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Inspection Summary


Overall summary & rating

Good

Updated 6 June 2019

Our rating of services stayed the same. We rated them as good because:

  • Staff understood how to protect patients from abuse and services worked well with other agencies to do so.
  • The majority of services, controlled infection risk well. Staff kept themselves, equipment and the premises clean. They mostly used control measures to prevent the spread of infection.
  • Whilst actual versus planned staffing levels were not always met. Services had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
  • Services provided care and treatment based on national guidance and evidence of its effectiveness.
  • Managers monitored the effectiveness of care and treatment and used the findings to improve them.
  • Staff cared for patients and women with compassion. Feedback from patients and women confirmed that staff treated them well and with kindness.
  • The trust planned and provided services in a way that met the needs of local people.
  • The trust had a vision for what it wanted to achieve and workable plans to turn it into action.
  • Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care.
  • There was a positive culture that supported and valued staff.

However:

  • From December 2017 to November 2018 the trust consistently failed to meet the standard of 95% of patients being admitted, transferred or discharged within four hours and performed worse than the England average in eight out of 12 months.
  • Mandatory training in key skills to all staff did not always achieve the trusts target.
  • Complaints were not always deal with in line with the trust policy and often took longer than the trust target.
  • Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) forms did not always contain sufficient evidence that mental capacity assessments had been carried out or considered.

Inspection areas

Safe

Good

Updated 6 June 2019

Effective

Good

Updated 6 June 2019

Caring

Good

Updated 6 June 2019

Responsive

Good

Updated 6 June 2019

Well-led

Good

Updated 6 June 2019

Checks on specific services

Medical care (including older people’s care)

Good

Updated 6 June 2019

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

  • Patients were protected from avoidable harm and abuse. Staff response to the deteriorating patient based on their early warning scores had improved since the last inspection as had screening patients for sepsis. At this inspection we found patient records were stored more securely and compliance with level three safeguarding children training had improved. However, we found that procedures for cleaning of equipment and storage of some medicines were not always followed.
  • Patients mostly had good outcomes because they received effective care and treatment that met their needs, but we did not see any evidence that the management of sepsis was being monitored.
  • Patients were supported, treated with dignity and respect, and were involved as partners in their care. Patients were overwhelmingly positive about the care and treatment they received from staff.
  • Patients’ needs were met through the way services were organised and delivered. Services were planned around the local population and individual needs, Care was co-ordinated across services and robust complaints processes were in place. However, discharge medicines sometimes delayed discharge and response time to referrals to the mental health team were not monitored.
  • The leadership, governance and culture promoted the delivery of high quality, person centred care. Leaders were knowledgeable and staff felt supported. A realistic strategy was in place based on the trust five objectives. There were good governance structures in place, information supported quality improvements and risks were identified and managed. There was a culture of openness and honesty and a strong focus on learning and improvement. There was no formal process in place for teams to take time out.

Services for children & young people

Good

Updated 31 March 2015

Staff on the children’s wards and the neonatal unit worked hard to provide safe care. There were arrangements in place to monitor incidents, and staff were clear on their responsibilities. Staffing levels were appropriate at the time of our visit, although we were aware there were pressure points in some areas.

Children were treated according to national guidance. We observed many examples of compassion and kindness shown by staff across all the departments and ward areas.

Services were planned and delivered to take into account local need. The capacity of the neonatal unit was stretched at times but there were plans in place to introduce more cots in early 2015. Services for children and young people were well-led. There were clear governance arrangements in place.

Critical care

Good

Updated 31 March 2015

There were safe levels of medical and nursing staff, and staff were supported to develop and maintain clinical expertise.

Competent medical, nursing and other professionals worked effectively together to ensure safety. There was one never event in the week prior to our visit which was fully investigated, procedures were amended and information cascaded to staff to reduce future risk.

All patients and relatives we spoke with told us that staff were supportive, efficient and caring. The service provided follow-up arrangements for patients who had been cared for in intensive care to reduce emotional and psychological distress after their experience. There was effective clinical leadership and managers worked closely to support improved patient care. Clear plans, protocols and procedures meant that the staff were aware of their responsibilities.

Arrangements for the management of level 2 patients in the high dependency units did not meet national standards. There was daily review by medical consultants but there was no routine involvement or support from intensive care consultants. Nursing staff were working to competency frameworks relevant to their specialty but few had critical care qualifications. Audits of performance, and outcomes for patients, in the high dependency areas were not compared against similar care units nationally.

