You are here

Inspection Summary


Overall summary & rating

Good

Updated 14 March 2019

  • Staff understood how to protect patients from abuse and the services 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.
  • Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary.
  • The service mostly had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment, however actual staffing levels did not always meet planned levels.
  • The services provided care and treatment based on national guidance and monitored patient outcome to monitor for the effectiveness.
  • 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 involved patients and those close to them in decisions about their care and treatment.
  • The trust planned and provided services in a way that met the needs of local people.
  • The services took account of patients’ individual needs.
  • Managers at all levels in the core services had the right skills and abilities to run a service providing high-quality sustainable care.
  • The trust had a 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 trust was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.

Inspection areas

Safe

Good

Updated 14 March 2019

Effective

Good

Updated 14 March 2019

Caring

Outstanding

Updated 14 March 2019

Responsive

Good

Updated 14 March 2019

Well-led

Good

Updated 14 March 2019

Checks on specific services

Medical care (including older people’s care)

Good

Updated 14 March 2019

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

  • Patients were protected from avoidable harm and abuse.
  • Patients had good outcomes because they received effective care and treatment that met their needs.
  • Patients were supported, treated with dignity and respect, and were involved as partners in their care.
  • Patients’ needs were met through the way services were organised and delivered.
  • The leadership, governance and culture promoted the delivery of high quality person centred care.

However:

  • Patients medicines were not always stored in a locked cupboard.
  • Potassium infusions were not stored separately from other infusions.
  • Some drug fridges had two thermometers and staff were not clear what the purpose of the second thermometer was.
  • Mental Capacity assessments were not always reviewed as required.

Critical care

Outstanding

Updated 8 March 2016

We found the adult critical care services were good for safe, effective, and responsive, and outstanding for caring and well led.

There was a genuinely open and honest culture in which incidents and concerns were shared across the services and changes implemented to improve patient safety. National, trust, and local audit data was used to support service improvements.

Internal training and support for staff development was of a good standard and well established, however we did have concerns about limited access to the critical care module for registered nurses in CCD.

Care was patient centred and continually assessed on an individual basis. Emphasis was placed on the safeguarding of patients who were unable to communicate due to their clinical condition.

Patients and visitors consistently expressed satisfaction with the care and treatment they received stating that staff were very kind, caring and nothing was too much trouble.

There was a collective enthusiasm across all staff groups with a clear knowledge of the vision, values and strategic goals for the adult critical care and cardiac critical care services.

Staff told us they were proud to work in the department, felt very supported in their work and their opinions were valued.

End of life care

Good

Updated 14 March 2019

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

  • Staff had a good understanding of how to protect patients from abuse and could describe what safeguarding was and the process to refer alerts.

  • Staff were aware of the trusts whistleblowing procedures and what action to take if they had concerns.

  • There were comprehensive risk assessments completed in the medical and nursing notes. These were commenced on admission and there was evidence that risk assessments continued throughout the patients stay in hospital.

  • We saw good examples of good multi-disciplinary working and involvement of other agencies and support services.

  • All patients and their relatives we spoke with, told us they were fully included in discussions around their plan of care.
  • The chaplaincy service had a key performance indicator of for referral to treatment times for emergency and urgent calls. Data showed that from January 2018 to October 2018, the chaplaincy service had achieved 98% against the trust target of 95%.
  • There were systems in place to ensure that staff affected by the experience of caring for patient at end of life were supported. For example, staff had access to counselling, and alternative therapies through a self-referral system.
  • Staffing ratios at Hayward house had improved since our last inspection and were now meeting the needs of the patients
  • The Trust had implemented the SWAN model of care across the organisation in November 2017, enabling staff to prioritise the patients and families’ priorities and recognise the future bereavement of the families going forward, thereby providing person centred care

However:

  • There were no audits to identify the ratio of cancer to no-cancer patients treated by the service
  • The CQC had previously identified that the service did not monitor if end of life patients died in their preferred place of death. This was still not being undertaken
  • The trust did not separately monitor delayed transfers of care for end of life care patients.
  • The CQC had previously identified that the service did not provide a seven day a week service from the hospital palliative care team. This was still not being undertaken
  • There were significant difficulties with the removal of the deceased patients from Hayward House

Outpatients and diagnostic imaging

Good

Updated 8 March 2016

We rated the outpatients and diagnostic imaging service as good overall.

