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Inspection carried out on 15-18 September 2015

During a routine inspection

Nottingham University Hospitals NHS Trust is the fourth largest acute trust in England and provides services to more than 2.5 million residents of Nottingham and its surrounding communities. It also provides specialist services to between three and four million people from neighbouring counties. The trust is based in the heart of Nottingham on three separate sites around the city: Queen’s Medical Centre, Nottingham City Hospital and Ropewalk House. Queen’s Medical Centre is the emergency care site, where the emergency department, major trauma centre and the Nottingham Children’s Hospital are located.

Nottingham University Hospital NHS Trust were inspected as one of 18 CQC new wave pilot inspections in November 2013 but the trust was not rated at this inspection. The purpose of this comprehensive inspection was to award a rating to the trust for the services it provided. We carried out an announced inspection to the three hospital locations between 15 and 18 September 2015. Unannounced visits were carried out on 28 September to medical wards and Haywood House.

Overall Nottingham City Hospital was rated as good with some aspects of outstanding. End of Life services however, required improvement.

Our key findings were as follows:

  • Overall patients we spoke with expressed a high level of satisfaction with the care and treatment provided to them. Pain relief was given to patients in a timely manner. Staff treated patients with kindness, dignity and respect.

  • There was good incident reporting culture in the trust and systems were in place to report incidents and largely there was effective learning from incidents. The exception to this was a backlog of radiology and maternity incidents where a lack of timely review may affect the ability to quickly implement any learning.

  • Cleaning services were contracted out to a private provider. There had been some concerns about the standard of cleanliness and this was reflected in some ward audits. On-going monitoring and performance management of the cleaning services, delivered by the private provider was planned. During the inspection the wards appeared visibly clean.

  • Hand cleansing facilities were available in all areas and mostly good practices were seen. However, we saw that some staff on Hogarth Ward did not always wash or cleanse their hands when going in and out of ward or bay areas. There were 31 cases of Clostridium Difficile (C. Diff) infections at the hospital between May 2014 and April 2015. C. Diff is an infection which causes diarrhoea. There were no cases of Methicillin Resistant Staphylococcus Aureus (MRSA) bacteraemia at the hospital in the same time period. MRSA is an infection that is sometimes very difficult to treat.

  • The systems for ensuring equipment was safe and fit for use was not robust. We found that some equipment was not checked or serviced as frequently as it should be.

  • In most areas staffing levels were sufficient and there were escalation systems in place to identify and address shortfalls in staffing levels. At Haywood House we found that some shifts had been short of staff which had affected the care patients received.

  • For end of life services we found that there was strong leadership for specialist palliative care services but this was not extended to end of life care provided on other wards.

  • There was an open culture throughout the trust and staff were generally positive and proud to work there. Across different disciplines staff worked well together. The trust board members were visible and positively regarded by staff.

  • The trust introduced shared governance in 2012. Shared governance gave staff the opportunity to create councils for each ward or department and any level of staff could join the council. It was a ‘bottom up’ model of management which aimed to empower frontline staff to make decisions about patient care at the point of care delivery.

We saw several areas of outstanding practice including:

Medical care (including older people’s care)

  • We saw examples of innovative practice in order to reduce risks to patients. On Southwell Ward we saw patients wore a coloured wrist band when they required oxygen to ensure they received the correct rate. This ensured staff could easily identify the patient’s required rate and dangerous levels of oxygen would not be administered.

  • Patients receiving oxygen through a nasal cannula were at risk of developing pressure ulcers where plastic tubing went over the tops of their ears. Sponge covers were placed over the tubing to prevent this from happening. (A nasal cannula is a lightweight tube which splits into two prongs placed in the nostrils and from which a mixture of air and oxygen flows).

Surgery

  • Theatres benchmarked activities against their own standards and compared their practices with external organisations. For example, they had compared some of their processes with neighbouring hospitals and as a result asked a trained band six nurse to do a specific eye procedure instead of a consultant.

