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Watford General Hospital Requires improvement

We are carrying out checks at Watford General Hospital. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 10 January 2018

West Hertfordshire Hospitals NHS Trust provides acute healthcare services to a core catchment population of approximately half a million people living in west Hertfordshire and the surrounding area. The trust also provides a range of more specialist services to a wider population, serving residents of North London, Bedfordshire, Buckinghamshire and East Hertfordshire.

Part of the inspection was announced taking place from 30 August 2017 to 1 September 2017 during which time Watford Hospital, St Alban’s Hospital and Hemel Hempstead Hospital were all inspected. We carried out the unannounced inspection on the 12 September 2017.

This was the third comprehensive inspection of the trust. The trust was rated as inadequate overall and was placed into special measures in September 2015. The last inspection took place in September 2016, where the trust and was rated requires improvement overall. It remained in special measures.

Urgent and emergency care services was rated inadequate during our last inspection in September 2016. Medical care, surgery, services for children and young people and outpatients and diagnostics were rated as requires improvement in 2016.Critical care, maternity and gynaecology and end of life care were rated as good.

At this inspection we rated Watford General Hospital as requires improvement overall.

During this inspection, medical care and surgery were rated as requires improvement. Critical care, maternity and gynaecology, services for children and young people, end of life care and outpatients and diagnostics have been rated as good. This means all these services, except medical care and surgery, have improved and provide a better service to their patients. However, emergency services were rated inadequate.

We saw several areas of outstanding practice throughout Watford General Hospital. For example:

  • There were a number of outstanding innovations in the children’s emergency department to support the needs of parents, children and younger people. This included support from voluntary groups charities and volunteers to tackle important issues such as mental health and suicide awareness.
  • The set up and design of the children’s emergency department as an environment to children was outstanding as it enabled the service to undertake interventions on children quickly. The design and space for a district general hospital was unique and was modelled on the set up of the tertiary children’s units.
  • We observed outstanding care interactions provided by staff to children in the emergency department and in the children’s observation bay.
  • The pathways of care in the children’s emergency department, their effective use within the department on patients was outstanding.
  • Staff kept patients at risk of harming themselves safe without depriving them of their liberty. There was an effective process for prompt senior nurse assessment and the provision of enhanced care for patients at risk. An enhanced care team was receiving training to make sure they provided patient centred care.
  • The “iSeeU” initiative provided women who were separated from their babies at birth the opportunity to use face-time technology to see their baby receiving care and treatment on the neonatal care unit.
  • The pilot Phoenix team provided a case loading service for women with uncomplicated pregnancies who wanted to give birth at home or at the birth centre. The team sent a congratulations card to every mother who was part of their team once they had delivered their baby.
  • An electronic referral pathway had improved the care for infants with prolonged neonatal jaundice. The pathway had been developed in partnership with GPs, health visitors, community midwives and local commissioners. This had resulted in a reduction in the referral to appointment time (under 48 hours) and the overall time for parents to receive their child’s results was two weeks from referral.
  • The diagnostic imaging service monitored its compliance by auditing best practice relating to patients receiving chest radiography. Guidance from the Royal College of Radiologists (RCR) states that it is best practice to undertake chest radiographs on patients in the poster anterior (AP) upright position, apart from when this is not appropriate due to immobility or ill health. Following an audit performed within the diagnostic imaging department, staff embraced the importance of change in practice especially in difficult casualty situations.

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

Importantly, the trust MUST:

  • The trust must ensure governance quality systems in ED, including the reporting of incidents, identification of risk and management of risk registers provide assurances that the service runs safely and effectively.
  • The trust must ensure that the staffing levels on duty are based on acuity, and ensuring the numbers on duty for nursing, medical and support staff are sufficient to ensure safe care.
  • The trust must ensure that appropriate action is taken to improve the culture within the emergency department.
  • Ensure that there are processes in place to complete patients’ venous thromboembolism risk assessments on admission and repeated assessments 24 hours after admission in line with national guidance.
  • Ensure that patient risk assessments are detailed with information to allow an accurate assessment of the patients’ clinical condition.
  • Ensure that there are processes in place to manage and report mixed sex accommodation as incidents and where possible prevent patients of the opposite sex being cared for in the same clinical area.
  • Ensure that patient personal identifiable information is not displayed or discussed openly within earshot of unauthorised persons.
  • Ensure that staff working within the DVT clinic are competent at the identification of medicines and contraindications.
  • The trust must ensure that where a person lacks capacity to make an informed decision or given consent, staff must act in accordance with the requirements of the Mental Capacity Act 2005 and associated code of practice. A formal decision specific mental capacity assessment must be undertaken of the patient’s ability to understand this decision and to participate in any discussions.
  • Ensure that all staff caring for patients under 18 years of age complete safeguarding children level three training.
  • Ensure staff in outpatient services are aware of the trust policy and fulfil the mandatory reporting duty for cases of female genital mutilation.
  • Ensure that World Health Organisation (WHO) five steps to safer surgery checklists are completed in their entirety.
  • Ensure that infection prevention and control standards are maintained in treatment rooms where minor operations are performed.
  • Ensure that all risks within the outpatient department are included in the departmental risk register.
  • Ensure clinical staff within the radiology department are up-to-date on fire and evacuation training.

