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Inspection Summary


Overall summary & rating

Good

Updated 7 February 2019

  • In urgent and emergency care, staff received appropriate training in safeguarding and mandatory skills. Infection risk, records and medicines were managed well. Risk assessments were completed where necessary and patients were seen in a timely way. The department performed positively against other hospitals. Staff worked well together to provide effective care. The patient remained at the centre of this, by staff ensuring they delivered care compassionately, provided emotional support where needed and involved carers and families. Flow through the department was positive, and the four-hour target was consistently met. Governance was positive, and information was used to support its activities.
  • Staff in medical care understood how to protect patients from abuse, completed relevant risk assessments and kept clear and legible records of patient care. The effectiveness of the service had improved since the last inspection. The medical care service met the needs of people it supported. We found the leadership, governance and culture in medical care supported the delivery of high-quality care.
  • Staff in surgical services understood how to protect patients from abuse and the service worked with other agencies to do so. Staff completed and updated risk assessments for each patient. The surgical division participated in both national and local audits to monitor people’s care and treatment outcomes and compare with other similar services. All staff were committed to providing excellent care to their patients. Quality improvement projects had helped to improve the service being delivered to patients, however some projects were in their infancy.
  • Staff in outpatients understood how to protect patients from abuse and there were clear processes for reporting safeguarding concerns. There were systems in place to manage maintenance of equipment and repair faults when identified. Staff kept appropriate records of patients care and treatment. The service made sure staff were competent for their roles. Patients were treated with compassion, kindness, dignity and respect throughout their visits to outpatient services. Staff within outpatients worked hard to ensure people with learning disabilities were able to access services. The trust identified where a system-wide approach was needed to meet the needs of the local population. Staff supported patients with additional needs such as patients living with dementia. The trust had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. There was a positive culture within outpatient services. The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff and patients.
  • We found the service had improved, but the surgical division still needed time to embed processes and practice, and improve certain areas, under new leadership. Staff understood how to protect patients from abuse and staff completed and updated risk assessments for each patient. There were processes to recognise and respond to a deteriorating patient. A sepsis care bundle was used for the management of patients with presumed or confirmed sepsis. The World Health Organisation (WHO) surgical safety checklist was used in theatres. The surgical division participated in both national and local audits. All staff were committed to providing excellent care to their patients. Quality improvement projects had helped to improve the service being delivered to patients, however some projects were in their infancy.
  • Although we found the surgical service was improving, the division still needed time to embed processes and practice, and improve certain areas, under new leadership. Medical gas oxygen cylinders were not being stored securely across surgical wards and theatres. Staff required some additional support to manage patients living with mental health needs safely. Staffing on wards was regularly at minimum staffing levels rather than at funded establishment, particularly at night times. A shortage of radiologists made it difficult to provide 24-hour cover. Staff demonstrated a limited understanding of the Mental Capacity Act. Systems used by the trust did not help promote flow and efficiency in theatres and risked the safety of patients.

However:

  • In urgent and emergency care, we found that although staffing levels were maintained, there was an over-reliance on bank and agency staff. We also found that there could have been better publicity of the emergency departments opening times.
  • In medical services systems and processes to keep people safe were not always followed in relation to infection control and medicines management. Performance in national audits was variable and outcomes for stroke patients needed improvement. The responsiveness of the medical service required improvement as national targets for referral to treatment times were not met for most medical specialities and the trust was not producing reliable data on referral to treatment times. In well-led, risk management processes needed to be improved as risks were not always graded, mitigated and reviewed appropriately.

  • In surgical services, oxygen cylinders were not being stored securely across the service. There was also a training need for staff around managing patients living with mental health needs. We found that staff felt they were stretched and overworked. This affected their wellbeing. Understanding of the mental capacity act could have been better and some support services, such as radiology were not part of formal rotas. Patients were not always able to access services in a timely way and systems used did not promote positive flow through theatres.

  • Outpatient services were primarily a five-day service. Lack of space was identified as an issue in certain clinic areas. The introduction of a new patient appointment booking system, had presented a number of difficulties in the delivery of services. The trust has been unable to report referral to treatment data to NHS England since November 2016 because of data quality issues following the introduction of a new electronic patient record system in December 2016. Patients could not always access services when they needed them.

Inspection areas

Safe

Good

Updated 7 February 2019

Effective

Good

Updated 7 February 2019

Caring

Good

Updated 7 February 2019

Responsive

Requires improvement

Updated 7 February 2019

Well-led

Good

Updated 7 February 2019

Checks on specific services

Medical care (including older people’s care)

Good

Updated 7 February 2019

  • We rated safe, effective, caring and well-led as good and responsive as requires improvement. Overall, we rated the service as good.
  • Staff understood how to protect patients from abuse, completed relevant risk assessments and kept clear and legible records of patient care.
  • The effectiveness of the service had improved since the last inspection. The service used audit processes to monitor patient outcomes and used this information to improve services. Patients pain was well managed, staff worked together for the benefit of patients and the trust ensured staff were competent for their roles.
  • The care provided by staff continued to be good. People were supported, treated with dignity and respect, and were involved as partners in their care.
  • The service met the needs of people it supported. Staff treated patients as individuals and supported patients living with dementia or a learning disability well.
  • The management of the service had improved since the last inspection. We found the leadership, governance and culture supported the delivery of high-quality care. There were clear governance processes from ward level up to the trust board. Staff were well engaged with quality improvement projects.

However:

  • Systems and processes to keep people safe were not always followed in relation to infection control and medicines management. Compliance with mandatory training for medical staff needed to improve and the environment of some areas did not always ensure people were safe.
  • Performance in national audits was variable and outcomes for stroke patients needed improvement.
  • The responsiveness of the service required improvement as national targets for referral to treatment times were not met for most medical specialities and the trust was not producing reliable data on referral to treatment times.
  • In well-led, risk management processes needed to be improved as risks were not always graded, mitigated and reviewed appropriately.

Critical care

Outstanding

Updated 19 June 2015

The effectiveness, caring and leadership of the service were outstanding, and safety and responsiveness were good. Treatment, care and rehabilitation by all staff were delivered in accordance with best practice and recognised national guidelines. There was a holistic and multidisciplinary approach to assessing and planning care and treatment for patients. Patients were at the centre of the service and the overarching priority for staff. Innovation, high performance and the highest quality care were encouraged and acknowledged. All staff were engaged in monitoring and improving outcomes for patients. They achieved consistently good results for patients who were critically ill and with complex problems and multiple needs.

Patients were truly respected and valued as individuals. Feedback from people who had used the service, including patients and their families, had been exceptionally positive. Staff went above and beyond their usual duties to ensure patients experienced compassionate care and care promoted dignity. People’s cultural, religious, social and personal needs were respected. Innovative caring for patients, such as the development of patient diaries, was encouraged and valued.

The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care. All the senior staff were committed to their patients, their staff and their unit with an inspiring shared purpose. There was strong evidence and data to base decisions upon and drive the service forwards from a clear, approved and accountable programme of audits. There was a high level of staff satisfaction, with staff saying they were proud of the unit as a place in which to work. They spoke highly of the culture and consistently high levels of constructive engagement. Innovation and improvement was celebrated and encouraged, with a proactive approach to achieving best practice and sustainable models of care.

There was a good track record on safety, with lessons learned and improvements made when things went wrong. This was supported by staff working in an open and honest culture and by a desire to get things right. Staff responded appropriately to changes in risks to patients. There was high-quality equipment and a safe environment. The unit was clean and well organised. Staff adhered to infection prevention and control policies and protocols. There were good levels of nursing and medical staff meeting the Core Standards for Intensive Care Units to keep patients safe. There was a daily presence of experienced consultant intensivists and doctors, and rarely any agency nursing staff or locum cover used. Patients’ records were excellent, clear, legible and contemporaneous, although their security needed to be improved.

Some improvement was needed to ensure that one stock of a specific controlled drug was clear and that consumables were within their expiry date. The patient harm data was low, but the internal and external recording and display of some information could be improved.

