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Queen Elizabeth The Queen Mother Hospital Requires improvement

We are carrying out checks at Queen Elizabeth The Queen Mother Hospital. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 5 September 2018

Our rating of services stayed the same. We rated it them as requires improvement because:

We rated safe, effective, responsive and well-led as requires improvement, and caring as good. We rated four of four core services as requires improvement.

Inspection areas

Safe

Requires improvement

Updated 5 September 2018

Effective

Requires improvement

Updated 5 September 2018

Caring

Good

Updated 5 September 2018

Responsive

Requires improvement

Updated 5 September 2018

Well-led

Requires improvement

Updated 5 September 2018

Checks on specific services

Critical care

Good

Updated 18 November 2015

We found appropriate and effective reporting and learning from incidents and Morbidity and Mortality (M&M) meetings. Patients were cared for in a clean, well maintained and safe environment. Staff demonstrated good awareness of infection control and there were systems in place to minimise the risk of health acquired infections.

Staffing levels were sufficient to meet people’s needs and consultants provided cover in line with the national recommendations. There was also adequate access to diagnostic and screening services out of hours. The care delivered in the unit reflected best practice and national guidance. There were systems in place to measure patient outcomes and the quality of the service provided. Care needs were risk assessed and the unit could demonstrate a track record of delivering harm free care. The CCU had procedures in place to ensure the safe storage, handling and management of medicines. Documentary evidence demonstrated that patients received their medicines in a timely manner and reasons for omission were clearly documented. Pharmacy support was provided as well as regular reviews and internal audits. Safety thermometer data was collected and collated and used to improve and drive service change. Data was displayed in a public area which meant it could be accessed by those who wished to view it. We found an adequate supply of serviced equipment to enable staff to care for their patients.

Staff demonstrated an established approach to multidisciplinary working with other specialists in the Trust and showed us how they could obtain treatment and care for patients with complex needs, including psychology assessments. The needs of people with delirium or dementia were met by well-educated staff but the Confusion Assessment Method for ICU (CAM-ICU) was not routinely used as an assessment tool. Training was provided on a rolling basis for nursing staff and a dedicated team ensured that trainees and new students were well supported and had the opportunity to develop. Leadership on the unit was found to be strong and effective.

Outpatients and diagnostic imaging

Good

Updated 18 November 2015

The Outpatient department was well led and had improved since implementing an outpatient improvement strategy. Despite the strategy being relatively new, the department was able to evidence improvements in health records management, call centre management, referral to treatment processes, increased opening hours, clinic capacity and improved patient experience through structured audit and review.

Although there was still improvement required in referral to treatment pathways, the outpatients department and trust demonstrated a commitment to continuing to improve the service.

As a part of the strategy, the trust had reduced its outpatient services from fifteen locations to six. We inspected five of these locations during our visit.

Managers and staff working in the department understood the strategy and there was a real sense that staff were proud of the improvements that had been made. Progress with the strategy was monitored during weekly strategy meetings with the senior team and fed down to department staff through staff meetings and bulletins.

Outpatients and diagnostic imaging departments at Queen Elizabeth Queen Mother Hospital were providing safe care to patients. There were systems in place, supported by adequate resources to enable the department to provide good quality care to patients attending for appointments.

Evidence based assessment, care and treatment was delivered in line with National Institute for Health and Care Excellence (NICE) guidelines by appropriately trained and qualified staff.

A multi-disciplinary team approach was evident across all the services provided from the outpatients and diagnostic imaging department. We observed a shared responsibility for care and treatment delivery. Staff were trained and assessed as competent before using new equipment or performing aspects of their roles.

We saw caring and compassionate care delivered by all staff working at outpatients and diagnostic imaging department. We observed throughout the outpatients department that staff treated patients, relatives and visitors in a respectful manner.

Nurse management and nursing care was particularly good. Nurses were well informed, competent and went the extra mile to improve the patient’s journey through their department. Nurses and receptionists followed a ‘Meet and Greet’ protocol to ensure that patients received a consistently high level of communication and service from staff in the department.

