about patient privacy and dignity in some areas of the urgent and emergency care service

However:

  • Patients we spoke to told us that staff were polite and professional and treated them with care and compassion. This was observed on all services we inspected.
  • Appropriate escalation policies were in place at the hospital and National Early Warning Scores were calculated and escalated in line with these polices
  • We observed safe medicines management, resuscitation trolleys were regularly checked with tamper proof seals in place and all medicines and items were found to be in date
Inspection areas

Safe

Requires improvement

Updated 15 February 2019

Effective

Good

Updated 15 February 2019

Caring

Good

Updated 15 February 2019

Responsive

Requires improvement

Updated 15 February 2019

Well-led

Good

Updated 15 February 2019

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 15 February 2019

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

  • The service did not always have appropriate numbers of staff to ensure patients received safe care and treatment. As a result, patients who had been assessed as requiring one to one supervision did not always receive the adequate level of care. This was sometimes due to not having extra staff on the ward to provide the supervision or staff providing the supervision were supporting patients within the bays with their own needs.
  • Mandatory training figures for medical staff did not meet the trust’s set target of 80% for 8 out of 18 courses. These included resuscitation and information governance. We saw that on various wards medical record trolleys were not always secure. Safeguarding training compliance varied between both medical and nursing staff.
  • At our inspection in May 2016 we identified hazardous substances used for cleaning and alcohol gels were not always stored securely. We found several solutions stored in areas where they could be accessed by patients.
  • The number of patients moved after 10pm had not changed since the last inspection in May 2016. The numbers fluctuated and varied between 632 to 760 patients per month between March and August 2018. Some of these included moving patients who were at risk of falls or living with dementia to non-medical areas.
  • A high number of medical patients stayed in clinical decision unit (CDU) based with the emergency department until a bed became available on a medical ward. At times patients remained on the CDU for between three and seven days. CDU was not designed for this purpose and was designed for patients who would move on from the area quickly.
  • The average of length of stayed varied between services with the majority slightly longer than the England average in both elective and non-elective specialities.
  • The trust was not investigating and closing complaints within the allocated timeframes.
  • The understanding of mental capacity and completion of documents such as capacity assessments and Deprivation of Liberty safeguards (DoLS) varied between staff, in particular registered nurses. As a result records did not always reflect the decisions made
  • Monthly audits varied between wards and showed lower audit results for nutrition and hydration needs. The trust was taking a number of steps to reduce the number of falls, however the trust performance within the inpatient falls audit was low
  • Patients had a higher than expected risk of readmissions in three areas for elective non-elective admissions. Within clinical haematology the risk was significantly higher.

However:

  • Mandatory training for registered nurses did meet the trust’s set target of 80% for 14 of 16 courses, with the remaining two slightly under the set target.
  • Patient records included all the relevant information, including observations and risk assessments.
  • Systems and processes were in place to check resuscitation equipment, fridge temperatures and electrical safety testing.
  • National guidelines were in place and evident within pathways. Action plans were in place for national audits where improvements were required. The majority of national audits were positive with the exception of inpatient falls. Monthly audits were completed on each ward for specific patient information.
  • Appraisal targets were met for different staff groups and staff worked together providing effective multidisciplinary team working. There was good links with the local mental health trust.
  • Patients were treated with care and compassion and patients told us they were treated with kindness. Patients felt that they were supported with their emotional needs and involved in decisions about their care.
  • Services were planned to meet the needs of the local people. This included the creation of different measures to reduce the length of stay within hospital. Alternative ways of working had been created, such as virtual clinics to review patients at home and frailty units.
  • Referral to treatment performance (percentage within 18 weeks) was consistently better than the England average by an average of 5.3%. Six specialities were above the England average, two had 100% and one 97.7% performance rates.
  • Staff were positive about the culture and leadership on the wards and within the CSUs. There had been various changes implemented which staff felt they were consulted on and were made aware of. The CSUs had clear visions and worked together to deliver the trust’s strategy.
  • Governance processes were in place to review the care provided to patients. Regular meetings were held to review and escalate the levels of risk.