Critical Care

  • A critical care consultant at the trust was developing a tool to support the complex decision making process for critically ill patients. The tool was based on an ethical and balanced approach to selecting a suitable treatment plan for patients and act as a base for further clinical decisions. The tool would then be used as a tracking system so that clinicians understood previous treatment choices and clinical outcomes. This was supported by colleagues and was considered to be an innovative development in tracking the decision making process in treating critical care patients.

  • The use of the trust’s simulation centre had helped staff in developing advanced communication skills.

  • Innovative approaches were used to gather feedback from people who used the service. One example was that patients and carers were invited to the opening of a new bed area to get their views on patient privacy.

End of life services

  • A project was set up and led by a ward sister at Hayward House following a high rate of incidents related to falls. An independent falls expert was invited to look at the environment and the day to day culture of nursing practice on the ward at Hayward House. This review found a lack of focus on patients who were at high risk of falling. Steps were taken following the review to reduce the risk of falls on the ward. Two cohort bays were set up. [A cohort bay is for patients at high risk of falling to be cared for together in the same area so their needs are managed more efficiently and safely]. A cohort nurse was allocated to the cohort bay. The cohort nurse wore a brightly coloured tabard to reduce the risk of interruptions and diversions. Changes to the ward environment included a colour theme to make it easier for patients to find their way around and equipment clutter removed from corridors. A six month review in June 2015 showed these changes had led to a 43% reduction in total falls, a 38% reduction in unwitnessed falls and a 67% reduction in repeated falls.

Maternity and gynaecology services

  • A member of staff designed an electronic application specifically for women using the trust’s services called the ’Pocket Midwife’. It was free to download and anyone could access it. It had information about each stage of pregnancy, and all of the maternity leaflets and maternity guidelines could be accessed easily. The service could add news flash information to the application for women to see, such as sending a reminder to women about flu vaccinations.

Outpatients and diagnostic imaging

  • The chemotherapy department demonstrated numerous examples of improvement and development. The service had developed projects to help the service run quicker and smoother for staff and patients. For example, the service had developed a purple bags initiative. This allowed patients to access treatment quicker after having their blood tested and authorised. Another initiative improved the flow of patients through the clinic by introducing a system for staff to quickly and easily see when a chair was available for patients to start their treatment.

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

Importantly, the trust must:

  • The trust must ensure consultant cover in the maternity service for the labour suite meets national recommendations and guidance.
  • The trust must ensure that there are sufficient numbers of suitably qualified, competent, skilled and experienced nurses working in the critical care service. The Core Standards for Intensive Care Units minimum requirement is for 50% of nurses in intensive care units to have a post-registration award in critical care nursing. There were 26% of nurses with this qualification at the time of our inspection.

  • Ensure that trained nurse presence on the neonatal unit meets the ‘British Association of Perinatal Medicine Guidelines (2011).’(BAPM).

  • Ensure that there is sufficient neonatal consultant cover during the out of hour’s period so that both hospital sites can access their own individual on call consultant. This is in line with the BAPM standards (3rd edition – section 5.1.4).

  • The trust must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced staff deployed to meet the needs of patients on the inpatient ward at Hayward House.

In addition the trust should:

  • The trust should ensure patients’ fluid and food charts are completed accurately
  • The trust should ensure oxygen is prescribed in line with the trust’s policy for patients who require it.
  • The trust should ensure immunosuppressed patients are not nursed in the same area as those with infections.
  • The trust should consider the installation of air conditioning in the Wolfson Cystic Fibrosis Unit to reduce distress for patients in warm weather.
  • The trust should ensure clinical waste bins awaiting collection are secure.
  • The trust must ensure City Hospital is secure at night time.
  • The trust should ensure all equipment, including electrical, has been appropriately serviced and received portable appliance testing when necessary.
  • The trust should ensure fire alarm break glass points have the necessary equipment so they can be activated.
  • The trust should ensure the proper and safe management of medicines by staff following the correct procedures for checking and administering medication to patients.
  • The trust should ensure assistance given to patients with oral hygiene is documented correctly and consistently by staff.
  • The trust should ensure staff have feedback on the auditing of fluid charts.
  • The trust should ensure adequate training is available for all staff using the inpatient adult risk assessment booklet NUH01873S in relation to pages 13, 14 and 15.
  • The trust should ensure all complaints and the outcome of the investigations are shared with the area concerned and the wider directorates.
  • The trust should ensure, as good practice, that prescription charts have the name of the prescriber written in capital letters with their contact number for identification purposes.
  • In the trust’s Family Health division 67% of staff had not completed training in the safe use of medical equipment. The trust should ensure staff are trained and competent to use equipment safely.
  • The trust should ensure that workforce requirements in the maternity service are analysed in terms of what women using the service need, rather than what midwives do.
  • The trust should ensure up to date guidance is available for staff in the maternity service regarding criteria for admission to the midwifery led unit.
  • The trust should ensure a home from home philosophy and environment for women giving birth in the midwifery led unit.
  • The trust should ensure there are operating theatre facilities and time dedicated for planned caesarean section operations.
  • The trust should ensure maternity service actively recruit user representatives.
  • The trust should ensure all senior and specialist staff in maternity services are visible on the wards and participate with clinical activities.
  • The trust should ensure women and their families using the maternity service have clear and accessible information about how to make a complaint.
  • The trust should ensure the maternity service meets the national neonatal audit programme standards for temperature taken at birth, and mothers receiving steroid medication in the antenatal period.
  • The trust should ensure confidentiality of information about women using the maternity service. Women’s names and details of their treatment should not be displayed where they may be seen by visitors.
  • The trust should ensure that all staff receive feedback about incidents.
  • The trust should ensure that nursing assessments are fully completed and babies care plans are reviewed regularly.
  • The trust should ensure that a complete record is kept for each baby, which includes appropriate information and documents the care and treatment provided.
  • The trust should ensure that each staff member has an annual appraisal.
  • The trust should ensure that each staff member attends mandatory training.
  • The trust should ensure that medical cover in the critical care service meets the Core Standards for Intensive Care Units recommendations at all times.
  • The trust should ensure all ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) forms are completed in line with the trust’s DNACPR policy.
  • The trust should have an end of life care strategy to ensure patients receive end of life care in line with national guidance and research based good practice.
  • The trust should increase the number of consultants in the specialist palliative care team to reflect the recommendations of the Association for Palliative Medicine of Great Britain and Ireland and the National Council of Palliative Care.
  • The trust should increase the specialist palliative care nursing team to ensure patients can access specialist palliative care services and receive a face-to-face consultation seven days a week, in line with National Institute for Health and Care Excellence (NICE) Quality Standard number 10 published in 2011 for end of life care for adults.
  • The trust should ensure end of life care champions are allocated protected time each week for carrying out their role.
  • The trust should consider updating their end of life care bundle to ensure staff record patients’ preference for involvement of the pastoral care team.
  • The trust should provide a structured programme of end of life care training for all staff to ensure patients receive appropriate care at the end of their life.
  • The trust should ensure effective monitoring of ‘fast-track’ discharges and compliance with patients’ wishes regarding preferred place of care and preferred place of death. Good practice in these areas should be shared across the trust and appropriate action taken to address any issues.
  • The trust should provide a structured programme of end of life care training for all staff to ensure patients receive appropriate care at the end of their life.
  • The trust should ensure the system for maintaining and testing clinical equipment is timely, effective and consistent to ensure it is safe to use.
  • The trust should ensure risk assessments are carried out where environmental issues may have an impact on outpatient services.
  • The trust should ensure there is a sufficient and effective portering service for patients attending outpatient clinics from the wards and when required to transport deceased patients to the mortuary.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 26-28 November 2013

During a routine inspection

Nottingham City Hospital is an acute hospital managed by Nottingham University Hospitals NHS Trust. The trust is the fourth largest acute trust in England, and provides services to more than 2.5 million residents of Nottingham and its surrounding communities. It also provides specialist services to between three and four million people from neighbouring counties. There are 1,690 beds across the trust, and it has a budget of £824 million. Nottingham City Hospital is a specialist and planned care site where the cancer cente, heart centre and stroke services are based. The trust employs more than 14,000 people.  Of the population of Nottingham, 34.6% belong to non-white minority groups; of this people from the Asian Pakistani groups constitute the largest ethnic group with 5.5%.

