St Peter's Hospital

Ashford and St Peter’s Hospitals became a foundation trust on 1 December 2010. As an NHS Foundation Trust there is greater freedom and scope to provide services for patients and the communities and more financial control of investments and expenditure.

The trust provides district general hospital services to a population of around 410,000 people living in the boroughs of Runnymede, Spelthorne, Woking and parts of Elmbridge, Hounslow and Surrey Heath. There are variations within those areas in terms of the ethnic diversity of the local populations and levels of deprivation. In Spelthorne and Runnymede the average proportion of Black and minority ethnic residents was 12.7% and 11% respectively, both lower than that of England of 14.6%. The average proportion of Black and minority ethnic residents in Hounslow was 48.6%, significantly higher than that of England (14.6%). Deprivation in all three areas was the same as the England average, but with higher-than-the-England-average rates of children in poverty and statutory homelessness in Hounslow. The trust also provided some specialist services including neonatal intensive care, bariatric (weight loss) and limb reconstruction surgery.

At the time of this inspection, there had been some recent changes within the executive team. The chief executive had been in post since September 2014, having previously been the chief nurse since 2010.The chief nurse had been in post since October 2014, having previously been the deputy chief nurse and associate director of quality. The chair had been in post since 2008.

We carried out this comprehensive inspection as part of our in-depth inspection programme. The trust had been assessed as band 6 and 5 in our ‘intelligent monitoring’ system between March 2014 and July 2014. (The intelligent monitoring looks at a wide range of data, including patient and staff surveys, hospital performance information, and the views of the public and local partner organisations.) Our inspection was carried out in two parts: the announced visit, which took place on 3–5 December 2014; and the unannounced visit, which took place on 14 December 2014.

Our key findings were as follows:

Safety

• Safety required improvement in urgent and emergency care, medical care, surgery, critical care and children and young people.
• Staff were aware of the requirements for reporting of incidents which were investigated with findings and learning being fed back locally.
• There were concerns with the safe storage of medicines in some medical and surgical wards and that staff in the children wards were not all up to date with medicines management training.
• The trust was taking action and implementing changes to respond to an increased demand in some outpatient clinic services. Some additional clinics were being run and action was being taken to improve the patient experience with regards to appointment booking.
• All areas visited were seen to be visibly clean.
• We looked at a selection of resuscitation equipment across clinical areas and found that this was correctly serviced, cleaned and checked at regular intervals.
• Records were not consistently stored to maintain patient confidentiality. Some records were not accurate in reflecting the needs of the patient.
• There were challenges in clinical areas being able to recruit and retain staff which led to a lack of sufficient permanent staff and caused a number to work additional hours in theatres, critical care and the children’s ward. Staff in other areas found it difficult at times to attend training.
• The trust was working to achieve a target of 100% for completion of the World Health Organization (WHO) checklist. There had been a recent re-launch and communication to staff as part of the drive for improvement.

Effective

• All services were found to be effective.
• There was evidence of good multidisciplinary working. Of note was the competent specialist palliative care team who worked successfully throughout the hospital. They were accessible, visible and utilised.
• The clinical effectiveness of the services was good. Care and treatment was delivered by trained and experienced medical staff and committed nurses. The service followed national guidelines, practice and directives.
• Patients’ pain was assessed in services using appropriate pain assessment tools and there was a dedicated acute pain team who were easily accessible to ward staff. For patients who had a cognitive impairment, such as dementia, staff used the Bolton Pain Assessment Scale to aid their assessment.
• Staff had access to policies and protocols which took account of requirements for National Institute for Health and Care Excellence (NICE) guidance relevant to their area of practice. For example, we specifically looked at the requirements of the guidance Acutely Ill Patients in Hospital (QS6), Preventing Falls in Older People (CG161) and IV Therapy in Adults in Hospital (CG174) and found that policies and practice met the guidance.
• Although no data was provided at this early stage, the Abbey Birth Centre was reporting improved outcomes for reduced uptake of pain relief, mobility in labour, less use of Syntocinon for augmentation of labour and fewer operative deliveries.

Caring

• All services were found to be caring.
• Caring staff throughout the hospital were seen to treat patients at the end of their lives and patients’ relatives with dignity and respect.
• The chaplaincy department of the hospital was proactive in its support of end of life care. The chaplain and volunteers visited the wards daily providing support to those patients who needed spiritual support. The chaplain was also present on the end of life steering group to ensure that the spiritual needs of patients continued to be in focus. The chaplain had also reintroduced the end of life care group for relatives to provide further support.
• Children and young people were encouraged by staff to be involved in their own care. Two young people told us that they were able to do a lot of things for themselves but that the staff were available if they needed any extra help or support. They were also able to speak to clinicians on their own.

