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Cheltenham General Hospital Requires improvement

Reports


Inspection carried out on 24-27 January 2017, 6 February 2017

During a routine inspection

Cheltenham General Hospital is one of two district general hospitals run by Gloucestershire Hospitals NHS Foundation Trust. It is an acute hospital with 379 beds. It provides urgent and emergency services, medical care, surgical care, critical care, maternity (midwife led) and gynaecology, end of life care and outpatient and diagnostic and imaging services. It provides specialist cancer care to patients from Gloucestershire, Worcestershire and Herefordshire as the hub for the three counties’ cancer network

We carried out an announced inspection 24-27 January 2017 and an unannounced inspection at on 6 February 2017. This was a focused inspection to follow-up on concerns from a previous inspection. As such, not all domains were inspected in all core services.

The inspection team inspected the following seven core services at Cheltenham General Hospital:

• Urgent and emergency services

• Medical care (including older people’s care)

• Surgery

• End of life care

• Outpatients and diagnostic imaging

We did not inspect the critical care services (previously rated outstanding) or maternity services (previously rated as good).

As we did not inspect and rate all services, we did not rate Cheltenham General Hospital following this inspection.

Safe

We rated the safe domain as requires improvement in urgent and emergency services, medical care and surgery. We rated it as good in, outpatients and diagnostic imaging and end of life services.

  • We had concerns about patient safety, particularly when the emergency department was crowded, which was a regular and frequent occurrence. Lack of patient flow within the hospital and in the wider community created a bottle neck in the department, creating pressures in terms of space and staff capacity. This in turn, increased the risk that patients may not be promptly assessed, diagnosed and treated.
  • Crowding in the emergency department meant that ambulance crews were frequently delayed in handing over their patients. Patients were not always assessed quickly on their arrival in the emergency department.
  • There was no designated room for mental health practitioners to conduct mental health assessments within the emergency department. Patients would be assessed in one of the review rooms, which did not meet the safety standards recommended by the Royal College of Psychiatrists.
  • Compliance with mandatory training was variable.
  • Within the medical division there was not a clear overview of Mortality and Morbidity (M&M) meetings held in line with the trust’s M&M meeting schedule. Staff did not always follow infection control procedures when entering wards and ensuring the cleanliness of equipment such as commodes. Staff did not always comply with legislation regarding the Control of Substances Hazardous to Health (COSHH).
  • Some areas were not fit for purpose and the fabric of the building did not always ensure efficient cleaning could be carried out.
  • Daily checking of equipment such as resuscitation equipment was not carried out in line with the trust’s policy in all areas.
  • There were new machines for checking of patients’ blood sugar however, not all staff had had training so the old machines were also still in use. Staff did not always calibrate these daily in line with manufacturer’s guidance.
  • Staff did not monitor fridge temperatures consistently or take actions where these fell out of normal range, which meant medicines were not always stored correctly. Staff did not always comply with the trust policy and best practice when receiving controlled drugs from pharmacy.
  • Records were not stored safely to ensure patient confidentiality was maintained.
  • Some wards scored low for compliance with harm free care and it was not obvious what actions were taken to improve practice.
  • Staff did not always assess risks to patients or follow up identified risks with mitigating care interventions.
  • Nursing staffing levels in wards, departments and theatres were at times below establishment and wards relied on bank and agency to cover shifts every day.
  • The trust did not assess the acuity of patients daily to ensure safe staffing levels were in place on each shift and particularly at night. This was a concern in the coronary care unit.
  • In the time frame since our last inspection, the number of surgical site infection rates for replacement hips had increased. However this had improved at this inspection.
  • There had been two never events reported in surgery since our last inspection. These had been investigated and actions taken to prevent these happening again. Not all staff within these specialities were aware of the never events and the learning from these.
  • Kemerton and Chedworth Suite was at times being used as an inpatient ward but domestic cover had not always been set up for weekends to provide cleaning and drinks to patients when the staff were busy.
  • The completion of six do not attempt cardio pulmonary resuscitation (DNACPR) forms we reviewed were of variable quality.
  • There were no centrally held training records for syringe driver training or competency for ward staff.
  • There was a trust major incident and business continuity plan. However, the chaplaincy service, mortuary staff, bereavement officers and in-patient and community palliative care teams had not been involved in the major incident plan practice exercises.
  • A number of patient 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 phlebotomy clinic environment was small and did not allow staff to respond to patients effectively if they became unwell.
  • Staff did not always have access to the most up to date policies and procedures within the outpatients department, and there were several versions one Patient Group Directive (PGD) in circulation in ophthalmology

However:

  • There was an openness and transparency about incident reporting and incidents were viewed as a learning opportunity. Staff felt confident in raising concerns and reporting incidents.
  • The endoscopy unit held join advisory group (JAG) accreditation and had procedures in place in line with the national safety standards for invasive procedures. Equipment was decontaminated and sterilised in line with best practice.
  • There were hourly board rounds undertaken by senior clinicians in the emergency department. This provided an overview of the department’s activity and provided an opportunity to identify and communicate safety concerns to the site and trust management teams. Patient safety checklists had been introduced, which provided a series of time-sequenced prompts to ensure assessments, care and treatments took place promptly and with the required frequency. There was a well-structured medical staff handover where patients’ management plans and any safety concerns were discussed.
  • Within the end of life service, potential risks to patients were assessed by ward staff. Identified patient safety risks were monitored and mitigating actions put in place.

Effective

We rated the effective domain as good in urgent and emergency services, surgery, end of life. We rated it as requires improvement in medical care.

