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Conquest Hospital Requires improvement

This service was previously managed by a different provider - see old profile

Inspection Summary


Overall summary & rating

Requires improvement

Updated 6 June 2018

Our rating of services remained the same. We rated it them as requires improvement because:

  • The rating requires improvement was given because although all of the services we inspected in March 2018 had shown significant improvements, the rating is aggregated with the ratings from previous inspections which continue to be considered where we have not re-inspected.
  • Staffing continued to be a challenge. There were innovative roles created to mitigate some of the risks, there was ongoing recruitment and there was better use of in-house bank staff over agency staff. The only area where we saw an unacceptable impact was with the administrative and reception staff in the emergency department who felt unable to have any breaks during long shifts.

However:

  • We were aware from our ongoing monitoring of wider improvement in core services which were not inspected in March 2018. These improvements cannot be reflected in the ratings as they have not been corroborated trough inspection.
  • The ongoing monitoring and information we hold about Conquest Hospital, coupled with discussions with numerous staff, showed a cultural shift which resulted in a more motivated workforce and a commitment to improving the quality and safety of services. This was true across all areas of the hospital whether inspected at this inspection visit or not.
  • Incident reporting and learning from incidents was embedded in everyday practice. Monitoring and reviewing activity enabled staff to understand risks and gave a clear and current picture of performance and safety. The number of incidents reported had increased steadily since our inspection in October 2015 but the number of incidents resulting in harm had fallen. This demonstrated a good reporting culture.
  • Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event. From December 2016 to November 2017, the trust reported three incidents classified as never events. The trust had provided a robust response to all incidents to reduce the risk of recurrence.
  • Staff took a proactive approach to safeguarding and focussed on early identification and intervention. Staff from the Conquest Hospital were actively engaged in the local safeguarding arena and with other providers. Staff were trained to the appropriate level.
  • Risks to patients were assessed, monitored and managed on a day-to-day basis. This included observing for signs of deteriorating health, medical emergencies and challenging behaviours.
  • Peoples care and treatment was planned and delivered in line with current national guidance and legislation. There was ongoing monitoring to ensure that practice and policy remained in line with best practice guidance.
  • People had comprehensive assessments of their needs with consideration of their clinical needs, mental health and nutritional needs. Data provided showed improvements in assessing individual risks such as for venous thromboembolism (VTE). There was also a steady decrease in the incidence of falls with harm resulting from improved risk assessments.
  • There was good multidisciplinary working across services.
  • Consent was obtained in line with the current legislation and guidance including the Mental Capacity Act 2005, and the Children Acts 1989 and 2004. People were supported to make decisions and where appropriate their capacity to consent was assessed and recorded.
  • Infection prevention and control practice was much improved and there was data available to demonstrate that the hospital was routinely cleaned to an acceptable level in line with the National Specification for Cleanliness in the NHS.
  • There was a very person centred culture that had developed since our previous inspection in October 2015. Staff wanted to provide good care and were kind and compassionate in their interactions with patients. This was reflected in the results from the Friends and Family Test.
  • On previous inspection visit in October 2015 some staff were unclear about their line management arrangements and felt unable to raise concerns. There were several complaints to the inspection team about bullying. This had now changed. Staff reported approachable and supportive managers, clear lines of accountability and an executive and senior management team who were visible and who listened to frontline staff.
  • The governance processes were robust and understood by all. Work had been done to streamline the Risk and Quality Delivery Strategy that made explicit the lines of accountability and reporting systems. There was effective information sharing in both directions between the frontline operations and the board.
  • In medicine for the referral to treatment time (percentage within 18 weeks) - admitted performance. The performance of the trust was consistently better than the England average from December 2016 to November 2017.
  • The length of stay and waiting lists were in line with national standards and comparators

Inspection areas

Safe

Requires improvement

Updated 6 June 2018

Effective

Good

Updated 6 June 2018

Caring

Good

Updated 6 June 2018

Responsive

Requires improvement

Updated 6 June 2018

Well-led

Requires improvement

Updated 6 June 2018

Checks on specific services

Critical care

Good

Updated 27 March 2015

The intensive care service uses procedures to ensure patients receive safe and effective care. Clinical outcomes were monitored, and practice changed where required improvements are identified. Staff were caring and compassionate, working to maintain the privacy and dignity of their patients. However, some improvements were required in relation to bed management processes, to ensure that patients did not remain in the intensive therapy unit (ITU) longer than required, which can impact on privacy and dignity. Leadership on the unit is good, but a change to the clinical unit management team has led to a lack of discussion when it came to dealing with planning issues, such as the clinical environment.