Urgent and emergency services

Requires improvement

Updated 5 September 2018

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

The service provided mandatory training in key skills to all staff but did not always make sure everyone completed it. Mandatory training compliance amongst doctors was low, the module with the least compliance (40%) was infection control level one, the modules with the highest (60%) compliance was moving and handling level one and health and safety. The overall mandatory training compliance for medical staff at Queen Elizabeth The Queen Mother hospital was 50%. This was significantly lower than the trust target of 85%.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. However, child safeguarding training compliance was low amongst both doctors and nurses but particularly low amongst doctors and significantly lower than the trust target of 85%. Only 27% of doctors had up to date level three child safeguarding training and 20% had were up to date with level two safeguarding training. This meant doctors caring for children may not have the necessary skills and knowledge to identify a child at risk. Staff gave us examples of how to recognise and report abuse.

Staff working in the triage area of the department did not have direct access to handwashing facilities. This meant staff had to leave the triage area to wash their hands.

Decontamination products for example, sanitising hand alcohol gel was not stored securely and in line with the control of substances hazardous to health guidelines. During our inspection we identified that the cupboard which contained the hand gel was unlocked.

We reviewed the cleaning log of the toys and play equipment in the Children’s department which showed that the toys were not cleaned every day. This meant there was no assurance that the equipment was being cleaned and could pose a risk of infection.

The environment in the emergency department did not always enhance patient safety.

The major treatment area and children’s treatment area, were too small for the numbers of patients and staff who used them. This meant staff had to constantly move patients from one space to another and that moving patients around the department was a slow and difficult process.

There was inconsistent checking of emergency equipment on the resuscitation trolleys in both the adult department and Children’s department. In addition, there was inconsistent checking of emergency equipment in the resuscitation bays. This meant there was no assurance that emergency equipment was available and fit for use.

The Children’s waiting area was not visible from the Children’s treatment area. This meant children could not be observed or supervised by staff in this area.

A “black breach” occurs when a patient waits over an hour from ambulance arrival at the emergency department until they are handed over to the emergency department staff. From February 2017 to February 2018 the trust reported 2,395 “black breaches”, with December 2017 having the highest number just over 350.

The department was using the National Early Warning Score system for the monitoring of vital signs in adult patients to highlight early signs of deterioration of a patient’s conditions. We identified two occasions when patients had a National Early Warning Score that required action to be taken, but there was no documentation in the patients electronic or paper record which outlined what action had been taken. This meant it was not possible to know if any action had been taken and the patients could be at risk of deterioration.

Staff told us that the department did not always feel safe. During busy times patients in the majors area were “doubled up” with one patient in front of the other, the patient in front was in the corridor and there was no access to suction or oxygen. Staff told us that they were unsure if the patient in the bay deteriorated if they could access the patient.

There was insufficient medical cover to provide consultant presence in the department for 16 hours a day, as recommended by Royal College of Emergency Medicine. Cover was only provided for 14 hours a day. This was consistent with our findings at the last inspection.

Patient safety checklist and risk assessments such as tissue viability assessments were not always completed. This meant the risks were not understood.

Staff cared for patients with compassion. However, there was no privacy and very little confidentiality for patients waiting on trolleys.  Staff did not use privacy screens.

Doctors told us that abdominal (tummy) and chest x-rays were not reviewed and reported on by a radiologist or radiographer.

The service did not always have enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. There were insufficient registered children’s nurses in post to ensure that the children’s emergency department had at least one registered children’s nurse on duty per shift in line with national guidelines for safer staffing for children in emergency departments. Between the hours of 07:30am and 10pm there was a children’s nurse within the children’s department, outside of these hours adult nurses cared for children. Since our inspection the trust have provided assurance that there was now competent staff supporting children in the department at night.

There was a vacancy rate of 67% amongst the consultants, this meant locums were used to support the service.

Risks were not adequately assessed and understood. The risk register only contained two risks and didn’t reflect areas of concern that we identified during our inspection.

Shared learning and feedback to staff from incidents was limited. This meant lessons learnt were not shared and changes communicated effectively.

