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Watford General Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 28 February 2019

At this inspection, we inspected urgent and emergency care, medical care, surgery and maternity. We did not inspect urgent and critical care, services for children and young people, end of life care or outpatients at this inspection, but we combine the last inspection ratings to give the overall rating for the hospital.

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

  • Our rating for safe remained requires improvement overall. Mandatory training compliance did not meet the trust target of 90% and safeguarding adults and children training compliance was below the trust target for medical staff.
  • Our rating for effective remained good overall. The trust was not meeting the target of 90% for staff receiving appraisals, with one area at 54.6%. There remained a lack of monitoring of patient outcomes and compliance with evidence-based protocols in the UCC and MIU. This had previously been identified by the Care Quality Commission as an area which required improvement.
  • Our rating for caring remained good overall. All services were rated good for caring. Staff cared for patients with compassion, kindness and respect. Feedback from patients and those close to them was positive about the way staff treated them. Patients felt supported and cared for by staff. Staff provided emotional support to patients to minimise their distress.
  • Our rating for responsive remained requires improvement overall. Not all patients could access services when required. In ED, waiting times to be seen for treatment were generally higher (worse) than the England average. In surgery, waiting times from referral to treatment and arrangements to admit treat and discharge patients were not in line with good practice. In maternity, delays were reported in antenatal clinic waiting times (ANC) and Triage waiting times which had continued to be a theme from complaints. Complaints were not dealt with in a timely manner across the urgent and emergency care services, nor were lessons learned and shared at the MIU.
  • Our rating for well led improved to good overall. Some of the issues identified in our 2017 inspection had not been resolved. For example, inpatient areas had patient names displayed on white boards in areas visible to visitors walking onto the ward. Service enhancements and improvements had not been sustained at the MIU and UCC. The ED did not have effective arrangements in place to ensure information used to monitor, manage and report on performance was accurate. Information was of a poor quality with a reliance on manual processes to extract data at the MIU and UCC; this was labour intensive and did not allow for real-time reporting.
Inspection areas

Safe

Requires improvement

Updated 28 February 2019

Effective

Good

Updated 28 February 2019

Caring

Good

Updated 28 February 2019

Responsive

Requires improvement

Updated 28 February 2019

Well-led

Good

Updated 28 February 2019

Checks on specific services

Medical care (including older people’s care)

Good

Updated 28 February 2019

Our rating of this service improved. We rated it as good because:

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had a good knowledge of their responsibilities to report safeguarding concerns and make referrals. They were supported by the trust safeguarding team to do this.
  • Risks associated with infection prevention and control were controlled well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection. Audits were completed to ensure staff adhered to national guidance.
  • There were enough medical staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
  • Care and treatment provided was based on national guidance and evidence of its effectiveness. Audits were completed to make sure staff followed guidance.
  • Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary and monitored the amount they ate and drank when necessary. The service made adjustments for patients’ religious, cultural and other preferences.
  • Staff assessed and monitored patients regularly to see if they were in pain. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain.
  • Managers monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them. There was a lower than expected risk of re-admission to hospital for medicine overall.
  • Managers made sure staff had access to training and assessed their skills and competence for their role.
  • Staff worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care. We observed excellent multi-disciplinary working. Therapies staff were based on some wards and staff communicated well with each other.
  • Most staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They were able to explain how they acted in patient’s best interests when they were unable to make decisions for themselves.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff provided emotional support to patients to minimise their distress.
  • Staff involved patients and those close to them in decisions about their care and treatment. Most patients were aware of plans for their care and treatment and said they had been provided with the information they needed to help them make decisions about their care.
  • Medical services planned and provided services in a way that met the needs of local people. They worked collaboratively with stakeholders to develop services to benefit the local population.
  • Staff took account of most patients’ individual needs. Interpretation and translation services were available for people who were unable to speak English. Most staff showed a good awareness of the needs of patients with some complex needs such as those with a learning disability or autism.
  • People could access the service when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were in line with good practice.
  • Managers treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.
  • Managers the had the right skills and abilities to run a service providing high-quality sustainable care. There was some variability of experience and skills at band seven level, however, the nursing leadership team were aware of the issues and providing support and development to staff.
  • Managers had a vision for what they wanted to achieve and workable plans to turn it into action. The vision and strategy were developed with involvement from staff and key groups representing the local community.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • A systematic approach was used to continually improve the quality of services and safeguard high standards of care by creating an environment in which excellence in clinical care would flourish. We found examples of discussion at department and divisional level to identify improvements to the quality, safety and effectiveness of care.
  • There were effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. Risks were clearly identified in the divisional risk registers.
  • Managers were committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation. We found numerous examples of continuous improvement and development of services to sustain them into the future.

