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Hull Royal Infirmary Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 15 February 2017

Hull and East Yorkshire Hospitals NHS Trust operates from two main hospital sites – Hull Royal Infirmary (HRI) and Castle Hill Hospital (CHH) in Cottingham. HRI is the main centre for emergency services including the emergency department (ED). The trust provides services for a population of approximately 602,700 people. This is made up of approximately 260,500 people in the city of Kingston Upon Hull, and 342,200 in the East Riding of Yorkshire.

We completed a comprehensive inspection of the trust from the 28 June to the 1 July 2016 which included a review of progress made on the previous inspections in May 2015 and February 2014. We inspected all eight core services at HRI. We also inspected the minor injuries service operated by the trust at East Riding Community Hospital and outpatient services at the Westbourne NHS centre. We did not visit any other outpatient services which operated in other locations. In addition, we carried out unannounced inspections on 9 June and the 11 July 2016.

We rated HRI overall as ‘requires improvement’; safe, responsive and well led were rated as ‘requires improvement’ with effective and caring rated as ‘good’. Improvements had been made since our last inspection but these were not significant enough to change the rating for HRI as whole. Some areas had made considerable improvements, especially the emergency department (ED) which was now rated as ‘good’. Medical Care, Surgery and Children’s Services had improved. End of Life Care remained ‘good’ across all domains. However, there was deterioration in the ratings overall for Critical Care, Maternity and Outpatients & Diagnostics from ‘good’ to ‘requires improvement’.

Our key findings were as follows:

  • The care of patients within the emergency department had significantly improved since the last inspection. The trust was meeting the locally agreed trajectories for the number of patients seen within four hours (in June 2016, 85.9% of patients were seen within four hours, which was in line with the agreed trajectory of 85.1%), it was still breaching the national target of 95%.
  • The trust reported and investigated incidents appropriately, the previous backlog had reduced. However, staff in some areas could not tell us about lessons learned or changes to practice, including within maternity where a never event had occurred.
  • The trust had effectively responded to a serious incident reported by Radiology in December 2015 related to a failure to print 50,000 radiology reports. A further seven serious incidents regarding specific patients had been reported four of which related to this printing issue. These incidents had been identified by the trust, action had been taken to change the system and additional safety alerts had been added which if breached were reported to the medical director.
  • A backlog of 30,000 patient episodes had been identified by the trust prior to the inspection. A cluster of eight serious incidents had been declared in outpatients, relating to patients that had not had their appointments when they should. This had led to delays in diagnosis and incidents of varying harm to patients. The trust had put in a clinical validation procedure in June 2016 to reduce the likelihood of this happening again.
  • We had concerns within the children’s services about: the competency of staff to care for patients with mental health needs; that not all incidents, including ‘near misses’ and some safeguarding incidents had been classified correctly and therefore not fully investigated or possible lessons learnt and; four safeguarding children guidelines were out of date.
  • Staff were not always assessing and responding appropriately to patient risk. The trust used a National early warning score (NEWS) and the Modified Early Obstetric Warning Score (MEOWS) to identify deterioration in a patient’s condition. We saw some examples of when escalation of a deteriorating patient had not happened in a timely way and some staff were unclear about what to do if a patient’s score increased (indicating deterioration). The trust was aware of this and was putting actions in place to improve this.
  • Falls risk assessments were often not completed or not fully completed. Nutritional assessments were partly completed in the patient records, which may have resulted in a failure to identify patients at risk of malnutrition. We also found poor compliance with the completion of fluid balance charts.
  • Nurse staffing shortages were evident across the majority of medical and surgical wards and board reports indicated that safer staffing levels were not always met. The trust recognised this was an issue and had put in place twice daily safety briefings and associated actions to minimise risk to patients as well as new ward support roles, such as discharge facilitators. The maternity service did not collect the relevant data and therefore could not provide assurance that women received one to one care in labour.
  • There were also some gaps within the medical staffing, especially within critical care.
  • The Summary Hospital-level Mortality Indicator (SHMI) for the Trust had deteriorated and was 112.2 which was higher than the England average (100) in March 2016. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die based on average England figures, given the characteristics of the patients treated there. The Hospital Standardised Mortality Ratio (HSMR) was 98.6 in May 2016 which was similar to the England ratio (100) of observed deaths and expected deaths.
  • There were three active outlier mortality alerts at the time of the inspection. These were for septicaemia (except in labour), coronary artery bypass graft (CABG) and reduction of fracture of bone (upper and lower limb). This meant that deaths within these areas had been outside of the expected range. The Trust had untaken a case note review to determine if any of the deaths were avoidable, what lessons could be learnt and actions were then put in place.
  • Although medicines were stored and administered appropriately, we found gaps and errors in the recording of medicines administration and in the monitoring of checks of controlled drugs which had been a concern at our 2015 inspection.
  • Leadership had improved. There was a clear vision and strategy for the trust with an operational plan on how this would be delivered. We found an improved staff culture, staff were engaged and there was good teamwork.
  • Feedback from patients and relatives was positive. We saw good interactions between staff and patients. Staff maintained patients’ privacy and dignity when providing care. Caring within medicine had improved although there were some instances on the acute medical unit at HRI where not all call bells were within reach of patients.
  • Patients told us they were offered a choice of food and regularly offered drinks. Patients were offered alternatives on the food menu and were provided with snacks, if required, during the day.
  • The areas we visited were clean and ward cleanliness scores were displayed in public areas. We observed good infection prevention and control practice on all wards we visited. There had been a significant improvement in the operating theatre environment at HRI.