The critical care service responded well to patients’ needs. There were bed pressures in the rest of Cheltenham General Hospital that sometimes meant patients were delayed on discharge from the unit, but incidences were below (that is better than) the NHS national average for similar units. Some patients were discharged onto wards at night, when this was recognised as less than optimal for patient wellbeing, but this rate was also below (better than) the NHS national average rate. There was a very low rate of elective surgical operations being cancelled because a critical care bed was not available.

The facilities in critical care were excellent for patients, visitors and staff, and met all the modern critical care building standards.

Patients were treated as individuals and there were strong link nurse roles for all aspects of patient need, including learning disabilities, dementia and mental health. There were no barriers to people who wanted to complain. There were, however, few complaints made to the department. Those that had been made were fully investigated and responded to with compassion and in a timely way. Improvements and learning were evident from any complaints or incidents.

End of life care

Good

Updated 5 July 2017

We rated this service as Good because:

  • End of life care provided at Cheltenham General Hospital was safe, effective caring, responsive and well led because:
  • The processes in place to keep people safe for end of life care were good. Staff in the specialist palliative care team and other areas understood their responsibilities to raise concerns, record safety incidents and report them. Lessons were learned and improvements were made when things went wrong.
  • Patient’s records demonstrated that nutrition and hydration needs were assessed and appropriate actions were documented as followed in patients’ individual care plans.
  • Records documented discussions with relatives around what to expect with the dying process.
  • Risks to patient’s receiving care at end of life were assessed by ward staff with appropriate assessments recorded in medical records for example the prevention and management of pressure ulcers and falls.
  • Staff we spoke with on the wards understood that end of life care could cover an extended period for example in the last year of life and also applied to patients with non-cancer diagnoses such as dementia. Staff, teams and services worked together to deliver effective care and treatment.
  • Staff we observed on wards delivering end of life care to patients were compliant with key trust policies such as infection control.
  • Arrangements in place for managing medicines kept patients safe. Medicines to relieve pain and other symptoms were available at all times. Wards had adequate supplies of syringe drivers (devices for delivering medicines continuously under the skin) and the medicines to be used with them.
  • There were reliable systems, processes and practices in place to keep patients safe and safeguarded from abuse.
  • The staffing levels and skill mix of the nurse and medical personnel in the specialist palliative care team were planned and reviewed and supported safe practice. We saw evidence of a yearly education programme of end of life care for medical, nursing and allied health professionals. This included: resuscitation, syringe driver training, quarterly end of life study days and symptom management.
  • The specialist palliative care team responded promptly to referrals, usually within one working day.
  • Patients were treated with kindness, dignity, respect and compassion. Staff took the time to interact with people who received end of life care and those close to them in a respectful and considerate manner.
  • We saw many written compliments about how caring staff were in the inpatient specialist palliative care team. We saw that patients’ and those people close to them, were involved as partners in their care.
  • The specialist palliative care team and wards staff understood the impact a patients’ care, treatment or condition had on their wellbeing and on those people close to them.
  • Emotional support for patients and relatives was available through the in-patient and community specialist palliative care team, the chaplaincy team and bereavement services. Staff had access to support through their own teams when needed.
  • Services were delivered and additional services planned in order to effectively meet patient’s needs. Plans and actions included audit to inform future planning so that the end of life team could inform better decision making with patients they cared for.
  • There was a clear vision and strategy to deliver care at end of life. The governance framework for end of life care ensured that responsibilities were clear and that quality, performance and risks were understood and managed.
  • Leadership encouraged openness and transparency and promoted good quality care. There were leads on the wards who supported the development and delivery of high quality end of life care.
  • Services within specialist palliative and end of 

    life care 

    had been continuously improved and sustainability supported since the last inspection March 2015.