We observed the service provided care and treatment based on national guidance and evidence of its effectiveness. However, there was limited oversight which checked to make sure staff followed guidance. In addition, Clinical guidelines had not been updated which meant they might not reflect the current best practice guidelines.

Although the service participated in national audits, local audits undertaken were limited. Audit results varied. Although there were areas where the department performed similar to the national average, results generally did not meet national standards, except for the Royal College of Emergency Medicine Audit: Venous thrombo-embolism (VTE) risk in lower limb immobilisation in plaster cast 2015/16. Performance in the Royal College of Emergency Medicine Audit: Severe sepsis and septic shock 2016/17 was also varied.

Two of the four consultants working in the department was on the General Medical Council Specialist Register and had completed and passed their specialist medical training in emergency medicine.

The trust’s urgent and emergency care Friends and Family Test performance (% recommended) was worse than the England average from January 2017 to December 2017.

The environment was not sufficient to meet the needs of patients and placed patients at an increased risk of harm.

The Royal College of Emergency Medicine recommends that the time patients should wait from time of arrival to receiving treatment is no more than one hour. The trust did not meet the standard for ten months over the 12-month period from February 2017 to January 2018.

The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the emergency department.

The trust did not meet the standard from February 2017 to January 2018.Performance ranged between 70% and 80%.

A lack of flow through inpatient areas resulted in the department being regularly overcrowded.

Governance processes needed embedding and were not effective. There was no formal structure to departmental meetings or minutes produced. Meetings were often cancelled due to the busyness of the department and staff being required to work clinically.

Managers we spoke with were clear about the challenges the department faced and they were committed to improving the patients’ journey and experience. However, we were not assured that there was a systematic approach to improving the quality of services and safeguarding high standards of care.

Staff told us during the winter they did not have time to give patients the care they required as they were so busy.

However:

Mandatory training compliance amongst nurses had improved since our last inspection, compliance for five of the six modules was better than the trust target of 85%.

Staff adhered to the infection control policy and used personal protective equipment such as gloves and aprons correctly when delivering care. There were effective systems in place to ensure that standards of cleanliness and hygiene were maintained.

The Children’s area was secured by swipe-cards to prevent people inappropriately entering areas where children were seen. It had a separate waiting area so that there was audio and visual separation of adults from children.

The mental health room used for conducting mental health assessments was compliant with the Quality Standards for Liaison Psychiatry Services Fifth Edition 2017. For example, the room had no cables, heavy weight furniture and no ligature points. However, directly opposite the mental health room was an unlocked office which contained items which a patient could use to inflict harm on themselves.

The median time from arrival to initial assessment was better than the overall England median in all the months over the 13-month period from February 2017 to January 2018.

In January 2018 the median time to initial assessment was two minutes compared to the England average of nine minutes.

The department was using a Paediatric National Early Warning Score system for the monitoring of vital signs in children to highlight early signs of deterioration in the child’s condition. We reviewed two Paediatric National Early Warning Score system forms and found they both been completed correctly and, where necessary, escalated to a senior decision maker.

Suspected or confirmed cases of sepsis (a life-threatening infection of the blood) were managed effectively using the Sepsis 6 care bundle. Sepsis 6 is a nationally recognised six-step care bundle that should be implemented within one hour. Our review of patient records and audit findings showed effective management of patients with sepsis.

De-briefs were regularly undertaken for staff to provide support after involvement in distressing situations. Staff gave an example of when a child died a consultant undertook a de-brief with the staff involved including ambulance staff who had also treated the child.

The emergency department provided care and treatment that was based on national guidance. This included National Institute for Health and Care Excellence and the Royal College of Emergency Medicine standards.

Unplanned re-attendance rate to the department within seven days was generally better than the national standard of 5% and generally better than the England average.

Eighty-eight percent of staff had received an appraisal which was better than the trust target of 85%.

We observed staff asked patients what name they wished to be called during their visit to the department and checked if patients were warm enough. Staff displayed an understanding and non-judgmental attitude towards patients.

The department had acknowledged the mental health needs of the local population and had access to mental health services 24 hours a day, seven days a week via the mental health liaison team.