We saw several areas of outstanding practice including:

  • The urology services had introduced robotic surgery for prostate cancers in May 2015; this had since been extended to cover colorectal surgery.
  • The critical care teacher trainers had been shortlisted for a national nursing award for their training courses and had been asked to write an article for a national nursing journal.
  • The perinatal mental health team/midwifery team had been shortlisted for the Royal College of Midwives Annual Midwifery Awards 2016 for effective partnership working in supporting women with perinatal mental health.
  • Recreational co-ordinators had been introduced in medical elderly wards. Their role was to provide patients with activities and stimulation whilst in hospital.
  • The responsiveness of the Specialist Palliative Care team (SPCT) in relation to acting on referrals.
  • The bereavement initiative of providing cards for relatives to write messages to their loved ones
  • The International Glaucoma Association had awarded the ophthalmology department an innovation award for their glaucoma monitoring work.
  • Radiology at the trust was an exemplar site for the BSIR (British Society of Interventional Radiology) IQ programme for interventional radiology.
  • The ultrasound department was the UK reference site for Toshiba in the fields of elastography and fusion guided imaging.

However, there were also areas of poor practice where the trust needs to make improvements. Importantly, the trust must ensure that:

  • Planning and delivering care meets the national standards for A&E; meets the referral-to-treatment time indicators and; eliminates any backlog of patients waiting for follow ups with particular regard to eye services and longest waits.
  • A review of the process for categorising incidents is carried out, including safeguarding incidents relating to children, to ensure effective investigation and lessons learnt.
  • Staff complete risk assessments and taken action to mitigate any such risks for patients; in particular, risk assessments for falls and for children with mental health concerns.
  • Learning from never events is further disseminated and lessons learnt are embedded.
  • Staff are knowledgeable about when to escalate a deteriorating patient using the trust’s National early warning score (NEWS) and Modified Early Obstetric Warning Score (MEOWS) escalation procedures; that patients requiring escalation receive timely and appropriate treatment and; that the escalation procedures are audited for effectiveness.
  • Staff have the skills, competence and experience to provide safe care and treatment for children with mental health needs and patients requiring critical care services.
  • It continues to work actively with other professionals, internally and externally, to make sure that care and treatment remains safe for children with mental health needs using the services.
  • Staff follow the established procedures for checking resuscitation equipment in accordance with trust policy.
  • Staff record medicine refrigerator temperatures daily and respond appropriately when these fall outside of the recommended range, especially within A&E.
  • Staff sign drug charts after the medication has been dispensed and not before (or before and after if required) to provide assurance that medications have been given to/ taken by the patient.
  • Records of the management of controlled drugs are accurately maintained and audited within A&E.
  • Patients’ food and fluid charts are fully completed and audited to ensure appropriate actions are taken for patients.
  • Staff who work with children and young people are knowledgeable about Gillick competence and that a process is in place for gaining consent from children under 16.
  • Antenatal consultant clinics have the capacity to meet the needs of women. They also must ensure there is enough capacity in the scanning department to implement GAP (Growth assessment protocol).
  • There is effective use and auditing of best practice guidance such as the “Five steps for safer surgery” checklist within theatres and standardising of procedures across specialties relating to swab counts.
  • Elective orthopaedic patients are regularly assessed and monitored by senior medical staff.
  • The critical care risk register is reviewed so that all risks to the service are included and timely action is taken in relation to the controls in place and escalation to the board.
  • Outpatient services have timely and effective governance processes in place to ensure they identify and actively manage risks and audit processes to monitor and improve the quality of the service provided.
  • Medical records are stored securely and are accessible for authorised people in order to deliver safe care and treatment, especially within outpatient and maternity services.
  • At all times there are sufficient numbers of suitability skilled, qualified and experienced staff (including junior doctors) in line with best practice and national guidance taking into account patients’ dependency levels on surgical and medical wards. And specifically to ensure critical care services have sufficient numbers of staff to sustain the requirements of national guidelines (Guidelines for the Provision of Intensive Care Services 2015 and Operational Standards and Competencies for Critical Care Outreach Services 2012).
  • It continues to work towards the national guidelines of 1:28 midwifery staffing ratio and collect data to evidence one to one care in labour.

