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Queens Hospital Requires improvement

This service was previously managed by a different provider - see old profile

Inspection Summary


Overall summary & rating

Requires improvement

Updated 6 June 2019

We have not taken the previous ratings of services at Burton Hospitals NHS Foundation Trust into account when aggregating the trust’s overall rating. CQC’s revised inspection methodology states when a trust acquires or merges with another service or trust in order to improve the quality and safety of care, we will not aggregate ratings from the previously separate services or providers at trust level for up to two years. During this time, we would expect the trust to demonstrate that they are taking appropriate action to improve quality and safety.

We rated them as requires improvement because:

  • Patients could not always access care and treatment in a timely way. Waiting times for treatment and arrangements to admit, treat and discharge patients were worse than the England average and national standard.
  • Mandatory training, safeguarding training, mental capacity act training and role specific training rates were variable across all staff groups.
  • Morbidity and mortality governance was variable with sporadic representation from some teams and inconsistent evidence of investigation and lessons learned.
  • Some services did not have 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. There was a reliance on temporary staff to cover staff vacancies in some areas
  • Changes to the leadership and governance structures since the acquisition were not yet fully embedded; information technology systems had not been integrated, service guidelines and standard operating procedures were not always up to date or aligned to the new trust and systems to extract and separate data were not well developed.
  • Medicines and medicines stationery were not always stored securely and managed in accordance with local policies.
  • Some services did not have suitable premises and patient’s security had not been considered. However, the trust took immediate action and put into place measures to ensure premises were secure. In critical care there were unmitigated fire safety and security issues despite on-going escalation through annual risk assessments.
  • Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) forms did not always contain sufficient evidence that mental capacity assessments had been carried out or considered.
  • 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.
  • The approach to continually improving the quality of some services and safeguard high standards of care was not robust, however we saw plans in place to make improvements.
  • Culture was variable across some services.

However:

  • Staff understood how to protect patients from abuse and the service 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.
  • Staff cared for patients and women with compassion. Feedback from patients and women confirmed that staff treated them well and with kindness.
  • Most services managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • Most services provided care and treatment based on national guidance.
  • The trust had a vision for what it wanted to achieve and workable plans to turn it into action.
  • Managers at all levels, and in most areas, had the right skills and abilities to run a service providing high-quality sustainable care.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Services took account of patients’ individual needs and staff were committed to meeting patient’s personal and emotional needs in addition to their clinical needs.
Inspection areas

Safe

Requires improvement

Updated 6 June 2019

Effective

Good

Updated 6 June 2019

Caring

Good

Updated 6 June 2019

Responsive

Good

Updated 6 June 2019

Well-led

Requires improvement

Updated 6 June 2019

Checks on specific services

Medical care (including older people’s care)

Good

Updated 6 June 2019

This was our first inspection since the acquisition, so we cannot compare our ratings with previous inspections. We rated it as good because:

  • Patients were protected from avoidable harm and abuse. There were sufficient staff with the right skills and experience available and they worked in suitable premises with enough equipment. Staff managed infection risks and medicines well and there were good processes for assessing and responding to patient risks. There was an open culture in reporting and investigating incidents and apologies were offered when necessary. However, we found that mandatory training rates for medical staff were much lower than required and agency staff new to the hospital were not always given a formal induction or training in the hospital’s electronic patient record system.
  • Patients had good outcomes because they received effective care and treatment that met their needs. However not all services were available at weekends and patients received less oversight from senior doctors and had less access to some therapies and diagnostic tests.
  • Patients were treated with dignity and respect and both they and relatives were offered the support they needed. Feedback from patients and relatives about their care was positive.
  • Patient’s needs were met through the way services were organised and delivered. Services were planned around the local population and in conjunction with other providers and with commissioners. Complaints systems were in place and patients were supported to complain.
  • Leadership, governance and the culture of the service promoted the delivery of high quality person centred care. Senior leaders were knowledgeable and visible and staff felt supported. A strategy was in place based on the five Trust 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.