However:

  • Documenting ‘Do Not Attempt Cardio-Pulmonary Resuscitation’ (DNACPR) decisions had improved since the last inspection however concerns regarding DNACPR remained. For example not all DNACPR having relevant clinical information and not all patients or those close to them being recorded as involved in discussions about resuscitation. These concerns were not identified as a risk and did not feature on a risk register
  • There were no centrally held training records for syringe driver training or competency for ward staff.
  • There was not a full understanding of performance for all aspects of end of life care. For example the percentage of patients dying in their preferred location and the percentage of patients discharged within 24 hours were not known for all wards or hospital sites.
  • There was no risk register specific to end of life care for the trust so oversight of all end of life risk was not easy.
  • When we reviewed maintenance records some provided were out of date. The trust told us they were clear that equipment listed was not in use. We saw email communication from directors supporting this.
  • There was not a seven day face to face service provided by the specialist palliative care team. The trust provided a face to face service 9-5 Monday to Friday. Out-of-hours there was a telephone advice line available 24 hours, 7 days a week for health care professionals to access.
  • Some of the ‘white rose’ symbols used to locate the mortuary at the hospital were not easy to follow. Signs were not always at eye level for someone walking or in a wheelchair and there were long gaps in signage that led to confusion. Mortuary and bereavement officers told us relatives had commented they were useful. Some relatives had reported they appreciated these signs. However bereavement office staff accompanied relatives when they knew people were attending the mortuary.

Maternity and gynaecology

Good

Updated 19 June 2015

There was a good culture of incident reporting, openness and learning, with good governance processes to support this. Women were provided with one-to-one care in labour, and patient risks were well managed. Care was delivered in line with national guidance in a caring and compassionate manner with high levels of patient satisfaction. The provision of gynaecological oncology services in Cheltenham General Hospital ensured timely access to ongoing oncology support and treatment. The maternity service meant women were able to have normal midwife-led care closer to their homes. The services were well-led by a long-established cohesive team.

However, there was no process to identify whether equipment had been cleaned and was ready for use, and medicines were not securely stored or held within tamper-evident containers.

Medical care (including older people’s care)

Requires improvement

Updated 19 June 2015

Outpatients and diagnostic imaging

Updated 5 July 2017

We did not rate this service as we did not inspect all domains. However, we found:

  • There were good infection control measures in place to help keep people safe, including hand hygiene practices, and the outpatient and diagnostic imaging departments had 100% compliance.

  • Patients who were vulnerable were protected from avoidable harm through comprehensive safeguarding procedures, and staff showed good understanding of these procedures and shared learning from safeguarding incidents.
  • Staff were given the right skills and training to do their jobs, and in ophthalmology a competency based training package had been developed for healthcare assistants.
  • Patients had access to specialist services, and the urology department had developed a dedicated consent form for cystoscopies and was expanding its one stop clinic service.
  • A new waiting list validation process had allowed some patients to be discharged back to primary medical care facilities for their ongoing care and follow up treatment.
  • Visually impaired patients were able to access services on an equal basis to others in ophthalmology through the use of colour coded signs, which made navigation of the department easier.
  • The oncology department provided an information presentation for all newly diagnosed patients which included opportunities to ask questions on a one to one basis.

However;

  • The service did not have sufficient arrangements to keep clinical and patient areas clean. Some treatment rooms in ophthalmology had carpet flooring and contained visibly dusty equipment, and the trust had not met its infection prevention and control training target.
  • The environment in the phlebotomy clinic was small and did not allow staff to respond to patients effectively if they became unwell..
  • The trust did not make sure staff had access to the most up to date policies and guidance, and had several versions of one Patient Group Directive (PGD) in circulation in ophthalmology.
  • The hospital was not meeting the 62 day waiting list target for cancer patients, and the trust was not meeting referral to treatment target in all specialities.
  • Patients were experiencing delays in diagnosis and treatment because the diagnostic imaging department had a reporting backlog of 19,500 films, and was not meeting its five day reporting target for accident and emergency x-rays.
  • A significant typing backlog was causing delays in sending out patient letters impacting on patient safety, diagnosis and ongoing treatment.
  • Implementation of new IT systems had impacted on waiting lists as some specialties could not see their live waiting lists.
  • Patients were not able to easily access the top floor clinics in outpatients due to the lift being out of order.