  • People’s care and treatment was planned and delivered in line with current evidence-based guidance and standards. There was a range of recognised protocols and pathways. Performance in national audits was mostly in line with other trusts nationally.
  • Nursing and medical staff received regular teaching and clinical supervision within the emergency department. Staff were encouraged and supported to develop areas of interest in order to develop professionally and progress in their careers.
  • Staff demonstrated knowledge and understanding of their responsibilities in relation to the Mental Capacity Act 2005 and consent.
  • Patients were having their pain effectively managed.
  • There was good culture of multidisciplinary working across all staff groups to make sure patients care was coordinated
  • Staff understood that end of life care could cover an extended period for example in the last year of life or patients.
  • End of life care was delivered with the principles of the Priorities for Care of the Dying Person set out by the Leadership Alliance for the Care of Dying Patient’s
  • There was a yearly programme of end of life care education for some medical staff which covered symptom management, levels of care, diagnosing dying, resuscitation and communication skills. There was also some evidence of a programme of non-medical staff education for nursing and allied health professionals for example , covering resuscitation, syringe driver training, quarterly end of life study days and symptom management.
  • Staff were supported with revalidation practices and there was a competence training and assessment framework in place to ensure nurses were competent to carry out extended skills.
  • There was an effective framework for ‘board round’ and ward rounds and included input from staff from the multidisciplinary healthcare teams.
  • There were effective processes in place to admit patients directly to Lillybrook ward when neutropenic sepsis was suspected.

However,

  • The trust was not meeting the standard which requires the percentage of patients re-attending (unplanned) the department within seven days to be less than 5%.
  • The trust had been identified as a ‘mortality outlier’ in to relation reduction of fracture of bone (Upper/Lower limb)’ procedures, which included fractured hip. However, the actions had implemented had made improvements and these were ongoing at the time of our inspection.
  • The emergency theatre was only manned on site for 20 hours each day. The remaining four hours were covered by ‘on call’ staff, which potentially placed patients at risk.
  • The trust had introduced a new computer system prior to our inspection. This was causing issues for staff resulting in work arounds to prevent any risks to patients.
  • Not all staff received annual appraisals.
  • Theatre utilisation figures were low.
  • Documentation relating to patients’ mental capacity and consent was not always complete or immediately obvious in ‘do not attempt cardio-pulmonary resuscitation’ (DNA CPR) records. Explanations for the reason for the decision to withhold resuscitation attempts were not consistently clear. Records of resuscitation discussions with patients and their next of kin, or of why decisions to withhold resuscitation attempts had been made were not always documented.
  • There was no organisational oversight of staff competency with regards to syringe driver training as records were not held centrally.
  • There was not a seven day face to face service provided by the in-patient end of life care team. Out-of-hours there was a telephone advice line available 24 hours, 7 days a week for health care professionals.
  • Whilst in some cases the possibility of dying had been recognised and communicated clearly, decisions made and actions taken in accordance with the person’s needs and wishes, not all appropriate patients experienced this.
  • The trust had evidence-based care pathways but these were not always reviewed and updated in a timely manner.
  • The medical service did not consistently review the effectiveness of care and treatment through national audits.
  • Information was not always accessible to staff including information about care and treatment pathways.
  • Staff did not always put actions in place when patients were at risk of malnutrition and hydration.

Caring

We rated the caring domain as good in all the services this domain was inspected (urgent and emergency services, medical care and end of life services).

  • All of the patients we spoke with during our inspection commented very positively about the care they received from staff. This was consistent with the results of patient satisfaction surveys which were mostly positive.
  • Patients were treated with compassion and kindness. We saw staff providing reassurance when patients were anxious or confused.
  • Patients were treated with courtesy, dignity and respect. Medical and nursing staff explained care and treatment in a sensitive and unhurried manner.
  • Staff and volunteers who worked with the department for spiritual support, bereavement officers and the mortuary were aware of and respectful of cultural and religious differences in end of life care.
  • Emotional support for patients and relatives was available through the in-patient and community end of life care team, through clinical psychology, social worker, ward-based nurse specialists and end of life champions, the chaplaincy team and bereavement services

However:

  • Information about patients was not always kept confidential.
  • The results from a patient-led assessment of the care environment demonstrated that privacy for patients was not always provided.

Responsive

We rated the responsive domain as requires improvement in urgent and emergency services, medicine, surgery and outpatients and diagnostic imaging. We rated it as good in end of life services.

  • The trust was not consistently meeting the standard which requires that 95% of patients are discharged, admitted or transferred within four hours of arrival at the emergency department.
  • Some patients spent too long in the emergency department because they were waiting for an inpatient bed to become available. Lack of patient flow within the hospital and in the wider community created a bottleneck in the emergency department, causing crowding.
  • Crowding meant that patients sometimes queued in the corridor, where they were afforded little comfort or privacy.
  • Patients with mental health needs were not always promptly assessed or supported, particularly at night time when there was no mental health liaison service. There was a lack of an appropriate welcoming space for patients with mental health needs.
  • The delivery of cardiology services did not meet the needs of the local population resulting in transfers out of the area.
  • There were delays to discharges, which meant patient flow through the hospital was compromised.
  • Due to pressure for beds and the demand on services, some patients had to use facilities and premises that were not always appropriate for inpatients.
  • Elective operations were being cancelled due to the pressure on the beds within the trust and medical patients were being cared for on surgical wards to meet the demand.
  • Not all patients had their operations re-booked within the 28-day timescale.
  • Six patients had been waiting over 52 weeks for treatment, which is not acceptable.
  • The average length of stay for both elective and non-elective (emergency) patients was above (worse) than the England average There was a waiting list for patients requiring endoscopic procedure.
  • The hospital was not meeting the 62 day target for cancer patients, and the trust was not meeting referral to treatment target in all specialities
  • The environment did not meet the needs of patients with dementia.
  • The hospital was not always compliant with the accessible information standards and information leaflets were not readily available for patients for whom English was not their first language.
  • Complaints were not responded to in a timely manner.
  • 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 computer 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.
  • There were no designated beds for people receiving care at end of life. Side rooms were used when available but could not be guaranteed.
  • The percentage of patients dying in their preferred location and the percentage of patients discharged within 24 hours were not all known for all wards or hospital sites.
  • The trust did not have systems in place to identify all patients in the hospital who were approaching end of life. 