Outpatients and diagnostic imaging

Requires improvement

Updated 26 January 2017

We found the outpatient and diagnostic imaging services at Conquest Hospital to be requires improvement. This was because:

  • There were 22,000 patient x-rays awaiting a report and a diagnosis.

  • Staffing numbers in the diagnostic imaging department were 33% below the numbers required to cover all examinations and the on call rota.

  • The trust referral to treatment time (RTT) had fallen below the 92% standard from March 2016 onwards, but had been the same as the England average since July 2015.

  • The trust was performing much worse than the 85% operational standard for patients receiving their first treatment within 62 days of an urgent GP referral.

  • Morale was low in the diagnostic imaging department. Staff felt they were not consulted on changes in the structure of the department and that there was disconnect between staff and managers.

  • The outpatient department had systems and processes in place to keep patients free from harm.

  • Infection prevention and control practices were in line with national guidelines.

  • Areas we visited were visibly clean, tidy and the environment was light, airy and comfortable.

  • A wide range of equipment was available for staff to deliver a range of services and examinations.

  • Medicines were stored in locked cupboards and administration was in line with relevant legislation.

  • Staff kept medical records accurately and securely in line with the Data Protection Act 1998.

  • The hospital had a comprehensive audit programme in place to monitor services and identify areas for improvement.

  • The outpatient services had sufficient numbers of appropriately trained competent staff to provide their services.

  • Staff completed appraisals regularly and managers encouraged them to develop their skills further.

  • Staff interacted with patients in a kind, caring and considerate manner and respected their dignity. Patients told us they felt relaxed when having their treatment.

  • The hospital was responsive to the needs of the local populations. Appointments could be accessed in a timely manner and at a variety of times throughout the day.

  • Staff in the outpatient department felt their managers were visible, approachable and effective.

Urgent and emergency services

Good

Updated 6 June 2018

The emergency department at Conquest Hospital has a four-bedded resuscitation bay, eighteen major cubicles/, a mental health assessment room, three minor injury assessment bays/cubicles emergency nurse practitioner bays, plaster room and eye examination room. There is a clinical decision unit connected to the emergency department by a corridor that has seven bed/trolley bays and is used to observe patients or await investigation results. A paediatric resuscitation bay, waiting area and a designated paediatric treatment cubicle are available. There is an x-ray facility in the emergency department.

The hospital does have an inpatients paediatric ward but not paediatric intensive care support. Children requiring intensive care are transferred to a specialist paediatric unit in London or Brighton. Children under the age of one year old after registering in the emergency department are sent directly to the paediatric ward. The department has a newly built primary care suite, which at the time of inspection was not fully functional. The future plan for the primary care suite is to develop a fit-to-sit GP and advanced nurse practitioner assessment service co-located in the emergency department.

Patients who go to the hospital with minor injuries or illnesses register with reception before a triage nurse assesses them. Urgent and emergency services were last inspected in 2016 when overall we rated it as requires improvement .We rated safe as inadequate, responsive, effective and well-led as requires improvement and good for caring.