Services for children & young people

Good

Updated 6 June 2019

This was our first inspection since the acquisition so we cannot compare our ratings with previous inspections.

Our rating of this service was good because:

  • Managers provided mandatory training in key skills to all staff and made sure everyone completed it. Although compliance data provided by the trust showed completion did not always meet the 90% target set by the trust, particularly in relation to medical staff, the overall completion rate was over 80%.
  • Staff understood how to protect patients from abuse and 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. We observed good multi-disciplinary working and good liaison with other services such as social care, in relation to child protection.
  • Staff controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
  • Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary. Early warning scores were used to identify deteriorating patients and staff took the necessary action when the scores indicated that escalation was needed.
  • Children’s 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.
  • Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care. Paediatric medical staff used paper based records in contrast to the electronic record used by other staff; although this interrupted the continuity of the record, it did not cause any impact on patient care.
  • Staff followed best practice when prescribing, giving, recording and storing medicines. Patients received the right medication at the right dose at the right time. We found an example of good practice in relation to medicines awareness, in that safety huddles (‘druggles’) were held monthly in children’s services to improve safety of medicines management.
  • Patient safety incidents were managed well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance. Staff were working towards accreditation of their services with external organisations that promoted best practice in the care of babies.
  • Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for patients’ religious, cultural and other preferences.
  • Staff assessed and monitored patients regularly to see if they were in pain. They supported those unable to communicate by using suitable assessment tools and gave additional pain relief to ease pain. Staff on the neonatal unit completed audits of pain assessments over two, two month periods and showed improvements in the second audit following the implementation of actions from the first audit.
  • Managers monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them.
  • Although previous performance in national audits were generally in line with or better than the national average, action plans to bring about further improvements were in place. Staff also carried out a range of local audits to assess patient outcomes.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
  • Staff worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • The service was working towards the provision of seven-day services. A paediatric consultant was on site seven days a week.
  • Staff were aware of their responsibilities for obtaining consent for treatment and the requirements in relation to obtaining valid consent in children and young people. They completed training in the Mental Capacity Act (2005) with special reference to paediatrics.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. We observed staff engaging well with patients and parents in a welcoming and friendly manner, putting them at their ease.
  • Staff provided emotional support to patients to minimise their distress. Parents praised the support they received from staff.
  • Staff involved patients and those close to them in decisions about their care and treatment. Parents were encouraged to be involved in the day to day care of their child as much as they wished.
  • The trust planned and provided services in a way that met the needs of local people.
  • Staff took account of patients’ individual needs. Staff took a very person-centred approach to the provision of care and treated everyone as an individual.
  • People could access the service when they needed it. There were appropriate systems in place for the referral and assessment of urgent and emergency patients and the accommodation of patients for planned surgery.
  • Managers treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff. The timescale for response did not always meet the trust target, however the average response time was 27.3 days against the target of 25 days.
  • Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care.
  • Managers had a vision for what they wanted to achieve. They had a plan for the immediate future and were developing plans for the longer term to bring together the service and move forward, with involvement from staff, patients and stakeholders.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • Managers took a systematic approach to continually improving the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish.
  • The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
  • Managers engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively.
  • Managers were committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.

However,

  • The environment with the theatre recovery area was not ideal for children, as they were separated from adults only by a curtain. We also identified an issue with secure exit from the children’s wards, which the trust also identified independently and took action to address.
  • Nurses in the adult outpatient department where children were cared for, did not have access to training in caring for children.
  • Fluids were sometimes withdrawn prior to surgery for longer than necessary for the well-being of the patient.
  • Staff working in adult outpatient departments where children were regularly seen, did not have any children’s training and found it difficult to access courses in caring for children.
  • The input of play specialists to the outpatient areas was limited.
  • A paediatric radiologist was not available on site and specialist advice was obtained from neighbouring hospitals, although action to recruit was being taken.
  • Facilities for children seen in the adult outpatient department and the theatre recovery area could be improved.
  • Systems to extract and separate data about children’s services from that of other patients were not well developed. This made it difficult to obtain accurate information and assess performance specific to children’s services. Patient records were managed safely using secure electronic systems with security safeguards and ensuring paper records were stored securely.