End of life care

Good

Updated 6 June 2019

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

  • The leadership, governance and culture were used to drive and improve the delivery of high quality person-centred care.
  • Senior managers and managers at all levels had the appropriate skills and capabilities to provide a good sustainable service for end of life and palliative care patients. Managers felt supported by the executive team and their own management team.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff throughout the trust, spoke with passion about their work and were proud of what they did. There was a culture of openness flexibility and willingness among all the staff we met.
  • There was a patient centred culture throughout the service. Patient stories were used in team meetings, so staff could reflect on what could be improved or share good practice. Staff said using patient stories helped them to focus on why they do job and ensure the patient was at the heart of everything they did.
  • Continuous learning, improvement and innovation was important to leaders and staff; patient stories were heard at board level, efforts were made to create a non-clinical environment for patients in their last hours of life and feedback from relatives was obtained and used to shape the future of the service.
  • The Nightingale Macmillan Unit had achieved MacMillan Quality Environment Award (MQEM) accreditation in 2017 with a maximum score of five out of five. MQEM is a detailed quality framework used for assessing whether cancer care environments meet the standards required by people living with cancer. It is the first assessment tool of its kind in the UK.
  • The bereavement office was committed to the needs of the local people both the deceased and the living. For example, they were made aware last year of a 95-year war veteran who had died in the hospital without any family or friends. The Bereavement office contacted the local regimental group, to see if any relatives could be found. After an appeal was put out by the regimental group, over 200 people attended the war veteran’s funeral, where the service was conducted with full military honours. The local paper reporting “There was standing room only at the funeral service”.
  • Staff who provided end of life care said they had received training in safeguarding children and vulnerable adults. Safeguarding training was part of the trust’s mandatory training programme.
  • We saw infection prevention and control (IPC) policies and procedures in place that were readily available to staff on the hospital intranet. Infection prevention and control was included in the trust’s mandatory training programme.
  • We saw comprehensive risk assessments completed in the medical and nursing notes. These were commenced on admission and there was evidence that risk assessments continued throughout the patients stay in hospital. Examples of this included skin assessments for pressure ulcer risk and updated care plans for patients with mouth care needs.
  • The trust used the AMBER care bundle system. This is a model which provides a systematic approach to management and care of hospital patients who are facing an uncertain recovery and who are at risk of dying in the next one to two months. We saw care nursing care records where the AMBER care bundle was used to assist in the planning and delivery of patient care.
  • The trust had good multidisciplinary working relationships with the local hospice to provide support for patients at the end of their lives and advice for the trust staff out of hours, with representatives from local hospices took part in the end of life care steering group meetings.
  • The end of life care medical documentation contained detailed discussion and decision making with the patient and/or family and outlined the professionals involved in the care. The document also provided guidance and flowcharts for clinicians on symptom control such as management of pain, nausea, agitation and breathlessness.

However:

  • The trust recognised they were not providing a HPCT seven days a week. However, they told us there were plans for this to commence, however, with the acquisition by merger of a neighbouring trust only recently undertaken, the trust was unable to advise the date this would commence.
  • During our inspection, we looked at 15 ‘Do Not Attempt Cardio Pulmonary Resuscitation’ (DNACPR) orders across the hospital and found there were inconsistencies in how these were completed. We found that out of 15 DNACPR orders we looked at, ten that were completed correctly, (65%) were on The Macmillan Nursing Unit. Five were not completed correctly (33 %) and these were on the wards throughout the hospital
  • The trust took an average of 45 working days to investigate and close two of the complaints. This is not in line with their complaints policy, which states complaints should be resolved within 25 working days. The one complaint still open at the time of reporting had been open for 38 working days. This was also not in line with the policy statement that complaints should be resolved within 25 working days

Outpatients and diagnostic imaging

Good

Updated 31 March 2015

There were reliable systems, processes and practices in place to protect patients from avoidable harm and abuse. Risks to patients using the services were assessed and appropriately managed.

Patient needs were assessed and their care and treatment were delivered in line with local and national guidance for best practice. Consent to care and treatment was obtained in line with legislation and guidance. Staff were suitably qualified and skilled to carry out their roles effectively and in line with best practice. There were good examples of staff working collaboratively to meet patient needs.

Patients spoke positively of staff they came into contact with. Staff were observed to be caring and compassionate in the way they dealt with patients and their families or carers. They were knowledgeable and enthusiastic about the service they provided and this was reflected in how they engaged with people.

Surgery

Good

Updated 31 March 2015

The surgical division had systems and processes in place to keep patients safe. Staff had a good awareness of the process for identifying and recording patient safety incidents.

Arrangements to minimise risks to patients were in place, with measures to prevent falls and pressure ulcers, the early identification of patient risk during surgery, good infection prevention and control practice and, the safe management of medicines.

Staff were competent and suitably trained to deliver care in line with trust policies and procedures, national guidance and, National Institute for Health and Care Excellence (NICE) quality standards.

Access to care, treatment and surgical outcomes for patients were mostly within the national average. Where improvements were required these had been identified and measures were in place.