In addition there were areas where the trust should take action and these are reported at the end of the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 15 February 2017

Effective

Good

Updated 15 February 2017

Caring

Good

Updated 15 February 2017

Responsive

Requires improvement

Updated 15 February 2017

Well-led

Requires improvement

Updated 15 February 2017

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 15 February 2017

At the comprehensive inspection in 2014 we rated Maternity and gynaecology services as ‘Good’. In 2016 the services were rated as ‘Requires improvement’ overall because:

  • We found process for recognising deteriorating patients were not always reliable. It was not clear from observation charts how frequently observations should be repeated if a patient was unwell.
  • The service did not meet the national benchmarking for midwifery staffing. Data was not collected on the number of women who received 1:1 care in labour to provide assurance about midwifery staffing levels.
  • We found that some governance arrangements did not always allow for identification of risk.
  • Lessons learnt following a recent never event were not embedded.
  • We found that in some areas the approach to service delivery was reactive especially in relation to how the service had implemented the Growth Assessment Protocol (GAP).

However:

  • Clinical areas were clean and tidy with sufficient equipment to meet the needs of patients.
  • Patient outcomes were in line with national averages when compared to similar services.
  • Women spoke positively about their experience and said they felt well supported and cared for.
  • The trust had engaged with the public and sought their views over the development of the midwifery lead birthing unit.
  • We saw strong leadership at a local level. Staff felt supported and felt their concerns would be listened to.

Medical care (including older people’s care)

Requires improvement

Updated 15 February 2017

In May 2015 Hull Royal Infirmary Medical Care services were inspected we rated them as 'Requires Improvement' overall. In 2016 the rating remained as ‘Requires improvement’ because:

  • Staff were not always assessing and responding appropriately to patient risk. The trust used a national early warning score to identify deterioration in a patient’s condition which required a higher level of care; however, some staff were unclear about what to do if a patient’s score increased.
  • Falls risk assessments were often not completed or not fully completed. This was particularly noted on the acute medical wards where some patients over 65 years of age did not have a completed falls assessment. We found poor compliance with the completion of food charts and fluid balance charts.
  • Fridge temperature checks were not always performed and we found that when recorded as out of range, no corrective action had been taken. Controlled drugs were appropriately stored with access restricted to authorised staff however, on most wards; we found daily and weekly checks were not consistent with trust standard operating procedures.
  • Nurse staffing shortages were evident across the majority of medical wards and the trust’s safer staffing levels were not met. The trust recognised this was an issue and had put in place twice daily safety briefings to minimise risk to patients.
  • The trust was not meeting the 18 week referral to treatment standard for some pathways. From April 2015 to March 2016, the percentage of patients that started consultant-led treatment within 18 weeks was consistently worse than the England average.
  • Although we saw improvements in the access and flow of medical care services, such as reduced length of stay on wards and a reduction in the number of bed moves especially at night, further improvements were needed. There were still issues with bed capacity and medical outliers were affecting other services.