Staff reported incidents appropriately and we saw evidence of incident investigation, actions and shared learning. Clinical areas were visibly clean with effective systems to ensure cleanliness was maintained. Medicines were stored appropriately and fridges and stock were checked regularly. Records were stored securely and were available on time for clinics. There were safeguarding policies and procedures in place and staff were aware of safeguarding leads. Staff were up to date with their mandatory training. Equipment was not always checked or maintained in line with trust policies and manufacturers guidance.

Outpatient and diagnostic imaging services worked to National Institute for Health and Care Excellence (NICE) and other national guidance. There were good examples of multi-disciplinary working. All staff we spoke with had received an annual appraisal, although outpatient and diagnostic imaging services fell just below the trust target of 90%. Radiology services offered a seven day service to hospital departments. Staff understood their role concerning the Mental Capacity Act 2005 and knew what to do when patients were unable to give consent for treatment.

Staff respected and maintained patients’ privacy and dignity. Patients were positive about staff and the way they were cared for. Staff gave examples of when they had gone the extra mile to help patients. Staff involved patients in their care and treatment.

In some areas, the environment had an adverse impact on the planning and implementation of outpatient and diagnostic imaging services.

The trust had not met cancer waiting time targets, which meant some patients did not have timely access to treatment. There were targeted clinics for communities or groups of people who were at risk of particular conditions. Interpreters and chaperones were available for patients who required them. There was limited information available in different languages. Staff were aware of the trust’s complaints policy and were able to describe what they would do in the event of a patient making a complaint.

There was a well-defined strategy for outpatient and diagnostic imaging services with clear links to the overall trust strategy. Risks were discussed at directorate meetings with clear actions and accountability to respond to them. Leaders were approachable and visible and were aware of the issues and risks affecting their service. Staff were well motivated and felt supported by their leaders. There was a patient centred and supportive staff culture. There were examples of where services sought continuous improvement and innovation.

Surgery

Good

Updated 8 March 2016

Overall we rated surgical services as good, with outstanding leadership.

Surgery services at City Hospital had systems to protect patients from harm and abuse. They managed and responded to risk effectively. The specialities and theatres had reliable processes to analyse learning from mistakes. Patient areas were visibly clean. There were robust arrangements for monitoring safety and cleanliness.

Staff were conscientious about mandatory training and ward managers had good local induction processes. Although there were wards with staff vacancies, ward managers ensured that patients were safely cared for. However, some equipment checks were not up to date, and some staff were unclear about their role in a major emergency.

The services were effective because they planned and delivered patient care and treatment in line with current evidence based guidance, standards, best practice and legislation. Managers and senior clinicians monitored this through audits and at governance meetings. Patients had comprehensive assessments of their needs. There was good multidisciplinary teamwork.

Staff were supported to deliver effective care and treatment including through meaningful and timely supervision and appraisals. Staff understood and documented arrangements for consent and understood how to apply the Mental Capacity Act.

Nurses, doctors and care assistants treated patients with dignity, respect and kindness during all interactions with staff. Patients felt supported. They were involved and encouraged to be partners in their care and in making decisions. Consultants and nurses spent time talking to patients, or those close to them. Patients received information in a way that they could understand. Staff found innovative patient orientated solutions to everyday problems.

The hospital had a new, modern admissions suite for planned surgery, did outreach work with the community and provided enough capacity to meet demand for operations. Services worked well to meet the needs of individual patients, such as people living with dementia.