There was an electronic application that patients and visitors could download which provided information about wait times for the department and neighbouring services such as the minor injury unit.

Despite widespread frustration there was a positive culture in the department which was centred on the needs and experience of patients. We observed relationships amongst staff in the department were cooperative, supportive and appreciative.

Maternity

Requires improvement

Updated 5 September 2018

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


  • Medical staff training compliance rates were below the trust's 85% target. The compliance rates varied from 67% to 87% for mandatory training modules with an average of 80%.

  • Safeguarding training amongst the medical staff fell below the trust’s own target of 85%.

  • Data requested for mental capacity training for medical and midwifery staff was not available therefore we could not determine whether staff had the knowledge and understanding of patients who lacked capacity to consent to some aspects of their care.
  • The risk register for the hospital showed us the unit was reaching 96.2% for the last year for 1:1 care in labour and falling short of the 100% target.
  • The midwife to birth ratio at the time of the inspection was 1:30. This was above the national benchmark of 1:28.
  • There were insufficient staffing levels across the trust and this meant the labour ward co-ordinator was not supernumerary on each shift. This meant their ability to provide leadership support, deploy resources, and oversee the quality of care in the department may be affected.
  • During the inspection, we reviewed the most recent caesarean section rate and found them to be 30%. This was higher than the England average.
  • The maternity unit environment was generally tired, and in need of modernisation.
  • There was a lack of recording of fridge temperatures and reporting out of range temperatures, which meant there was a risk to medicines and breast milk not stored correctly and posed an infection risk.

There was a lack of effective audit and quality assurance systems to monitor quality outcomes and benchmark against national standards.

However:

  • We received positive feedback from patients via patient surveys and comments from the comment box.
  • There was a key focus on education and training, with midwifery and nursing staff compliant in mandatory training in all areas other than information governance.
  • There are staff shortages which have impacted on 1:1 care of women. However, staff recruitment drives have taken place. The risk has been placed on the risk register report and the head of maternity complete a staff review by June 2018.
  • Staff are motivated and have been involved in fundraising events for the maternity unit
  • Staff felt recent changes have been positive, staff feel valued and feel they work within a good team.
  • The care provided reflected best practice and national guidelines.
  • Managers identified the need for further improvement to feedback from lower level incidents and cross-site learning and staff engagement as an area for continued improvement.

Maternity and gynaecology

Requires improvement

Updated 21 December 2016

We rated this service as requires improvement because;

  • Lack of staffing affected many areas of service planning and the care and treatment of women. This included not meeting national safe staffing guidelines, meaning 1 in 5 women did not receive 1:1 care in labour.
  • The physical environment was not conducive to the safe care and treatment of women. The department was intolerably hot, with patients visibly struggling with the heat. The trust rated unworkable temperatures as ‘low severity’ when reported by staff.
  • Hospital management did not ensure robust governance, for example, hospital data of the number of surgical abortions was incorrect as figures included women who had miscarried and had a surgical evacuation.
  • On our previous inspection, we found there was an ingrained bullying culture within women’s services. This had since improved, however, the trust focused on overall culture rather than tackle individual cases.

However;

  • Staff provided a caring, empathetic environment for women during their pregnancy and labour.
  • Care and treatment was evidence based and patient outcomes were in line with other trusts in England.

On this inspection we have maintained the rating as requires improvement from the last inspection

Medical care (including older people’s care)

Good

Updated 21 December 2016

We found the medical services at the QEQM Hospital good because;

  • The trust had a robust system for managing untoward incidents. Staff were encouraged to report incidents and there were processes in place to investigate and learn from any adverse events. The hospital measured and monitored incidents and avoidable patient harm and used the information to inform priorities and develop strategies for reducing harm.
  • The trust prioritised staff training, which meant staff had access to training in order to provide safe care and treatment for patients.
  • There were systems in place to maintain a clean and therapeutic environment. Staff effectively managed infection control and maintained the environment appropriately.
  • Medical care was evidence based and adhered to national and best practice guidance. Management routinely monitored that care was of good quality and adhered to national guidance to improve quality and patient outcomes.

