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Worcestershire Royal Hospital Inadequate

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

Inspection Summary


Overall summary & rating

Inadequate

Updated 5 June 2018

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

  • Patients could not access services when they needed them. Waiting times for treatment were not in line with good practice. The percentage of patients whose operation was cancelled and were not treated within 28 days was worse than the national average.
  • Not all systems in place were effective in recognising and responding to deteriorating patients’ needs. This included harm reviews of patients waiting for a procedure.
  • The trust was performing worse than the England average for patients waiting over 60 minutes before being handed over to emergency department staff. Not all patients were recorded as being seen by a specialist doctor despite being referred.
  • The trust did not ensure everyone completed mandatory training.
  • While staff understood the need to protect patients from abuse, not all staff had completed training at the required level to ensure they had the appropriate level of knowledge to do so.

  • There were inconsistencies in staff being able to recognise and report incidents. Mixed sex breaches were not always reported.
  • Not all staff had received an appraisal. Not all staff received supervision to provide support and monitor the effectiveness of the service.
  • Some areas did not have enough 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.
  • The hospital had medical staff with the right qualifications, skills and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. However, there was insufficient medical cover to provide consultant presence in the department for 16 hours a day, as recommended by Royal College of Emergency Medicine.
  • The trust did not have effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. Not all risks identified during the inspection were documented on risk registers.
  • The trust planned but did not provide services in a way that met the needs of local people.
  • Services did not always have a documented vision or strategy.
  • Information was not always collected, analysed, managed and used well to support activity.
  • There were inconsistencies with infection control and prevention techniques, particularly hand hygiene.
  • Processes to monitor the safe storage of medicines were not always followed.
  • There was no privacy and very little confidentiality for patients waiting on trolleys in the emergency department corridor. Staff did not use privacy screens.

However:

  • Managers investigated reported incidents and shared lessons learned with the whole team. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The hospital had suitable premises in most areas and systems were in place to ensure most equipment was well looked after.
  • The hospital prescribed, gave, and recorded medicines well. Patients generally received the right medication of the right dose at the right time.
  • Staff ensured that patients’ individual care records were well managed and stored appropriately.
  • Generally, the hospital provided care and treatment based on national guidance and evidence of its effectiveness.
  • The hospital managed patients’ pain effectively and provided or offered pain relief regularly.
  • Staff generally gave patients enough food and drink to meet their needs and improve their health.
  • Multidisciplinary staff worked together as a team to benefit patients.
  • 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 managers, but not all, across the hospital promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
Inspection areas

Safe

Inadequate

Updated 5 June 2018

Effective

Requires improvement

Updated 5 June 2018

Caring

Good

Updated 5 June 2018

Responsive

Inadequate

Updated 5 June 2018

Well-led

Inadequate

Updated 5 June 2018

Checks on specific services

Outpatients and diagnostic imaging

Inadequate

Updated 20 June 2017

We rated the outpatients and diagnostic imaging services as inadequate because:

  • There was a lack of radiation protection infrastructure.
  • There was inadequate review and document control of protocols for standard x-ray examinations. Some protocols were in a handwritten format with alterations made by various members of staff without apparent ratification.
  • Aging and unsafe equipment across the trust that was being inadequately risk rated with a lack of capital rolling replacement programmes in place.
  • There have been two patient safety incidents in the trust whereby patients had been physically injured by unsafe x-ray equipment.
  • Whilst staff were aware of their roles and responsibilities with regards to reporting patient safety incidents, incident reporting in outpatients was low and where incidents had been reported, the dissemination of lessons learnt was insufficiently robust.
  • The trust was failing to meet a range of benchmarked standards with regards to the time with which patients could expect to access care.

However:

  • Staff were dedicated and caring.
  • Patients were treated with kindness, dignity and respect and were provided the appropriate emotional support.
  • The premises were visibly clean.
  • The process for keeping patients informed when clinics overran was established and well managed.
  • Leadership within the outpatient’s team was visible however, the management of risk was insufficiently robust and further improvements were necessary.