However:

  • The emergency and urgent care service had a number of admission avoidance initiatives in place to improve patient flow. These include the integrated assessment team who proactively identified and assessed appropriate patients who may be able to be supported in the community to avoid hospital admission.
  • Though not managed quickly enough, complaints were used to drive improvement.
  • The emergency department had recently developed a team known as the Gloucestershire elderly emergency care (GEEC), championed by an ED consultant. The aim was to raise awareness of the issues faced by frail elderly patients in the emergency department and to identify areas where the experience of this patient group could be improved.
  • Multi-agency management plans had been developed for patients with mental health needs who were frequent attenders in the ED.
  • The trust’s referral to treatment time (RTT) for admitted pathways for medical services was better than the England overall performance. For surgical services between January 2016 and November 2016 it had been about the same as the England overall performance.
  • The oncology service provided a 24-hour helpline and facilitated direct admissions when sepsis was suspected in patients with neutropenia.
  • Staff in theatres and recovery had guidance in place to help reduce the anxiety of patients living with dementia when they using their services.
  • The hospital had introduced a new waiting list validation process to discharge some patients back to primary medical care facilities.
  • Visually impaired patients were able to access services 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.
  • The specialist palliative care team responded promptly to referrals, usually within one working day.

Well-led

We rated the well-led domain as good in urgent and emergency services, and end of life and requires improvement in medical care. We did not inspect this domain in surgery or outpatients and diagnostic imaging.

  • There was a strong, cohesive and well informed leadership team within the urgent and emergency care service, who were highly visible and respected. There were cooperative and supportive relationships among staff. We observed exceptional teamwork, particularly when the department was under pressure. Staff felt respected, valued and supported. Morale was mostly positive, although to an extent, undermined by workload pressures. There was a detailed improvement plan in place with clear milestones and accountability for actions.
  • The emergency department produced high quality information which analysed demand capacity and patient flow, and which was used to inform the improvement plan.
  • There were robust governance arrangements in place within the urgent and emergency care service. Clinical audit was well managed and used to drive service improvement. Risks were understood, regularly discussed and actions taken to mitigate them. Service improvement was everybody’s responsibility. Staff were encouraged and supported to undertake service improvement projects.
  • The trust had a clear vision and strategy to deliver care at end of life linked to national best practice including Priorities for Care of the Dying Person set out by the Leadership Alliance for the Care of Dying Patient’s. The governance framework for end of life care ensured that responsibilities were clear and that quality, performance and risks were understood and managed.
  • Services within specialist palliative and end of 

    life care 

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

  • Staff felt supported by managers and senior management felt assured by the new executive team.

However;

  • The emergency department’s management team did not feel there was a culture of collective responsibility within the trust in relation to patient flow. There was frustration expressed that the emergency department bore a disproportionate level of risk, while the responsibility for the exit block sat with others. The emergency department was unable to influence the cultural shift which was required to address this significant barrier to improving patient flow and capacity.
  • Pressures faced by staff in the emergency department in relation to crowding were well understood and articulated by the management team but it did not appear that the risks relating to staff wellbeing, resilience and sustainability, had been widely shared or escalated within the organisation and they were not included on the department’s risk register.
  • There was a limited approach to obtaining the views of people who used the service.
  • Workload pressures prevented opportunities for staff reflection or meaningful staff engagement and involvement in shaping the emergency and urgent care service.
  • There was no risk register specific to end of life care for the trust so there was no easy trust wide oversight of risk relating to the service.
  • There was a program of internal and national audits for end of life care, which were on time. However most local audit activity had not yet benefited from a thorough analysis of the data produced

    .

  • There was a lack of overview and governance around mortality and morbidity (M&M) meetings within the medical care.
  • There was a lack of understanding of the risk to safe patient care, the acuity of patients on daily basis have. Risk were not always aligned with the risk registers

We saw several areas of outstanding practice including:

  • Direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicine.
  • The emergency department had recently developed a team known as the Gloucestershire elderly emergency care (GEEC), championed by an ED consultant. The aim was to raise awareness of the issues faced by frail elderly patients in the emergency department and to identify areas where the experience of this patient group could be improved.
  • The expansion of the ‘MAD’ multi-disciplinary clinics in urology allowed more patients to access the one stop services and receive same day tests and results for the majority of cases.
  • A new initiative had been developed in the oncology outpatient department where nurses were trained to give a group presentation to new patients. The presentation covered information such as car parking, dietary tips and financial advice. During the session, one to one sessions were also provided with specialist nurses.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure that all information related to patients’ mental capacity and consent for ‘Do Not Attempt Cardio-Pulmonary Resuscitation’ (DNA CPR) is available in patient records.
  • Ensure trust staff comply with all the requirements of the Mental Capacity Act (2005).
  • When using Kemerton and Chedworth Suite for inpatients, provision must be made for the cleaning of the units at weekends and to provide patients with clean water jugs and drinks.
  • Review processes to monitor the acuity of patients to ensure safe staffing levels.
  • Ensure wards are compliant with legislation regarding the Control of Substances Hazardous to Health (COSSH).
  • Ensure machines used for near patient testing of patient’s blood sugar, are calibrated daily and this is recorded or ensure all staff are trained in how to use the new machine so the old machines can be removed.
  • Ensure effective cleaning of ward areas and equipment.
  • Review the governance and effectiveness of care and treatment through participation in national audits.
  • Ensure staffing levels meet the acuity of patients in the coronary care unit.
  • Ensure patient records are kept securely at all times.
  • Ensure steps are taken to reduce the current typing backlog in some specialities
  • Ensure specialities have oversight of all of their waiting lists.
  • Ensure that all staff are up-to-date with mandatory training and receive yearly appraisals in line with trust policy
  • Ensure that patients arriving in the emergency department receive a prompt face-to-face assessment by a suitably qualified clinician.
  • Ensure that a suitable space is identified for the assessment and observation of patients presenting at the emergency department with mental health problems.