  • Patients were supported through consultant led care and effective delivery of care through multidisciplinary teams and specialists. There were clear lines of accountability that contributed to the effective planning and delivery of patient care.

  • Staff treated patients with kindness and compassion.
  • The trusts average length of stay for both elective and non-elective stays were better than the England average for the majority of medical specialities.
  • There was good provision of care for those living with dementia and learning difficulties. There were support mechanisms and information available to take individual patients needs into account.
  • The trust had clear corporate vision and strategy. The trust included the opinions of clinicians, staff and stakeholders when developing the strategy for medical services. Staff felt engaged with the direction of the trust and took pride in the progress they had made to date.
  • The trust had clearly defined local and trust wide governance systems. There was well-established ward to board governance, with cross directorate working, developing standard practices and promoting effective leadership. The trust acknowledged they were on an improvement journey and involved all staff in moving the action plan forward.

However

  • There was a shortage of junior grade doctors and consultants across the medical services at the QEQM Hospital. This meant that consultants and junior staff were under pressure to deliver a safe and effective service particularly out of hours and at night.
  • We found there were nursing shortages across the medical services. The situation had improved due to the use of agency and bank staff. Although the trust had recruited overseas nurses, there remained staffing shortages on the wards.
  • Staff did not always complete care records in accordance with best practice guidance from the Royal Colleges. We found gaps and omissions in the sample of records we reviewed. The trust did not have a robust system in place to audit, monitor and review care records to ensure they always gave a complete picture of the assessments and interventions undertaken.
  • The trust did not have adequate maintenance arrangements in place for all of the medical devices in clinical use. This was a risk to patient safety and did not meet MHRA (Medicines & Healthcare products Regulatory Agency) guidance.

  • The trust had not completed its audit programme. This meant the hospital was not robustly monitoring the quality of service provision. The hospital performed poorly in a number of national audits such as the stroke and diabetes services.
  • We found that the hospital was not offering a full seven-day service. Constraints with capacity and staffing limited the responsiveness and effectiveness of the service the hospital was able to offer.
  • Patients’ access to prompt care and treatment was worse than the England average for a number of specialities. The trust had not met the 62-day cancer referral to treatment time since December 2014. Referral to treatment within 18 weeks was below the 90% standard as set out in the NHS Constitution and England average for six of the eight specialties from June 2015 to May 2016.

  • The hospital had improved the number of bed moves patients had during their stay. However, a fifth of all medical patients moved wards more than once during their stay. This meant the hospital transferred some patients several times before they had a bed on the right ward, which put additional pressures on the receiving wards.

At our last inspection, we rated medical services as Requires improvement. On this inspection we have changed the rating to good because of improvements in incident reporting, staff training, infection control, staff engagement and ward to board governance.

Surgery

Requires improvement

Updated 5 September 2018

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

  • The service had not taken sufficient action to maintain the premises and equipment in main theatres. Leaders were aware of safety concerns regarding lack of maintenance of some of the premises and equipment in main theatres but had failed to address this.
  • Nursing staff in day surgery theatres did not have had a sufficient level of safeguarding children training in line with national intercollegiate guidance.
  • Medical and dental staff failed to meet the trust’s mandatory training target of 85% between January and December 2017 for any of the six required modules. Nursing staff also did not meet the 85% target for information governance training.
  • Nurse staffing in the main surgery recovery areas did not meet the Royal College of Nursing standards during paediatric operating lists. This was because there was not at least one registered children’s nurse on duty in the recovery area during children’s operating lists.
  • The service sometimes had insufficient nursing staff on the surgical wards to meet patients’ needs. Nurse staffing shortages did not feature on the risk register. This meant the service might not have had sufficient oversight of this risk.
  • The service did not have assurances staff always stored refrigerated medicines within the manufacturer’s recommended range to maintain their function and safety.
  • Referral to treatment times (RTT) for admitted pathways for surgery were worse than the England average. In December 2017, 57% of patients were treated within 18 weeks, which was worse than the England average of 72%.
  • Governance meetings were not given sufficient priority. Clinical governance meetings did not regularly take place, and there was poor attendance from staff.
  • The trust values did not appear to have been embedded amongst staff. Most staff we asked were unable to tell us the trust values, despite them being included in staff appraisals.