Critical care

Outstanding

Updated 15 February 2019

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

  • We found improvements in all domains we inspected. The safe and responsive domains were rated as good, effective, caring and well led were rated as outstanding.
  • Significant work had been undertaken within the service since the last inspection. The areas identified as requiring improvement had been a focus alongside staff wellbeing and patient centred care delivery.
  • Nursing and medical staffing was in line with Guidelines for the Provision of Intensive Care Services (GPICS) recommendations and the majority of staff groups met trust expectations for mandatory training.
  • Reliable systems and processes were in place for the management of medicines, patient records and the monitoring, assessing and responding to risk.
  • Patient outcomes were in line with, or better when compared to similar units. Care and treatment was evidence based. The units were continually working to improve their services based on data and best practice.
  • There was effective monitoring of sedation and delirium and the nutrition and hydration needs of patients were consistently met.
  • There was significant focus on the training and development of staff at all levels within the service.
  • Feedback from patients and families was consistently positive. We observed compassionate care delivery and a drive to deliver individualised patient centred care.
  • A critical care patient flow team had been established and an online system based on clinical emergency medicine books (CEM books) had been developed. This enabled oversight of access and flow and supported risk based decision making.
  • A follow-up clinic was in place to support critical care patients following discharge from hospital. Significant work had been done in relation to CG83 rehabilitation after critical illness. The psychological needs of patients formed a key part of this.
  • We observed a strong, visible leadership on the units supported by clinical leadership.
  • The team had developed a strong vision and strategy with clear system to support and monitor its delivery.
  • Governance processes were embedded and there was effective risk management in place.

However:

  • The unit acquired infections in blood per 1000 patient bed days was significantly higher than other similar units.
  • Medical staff did not meet the trust target for mandatory resuscitation training and medical staffing on the HDU did not fully meet GPICS recommendations.

End of life care

Good

Updated 27 September 2016

We rated end of life care as good because:

  • Safety incidents were investigated when things went wrong and lessons learned were widely shared among staff to reduce the risk of re-occurrence. Staff were open and honest when they spoke with patients and families about incidents.
  • There was clear guidance for staff to follow within the care of the dying person individualised care plan when prescribing medicines at end of life.
  • There were some very good examples of record keeping in the individualised care plans; patients’ individual needs and wishes at end of life were represented clearly in the documentation.

Maternity and gynaecology

Good

Updated 27 September 2016

We rated maternity and gynaecology services as good because:

  • Staff were encouraged to report incidents and systems were in place following investigation to disseminate learning to staff.
  • Equipment was available to meet people’s needs.
  • Records relating to women’s care were of a good standard. Risks to women were identified, monitored and managed to keep them safe. Records were kept secure in line with the data protection procedures.
  • Systems were in place to protect patients from abuse and staff were aware of the procedures to follow.

However:

  • Medical staffing levels did not meet national guidelines.
  • Not all staff were up to date with mandatory training.
  • Some of the delivery suite furniture was not fit for purpose and could not be effectively cleaned.

Outpatients and diagnostic imaging

Good

Updated 1 July 2014

Outpatient areas at both St James’s University Hospital and Seacroft Hospital were appropriately maintained and fit for purpose. We found consistency in leadership and governance from the clinical service unit at both sites. Staff at all levels told us they felt encouraged to raise concerns and problems. Incidents were investigated appropriately and actions were taken following incidents to ensure that lessons were learned and improvements were shared across the departments and hospitals. The infection control procedures were adhered to in clinical areas, which appeared clean and reviewed regularly. Staffing levels were adequate to meet patients’ needs.

The trust completed audits and had implemented changes to improve the effectiveness and outcomes of care and treatment.

Patients told us they felt involved in their care and treatment and that staff supported them in making difficult decisions. The hospitals provided interpretation services and patients’ privacy and dignity were respected. However, a common theme from the analysis of patient feedback was that waiting times in clinics could be improved in terms of length of wait and patients being informed of why and how long they were expected to wait.

The outpatients were focused on patient care and this was reflected at all levels within the departments. Staff understood the vision and values of the organisation and felt encouraged to achieve continuous improvement.

