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Reports


Inspection carried out on 7, 8 & 11 December 2016

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

This inspection was a focussed, responsive, unannounced inspection looking only at the adult emergency department and the short stay observational ward (Lyn Jarrett Unit). We did not inspect the children’s emergency department, the major trauma centre or the eye casualty. We inspected this service because of concerns about the trust’s performance against the four hour waiting time standard for emergency departments.

This report describes our judgement of the quality of care at this hospital. It is based on a combination of what we found when we inspected and information given to us from patients, the public and other organisations.

Our key findings were as follows:

  • Patients did not have timely access to initial assessment and diagnosis.
  • There was a risk that high demand, unrelenting pressure and staff perception that they were providing a poor service would lead to a demoralised culture and a lack of service sustainability.
  • Call bells were not available in the majors cubicles and there was insufficient seating for patients waiting in reception and for relatives in the majors and resuscitation areas.
  • Staff did not always assess and respond to patient risks appropriately whilst they were waiting to be seen in the department but leaders responded swiftly to address and mitigate these risks when we brought them to their attention.
  • Ongoing issues with the implementation of a new computer system meant staff did not always have the information they needed to deliver effective care.
  • The overcrowding in the department made it difficult for staff to protect the privacy and dignity of patients.

However:

  • People were protected from avoidable harm and abuse. There was a good track record on safety. Standards of cleanliness and hygiene were generally well maintained, staff received effective mandatory training and there were appropriate nursing and medical staffing arrangements.

  • People’s care and treatment achieved good outcomes and was based on the best available evidence with staff, teams and services working together effectively. Patients’ pain was assessed and managed appropriately and they were given drinks and where appropriate food. Staff were given the skills and knowledge to deliver effective care and treatment and there was an ethos of continual learning in the department.

  • Despite the overcrowding in the department staff cared for patients with compassion, patience and kindness.

  • Services were planned and delivered to meet the needs of local people and individuals. People’s concerns and complaints were responded to and used to improve the quality of care.

  • Leadership, governance and culture were used to drive and improve the delivery of sustainable, high quality person-centred care. There was a supportive culture focussed on continuous learning with strong collaboration and support across all functions and a common focus on improving quality of care and people’s experiences.

We saw some outstanding practice including:

  • Nursing handovers, called ‘roll call’ took place in the emergency department at 7am and 7pm. All qualified and unqualified nursing staff attended. They were shown an electronic presentation of information including themes of complaints and any changes to practice. The outgoing nurse in charge gave information about the previous shift, patients in the department, cleaning and stock levels. A member of the department for research and education in emergency medicine, acute medicine and major trauma (DREEAM) team also attended to deliver short teaching sessions as appropriate. This staff member would also ensure agency staff had received an induction to the department which was recorded.

Professor Sir Mike Richards

Chief Inspector of Hospitals

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, 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 carried out on 26-28 November and 8 December 2013

During a routine inspection

Queen’s Medical Centre 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. Queen’s Medical Centre is the emergency care site, where the emergency department, major trauma centre and the Nottingham Children’s Hospital are located. There are 975 beds on this site.

The trust employs more than 14,000 people. Of the population of Nottingham, 34.6% belong to non-white minority groups.

We chose to inspect the acute services at Queen’s Medical Centre 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 carried out the inspection, our risk methodology had revised that assessment to a medium risk provider. Queen’s Medical Centre has been inspected six times since it was registered in October 2010.

The trust scored better than the national average in 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 Queen’s Medical Centre 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 accident and emergency (A&E) department was seeing increasing numbers of patients, and it could not always maintain the privacy and dignity of all of its patients.

The trust calculated nurse staffing levels for services (with the exception of children’s care services) using a recognised dependency tool. It was currently developing a staffing dependency tool for children’s services.

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 we spoke to said that their care had been positive, and we saw some good examples of staff delivering compassionate care to patients. Nevertheless, some people highlighted areas where they thought 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 7 October 2013

During an inspection in response to concerns

We carried out this inspection in response to information received raising concerns about staffing levels on ward D57, an emergency assessment ward at the Queen’s Medical Centre.

We had previously inspected ward D57 on 19 July 2013 and found that there were not always enough qualified, skilled and experienced staff to meet people’s needs. We set a compliance action and the trust provided us with an action plan setting out the actions they would take in response to our report. Most actions had been timetabled to have been completed at the time of our most recent inspection but not all.