However, some facilities such as the old theatres waiting area were less patient friendly.

Surgery services had a clear vision which was translated into measurable achievements by speciality action plans.

The leadership, management and governance of surgery services assured the delivery of high quality, person-centred care. Surgery leaders worked in partnership with other organisations to improve care outcomes.

Services used innovative approaches to gather feedback from people who used services and the public. Surgery services welcomed constructive challenge and feedback from the public and comparison with similar organisations.

Staff and leaders participated in continuous improvement and staff were accountable for delivering change. Innovation and achievement were celebrated and publicised.

Neonatal services

Good

Updated 14 March 2019

  • Babies received high quality care from dedicated and caring staff who had received appropriate training and education to enable them to provide safe care and treatment. The service had nursing staff with additional training in a variety of quality roles such as research, tissue viability, feeding, infection prevention and control and safeguarding.
  • The NICU 2017/18 annual infection control report stated the Nottingham service were one of the units completing 100% data input of blood cultures in the data system for 2017 allowing them to be part of the NNAP report. Data demonstrated that for units delivering >500 central line days in infants <32w the service were ranked 3rd best overall in terms of infections per 1000 central line days. The rate of 5.6/1000 line days was below the UK average of 8.2. The unit was well maintained and decorated with appropriate equipment and facilities to care for patients and provide a caring, supportive environment for parents and families.
  • Staff completed and updated risk assessments for each baby. They kept clear records and asked for support when necessary. Senior staff had identified a risk of pressure damage to babies’ nasal septum so had introduced a new style of ventilator cap. Staff were being trained in the use of the new cap during our inspection to reduce the risk of pressure ulceration.
  • Specialist staff supported mothers to improve breast feeding rates. There were facilities to help mothers express and store breast milk.
  • Feedback from parents and families was without exception positive about the care their babies had received. We saw many examples of the care and support offered to parents and siblings. The bereavement team offered comprehensive, caring support to bereaved families including siblings.
  • The service used technology to support mothers who could not visit the unit and minimise mother and baby separation.
  • Staff we spoke with were proud to work for the service. There was a positive open culture in which staff felt able to ask for help and report concerns. Staff were encouraged to develop themselves and services for patients and families.

Maternity

Requires improvement

Updated 14 March 2019

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

We rated safe and well-led as requires improvement and effective, caring and responsive as good. We rated it as requires improvement overall because:

  • The service had enough midwifery staff with the right qualifications, skills, training and experience, however, low staffing levels were affecting staff morale and reducing their ability to complete tasks such as cleaning and mandatory training.

  • The service did not always control infection risk well. Staff kept themselves clean but did not always keep equipment and the premises clean.
  • The service had suitable premises and equipment, however some clinical areas were not appropriate for the activity. women were not always assessed in the most appropriate place and their ongoing treatment was sometimes delayed due to workload. Checking of emergency equipment was inconsistent.

  • The service did not always follow best practice when prescribing, giving, recording and storing medicines, however women received the right medication at the right dose at the right time.
  • Staff did not always recognise, report and grade incidents appropriately, however managers shared lessons learned with the whole team and the wider service.
  • Although women could access the service when they needed it, sometimes women had to wait for long periods to be seen in outpatient areas.
  • Although the trust had made improvements to the leadership and governance structures, the changes had not yet been fully embedded and there was still a lack of oversight and assurance in some areas.
  • There was not a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Managers had not effectively engaged with all junior staff, who did not fully understand the new structure, however we saw managers were trying to implement change.

However:

  • 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.
  • Managers monitored the effectiveness of some care and treatment provided and used the findings to improve them. They compared local results with those of other services to learn from them.
  • Staff cared for women with compassion. Feedback from women confirmed that staff treated them well and with kindness.
  • The service took mostly account of women’s individual needs.
  • The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from women, and key groups representing the local community. The trust engaged well with women, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively