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We are carrying out checks at Castle Hill Hospital using our new way of inspecting services. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Good

Updated 1 June 2018

Our rating of services improved. We rated them as good because:

  • We rated effective, caring, responsive and well led as good and we rated safe as requires improvement.
  • We rated three of the hospital’s five services as good and two as requires improvement.
  • The rating of surgery stayed the same as our last inspection and the rating of medical care improved.
  • We saw improvements in the processes to identify patients who were deteriorating. Staff completed records correctly and we saw evidence of appropriate escalation.
  • The trust provided care based on evidence based practice and national guidance. Services reviewed the effectiveness of care through national and local reviews and implemented any findings. We saw improvements in how the trust reviewed effectiveness of the care, through monitoring and auditing compliance with nine fundamental standards.
  • Staff cared for patients with care and compassion and respected patient’s wishes. Staff provided individualised care and involved patients and those close to them in decisions about their care and treatment. Staff provided patients with emotional support to minimise their distress.
  • Patient’s individual needs were met. Systems were in place for identifying patients living with dementia and learning difficulties and to support them through their hospital stay.
  • Staff morale was good and teams worked well together and supported each other. Managers were proud of their staff and success was celebrated through local and trust wide events.

However:

  • At this inspection it was apparent the five steps to safer surgery checklist was still not embedded as a routine part of the surgical pathway. The trust had reported three never events associated with wrong site surgery or the wrong prosthesis being inserted. We could therefore not be assured that the checklist was being used correctly consistently.
  • The trust did not always meet referral to treatment indicators. We saw high numbers of patients waiting for first and follow up appointments across several outpatient areas. In addition to this the trust declared a serious incident related to a trust wide tracking issue within the electronic database. This resulted in a number of patients being lost to follow up.
  • Patients’ records were not always stored securely or in an organised manner. There was a risk that staff may not have access to the information they needed to deliver patient care and that the public could access patients’ confidential records.
  • Records we reviewed showed that surgical in-patients were being fasted for too long prior to surgery. Eight out of eight records we reviewed all showed that patients had fasted for longer than national guidance.
  • The trust did not always have appropriate numbers of staff to ensure patients received safe care and treatment. The trust had introduced some additional staff and roles to provide cover and mitigate some of the risk. However, despite the shortage of registered nurses in particular, the trust managed staffing well and had a robust escalation and review process.
Inspection areas

Safe

Requires improvement

Updated 1 June 2018

Effective

Good

Updated 1 June 2018

Caring

Good

Updated 1 June 2018

Responsive

Good

Updated 1 June 2018

Well-led

Good

Updated 1 June 2018

Checks on specific services

Outpatients and diagnostic imaging

Requires improvement

Updated 15 February 2017

We rated outpatients and diagnostic imaging services as ‘requires improvement’ overall. [KK1]

We rated the safe and responsive domains domain as ‘inadequate’, the well-led domain as ‘requires improvement’ and the caring domain as ‘good’. The effective domain was inspected but not rated. This was because we are currently not confident we are collecting sufficient evidence to rate effectiveness for outpatients and diagnostic imaging.

  • Radiology had reported a serious incident in December 2015 related to a failure to print 50,000 radiology reports. A further six serious incidents regarding specific patients had been reported, of which three 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.
  • In addition, a cluster of eight serious incidents had been declared in outpatients, relating to patients that had not had their appointments when they should. Three of these serious incidents were at the HRI site and six at the CHH site; all eight had been reported since the last inspection. 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 and a serious incident was declared in December 2015 due to 50,000 radiology reports failing to print. This printing issue had led to a further four serious incidents related to printing errors, being declared by the time of the inspection.
  • 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 for nursing and support staff in some outpatient specialties, and in radiology there were five vacant radiologist posts and a significant proportion of radiographer vacancies in general x-ray.
  • Outpatients and radiology had increased their appointment capacity by running clinics out of hours and at the weekends, to cope with the increased demand and ensure patients had their appointments. However, there were ongoing concerns about the trust not meeting national standards for referral to treatment and urgent cancer treatment. However, a plan was in place and locally agreed trajectories, agreed with commissioners and NHSI were being met. All of the patients on the trust waiting lists were being clinically reviewed to ensure no patient came to harm. Weekly performance meetings reviewed the backlog and the individual Health Groups were taking action to review any issues.
  • Staff providing care and treatment to people in outpatients and radiology were caring. Patients gave positive feedback about the care they received and we saw 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 impairment or those who needed an interpreter.
  • The facilities and premises used to deliver services were good. The environment in all of the areas visited was in good state of repair, clean and comfortable and sufficient well-maintained equipment was available.
  • We found there were 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.
  • Outpatient services were split between the four Health Groups, meaning there were different levels of management and clinical support for each service. There was no outpatients risk register. Risks were identified on risk registers of Health Groups; however, this did not allow a cohesive oversight. There was also limited evidence of outpatient audits and quality monitoring.
  • There was inconsistency in the governance and management oversight in outpatients due to it being split across the four Health Groups. This was starting to be addressed with the setting up of a weekly Performance and Access (PandA) group, which reviewed all waiting lists by speciality. An ‘outpatient transformation project’ was also in progress, but this was running behind schedule. This project’s aims included improving clinic utilisation, bookings processes and performance against standards. We were also told that an overarching management post was to be developed.
  • 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 in which 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.
  • 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.