Critical care

Requires improvement

Updated 6 June 2019

This was our first inspection since the acquisition, so we cannot compare our ratings with previous inspections.

We rated it as requires improvement because:

  • Staff did not have access to consistent, up-to-date policies and standard operating procedures regarding specific types of care and care pathways.
  • Although audit data overall was timely, consistent and demonstrated good standards of practice, there was a lack of assurance from the senior team that audit standards were adhered to.
  • There were unmitigated fire safety and security issues in the unit despite on-going escalation through annual risk assessments. We were not assured the senior divisional team understood these risks.
  • We found inconsistent application of the Mental Capacity Act (2005) and understanding of the Deprivation of Liberty Safeguards (DoLS) amongst consultants.
  • The available of specialist support and review from several services was inconstant or unavailable. Although standard operating procedures were in place for some specialties, such as renal medicine, other services provided sporadic care.
  • Audits to measure compliance and performance identified consistently good practice across multiple areas, including risk assessments, pain relief and infection control. However, staff did not always take timely action to address poor or inconsistent results.

However:

  • Standards and completion rates of mandatory and additional professional clinical training were consistently good. Staff had challenges in accessing trust training courses that had limited capacity and senior staff addressed this by effectively planning ahead.
  • The unit demonstrated consistent compliance with network standards and used peer-reviews and self-assessments to assess and benchmark care.
  • Where specialist clinical services were unable to provide a continuous, on-site service, alternatives were arranged through service level agreements and staff training.
  • Multidisciplinary working from multiple specialties was clearly embedded in care planning and delivery. Care from physiotherapists was prominent, consistent and demonstrably improved care and patient experience.
  • Staff were demonstrably committed to meeting patient’s personal and emotional needs in addition to their clinical needs. They had a clear understanding of the needs of patients, including the psychological needs typically experienced after protracted stays in critical care.
  • We observed staff go above and beyond their role to provide patients with emotional support and reassurance when they felt low and upset. All members of the team adapted their approach to communication to more effectively meet individual needs and provide a calmer environment.
  • A follow-up programme was well-established and provided patients with targeted, structured support during periods of extended recovery.
  • Staff managed persistent challenges to infection control and the unit demonstrated a consistent track record in the avoidance of hospital-acquired infections.

End of life care

Good

Updated 6 June 2019

This was our first inspection since the acquisition so we cannot compare our ratings with previous inspections.

We rated it as good because:

  • 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.
  • The mortuary had swipe card access and closed-circuit television (CCTV) surveillance to maintain security. The mortuary waiting and viewing rooms were visibly clean, they provided facilities for relatives such as comfortable seating and information booklets about bereavement, the trust’s bereavement service and organ donation programme
  • 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 a protocol called ‘The five priorities for end of life care.’ The protocol was for the last 48 hours of life and provided guidelines for staff on actions to take such as anticipatory prescribing
  • The service had no never events reported for patients’ receiving end of life care. Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event. From January 2018 to December 2018, the trust reported no incidents classified as never events within end of life care.
  • In accordance with the Gold Standards Framework, MDT meetings took place weekly to ensure any changes to patients needs could be addressed promptly.
  • The chaplaincy service provided a 24-hour seven day a week on call service for patients in the hospital, as well as their relatives and loved ones and aimed to see people within the hour.
  • The hospital palliative care team (HPCT) provided two outpatients clinics to offer treatment for patients being cared for by the team.
  • 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.