In addition the trust should:

  • Ensure all complaints are handled within trust policy timescales
  • Ensure all risk identified relating to the provision of end of life care is included on a risk register.
  • Ensure the training needs analysis for general staff on wards related to end of life care is completed by the trust end of life care strategic group.
  • Consider involving specialist palliative care team and support teams in major incident plan practices or exercises.
  • Review the signage and consider if the system of using ‘white rose’ symbols to assist location of trust mortuaries is effective
  • Ensure staff in specialist palliative care team are able to use the results of the safety thermometer information in relation to patients receiving end of life care.
  • Ensure all staff within the surgical specialities is aware of Never Events and the learning needed to prevent a reoccurrence.
  • Continue to make improvements with the reduction of surgical site infection rates.
  • Consider a system to recognise and respond to blank boxes on prescription charts to make sure patients receive medicines as prescribed.
  • Ensure emergency trolleys should be checked in line with trust policy and best practice guidance.
  • Review the pre admission clinic area including appropriate seating.
  • Provide resuscitation equipment for the pre admission unit to ensure if a patient collapsed, they receive the correct care in a timely manner.
  • Review the equipment in the pre-admission unit to ensure it meets the needs of the service.
  • Ensure the safe management of medicines at all times and including the checking and signed for controlled drugs administration. Ensure all patient group directions (PGDs) are reviewed and in date. Review processes to recognise and respond to blank boxes on prescription charts to make sure patients receive medicines as prescribed.
  • Review the lack of 24-hour emergency theatre to ensure no patients will be put at risk.
  • Reduce the number of patients who have their operation cancelled on the day of surgery, and reduce the number of patients not rebooked within 28 days.
  • Ensure oversight of mortality and morbidity (M&M) meetings across all services.
  • Ensure staff can decontaminate hands on entering and leaving clinical areas where care is delivered.
  • Ensure staff follow best practice when patients are admitted with potentially transmittable viruses such as diarrhoea and vomiting.
  • Ensure replacement of equipment to ensure safe diagnosis of medical conditions.
  • Ensure medicines are stored, used and disposed of in line with manufacturers specifications and trust policy.
  • Ensure fire doors are secured in line with fire risk assessments.
  • Ensure treatment pathways are reviewed and update to ensure best evidence-based treatment.
  • Ensure effective monitoring of clinical improvement and audits, including compliance with accurate and timely NEWS assessments
  • Review processes to ensure compliance with the accessible information standards.
  • Continue to work in collaboration with partners and stakeholders in its catchment area to improve patient flow within the whole system, thereby taking pressure off the emergency department, reducing crowding and the length of time that patients spend in the department.
  • Consider ways to ensure the emergency department is supported by the wider hospital and that there is more engagement from specialties in addressing the risks associated with patient flow.
  • Ensure steps are taken to reduce the current typing backlog in some specialities
  • Ensure effective cleaning systems are in place in clinical areas of both the environment and equipment.
  • Ensure specialities have oversight of all of their waiting lists.
  • Ensure patient records are stored securely at all times.
  • Take steps to ensure all patients’ referral to treatment times do not exceed national targets including cancer wait targets.
  • Continue to reduce the current reporting backlog.
  • Take action to monitor and reduce the numbers of temporary notes in use.
  • Ensure reporting of plain film x-rays for the accident and emergency department meet the three day turnaround.
  • Ensure flooring in treatment rooms conforms to infection prevention and control standards.
  • Review the phlebotomy clinic environment so it is fit for purpose and accessible to all patients.
  • Ensure patient privacy and dignity is respected at all times when giving care or treatment.
  • Ensure steps are taken to allow patients with limited mobility to access all services on an equal basis to others by fixing lifts.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 10 - 13 March 2015, and 20 March 2015

During a routine inspection

Cheltenham General Hospital is one of two district general hospitals run by Gloucestershire Hospitals NHS Foundation Trust. It is an acute hospital with 379 beds. It provides urgent and emergency services, medical care, surgical care, critical care, maternity and gynaecology, end of life care and outpatient and diagnostic and imaging services. It provides specialist cancer care to patients from Gloucestershire, Worcestershire and Herefordshire as the hub for the three counties’ cancer network

We inspected this trust as part of our in-depth hospital inspection programme. The trust was selected as it was an example of a low risk trust according to our new Intelligent Monitoring model. The inspection took place with an announced inspection on 10–13 and unannounced inspection 20 March 2015.

Overall, this hospital was rated as requiring improvement. We rated it as good for caring and as requiring improvements in safety, effectiveness, being responsive to patients’ needs and being well-led. Overall, critical care was rated as outstanding. Maternity and gynaecology and services for children and young people were rated as good with the remaining core services rated as requiring improvement.

The trust’s services are managed through a divisional structure that covers all the hospitals within the trust, with some staff rotating between the three sites Gloucestershire Royal Hospital, Cheltenham General Hospital and Stroud Maternity Hospital; therefore there are significant similarities between the content of the three location reports

Our key findings were as follows:

Safe

  • Safety was judged as good in critical care, surgery and maternity, but in all other areas it required improvement.
  • The emergency department was frequently overcrowded; this was associated with a lack of patient flow, which in turn led to the risk that patients might not be promptly assessed, diagnosed and treated. Patients were not always cared for in the appropriate part of the department, with particular concerns about the safety of patients being cared for in the corridor when the department was so busy that it could not accommodate patients in clinical areas.
  • Staff were aware of how to report incidents and felt encouraged to do so. However, overall the trust was reporting fewer incidents than the national average (6.8 per 100 admissions compared with 9.3 per 100 admissions for the NHS England average in the period from November 2013 to October 2014).
  • The majority to staff stated they received feedback after reporting incidents; however, some staff, for example, nurses in the emergency department and outpatient staff, reported that they did not receive feedback. In all areas there were examples of learning from incidents.
  • The trust had reported one Never Event in 2014 for interventional radiology, which was related to wrong-site surgery. (Never Events are serious, largely preventable patient safety incidents, which should not occur if the available preventative measures have been implemented.) This incident had been thoroughly investigated and an action plan was in place. This incident took place in one of the specialist theatres, and changes to practice had been made with the introduction of the World Health Organization (WHO) checklist in this area; however, no audit of the use of the checklist had been undertaken.
  • A further two Never Events had taken place in January 2015, which were still under investigation at the time of our inspection.
  • Overall, the hospital was visibly clean; however, there were some areas such as in the emergency department, where a toilet was not clean, and the waiting room was untidy at the end of the day. In the imaging department, where building work was taking place, dust and dirt were escaping into the corridor, and the room for patients with mental health needs and areas in the medical wards were found to be dusty, dirty and/or to contain litter.
  • The number of cases of Clostridium difficile had been significantly lower than previous years, and at 34 cases up to February 2015 was well below the trust’s target maximum of 55 for the year. There had been just one case of methicillin-resistant Staphylococcus aureus (MRSA) in the year to date.
  • Throughout the hospital we found medication stored in resuscitation trolleys was not secured to demonstrate it had not been tampered with between checks.
  • In some areas, records were not stored securely.
  • The majority of staff had attended safeguarding training in order to keep people safe from abuse. The exception to this was staff in urgent and emergency services, where for level 2 child protection training, particularly for junior doctors, completion rates were low at 68% compared with the trust’s target of 90%.
  • Staff had access to a range of mandatory training, and attendance was monitored; this showed that the majority of staff had attended the required mandatory training, and the trust’s target of 90% was exceeded. However, in the unscheduled care division, medical staff were performing less well at accessing such training.
  • Systems were in place to assess and respond to patient risk; these included risk assessments relevant to patients’ needs and early warning scoring systems to determine whether patients were at risk of deteriorating.
  • The trust’s target for completion of venous thromboembolism (VTE) risk assessment had not being met since the first quarter of 2013/14.
  • Nurse staffing levels had been reviewed and assessed, with oversees recruitment having taken place in order to meet the National Institute for Health and Care Excellence (NICE) Safe Staffing Guidance. Some areas, such as the flexible capacity wards, relied heavily on the use of bank and agency staff.
  • Medical staffing was at safe levels in many services. However, there were some exceptions; these included consultants in acute medicine, general and old age medicine and radiology, and junior doctors in medicine and emergency care.
  • The trust had a major incident and business continuity plan in place. The majority of staff were aware of their roles and responsibilities should the plan be activated.

Effective

  • Services were found to be effective in surgery, maternity and gynaecology, end of life care and critical care. The latter we judged as outstanding. Improvements were required in urgent and emergency services and medicine.
  • In most services, people’s needs were assessed and care and treatment delivered in line with legislation, standards and evidence-based guidance.
  • Mortality rates were in line with those of other trusts as measured by the Hospital Standardised Mortality Ratio.
  • Information about patient outcomes was routinely collected and monitored, with the trust participating in a number of national audits so it could benchmark its practice and performance against that of other trusts. In a number of these audits, the trust was performing less well than other trusts, for example the College of Emergency Medicine (CEM) audits, the National Sentinel Stroke Audits, The National Heart Failure Audit, and the Royal College of Physicians National Care of the Dying Audit 2104. Overall in surgery and critical care, the trust was performing better than the England average in most of the national audits it took part in.
  • Patient pain was assessed and well managed; the exception to this was in the emergency department, where not all patients had a pain score recorded and not all patients consistently received prompt pain relief.
  • In the ward areas, we found that patients had access to adequate food and fluids, observing that drinks were left within their reach.
  • Staff had access to training to develop their skills, knowledge and experience to deliver effective care and treatment. The trust’s target for the percentage of staff who had an annual appraisal was 90%, with the actual figure standing at 85%.
  • Multidisciplinary working was evident in all areas we inspected.
  • The hospital was working towards providing services seven days a week. The pharmacy service was open for limited hours on a Saturday and Sunday. Some on-call cover was provided at weekends by allied health care professionals. The palliative care team was available from 9am to 5pm, Monday to Friday, with the specialist palliative care nurses providing an out-of-hours telephone advice service for clinicians.
  • Weekend ward rounds did not take place in some areas such as stroke, gastroenterology or the diabetes and endocrinology wards. In cardiology, a ward round took place on both days of the weekend.
  • Weekend discharges were problematic, with significantly fewer patients being discharged at this time.

Caring

  • Staff were providing kind and compassionate care with dignity and respect. Caring in critical care was outstanding, with all other areas rated as good.
  • Prior to the inspection, we received a number of concerns from patients and relatives about a lack of clear communication; however, during the inspection we found that patients and, when appropriate, those close to them were involved in decisions about patients’ care and treatment.
  • Patients generally received the support they needed to help them cope emotionally with their care, treatment and condition.
  • Spiritual support was available from within the hospital through the chaplaincy service, which provided a 24-hour on-call service.