We spoke with four patients who were on the ward during our inspection and asked about staffing levels on the ward. We were told by one patient, “It’s been fine, I think there are plenty of staff.” Another patient said, “The staff have been very caring and come to help when I’ve needed it.” A further patient said, “They’ve been good on this ward, kept my water topped up and kept checking I am alright.”

We spoke with four relatives of patients who were present during our inspection. One person said, “We have been seen to pretty quickly on this ward, I am quite happy with the staffing levels.” Another person said, “There seem to be plenty of staff around, they’ve been to talk with my relative and let us know what’s happening.”

We spoke with eight members of staff who gave us mixed information about the staffing levels on the ward.

We found there were enough qualified, skilled and experienced staff to meet people’s needs on ward D57. We also found that the trust was taking action to address the concerns being raised by staff on this ward.

Inspection carried out on 19 July 2013

During an inspection in response to concerns

We visited two wards during the inspection. We looked at staffing levels on ward D57 and consent processes on ward F22. We spoke with 14 patients, one relative and nine staff. We looked at five patient records.

Patients told us that they were asked for their consent before they received any care or treatment. All patients told us they signed a consent form. Three of the four patients told us they had not received a copy of the consent form. A patient said, “Yes, they sit and talk to me, they make sure I understand what is happening. They tell you properly and ask me if I have any questions. Yes, I have had to sign a few consent forms. They go through it on this ward, tell me any complications and ask if I have any questions then I sign it. I don’t get a copy.”

Nine of the ten patients we asked told us they felt there was enough staff to meet their needs. A patient said, “They have time to care.” Another patient said, “There are enough staff and they have been respectful and caring. The staff are spread evenly.” The patient who did not feel their needs were met said, “I think there are enough staff but they need to be better organised.”

We found that before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. However, we also found that there were not always enough qualified, skilled and experienced staff to meet people’s needs on ward D57.

Inspection carried out on 27, 28 September 2012

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

Patients told us their privacy and dignity were respected and they were asked for their consent before they received any care or treatment. Patients told us they were happy with the care and treatment they received and felt safe. They knew who to speak to if they had concerns. Patients told us they had no concerns about the environment or the confidentiality of their records.

We found that patients' privacy and dignity were respected and staff obtained consent before carrying our treatment. Patients received appropriate care and treatment and received appropriate nutrition and hydration. The provider worked effectively with other providers and there were arrangements in place to ensure the safety of patients. The premises were appropriate and records were kept securely. However, records were not always accurate and fit for purpose.

Inspection carried out on 20 March and 28 May 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 29 September 2011

During an inspection in response to concerns

Most patients told us that they understood the care and treatment choices available to them. One patient said, "I’ve been given literature about my condition and treatment each step of the way to help me take it all in and help me reflect, I know I’m in the driving seat." However, one patient told us that they had not been given enough information to enable them to make an informed choice about treatment.

Patients told us that they could express their views and were involved in making decisions about their care and treatment. One patient said, "I’m in control, they give me the information I need and I make my own decisions." Patients told us their privacy and dignity was respected.

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 told us they were very satisfied with the way their individual care needs had been assessed and managed. Another patient said, "I’ve had ultrasounds and x-rays, and other procedures in other departments and they’ve all been brilliant." Some patients had experienced delay in the implementation of their assessment and treatment plans. Two patients expressed their frustration that they had not been told about delays to their planned procedures. Neither patient had been told to anticipate delays nor were they given an explanation of the reason for the delay and what was being done to address the problems.

One patient told us that the food was fine but said, "Then again, I’d eat anything, it’s not always that hot but I don’t mind that." One patient said, "[The food was] absolutely diabolical, even the sandwiches are old, pre-packed, dry and awful." Another patient said, "The food is very poor, lukewarm at best."

One patient thought the liaison between services was, "excellent." Another patient told us that there had been very good communication between departments and that information had been shared with them so that they knew what was happening and planned for them. However, three patients we spoke with in the discharge lounge had experienced significant delays waiting for their prescriptions to be filled by the hospital pharmacy and for transport to take them home.

Patients told us that they felt safe and they knew who to speak to if they had any concerns. Patients told us that they were happy with the premises.

Patients told us that their needs were met by competent staff. They also told us that staff were well trained and worked hard. Most patients knew where their records were kept and were happy they were available for staff to use but kept secure enough so as to be safe and confidential.

Inspection carried out on 22, 26 September 2010

During a routine inspection

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.