Maternity

Good

Updated 5 June 2018

We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings.

We rated this service as good overall because:

  • Staff cared for patients with compassion, kindness, dignity and respect. Women were overwhelmingly positive about their care and treatment, and felt staff often went “the extra mile”. 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 feedback received.
  • 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.
  • Women’s 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. Patient outcomes were generally in line with national averages.
  • Service provision met the needs of local people. They worked closely with commissioners, clinical networks and service users to plan and improve the delivery of care and treatment for the local population.
  • Leadership was strong, supportive and visible. The leadership team understood the challenges to service provision and actions needed to address them. Staff were committed to providing the best possible care for women. However, some community staff did not feel part of the overall maternity service.
  • The service had a vision of what it wanted to achieve and clear objectives to ensure the vision was met. The vision and strategy was developed with involvement from patients and key groups within the local community, and reflected national recommendations for maternity care provision.

However:

  • Medical staff compliance with safeguarding adults and children training was below the trust target. Furthermore, the majority of staff had not completed the appropriate level of Mental Capacity Act 2005 and deprivation of liberty safeguards training.
  • Maternity specific training compliance did not always meet trust targets, such as cardiotocography (CTG) interpretation. Some staff did not have up-to-date competency in CTG assessment.
  • Not all community midwives had access to carbon monoxide monitors. This meant some women did not have a carbon monoxide reading taken at the initial antenatal appointment. This was not in line with national recommendations.
  • Prescription charts were not always completed with patient’s weight or allergy status, which was not in line with national standards.
  • Not all staff had received an annual appraisal.
  • Trust data showed that compliance with CTG trace peer reviews had generally worsened since our previous inspection (November 2016). However, during our inspection we observed CTG peer reviews were completed.

Outpatients

Inadequate

Updated 5 June 2018

  • The service did not ensure everyone completed mandatory training. The trust target for mandatory training compliance was not met for all nursing staff.
  • Not all staff had received the appropriate level of safeguarding training on how to recognise and report abuse.
  • There were not enough pharmaceutical 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.
  • Effective systems were not always used to recognise and respond to deteriorating patients’ needs.
  • Most but not all staff had received an appraisal.
  • Continuous improvement, and learning from when things go wrong was not evident across all areas.
  • Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care. Most, but not all records were contemporaneous and not all ensured patient confidentiality.
  • The trust planned but did not provide services in a way that met the needs of local people.
  • Patients could not access the service when they needed it. Waiting times for treatment were not in line with good practice.
  • The service did not have a documented vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.
  • The service did not have a fully embedded systematic approach to continually monitor the quality of its services.
  • Not all systems in place were effective in recognising and responding to deteriorating patients’ needs. This included harm reviews of patients waiting for a procedure.
  • Information was not always collected, analysed, managed and used well to support activity.

However:

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • The service generally controlled infection risk well. Most staff kept themselves, equipment and the premises clean. Control measures were in place to prevent the spread of infection.
  • Most staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team.
  • The service had suitable premises in most areas and systems were in place to ensure equipment was well looked after.
  • Most areas had enough 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.
  • The service managed medicines well. Patients received the right medication at the right dose, and most patients received this at the right time.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness.
  • The service managed patients’ pain effectively and provided or offered pain relief regularly.
  • Staff generally gave patients enough food and drink to meet their needs and improve their health.
  • The service monitored the effectiveness of care and treatment and used the findings to improve them.
  • The service took account of patients’ individual needs.
  • Multidisciplinary staff worked together as a team to benefit patients.
  • 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.
  • Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

Maternity and gynaecology

Updated 8 August 2017

We carried out a focused inspection to review concerns found during our previous comprehensive inspection on 22 to 25 November 2016. We inspected parts of four of the five key questions but did not rate them. We found significant improvements had not been made in these areas:

  • Although perinatal mortality and morbidity meetings were minuted, there was no evidence that action was taken to address learning from case reviews. We were not assured an effective system was in place to ensure learning from perinatal mortality and morbidity meetings was shared, and actions were taken to improve the safety and quality of patient care.
  • Staff did not consistently follow trust processes for storing medicines at the recommended temperatures, despite there being policies in place.