Surgery

Good

Updated 7 February 2019

  • We rated safe, effective, caring and well-led as good, and responsive as requires improvement.
  • We found the service had improved, but the surgical division still needed time to embed processes and practice, and improve certain areas, under new leadership.
  • Staff understood how to protect patients from abuse and the service worked with other agencies to do so.
  • Staff completed and updated risk assessments for each patient.
  • There were processes to recognise and respond to a deteriorating patient. A sepsis care bundle was used for the management of patients with presumed or confirmed sepsis.
  • The World Health Organisation (WHO) surgical safety checklist was used in theatres. Observations in theatre showed this was performed well and staff were engaged in the process.
  • The surgical service provided care and treatment based on national guidance and evidence of its effectiveness.
  • The surgical division participated in both national and local audits to monitor people’s care and treatment outcomes and compare with other similar services. Reviewing data for audits, the trust was generally performing well or as expected when benchmarked nationally.
  • Staff of different roles and disciplines worked together as a team to benefit patients. Effective multidisciplinary team working was evident on all wards, theatres and units.
  • All staff were committed to providing excellent care to their patients. There was a patient centred culture and staff preserved patient privacy and dignity.
  • The trust did not need to cancel elective patients at the start of the 2018 year when operational pressures were high nationally, and there was a national directive to cancel elective patients.
  • There was a new leadership team in many areas of the surgical division, and trust wide, to strengthen surgical leadership, but time was required for embedding change and actively shaping culture.
  • Quality improvement projects had helped to improve the service being delivered to patients, however some projects were in their infancy.
  • The surgical division had a vision for what it wanted to achieve and workable plans to turn it into action.
  • There was a clear divisional risk management and governance structure for the surgical division.
  • Quality improvement projects were key in proactively engaging and involving staff and patients, to shape and improve services.
  • The surgical division promoted learning, continuous improvement and innovation. Staff were passionate about quality improvement projects and quality improvement appeared well embedded.

However:

  • Medical gas oxygen cylinders were not being stored securely across surgical wards and theatres.
  • Staff required some additional support to manage patients living with mental health needs safely.
  • Staffing on wards was regularly at minimum staffing levels rather than at funded establishment, particularly at night times. We were unable to identify any impact on safety of the low staffing numbers. However, this was detrimental to the well-being of staff who regularly felt they were overworked, exhausted and not always getting enough breaks.
  • There were gaps in rotas for non-consultant medical staffing.
  • Staff demonstrated a limited understanding of the Mental Capacity Act. We observed assessments which were not decision specific. However, staff were compliant with training for Mental Capacity Act.
  • Deprivation of liberty safeguards applications did not adequately describe the treatment proposed or restrictions to be placed upon somebody.
  • A shortage of radiologists made it difficult to provide 24-hour cover. There was still no formal out of hours interventional radiology rota for vascular, urology and gastro intestinal services. There was a risk to patient safety in treating patients in a timely manner in an emergency.
  • Patients were not always able to access the service when they needed it. Waiting times from referral to treatment was delayed and not in line with good practice for some specialties.
  • Systems used by the trust did not help promote flow and efficiency in theatres and risked the safety of patients. However, this was well known to the trust and being reviewed and improved at the time of our inspection via the theatre transformation project.
  • The pre-operative assessment clinic had a backlog of patients to be assessed. This risked patients not being properly assessed and cancelling their operations. However, Saturday clinics were being held to address the backlog.
  • The signage across both hospital sites did not help patients access and find services easily, the day surgery units. This was also not always clearly indicated on surgical appointment letters received by patients. This was being addressed by the trust.
  • There were no review dates for risk registers, or a clear trail of dates of added and reviewed risks.
  • The information used in reporting, performance management and delivery quality care were not always accurate, valid and reliable. The trust had suspended national reporting of their referral to treatment times and cancellations since November 2016 due to problems with data quality.