The trust SHOULD:

  • Review the arrangements for the collection of blood samples from the emergency department.
  • Review ambulance offload and handover times in the emergency department.
  • Consider how to effectively learning from complaints is fully implemented to improve patient experience.
  • Develop an integrated governance system for the children’s emergency department, ensuring there are effective reporting system, and management of risk processes.
  • Ensure that all staff maintain all infection control and prevention practices.
  • Patients’ nutrition and fluids should be accurately recorded and totalled daily.
  • Ensure theatres are compliant with national standards, including the ventilation in the theatre preparation rooms.
  • Take steps to ensure the facilities for day surgery patients are appropriate.
  • Patients should not be nursed in recovery or ESAU overnight.
  • Ensure patients whose surgery is cancelled are treated within 28 days of the cancellation.
  • Ensure all surgical patients have access to timely treatment after referral.
  • All relevant staff, including junior doctors, should be trained to recognise and respond to signs of sepsis.
  • All patient records should be available at pre-operative assessment clinics.
  • The route in which the painkiller Paracetamol is to be administered should always be clearly documented in patients’ prescription charts.
  • Audits of the WHO Surgical Safety Checklist and five steps to safer surgery are improved to assess how well teams are participating in the checks.
  • Surgery services should fully participate fully in implementing the National Local Safety Standards for Invasive Procedures.
  • The audit programme should be managed effectively and that actions identified are completed and re-audited. This should include an audit of the recognition of sepsis and the treatment provided to patients with signs of sepsis.
  • All staff should comply with the trust’s hand hygiene policy.
  • Standards of cleanliness and hygiene continue to be monitored on Starfish ward.
  • Patients should be discharged from the critical care unit within four hours of the decision to discharge, to improve the access and flow of patients within the critical care unit (CCU).
  • Patients requiring admission to CCU should be received in four hours of the decision to admit.
  • A microbiologist should have daily input to the ward rounds on CCU to review patients care in line with the Guidance for the Provision of Intensive Care Services 2015 (GPICS).
  • Take actions to reduce the incidence of mixed sex breaches in the critical care unit.
  • Local mortality and morbidity review meeting minutes should include clear delegated actions and monitoring of these.
  • The risk register contains all current risks identified to the provision of the critical care service.
  • Ensure the service reviews its processes to provide at least 50% of nursing staff with a post registration critical care qualification in line with GPICS standard (2015) and mitigate for any gaps.
  • Medicines should be stored within the recommended temperature range.
  • All medicines given are documented in line with national guidance.
  • All equipment is safety tested annually.
  • Resuscitaires should be checked daily.
  • Symphysis-fundal height measurements (maternity) are clearly plotted on growth charts.
  • Actions should continue to be taken to reduce the caesarean section rate.
  • Actions should be taken to improve the perinatal mortality rate and reduce the number of full term babies admitted to the neonatal care unit.
  • All complaints are investigated and closed in a timely manner.
  • Reduce the number of medical outliers to the gynaecology ward.
  • Take action to reduce staffing vacancies and turnover of staff.
  • Consider reconfiguring the neonatal unit as its current configuration meant there was insufficient space, which did not reflect current guidelines.
  • Continue to monitor the movement of children from the inpatients’ wards to the operating theatre along a corridor that was not fit for that purpose.
  • Consider ways of improving the environment for children in the operating and recovery areas of the trust.
  • Access to emergency equipment should not be impeded.
  • Dietary supplements should be stored securely.
  • All staff should receive training in a major incident exercise or undergo major incident training.
  • The information system for the diabetes service should meet the needs of the service.
  • Consider ways to improve the response to the Friends and Family Test in children’s services.
  • Continue to monitor the level of cancelled outpatient appointments over six weeks in children’s services.
  • Consider how to improve the results of the next Picker survey in children’s services.
  • Review the risk register process to ensure the trust was aware of the risks for the end of life care and mortuary services.
  • The main outpatient department should have a dedicated area suitable to care for patients on a stretcher, bed or wheelchair.
  • Decontaminate reusable naso-endoscopes in a washer-disinfector at the end of each clinic to meet best practice, as outlined in the Department of Health Technical Memorandum (HTM) 01-06 Decontamination of flexible endoscopes.
  • Ensure staff are up-to-date on the mental capacity act and deprivation of liberty safeguards training.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 10 January 2018

Effective

Good

Updated 10 January 2018

Caring

Good

Updated 10 January 2018

Responsive

Requires improvement

Updated 10 January 2018

Well-led

Requires improvement

Updated 10 January 2018

Checks on specific services

Critical care

Good

Updated 10 January 2018

We rated this service overall as good because:

  • Leaders fostered a culture where patient safety was the highest priority. This was supported by an active incident reporting culture, maintenance of healthcare records, medicines management and the appropriate level of monitoring for patients.
  • Staff attended mandatory training, completed competencies, received annual appraisals of their development needs and received support from the unit’s professional development nurse.
  • The unit contributed to the Intensive Care National Audit and Research Centre (ICNARC) that monitored patient outcomes and mortality indicators. The annual report for 2016/17 showed the unit was performing as expected (compared to other similar services) in all the indicators, except for two related to delayed discharges.
  • Despite the delays encountered with discharges from the unit, patients were not being transferred out to wards in the hospital overnight nor transferred to other units as a result.
  • The critical care unit nursing and medical staffing was in line with guidance for the provision of intensive care services (GPICS 2015).
  • The unit had an active research and development programme and patients’ care and treatment was assessed and delivered according to national and best-practice guidelines.
  • There were low infection rates and good adherence to infection prevention and control policies, including use of handwashing and personal protective equipment.
  • Patients were treated with dignity, respect and kindness. The critical care team were committed to involving patients and their relatives in care and treatment decisions.
  • The service was provided in appropriate facilities to care for critically ill patients and relatives and visitors had access to appropriate areas of the unit.

However:

  • Systems and processes related to the maintenance of equipment were not always effective. We found five items of equipment that had not been serviced appropriately. We raised this issue and it was addressed during our inspection.
  • Staff were not clear how often the contents of the difficult airway trolley should be checked.
  • The unit did not meet the guidance for the provision of intensive care services (GPICS 2015) standard of 50% of nursing staff having a qualification in critical care. This was 42% at the time of the inspection.
  • Despite actions being taken in conjunction with the trust regarding delayed discharges, this remained an issue for many patients in the critical care service. This also reflected in the increasing number of mixed sex accommodation (MSA) breaches, from June 2016 to May 2017, there were on average 10 each month.
  • Delayed discharges from critical care appeared to impact the services ability to always admit critically ill patients in a timely manner.
  • Divisional level mortality and morbidity meetings included critical care services. However, local review minutes were brief and actions to be taken were not always clear.
  • There were risks to the provision of the critical care service we found were not included in the risk register. For example, the delays with servicing equipment.
  • The microbiologist was available on call and attended the unit three times a week. This did not meet the daily requirement as stated in GPICS (2015).

Outpatients and diagnostic imaging

Good

Updated 10 January 2018

Overall, we rated the outpatients and diagnostic imaging service as good because:

  • Since our previous inspection in September 2016, an outpatient quality improvement plan (QIP) had been implemented. This included all issues raised during the previous inspection and we found that 14 out of 15 had been completed in August 2017. Performance data had improved since the plan was implemented and the service was performing in line with their planned trajectory.
  • There was a positive incident reporting culture across the services provided. We saw robust departmental learning from a recent never event.
  • Our last inspection in September 2016 highlighted issues with non-compliance with hand hygiene and lack of hand hygiene audits. We found this had improved during our inspection in August 2017. Good standards of hand hygiene were maintained and the department was compliant with hand hygiene audits.
  • Patient records were stored securely in locked rooms and trolleys. This was an improvement since our last inspection.
  • Radiation protection in the diagnostic imaging department was robust and supervisors were appointed in each clinical area. Medical physics experts and radiation protection supervisors actively worked with staff to provide advice and ensure compliance with safety standards.
  • Nurse staffing levels were appropriate with minimal vacancies and staffing levels met patient needs.
  • Staff in all departments were aware of the actions they should take in case of a major incident.
  • Risk to patients on the waiting list for outpatient appointments was discussed at weekly meetings. Clinical assessments were conducted if patients waited 30 weeks or more for outpatient services.
  • Care and treatment was delivered in line with evidence-based guidance, standards and best practice.
  • The diagnostic imaging department was working towards the Imaging Services Accreditation Scheme (ISAS).
  • There was a comprehensive clinical audit programme in the radiology department to monitor compliance with trust policy and Ionising Radiation (Medical Exposure) Regulations (IR(ME)R). Results showed consistent compliance and actions taken to improve.
  • Appraisal rates met the trust target, which was an improvement since the previous inspection.
  • Multidisciplinary meetings were held in various specialties so that all necessary staff were involved in assessing, planning and delivering patient care.
  • Patients were treated with compassion, kindness, dignity and respect.
  • Chaperones were available throughout the outpatient and diagnostic imaging services. Information on the chaperone policy was displayed in clinical rooms and waiting areas.
  • Patients we spoke with felt well informed about their care and treatment.
  • Our last inspection identified issues with patients being treated in the corridor in dermatology. During this inspection, there was a dedicated room for wound care. This was an improvement.
  • Improvements had been made in the ophthalmology department to maintain patient confidentiality. During our previous inspection, two orthoptists shared a clinic room and saw patients at the same time, which did not maintain confidentiality. At this inspection we found that clinic rooms were no longer shared.
  • During our last inspection, we were not assured that patients had timely access to treatment as the trust performed worse than the England average for the percentage of patients receiving an outpatient appointment within 18 weeks of referral. However, this had improved and met the England average from April 2017 onwards.
  • The trust had improved its performance for cancer waiting times and was meeting the national standard in four out of five measures.
  • Patients had timely access to diagnostic imaging services and the percentage of patients waiting more than six weeks was lower than the England average.
  • Diagnostic imaging services were available seven days a week and patients were able to change appointments to suit their needs.
  • Outpatient specialties held additional evening and weekend clinics to reduce the length of time patients were waiting.
  • Our last inspection identified issues with lack of written information for patients prior to their appointment, for example, what to expect on the day. During this inspection, we saw letters contained detailed information for patients. This was an improvement.
  • Poor communication between medical and nursing staff was highlighted at our previous inspection for example, clinics were held that nursing staff were unaware of. During this inspection, staff said this had improved.
  • Staff completed a weekly monitoring of waiting lists and clinics flexed to meet any changes in demand or noted increased numbers.
  • A new cardiac suite had been opened and magnetic resonance imaging (MRI) was available seven days a week to meet the needs of patients.
  • There was good awareness of the needs of patients with a learning disability and dementia. Twiddle muffs were introduced for patients living with dementia attending the diagnostic imaging department to assist with restlessness as promoted by the dementia society.
  • Some departments had developed services, such as one-stop clinics, in order to better meet the needs of patients and improve service provision.
  • Staff felt that managers were visible, supportive and approachable.
  • All staff we spoke with felt respected and valued. The culture across outpatient and diagnostic imaging services encouraged openness, candour and honesty.
  • Patients, relatives and visitors were actively engaged and involved when planning services. Clinical leads led an outpatient user group to gather information on patient experience.
  • Leadership of the diagnostic imaging department was focused on driving improvement and delivering high quality care to patients. Radiology governance and risk management processes were robust and effective.
  • The service had leadership, governance and a culture, which were used to drive and improve the delivery of quality person-centred care.
  • There were high levels of staff satisfaction, and individuals were proud to work for the trust.

However:

  • We saw evidence that learning from incidents was shared across Watford General Hospital, Hemel Hempstead Hospital and St Albans City Hospital; however, this learning was predominantly within divisions and did not include services provided by different divisions. For example, staff in the main outpatient department which was run by the medical division were unaware of any learning from the never event that occurred in ophthalmology, which was run by the surgical division.
  • The World Health Organisation (WHO) five steps to safer surgery checklists had not been completed consistently for patients who had undergone minor surgery with local anaesthetic. For example, we looked at five patient records in the dermatology clinic and saw safety checklists had not been completed in three out of five records.
  • Not all band 5 nursing staff who had direct contact with children in outpatients had received level three safeguarding children training.
  • Compliance with fire safety training in the radiology department was below the trust target of 90%. Non-clinical staff compliance was 78% and clinical staff compliance was 73%.
  • Patients attending the clinic for the first time and identified as having a learning disability or living with dementia did not always have their records or referral letter flagged. This meant any adjustments could not be made prior to their attendance to facilitate their journey through the department.
  • Risks that were identified during both the previous and most recent inspections, such as missing records were not on the departmental risk register.

Urgent and emergency services

Inadequate

Updated 10 January 2018

  

  • The service was in breach of Regulation 17 and 18 HSCA (Regulated Activities) Regulations 2014 in regard to the emergency department.
  • Regulation 17 HSCA (Regulated Activities) Regulations 2014 (1) (2) (a) (b) (c)
  • Regulation 18 (1) (a) Staffing
  • We were not assured that there were sufficient staff on duty to provide safe care.
  • We were not fully assured that the consultant body within the department was working the hours required to safely staff or manage the emergency department.
  • Only 66% of nursing staff had received Paediatric Intermediate Life Support Training.
  • Training rates for safe breakaway was lower than expected for doctors and administration staff.
  • There was a lack of middle grade cover on the rota overnight and at weekends.
  • On average 65-78% of ambulances attending Watford General Hospital are delayed for more than 30 minutes.
  • Between July 2016 and June 2017 the trust reported 3211 “black breaches”.
  • Learning and outcomes from complaints were not always effectively implemented to improve care.
  • There were differences in opinions between the leaders within the service causing this dysfunctionality and it meant that the directorate leaders relationships in some cases had broken down.
  • The culture within the department had not improved to a sufficient level since our last inspection. The concerns with this culture had not been adequately addressed by the trust. This lowered staff morale.
  • The children’s emergency department was not part of an integrated governance approach to ensure all aspects of the service were included between the two responsible directorates.
  • We were not assured that all risks were being adequately identified, or incidents reported and either placed on the risk register or escalated accordingly.