We also found other areas of concern:

  • There was no system in place to ensure medicines stored in the emergency gynaecology assessment unit were safe for patient use. Immediate action was taken by the trust once we raised this as a concern.
  • Training data showed that 86% of midwifery staff and 53% of medical staff had completed safeguarding children level three training. This was an improvement from our previous inspection. However, compliance was still below the trust target of 90%, particularly with medical staff.
  • The waiting room and toilet facilities for patients attending the emergency gynaecology assessment unit were mixed sex, as these were shared with the respiratory outpatient clinic. Furthermore, this assessment unit did not have appropriate facilities such as bathrooms, to facilitate personal care for patients who had to stay overnight at times of increased bed pressures.

However, we observed improvements for the following:

  • Standards of cleanliness and hygiene were well maintained. Staff adhered to infection control and prevention guidance.
  • Effective systems had been introduced to ensure emergency equipment was checked daily. Equipment was well maintained and had been safety tested to ensure it was fit for purpose.
  • The hospital did not have a dedicated gynaecology inpatient ward. This meant some patients stayed overnight in the outpatient emergency gynaecology assessment unit and were nursed in medical wards. However, the trust had put processes in place to ensure patients were cared for in environments that were suitable for their needs.
  • The number of staff who had completed Mental Capacity Act and Deprivation of Liberty Safeguards training had improved.
  • Daily ward rounds by a gynaecology consultant and nurse were carried out to ensure gynaecology patients were appropriately reviewed and managed, regardless of location within the trust.
  • Staff caring for gynaecology patients on Beech B1 ward had received training on bereavement care, including early pregnancy loss and the management of miscarriage.
  • Risks identified were reviewed regularly with mitigation and assurances in place. Staff were aware of the risks and the trust board had oversight of the main risks within the service.

Medical care (including older people’s care)

Requires improvement

Updated 17 January 2018

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

  • Ward nurse staffing levels were frequently below the nurse establishment particularly at night. Ward managers escalated any concerns with patient acuity and staffing to arrange additional support where possible.
  • Staff skills in the Trauma Assessment Unit and Silver Oncology Unit did not necessarily meet the requirements for the patients cared for within these areas. There were plans in place to address this in the Silver Oncology Unit.
  • Senior medical cover, at night was minimal, with one registrar responsible for all medical inpatient areas and acute admissions.
  • Mandatory training figures did not meet the trust target of 90%. This included poor compliance with safeguarding children and vulnerable adults training in nurses and doctors.
  • There was poor compliance with Mental Capacity Act 2005 training amongst nurse and doctors.
  • Appraisal rates for medical and nursing staff did not meet the trust target of 90%.
  • Escalation areas, such as the trauma assessment unit, were not always fully equipped to meet the demands of inpatient care.
  • There was variable performance in national audit outcomes. For example, the Hospital Standardised Mortality Ratio and Summary Hospital-level Mortality Indicator was worse than expected.
  • The upper gastrointestinal endoscopy performance was worse than expected and the Joint Advisory Group accreditation had been deferred following a recent inspection of endoscopy services.
  • The stroke service did not provide a seven day transient ischaemic attack clinic in line with national guidance.
  • The service performed worse than the national average in the dementia care audit.
  • The service reported a high number of patient bed moves between 10pm and 8am.
  • Patient complaints were not responded to within the 25 days outlined in trust policy.
  • There were variable accounts of clinical leadership, with some reports that specialities were disjointed due to differing consultant opinions. Staff reported that this affected cross-site working.
  • There were pockets across the service where changes were not established.

