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Kent & Canterbury Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 21 December 2016

The Kent and Canterbury Hospital (K&C) is one of five hospitals that form part of East Kent University Hospitals NHS Foundation Trust (EKUFT). EKUHFT provides local services primarily for the people

living in Kent. The Trust serves a population of approximately 759,000 and employs approximately 6,779 whole time equivalent staff.

The Kent and Canterbury Hospital is an acute hospital providing a range of elective and emergency services including an Urgent care (UCC). Thishospital provides a central base for many specialistservices in East Kent such as renal, vascular,interventional radiology, urology, dermatology, neurology and haemophilia services.

We carried out an announced inspection between 5th and 7th September 2016, and an unannounced insection on 21st September 2016.

This is the third inspection of this hospital. This inspection was specifically designed to test the

requirement for the continued application of special measures to the trust. Prior to inspection we risk

assessed all services provided by the trust using national and local data and intelligence we received from a number of sources. That assessment has led us to include four services (emergency care, medical services, maternity and gynaecology and end of life care) in this inspection.

We rated The Kent and Canterbury Hospital as Requires Improvement overall

Safe

We rated The Kent and Canterbury Hospital as Requiring improvement for safe because:

  • There was a shortage of junior grade doctors and consultants across the medical services at the 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.

 

  • The trust did not use a recognised acuity tool to assess the number of staff needed on a day-to-day-basis.

 

  • We found poor records management in some areas. Staff did not always complete care records according to the best practice guidance

  • We found there were nursing shortages across the hospital.

 

  • 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.

However

  • Staff reported incidents and adverse events that were investigated through robust quality and clinical governance systems. Lessons arising from these events were learned and improvements had been made when needed.

 

  • Staff followed cleanliness and infection control procedures. Potential infection risks during the building works were anticipated and appropriate responses implemented and measured

Effective

We rated The Kent and Canterbury Hospital as Requiring improvement for effective because:

  • Documents and records supporting the learning needs of staff were not always competed and there were gaps in the records of training achieved.

  • The trust had not completed its audit programme. This meant the hospital was not robustly monitoring the quality of service provision

  • Appraisial rates across the hospital needed to be improved.

 

  • There was poor compliance in the use of the end of life documentation across the wards we visited which was reflected in the May 2016 documentation audit undertaken by the SPC team.

However

  • We saw good examples of multidisciplinary working between doctors, nurses, ENPs and other healthcare professionals, including colleagues from the other emergency departments.
  • Care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation.
  • Comfort rounds had been performed and audited. These provided good assurance that pain assessments had been performed, analgesia administered.

 

Caring

We rated The Kent and Canterbury Hospital as Good for caring because:

  • Staff treated patients with kindness and compassion.
  • Patients and relatives we spoke with were complimentary about the nursing and medical staff.
  • Patients were given appropriate information and support regarding their care or treatment and understood the choices available to them.

  • Staff we observed were consistently respectful towards patients and mindful of their privacy and dignity.

 

Responsive

We rated The Kent and Canterbury Hospital as Requiring improvement for responsive because:

  • 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.

  • We found 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.

  • Admission criteria for the UCC appears to be an ongoing issue of confusion to some parts of the local community, as evidenced by inappropriate ‘walk in’ patients arriving at the department.

However

  • There was an average of 17 60-minute breaches in ambulance handover times per month over the last four months. This represented 2.2% of the total number of patient handovers and was better than the regional average of 3%.
  • The trust employed specialist nurses to support the ward staff. This included dementia nurses and learning difficulty link nurses who provided support, training and had developed resource files for staff to reference. Wards also had ‘champions’ who acted as additional resources to promote best practice.

 

Well led

We rated The Kent and Canterbury Hospital as Requiring improvement for well led because:

  • In some areas risk management and quality measurement were not always dealt with appropriately or in a timely way. Risks and issues described by staff did not correspond to those
  • Where changes were made, appropriate processes were not always followed and the impact was not fully monitored in maternity and gynaecology services
  • No separate risk register was available for palliative /end of life care. A separate risk register would allow the risks to this patient group be discussed regularly at the end of life board, and allow plans to be made to alleviate any identified risks.
  • Changes in leadership in end of life care had only recently been realised and as a result had yet to fully address the issues relating to these services.
  • Although there were measures in place to promote positive behaviour and eliminate bullying, staff still reported incidents of poor behaviour from colleagues.