Responsive

• Aside from urgent and emergency services all were found to be responsive.
• The emergency and urgent care services at St Peter’s Hospital were not always able to achieve and sustain delivery on the expected targets, despite their best intentions. This impacted on patient flow and there were frequent occurrences of patients staying in the department for excessive hours, awaiting ward beds.
• The trust had introduced a telephone reminding service for appointments. This had helped to reduce the rate for patients not attending appointments from 13% to an average in the last 12 months of 8%.
• To reduce the number of times a patient may have to attend for several outpatient appointments, staff aimed to arrange to have more than one appointment on the same day. Patients’ experience was that this worked well and, though they had a long wait at times, they were please they only had to visit the hospital once.

Well-led

• We judged improvements were required in the well led domain for critical care, services for children and young people and maternity and gynaecology services. All other services were found to be well-led.
• In critical care we found there was no robust programme of governance, risk assessment, assurance and audit. The governance arrangements of the service were not providing feedback on incidents, audits, or results from those quality measures it had. There was a lack of accountability for driving through actions and improvements.
• In maternity and gynaecology We found a considerable number of staff had been impacted by what had been acknowledged as some inappropriate leadership behaviours. The new Associate Director of Midwifery had been in post for 14 months and a new engaging leadership style was evident. The current leadership team had developed a vision and were working on an action plan following the external review which focused on quality and team work.
• In services for children and young people staff on Ash Ward told us they had not had any formal leadership for the last six months and it had been a very difficult period. We were told of a number of new appointments to senior posts that were just about to start, meaning that all of the wards and departments would have their current designated senior posts filled. A Recent senior nursing staff appointment had been welcomed as there had been a period of time without leadership within the paediatric services.
• All staff we spoke to across the hospital were aware of the trust’s vision. We observed that staff were putting the principles into action and could give examples of how they did so.
• All staff we spoke with told us that trust and divisional leaders were highly visible.

We saw several areas of outstanding practice including:

• Good joint working between the wards and departments, the bereavement services, chaplaincy services and the mortuary services to ensure as little distress as possible to bereaved relatives.
• Caring staff throughout the hospital, who were seen to treat patients at the end of their lives and patients’ relatives with dignity and respect.
• The trust had a proactive escalation procedure for dealing with surges in activity and managing capacity.
• The major incident procedures had been regularly tested internally and with external partners with reviews of learning being implemented.
• The trust had developed an Older People’s Assessment and Liaison (OPAL) team which enhanced the care of the frail elderly by ensuring these patients were effectively managed by a specialist team early in their admission. Their interventions decreased the number of admissions of this group to speciality wards, and also contributed to fewer patients being readmitted. Patients and their supporters said they felt involved in care planning and discharge arrangements.
• The electronic patient record system in the intensive care unit (soon to be brought into the high dependency unit) was outstanding. Patients benefitted from comprehensive, detailed records in one place, where all appropriate staff could access and update them at all times.
• In critical care there was an outstanding handover session between the consultants going off duty and those coming onto shift. This included trainee doctors and made excellent use of the electronic patient record system.
• The dinosaur trail designed to distract children on their walk to the operating theatre had proven to be very successful. It meant children were not scared when they arrived at the operating theatre.
• The play therapy team who worked within the paediatric services were very enthusiastic about their work, were well-respected by children and their parents and staff. The team had won a £3,000 prize for innovative ways to brighten up the playroom.
• The children’s ward staff worked hard, with the clinical nurse specialist to ensure patients with diabetes had a high standard of care and there was a well-established transition to adult services.
• The trust had a very detailed policy for use at times when patient safety needed to be maintained to enable treatment through applying ‘mittens’. The policy provided staff with guidance on their use in line with the Mental Capacity Act 2005, from the assessment of the patient, recording the decisions and the continual review of decision and when to stop using them.
• The trauma and orthopaedic unit had set up an early discharge team to reduce the length of stay for patients with hip fractures. Patients had continuity of care from hospital into their own home as they had the same staff. This had reduced their length of stay in hospital.