However:

  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with staff to continuously improve patient safety.
  • When things went wrong, staff apologised and gave patients honest information and suitable support. This was in line with the duty of candour regulation under the Health and Social Care Act (Regulated Activities Regulations) 2014.
  • Staff kept records of patients’ care and treatment in line with Nursing and Midwifery Council and General Medical Council guidance and standards. Records were clear, up-to-date and available to all staff providing care.
  • The service used safety monitoring results well. Staff collected safety thermometer information, such as rates of falls, pressure ulcers and catheter-acquired urinary tract infections and shared it with staff, patients and visitors.
  • The service carried out assessments of risks to patients and took action to lessen risks such as falls and pressure ulcers. We saw evidence of regular observations of patients using an early warning system and action taken to escalate any deterioration.
  • The service provided care and treatment based on national guidance and best practice. The service carried out audits to check staff followed internal policies and guidance.
  • Patients had good outcomes following surgery. Results from national audits showed the service performed well, with patient outcomes about the same as other NHS acute hospitals nationally.
  • The service made sure staff were competent for their roles. Managers appraised staff performance, and we saw evidence of meaningful appraisals. Competency records we reviewed provided assurances staff had the skills they needed to do their jobs.
  • Staff of different kinds worked together as a team to benefit patients. We saw positive examples of multidisciplinary working between different staff groups, including doctors, nurses and therapists.
  • Staff obtained patient consent in line with national guidance and legislation. Staff understood their roles and responsibilities under the Mental Capacity Act 2005. They knew how to support patients who lacked the capacity to make decisions about their care.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • Staff provided emotional support to patients to minimise their distress.
  • Staff took account of patients’ individual needs. The service took action to meet the needs of different patient groups so they could access the service on an equal basis to others.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results. The service shared learning from complaints with relevant staff to help drive continuous improvement.
  • Managers across the trust promoted a positive culture that supported and valued staff. Staff generally spoke positively of the culture and described positive working relationships with colleagues and managers.
  • The service took action to actively engage with staff and seek their views through focus groups and open forums.
  • The service had a strong focus on training and developing its own staff. The service had recently introduced an “improvement journey” programme to support nurses recently promoted from band five staff nurses to band six junior sisters/charge nurses. The service hoped this would help fill some of the nursing vacancies by helping improve staff retention.
  • The service had some recent areas of innovation. This included a tool for ward clerk post-discharge telephone calls and a smartphone application for orthopaedic patients called “my journey”. The application, which was due to be rolled out two weeks after our visit, supported patients on their journey from pre to post-operative. The application reminded patients of their medications and exercises to support them as they prepared for, and recovered from, surgery.

Services for children & young people

Requires improvement

Updated 18 November 2015

The children’s and young people’s service at Queen Elizabeth The Queen Mother Hospital (QEQM) requires improvement.

We found the safe and well-led domains required improvement. We identified some potential risks to children’s safety due to an insufficient number of nursing staff in Rainbow ward and in the Special Care Baby Unit (SCBU).

We noted a large number of incidents reported on Datix had not been investigated in a timely manner and there were concerns that themes from these incidents had not always been examined so that lessons could be learnt.

Paediatric early warning score charts had not always been completed correctly. This was a serious concern because these charts were used to identify patients in urgent need of medical intervention. This meant that critically ill patients might not have received appropriate care and treatment in a timely manner.

There had been no never events and two serious incidents over a one year period. The latter had been thoroughly investigated and lessons had been learnt. The second of the serious events was attributed to a rare complication of an infection and was not caused by suboptimal care.

The environment was reasonably clean and tidy. There had been no incidents of C. difficile or MRSA infection. However, the building was not always kept in a good state of repair.

Staff had received mandatory training. However not all medical staff had received level 3 training in safeguarding, which was a statutory requirement.

We found gaps on the checklist for the resuscitation trolley in June and July 2015. The trolley had not always been checked daily and this had potentially exposed patients to the risk of serious harm, if an apparatus required for resuscitation had gone missing or was not in good working order.