However:

  • 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, 11 were not completed correctly (74%).
  • Mental capacity assessments were not always completed correctly or in appropriate circumstances.
  • The end of life care strategy had vision, values and a strategy which had been developed using a structured planning process in collaboration with staff at the trust. However, the management of the end of life care strategy was not well embedded across the trust.

Maternity

Good

Updated 6 June 2019

  • 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.
  • 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 controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
  • 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.
  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. 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.
  • Staff 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 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;

  • Not all midwifery staff at Samuel Johnson Community Hospital had completed all the mandatory training modules required for their role. Also, medical staff for Queen’s Hospital Burton had not all completed the mandatory training.
  • The service did not have robust measures in place to keep babies secure on the delivery suite and postnatal ward at Queen’s Hospital. The trust took immediate action and put into place measures to ensure the units were secure.
  • The antenatal clinic at Queen’s Hospital had low staffing levels but managers planned cover and longer-term solutions.
  • The service’s guidelines were not always up to date and were difficult for staff to access on the intranet site.
  • The maternity service at Burton did not have a complete dashboard due to the systems used. Managers had to manually extract data from the birth register and other records to produce some figures for monitoring patient outcomes
  • 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.
  • The approach to continually improving the quality of its services and safeguard high standards of care was not robust, however we saw plans in place to make improvements.
  • The trust’s systems to collect, analyse and manage information did not support staff in their roles.

Outpatients

Requires improvement

Updated 6 June 2019

This is the first time we have inspected this service since acquisition. We are not therefore able to compare to past ratings of this service.

We rated it as requires improvement because:

  • The service provided mandatory training in key skills to nursing staff, however we were not assured medical staff had sufficient up to date mandatory training.
  • There were no registered children’s nurses in outpatients at Burton, access to support from paediatric nurses was sourced through the paediatric wards.
  • The approach to managing the deteriorating adult or child outpatient was inconsistent and, in some cases, informal. In outpatients A and B and other clinics at Queens Hospital Burton staff, were unable to explain an escalation policy or confirm that they had seen one.
  • We were not assured infection prevention and control procedures were robust. We found inconsistent arrangements to ensure cleaning was carried out. Not all clinics had rigorous arrangements to keep play equipment clean. Hand hygiene audits were not always used to monitor hand washing compliance amongst staff.
  • Whilst nursing leaders in outpatients A and B understood the challenges to quality and sustainability, they did not always understand the actions they could take to address them.
  • The absence of team meetings at operational level in outpatients A and B meant that incidents, complaints and policies were not discussed collectively or knowledge about incidents elsewhere in the trust shared.
  • Nursing leaders had not developed plans to address key workforce issues such as staffing, succession and turnover.
  • Culture was variable across outpatient clinics and there was inconsistent use of team meetings and daily briefings for staff to learn about incidents, complaints and policies.

However:

  • Outpatient care and treatment in the specialties we inspected was based on evidence from NICE and professional bodies. Specialties participated in national audits and used new technology to improve patient care.
  • Technology and equipment was used to enhance care in some services.
  • Staff were kind, friendly and polite and we observed them interacting with patients in a compassionate way. They had an understanding approach to outpatients with mental health, learning disability or dementia diagnoses.
  • The service was mapping provision to local demand. Specialties reviewed capacity to deliver services on an ongoing basis.
  • In most cases outpatients had access to a timely appointment. The service generally compared well for waiting list (Referral to Treatment) and cancer waiting list performance.
  • Staff made reasonable adjustments and tailored care to individual needs. They made efforts to coordinate care for patients with multiple appointments.

Surgery

Good

Updated 6 June 2019

This was our first inspection since the acquisition, so we cannot compare our ratings with previous inspections.