However, we also found that:

  • Equipment was checked annually for fitness for purpose.
  • Patients were assessed on admission and at regular intervals using nationally recognised assessment tools. Patient records were up to date, clearly written and held securely.
  • The service had introduced a safer staffing application, which was used to monitor staffing across the hospital, enabling senior staff to identify areas of pressure.
  • Medicines were stored appropriately with processes in place for monitoring usage and safe storage. Medicines were prescribed and administered in line with guidance and patients received the right dose at the right time.
  • There were robust processes in place for the recording, escalation and sharing of learning from incidents.
  • Policies and processes used were based on national guidance.
  • Patient’s pain was assessed and monitored with processes in place to offer appropriate pain control and refer for additional support when necessary.
  • Patients were treated with compassion, respect with dignity maintained at all times.
  • Capacity and flow had been reviewed with ward managers taking the responsibility for pulling patients to speciality wards to ensure that patients were located in the correct environment for their clinical condition.
  • Leadership had been reconstructed and staff felt that this had improved the progression of the service.
  • Staff felt supported, able to challenge, and felt listened too.
  • The service used divisional dashboards to review and monitor performance. This was discussed locally within the division and escalated to the trust board for oversight of performance.
  • The service used a risk register to identify risks to the service and any mitigating actions taken to reduce risk.

Diagnostic imaging

Requires improvement

Updated 5 June 2018

We previously inspected diagnostic imaging jointly with outpatients and therefore, ratings cannot be directly compared to this core service only. We rated the service as requires improvement because:

  • The service failed to meet trust targets for most mandatory training topics, including safeguarding adults and children and Mental Capacity Act 2005.
  • There were inconsistencies with infection control and prevention techniques, particularly hand hygiene.
  • Although the premises and equipment were suitable and well looked after, the environment did not always provide appropriate waiting areas for patients. This meant that the service did not always take into consideration the patients’ individual needs.
  • Appraisal rates for all staff groups were below the trust target.
  • Patients’ needs were not always addressed.
  • Patients could not always access the service when they needed it. Waiting times for referral to treatment and reporting on investigations were variable.
  • Reporting times were not consistently within targets.
  • There was limited engagement with patients and service users.

However:

  • Equipment and premises were clean.
  • The service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and abuse and to provide the right care and treatment. The service outsourced activity to ensure timely treatment was provided.
  • There were processes in place to store, administer and manage medicines safely.
  • Patient safety incidents were reported, investigated and any learning shared across all areas.
  • Care and treatment was provided in line with national guidance. Policies and procedures were up to date.
  • There was effective team working across all staff groups.
  • Staff were compassionate and caring.
  • We saw some outstanding examples of patient care. Staff made additional efforts to ensure that children attending the departments had a positive experience. Clinicians spoke directly to them, putting then at ease. Distractions activities were also used.
  • Patients and their relatives were included in care and treatment and provided with support throughout investigations.
  • Patients were able to access services across all sites.
  • Complaints and concerns were investigated fully and actions taken to reduce reoccurrence.
  • The service had managers with the right skills and abilities to run a service providing high-quality sustainable care. Managers promoted a positive culture that supported and valued staff.
  • Staff were generally happy with their work and the team.
  • There was a strong culture for delivering high-quality care.
  • The service had effective systems for identifying risks, planning to eliminate or reduce them, and a systematic approach to continually improving the quality of its services.
  • The service was committed to improving services by learning from when things go well and when they go wrong.

Urgent and emergency services (A&E)

Inadequate

Updated 5 June 2018

  • Not all systems in place were effective in recognising and responding to deteriorating patients’ needs. The trust was performing worse than the England average for patients waiting over 60 minutes before being handed over to emergency department (ED) staff. Not all patients were recorded as being seen by a specialist doctor despite being referred.
  • The service did not ensure everyone completed mandatory training. The trust target for mandatory training compliance was not met for nursing or medical staff.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. However, the service had not met the national trajectory of 85% by March 2018 in PREVENT training as set out by the NHS England.
  • The service did not control infection risks well. There was poor compliance with the use of control measures to prevent the spread of infection.
  • During the previous inspections of November 2016, April 2017 and November 2017 we highlighted concerns regarding the completion of the 24 hour re-assessment regarding venous thromboembolism. During this inspection we saw that the concern remained which meant they were not compliant with the National Institute for Health and Care Excellence (QS3) guidance.
  • The service had medical staff with the right qualifications, skills and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. However, there was insufficient medical cover to provide consultant presence in the department for 16 hours a day, as recommended by Royal College of Emergency Medicine.
  • Mortality and morbidity remained an area of concern during the previous inspection of November 2017 and had not improved. During this inspection we found that reviews lacked detail and there was little evidence of actions or learning as a result.
  • Staff cared for patients with compassion. However, there was no privacy and very little confidentiality for patients waiting on trolleys in the corridor. Staff did not use privacy screens.

