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Inspection Summary


Overall summary & rating

Good

Updated 8 March 2016

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, children’s wards and the maternity department.

Overall, Queens Medical Centre was rated as good with some elements of outstanding. End of Life services however, required improvement.

Our key findings were as follows:

  • There was good incident reporting culture in the trust and staff, 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.

  • Staff mostly followed infection prevention and control policies and cleaned their hands between patients. There was mostly suitable hand cleansing facilities in place apart from one area where staff had to leave the toilet to wash their hands. Equipment was cleaned following use and was labelled appropriately.

  • Cleaning services were contracted out to a private provider. There had been problems with cleanliness prior to and following our inspection which were identified through the trusts own audits and those carried out by the Trust Development Authority. These were been monitored and action was being taken to improve. Progress was been closely monitored by the executive team. During our inspection, we generally found the hospitals to appear visibly clean.

  • Actual and planned staffing levels were clearly displayed across the trust and generally we found then actual levels were in accordance with the planned.

  • Although agency staff were used, overall the trust used slightly less bank and agency staff than the national average. There was an induction process for agency staff to make sure they were familiar with their working environment.

  • 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.

We saw several areas of outstanding practice including:

Urgent and emergency care services

  • In January 2015 the NHS invited individual organisations and partnerships to apply to become ‘vanguard’ sites for the new care models programme. Vanguards are where groups of providers come together to change the way they work together to provide more joined up care for patients. Nottingham University Hospitals along with partners in the South Nottinghamshire health community were awarded vanguard status for urgent and emergency care. This has allowed the trust to trial new approaches to improve the coordination of services, and reduce the pressure on A&E departments.

  • Working with four local clinical commissioning groups, GPs, and out of hours GP services, the trust reduced unnecessary hospital admissions from 28% to 5% following the launch of the Nottingham Care Navigator programme. This programme offered an alternative to urgent hospital admission, where possible, providing direct access to advice and support from the right clinical service first time via an online health navigation tool.

  • During 2014 the trust piloted having GPs at the front door of A&E on two separate peak activity weekends. As a result, patients seen by a GP spent 50 minutes less in the department. There was also a reduction in patients needing to be seen by the minor illness and injury teams. The findings showed 54% of patients were redirected away from A&E to more appropriate services, with the majority being directly discharged home.

  • The trust was delivering an Injury Minimisation Programme for Schools (IMPS) in partnership with schools and a public health organisation. The programme was designed with the aim of educating children aged 10 and 11 to recognise potentially dangerous situations and prevent injuries. Small groups of children from Nottingham city schools attended the children’s emergency department each morning to learn first aid and resuscitation skills, helping them to respond effectively to accidents and take safe risks. More than 2,300 children received health education through this programme each year

Medical care (including older people’s care)

  • An occupational therapist on ward F20 had undertaken a six month pilot project called ‘Playlist for life’. The project involved asking patients about songs that were personal to them that they would like to listen to. Where patients were unable to list songs that were personal to them, their family or carers were encouraged to create a playlist on the patients behalf. The playlists were then created using hand held devices and provided to patients free of charge. Evaluation of the project was underway.
  • With the support of nursing staff, a consultant on ward F20 had started an ice cream project in order to support patients who were nutritionally at risk. Patients who were nutritionally at risk had an ice cream sign placed on the board above their bed, this prompted staff to ensure these patients were supported to eat ice cream. The project had come to an end and the consultant was working on applying for more funding to continue the ice cream project.
  • Patients wore a coloured wrist band to highlight the oxygen rate they were prescribed. This ensured staff could easily identify the patient’s required rate to ensure they were receiving safe care.

Surgical services

  • Theatre staff had successfully standardised practices and processes at QMC and Nottingham City Hospital to ensure safe ways of working and reduce cultural differences. The theatres safety improvement programme implemented a variety of safety projects. It ensured that all theatre staff were trained on team etiquette. This emphasised safety, mutual respect, effective communication, accountability and situational awareness. As a result, theatres ran more safely and efficiently.
  • There was a ‘Dragons Den’ project where staff could present their ideas for service improvements. Theatre staff had been successful in presenting their ideas for improvements in equipment used in vascular surgery at QMC.
  • The theatre PPI group had been shortlisted for a Nursing Times Award for Enhancing Patient Dignity and were due to present their work in September 2015.
  • The theatre PPI group were working on a DVD to show to patients before their operation. The DVD will show patients what to expect when coming to theatres to help reduce fear and anxiety.

Critical care services

  • Innovative approaches were used to gather feedback from people who used the service through inviting patients and carers to opening of a new bed area and getting their views regarding patient privacy.
  • The ‘just do it’ project to avoid cancelled elective surgery due to lack of critical care beds has been successful. This is also an example of several departments working together to solve a problem.

Maternity and gynaecology services

  • A member of staff designed a maternity app specifically for the women at NUH called the ’Pocket Midwife’. The free ‘app’ had information about each stage of pregnancy, including leaflets and information. The service could add news flash information to the app for women to see, for example flu vaccinations alerts. Maternity leaflets and trust guidelines were easily accessed via a guideline app.
  • Maternity services identified successful processes within the hospital and engaged with the staff who were involved. For example the ‘breaking the cycle team’ had been successful in reducing emergency waiting times. This team were invited to work with maternity services to improve the efficiency of the discharge process.

Outpatients and diagnostic imaging

  • In recognition of the challenge to outpatient services, in July2014 the trust came together with five other NHS trusts from across the country to share good practice and highlight themes for development. This was reported in the Health Services Journal.

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

Importantly, the trust must:

  • The trust must take action to ensure that nursing staff working in the eye casualty receive training in the recognition and treatment of sick children.
  • In surgical services the trust should take action to ensure that the principles of the Mental Capacity Act 2005 are correctly and consistently applied in assessing the capacity of patients to make specific decisions
  • The trust must ensure 50% of nursing staff within critical care have completed the post registration critical care module. This is a minimum requirement as stated within the Core Standards for Intensive Care Units.
  • The trust must ensure midwives have appropriate training to provide safe care for high dependency women in an appropriate environment.
  • The trust must ensure midwives have the appropriate competence and skills to provide the required care and treatment to women who are recovering from a general or local anaesthetic.
  • The trust must be consistent in the documentation of checking of emergency equipment and ensure that the resuscitation trolleys, neonatal transport systems and resuscitation equipment are checked, properly maintained and fit for purpose in all clinical areas.
  • The trust must take action to ensure Do Not Attempt Cardio-Respiratory Resuscitation decisions are documented legibly and fully in accordance with the trust’s policy and the legal framework of the Mental Capacity Act 2005.

In addition the trust should:

  • The trust should consider holding major incident exercises in the emergency department and ensure that staff in all specialities are familiar with emergency planning and major incident procedures

  • The trust should consider improving the availability of patient information leaflets, including those in other languages and accessible formats.

  • The trust should consider the appropriateness of the environment and facilities in the eye casualty waiting area for children and young people.

  • The trust should consider nurse staffing levels and skill mix in the eye casualty department.

  • The trust should consider availability of consultants to ensure direct admission and transferred major trauma patients are seen by a consultant within five minutes of arrival at the major trauma centre.

  • Providers should ensure staff follow policies and procedures to ensure medicines are administered appropriately to make sure people are safe.

  • The trust should consider measures to increase the number of nurses receiving appraisals in the emergency departments.

  • The trust should consider the availability of hospital play specialists in the children’s emergency department.

  • The trust should ensure oxygen is prescribed in line with the trust’s policy for patients who require it.

  • The trust should ensure consistency in the completion of patient’s nutritional screening and the completion of nutrition and fluid charts on ward B49.

  • The trust should ensure all staff are aware of their responsibilities in relation to infection, prevention and control.

  • The trust should consider placing hand washing facilities inside staff toilets to reduce the risk of the spread of infection.

  • The trust should ensure patients on all of the health care of older people (HCOP) wards have equal access to meaningful activities.

  • The trust should ensure pre-printed care plans are consistently personalised to each individual’s needs.

  • The trust should ensure care plans reflect how staff should support patients who present with complex and challenging behaviour.

  • Ensure that ward temperatures are regulated and that a system is in place to date check equipment in a timely manner

  • Put patients at their ease before they go into theatre by providing a suitable waiting area with privacy

  • Continue to make efforts to help patients sleep by mitigating noise levels on wards at night.

  • The trust should consider using the emergency planning boards on all wards to ensure important information is easily available for staff.

  • The trust should consider improving the experience of patients at mealtimes by serving each course separately.

  • The trust should consider extending the availability of the Learning Disability Liaison team to include weekends.

  • The trust should work towards there being at least one nurse per shift in each clinical area (ward / department) within the children’s and young people’s service is trained in advanced paediatric life support or European paediatric life support.

  • A lack of specialist radiology cover out of hours meant that babies had to be transferred to another hospital to receive this service. The trust should consider how the service can be improved to ensure radiology care could be delivered on site.

  • The trust should ensure that staff in the maternity service have received up to date training for the safe operation of equipment.

  • The trust should ensure that staffing within the neonatal unit follows the British Association of Perinatal Medicine standards

  • The trust should ensure that an accurate record is kept for each baby, child and young person which includes appropriate information and documents the care and treatment provided.

  • The trust should ensure that they have written formal arrangements in place with the children and adolescent mental health team so that the needs of children and young people with mental health problems are met.

  • The trust should ensure all midwifery guidelines are available for staff to use when providing care.

  • The trust should work towards capturing the users’ comments on the partners in maternity committee.

  • The trust should review the home from home values of the midwife led unit.

  • The trust should ensure medical staffing ratios in midwifery meet national recommendations.

  • The trust should review the elective caesarean section pathway to improve the experience for women and families.

  • The trust should consider formulating an overall strategy for end of life care across the trust which is disseminated to all staff across all divisions.

  • The trust should consider increasing the number of consultants providing end of life care to reflect the recommendations of the National Council of Palliative Care.

  • The trust should consider increasing the hours of the specialist palliative nursing team to ensure patients who require it can receive a face-to-face consultation seven days a week as per NICE (National Institute for Health and Care Excellence) Quality Standard number 10 published in 2011 for end of life care for adults.

  • The trust should consider ensuring end of life ‘champions’ are allocated protected time to disseminate matters relating to good practice end-of life care to other staff in their team.

  • The trust should consider updating the end of life care bundle to ensure a patient’s preference for involvement of the pastoral care team is recorded.

  • 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 consider ensuring up to date information reflecting good practice at end of life is readily available in each area and staff are aware of its location.

  • The trust should ensure all staff have access to on-going training for end of life care to ensure staff understand their roles in delivering quality care.

  • The trust should ensure regular auditing of ‘fast-track’ discharging and patients preferred place of death is undertaken to identify any concerns and put actions in place to address the issues

  • Ensure that all reports of radiation incidents are investigated in a timely manner, and ensure recommendations are put in place in a reasonable timescale.

  • Ensure all staff are able to attend annual fire safety training.

  • Ensure that small portable sanitising hand gel dispensers are safe to use in outpatient departments.

  • Ensure that the risks of lone working are reviewed and managed in all relevant outpatient and diagnostic departments.

  • The trust should ensure the system for maintaining and testing clinical equipment is timely, effective and consistent to ensure it is safe to use.

  • Extend outpatient and diagnostic imaging services beyond working hours, Monday to Friday.

  • Improve the outpatient appointment booking procedures to reduce the rate of cancelled appointments.

  • Improve the visual environment in the eye centre.

  • Provide varied seating in outpatient waiting areas to meet different people’s requirements.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 8 March 2016

Effective

Good

Updated 8 March 2016

Caring

Good

Updated 8 March 2016

Responsive

Good

Updated 8 March 2016

Well-led

Good

Updated 8 March 2016

Checks on specific services

Maternity and gynaecology

Good

Updated 8 March 2016

Overall, we rated maternity and gynaecology services as good.

There were recently developed local and divisional risk and governance arrangements, staff felt the service had a profile on the trust board agenda. There were processes in place to share lessons learnt from incidents and investigations.

There was a multidisciplinary approach to care and treatment, which involved a range of staff in order to enable services to respond to the needs of women. All staff told us that that working relationships between the professional groups was excellent.

Women using the women’s health services received care based on up to date guidelines and national guidance. The guideline for admission of a woman to the midwifery led care unit had been removed from the intranet to be reviewed and ratified by governance staff, leaving staff to admit women to the midwife led unit without a criteria.

The departments were found to be caring and compassionate. Women, families, and visitors were treated with respect and their wishes considered. Support was given to women in their chosen method of feeding their babies.

Services responded well to the needs of the individual, and women were given a choice of where to birth. New methods of sharing information had been introduced with the use of the new maternity phone application.

Maternity care was offered between the two hospital sites, and women’s care was occasionally diverted due to staff and bed shortages.

Leadership and culture in the hospital encouraged openness and transparency. Staff all felt very supported and enjoyed their work at the hospital.

Staff worked hard to provide new and innovative projects to improve the service for women.

The midwife led care centre did not fully embrace the ‘home from home’ values of midwife

Staff had not always documented that essential lifesaving equipment had been checked. Midwives were delivering post-operative care without the required formal training and competency assessments.

Medical care (including older people’s care)

Good

Updated 8 March 2016

Overall we rated medical services (including older people’s care), as good.

Patients were protected from avoidable harm and staff were encouraged to report incidents and monitor risks. Staff understood their responsibilities to raise concerns, to report and record safety incidents and near misses, and there was appropriate investigation of incidents.

There was a good culture around reducing the risk of falls for patients who were identified as being at high risk. There was good engagement with the falls team and continual assessments were completed to identify any changes to the risk of these patients.

Staff mostly demonstrated a good understanding of infection prevention and control. However, we saw isolated incidents where staff did not adhere to the appropriate procedures.

Staffing levels were set to meet patients’ needs and shortfalls had been filled by agency nurses and staff from other wards. However, there were high numbers of nurse vacancies across all of the medical wards.

Risks to patients were assessed, monitored, and managed appropriately, including patients with signs of deteriorating health. Where patients conditions deteriorated, concerns were appropriately escalated to the responsible clinician.

We saw numerous examples of staff responding to patients with kindness and compassion. We saw isolated incidents where staff did not use person-centred or appropriate language when referring to patients.

Patients, and those important to them, were positive about their experience of care and the kindness that staff showed towards them.

Systems were in place to receive, review, and learn from complaints and compliments. Staff listened to patients and took action to improve the quality of care.

The leadership, management, and governance of acute medical services formed a good basis for the delivery of the services it provided.  Annual plans were in place for each of the specialities within the directorate of acute medicine; and quality, performance, and risks were understood. There were effective governance frameworks in place to support the delivery of the division’s plan. 

Urgent and emergency services (A&E)

Requires improvement

Updated 23 February 2017

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.

Intensive/critical care

Good

Updated 8 March 2016

Overall, we found the adult critical care service at QMC to be good.

Patients and visitors consistently expressed satisfaction with the care and treatment they received, stating that staff went out of their way to support them during a difficult time.

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

Training and support for staff development was established, however we did have concerns that there was limited access to the post registration critical care module for registered nurses.

Care was patient centred and focussed on continual assessment, including an outstanding approach to safeguarding and the application of Deprivation of Liberty when required.

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

The service had a comprehensive annual plan with clear actions, measurable outcomes, named responsibility and targets.

There was a systematic approach to working across the trust to improve care and outcomes for patients and provide best value for money.

Staff worked very well together across hospital sites and across departments. There was a collective enthusiasm across all staff groups and a clear knowledge of the vision, values and strategic goals for critical care. Staff told us they were proud to work in the department.

Governance processes were established across adult critical care with active involvement from all staff groups. Staff unanimously spoke highly of the local leadership and said they felt supported and able to raise concerns or challenge decisions about patient care.

There was a positive culture of innovation and service development which was not only shared within the critical care and across the trust but also extended to other trusts through training within the departments clinical simulation centre.

Information in the form of data analysis and audit was used to proactively drive service improvement.

Services for children & young people

Good

Updated 8 March 2016

Overall, the children’s and young people’s service was rated as good.

We found services for children, young people and their families were effective, caring, responsive and well led. However, improvements were needed for the service to be safe.

Although, staffing shortfalls had been recognised some staff felt this had impacted negatively on staff morale, although the staff survey results for children's services were largely positive. Additional monies were identified for the recruitment of trained nursing staff within the children’s and neonatal service. The 2015 workforce review document identified 25 vacancies in children’s services, and 28 vacancies in the neonatal service. The trust met the Royal College of Paediatrics and Child Health (RCPCH) standards for paediatric consultant staffing levels.

Shortfalls in trained nurse provision on the neonatal unit and within children’s services were managed through escalation pathways. The family health directorate recognised that staffing did not meet Royal College of Nursing (2013) and British Association of Perinatal Medicine Guidelines (2011) and had identified this on the trust risk register.

There was generally good access and flow within the children’s service. Patients received evidenced based care and treatment and good multi-disciplinary working existed between the children’s services, external providers and the child and adolescent mental health service (CAMHS). However, the admission of children who experienced mental health problems had increased and we were told their needs were not always met. This meant that children were cared for in an environment, which did not meet all of their needs.

Risks to patients were assessed but we did not see that all risks had been addressed. Ligature risks remained in place, despite ligature audits, which had been completed within the clinical areas we visited. Actions remained to remove these risks to reduce the risk to children and young people with mental health needs who may be at risk of self-harm.

There were difficulties when discharging children to tier four mental health beds which had delayed children’s and young people’s discharges. Tier four beds are specialist mental health beds.

Monitoring records of resuscitation equipment and neonatal transport systems showed that monitoring of this equipment had not taken place daily.

Whilst the trust identified they did not have one nurse per shift with either the ‘Advanced Paediatric Life Support (APLS) or European Paediatric Life Support (EPLS) training', there was a plan where the trust were aiming for one nurse per ward (resuscitation link nurse). A training schedule was in place to monitor and plan the delivery of training. However, we were aware that the children’s service were supported by children’s critical care and retrieval services which meant that these staff may be available to support emergency resuscitation situations throughout the children’s service.

The children’s service had no planned out of hours radiology support and a full review of the paediatric forensic examinations service and environment was required. Both had been recognised as a risk by the trust.

Staff were caring, compassionate and respectful. Staff were positive about working in the service and there was a culture of flexibility and commitment.

The service was well led and a clear leadership structure was in place. Individual management of the different areas providing acute children’s services were well led. Governance processes, clinical risks monitored, and feedback from staff, parents and children and young people had resulted in changes to aspects within the service.

End of life care

Requires improvement

Updated 8 March 2016

Overall, we judged that end of life care for patients required improvement.

The National Council for Palliative Care recommends one whole time equivalent consultant for every 250 beds; the trust did not meet this. End of Life services protected patients from avoidable harm, and staff were able to raise concerns and report incidents although learning from them was not always shared.

We saw elements of good practice including infection control and prevention. The organisation of some patient records was poor which could lead to a loss of documents and breach of patient confidentiality.

End of life training was not delivered regularly to staff. Patients’ needs for pastoral care was not assessed or identified within their care plan. Patients did not have access to a seven day face-to-face service from specialist staff, and staff were not adhering to the trust’s policy for the completion of Do Not Attempt Cardio-Respiratory Resuscitation decisions.

Patients were involved in their care as much as possible and were treated with dignity and respect; although care was not always responsive to patients’ specific needs. Audits of patients dying in their preferred place had not taken place. The last audit relating to the length of time patients were waiting for a ‘fast track’ discharge had been completed in 2013/14. It was therefore not possible to identify and address any current concerns or potential delays.

The trust did not have an overall strategy for end of life care. Although there was one in place for those receiving palliative care, it had not been communicated across the trust. The quality, risks, and performance issues within end of life care were monitored through the clinical effectiveness committee. There was a dedicated executive lead in place for end of life care within the trust, although most staff were unaware of who this was.

Staff on occasions wished they had more staff to deliver good quality care to patients at the end of their lives. Although most wards had a designated end of life ’champion’ in place, they did not have protected time to study or teach their ward colleagues about giving good quality end of life care. Where staff had access to a palliative care resource folder these were not always up to date to support staff in the provision of best practice when providing end of life care.

Outpatients

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.