However;

  • Leadership had improved. There was a clear vision and strategy for the Medicine Health Group with an operational plan on how this would be delivered. We found an improved staff culture, staff were engaged and there was good teamwork. There was a drive for continual change and improvement within the Medicine Health Group. Further work was needed to embed the changes and to continue to improve standards.
  • Staff were caring. Feedback from patients and relatives was positive. We saw good interactions between staff and patients and staff maintained patients’ privacy and dignity when providing care. Patients and relatives felt well informed and involved in decision making about their care. We found that patients’ access to call bells had improved and the trust was auditing this regularly.
  • Overall compliance with appraisals for the Medicine Health Group (across both sites) for 2015 to 2016 was 79.9%. This was an improvement on the previous two years where compliance had been 68.7% and 74.9%. There were mixed results in national audits; however, action plans were in place to improve areas of poor performance. The endoscopy service met the requirements of the Joint Advisory Group on GI Endoscopy (JAG) accreditation.

Urgent and emergency services (A&E)

Good

Updated 15 February 2017

 At our previous inspection in May 2015, the service was rated as ‘Requires improvement’ overall. In June 2016 we rated this core service as ‘Good’ because:

  • The service was meeting a locally agreed trajectory to see and treat patients within four hours of arrival, and had done so for three consecutive months.
  • The trust had invested substantially in the environment of the emergency department and in new equipment including its major trauma facilities.
  • Staff were encouraged to report incidents and lessons were learned from the investigation of incidents.
  • Nursing staffing was close to meeting planned establishment levels and medical staffing had significantly improved.
  • Patients care and treatment followed evidence based guidance and recognised best practice standards that were monitored for consistency. Care was delivered with compassion and staff treated patients with dignity and respect.
  • Risks to the delivery of care and treatment for patients were appropriately managed. The governance of the department had become more embedded
  • A positive culture in the emergency department reflected the improved culture in the trust and staff commented to us favourably about this. The executive team and senior staff in the emergency department were recognised and respected.

However:

  • For an extended period, the trust has failed to meet the target to see and treat 95% of emergency patients within four hours of arrival.
  • We found gaps in the recording of medicines administration and in the monitoring of checks of controlled drugs.
  • No formal arrangements or protocols were in place for liaison with other specialties.

Surgery

Requires improvement

Updated 15 February 2017

In 2015 we rated surgical services at HRI as ‘Inadequate’. At the 2016 inspection the services had improved and were rated ‘Requires improvement’ overall because:

  • We had concerns over the escalation process of deteriorating patients; the systems used were not always effective. We found examples of patients with high early warning scores, indicating they should have been escalated for medical review, but this had not always occurred.
  • We had concerns over the effectiveness of the five steps to safer surgery checklist, from our observations it was apparent this process was not embedded as a routine part of clinical roles.
  • From medical notes, we reviewed and staff we spoke with we did not see an effective process to ensure clinical review of orthopaedics patients by senior medical staff at both sites.
  • There were staff shortages of nursing and medical staff; these shortages were evident in all surgical areas. The trust recognised this was an issue and had twice daily safety briefings to minimise the risks to patients.
  • Within medical staffing there were gaps in the junior doctors’ rota, especially overnight; this was highlighted on the risk register.
  • Nursing staff did not always complete accurately the falls and dementia risk assessments.
  • National audit performance was variable; the national hip fracture audit 2015 showed that the trust performed worse than the England average for five out of eight indicators. The emergency laparotomy organisational audit 2015 scored red for six out of 11 outcome measures. We saw variable results in the bowel cancer audit 2015 and in the lung cancer audits.
  • At the time of the inspection, the trust did not provide a dedicated trauma consultant rota.
  • Due to the environment in the day surgical unit it was difficult to maintain privacy and dignity.
  • Patients were not always able to access services for treatment in a timely or effective manner. The trust did not meet national performance standards for treatment and cancer standards.
  • The senior management team had appointed substantive roles within the Surgical Health Group, this team recognised that they needed more time to develop and become fully effective in their roles.