However:

  • Duty of candour was evidenced by the service. The service was able to demonstrate where the duty of candour was applied following incidents.
  • Lessons from incidents were being learned.
  • We observed good hand hygiene practice, in the majority of cases, during the inspection.
  • Safeguarding of vulnerable adults and children training compliance have much improved since the last inspection.
  • The service had significantly improved the management and treatment of patients with sepsis.
  • Pain was assessed on arrival and levels of pain for children were checked at stages throughout their time in the children’s emergency department.
  • Excellent pathways of care were established within the children’s emergency department.
  • The leadership, culture and staff satisfaction within the children’s emergency department was very positive.
  • Staff engagement has improved since the last inspection.

Maternity and gynaecology

Good

Updated 10 January 2018

We rated this service as good because:

  • Staff understood their responsibilities to raise concerns and report patient safety incidents. There was a robust governance and risk management framework in place to ensure incidents were investigated and reviewed in a timely way. Learning from incidents was shared with staff and changes were made to the delivery of care because of lessons learned.
  • Staff understood their responsibilities for safeguarding vulnerable adults, children and young people and were confident to raise concerns. A dedicated team of midwives provided support, care and treatment to women who were considered to be in vulnerable circumstances. There was effective engagement with other professionals and teams to ensure women in vulnerable circumstances were protected. A female genital mutilation (FGM) clinic had been established, which provided tailored care, treatment and support to women with FGM.
  • Staff had the right qualifications, skills, knowledge and experience to do their job. There were systems in place to develop staff, monitor competence and support new staff. Mandatory training compliance figures had improved and generally met the trust target.
  • Systems were in place for assessing and responding to risk. Staff received multidisciplinary training to help them manage emergencies.
  • Women’s care and treatment was planned and delivered in line with current evidence-based practice. National and local audits were carried out and actions were taken to improve care and treatment when needed.
  • Performance outcomes and measures were regularly monitored and reviewed. Action was taken to improve performance.
  • Woman had access to care and treatment in a timely manner. Gynaecology referral to treatment times were generally better than the England average.
  • Women were positive about their care and treatment. They were treated with kindness, dignity and respect. Women felt involved in their care and were given an informed choice of where to give birth. Actions were taken to improve service provision in response to complaints and concerns received.
  • Leadership was strong, supportive and visible. The leadership team understood the challenges to service provision and actions needed to address them. Continued improvement had been made to ensure staff and teams worked collaboratively. There was a positive culture, which was focused on improving patient outcomes and experience. Staff were proud to work at the trust.

However:

  • The emergency caesarean section rate was significantly higher than the national average. However, the trust had introduced a number of initiatives to address this and the latest delivery figures showed caesarean section rates were declining.
  • The trust’s perinatal mortality rate was worse than trusts of a similar size and complexity and the number of full term babies admitted unexpectedly to the neonatal unit had increased since our previous inspection. A quality improvement plan had been developed to address this. The service was compliant with the majority of recommendations made in the MBRRACE-UK perinatal audit report.
  • Due to bed pressures, patients from other medical specialities were cared for on the gynaecology ward. This meant there were times when gynaecology patients were cancelled on the day of their planned surgery. The high number of medical outliers had had a detrimental effect on staff morale.
  • Although staffing levels and skill mix was planned and reviewed so that patients received safe care, staffing levels were generally below planned levels in both maternity and gynaecology. Bank and agency staff were used to meet staffing needs whenever possible.
  • Medicines were not always documented in line with national guidance. The trust took immediate action to address this concern. However, there had been improvement in the storage and management of medicines.
  • Not all equipment had evidence of annual safety testing.

Medical care (including older people’s care)

Requires improvement

Updated 10 January 2018

We rated this service as requires improvement because:

  • The service was found to be in breach of Regulation 10; Safe Care and Treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, due to patients not always being segregated from members of the opposite sex.
  • The service was found to be in breach of Regulation 10; Safe Care and Treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, due to personal identifiable information being on display on wards and patient sensitive information being discussed within earshot of non-authorised persons.
  • The service was found to be in breach of Regulation 12; Safe Care and Treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, due to inconsistent risk assessment and reassessment of venous thromboembolism medicine risks.
  • The service was found to be in breach of Regulation 12; Safe Care and Treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, due to antibiotic regimes not consistently being assessed after 48 hours of initial treatment.
  • The service was found to be in breach of Regulation 12; Safe Care and Treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, due to a registered nurse not always delivering care and treatment in the deep vein thrombosis clinic.
  • The service was found to be in breach of Regulation 17; Safe Care and Treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was due to nursing risk assessments not always being fully completed and patient information boards being openly displayed and discussed in sight or earshot of non-authorised persons. This meant that confidential information could be viewed or overheard.

