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Gloucestershire Royal Hospital Good

Inspection Summary


Overall summary & rating

Good

Updated 7 February 2019

Our rating of services improved. We rated it them as good because:

  • In urgent and emergency care staff complied with systems and processes designed to keep people safe from avoidable harm including the management of safeguarding risks. Records, incidents, infection control, and changing risks of patients, including those of a deteriorating patient, were managed well. We found that patients needs were met in relation to pain management, and services were planned and delivered in line with best practice. Staff understood their responsibilities to mental capacity, and spoke to patients with compassion, dignity and respect. Although the department was busy, there had been innovative changes to patient pathways and streaming since our last inspection. There were concerns over local operational leadership at the hospital.
  • In medical care staff understood how to protect patients from abuse, completed relevant risk assessments and kept clear and legible records of patient care. The service used audit processes to monitor patient outcomes and used this information to improve services. 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. The management of the service had improved since the last inspection.
  • 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.

However:

  • In the emergency department there was a continuing shortage of middle grade medical staff and heavy reliance on temporary staff. Also, the management of medicines could have been improved. We found the department was frequently crowded which meant that individual needs could not always be met. During busy times, we found that some patients felt their care was rushed. We found there was poor day-to-day operational oversight of the department. There was little engagement with patient groups.
  • Although the timeliness of some elements of care provision had improved, patients did not always receive care and treatment within an acceptable timeframe and in the right place. Patient’s dignity and privacy were not always maintained and patients who became agitated did not always receive compassionate care from nursing staff.
  • In medical care, systems and processes to keep people safe were not always followed in relation to infection control and medicines management and performance in national audits was variable and outcomes for stroke patients needed improvement. National targets for referral to treatment times were not met for most medical specialities. Risk management processes needed to be improved as risks were not always graded, mitigated and reviewed appropriately
  • Although we found the surgical service had improved, 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.
  • Outpatient services were primarily a five-day service. 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

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

  • 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.

Services for children & young people

Updated 5 July 2017

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

  • There was an open reporting culture by staff who worked in the children’s services. This helped to maintain the safety of treatment and care for babies, children and young people.

  • There was evidence to show incidents, concerns or trends were investigated for learning opportunities and actions taken to improve practice.
  • Staff understood their roles and responsibilities to safeguard children from potential risks or abuse and received supervision on a regular basis. The trust’s safeguarding teams worked with community and social care colleagues to identify and support children who may be at risk.
  • Systems for staff shift handovers promoted the safety of children. Staff were fully included in processes and encouraged to contribute.
  • Records showed electrical and mechanical equipment was regularly maintained to ensure it was safe to use and review dates were clearly indicated.
  • Risk assessments were used with all children to identify the level of care they needed. These were audited regularly to check they had been completed correctly and concerns had been escalated for further advice where necessary.
  • Staffing levels were regularly reviewed and planned to follow national guidelines and standards. However, staffing levels had been challenged with unexpected staff absences. Managers were taking steps to fill gaps in the short term, recruit staff on a permanent basis and maintain staffing levels.

However:

  • Compliance with audit processes for infection prevention and control was variable across the children’s services and had not been consistently completed.
  • Routine stock checks of some medicines were not always completed according to the trust protocol.

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 that patients experienced compassionate care and that 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 strong track record on safety, and lessons were 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 stocks of medicines and other consumables were stored safely, were in date, and details were recorded accurately. 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 Gloucestershire Royal Hospital that sometimes meant patients were delayed on discharge from the unit, but the number of incidences was only just above 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 the rate was the same as the NHS national average. 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. The trust had responded to the need to improve patient flow by opening a new surgical high dependency unit with four new beds (and expansion capability to six beds) in January 2015.

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 Gloucestershire Royal 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 end of life 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 and in the community 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 and community 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
  • The bereavement office was one of two sites in the country involved in a pilot project to improve death certification which was more supportive to bereaved relatives and provided better oversight of causes of death.
  • 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 in-patient and community end of life 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

Updated 5 July 2017

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

  • All areas had access to emergency resuscitation trolleys. However, in some areas, a systematic check of the trolleys was not documented as having being carried out on a daily basis. There were no up to date Resuscitation Council (UK) guidelines available on the resuscitation trolleys. Intravenous fluids on the emergency resuscitation trolleys were not stored securely to ensure they were tamper proof. This meant staff could not be assured the right equipment and guidance would be available in the case of an emergency.
  • Not all drug storage fridge temperatures were documented daily. There was no process in place if a temperature fell outside of acceptable limits. This meant staff could not be assured medicines requiring refrigeration were being stored at the required temperatures.
  • There were a number of out of date patient group directives (PGD’s) in use in maternity services. The lists of medicines that were subject to PGD’s had no doses or route of administration detailed on them. We drew this to the attention of senior staff and the PGD’s were removed from use.
  • Community midwives could not always print out clinical notes from the electronic system to go into women’s handheld notes. They also reported poor mobile phone coverage which meant there was sometimes a delay in getting messages. This could have an impact on a woman who was trying to get some help or advice from a midwife.
  • An electronic patient record system had been introduced trust wide in December 2016. There were some ongoing issues with allocation of baby NHS numbers and records migrating to the new system. This meant that babies may miss out on vital tests following birth. Midwives had devised solutions to ensure each baby had an NHS number.
  • Senior House Officers (SHO) did not attend skills drills training when they started at the trust. Those that spoke to us said whilst they did not cover the delivery suite they did carry an emergency bleep and if they arrived in the delivery suite first they often felt out of their depth.
  • There were often long waiting times in the triage area. Whilst systems were being put in place to increase medical and midwifery staffing, women were not seen within 15 minutes of attending the unit. This could mean that urgent issues may be missed.
  • Consultant presence, on labour suite, was below the recommendations of the Royal College of Obstetricians and Gynaecologists (RCOG) Safer Childbirth (2007) guidance.