However

  • The hospital had well-documented and publicised vision and values. Their vision was to provide ‘Great healthcare from great people’, with the mission statement ‘together we care: Improving health and lives’. These were readily available for staff, patients and the public on the trust’s internet pages, posters around the hospitals and on the trust’s internal intranet.

We saw several areas of outstanding practice including:

  • Improvement and Innovation Hubs were an established forum to give staff the opportunity to learn about and to contribute to the trust’s improvement journey.

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

Importantly, the trust must:

  • Ensure that there are sufficient numbers of staff with the right competencies, knowledge, qualifications, skills and experience to meet the needs of patients using the service at all times. This includes medical, nursing and therapy staff.

  • Have systems established to ensure that there are accurate, complete and contemporaneous records kept and held securely in respect of each patient.

  • Ensure that all staff have attended mandatory training and address gaps in training records that make it difficult to determine if training meets hospital policy requirements.

 

  • Ensure generalist nurses caring for end of life patients undergo training in end of life care and the use of end of life care documentation.

 

  • Take steps to ensure the 62-day referral to treatment times for cancer patients is addressed so patients are treated in a timely manner and their outcomes are improved.

  • Ensure that patient’s dignity, respect and confidentiality are maintained at all times in all areas and wards.

  • Ensure the trust’s agreed audit programme is completed and where audits identify deficiencies that clear action plans are developed that are subsequently managed within the trust governance framework. To have assurance that best practice is being followed.

Action the hospital should take to improve

  • Ensure the administration of pain relief medication is provided to patients in a timely manner in the urgent care unit and minor injury unit.

There is no doubt that further improvements in the quality and safety of care have been made since our last inspection in July 2015. At that inspection there had been significant improvement since the inspection in March 2014 which led to the trust entering special measures. In addition, leadership is now stronger and there is a higher level of staff engagement in change. My assessment is that the trust is now ready to exit special measures on grounds of quality, However, significant further improvement is needed for the trust to achieve an overall rating of good.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 21 December 2016

Effective

Requires improvement

Updated 21 December 2016

Caring

Good

Updated 21 December 2016

Responsive

Requires improvement

Updated 21 December 2016

Well-led

Requires improvement

Updated 21 December 2016

Checks on specific services

Maternity and gynaecology

Not sufficient evidence to rate

Updated 21 December 2016

We have also included our findings of the services at Kent and Canterbury Hospital in the William Harvey Hospital location report due to the limited number of maternity services at this location. Births do not take place at Kent and Canterbury Hospital with mothers going to either the William Harvey Hospital in Ashford, or the Queen Elizabeth the Queen Mother Hospital in Margate. Kent and Canterbury Hospital has a midwife led unit providing pre and postnatal services including education classes and breast feeding support.

Medical care (including older people’s care)

Requires improvement

Updated 21 December 2016

We found the medical services at the hospital required improvement because;

  • Although the trust had recruited overseas nurses, there remained staffing shortages on the wards. On medical wards staffing numbers have been increased and the trust monitors safe staffing levels. However, there was a lack clarity amongst staff about the acuity based tool ( to assess appropriate staffing for the complexity of patients cared for ) and leaves staff convinced that there is still insufficient staff on duty for many shifts.
  • There was insufficient numbers of junior grade doctors and consultants across medical services at Kent and Canterbury Hospital. This meant consultants and junior staff were under pressure to deliver a safe and effective service, particularly out of hours and at night.
  • 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. The hospital performed poorly in a number of national audits such as the stroke and diabetes services.
  • We found 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. Waiting times are set out in the NHS Constitution; in addition, there are waiting times performance targets measures, which are monitored by NHS England.
  • The trust was not meeting the 62-day cancer referral to treatment time since December 2014. Referral to treatment within 18 weeks was below the 90% national standard and the England average for six of the eight specialties from June 2015 to May 2016.
  • Although the trust had put measures in place to promote positive behaviour and eliminate bullying, staff still reported incidents of inappropriate behaviour from colleagues.