There was consultant cover seven days a week and all acute patients saw a consultant within 24 hours.

Staff had yearly appraisals and felt supported by their line managers, including newly qualified staff and junior doctors. Mentorship was in place for student nurses, who had good learning opportunities.

Staff had access to trust policies and procedures, which were in line with national guidance. Some national clinical audits had been undertaken and improvements had been made in clinical practice as a result.

There was effective multidisciplinary working, both within the trust and with external services.

Patients had open access to the Child Care Unit, once they had been referred by the family doctor. This meant patients did not have to wait long to be seen and parents felt there was continuity of care on the children’s ward.

Mothers of babies in the SCBU were complimentary about the medical and nursing staff and felt their baby had received appropriate care and treatment. Staff treated patients and their family with respect and dignity and were compassionate in providing care.

In view of the various concerns raised, such as a prolonged period with insufficient staff numbers, delay in reviewing incidents reported on Datix and slow response in addressing issues raised, we considered senior managers had not acted fast enough to rectify the shortfalls and to ensure patients received safe and appropriate care at all times.

End of life care

Requires improvement

Updated 5 September 2018

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

  • Incidents were not being reported on the trusts electronic reporting system. For example, the practice of placing two deceased patients in a fridge space designed for one had been happening during particularly busy periods. Although a risk assessment had been carried out and the matter had been escalated, it had never been reported as an incident.

  • We did not see a comprehensive record of a formal mental capacity assessments having taken place. A patients mental capacity was mentioned in the records, and on the do not attempt cardio pulmonary resuscitation orders. There was no face-to-face seven day service. The Palliative Care and end of life care service operated Monday- Friday 9am – 5pm. There was a 24 hour a day, seven day a week advisory line available for all hospital staff out of hours from the local hospice.
  • The trust participated in the End of life care Audit: Dying in Hospital 2016 and performed worse than the England average for all of the five clinical indicators. The trust scored particularly poorly for the measure, “Is there documented evidence that the needs of the person(s) important to the patient were asked about?”
  • Capacity issues within the mortuary led to processes for storing the deceased that did not ensure that people’s dignity was respected during care after death. We were told, and were shown a table that demonstrated that this had happened during the winter, specifically once in February and 16 times in March.
  • Complaints relating to the care of patients at the end of life were reviewed by the end of life care board and themes identified. However, it was not clear how these were shared with staff in a way that ensured lessons were learned and care improved.
  • There was written material available for patients and their relatives regarding end of life. However, these were not available in any languages other than English.
  • The challenges facing the service were known to the leaders and the mechanisms were in place for improvements to be made. However, action plans lacked details of how the improvements would be achieved.
  • A formal agreement with the hospice regarding the provision of palliative care consultant cover had still to be finalised despite being in preparation for at least 18 months.

However,

  • Fridge temperatures in the mortuary were monitored remotely through a system that could be accessed wherever there was access to the internet. A mobile phone app that linked to this system was available to the mortuary manager. This meant that temperatures could be monitored 24 hours a day, seven days a week.
  • We found evidence that teams from different disciplines worked well across the hospital and weekly palliative care multidisciplinary team meetings were held at the Queen Elizabeth the Queen Mother Hospital.
  • Staff treated patients and their relatives with kindness, dignity and respect. Staff were always willing to give relatives the time they needed to explain what was happening and what would happen next.
  • Staff dealing with families that had recently been bereaved were conscious of the needs of those people. We saw that staff allowed relatives as much time as they needed to be with their loved ones soon after death.
  • Family members of patients approaching the end of life had access to a large, clean and welcoming room where they could rest, prepare meals, sleep and wash so they didn’t have to leave the hospital site.
  • Chaplaincy services were available for those that requested it and could be provided by chaplains of different faiths as well as those with no faith.
  • The leaders of the service were visible and approachable to all staff that dealt with patients approaching the end of their life.
  • Staff described a positive working culture where there was a belief that all staff had the opportunity to contribute to the care of those patients approaching the end of their life.