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

  • Staff worked in a culture that empowered them to report incidents. Learning from incidents, including serious incidents, had improved since our last inspection. Staff confirmed they received feedback and learning from incidents.
  • The service was delivered by staff that were competent, trained and supported by their managers, and in sufficient numbers, to provide safe and effective care.
  • The service used local and national audits to identify areas of weakness, to develop improvement plans, and to increase the effectiveness and responsiveness of the department.
  • The service worked with the local commissioners and other stakeholders to plan, deliver and further develop the urgent and emergency services to meet the needs of the local community.
  • The median time from arrival by ambulance to initial assessment was consistently better than the overall England median over the whole of the 12 month period from December 2016 to November 2017.
  • An audit demonstrated poor performance in the management of sepsis as a result the service developed an action plan. Recent audit data showed a marked improvement in the management of sepsis since the improvement plan was implemented.
  • There was parity in the quality of care given to all patients who attended the department regardless of their health needs.
  • Over the 12 months from January to December 2017, no patients waited more than 12 hours from the decision to admit until being admitted.
  • Performance against national standards was showing an improving trend.
  • Leaders across the directorate, and hospital had a strategy for the service, were visible, dynamic and supported their staff. Leaders understood the risks and challenges to the service.
  • Care and treatment provided reflected evidence based practice and national guidelines.
  • Consultants had clinical oversight and ownership of all the patients in the department.
  • Staff were engaged, felt valued and were proud of their department. Staff safety and welfare was paramount to the leadership team.
  • The mental health service provided had improved and the service worked in collaboration with the emergency department to ensure both physical and mental health needs of patients were met.
  • Both staff and managers reported difficulties accessing child and adolescent mental health services, especially out of hours.

However:

  • There was no information regarding how patients could make a complaint or comment. However, when this was highlighted to the leadership team immediate action was taken and information was displayed by the end of our inspection.
  • There was no facility available for families to spend time with their deceased relative as recommended by the Royal College of Emergency Medicine guidelines. Families could spend time with a deceased relative in the resuscitation department or chapel of rest.
  • The toilets in the department posed a risk to service users with a mental health illness. They contained a number of fixtures and fittings that could be used as ligature points. This was resolved shortly after our inspection after raising it with the department staff.
  • Mandatory training compliance although better than our last inspection still required improvement.
  • Out of date medicines were found within a fridge in the resuscitation unit and three out of date pieces of disposable equipment were found in the resuscitation trolleys.
  • The department’s performance in the Royal College of Emergency Medicine was varied; however some of this audit were undertaken two years ago and may not reflect the improvements made.

Maternity

Good

Updated 6 June 2018

  • Staff understood how to protect patients from abuse. The safeguarding team integrated well with the wider trust and community to ensure training was completed and to assure that staff knew how to care for vulnerable women, families and infants.
  • Staff felt able to raise concerns, report near misses and report incidents. There was openness and integrity at risk meetings and learning from incidents was shared across the team in a variety of ways.
  • Mandatory training targets had improved since the last inspection and staff appraisals were benchmarked against the trust’s visions and values.
  • Patients received co-ordinated care from a team of competent staff and a cohort of specialist services. Staff worked together to meet patients’ individual needs which meant that their mental health, emotional wellbeing as well as their physical health was cared for.
  • Women had access to a range of pain relief methods including a birthing pool. Epidurals were available 24 hours, seven days a week.
  • Staff and managers demonstrated commitment to best practice performance and risk management. Risk and performance was reviewed and managed through a series of local and trust wide meetings.
  • There was a commitment to drive innovations forward by staff as well as leaders. Feedback from patients, staff and stakeholders was used to initiate changes for the better within the department.
  • Local and national audits were used to benchmark and measure performance to drive the quality of care within the department
  • The culture within the trust was supportive and staff felt and listened to. Staff were proud of the department and their work colleagues.

Maternity and gynaecology

Requires improvement

Updated 26 January 2017

We rated this service as 'requires improvement' because:

  • The triage system did not ensure all calls were answered in a timely manner and sometimes led to calls being missed.

  • We were told of delays in the day assessment unit out of hours due to staff being moved to the delivery suite. We witnessed this during our un-announced inspection on a Saturday.

  • Midwives were not always able to attend the daily risk meetings and feedback was not always ensured.

  • Cleaning schedules in theatres were not always completed and we saw high level dust on inspection.

  • Sterile equipment on the labour ward resuscitation trolley was not in date and two sterile packages were ripped open and left on the trolley.

  • Mandatory training fell below trust targets in many areas across the whole department.

  • Several of the maternity policies and procedures were outside their review date. This meant the service might not have worked to all the relevant and current evidence-based guidelines, standards or best practice.

  • There were delays for patients using gynaecology services and referral to treatment times were consistently worse than the 18-week target.

  • Mirrlees ward was often taking patients that were not gynaecological patients (medical outliers).