  • There was variable compliance with infection control and prevention practices, with staff not consistently washing their hands at the appropriate points, or using hand sanitiser when exiting or entering clinical areas.
  • Flow through the hospital did not appear to always be managed effectively, with escalation areas used frequently, limiting services available and impacting patient journey.
  • Clinical specialities did not always meet the national average referral to treatment times.
  • Flood and fluid charts were not always completed as details of total input and output were missing.

However:

  • The service shared details of incidents and used these to identify any learning, sharing information across the service, through local team meetings, peer support meetings and formal mortality review meetings.
  • Safety thermometer data was used to identify areas for improvement and changed the way in which the service provided targeted training.
  • Personal protective equipment was used by staff appropriately.
  • Equipment used across all clinical areas was clean and ready for use. There was an adequate supply for the management of patient care and welfare.
  • Patients nursing and medical notes were stored securely and information was contemporaneous and accurately reflected patient care.
  • Staff mandatory training was collectively above the trust target of 90%.
  • There were processes in place to escalate patients appropriately when their clinical condition changed or deteriorated. There were support networks in place to provide support out of hours.
  • The service ensured adequate staffing levels. Locum doctors and agency nursing staff supplemented staffing numbers and integrated into the trust using generic templates and checklists.
  • Some staff had completed a training exercise in line with the major incident policy.
  • National guidance and protocols to manage patient care and treatments were reflected in service policy and procedures.
  • Patients’ pain and nutritional needs were well managed.
  • The service had achieved the highest rating for the Sentinel Stroke National Audit Programme (SSNAP) for one year.
  • The Hospital Standardised Mortality Ratio (HSMR) for the twelve-month period from January 2016 to December 2016 the HSMR was better than expected at a value of 93 compared to 100 for England.
  • For the twelve-month period from January 2016 to December 2016, the Summary Hospital-level Mortality Indicator (SHMI) was lower than expected at a value of 90 compared to 100 for England.
  • Staff training was inclusive of all staff working across the service and focused on staff development and patient safety. Internal and external courses were readily available to all staff.
  • Multidisciplinary team working was inclusive of all professions and patient centred.
  • The medical service provided over seven days, with some services such as dietetics and clinical investigations requiring a referral out of hours or at weekend.
  • There was a clear process in place for the completion of mental capacity assessments and Deprivation of Liberty Safeguards (DoLS) referrals with alignment to specific issues and detail.
  • All staff treated patients with respect and in a considerate manner. Discussions were open and inclusive. Patients and their relatives were included in decision making about treatment and care.
  • Patients and their relatives felt that they were involved with care and treatment plans.
  • The medical division was involved with trust wide development plans to realign services to other clinical areas.
  • Staff were aware of their roles in line with the trust escalation plan.
  • The service had reduced the number of inpatient moves since our last inspection.
  • Staff were able to access services to ensure patients with specialist needs were addressed. This included interpreters, patient advocates, specialist equipment such as pressure relieving mattresses and patient passports/ “This is Me” to inform care.
  • Complaints were managed effectively with responses made to complainants in a timely manner and in line with trust policy.
  • There was clear leadership across the speciality.
  • Local managers were enthusiastic about improving their ward, team and sharing knowledge.
  • Team and clinical leads were accessible and respected by all staff.
  • Staff were aware of the trust’s vision and aims.
  • Staff were committed to the trust and had pride in their role.
  • Locum staff were included in all activities and felt valued and supported.

Surgery

Requires improvement

Updated 10 January 2018

We rated this service as requires improvement because:

  • Ward staff were not protecting patients’ confidentiality, because identifiable personal information was visible in public areas on the wards and patient sensitive information was discussed within earshot of other patients and members of the public.
  • Doctors did not routinely record reassessments of patients’ risk of developing a blood clot.
  • Nearly half of ophthalmology patients were waiting more than 18 weeks for surgery.
  • When patients’ surgery was cancelled, they were not always treated within the following 28 days in line with expected standards.
  • The surgery audits on the trust’s audit register were nearly all behind schedule.
  • The theatres, recovery area and the day surgery unit needed refurbishment in order to comply with national standards.
  • Patients were sometimes cared for on the Emergency Surgical Assessment Unit (ESAU) and in recovery overnight because there were not enough available beds on the wards.
  • Surgery services were not fully engaged in the implementation of national standards or checking they were doing everything they could do prevent avoidable harm to people having a surgical procedure.
  • We found examples of consultants and doctors undermining teamwork because of their attitude to nursing staff.
  • Patients’ records were not always available at pre-operative assessment.
  • The route to administer a commonly used painkiller was not clearly documented on patients’ prescription charts.
  • Patients did not always get the written information they needed about their treatment.