Outpatients

Good

Updated 1 June 2018

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings. We rated the service as good because:

  • The previous inspection identified a lack of effective governance processes within outpatients. At this inspection we saw the trust had strengthened these processes by introducing performance reports, performance and access meetings and a trustwide outpatients governance committee.
  • Staff we spoke with knew how to report incidents and about learning lessons from incidents within the individual health groups.
  • All staff we spoke with felt positive about the new management changes and the future of outpatients.
  • Some work had been undertaken to look at staff skills and develop training specific to the needs of individual staff.
  • Most patients we spoke with told us that staff were caring and friendly.
  • Complaints were investigated thoroughly and in a timely manner.
  • Mandatory training compliance figures were high.

However:

  • Some problems with the storage of patient records remained. Patient records were not always stored securely in some clinics visited.
  • The trust was not meeting its internal appraisal standard.
  • The previous inspection found issues with waiting times for patients and referral to treatment indicators not always being met. During this inspection, we found that referral to treatment indicators were still not always met.
  • We saw high numbers of patients waiting for first and follow up appointments across several outpatient areas, resulting in backlogs. This issue was also identified within the previous inspection report.

Medical care (including older people’s care)

Good

Updated 1 June 2018

  • We saw improvements with medicine compliance previously raised as a concern with the trust. Medicine reconciliation, recording of fridge temperatures and recording of controlled drugs had all seen improvement since our last inspection in June 2016.
  • We saw improvements in how the trust reviewed effectiveness of care through auditing clinical practice within appropriate time frame. Patients received adequate food and drink during their admissions. Pain relief was provided. Patient outcomes were audited and reviewed in line with national audits. Multidisciplinary team working was in place and staff had the relevant training to be competent in their roles.
  • Staff provided care with compassion and treated patients with kindness. Emotional support was provided to patients to minimise their distress. Patients felt involved in their care and were well informed by staff.
  • Flow was managed throughout the hospital. Various projects were in place to reduce the length of stay and provide care within a home environment. The number of bed moves had reduced since our last inspection in June 2016.
  • We saw that services were well-led and staff were provided with leadership and a clear vision for their health group. Governance and risk management systems were in place to provide assurances across the services.

However:

  • We were not assured that patient’s documentation was fully completed. Some records did not always contain the relevant information and staff had not completed certain risk assessments such as falls, nutrition and mental capacity. Nursing and medical staffing levels were not always at the required level and staff fill rates were reduced as a result.
  • We were not assured that nursing staff followed the trust policy or nursing and midwifery (NMC) standards in administering medicines to patients.
  • Knowledge of mental capacity and Deprivation of Liberty Safeguards (DoLS) varied between staff. We were not assured that patient’s mental capacity was recorded to reflect the patient’s current mental capacity.

Surgery

Requires improvement

Updated 1 June 2018

  • From our observations it was apparent the five steps to safer surgery checklist, was not embedded as a routine part of the surgical pathway.
  • Records we reviewed showed that surgical in-patients were not fasted prior to surgery in line with best practice guidance.
  • We saw variable performance in all national audits. Action plans we reviewed did not capture all the issues of concern within the audit and did not address all the areas of action that the trust had taken.
  • We did not see consistent use of the abbreviated mental test score for patients over 75 who had been admitted to hospital for more than 72 hours.
  • The trust was not meeting the national performance standards for treatment or cancer standards. The trust referral to treatment times were consistently worse than the England average, fluctuating around 60%. Seven out of nine surgical specialities were worse than the England average performance.
  • There were shortages of nursing and medical staff: these shortages were evident in the majority of surgical areas.
  • Appraisal rates for staff were worse than the trust target. Seventy seven percent of nursing staff had received an appraisal which was worse than the 85% target and 76% medical and dental staff had received an appraisal which was worse than the target of 90%.

However:

  • Patients we spoke with were consistently positive about the care and experience they had received.
  • Policies and procedures were based on guidance from the Royal College of Surgeons and the National Institute for Health and Care Excellence (NICE).
  • The service had systems in place for reporting, monitoring and learning from incidents. Staff we spoke with knew how to report incidents.
  • We found wards and departments we visited visibly clean and tidy, and we saw ward cleanliness scores displayed in public corridors.
  • The health group had a stable management structure in place and staff we spoke with felt supported by the senior management team.

Intensive/critical care

Requires improvement

Updated 15 February 2017

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% standard of nurses with a post registration qualification in critical care.
  • During this inspection, we identified risks to the service that were not on the risk register. We were concerned about the out of hours medical cover at CHH and the impact of the trust’s reconfiguration of services. There was a lack of recognition of this or forward planning from the Health Group management team or executive team to mitigate the risks.
  • Controls for some of the risks that had been identified were limited and unsustainable and 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 on some of the risks on the risk register.
  • We had concerns about the sustainability of the consultant rota as intensivists worked additional shifts to cover CHH. Some patients were not seen by a consultant within 12 hours of admission and twice daily ward rounds did not take place which was not in line with guidelines for the provision of intensive care services (2015).
  • Junior medical staff that worked on ICU2 out of hours did not have skills in tracheostomy and epidural management.
  • Only twenty five percent of nurses had completed a post registration critical care qualification which was lower than the minimum recommendation of 50%.
  • Planned nurse staffing levels were not consistently achieved and this impacted on the number of beds available in the critical care units.The critical care outreach team was staffed by one nurse on site 24 hours a day. The member of staff was part of the cardiac arrest and transfer team which meant they may not always be immediately available or on site.
  • 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 formal mechanisms for collecting patient or relative feedback.

However,

  • 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.
  • The service showed a good track record in safety. There had been no never events, or serious incidents.
  • There was clear nursing and medical leadership on the units and in the critical care outreach team and it was clear that staff had confidence in the units’ leadership.
  • We observed patient centred multidisciplinary team working.

End of life care

Good

Updated 15 February 2017

The last comprehensive inspection of End of life care services at the hospital was in February 2014, when we found the service to be good. During this inspection we rated this core service as ‘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 and 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 multidisciplinary 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.