However;

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Daily risk meetings and the sharing of incident learning ensured that staff learned from incidents to prevent recurrences.

  • When staff identified issues we saw that they initiated projects to try and understand the causes for this. For example (HIE) cases were further reviewed to look for causes and possible actions to reduce recurrence.

  • There was enough equipment to allow staff to safely treat patients. Equipment was regularly checked and maintained to ensure that it worked safely.

  • Staff followed infection control procedures and demonstrated a good understanding of these. The use of personal protective equipment (PPE) was audited to ensure staff were following guidelines.

  • Staff received mandatory training in safety systems, including responding to childbirth emergencies such as post-partum haemorrhage (and

  • Safeguarding vulnerable adults and children was given sufficient priority. Staff received an appropriate level of safeguarding training to allow them to identify safeguarding concerns and knew how to raise these.

  • Outcomes for people who used services were generally positive and met expectations.

  • Appraisal rates met expected trust targets. Staff we spoke with found senior staff members supportive.

  • Staff treated people with dignity, respect and kindness. Patients felt supported and said staff cared about them. We saw a rapid disciplinary response from staff members when a patient’s dignity was not considered by a colleague who made an inappropriate comment.

  • People and staff worked together to plan care and there was shared decision-making about care and treatment. Women’s wishes were understood and met if possible with clear explanation if this could not happen.

  • The service made reasonable adjustments to remove barriers when people found it hard to use or access services, for example, through provision of interpreters.

  • The service had good links to services within the community and outside organisations such as GP surgeries and social services.

  • Response times to complaints had improved significantly since April 2016. We saw evidence of appropriate responses to complaints, and learning from complaints and concerns.

  • The leadership was knowledgeable about quality issues and priorities, understood what the challenges were and took action to address them.

  • The service proactively engaged and involved all staff through the maternity service review and other channels and ensured that the voices of all staff were heard and acted on.

  • Staff felt respected, valued and supported. All staff we spoke to felt the culture had improved since our last inspection, and gave us examples of positive improvements.

  • The trust had a programme of project groups related to maternity, which drove improvements in different areas of the service.

  • The culture within the trust was good and staff felt supported and listened too. Staff were proud of the department and their work colleagues.

Medical care (including older people’s care)

Good

Updated 6 June 2018

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

  • Staff demonstrated good understanding of the different types of abuse and could tell us the process for reporting a safeguarding concern. Each area had a safeguarding champion who linked into the trust safeguarding team who ensured their area had the most up to date safeguarding information.
  • In the majority of mandatory training topics, the medical department was meeting the trust target for mandatory training compliance.

  • There was an improved culture of incident reporting, particularly the lower grade incidents such as bullying and harassment, showing staff felt safe to report these issues. Incidents were recorded on electronic systems that incorporated fail-safes about aspects such as duty of candour. Learning from incidents was shared across the department and staff received the outcome of the investigation following the incident they had reported.
  • Staffing and patient acuity was monitored regularly throughout the day and staff moved to ensure a safe level of staffing and skill mix at all times.
  • Risks to patients were assessed, monitored and managed throughout their admission. This included potential risks of being unwell, rapid deteriorating health and risk on discharge.

  • The medical department used an integrated care pathway record, which was shared by doctors, nurses and other healthcare professionals. Records were clear, up to date and available to all staff providing care for the patients. The medical department audited records regularly and audits showed actions taken to improve any issues identified.

  • Learning from incidents was shared across the department via cross-site departmental meetings, ward meetings and electronic communication.

  • People’s care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation. This was monitored to ensure consistency of practice.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Staff involved patients and those close to them in decisions about their care and treatment.
  • All patients and relatives we spoke with gave positive feedback about the care they received on the unit. Staff maintained their patients’ privacy and dignity at all times.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.
  • We found evidence of a positive culture that promoted openness and inclusiveness, this included all levels of staff from band one upwards had a voice within the team.
  • We found evidence of a cohesive leadership team who provided sufficient support to staff and had a good oversight of the medical division.
  • Staff told us the leadership and executive team were supportive, visible and approachable.