However:

  • Surgery services had taken action to improve access to unplanned and planned treatment. The emergency surgical assessment unit provided timely review of patients from appropriately skilled medical staff and consultants. Most surgical patients waited less time for planned surgery than when we last inspected.
  • Surgery services leaders had a clear understanding of risks and the actions needed to manage these so that patients were kept safe from avoidable harm. They made the case for additional resources so that risks, such as a shortage of consultant staff, were eliminated.
  • There was a drive to standardise treatment and care. Examples included ward staff taking action to prevent patients getting pressure ulcers, and consultants managing patient treatment. There were a number of initiatives to improve care and treatment, such as cross-site meetings to review reasons for cancelled operations.
  • Staff followed national guidance in order to provide effective treatment and care. Surgical specialities participated in national audits and used the results to make improvements to treatment. Outcomes for surgical patients were similar to or better than the national average.
  • There was a culture that supported the reporting and learning from incidents. There was a shared understanding among all professions of the importance of being open when things did not go well. Patients were kept informed when there was an investigation of a serious incident.
  • Staff asked for feedback from patients and relatives to check they were satisfied with their care. There was a timely and responsive investigation of complaints. There was action to improve services based on feedback and complaints.
  • Patients were protected from the risk of infection because staff followed infection control practices and the premises and equipment were kept clean. Medicines were stored safely and pharmacists supported ward staff in checking that medicines were prescribed and administered safely.
  • Ward staff completed risk assessments to make sure patients were given the care and treatment they needed. However, these were not always followed up.
  • When a patient’s condition deteriorated, there was action to make sure they received a prompt review. An outreach team was available at all hours to support ward staff with a sick patient.
  • Surgery services assessed staffing levels to make sure there were enough staff to keep patients safe from avoidable harm. Locum doctors and bank or agency nurses covered vacancies, sickness or other absences. Physician assistants and the hospital at night team helped junior doctors manage their workload. There was recent recruitment of additional anaesthetists and surgeons.
  • There was work to improve the information provided to patients so that they had a better understanding of what to expect before they came to hospital. Patients and their relatives told us staff explained their treatment clearly when they were in hospital.
  • Staff followed national standards when they obtained consent for surgery.
  • Staff protected the rights of people with a mental health condition. There was an effective and patient centred process to make sure people were kept safe from harming themselves without depriving them of their liberty.
  • Patients we spoke with commented on the caring, attentive, and compassionate service they received.
  • There was effective multi-disciplinary working in some surgical specialities, which included close working relations between consultant and nursing staff.
  • Therapy staff encouraged patients to become mobile by moving around, out of bed, as soon as possible after surgery. An enhanced recovery nurse supported some patients to prepare for and to recover from surgery.
  • Staff spoke positively about working within the service and felt local and senior managers were approachable.
  • Nursing and theatre staff told us they had opportunities for professional development. Practice development support was available to all ward and theatre staff. Doctors in training were receiving appropriate training and support.

Services for children & young people

Good

Updated 10 January 2018

Overall, we rated services for children and young people as good for safe, effective, caring, responsive and well-led because:

  • Staff were confident to report incidents and staff were encouraged to raise concerns. There was a robust governance and risk management framework in place to ensure incidents were investigated and reviewed in a timely way. Learning from incidents was cascaded to staff and actions were taken to minimise risk and prevent incidents from reoccurring. This was an improvement from our previous inspection in September 2016 where feedback from staff had been mixed as to whether incident reporting was encouraged.

  • At our previous inspection in September 2016 there had been a significant division of staff concerning opinion and practice in the neonatal unit. Some staff felt this might have had an impact on patient care. Following a thematic review and implementation of the recommendations there was evidence of good local leadership from clinicians and managers. Consultants in the neonatal unit were working well together.
  • There was clear and visible leadership from the divisional clinical lead, clinicians, the lead nurse, matrons and managers who were approachable and fully engaged with providing high quality child centred care.
  • All staff were aware of the Duty of Candour Regulation and knew how to apply it which was an improvement from our last inspection in September 2016.
  • At our previous inspection in September 2016 staff did not always follow the correct security procedures for entering and exiting the neonatal unit, Starfish and Safari wards. During our inspection we observed it was not possible to enter or leave the ward and unit without being challenged by staff who always followed the correct security procedures.
  • At our previous inspection in September 2016 there was no safety thermometer on Starfish ward which was contrary to guidelines issued by the NHS. A safety thermometer was implemented in April 2017 which reported 100% harm free care on Starfish ward for the period April to July 2017.
  • At our previous inspection in September 2016, children who showed signs of deterioration were not always escalated to a senior nurse or doctor. During our latest inspection we saw in patient records that patients were appropriately escalated to either the nurse in charge or the doctor, whichever was indicated.
  • At our previous inspection in September 2016, there were gaps in management and support arrangements for staff, such as mandatory training and appraisal. During our latest inspection all staff in children’s services were achieving 93% for mandatory training and appraisal.
  • At our previous inspection in September 2016, there were a high number of cancellations of outpatient appointments for children. Children’s services had reduced cancellation rates for appointments less than six weeks. There was an improving picture for cancellations over six weeks.
  • We observed the majority of staff followed best practice guidance for infection control to reduce the risk of infection through staff washing their hands, using personal protective equipment and following sterile techniques.
  • Suitable arrangements were in place for the management of medicines which included the safe ordering, prescribing and dispensing, recording handling and storage of medicines. There was a paediatric pharmacist in post.
  • Staff treated children with kindness, dignity and respect. All parents and children we spoke with told us how “wonderful” the service was and staff always went the ‘extra mile’ when caring for children and families. There was a strong child centred culture across the service and staff told us how “proud” they were to work in the children and young people’s service.
  • Staffing levels were safe for the number and acuity of children. There were effective measures in place to ensure that when there was increased activity, staff numbers increased. There were sufficient medical staff in post to provide 24 hour, seven day a week care for babies, children and young people.
  • There were practice nurses in post to identify and deliver individual and service wide training needs. Staff had the relevant experience, knowledge and qualifications to care for and treat patients.
  • There was effective multidisciplinary team working. This included, safeguarding services, mental health services, dieticians, physiotherapists and occupational therapist, play specialists and pharmacists. There were effective working relationships with other trusts, tertiary services and external organisations.