However:

  • Only 74% of medical staff had attended trust adult safeguarding training at level 2 as compared with a trust target of 90%.
  • The environment in which medical services were provided were not always designed and managed to ensure the safety of patients using them. We found measures to improve the safety of the environment for patients with delirium and dementia were not fully implemented and learning was not transferred to other wards. Staff reported maintenance issues, however, they were not always addressed in a timely manner.
  • Staff did not always escalate or refer patients when their risk score (NEWS) indicated a deterioration in their condition.
  • There were mostly enough nursing and theatre staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm. However, the skills and deployment of staff sometimes impacted on the timeliness and responsiveness of care.
  • When antibiotics were prescribed, there was no evidence of a review date or rationale for continuing the medicines in the medicines administration record.
  • Staff did not always receive feedback about incidents and lessons learned from them. We found examples of actions taken in response to incidents in one area, in which lessons from the incident were not applied in other similar areas. Managers did not always appraise staff’s work performance to provide support and monitor the effectiveness of the service. We also identified some concerns with the skills of two nursing staff in calming a patient living with dementia.
  • Mental capacity assessments and best interest decisions were not always documented as required.
  • We identified a lack of shower facilities and single sex toilet facilities on the medical assessment unit, which was being used to care for inpatients at the time of the inspection.
  • Adaptations to the environment on care of the elderly wards were not consistently or fully implemented, to improve the experience of patients living with dementia.
  • There were no agreed criteria for the use of the medical assessment unit as an inpatient area in times of capacity issues.
  • The trust information technology systems were slow and access to computers was an issue for staff in some areas. We also found some areas had patient names displayed on white boards in areas visible to visitors walking onto the ward.
  • We found that learning identified in one area did not always result in changes in others and some areas of concern we identified at our inspection in September 2017 had not significantly improved.

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.

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).

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.

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.

Surgery

Good

Updated 28 February 2019

Our rating of this service improved. We rated it as good because:

  • The service was committed to improving services by learning from when things went well and when they went wrong, promoting training, research, and innovation. Recruitment had improved which had in turn improved the culture and morale of the staff.
  • Mandatory training was provided in key skills to staff and generally everyone completed it. There was improving compliance with the trust target of 90% completion.
  • Infection risks were controlled well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
  • There were enough medical and nursing staff with the right qualifications, skills, training, and experience to keep people safe from avoidable harm and to provide the right care and treatment. Staffing levels were appropriate to meet patients’ needs during our inspection.
  • Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. Most nursing staff had received training on how to recognise and report abuse and they knew how to apply it
  • Patient safety incidents were managed well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary. Oversight of risk to patients on a waiting list was effective.
  • Outcomes were mainly good with the trust performing better than national average for most indicators. They compared local results with those of other services to learn from them.
  • Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care.
  • There was a vision for achievement and workable plans to turn this into actions, developed with involvement from staff and patients.
  • There was a systematic approach to continually improving the quality of services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish.
  • There were effective systems in place for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
  • Information was collected, analysed, managed, and used to support all activities, using secure electronic systems with security safeguards.
  • Patients and staff were engaged with to plan and manage appropriate services and collaborated with partner organisations effectively.

However:

  • Patients could not always access the service when they needed it. Waiting times from referral to treatment and arrangements to admit treat and discharge patients were not in line with good practice. Cancelled operations were still higher than the national average.
  • Premises were not always suitable for purpose. There had been a delay in the service’s theatre refurbishment plans. Managers were actively working on revised plans.
  • Medical staff compliance with annual refresher safeguarding training was 72% at the time of inspection.
  • Managers monitored the effectiveness of care and treatment but did not always use the findings to improve them.
  • Improvements had been made in venous thromboembolism (VTE) assessments but still did not meet trust targets. Compliance with staff debriefs post-surgery was variable.

Urgent and emergency services

Requires improvement

Updated 28 February 2019

Our rating of this service improved. We rated it as requires improvement because:

  • The service did not have effective arrangements in place to ensure information used to monitor, manage and report on performance was accurate.
  • Appropriate records of patients’ care and treatment were not always kept. Records were not always up-to-date and were sometimes completed retrospectively. Mental health risk assessments completed by the mental health provider were not available to ED staff.
  • Not all patients could access the service promptly when they needed it. Waiting times to be seen for treatment were generally higher (worse) than the England average. More patients waited longer than four hours for a decision to admit, treat or discharge than the England average.
  • We were not assured that adult patients with mental health concerns were appropriately monitored at all times.
  • Patient confidentiality was not always protected due to the layout of the main reception area and location of the streaming window.
  • The emergency department was generally unsecured.
  • Not all staff had received an annual appraisal.
  • The Friends and Family Test response rate was worse than the England average.

However:

  • Staff cared for patients with compassion, kindness and respect. Feedback from patients and those close to them was positive about the way staff treated them. Staff involved patients and those close to them in decisions about their care and treatment. Actions were taken to improve service provision in response to complaints and feedback received.
  • The service had sufficient medical and nursing staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. This was an improvement since the last inspection in 2017. Mandatory training in key skills was provided and most staff were up to date with annual refresher training.
  • Staff understood their responsibilities to raise concerns and report patient safety incidents. There was an effective 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.
  • Care and treatment was planned and delivered in line with current evidence-based guidance. National and local audits were carried out and actions were taken to improve care and treatment when needed. While the service did not generally meet national standards, performance was mostly comparable with national averages.
  • Leadership was strong, supportive and visible. The leadership team understood the challenges to service provision and actions needed to address them. There was a positive culture within the emergency department and staff were committed to providing the best possible care for patients.
  • The service had a vision of what it wanted to achieve and clear objectives to ensure the vision was met. Issues with capacity and flow in the department were now seen as a hospital-wide concern, and staff from all areas were working together to improve ED performance and the patient experience.
  • The service had made significant improvements in ambulance turnaround times since our last inspection.

Maternity

Good

Updated 28 February 2019

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

  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance. Local and national audits were completed and actions were taken to improve care and treatment when indicated.
  • Staff cared for women and babies with compassion and they were motivated to provide care that promoted women’s privacy and dignity. Feedback from women and relatives confirmed staff treated them well and with kindness.
  • The service planned and delivered services in a way that met the needs of local people. The importance of choice and continuity of care was reflected in future maternity care provision.
  • The maternity service took account of women’s individual needs, including those who were in vulnerable circumstances or had complex needs. Bereavement care provision was in place to support families from their initial loss throughout their time in hospital and return home.
  • Maternity services had a clear vision and set of values which focused on quality and safe care. The service was reviewing its vision, values and maternity strategy which were expected to be completed by March 2019.
  • Governance arrangements were proactively reviewed and reflected best practice. The service used a systematic approach to improving quality of its services and safeguarding high standards by creating an environment in which the quality of care could flourish.
  • Staff recognised incidents and reported them appropriately. Managers investigated incidents and provided feedback to staff. Lessons were learnt as a result of incidents and actions monitored. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The service had suitable premises and equipment and looked after them well. Equipment was checked at regular intervals to ensure it was safe to use. The service continued to review the security arrangements of its premises to ensure the safety of women and babies.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies. The trust target of 90% completion was met for the majority of safeguarding children training.
  • The service monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them.
  • Although the service had sufficient midwifery staff with the right qualification, skills, training and experience at the time of the inspection, staff raised concerns about staff shortages. Suitable measures were in place through appropriate use of bank and agency staff which kept women and babies safe and provided the right care.
  • The service followed best practice when prescribing, giving, recording and storing medicines. Patients received the right medication at the right dose at the right time.
  • Women’s and babies’ nutrition and hydration needs were identified, monitored and met. Pain was assessed and managed well on an individual basis and was regularly monitored by midwifery and nursing staff.
  • Leaders had a shared purpose and strived to deliver and motivate staff to succeed. Although there were high levels of satisfaction among the majority of staff, satisfaction and morale amongst some staff was mixed.

However:

  • Staff in triage and the Maternity Day Assessment Unit (MDAU) were not always aware of best available evidence and plans for the management and care of women with reduced fetal movements.
  • Records on delivery suite were not written clearly by medical staff and signatures were not always printed and were not legible.
  • Mandatory training compliance for staff in maternity services was variable as staff were not meeting the trust target of 90% for mandatory training.
  • Safeguarding training compliance for medical staff was variable as staff were not meeting the trust target of 90% for children and adults training at levels 1 and 2.
  • Delays were reported in antenatal clinic waiting times (ANC) and Triage waiting times which had continued to be a theme in patient complaints.
  • A theme from complaints was the delay in administration of pain relief. The service was taking appropriate steps to address concerns and action plans were in place.
  • Functionality and interface of information technology systems was impacting on care quality and staff morale. There was a lack of information technology support in the hospital and connectivity issues in maternity teams in the community.