Responsive

  • Urgent and emergency care and medicine required improvement; all other services were rated as good.
  • Bed occupancy at the hospital was constantly over 91%, which was above both the England average of 88% and the 85% level at which it is generally accepted that bed occupancy can start to affect the quality of care provided to patients and the orderly running of the hospital. The hospital had been operating at near 100% occupancy in the months leading up to the inspection.
  • There were issues with the flow of patient into, through and out of the hospital. The emergency department frequently became overcrowded when demand for services exceeded capacity. This was a hospital and community-wide issue. In December 2014 and January 2015, the trust had declared an internal major incident when the situation became unmanageable.
  • The standard that requires 95% of patients to be discharged, admitted or transferred with four hours of arrival in A&E was consistently not being met. Trust-wide performance was 82.86%, with Cheltenham General Hospital achieving 80.59%.
  • There were numerous examples of initiatives to reduce inappropriate emergency department attendances, to ensure patients were directed to the appropriate services, to prevent admission and to shorten length of stay. Some of these were in their infancy and not yet fully developed to enable an effective and comprehensive service to be provided seven days a week.
  • The average length of stay for patients admitted as elective cases fell to its lowest level in February 2015; however, this masked a performance that was better than the national average in surgery and worse than the national average in medicine. For non-elective patients, the average length of stay had risen to 6.7 days, which was above the trust’s target of 5.8 days for the third month in a row.
  • The number of emergency admissions within 30 days of discharge for both elective and emergency patients was above the trust’s target and had been for the last year.
  • The 18-week referral to treatment targets were being met in almost all surgical specialities. Urology and ophthalmology were just behind the 90% target at 85% and 87% respectively. The trust was below (that is worse than) the NHS England average 62-day cancer waiting time target. The trust was treating 74.7% of cancer patients within the 62-day target against the NHS England average of 81.2%.
  • The number of elective patients cancelled on the day of admission for a non-medical reason had not met the target in over a year, reaching its peak over the three months from December 2014 to February 2015, which matched the time during which the trust had been facing significant increased demand. This was also reflected in the number of patients who were cancelled and not rebooked within 28 days, which saw a significant rise in January 2015.
  • There was an agreement with partners in the local health economy that the daily number of patients who were medically fit discharge would not be more than 35 a day; this had reached 74 in February 2015.
  • The two-week wait target for urgent GP referrals for cancer and the 62-day wait from GP referral to treatment were not consistently being met. However, other targets such as the 31 days for surgery and radiotherapy were constantly met, as was the 31-day period from diagnosis to treatment.
  • Systems were in place to identify patients who were living with dementia or who had a learning disability and might need additional support.
  • Patients knew how to make a complaint if they wanted to, and information was available around the hospital outlining how to make a complaint and how it would be dealt with. There were examples of learning from complaints to improve care.

Well-led

  • Leadership in critical care was rated as outstanding; surgery, maternity and gynaecology, and outpatients were also well-led. Urgent and emergency care, medicine and end of life care all required improvement.
  • Most services had a five year strategy in place. The exception to this was end of life care. Whilst the team demonstrated understanding of the national policy and priorities there were no defined work plan priorities for Cheltenham General Hospital for the present and future.
  • Staff were generally aware of the trust’s values of listening, helping, excelling, improving and uniting.
  • The trust was organised into four clinical divisions which operated across all trust sites; each was led by a chief of service, a divisional nursing director and a divisional operations director. This team was supported by a clinical director, a matron and a general manager in each specialty. Staff in all areas stated they felt supported by these lead staff. Of the executive directors, the director of nursing was singled out by many staff as visible and approachable.
  • Generally appropriate governance systems were in place; each specialty had governance meetings, and these were reported to the divisional governance meetings, with significant issues reported on to the trust’s quality governance meetings. Shortcomings were identified in two main areas. Monitoring of mortality and morbidity meetings in medicine was poor. We were informed these meetings took place, but we were not able to view any minutes of these meetings. In end of life care, governance and quality measurement were inconsistent. Whilst governance meetings were held, the minutes lacked details on information relating to actions planned or taken.
  • In the 2014 staff survey, the trust was performing less well than other trusts on staff engagement; however, there had been an improvement from the previous year. Many staff told us about the executive walk-arounds and the top 100 leaders’ information meetings.

We saw several areas of outstanding practice including:

  • Patient record keeping in critical care was outstanding. All the patients’ records we saw were completed with high levels of detail. The records contained all the essential details to keep patients safe and ensure all staff working with them had the right information to provide safe care and treatment at all times.

  • There was an outstanding holistic and multidisciplinary approach to assessing and planning care in the department of critical care. All the staff involved with the patients worked with one another to ensure the care given to the patient followed an agreed treatment plan and team approach. Each aspect of the care and treatment had the patient at its centre.

  • In critical care, there was an outstanding commitment to education and training by both nurses and trainee doctors. Nurses and trainee doctors followed comprehensive induction programmes that were designed by experienced clinical staff over many years. All the staff we met who discussed their training and development spoke very highly of the programmes on offer and there being no barriers to continuous learning.

  • There was outstanding care for bereavement in critical care. All staff spoke highly of how they were enabled to care for and support patients and relatives at this time. Bereavement care had been created with input from patients, carers, relatives and friends, and staff were particularly proud of the positive impact it had on bereaved people and patients nearing or reaching the end of their life.

  • The outstanding arrangements for governance and performance management in critical care drove continuous improvement and reflected best practice. There was a serious commitment to leadership, governance and driving improvements through audits, reviews, and staff honesty and openness. All staff had a role to play in this area and understood and respected the importance of their work.

  • The trust had a mobile chemotherapy unit, which enabled patients to receive chemotherapy treatment closer to their home to prevent frequent travel to hospital.

  • On the surgical division, we found the following outstanding practice: the trust had developed and printed its own style of controlled drugs register for patients’ own controlled drugs. Patents with ‘patients own controlled drugs’ were listed on a whiteboard on the controlled drugs cupboard door to help ensure patients took all their medicines home with them.

  • Medicines dispensed for an individual patient but not labelled for discharge had an additional yellow label attached stating, “NON-STOCK DO NOT SEND HOME WITH PATIENT”.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Improve its performance in relation to the time patients spend in the emergency department to ensure that patients are assessed and treated within appropriate timescales.

  • Continue to take steps to ensure there are sufficient numbers of suitably qualified, skilled and experienced consultants and middle grade doctors to provide senior medical presence in the emergency department 24 hours a day, seven days a week, and to reduce reliance on locum medical staff.

  • Continue to reduce ambulance handover delays and take steps to ensure that patients arriving at the emergency department by ambulance do not have to queue in the corridor because there is no capacity to accommodate them in clinical areas.

  • Develop clear protocols with regard to the care of patients queuing in the corridor. This should include risk assessment and the identification of safe levels of staffing and competence of staff deployed to undertake this care.

  • Work with healthcare partners to ensure that patients with mental health needs who attend the emergency department out of hours receive prompt and effective support from appropriately trained mental health practitioners.

  • Ensure that systems to safeguard children from abuse are strengthened and children’s safeguarding assessments are consistently carried out. There must be a process to ensure all appropriate child safeguarding referrals are made.

  • Ensure that senior medical staff in the emergency department are trained in level 3 safeguarding.

  • Ensure that patients in the emergency department have an assessment of their pain and prompt pain relief administered when necessary.

  • Take steps to strengthen the audit process in the emergency department to provide assurance that best (evidence-based) practice is consistently followed and actions continually improve patient outcomes.

  • Ensure the administration of eye drops complies with the relevant legislation.

  • Ensure minutes are kept of mortality and morbidity meetings in medicine so that care is assessed and monitored appropriately, lessons learnt and actions taken and recorded.

  • Ensure that patients’ records across the hospital are stored securely to prevent unauthorised access.

  • Ensure an effective system is in place in the medical wards to detect and control the spread of healthcare-associated infection.

  • Ensure patients’ mental capacity is clearly documented in relation to ‘do not attempt cardio-pulmonary resuscitation’ (DNA CPR) and ‘unwell/potentially deteriorating patient plan’ (UP) forms. Improvements in record keeping must include documented explanations of the reasoning behind decisions to withhold resuscitation, and documented discussions with patients and their next of kin or reasons why decisions to withhold resuscitation were not discussed.

  • Review communication methods within maternity services to ensure sensitive and confidential information is appropriately stored and handled, whilst being available to all appropriate staff providing care for the patient concerned.

  • Ensure that in the surgical division, when medicines are issued from wards or departments, the issued medicines comply with the relevant legislation and best practice.

  • Ensure that appropriate written consent is obtained prior to procedures being carried out in the outpatient department.

  • Ensure that all patients (men and women) are able to access the full range of tests in the urology outpatient department.

  • Ensure that systems are in place to ensure that medication available in departments is in date and therefore safe to use.

In addition the trust should:

  • Review how staff perceive the feedback they get from incident reporting and the level of detail received.

  • Ensure that patients, including children, are adequately monitored in the emergency department waiting room to ensure that seriously unwell, anxious or deteriorating patients are identified and seen promptly.

  • Take steps to improve the experience for patients and visitors in the emergency department waiting room. This should include the provision of drinking water, a TV, and appropriate reading material and information about waiting times.

  • Review the emergency department nursing staff mix and training to ensure adequate numbers of staff are trained to identify, care for and treat seriously ill children.

  • Continue to improve hospital-wide ownership of the emergency department four-hour target, to ensure that delays in admission are minimised.

  • Identify suitable accommodation for the ambulatory emergency care unit and ensure that it is adequately staffed to provide a more comprehensive and effective service.

  • Reduce the number of patients who have their operation cancelled on the day of surgery, and reduce the number of patients not rebooked within 28 days.

  • Consider displaying feedback from patients and relatives for each individual medical ward.

  • Consider a system to identify when patient equipment has been cleaned.

  • Ensure all areas are clean and free from litter.

  • Record all controlled drugs in critical care in line with the trust’s policy.

  • capture and report safety thermometer data in the department of critical care alongside the other data on patient harm data that the department collects.

  • Ensure all items are within their expiry date.

  • Maintain continuity of care for patients on the day surgical unit to ensure they have their needs met when it is open 24 hours a day, seven days a week.

  • Review the medical and surgical cover at weekends for the day surgery unit to make sure patients are reviewed and discharges not held up.

  • Ensure patients who are admitted to the surgical day surgery unit can have their needs met by the staff team.

  • Reduce the number of times patients are moved between wards for continuity of care.

  • Review the security and safe storage of medicines, including medical gases.

  • Review the security of and records of equipment and medicines, including medical gases required for resuscitation and the treatment of anaphylaxis.

  • Review the security and safe storage of medicines, including medical gases in the mobile theatre.

  • Review the staffing levels of physiotherapists against the requirements of the Faculty of Intensive Care Medicine Core Standards.

  • Ensure the specialist palliative care team can be sustained and are able to remain responsive to the evidenced increased demands of complex referrals, provide a face-to-face seven-day service, provide ongoing staff training in line with national policy, and make improvements to inconsistent governance, risk management and quality measures.

  • Ensure a strategy for end of life care is developed.

  • Ensure all patients who are referred by their GP with suspected cancer are seen with two weeks of referral and treatment is started within 62 days of referral.

  • Ensure that in maternity services, both service risk registers detail actions underway to mitigate risks.

  • Ensure that cleaning schedules in maternity services are reviewed and systems devised to ensure staff know when equipment has been cleaned and is ready for use.

  • Review the processes in maternity services to ensure early screening (pre 10 weeks’ gestation) can occur where the need for such screening is indicated.

  • Within maternity services, review the timeliness of access to patient information in alternative languages.

  • Ensure all patients’ referral-to-treatment times do not exceed national targets, and that services are delivered in a way that focuses on patients’ holistic needs and does not mean patients experience long delays in receiving their first outpatient appointment.

  • Ensure all outpatient departments provide sufficient facilities for disabled people, such as accessible toilet facilities.

  • Ensure staff promote the confidentiality of patients by ensuring conversations about patients cannot be overheard by other patients.

  • Ensure that the temperature of fridges used for the storage of medication and equipment can be checked daily.

  • Ensure that patients’ privacy and dignity are fully respected when patients are waiting for tests in public areas such as waiting rooms.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 29, 30 May 2013

During a routine inspection

We carried out this inspection of the neonatal and paediatric services at Gloucester and Cheltenham hospitals in response to a request from the coroner’s office. The coroner made this request because they had concerns about the service provided in both hospitals after the death of a baby at Cheltenham hospital in December 2010. We were asked to check if current arrangements at these hospitals were putting babies at risk.

We found that in 2011 the trust had re-structured the maternity services and all the neonatal and paediatric services had been moved to the Gloucester site. Cheltenham hospital now had a midwife led birthing centre for low risk births. During this inspection we visited the neonatal and paediatric units in Gloucester and the birthing centre in Cheltenham. We spoke with ten staff and five parents of babies who were being cared for in the units.