Urgent and emergency services

Good

Updated 6 June 2019

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

  • Staff understood safeguarding processes, were trained to stream and triage effectively and could identify and treat sepsis quickly. The service had sufficient nursing and medical staff with the right qualifications to deliver good quality care and treatment. Patients with mental health issues were assessed in a timely manner.
  • Time from admission to triaging was consistently lower than the England average. The service provided safe care and treatment based on national guidance, patient’s pain was assessed and they were given appropriate fluid and nutrition.
  • Staff were competent in their roles and worked together as a strong cohesive team. Patients had access to 24-hour diagnostic screening, specialist and support services.
  • Staff understood their roles and responsibilities concerning the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff took account of patient’s individual needs, caring for patients with compassion and understanding, involving them in decisions about their care and providing emotional support when necessary.
  • The trust had systems and processes in place to promote access and flow through the department and any complaints and concerns made were treated seriously, investigated and lessons learned from them.
  • Managers at all levels had the skills and abilities to run a service providing high quality and sustainable care. There was a vision for what the service wanted to achieve and workable plans to turn it into action and systems were in place to identify risks with plans to eliminate or reduce them.
  • The trust was committed to improving services and promoting training and research. Innovative systems had been put in place for those with a hearing impairment and to empower adult patients to request a review of their pain. A system had been introduced to improve the quality of care in the department which had received a nomination from the National Patient Safety Awards.

However:

  • The trust had not achieved its own targets for all mandatory training elements for all members of staff and the adult emergency department (ED) could not access patient’s notes relating to their care in the local mental health trust.
  • There were low numbers of hand gel dispensers at entrances to each area in adult ED and at point of care.
  • The digital system in adult ED had not been updated to meet the reporting requirements for the 2018 emergency care data set (ECDS). No documented triggers were in place to denote when a patient required additional observations if their NEWS2 score was five or above.
  • Two sets of clinical guidance were available on the trust’s intranet, one of which had not been reviewed. However, the trust were aware of this and were taking actions to mitigate any risk.
  • The space in the ‘major’s area was inadequate for the number of patients requiring it later in the day and patients complained about their length of stay.
  • From December 2017 to November 2018 the trust consistently failed to meet the standard of 95% of patients being admitted, transferred or discharged within four hours. There was no designated space for patients requiring a quiet space due to dementia, learning disability or autism.
  • Junior staff did not have the opportunity to attend governance meetings and risks on the risk register dated 14 November 2018 had review dates that were in the past.
  • There no specific engagement arrangements in place to receive feedback from patients with mental health and emotional well-being concerns.

Maternity

Good

Updated 6 June 2019

We previously inspected maternity jointly with gynaecology so we cannot compare new ratings directly with previous ratings.

We rated this service as good because:

  • The service had midwifery staff with the right qualifications, skills, training and experience to keep women and babies safe from avoidable harm and to provide the right care and treatment, however staffing levels did not always meet the planned levels in some areas.
  • Staff understood how to protect women and babies from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • The service did not always control infection risk well. Staff kept themselves clean but did not always keep equipment and the premises clean.
  • The service followed best practice when prescribing, giving, recording and storing medicines and women received the right medication at the right dose and at the right time.
  • Staff recognised incidents and graded them appropriately, however they didn’t always report all incidents. Managers shared any lessons learned with the whole team and the wider service.
  • The service used safety monitoring results well. Staff collected safety information and shared it with staff, women and visitors. Managers used this to improve the service.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness.
  • Managers monitored the effectiveness of some care and treatment provided and used the findings to improve them. They compared local results with those of other services to learn from them.
  • Staff kinds worked together as a team to benefit women. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Staff cared for women with compassion. Feedback from women confirmed that staff treated them well and with kindness.
  • Staff involved women and those close to them in decisions about their care and treatment.
  • People could mostly access the service when they needed it. Arrangements to admit, treat and discharge women were in line with good practice.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.
  • Throughout pregnancy and postnatally, specialist midwives worked closely with mental health and community support teams to make suitable arrangements for people with addition needs.
  • Bereavement midwives supported and trained staff to provide care for families after a pregnancy loss.
  • The trust used a systematic approach to continually improve the quality of its services and safeguarding high standards of care.
  • The trust was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.

However, we also found;

  • The service had medical staff with the right qualifications and skills, however the service did not always make sure all medical staff completed their mandatory training.
  • The service had suitable premises and equipment, however equipment checking was inconsistent.
  • Although the trust had made amendments to the leadership and governance structures, the changes had not yet been fully embedded and there was still a lack of oversight and assurance in some areas.
  • Managers at all levels in the service had the right skills and abilities to run a service providing high-quality sustainable care. However, staff did not fully understand the new structure since the acquisition and were not aware of future plans for the service.
  • There was a positive culture that supported and valued staff at a local level, creating a sense of common purpose based on shared values, however we were told by staff the senior leadership team and some middle management were less so.
  • The trust had systems for identifying risks and were planning to eliminate or reduce them, but the processes were not fully robust.
  • Senior managers across the trust were not always visible.