  • Speciality trainee doctors (ST3 and ST4) and some consultants felt that a senior house officer equivalent was needed at night as sometimes no other medical staff to assist with emergency caesarean sections were available. This also meant other patients, across maternity and gynaecology services, who needed to see a doctor sometimes had to wait for long periods of time.
  • The morning medical handover was informal and there was no input from the co-ordinating midwife about the women in labour at the time of the meeting. The registrar who had been on duty overnight presented the cases but said they were often tired and did not always have the full up to date details of the women. This may mean that the most up to date information is not being given to the next staff coming on duty.

However:

  • Staff understood their responsibilities to raise concerns and report incidents using the electronic reporting system. There was a culture of shared learning from incidents.
  • Staff spoke confidently about the duty of candour and gave examples of where it had been applied. Relevant staff had received training.
  • All areas we visited were visibly clean and tidy. There were antibacterial hand sanitizers at the entrances to each unit/ward. Staff were seen adhering to the trusts infection control policies including ‘bare below the elbows”. This meant people visiting the maternity services were protected from the spread of infection.
  • All rooms on the delivery suite, including the triage area had wireless cardiotochograph (CTG) machines for monitoring the foetal heart. The CTG machines were linked to a central monitor point, which allowed the co-ordinating midwife to review traces. The wireless aspect meant women could still be monitored whilst in a birthing pool.
  • Doors into all wards/units were locked, with a buzzer entry system and CCTV. Although reception areas were not manned 24 hours per day; when there was no receptionist other staff on duty took on the role. A baby security tagging system was in place on the maternity unit.
  • There were systems in place for recognising and reporting safeguarding concerns. Staff were confident to raise any matters of concern and escalate them as appropriate.
  • A ‘vulnerable women’s team’ had been developed that included a full time perinatal mental health midwife, substance misuse and teenage pregnancy midwife and the lead safeguarding midwife. The team were able to offer an enhanced service to those women identified as being at risk. The team also offered advice and support to midwives who had concerns.
  • Staff said there was good access to mandatory training. Mandatory training for maternity services included a PROMPT (Practical Obstetric Multi-Professional Training) skills drills training day and a one-day maternity update for staff working within the maternity unit.
  • The maternity services offered Birth Choices Clinic for women identified as being high risk but who requested midwife-led care. They were seen by a supervisor of midwives and a complex care plan devised in agreement with the woman and in discussion with an obstetrician.
  • The service had a commitment to managing women’s peri-natal mental health issues and were trying to establish a team to include a consultant psychiatrist.
  • The development of a training package for midwives to enable them to administer flu vaccinations to at risk women had meant that a high number of women who would otherwise have not had the flu vaccine had received it.
  • The gynaecology ward had been relocated, in December 2016, to a ward with less beds (20 beds to 13 beds) to reduce the incidence of outlying patients (that is patients from medical or surgical wards) which sometimes meant elective gynaecology surgery had to be cancelled. The ward sister said the number of outliers had reduced significantly and as a result there were less elective gynaecology procedures being cancelled.
  • The clinical scorecard between April 2016 and November 2016 showed that staff were providing one-to-one care in labour 98% of the time.
  • A telephone triage system staffed by midwives was located within an ambulance service hub. Midwives directed women to the most appropriate place for their care. The system had reduced the volume of calls directly to the triage area.
  • There was 24-hour consultant on-call cover. The delivery suite had access to anaesthetists 24 hours a day, seven days a week. Doctors we spoke with said that consultants always came in at night if they were asked to.

Surgery

Good

Updated 7 February 2019

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

  • 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. However, the trust told us they established an interventional radiology service on the 19 November 2018, following our inspection.
  • 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, in particular 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 was 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

  • Staff complied with systems and processes designed to keep people safe from avoidable harm including the management of safeguarding risks.
  • Infection risk was controlled well.
  • The utilisation of the environment had improved since the last inspection.
  • 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 and initial assessment times were better than the England average.
  • Staff responded well to the changing risks of patients, including identifying the deteriorating patient.
  • Records were managed well.
  • Incidents were managed well and lessons were learnt when something went wrong.
  • Patients received care from staff with the right skills, experience and knowledge.
  • Pain, nutrition and hydration were managed well.
  • The department provided care in line with evidence-based guidelines and evidence and were comparable with other sites when looking at audit results.
  • Staff from different teams and divisions worked effectively together as a team to benefit patients.
  • Staff mostly had access to up-to-date, accurate and comprehensive information on patients’ care and treatment.
  • Staff understood how and when to assess whether a patient had the capacity to make decisions about their care.
  • When staff spoke with patients and those close to them, it was in a respectful and considerate way.
  • Staff responded in a compassionate, timely and appropriate way when people experienced physical pain, discomfort or emotional distress.
  • Medical assessments at both hospitals were unrushed and staff took extra time to allow patients with cognitive impairment to understand and cooperate with their examinations.

However:

  • Mandatory training rates could have been better.
  • Concerns raised by CQC regarding the security of the children’s area could have been managed quicker.
  • The management of medicines could have been improved.
  • Staff sometimes needed to improve how they provided compassionate care to patients and others needed to provide better emotional support to minimise distress.
  • The service did not consistently take account of patients’ individual needs when they were in vulnerable circumstances.
  • Patients could not always access care and treatment when they needed it and in the right setting.
  • There was poor day to day oversight in the department which was impacting on patient safety.
  • The service had identified risks to high quality care, but in some areas, there were limited plans for addressing them.
  • There was little evidence of engagement with patient groups.

Outpatients

Good

Updated 7 February 2019

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new findings 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 risk 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.