All parents we spoke with were very positive about their experience of the service. All staff we spoke with told us they felt supported to carry out their roles had had access to relevant training. There was evidence that learning from incidents took place and appropriate changes were implemented. Records were accurate and fit for purpose.

Overall we found that people who used the neonatal and paediatric services at Gloucester and Cheltenham hospitals received good care. We found no evidence to suggest that babies born in any of the units across both hospitals were being put at risk.

During a check to make sure that the improvements required had been made

We carried out this review to check if improvements had been made to the arrangements for the storage of medicines on the winter pressure ward we visited on 24 April 2013. We looked at the action plan the trust sent us on 14 May 2013 and received feedback In June 2013 that these actions had been completed.

We were satisfied that appropriate action had been taken by the trust and they were now compliant in the safe storage of medicines.

Inspection carried out on 24 April 2013

During an inspection in response to concerns

Concerns had been raised with us about the staffing and medicines management of one ward at the hospital. This ward was opened in January 2013 in response to the demand for additional beds during the winter months.

During this visit to check these concerns we spoke with 17 patients, three of their relatives and 12 staff. All patients and their relatives told us they were happy with the care provided to them and staff treated them well. Some patients told us, “very good, very helpful”, “lovely staff” and “absolutely fine, no complaints at all”. We observed staff interacting with patients in an attentive and respectful manner.

Overall we found that there were enough qualified, skilled and experienced staff to meet patient’s needs and the care and treatment provided met patient’s needs. Where concerns about patient safety and staffing levels had been reported appropriate action was taken to learn from the incidents and minimise the risk of re-occurrence.

Appropriate arrangements were in place in relation to obtaining and the recording of medicines. Suitable arrangements were not in place for the storage of all medicines because some cupboards were unlocked at the time of our inspection and some could not be safely secured. This increased the risk of medicines being accessed by unauthorised people and could cause harm to them or others.

Inspection carried out on 18 February 2013

During an inspection to make sure that the improvements required had been made

During this inspection to check improvements to record keeping we looked at patient medicine administration and care records on four wards. We looked at the electronic staff rota system and spoke with staff on two wards about the staffing levels.

The pharmacist inspector looked at 27 patients’ medicines prescription and administration records on two wards previously visited. We found that significant improvements had been made although we still saw occasional gaps on these records. We looked at the care records for 30 patients to check the patient profile forms (these recorded a daily assessment of a patient’s needs). We found that apart from two records all had been completed on the day of our visit to reflect the needs of the patients.

We saw that the electronic staff rota system had been updated and implemented on more wards since our last visit. We saw that in most instances the electronic system was updated to reflect changes to staffing as they happened. Where it was not possible to update the electronic system to reflect staff changes, paper records of staffing levels were held on individual wards.

Overall, we found records for the administration of medicines and care records had improved and were mostly being accurately kept. We also found that when paper records were looked at in conjunction with the electronic system we could see that the trust knew where staff were working and the staffing levels of each ward.

Inspection carried out on 19 July 2012

During an inspection in response to concerns

Seven CQC Compliance Inspectors, a CQC Pharmacist and an Emergency Department expert spent four days in July 2012 visiting Cheltenham General Hospital. We spoke with 118 staff, one volunteer, 87 patients and some relatives and visitors. We visited 14 wards, the oncology outpatients department, the discharge waiting area, the Patient Advice and Liaison Service (PALS) and the Emergency Department.

We met and talked to inpatients and outpatients, hospital directors, senior management, health care assistants, physiotherapists, domestic staff, nurses from all divisions of the hospital, administration staff, a consultant and doctors. We saw and were given evidence from hospital records, audits, surveys and trust board reports. This enabled us to see how the hospital had been assessed against the essential standards of quality and safety. We reviewed our visit with Dr Frank Harsent (Chief Executive Officer of the trust) and five other board members on July 31 2012.

Patients told us that staff treated them with dignity and respect and addressed them by the name of their choice. Patients also told us that both the medical and nursing staff told them about their treatment choices and kept them informed about their progress and any changes to their treatment. Patients' made the following comments to us about their care and treatment, “wonderfully organised and they kept me informed of my plan for being discharged”, “very good”, “brilliant, so good and staff have been really kind”, “I cannot fault them here” and “with the person next door to me, who has Alzheimer’s disease, they have never lost their patience with them”.

We looked at seven of the essential standards of quality and safety. We found them compliant with six of the essential standards and we have minor concerns with one of the essential standards. More detailed information on each of the essential standards is covered in other parts of our report under the relevant Outcomes.

Inspection carried out on 1 March and 18 May 2011

During an inspection in response to concerns

People were pleased with the care they had received from staff. People told us that ‘staff are excellent’, ‘staff are wonderful, I can’t fault them’ and ‘I have had personal attention. Staff are respectful and respect privacy’. One person said ‘the team today are brilliant, they have time for me but the team yesterday were not so good’, while another said ‘I couldn’t have had better if I had had private treatment. Staff have treated me respectfully.’

We received a number of positive comments from relatives and visitors that we spoke to. One told us that ‘the hospital is brilliant, it is fantastic. There is a very calm atmosphere and staff are very helpful. It has been a good experience in difficult circumstances.’

People we spoke to gave us a mixed response in relation to the food that was provided. We received positive comments such as ‘what food I have had is very good’ and ‘the food is lovely – it has encouraged my appetite and I look forward to the meals’. We also received more measured comments such as ‘the food is moderate – the vegetables are not cooked well’, ‘the food is reasonable’, and ‘the food is not particularly brilliant – it’s not like home cooking and has an indifferent taste’. Some of the comments we received were more negative, such as ‘It is good food but it had gone through too many processes and by the time it gets to you it has lost its taste’.

People told us that they were pleased with the cleanliness and the hygiene of the hospital. One person who was visiting a relative told us ‘it is very clean’, and another said, ‘the wards are cleaned twice a day and an inspector does spot checks’. People told us that the sheets on their beds were changed daily.

People in the oncology unit said they particularly liked the garden area there. One person told us ‘it doesn’t feel like being in a hospital’.