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Queen's Medical Centre Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 17 December 2020

Summary findings

We carried out a focused desk based review of East Midlands Children and Young People's Sexual Assault Service (EMPCYPSAS) in October 2020.

The purpose of this review was to determine if the healthcare services provided by Nottingham University Hospital Trust (NUHT) were now meeting the legal requirements and regulations under Section 60 of the Health and Social Care Act 2008. We found that improvements had been made and the provider was no longer in breach of the regulations.

We do not currently rate the services provided in sexual assault referral centres.

During this desk based review we looked at the following questions:

Are services well-led?

Background:

The East Midlands Children’s and Young People’s Sexual Assault Service (EMCYPSAS) was provided from two regional hubs. The Serenity Suite in Northampton (inspected in 2018) and The Children and Young People’s Suite at the Queen's Medical Centre, Nottingham. This inspection looked at the well led aspects of paediatric sexual assault referral centre (SARC) services provided from The Children and Young People’s Suite at Queen's Medical Centre (QMC), Nottingham University Hospitals NHS Trust (NUHT).

The children and young people’s suite at the Queen's Medical Centre accepted referrals from children and young people who had been a victim of rape or serious sexual assault and reside in Derbyshire (including Derby City), Lincolnshire and Nottinghamshire (including Nottingham City) or if the assault had been committed in that area.

The SARC saw children and young people up to 18years and 18-24year olds with additional needs. There was an on-call out of hours rota for telephone advice and strategy discussions.

The suite was designed and refurbished to deliver paediatric SARC services with a dedicated forensic waiting and examination room. There was also a non-forensic waiting room. The areas had been made as child and young person friendly as possible. They were bright and secure. There had been refurbishment work to add an additional non recent clinical examination space however we have not seen this as we have not been onsite to complete this review. Nottinghamshire Sexual Violence Support Services (NSVSS) delivered a single point of access (SPA) for the regional service and provided crisis workers 24 hours a day to the Nottingham Hub. Self referrals were not accepted for children and young people aged 13yrs and under. With appropriate assessment young people over the age of 16yrs could self refer. All forensic examinations were completed by doctors. The suite was staffed by doctors, specialist nurses and crisis support workers.

We last inspected the service in November 2019 when we judged that NUHT was in breach of CQC regulations. We issued a requirement notice on 5 February 2020 in relation to Regulation 17, Good Governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The report on the November 2019 inspection can be found on our website:

https://www.cqc.org.uk/location/RX1RA/reports

This desk based review was completed by a CQC children's services inspector. We reviewed evidence and had a telephone conversation with SARC staff including the clinical and governance leads for the service.

Prior to this review, we reviewed the action plan submitted by NUHT. This demonstrated how they would achieve compliance.

Documents we reviewed included:

  • EMCYPSAS risk matrix
  • Revised Quality, Risk and Safety (QRS) terms of reference
  • Completed Quality, Risk and Safety template
  • EMCYPSAS staff structure
  • SARC report for Quality Assurance Committee July 2020
  • Leaflets for patients pre and post examination
  • SARC reporting structure
  • Staff job descriptions and person specifications
  • EMPCYPSAS nursing metrics

We did not visit EMCYPSAS at Queens Medical Centre to carry out the desk based focused review. This was due to the Covid-19 pandemic and because we were able to gain sufficient assurance through documentary evidence provided and a telephone discussion.

At this inspection we found:

  • Local leadership capacity for the SARC service had been increased to support development of governance and management systems.
  • Analysis of risk was up to date and there was an oversight mechanism for risk through the Quality, Risk and Safety (QRS) group.
  • Lines of accountability were defined through the divisional reporting structure. We saw an example of a comprehensive report that identified strengths and areas that the SARC was still working on.
  • There was an agreed template for speciality services to report risk.
  • There was a clearly defined team structure with appropriate job descriptions. Staff had appraisals, opportunities to access training and had identified workplans to support their development.
  • The SARC had identified that there were ongoing issues regarding training for crisis support workers. They were working together with the subcontracted agency to ensure that all crisis support workers had accessed appropriate training.
  • The SARC continued to receive overwhelmingly positive feedback from patients.

Inspection areas

Safe

Requires improvement

Updated 17 December 2020

Effective

Requires improvement

Updated 17 December 2020

Caring

Good

Updated 17 December 2020

Responsive

Requires improvement

Updated 17 December 2020

Well-led

No action required

Updated 17 December 2020

At our last inspection we found that there was a lack of systems and processes to assess, monitor and improve the quality and safety of services being provided.

These are the areas reviewed during this desk based review:

Governance and Management

  • The provider had reviewed reporting arrangements since the initial inspection. This included strengthening reporting of SARC activities through the trust’s governance structures. For example the SARC produced a six monthly Quality Assurance Committee report. This was comprehensive and highlighted successes, ongoing challenges and how they were being managed.
  • There was monthly exception reporting through the Family Health Divisional governance structures. This highlighted incidents and ensured that they had been followed up in the appropriate timescales. This was important to ensure that the provider was aware of risks that impacted on the ability to deliver a high quality service. We were assured through our review of documents, all incidents had been addressed or there were plans to mitigate risks.
  • An increase in nurse leadership capacity had contributed to the development of assurance tools and processes. An individualised monthly nursing metric tool had been developed. This provided oversight on issues such as infection prevention control and medication safety.
  • We were assured that there was an accurate understanding of risk. Issues identified on the risk spreadsheet had been consistently reported for example through Quality Risk and Safety template and a comprehensive six monthly report.
  • We identified issues at the initial inspection regarding responsibility and training for subcontracted crisis support workers (CSW). The provider had worked to review and clarify the CSW role. This included assurance on the level of training and competency from the subcontracted agency. Work to resolve issues were ongoing at the time of our review. Through our document review and discussion with SARC leaders we could see that risks related to this issue were managed. Feedback from service users remained overwhelmingly positive.
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:

  • Clinical and operational staff used an effective system to ensure medical patients cared for as outliers on surgical wards received regular medical reviews and individualised care. This included multidisciplinary care and reviews from specialist teams such as allied health professionals and the rapid response psychiatry team.
  • The safeguarding team were working with regional partners to standardise safeguarding training in line with new intercollegiate guidance. This would ensure local practice was benchmarked against national standards.
  • The patient safety team had a key role in maintaining and improving safety standards, including through benchmarking and acting on local risks. The team used the human factors analysis and classification system as a tool during the root cause analysis of serious incidents to ensure they fully understood the actions and thought processes of staff.
  • Multidisciplinary staff had introduced a range of initiatives to improve nutrition and hydration, including of older patients, in addition to standard use of the malnutrition universal scoring tool. This included a gold standard programme to ensure patients had access to nutritious food that was culturally appropriate and served during facilitated mealtimes to promote social contact.
  • Professional development and education were clear priorities for medical care. Patient outcomes had demonstrably been improved as a result and staff were able to pursue more advanced qualifications and training.
  • Multidisciplinary working was embedded in care services and a diverse range of specialist teams had established links with each other to address gaps in care provision and to improve patient outcomes and experience, including when patients transitioned to community care.
  • The integrated discharge team worked across the hospital to improve access and flow through a more robust, patient-centred model of discharge planning and delivery. This was a multidisciplinary team that supported ward teams to establish more advanced understanding of discharges and had established a team of trained discharge coordinators.
  • Staff routinely went above and beyond their responsibilities to provide additional care for patients that demonstrated the culture of compassion and kindness. This included setting up a clothes bank for patients with limited means to buy new clothes, fundraising for blankets for patients going home in the winter and liaising with the British Red Cross to support a patient at the end of their life.
  • Specialist teams were increasingly aware of population-based health models and explored the needs and demographics of their target population to shape care and treatment, including health promotion interventions.
  • A range of work had been completed to assess and improve accessibility to all elements of the service. This included improved access to mental health and drug and alcohol dependency care, language support and strict standards for information access. NHS England had certified the communications team as meeting The Information Standard, a national standard for health and social care information.
  • The integrated discharge team and specialist services had developed discharge improvement projects based on the needs of their patients. The frailty service had experienced significant improvements, including a 5% increase in the pre-noon discharge rate and a 25% increase in use of the discharge lounge.
  • Staff spoke positively of the trust’s vision and strategy and had adapted local variations to meet the trust’s objectives and reflect the needs of their patients. This included specialist teams not based on specific wards and reflected the enthusiasm of staff to deliver sustainable care.
  • Governance processes and structures were well-established with clinical and operational oversight and assurance provided by a series of committees and multidisciplinary groups. Governance, risk and quality management processes demonstrably led to improved practice.

However:

  • The overall nurse vacancy rate was 19%, which reflected wide variations between specialties including one ward with a 50% vacancy rate.
  • There was a lack of assurance around fire safety risk, including staff understanding of evacuation processes and training.
  • From June 2017 to May 2018, patients at Queen's Medical Centre had a higher than expected risk of readmission for elective admissions and a higher than expected risk of readmission for non-elective admissions when compared to the England average.
  • Some teams did not feel part of the broad improvements and innovative projects taking place in the hospital and did not feel they were valued by the trust or their colleagues.

Services for children & young people

Good

Updated 14 March 2019

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

  • Children’s and neonatal services had appropriate arrangements for investigating incidents and shared the learning from them.
  • The services had a well- developed approach to assessing and responding to risk. Staff used a paediatric early warning system to take action on any deterioration in child health. There was a well-established and understood approach to managing and escalating suspected sepsis. Mental health risks were recognised and the service worked well with mental health professionals.
  • People’s care and treatment was focused on achieving good outcomes, and this was supported by learning from clinical audit, and initiatives to improve clinical pathways.
  • Parents and children told us that nurses and doctors were kind and took time to talk to them and explain care arrangements. The services did as much as possible to ensure that children were comfortable and they responded quickly if a child or young person was in pain. The services helped young children feel settled through play specialists and a variety of volunteers who entertained them, such as Spiderman, a magician, and a therapy dog.
  • The services took a holistic approach to childhood and teenage cancer treatment and offered emotional support and arranged relevant social activities for them.
  • Children generally had access to timely initial assessment, test results, diagnoses and treatment. Waiting list performance for the service was better than the national target of 92% of patients being definitively treated within 18 weeks (incomplete pathway). The cancer service was responsive and timely.
  • Senior leadership capacity for children’s and neonatal services was improving and the leadership team was starting to address significant strategic risks and issues, for example how to ensure staffing and skills levels long term.

However:

  • Some beds on wards were not open to children because there were insufficient staff to manage them safely.
  • Vacancy rates and turnover figures were high for doctors in neonatal services. The service was advertising for three new neonatologists to give the services some resilience across City and QMC sites in 2019.
  • Outpatient appointments did not always run on time and the service did not inform families or display wait times publicly. The outpatient waiting area was very crowded.
  • Not all services were available 24/7 and outpatient and day surgery appointments were predominantly during the week between 9am and 5pm.
  • Lack of out of hours access to paediatric interventional radiology meant that some babies needed to be transferred to other hospitals, and this had been on the service’s risk register for three years.
  • Arrangements for MRI scans 48 hour after tumour removal were not sufficiently formalised for children who needed a general anaesthetic.
  • Children and young people’s matters did not have a strong profile at Board level and lacked specific non-executive director representation.
  • Processes around monitoring that products were kept at a safe temperature in fridges were not robust.

Critical care

Good

Updated 14 March 2019

  • The service had innovative and leading practices that improved the experience and outcomes for patients and their families.
  • The service was a national lead in critical care practice and guidance.
  • The service had enough staff, who had completed required training. Staff were supported by managers and had annual appraisals.
  • On both units the environment was clean, tidy and equipment was readily available, clean and well maintained.
  • The service stored and administered medicines well.
  • Staff worked well in multidisciplinary teams and provided compassionate, appropriate and individualised care to ensure good outcomes for patients.
  • Staff provided emotional support to patients and relatives to help them to manage through a traumatic experience.
  • The service responded where there was a need for improvement. For example, staff carried out many local audits, compared results to national target and set actions to improve the service.
  • Managers supported staff, promoted learning from incidents, concerns and complaints and used available information to improve to the service.

However:

  • The service had become accredited to deliver the post registration critical care module and 37% of staff were due to complete the course by March 2019. However, there was a risk that the course would not be funded after March 2019 and the service would not be able to ensure that 50% of staff had completed the course.
  • Follow up clinics were not available for patients discharged from critical care. Managers planned to create follow up clinics and had created a new coordinating specialist nurse for continuing care role. Follow up clinics for critical care patients had not received support from commissioners.
  • Discharge summaries did not include personalised rehabilitation goals and were not consistently sent to patient’s GPs at the time of discharge.
  • The lack of a critical outreach team service overnight had put a strain on the capacity in the adult intensive care unit and higher demand on the critical care consultant.
  • Training completion rates for medical staff were lower than expected.
  • The service had higher than expected numbers for patients transferred out of the unit for non-clinical reasons and out of hours discharge to the ward from the adult intensive care unit due to activity and continual high number of admissions to the unit.

End of life care

Good

Updated 14 March 2019

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

  • The trust had taken steps to improve consistency in completion of patient’s nutritional screening and the completion of nutrition and fluid charts.
  • Improvements had been made to the availability of patient information leaflets, including those in other languages and accessible formats.
  • Staff followed policies and procedures to ensure medicines were administered appropriately to make sure people are safe.
  • The trust had implemented care plan documentation specific to end of life care.
  • The Trust had increased their number of palliative care consultants to improve availability of a senior end of life care clinician.

However:

  • Do Not Attempt Cardio-Respiratory Resuscitation (DNACPR) forms were not always completed correctly.
  • Conversations with patients and relatives regarding DNACPR decisions were not always documented in patients’ medical record.
  • Mental Capacity Act assessments were not always completed for relevant patients when making DNACPR decisions.
  • Care plans, although personalised and improved since last inspection, did not always document conversations about patient’s mental health needs, spiritual and pastoral needs.
  • There was a lack of audit processes to monitor the effectiveness of end of life care.
  • The service did not monitor or audit if end of life care patients died in their preferred place of death (PPD).
  • The trust was not providing a HPCT seven days a week. However, this would commence in April 2019.

  • The service did not record palliative or end of life care patients as delayed transfers of care

Outpatients and diagnostic imaging

Good

Updated 8 March 2016

Overall, we judged the outpatients and diagnostic imaging services to be good.

There were reliable processes to protect patients from avoidable harm. Departments were mostly clean and hygienic, and risks to patients attending appointments were monitored and well managed. Staffing levels were appropriate to the needs of each outpatient clinic, but there were unfilled vacancies in radiology which had an impact on the service. Patient records were not always well managed; paper files were overdue for collection and secure storage and patient letters were sometimes misfiled.

The care and treatment of patients was delivered in line with current evidence based practice and recognised national guidance. Staff had good opportunities for personal and professional development. There was effective multidisciplinary working in many departments. There were few seven day services. Staff supported patients in a caring, kind and compassionate way. They respected patients privacy and dignity, and made sure that people's individual needs were met.

Services were largely planned to meet people's needs. While the trust was able to provide timely assessments for people with non-urgent conditions, the trust did not meet national standards for urgent referrals. There were higher than average rates of cancelled appointments, both by hospital staff and patients. The hospital had put in place some innovative methods aimed at reducing cancellation and unattended appointments. There were largely effective governance structures, but not all risks were recorded and addressed. There was work in progress to re-design the outpatient pathway and improve the trust-wide outpatient service. Staff were committed to their roles and in most departments there was a positive, supportive working culture. There was good staff and public engagement, and a focus on continued improvement.

Surgery

Good

Updated 8 March 2016

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

Staff understood their responsibilities to raise concerns, to record safety incidents, concerns and near misses, and to report them. Lessons were learnt from incidents and shared widely to support improvement in all areas.

Systems, processes and practices in place to keep patients safe were mostly reliable. The exception to this was the system for ensuring equipment was maintained in line with manufacturers and other guidance. Many items of equipment on the wards had not been checked or tested for over a year.

Staffing levels were generally maintained as planned. There was safe and effective management of infection control measures, medicines and patient records.

Risks to patients were assessed, monitored, and managed appropriately. This included patients with signs of deteriorating health.

Care and treatment achieved good outcomes for patients, were evidence based and in line with local and national guidance. Outcomes for patients were generally in line with or better than national averages.

Patients’ pain relief, and their nutritional and hydration needs were generally well managed. Consent to care and treatment was not always in line with legislation and guidance.

Surgery services were planned and delivered to meet the needs of local people and those from further afield requiring specialist services. Multidisciplinary team working was well established and effective in ensuring patients’ needs were met.

Staff treated patients with compassion, kindness, dignity and respect. Most patients we spoke with or had feedback from were positive about the care they had received.

The leadership, management and governance of surgery services assured the delivery of high quality, person-centred care. Service strategies and objectives were supporting by stretching, but achievable action plans. Quality, performance and risk management was in line with best practice and effectively promoted continuous improvement.

Staff were proud of working for the trust and felt valued and respected. They actively sought patient feedback and worked collaboratively to provide new solutions for patients.

Urgent and emergency services

Requires improvement

Updated 14 March 2019

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

  • The ED performed consistently poorly in national measures of performance, including in the time from arrival to treatment and the time from arrival to transfer or discharge.
  • We were not assured of appropriate safety processes at service level for laser equipment in eye casualty. There were discrepancies between the services the trust believed were offered in the laser service and the services offered in practice. The most recent annual laser protection audit identified areas in need of significant improvement.
  • Staff training and care pathways did not consistently meet the needs of patients with mental health conditions or challenges.
  • Performance against national averages was variable and the hospital performed worse in measures relating to time from arrival in ED to initial assessment, which was 41 minutes compared with seven minutes nationally.
  • There were significant unmitigated risks in eye casualty caused by inadequate staffing levels and the failure of the division and trust to address long-standing concerns raised by staff. This reflected embedded disconnections between senior staff in the trust and the team in eye casualty who delivered clinical care.
  • Results in national Royal College of Emergency Medicine audits were highly variable, including poor results in the acute severe asthma audit, the consultant sign-off audit and the severe sepsis and septic shock audit.
  • Risk management governance in some areas was variable with sporadic representation from some teams and inconsistent evidence of risk reduction and safety improvement.

However:

  • The department of research and education in emergency medicine, acute medicine and major trauma (DREEAM) team had implemented training and development programmes for nurses in the ED that contributed to retention and recruitment. This led to an over-establishment of nurses and a significant reduction in turnover and was part of a range of initiatives led by multiple staff and teams to ensure the service could meet demand and remained sustainable.
  • Major incident and emergency planning had been significantly improved through simulated exercises and more advanced training.
  • From 2016 to 2018 the number of patients attending ED who required an inpatient admission decreased from 23% to 19%.
  • Broad improvements were needed in mental health provision across all emergency care services. This included environmental modifications to the paediatric ED and more accessible and advanced training for staff.
  • A wide-ranging transformation plan was underway to increase capacity and improve patient flow, experience and care. This was planned to be implemented from December 2018 and would address a number of issues we previously highlighted to the trust.
  • A dedicated, multidisciplinary patient safety team worked across urgent and emergency services to support staff skills and improve practice and patient outcomes.
  • Medical staff, nursing staff and the psychiatric liaison team and the security team used joint risk assessment tools to support patients at risk of self-harm or absconding due to mental health needs. This was an effective system that promoted patient safety and reduced the need for restraint.
  • Care was demonstrably multidisciplinary and staff from a range of specialist clinical, non-clinical and research worked together to benchmark standards and improve patient outcomes and experience. Audits and research demonstrably improved standards of care and treatment and promoted skill development amongst staff.
  • Staff had developed clinical care to meet the specific needs of the local population, including the elderly, students and those experiencing mental health problems.

Maternity

Inadequate

Updated 2 December 2020

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

  • Staff had not completed training in key skills and did not always understand how to keep women and babies safe. The service did not always have enough midwifery staff to keep women and babies safe and provide the right care and treatment. Staff did not always risk assess women appropriately and in line with national and local guidance, and records were not always well maintained. Incidents were not always reported due to the demand on staff and the ineffective feedback and escalation, and lessons were not being learnt.
  • There was limited evidence of managers monitoring the effectiveness of care and treatment and driving improvement. Managers did not ensure all staff were competent for their role.
  • Leaders did not have the skills and abilities to effectively lead the service. The service did not have an open culture where staff felt confident raising concerns without fear. Leaders did not operate an effective governance process to continually improve the quality of the service and safeguard the standards of care.

However:

  • The service mostly had enough medical staff with the right qualifications, skills, training and experience to keep women and babies safe from avoidable harm.
  • Staff were focused on the needs of women receiving care despite the challenges they faced. The service promoted equality and diversity in daily work.