However;

  • 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 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.
  • Management prioritised staff training, which meant staff had timely 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 appropriately maintained the environment.
  • 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.
  • Overall Staff treated patients with kindness and compassion.
  • The trust had plans in place to ensure that medical services across the county were sustainable and fit for purpose. The trust was engaging with all stakeholders to implement any changes. The trust had taken action to address the delays to the patient pathway, such as rapid access clinics, rapid discharge team and outsourcing diagnostic investigations.
  • Staff provided good provision of care for patients living with dementia and patients’ different needs were taken into account. Staff admitted the majority of patients to the correct bed for their speciality and did not move beds or wards for the entirety of their stay.
  • The trust had a clear corporate vision and strategy. The trust reflected staff engagement when developing the strategy for medical services. Clinicians, staff and stakeholders’ opinions were taken into consideration.
  • 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. Staff felt engaged with the direction of the trust and took pride in the progress they had made to date.

 

At our last inspection, we rated the service as requires improvement. On this inspection we have maintained a rating of requires improvement but have seen improvements in incident reporting, staff training, infection control, staff engagement and ward to board governance.

Urgent and emergency services (A&E)

Good

Updated 21 December 2016

  

We rated this service as Good because:

  • Staff reported incidents and adverse events that were investigated through robust quality and clinical governance systems. Lessons arising from these events were learned and improvements had been made when needed.
  • Staff followed cleanliness and infection control procedures. Potential infection risks during the building works were anticipated and appropriate responses implemented and measured.
  • Care pathways, policies and guidance were readily available to staff through the trust’s intranet. The care delivered was measured through national audits to improve quality and patient outcomes.

  • Patients told us they were treated with dignity and respect. People’s concerns and complaints were listened and responded to and feedback was used to improve the quality of care.
  • The trust had clear vision and strategy for improvement, which engaged staff. Staff engagement was reflected in the developing strategy for emergency services where clinicians, staff and patients’ opinions were taken into consideration. Trust managers were candid about the improvement challenges and involved all staff in moving action plans forward.
  • There was an average of 17 60-minute breaches in ambulance handover times per month over the last four months. This represented 2.2% of the total number of patient handovers and was better than the regional average of 3%.

However,

  • There were gaps in mandatory and additional training records that made it difficult to determine if training met policy requirements. Appraisal rates were worse than the other locations we inspected and the number of staff who had completed training in major incidents; safeguarding, consent and the Mental Capacity Act were low.
  • We saw delays in the administration of pain relief medication.
  • At our last inspection, we saw adult patients being seen in the paediatric treatment area. This practice was still happening.
  • Reception and initial screening processes had improved and we saw that building works were underway to help address issues such as patient flow and safer, more dignified care. Delays had occurred that were beyond the control of the trust, but it meant that we could not fully evaluate the results of the new layout and anticipated improvements.
  • Resuscitation trolleys were not always checked daily, which raised the risk that they would not be fully operational for immediate use and an outdated copy of the British National Formulary (BNF) from 2014-15 was near the paediatric resuscitation trolley. An out-of-date BNF had been found in the department at our last inspection.
  • Although building work was underway to enhance the layout, the department still had challenges related to security of access, adults being treated in child cubicles and minimal child friendly décor.
  • Admission criteria for the UCC appears to be an ongoing issue of confusion to some parts of the local community, as evidenced by inappropriate ‘walk in’ patients arriving at the department. While some aspects may remain outside the trust’s influence and control, improved signposting and information should be made available to the public. For instance, signage at the location varied from ‘emergency care’ to ‘accident centre’ and terms used on public websites such as ‘A&E’ and ‘urgent care centre’.

 

At our last inspection, we rated the service as requires improvement. On this inspection we have given a rating of good because we saw improvements in local innovation, staff engagement, staff recruitment, updated systems, policies and procedures and improved governance.

 

Surgery

Requires improvement

Updated 18 November 2015

The environment in which surgical services were provided was not always suitably maintained. Storage of intravenous fluids was not sufficiently safe.

Referral-to-treatment times were not always met. Theatre utilisation was not always maximised.

Staff were not always afforded the opportunity to have their performance formally reviewed. A number of staff had not completed all the required mandatory training, which supported the delivery of safe patient treatment and care. There was a lack of understanding regarding Deprivation of Liberty Safeguards.

Patient risk assessments were not always undertaken and acted upon.

There were safe and effective arrangements in place for reporting adverse events and for learning from these. Staffing arrangements in surgical areas were managed to ensure sufficient numbers of skilled and knowledgeable staff were on duty during day and night hours.

Consent was sought from patients prior to treatment and care delivery. Consultants led on patient care and there was access to specialist staff for advice and guidance.

Procedures were in place to continuously monitor patient safety and surgical practices. Patient treatment and care was generally delivered in accordance with professional guidance. Surgical outcomes were in the main good and results were communicated through the governance arrangements to the ttrust board.

Patients commented positively with regard to the level of information provided and their involvement in decision making. Most patients were satisfied with the treatment and care provided by doctors, nurses and other staff.

Surgical staff spoke positively about their departmental leadership and felt respected and valued. Staff were aware of the trust’s values and direction of improvement. Staff reported having opportunities to develop their skills and expertise, and were supported by suitably skilled leaders. Staff were encouraged to be innovative and share ideas.

The governance arrangements supported effective communication between staff and the trust board. Risks were identified and continuously reviewed. The trust board was informed and updated with regard to service delivery and performance. The views of the patients were sought in respect to improving and developing services.

Intensive/critical care

Good

Updated 18 November 2015

Patients were cared for in a clean and safe environment and staff showed good awareness of reducing the risk of infection. On the day of our inspection staff were very busy but we witnessed a well-co-ordinated team and a good standard of patient care and safety.

We found 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.

Appropriate measures in place to ensure that patients were protected from the risk of acquiring hospital acquired infections, and staff were observed to follow trust infection control guidance. Staff had access to PPE (Personal Protective Equipment) and was observed using it in line with trust policy.

The unit could demonstrate delivering care that reflected national guidance and took into account the latest research. The care delivered was assessed by continuously audited to ensure a high standard and outcomes that were in line with the England average when comparted to other critical care units.

Patient had their dignity respected and their human rights protected whilst in the unit. Appropriate systems were in place to report and action safeguarding and DoLS (Deprivation of Liberty) concerns. We saw evidence that demonstrate that patients and their loved ones had their individual preferences taken into account when planning care and were possible, were involved in planning their care.

Patients and relatives spoke positively about their experience of care and treatment. Staff showed good communication practices and used this to ensure patients with complex needs received timely and expert treatment. There was a positive drive to increase the use of the Confusion Assessment Method for the ICU (CAM-ICU) for patients at risk of delirium.

Medical records were fit for purpose, kept confidential and stored appropriately. There were systems in place to ensure the safe storage, handling and administration of medication.

There was evidence that staff implemented learning from incidents and that training for staff helped them to continually improve patient care. The conversations we had with staff and the data we reviewed demonstrated a healthy culture in the department towards incident reporting. Regular Mortality and Morbidity (M&M) meetings were in place to monitor mortality on the unit.

We found sufficient numbers of skilled staff who had the appropriate skills needed to care for critically ill patients. The unit had a robust competency bases induction and ongoing learning and development programme for all staff.

Patients were looked after by a multi-disciplinary team that included appropriate consultant input. Leadership and educational support on the unit was found to be strong. Feedback received from staff about their line managers and culture in the unit was very positive and complimentary.

There was an appropriate major incident plan in place. Staff were able to tell inspectors of their roles and processes to follow should a major incident occur.

Services for children & young people

Good

Updated 18 November 2015

Kent and Canterbury hospital (KCH) children’s assessment unit (CAU) staff understood their responsibilities to raise concerns and report incidents and were fully supported by the trust when they did so. The children’s and young people’s service had systems in place to ensure that incidents were reported and investigated appropriately. Children and young people’s safety performance showed a good track record and steady improvements. Processes were in place for lessons to be learned and these were communicated widely to support improvement in other areas as well as services that were directly affected.

The trust was using the Kent safeguarding children’s board procedures; but had not produced a trust safeguarding children policy. Staff worked effectively with others to implement protection plans. There was active and appropriate engagement in local safeguarding procedures and effective working with other relevant organisations.

The children’s assessment unit (CAU) had been designed and built with children in mind. The ward areas provided a safe environment for children and families which were effective for cleaning and maintenance.

Staffing levels and skill mix were planned, implemented and reviewed to keep children and young people safe at all times.

Risks to children and young people were assessed, monitored and managed on a day-to-day basis. These included signs of deteriorating health and medical emergencies . Staff recognised and responded appropriately to changes in risks to children and young people who use services.

Risks to safety from service developments, anticipated changes in demand and disruption were assessed, planned for and managed effectively. Plans were in place to respond to emergencies and major situations.

Feedback from children, young people and their families who use the service was consistently positive about the way staff at CAU treated people. The Dolphin ward friends and family test (FFT) results were consistently favourable.

There was a strong, visible person-centred culture. Staff we spoke with were motivated and inspired to offer care that was kind, and promoted children, young people and their families’ dignity.

Relationships between staff patients and their families were caring and supportive. Staff took patients and their families’ personal, cultural, and social needs into account.

Patients and their families were active partners in their care. Staff were fully committed to working in partnership with children, young people and their families. Staff always empowered patients and their families to have a voice and to realise their potential. Patients’ preferences and needs were always reflected in how care was delivered.

Children, young people and their families’ social needs were highly valued and embedded in their care and treatment. Patients’ needs were met through the way services at the CAU were organised and delivered.

Children and young people’s services were planned and delivered in a way that met the needs of the local population. The importance of flexibility, choice and continuity of care was reflected in the services provided.

The needs of different children and young people were taken into account when planning and delivering services. Patients care and treatment was coordinated with other services and other providers.

Reasonable adjustments were made and actions were taken to remove barriers when children and their carers found it hard to use or access services.

The values for children and young people’s services had been developed with elements such as compassion, dignity and equality. However, there was no long-term vision or strategy in place for children and young people’s services. The trust had conducted a recent strategic review of children and young people’s services, and concluded that the proposed strategy of children and young people’s services operating from one site was not viable. At the time of our inspection there was no decision pending on what the vision or strategy would be for children and young people’s services.

Children and young people’s staff were unaware of the trust’s strategic goals for children and young people’s services as the trust had not made a final decision about the future strategy for the service.

The board and other levels of governance within the organization had undergone changes in the past 12 months. The chief nurse and director of quality had been instated as the children and young people’s services lead. The service’s structures, processes and systems of accountability were set out and understood by staff.

There was an effective process in place to identify, understand, monitor and address current and future risks. Performance issues were escalated to the relevant committees and the board through clear structures and processes. Clinical and internal audit processes were in place.

The leadership was knowledgeable about quality issues and understood what the challenges to children and young people’s services were, and was taking action to address them. However, face to face monitoring at KCH CAU was a challenge due to the matron being based in Maidstone.

Leaders at every level prioritised safe, high quality, compassionate care and promoted equality and diversity. The culture change programme encouraged cooperative, supportive relationships among staff so that they felt respected, valued and supported.

There was evidence that the leadership had introduced processes that would actively shape the culture through effective engagement with staff, people who use services and their representatives and stakeholders. Senior leaders encouraged a culture of collective responsibility between teams and services. But, these processes were not embedded.

The children’s and young people’s service was proactively engaging with and involving all staff to ensure that the voices of staff were heard and acted on. The leadership actively promoted staff empowerment to drive improvement and a culture where the benefit of raising concerns was valued. Safe innovation was being supported and staff had objectives focused on improving the culture of the trust.

End of life care

Requires improvement

Updated 21 December 2016

We have given Safe a rating of Requires Improvement because:

• Staff understood their responsibilities to raise and report concerns, incidents and near misses. They were clear about how to report incidents and we saw evidence that learning was shared across the teams. However, the IT system was slow with some staff suggesting not all incidents were reported because of this. This has not improved since the last inspection.

• Generally, we found out of date syringe driver prescription charts were no longer in use.

• A greater proportion of patients were identified as dying however; we found the decision often left staff confused as active treatments were still being delivered. Experienced staff were able to question clinical practice however, more junior staff would not.

• End of life training of the generalist staff was patchy, and many had received no training around the use of end of life care documentation. There was a gap in the skills set of the generalist staff delivering end of life care. This gap will continue to exist until the link nurse are fully training and performing their new support roles. Staff still found accessing the training modules difficult.

• No 7 day face to face access to the SPC team was available which meant that processes out of hours was often difficult, and time consuming which could delay treatment times for patients.

• Nursing records were poorly completed which meant it was unclear if patients were being reviewed regularly in line with national guidance.

 

However :

• We found portering training had improved since the last inspection. Porter’s received training around new trust policies.

• We were able to view the training records on the wards of the syringe driver’s competency programme. This programme had been introduced since the last inspection.

 

On this inspection we have maintained a rating of requires improvement since the last inspection

Outpatients

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, through structured audit and review 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.

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 long term.

As a part of the strategy the trust had pulled 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.

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 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.