Surgery

Requires improvement

Updated 15 February 2019

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

  • We were not assured staffing levels and mix always supported the delivery of safe care and treatment; especially in high patient volume areas and wards with comparatively more outlier patients. We saw there were a high number of outliers in the surgical bed base; and data showed a high number of bed moves at night within surgical services at the location.
  • Medical staff did not achieve compliance targets for level two resuscitation training and advanced resuscitation training modules, and higher-level safeguarding training targets were not attained.
  • We observed good use of the WHO surgical safety checklist during our inspection. However, audit data for the location showed low team brief and de-brief compliance. Data also showed variable compliance with blood clot risk assessment (within 24 hours of admission) across surgical service areas at ward level.
  • We found that infection prevention and control (IPC) protocols were not consistently followed on wards and in theatres. We also had concerns about the number of healthcare acquired infections (HCAI) in surgical services at the location.
  • At trust level, 18-week referral to treatment time (RTT) for admitted pathways for surgery was similar to or better than the national average. However, at the location, RTT for urological surgery was 10.1% below the national average and RTT for general surgery was 14.5% below the national average.
  • From April 2016 to March 2018, the percentage of patients whose operation was cancelled and not treated within 28 days, and the percentage of cancelled operations as a percentage of elective admissions, were consistently higher at the trust when compared to national averages. Urology, thoracic, and ophthalmology patients at the location had a higher than expected risk of readmission for elective admissions when compared to the national average.
  • Senior staff and management teams were aware of risks facing the service, and had plans in place to improve patient care. However, we were not always assured there was sufficient oversight of action implementation; and that strategic decisions translated into tangible and sustainable changes on the ground.

However:

  • The service had escalation policies, guidance and care pathways for deteriorating patients. We saw national early warning scores (NEWS) and observations were calculated and escalated in line with trust guidance. Resuscitation trolleys viewed had tamper proof seals, with few exceptions were regularly checked, and all equipment was found to be in date.
  • The service had systems in place for the identification and management of adults and children at risk of abuse. Key mandatory training target compliance rates (including those for safeguarding training modules) were often surpassed or close to being met for nursing staff. The service had systems in place for reporting, monitoring and learning from incidents.
  • Surgical service bed occupancy and theatre utilisation rates were high. Overall, there was a lower than expected risk of readmission for non-elective admissions compared to the national average. There was a relatively low proportion of delayed discharges within the service.
  • We saw evidence of learning, continuous improvement and innovation within surgical services at the location.

Urgent and emergency services

Requires improvement

Updated 15 February 2019

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

  • Nurse staffing did not always meet minimum safe levels and there was a high turnover of nursing staff.
  • Several safeguarding and resuscitation training modules had compliance rates below the trust target.
  • Initial patient streaming was not always in line with best practice guidance.
  • The department had a high number of outstanding incident reports awaiting closure
  • We were concerned that some patients found the MIU difficult to access.
  • The mental health assessment room did not meet recommended standards. However, the trust had already begun work to review the mental health assessment rooms in line with the recommended standards. Performance in royal college of emergency medicine (RCEM) audits was mixed.
  • We had concerns about patients’ privacy and dignity in some areas of the department.
  • Performance standards were consistently below the England average.
  • Although we saw improvements in the time taken to close complaints, it was still not in line with trust policy.

However:

  • Staff demonstrated good safeguarding knowledge and practices.
  • There were processes in place to improve flow in the department.
  • The department was clean and tidy, and equipment was well maintained.
  • Arrival to initial assessment times were better than the England average.
  • Patient monitoring and escalation was carried out appropriately.
  • Medicines were managed safely.
  • Policies and practices were based on national guidance.
  • Patients’ needs were met in relation to food, drink and pain relief.
  • Staff received comprehensive induction, training updates and regular appraisals, and learning from incidents was embedded in the department.
  • We saw good examples of cross-site and multi-disciplinary working.
  • Staff were caring, compassionate and respectful.
  • We saw good examples of leadership within the department, and the culture appeared positive.