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

Importantly, the trust must:

• Take action to ensure medicines in medical care services are stored at temperatures that ensure they remain in optimum condition and provide effective treatment.
• Ensure that all trained paediatric nurses are up to date with medicines management training.
• Take action to ensure patient records are kept securely and can be located promptly when required.
• Take action to ensure the critical care department has sufficient numbers of suitably qualified, skilled and experienced nursing staff on the units and the outreach team to safeguard the health, safety and welfare of patients at all times.
• Take action to ensure staffing levels on Ash Ward are such that they are able to meet the needs of their patients at all times.
• Take action to ensure theatres, anaesthetics and surgical wards have sufficient numbers of suitably qualified, skilled and experienced nursing staff to safeguard the health, safety and welfare of patients at all times.
• Ensure in the critical care department that there is a full range of robust safety, quality and performance data collected, audited, examined, evaluated and reported. The trust must ensure it has sight of this data, which follows the standards of a national programme, at board level.

In addition the trust should:

• Ensure the security arrangements for accessing the paediatric area in the A&E department are adhered to in order to prevent unauthorised access.
• Ensure the layout of the A&E department waiting area enables sufficient visibility for staff to identify if a patient’s condition deteriorated.
• Ensure the access/exit routes of the room used for psychiatric assessment in the A&E department are not obstructed to protect the safety of staff and patients.
• Follow up the recommendations from the maternity external review to provide an improved experience and outcomes for women and their babies from ethnic minorities and for families with greater social factors and stress.
• Ensure adherence to the trust policy on inappropriate movement of patients at night, in particular those receiving palliative care.
• Ensure those patients who receive palliative care and have complex needs do not have a protracted journey via several clinical areas on their admission to hospital.
• Report on and display in the critical care department incidents of all categories of patient harms. These should be reported in staff and clinical governance meetings and actions taken around any trends or performance improvement identified.
• Ensure in the critical care department that all investigations it carries out into serious incidents have action plans attributable to members of the team, and mechanisms for actions to be followed up and reported.
• Ensure in the critical care department that all clinical areas are able to be easily cleaned and free from dust and sticky tape on the walls in clinical areas. The critical care operational policy should set out what area is considered as the ‘clinical area’ and how staff should behave in relation to infection prevention and control in this area. This should follow the trust policy on infection control.
• Audit critical care recommendations for the Faculty of Intensive Care Medicine Core Standards and escalate areas where it does not meet the standards to the trust risk register. This should extend to: cover provided from allied health professionals, including the pharmacist, confidentiality of patient records in the high dependency unit (HDU), and the environment of the HDU.
• Ensure any secure areas, such as the clinical room in the HDU, are attended to immediately when security fails due to broken door locks.
• Ensure critical care has access to a practitioner skilled in advance airway techniques at all times.
• Monitor all critical care patients for delirium using a recognised tool.
• Look to provide patients in the critical care department with innovative services to contribute to their emotional support and wellbeing. Patients’ and relatives’ views should be sought to determine what patients want from critical care. Their views and opinions should be acted on and used to improve the service.
• Ensure that any policy used in the critical care department be approved by the relevant party within the hospital trust. Operational policies should be written in accordance with trust policies. The critical care operational policy should ensure statements around patient consent are made in line with current legislation and the Mental Capacity Act 2005.
• Consider how to improve the dementia-friendly design of its facilities.
• Ensure that medical care services consider how it formulates and records its strategy.
• Ensure negotiations remain ongoing with the local clinical commissioning group around designation of high dependency beds on Ash Ward.
• Ensure the staff skill mix on Ash Ward is such that the needs of children and young people with mental health needs can be effectively cared for and managed at all times.
• Ensure that all parents and staff are aware of the hot drinks policy when on the paediatric wards.
• Ensure the inpatient observation charts include a section for ongoing pain assessment, including how a child is responding to pain relief given.
• Review the dispensing of medication on Wren Ward from their medication room directly to patients without the use of safe and secure storage facilities.
• Review the storage arrangements of the oxygen cylinders in the sluice area in recovery.
• Ensure that staff receive safeguarding training to meet their target.
• Review the use of the mobile privacy screen on Wren Ward to ensure privacy for patients.
• Ensure assistance is provided to visually impaired patients with their meals.
• Consider how they ensure that staff in A&E understand their responsibilities regarding the Mental Capacity Act 2005 and its associated Deprivation of Liberty Safeguards.

Professor Sir Mike Richards

Chief Inspector of Hospitals