However,

  • We noted major improvements from the 2015 inspection to the theatre environment.

  • We saw improvements in the timely investigations of incidents and the sharing of lessons learned.
  • Policies for the Health Group, which we reviewed, were up to date and based on national guidance.
  • We observed good multidisciplinary working between physiotherapy teams, dieticians, and ward staff.
  • The majority of patients we spoke with provided positive feedback about their inpatient stay.
  • The Short Observational Framework for Inspection (SOFI), we carried out showed that the majority of patient mood states were mainly positive or neutral and interactions with patients were positive.
  • The Health Group had developed a clinical strategy; the strategy referenced national reports and recommendations and was aligned to the trust’s values and strategy.

Intensive/critical care

Requires improvement

Updated 15 February 2017

We had not inspected critical care services at HRI since February 2014 when they were rated as ‘Good’. During this inspection we rated critical care as ‘Requires improvement’ because:

  • The trust had not addressed some of the issues raised from the comprehensive inspection in February 2014, for example, staffing in the critical care outreach team, the frequency of the consultant on call rota and less than the 50% national standard of nurses with a post registration qualification in critical care.
  • During this inspection, we identified that controls for some of the risks on the risk register were limited and unsustainable. There was not clear evidence or assurance of escalation of the risks beyond the Health Group. Staff gave us examples of a lack of action of some of the risks on the risk register.
  • There was no documented evidence that some patients were seen by a consultant within 12 hours of admission or that twice daily ward rounds took place. The medical staff to patient ratio, during out of hours, exceeded recommendations. This was not in line with guidelines for the provision of intensive care services (2015)
  • We identified risks to the service that were not on the risk register. For example, non-compliance with guidelines for provision of intensive care services (2015), particularly a rehabilitation after critical illness service, critical care outreach staffing and service suspension and lack of escalation of NEWS scores.
  • We had concerns about the sustainability of the consultant rota as intensivists worked additional shifts. Some patients were not seen by a consultant within 12 hours of admission; twice daily ward rounds did not take place and medical staff to patient ratio, during out of hours, exceeded recommendations. This was not in line with guidelines for the provision of intensive care services (2015).
  • Planned nurse staffing levels were not consistently achieved and this impacted on the number of beds available in the critical care units Only twenty five percent of nurses had completed a post registration critical care qualification which was lower than the minimum recommendation of 50%.
  • The critical care outreach team was staffed by one nurse on site 24 hours a day. This member of staff was part of the trauma and transfer teams which meant they may not always be immediately available or on site. They were also part of the cardiac arrest team. We saw evidence of two incidents that had been reported due to the lack of a critical care outreach service.
  • We saw evidence during our inspection of patients who were referred to critical care requiring level three care that had not been escalated in line with trust policy.
  • The rehabilitation after critical illness service was limited and not in line with the guidelines for the provision of intensive care services (2015).
  • Patients did not have access to formal psychology input following critical care. The service had limited mechanisms of collecting patient or relative feedback.

However, we also found:

  • Patient outcomes were the same as or better than similar units and care and treatment was planned and delivered in line with evidence-based guidance, standards, best practice and legislation.
  • There was clear nursing and medical leadership on the units and in the critical care outreach team and staff had confidence in the units’ leadership.
  • Senior staff acknowledged the psychological needs of their staff. Staff had the opportunity to have post traumatic incident debriefing sessions.
  • We observed patient centred multidisciplinary team working.
  • The service showed a good track record in safety. There had been no never events, or serious incidents.

Services for children & young people

Good

Updated 15 February 2017

At the 2015 inspection, we rated the services for children and young people as ‘Requires improvement’.

At the 2016 inspection we saw improvements had been made and rated the services overall as ‘Good’ because:

  • Nurse staffing was appropriate and was planned using an acuity tool. Multidisciplinary working took place and staff worked well as a cohesive team. Staff were passionate about their roles and were dedicated to making sure their patients had the best care possible.
  • Requirements around the duty of candour were being met.
  • The service performed positively in infection prevention and control audits.
  • Policies were based on national and local guidelines. Consent to care and treatment was obtained in line with legislation and guidance.
  • Staff treated children, young people and their relatives/carers with kindness, compassion, dignity and respect. Families felt informed about the care of their child, and involved in the decisions about care.
  • Wherever possible mothers were not separated from their new-born baby and facilities were available for parents to be resident at the hospital with their child.
  • We saw children and young people being assessed and treated in a timely way. A discharge liaison team was available to ensure babies were discharged from the neonatal unit in a timely way.
  • Playrooms and a schoolroom were available to meet the learning needs of patients.
  • Following our inspection, the trust informed us they had decided to commission an out of area review by an independent mental health provider trust. This was to make sure the service was meeting people’s needs.
  • Staff spoke positively about their managers and the culture of the trust and were able to articulate the trust’s vision and values.

However,

  • Not all incidents, including ‘near misses’ and some safeguarding incidents had been classified correctly and therefore not fully investigated or possible lessons learnt and four safeguarding children guidelines were out of date.
  • The care documentation did not clearly reflect the mental health needs of the patients and how those needs would be met.
  • We were not assured that staff had the knowledge and competencies to meet the needs of children and young people with mental health needs in their care.
  • There were several unfilled junior doctors posts, which had resulted in the inability to meet the demands of the service.
  • Records concerning the administration of medications were not appropriately completed.

End of life care

Good

Updated 15 February 2017

At the comprehensive inspection of end of life care services in February 2014 we found the service to be ‘Good’ overall. In 2016 the rating remained ‘Good’ overall because:

  • Patients were protected from avoidable harm and abuse. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and managers shared the learning from incidents.
  • Mandatory training across most services was above the trust targets and medicines were prescribed and administered safely in line with policy. Staffing levels were appropriate for the services provided.
  • People’s care and treatment was planned and delivered in line with current evidence-based guidance. Information about people’s care and treatment, and their outcomes, were routinely collected and monitored. Staff providing care at the end of life were highly skilled and competent. There was evidence of multi-disciplinary working across all teams. The trust had recently employed more resources to provide seven-day specialist palliative care nursing availability. Consent to care and treatment was obtained in line with legislation and guidance.
  • Feedback we received from patients was consistently positive about the way staff treated them. We observed a number of staff and patient interactions during our inspection. We observed consistently caring and compassionate staff. Patients and their families were supported emotionally. We saw an initiative that had been implemented by the bereavement team that we thought was outstanding.
  • Services were planned and delivered in a way that meets the needs of the local population. All teams involved in caring for patients at the end of life were highly responsive to the needs of the patients in their care and those close to them. Care and treatment was coordinated with other services and other providers to ensure that specialist teams saw patients in a timely manner and patients’ choice in relation to where their care was delivered was achieved. We saw evidence that staff were responsive to meeting the needs of vulnerable patients including those living with dementia.
  • All teams were aware of the trust vision and values. Whilst there was no trust end of life strategy at the time of our inspection, the Specialist Palliative Care Team (SPCT) were working collaboratively with other providers and using the national End of Life Care strategy to benchmark and influence the care and treatment they provided to patients. Robust governance, risk management and quality measurement processes were embedded. Staff told us that senior staff were visible and supportive. There was a lead consultant for end of life care and a director who provided representation at the trust board. We found that staff in all teams were consistently positive, friendly, helpful and approachable in all areas we visited. All staff were team focused and we saw examples of innovation, improvement and sustainability.

Outpatients

Requires improvement

Updated 15 February 2017

At the inspection in 2015 we rated outpatients and diagnostic imaging services as ‘Good’ overall. The effective domain was inspected but not rated. This was because we are currently not confident that we are collecting sufficient evidence to rate effectiveness for outpatients and diagnostic imaging. In 2016 we rated the services overall as ‘Requires improvement’ because.