We chose to inspect the acute services at Nottingham City Hospital as one of the Chief Inspector of Hospital’s first new inspections because we were keen to visit a range of different types of hospital, from those considered to be high risk to those where the risk of poor care is likely to be lower. When we announced our inspection, we described the trust as a high risk provider. By the time we undertook the inspection, our risk methodology had revised that assessment to a medium risk provider. Nottingham City Hospital has been inspected four times since it was registered in October 2010. Three inspections took place in 2012, and they found that the hospital was meeting the standards set out in legislation.

The trust scored better than the national average for the CQC 2012 Inpatient Survey and the NHS Friends and Family Test, which asks patients if they would recommend services to people they know. We found some good examples of caring and compassionate care.

In general, we found that Nottingham City Hospital provided safe care. Most areas had good processes in place to recognise, investigate and learn from patient safety incidents. The hospital also responded well to the needs of its patients. Patients reported that there were good interpreting services. Written information was available in other languages on request.

The hospital calculated nursing staffing levels using a recognised dependency tool. Although staff were very busy, we found the staffing levels were in accordance with the levels defined by the dependency tool in use.

We found some examples of good leadership in the hospital, and most staff felt very well supported by their managers. Many said that they had excellent training and development opportunities. Doctors who were in training also felt well supported and said that the consultants provided effective supervision.

The vast majority of people spoke positively about their care, and we saw some good examples of staff delivering compassionate care to patients. Nevertheless, some people highlighted areas where they felt the hospital needed to improve.

We found that there was a back log of maintenance of clinical equipment. The trust was already aware of this and it was on their risk register. We found they had taken steps to manage this risk by making sure the more high risk equipment, such as ventilators which are used to breathe for patients, were serviced according to manufacturer’s instructions. We also found that about 40% of staff were not up to date with their mandatory training. Again, the trust were already aware of this issue and had a plan in place to address the shortfall. We found they were making good progress against their plan and we did not find any impact on patient care.

Inspection carried out on 20 August 2012

During a themed inspection looking at Dignity and Nutrition

People told us what it was like to be a patient in Nottingham City Hospital. They

described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older patients in hospitals were treated with dignity and respect and whether their nutritional needs were met.

The inspection team was led by three Care Quality Commission (CQC) inspectors joined by a practising professional and an Expert by Experience, who has personal experience of using or caring for someone who uses this type of service.

To carry out the inspection, we identified two wards, where there were a percentage of older patients, in order to focus the dignity and nutrition inspection (DANI). As part of the inspection process we spoke with a number of patients and visitors on both wards. We also spoke with a senior member of staff for Nottingham University Hospitals Trust. A range of staff members were spoken with on both wards throughout the site inspection. We did this to gain the views of patients who received care and treatment and people who visited the hospital or worked there. We also observed care, spoke with patients and staff on two other wards.

Patients were very happy with the care being provided by staff. One patient said, “Staff always pull the curtains round when providing me with personal care and respect me.” Another patient said, “My decisions are respected by staff.” Another patient told us their privacy and dignity were respected by staff.

Patients told us that they were happy with the information provided to them and they had opportunity to give their views on whether they were happy with the care provided. Two patients told us they had expressed a preference regarding the gender of the carer providing them with personal care. They told us that their wishes had been respected by staff.

Patients we spoke with had mixed views about the quality of food. One patient said, “lovely food, can’t complain.” Another patient said, “fish pie was beautiful but carrots and cauli – no juice – too dry.”

Patients we spoke with told us that they had enough to drink. A patient said, “There’s plenty of drinks, always a decent drink.” Patients told us that a range of drinks were available including tea, coffee, malted milk and hot chocolate and they described having drinks at times other than the prescribed times.