However:

  • The service managed patient safety incidents 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 kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care.
  • The service had enough nursing staff with the right qualifications, skills and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • Generally the service prescribed and stored medicines well.
  • Staff cared for patients with compassion. Feedback from most patients confirmed that staff treated them well and with kindness.
  • Staff provided emotional support to patients to minimise their distress.

Surgery

Inadequate

Updated 5 June 2018

Our rating of this service went down. We rated it as inadequate because:

  • Not all systems in place were effective in recognising and responding to deteriorating patients’ needs.
  • The service did not ensure everyone completed mandatory training. The trust target for mandatory training compliance was not met for nursing or medical staff.
  • Most nursing staff had received safeguarding training on how to recognise and report abuse. However, not all medical staff had completed safeguarding training to the required level.
  • Processes to monitor the safe storage of medicines were not followed. Room and fridge temperatures were not routinely monitored.
  • Staff recognised incidents but did not always report them. Mixed sex breaches were not always reported.
  • Some areas did not have enough 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.
  • The service did not have robust processes in place to ensure staff were competent for their roles.
  • Not all staff had received an appraisal. Not all staff received supervision to provide support and monitor the effectiveness of the service.
  • Most staff had not received training in the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards. Staff generally understood their roles and responsibilities under the Mental Health Act 1983 and the MCA.

  • The trust planned but did not provide services in a way that met the needs of local people.
  • Patients could not access the service when they needed it. Waiting times for treatment were not in line with good practice. The number of cancelled operations for non-clinical
  • The service did not have a documented vision for what it wanted to achieve. However, plans for the future vision were in development with involvement from staff, patients, and key groups representing the local community. Not all ward staff and managers across the service promoted a positive culture that supported and valued one and other.
  • The service had a systematic approach to continually monitor the quality of its services, however, this was not fully embedded.
  • Not all systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected were effective.
  • Information was not always collected, analysed, managed and used well to support activity.
  • Continuous improvement, and learning from when things go wrong was not evident across all areas.

However:

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
  • The service had suitable premises in most areas and systems were in place to ensure equipment was well looked after.
  • The service had enough medical staff with the right qualifications, skills, and experience to keep people safe from avoidable harm and abuse.
  • Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care.
  • The service used some safety monitoring results well. Staff collected safety thermometer information and shared it with staff, patients and visitors.
  • The service prescribed, gave, and recorded medicines well. Patients generally received the right medication of the right dose at the right time.
  • Managers investigated incidents. There were systems in place to share lessons learned. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • Generally, the service provided care and treatment based on national guidance and evidence of its effectiveness.
  • The service managed patients’ pain effectively and provided or offered pain relief regularly.
  • Staff generally gave patients enough food and drink to meet their needs and improve their health.
  • The service monitored the effectiveness of care and treatment and used the findings to improve them.
  • Multidisciplinary staff worked together as a team to benefit patients.
  • 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.

Intensive/critical care

Requires improvement

Updated 20 June 2017

We rated critical care as requiring improvement because:

  • We found that clinical incidents were not always categorised accurately or reported externally. We saw evidence that staff remained confused as to what constituted a near miss incident and reported incidents as a near miss when patients were placed at risk.
  • Outside of critical care, staff felt pressurised and unsupported. Nursing staff felt that patient care was not a priority to the trust.
  • The executive team were not visible across the organisation and staff felt that the lack of a permanent executive team affected progress.
  • Nursing records within the high dependency units were not always contemporaneous, with data entries being completed at the end of clinical shifts and not when events occurred.
  • The clinical environment for the critical care and high dependency units did not meet all the recommendations set out in the Health Building Note 04-02 Critical care units’ standards. This included limited washing and toileting facilities for mobile patients on the critical care and high dependency units.
  • Staff did not always adhere to infection control and prevention practices.
  • Consultants were responsible for the management of children admitted as an emergency until transfer to a children’s specialist hospital was arranged.
  • Patients on the high dependency units who were categorised as level two due to arterial line being in situ were not provided with additional screens or privacy when placed in beds opposite a member of the opposite sex.
  • We saw that venous thromboembolism assessments were not always completed in line with recommendations, with the repeat assessment after 24 hours of admission missing.
  • Mandatory training compliance did not always meet the trust target. High dependency staff had not completed critical care handbooks at the time of inspection, although these were in progress.
  • Medical consultants were not always allocated to the care of patients following discharge from critical care, which affected patient follow up after discharge.
  • There was a limited follow up service for patients discharged from critical care with no provision of a formal medical lead clinic.

However:

  • Critical care staff completed a daily safety brief where they discussed any incidents or complaints and identified learning. Learning was also shared across the service at team meetings.
  • Appropriate staff regularly reviewed patients. Medical teams reviewed patients a minimum of twice daily. The critical care outreach service assisted with the monitoring and treatment planning of sick patients across the trust, providing local support for teaching and monitoring of compliance in trust wide deteriorating patient audits.
  • Critical care were able to ensure safety across the county wide service by transferring skilled staff to assist with the management of patient care according to need.
  • The service had implemented a weekly multidisciplinary team meeting to review patient’s rehabilitation needs.
  • Critical care used evidence based patient pathways, policies and protocols to provide care.
  • Trust data published by the Intensive Care National Audit and Research Centre detailed that the service performed in line with similar sized organisations and as expected.
  • The service provided a seven-day service with access to specialists, such as dietetics and pain specialists, for additional treatments or advice. Specialist were involved with the planning of treatments and participated in multidisciplinary team meetings.
  • The service had a robust training programme for staff that included the use of a competency handbook, local training support from the practice development nurses and scenario based training.
  • Patients and their relatives were treated in a compassionate, respectful manner. Staff provided privacy for relatives and patients. Patients and their relatives were supported during their stay within critical care with staff offering opportunities to discuss care and treatment.
  • There were additional facilities within the critical care unit, which enabled patient’s relatives or loved ones to stay on site. There were also facilities for those requiring additional support for aspects such as learning disabilities, translation services.
  • Staff and relatives used patient diaries to record events. These helped patients understand what had happened whilst they were sedated.
  • There were systems in place to address formal and non-formal complaints. The most relevant persons completed investigations and responses and learning shared amongst the team though open discussion and team meetings.
  • Critical care had a vision of the service, which reflected the trust core values. This included the plans to centralise critical care services and build a high dependency unit.
  • The service had a robust governance structure and cascaded service performance data to the trust board and to staff on the units.
  • Local leaders were reported as being supportive, accessible and approachable.

Services for children & young people

Requires improvement

Updated 5 June 2018

Our overall rating of this service has improved since our November 2016 inspection when we rated it inadequate. At this inspection in January 2018, we rated it as requires improvement because:

  • The service did not always have enough nursing staff with the right qualifications, skills, training, and experience to keep patients safe from avoidable harm and abuse and to provide the right care and treatment.
  • While staff understood the need to protect patients from abuse, not all staff had completed training at the required level to ensure they had the appropriate level of knowledge to do so. Awareness of female genital mutilation and child sexual exploitation was variable.

  • Staff had not received mental health training, which meant we could not be assured that staff understood how to appropriately support the needs of children and young people with mental health concerns.
  • Staff did not always have an effective understanding of how to correctly gain consent from children and young people, and the national guidance around this. For example, three of the eight staff we asked, were not able to explain the principles of the Gillick competency and Fraser guideline, which are used to make decisions about the ability of a young person to consent to procedures.
  • The service did not always take account of patients’ individual needs. For example, there was no designated room on the neonatal unit to enable sensitive discussions to take place in privacy.
  • The divisional leaders had limited operational oversight of day-to-day issues within the service, such as risk, staffing issues and services for children provided in the adult outpatient departments and wards.
  • The culture of the senior leadership team within the service was a concern. Staff reported that these individuals did not recognise the improvements staff had already made within the service, and instead, solely focussed on areas that needed improvement.
  • The service did not have effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. Not all risks identified during the inspection were documented on the service’s risk register. For example, the service had expanded its oncology service without employing additional staff and this potential risk was not recorded on the risk register.

However:

  • The assessment and management of risks to patient safety had improved and patients received assessments, treatment, and observations in a timely way.
  • Staff ensured that patients’ individual care records were well managed and stored appropriately. Records seen were accurate, legible, up to date and available to all staff providing care.
  • The service used current evidence-based guidance and best practice standards to inform the delivery of care and treatment, and evidence its effectiveness. Pathways were written in line with the National Institute for Health and Care Excellence and Royal College of Paediatrics and Child Health guidelines.
  • 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. Outcomes were generally better than national average.
  • Staff cared for patients with compassion. Feedback from patients and parents confirmed that staff treated them well and with kindness.
  • Patients could generally access the service when they needed it. Waiting times for treatment met national standards and had improved since our inspection in November 2016. Arrangements to admit, treat and discharge patients were generally in line with good practice.

End of life care

Good

Updated 20 June 2017

We rated end of life care as good because:

  • Staff understood their responsibilities to raise concerns and to record safety incidents. Incidents relating to end of life care were reviewed by the lead nurse for specialist palliative care.
  • There was good identification of patients at risk of deterioration and identification of patients in the last days of life.
  • The trust had taken action to improve the facilities in the mortuary since a previous inspection. This included replacing fridges, flooring and improving the hot water facilities.
  • There was clear evidence of the trust using national guidance to influence the care of patients at the end of life. A comprehensive programme of end of life care training was available for the full range of staff within the trust.
  • There was good evidence of multidisciplinary working and involvement of the specialist palliative care team throughout the hospital including allied healthcare professionals as well as medical and nursing members. The specialist palliative care team provided a seven day face to face assessment service across the trust.
  • People were supported, treated with dignity and respect and told us they felt involved in their care. We observed staff communicating with patients and relatives in a manner than demonstrated compassion, dignity and respect.
  • Patients and relatives told us that the staff were caring, kind and respected their wishes. People we spoke with were complimentary about the staff and told us they felt appropriately supported.
  • The specialist palliative care team responded quickly to referrals and typically would see patients within a few hours if the need was urgent. The majority (92%) of patients were seen within 24 hours and there was a good balance between cancer and non-cancer referrals.
  • The specialist palliative care team worked proactively with the emergency department to identify patients who may benefit from palliative care input.
  • The trust had begun to record and audit preferred place of care at the end of life and there were clear systems in place to make improvements in this area.
  • The specialist palliative care team had audited complaints that had an end of life care component, identified trends and had taken action to address improvements.
  • There was a clear vision for the service and a draft strategy was in place, highlighting the key areas the trust were focusing on in relation to end of life care.
  • There was consistent promotion of the delivery of high quality person centred care and strong leadership for end of life care. Staff were consistently passionate about end of life care, positive about their roles and consistent in their belief that the quality of end of life care was good.
  • Innovations included close working between the specialist palliative care team and emergency department staff to identify patients at the end of life and provide specialist support. The trust was one of ten that had been chosen to participate in a quality improvement partnership with The National Council for Palliative Care and Macmillan Cancer Support.

However:

  • Discussions around DNACPR (do not attempt cardiopulmonary resuscitation) decisions were not always sufficiently recorded within patient’s medical records.
  • Feedback from relatives and staff showed there had been some delays in obtaining death certificates, although we saw that this had been discussed at the meeting of the bereavement group and we were told the lead nurse was taking the lead on addressing this issue.