  • The trust was not meeting the national referral to treatment (RTT) standards for incomplete pathways. This meant patients were not always able to access outpatient services when they needed to. There were appointment backlogs and waiting lists in the majority of outpatient specialties, which totalled over 30,000 patient episodes at the time of the inspection.
  • A cluster of eight serious incidents had been declared in Outpatients, relating to patients that had not had their appointments when they should. This had led to delays in diagnosis and incidents of varying harm to patients, including deaths. The trust had put in a clinical validation procedure in June 2016 to reduce the likelihood of this happening again.
  • In radiology, there had been two never events involving wrong site/side surgery since the 2015 inspection and a previous never event in March 2015.
  • One of the issues identified at the last inspection was the inconsistent use of safety checklists when carrying out day surgery in outpatients and interventional radiology procedures. We found there was still inconsistency in the use of safety checklists across different specialties, and this was not being audited.
  • The numbers of suitably qualified and experienced staff were insufficient in some areas at the last inspection, notably histopathology consultants and echo cardiographers. At this inspection, we found staffing for these two groups had improved, although there were still vacancies. However, we found high levels of vacancies in some outpatient specialties, and in radiology, there were five vacant radiologist posts and a significant proportion of radiographer vacancies in general x-ray.
  • The facilities and premises used to deliver services were of variable quality. Some outpatient clinics were short of space, and some clinical areas located in the main building were in need of refurbishment and repair.
  • We found there was a high number (166) of complaints about outpatients; 26% of the complaints received by the trust in the previous financial year related to outpatients. Patient care was the main category of complaint received. Radiology had received eight complaints in the same period and pathology none.
  • There was inconsistency in the governance and management oversight in outpatients due to the clinics being split across the four Health Groups. The trust had recognised this and it was being addressed with a weekly Performance and Access (PandA) group, which reviewed all waiting lists, by speciality and an ‘outpatient transformation project’, which was running behind schedule. This project was to improve clinic utilisation, booking processes and performance against national standards. We were also told that an overarching management post was to be developed.

However,

  • The trust was working with local commissioners on capacity and demand planning and had agreed local trajectories in order to move towards achieving the national target of 92% for the 18-week incomplete pathway. Standard operating procedures and clinical validation had been agreed in early June 2016 and was ongoing at the time of the inspection. Weekly performance meetings reviewed the backlog and the individual Health Groups were taking action.
  • At the last inspection, patients undergoing hysteroscopy within gynaecology outpatients were not completing consent forms. We found these patients were now completing consent forms as required.
  • Outpatients and radiology had increased their capacity by running clinics out of hours and at the weekends, to cope with the increased demand and to make sure patients had their appointments in a timely manner.
  • Staff providing care and treatment to people in outpatients and radiology were very caring. Patients gave positive feedback about the care they received, and staff treated patients with dignity and respect.
  • Service planning and delivery accommodated the individual needs of people with additional needs or disabilities in the majority of the areas we visited. For example, there was additional support for patients with learning needs, dementia, hearing deficiencies or those who needed an interpreter.
  • Risks recorded within the Health Groups’ risk registers reflected the main concerns. There was no overarching risk register for outpatients which meant there was a lack of cohesive oversight, and limited evidence of outpatient audits and quality monitoring.
  • Leadership, governance and continuous quality improvement in radiology and pathology was well established. There were robust processes for risk management and quality monitoring and both departments were accredited. Radiology was partway through a five-year equipment replacement programme, all of the computerised radiology (CR) equipment was being replaced with digital radiology (DR) equipment. The department had enough CR equipment to maintain the service while refurbishments (retrofits) were being carried out.
  • The trust had effectively managed a serious incident that had been declared by Radiology in December 2015 regarding 50,000 radiology reports failing to print. This printing issue had led to a further four serious incidents being declared by the time of the inspection. These incidents had been identified by the trust, action had been taken to change the system and additional safety alerts had been added which if breached were reported to the medical director.
  • Staff and managers in radiology had a clear vision and strategy for future developments within the department and were aware of the risks and challenges they faced. The trust had effectively managed a serious incident that had been declared by Radiology in December 2015 regarding 50,000 radiology reports failing to print. This printing issue had led to a further four serious incidents being declared by the time of the inspection. These incidents had been identified by the trust, action had been taken to change the system and additional safety alerts had been added which if breached were reported to the medical director.
  • Staff and managers in Radiology had a clear vision and strategy for future developments within the department and were aware of the risks and challenges they faced.