Patients we spoke with told us there was plenty of food available at mealtimes and other food was available between mealtimes. They also told us that if they were away from the ward at mealtimes then food would be made available for them when they returned.

Most patients we spoke with told us they did not have any specific cultural or religious requirements in relation to their food or drink, however, patients told us they felt staff would accommodate their wishes if they did have those requirements. They also told us they had been asked whether they had any cultural or dietary requirements when they were admitted to the ward. Patients who required gluten-free or diabetic food told us that this food was available for them. A patient said, “It’s alright, I eat it, there’s quite a large choice, I order it in the morning and get it delivered, there’s plenty to eat.”

Patients told us they received support at mealtimes if they needed it. They also told us that staff monitored their eating and drinking in their records and also weighed them regularly.

Patients we spoke with told us that they felt safe. They also told us they had not seen any practice that they were not happy with. Patients also told us they knew who to speak to if they had any concerns.

Patients were very happy with the care they received from staff. A patient said, “They are all kind, the level of care is to be commended.” Another patient said, “[The staff are] absolutely fantastic, outstanding, nothing’s been too much trouble.” Another patient said, “[I have] nothing but praise [for the staff].”

Patients felt there were generally enough staff to provide care. Staff were busy at times but one patient said, “Staff apologise if they’ve kept you waiting.” Patients told us that call bells were always answered and staff generally answered them quickly.

Some patients we spoke with had seen their care records, some patients had not. One patient told us they knew where their records were and would ask staff if they wanted any information. Another patient told us they had looked at their records and a nurse had explained some of the information to them. Another patient said, “never thought to look at notes, I don’t know if you can or not. I rely on doctors coming round to explain things.” Another patient said, “not seen medical records, not been offered to see medical records.”

Patients did not raise any concerns about the security of their records.

Inspection carried out on 20 September 2012

During an inspection to make sure that the improvements required had been made

We spoke with eight patients. All patients told us they felt safe and they knew who to speak to if they had any concerns. No patients had seen any incidents that had caused them concern.

All patients told us they had no concerns about the environment. One patient said it was, “Brilliant – clean, calm, tranquil.” Another patient said, “The showers are lovely.” Another patient said, “The new bathroom is fantastic, it is well designed.”

All patients told us they had no concerns regarding the confidentiality of their records. One patient said, “Confidentiality is respected – only doctors and nurses see them.” Another patient said, “My main file is kept at the nurse station which I believe is secure as a member of staff is always there.”

We found that patients were protected from the risk of abuse because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. We found that patients, staff and visitors were protected against the risks of unsafe and unsuitable premises and that patients' personal records, including medical records, were kept securely.

Inspection carried out on 20 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 26 September 2011

During an inspection in response to concerns

Patients told us that they understood the care and treatment choices available to them. One patient said, "I was given options, choices, the risks and the prognosis, they were my decisions to make." They also told us they could express their views and were involved in making decisions about their care and treatment. One patient said, "I’ve always felt in control." Patients told us their privacy and dignity was respected and that their views were taken into account.

Patients told us that they were able to give consent to the care and treatment that they received. They also told us that they understood and knew how to change any decisions about care and treatment that had been previously agreed. One patient said, "I have changed my mind about this [treatment options available] and I refused to continue a certain treatment."

Patients told us that they experienced appropriate care and treatment that met their needs. Most patients told us that they received safe and coordinated care where more than one provider was involved or when they were moved between services. However, we were also told that patients were left waiting long periods (3+ hours) for transport home after receiving radiotherapy treatment.

Patients told us that they felt safe and they knew who to speak to if they had any concerns. Most patients told us that they were happy with the premises. However on one ward, there were no lockers for patients to store their belongings in. On this ward, one patient said, "I don’t know if my belongings are safe, there’s no lockers, my things are on the floor."

Patients told us that their needs were met by competent staff. One patient said, "My buzzer’s always answered in good time, they’re confident and I’ve got confidence in them." Another patient said, "They all know what they’re supposed to be doing and they get on and do it." Patients also told us while they were not aware of the content of their records they were confident that their records were accurate and held securely.