However:

  • At our previous inspection in September 2016, there was insufficient space, which did not reflect current guidelines, in the neonatal unit. During our inspection we saw there was still insufficient space. A thematic review had been undertaken which had identified the unit to be safe in the interim and mitigating arrangements were in place to manage patient flow and safe staffing levels on a daily basis.
  • Children who were moved from inpatient wards to the operating theatre travelled along a corridor that was not fit for that purpose. However, a risk assessment was in place and a health and safety review had been undertaken to mitigate the risks to children and young people.
  • Operating theatre and recovery arrangements did not consider adequately the specific needs of children.
  • Standards of cleanliness and hygiene were not consistently maintained on Starfish ward. We raised this at the time of the inspection and senior staff immediately addressed the issues.
  • The information technology system for the paediatric diabetes service was not fit for purpose and required the clinical team to spend extensive periods of time on non - clinical activities.
  • Results from the Picker 2016 national inpatient survey for children’s services were worse than the trusts previous survey in 2014. Results were worse than average compared to similar trusts in 2016.
  • The children’s service took an average of 47 days to investigate and close complaints compared to the trust standard of 25 days.
  • Children’s services were incorporated into the trust clinical strategy 2015 - 2020 and the children’s services strategy 2017. However, not all staff in the service were clear about the longer term development of children’s services at the trust.
  • Although efforts were being made by the service to engage children and carers in feedback about the service, response rates around the Friends and Family Test were consistently low.

End of life care

Good

Updated 10 January 2018

We rated the service as good for the safe, caring, responsive and the well-led key questions. End of life services requires improvement across the effective key question:

  • The service was in breach of Regulation 11: Need for Consent Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: There was no evidence, that decision specific mental capacity assessments were always fulfilled when staff completed DNACPR forms

  • There were systems in place to protect patients from harm and a good incident reporting culture.
  • Medicines were provided in line with national guidance. We saw good practice in prescribing anticipatory medicines for patients who were at the end of life.
  • The trust had a replacement for the Liverpool Care Pathway (LCP) called the ‘individualised care plan for the dying patient’ (ICPDP). The document was embedded in practice on the wards we visited.
  • The service had produced a detailed action plan to address the shortfalls and issues raised by the national care of the dying audit of hospitals (NCDAH) 2014 to 2015. Local audits were in place to measure the effectiveness and outcomes of the service.
  • Do not attempt cardio-pulmonary resuscitation (DNACPR) records we reviewed were signed and dated by appropriate senior medical staff.
  • Relatives were happy with the care their relatives had received and felt involved in their care planning at the end of their life. Staff demonstrated compassionate patient centred care throughout the inspection.
  • Care and treatment was coordinated with other services and other providers. The specialist palliative care team had good working relationships with discharge services and their community colleagues. This ensured that when patients were discharged their care was coordinated.
  • All adult wards had compassionate care champions who were trained in providing end of life care and were a direct link to the SPCT.
  • The SPCT saw 91% of patients within 24 hours of referral.
  • The trust had an executive and a non-executive director on the trust board with a responsibility for end of life care.
  • There was a clear vision and strategy for end of life care.

However:

  • We could not find evidence that decision specific mental capacity assessments were always fulfilled when staff completed DNACPR forms. In 11 forms we reviewed, the doctor implied the patient did not have capacity. However, in four (36%) of these cases, we could not see any evidence a formal decision specific mental capacity assessment had been undertaken of the patient’s ability to understand this decision and to participate in any discussions. This meant that staff did not act in accordance with the requirements of the Mental Capacity Act 2005 (MCA) and associated code of practice.
  • The trust had systems in place to identify risks. The trust was aware of the risks for the end of life care and mortuary services.