Urgent and emergency services

Good

Updated 7 February 2019

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

  • We rated all five domains of safe, effective, caring, responsive and well led as good.
  • Staff working within the service received up to date mandatory training and safeguarding training.
  • Record keeping within the service were well managed.
  • Infection risk was controlled well.
  • Risks to patient safety were managed well, including identifying and treating a deteriorating patient. There were good practices in place to protect children.
  • Staffing had greatly improved since the last inspection and shift fill rates were high.
  • There were good practices in place to manage the safety of children in the department.
  • Ambulance handovers were positive, with low numbers of breaches compared to other hospitals.
  • Medicines were managed well.
  • Processes to manage incidents made sure that learning was gained.
  • Care was provided in line with evidence-based practice and national guidance and audits identified positive performance.
  • Nutrition and hydration needs of patients was managed well.
  • Staff from different teams worked well together.
  • Staff cared for patients with compassion, provided emotional support, and involved carers in decision making.
  • Patients were consistently always able to access care and treatment in a timely way.
  • The service took account of patients’ individual needs.
  • The service treated concerns and complaints seriously, investigated them, learned lessons from the results, and shared these with all staff.
  • Managers had the right skills and abilities to run a service providing high-quality sustainable care.
  • Managers promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • There was a systematic approach to continually improving the quality of its services.
  • The emergency department collected, analysed, managed and used information well to support all its activities.
  • The service was committed to improving services by learning from when things went well and when they went wrong.

However

  • There needed to be more publicity to the local population about service provision at night.
  • There was little evidence of engagement with patient groups and there was limited evidence to show how patient feedback was used to plan or improve services.

Outpatients

Good

Updated 7 February 2019

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

We rated it as good because:

  • Staff understood how to protect patients from abuse and there were clear processes for reporting safeguarding concerns.
  • The service controlled infection risks well. Staff kept themselves, equipment and the premises clean and used control measures to prevent the spread of infection.

  • There were systems in place to manage maintenance of equipment and repair faults when identified.
  • Staff could identify and respond to a deteriorating patient within the outpatient environment, including medical emergencies.
  • Staff kept appropriate records of patients care and treatment. Records were clear, up-to-date and available to all staff providing care.
  • The service prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time.
  • Staff understood their responsibilities to report near misses, patient safety concerns and incidents.
  • Nutrition and hydration was considered as part of the patient assessment. Refreshments were also available to patients in the outpatient setting.
  • The service made sure staff were competent for their roles. Professions worked together to provide seamless patient care, including when care was provided across different specialisms.
  • Patients were treated with compassion, kindness, dignity and respect throughout their visits to outpatient services.
  • Staff provided emotional support to patients to minimise their distress. We observed staff providing emotional support to patients and relatives during their visit to the department.

  • The services provided reflected the needs of the local population by offering choice, flexibility and continuity of care.
  • The service took account of patients’ individual needs and considered different needs and preferences. Reasonable adjustments were made, and staff supported people with additional needs.
  • Staff within outpatients worked hard to ensure people with learning disabilities were able to access services.
  • The trust identified where a system-wide approach was needed to meet the needs of the local population. Within endocrinology, rheumatology and dermatology, work was ongoing with commissioners and partners in primary care to find solutions to the demand for services.
  • Staff supported patients with additional needs such as patients living with dementia. An alert was placed on patients’ records and early appointment times allocated to reduce anxiety.
  • Translation services were available for patients whose first language was not English.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.
  • The trust had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. There was a positive culture within outpatient services.
  • The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff and patients. The trust had produced a “Transformation Plan” for the outpatient’s services they provided.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff were proud of their work in the outpatient services.

  • There were appropriate levels and structures of governance across outpatient services to ensure safety was monitored and improvements supported. There were clear lines of accountability and reporting.

  • The trust engaged well with patients, staff, and the public to plan and manage appropriate services, and collaborated with partner organisations effectively.
  • There was a focus on learning, improvement and innovation throughout outpatient services. Staff were engaged with the outpatient transformation and very positive about delivering an improving and innovative service.

However:

  • Outpatient services were primarily a five-day service.

  • Lack of space was identified as an issue in certain clinic areas.
  • The introduction of a new patient appointment booking system, had presented a number of difficulties in the delivery of services. There had been large increases in waiting times and a build-up of delayed clinic letters that needed to be sent out.
  • The trust has been unable to report referral to treatment data to NHS England since November 2016 because of data quality issues following the introduction of a new electronic patient record system in December 2016

  • Patients could not always access services when they needed them. There was not always timely access to treatment. The trust could not be assured that waiting times for treatment were and arrangements to admit, treat and discharge patients were in line with good practice.