We rated it as good because:

  • There were effective processes for incident reporting, investigation and evidence of improved shared learning from incidents.
  • There was a good supply and availability of surgical instruments with no recent cancellations of surgery attributed to lack of equipment.
  • There was good compliance with infection prevention and control processes and low rates of infection.
  • The service worked collaboratively with other trust staff and external agencies to ensure that children and vulnerable adults were safeguarded.
  • Nationally recognised assessment tools were used to assess surgical patients’ needs, and appropriate measures taken to reduce risks and manage deteriorating patients.
  • Staff at all levels were clear in their responsibilities for safer surgery checks and demonstrated compliance with the required standards.
  • Staff were committed to working collaboratively and demonstrated multi-disciplinary working.
  • Surgical pathways were planned and delivered in line with referenced national clinical guidance. A clinical audit programme informed service development.
  • Staff had the required knowledge, skills and competencies to carry out their roles effectively. Managers appraised staff performance and provided developmental support.
  • Patients, relatives, and carers gave consistently positive feedback about the quality of care they received.
  • The length of stay for elective and non-elective surgery patients was similar to the national average.
  • The trust was focused on reducing referral to treatment backlogs and managing patient access and flow.
  • Patients had a similar to expected risk of readmission for elective surgical admissions compared to the England average.
  • There were reasonable adjustments in place to support patients living with dementia and those living with a learning disability.
  • Staff were largely positive about the integration of services since the trust acquisition in July 2018, and described the leadership team as accessible, supportive, and open to ideas and feedback.
  • The service promoted learning and development, and research and innovation. Staff were positive about the support they received to challenge existing practice and try out new ideas.

However, we also found:

  • Changes to the leadership and governance structures since the acquisition were not yet fully embedded.
  • Compliance with mandatory training and appraisal did not always meet the trust target in all areas.
  • There was a reliance on temporary staff to cover staff vacancies in some areas
  • Queen’s Hospital Burton and Sir Robert Peel Hospital used a different patient administration and record system to that of Derby Royal Hospital. The two systems functioned independently and were configured differently. Whilst there was no evidence that this caused any problems it had been added to the risk register. Work was in progress to simplify and integrate information technology systems.
  • Medicines and medicines stationery were not always stored securely and managed in accordance with local policies.

Urgent and emergency services

Requires improvement

Updated 6 June 2019

This was our first inspection since the acquisition, so we cannot compare our ratings with previous inspections.

We rated it as requires improvement because:

  • Although we found the service largely performed well, it did not meet requirements relating to The Department of Health and Social Care’s standard for emergency departments, meaning we could not give it an overall rating higher than requires improvement.
  • Patients were not always protected from avoidable harm. There were handover delays for patients arriving by ambulance.
  • Patients could not always access care and treatment in a timely way. Waiting times for treatment and arrangements to admit, treat and discharge patients were worse than the England average and national standard.
  • Results in national Royal College of Emergency Medicine audits were highly variable, including poor results in the acute severe asthma audit and the consultant sign-off audit.
  • Morbidity and mortality governance was variable with sporadic representation from some teams and inconsistent evidence of investigation and lessons learned.
  • Medical staff did not meet the trust standard for mandatory training, safeguarding training and mental capacity act training, rates were particularly variable.
  • Although the right number of medical staff were deployed, the service was reliant on locums to fill gaps in the rota, particularly overnight and at weekends.

However, we also found areas of good practice:

  • Feedback from patients, we spoke with, confirmed that staff treated them well and with kindness. Patients told us they had been given enough information about their condition and/or treatment in a way that they could understand.
  • Major incident and emergency planning had been significantly improved through simulated exercises and more advanced training.
  • Staff had developed clinical care to meet the specific needs of the local population, including the elderly and those experiencing mental health problems.
  • There was the leadership capacity and capability to deliver high-quality, sustainable care. Leadership within the department was effective, there was one individual taking overall responsibility for the day to day running of the department. Front line staff feet supported, respected and valued by their immediate line manager(s). Staff were engaged and morale in the department was high.
  • The service had a vision for what it wanted to achieve and we saw evidence of actions to achieve it.