Surgery

Good

Updated 6 June 2018

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

  • We found that the surgical department was well led. There were appropriate leadership arrangements at all levels within the surgical department and staff felt supported by their managers. Managers, matrons, clinical leads and members of the executive team were visible and approachable. They were actively involved in safety huddles and governance meetings. Staff said they were listened to and senior managers understood and acted on their concerns.
  • The cancellation rate of operations was lower (better) than the average for England. The service proactively monitored procedures and investigated all cancellations to ensure that it did not happen again.
  • Care and treatment was delivered in line with current legislation and nationally recognised guidance. The clinical effectiveness team reviewed all newly published guidelines and ensured they were adapted into local policies.
  • Conquest Hospital was committed to improving services by reporting, investigating and learning for concerns or incidents. The service had reported one never event between December 2016 and November 2017. Staff told us information was disseminated through safety huddles, communications books and meetings to ensure lessons were learned from incidents.
  • Junior members of staff and students were supported throughout their training. Students were allocated and rostered with their mentor throughout their placement. Junior doctors spoke positively about the support they received in theatres. Each had a specific learning development plan and good contact with consultants.
  • Patient records and clinical notes were completed. This included the World Health Organisation surgical safety checklist and five steps to safer surgery and risk assessments.
  • Staff treated patients with compassion, dignity and respect at all times. Care plans were adjusted at the pre-assessment appointment to meet the needs of each individual.
  • Risks were reported to the risk register. This was monitored twice a month at the risk and clinical governance meetings and action plans were implemented to reduce or remove the risk.
  • The service had made improvements in the way medicines were prescribed, recorded and stored; this was in line with national guidance. Automated systems were in uses in most areas. We undertook a random check of controlled drugs in the anaesthetic room for theatre four. The controlled drugs book was accurately completed with no block signatures. The medicines in the locked controlled drugs cupboard were reflected in the book.
  • There was multidisciplinary participation in all patient care. Patient records demonstrated input from physiotherapist, the medical team, surgical nurses, occupational therapists and specialist nurses. Nursing and operating department practitioners spoke of good working relationships with doctors. Staff of all levels were seen interacting positively with each other.

However,

  • There was still a heavy reliance on temporary staff. There were 20 vacancies for surgery at the time of our inspection.
  • Areas within the theatre environment created safety hazards and were in need of refurbishment. The service was aware of the hazards and these were monitored monthly at the risk register meeting. Minor improvement requests for works had been made by the service.

Services for children & young people

Requires improvement

Updated 26 January 2017

We rated this service as requires improvement because:

  • The environment was generally cluttered with equipment stored in the corridor. One bay was crowded with insufficient space for the number of beds. This was rectified during our inspection.

  • Feedback and learning from incidents was mixed with some staff saying that they didn’t get feedback when they had reported an incident. We also heard that some incidents weren’t reported as the process was too long or staff wouldn’t report some incidents in case there were repercussions.

  • Outpatient waiting times were excessive with 79 of 1106 patients waiting over 18 weeks for their appointment.

  • There was no play specialist to lead and develop play services.

  • There was no parents room that could be used to have private or difficult conversations

  • The outside play area was not able to be used due to the type of flooring. The equipment available had also been left for so long that it was not fit for use.

However:

  • Staff understanding of child safeguarding responsibilities, processes and protocols was well embedded. We found there was a strong focus on safeguarding when staff were caring for children.

  • Although cluttered, the equipment on the ward and the ward was clean. This was reflected in the cleanliness and hand hygiene audits.

  • The trust had appointed a consultant who had dedicated time to review all National Institute for Health and Care Excellence (NICE) guidelines and implement them.

  • Internal auditing was comprehensive and each audit was given a priority rating.

  • There was an appropriate response when a child’s condition deteriorated.

  • We observed compassionate care from all staff who had interaction with both children and their families

  • Safety huddles, which started at Eastbourne SSPAU and on the SCBU were introduced on the Kipling ward in August 2016

  • We heard how the culture across the ward was supportive, praising and caring which promoted close working relationships across the teams.

  • There was a published strategy for Womens and Childrens Services with explicit priorities and measurable performance indicators.

  • There was clear leadership of the children’s services with Board level representation.

End of life care

Requires improvement

Updated 26 January 2017

Overall we rated the end of life care service at the Conquest Hospital as ‘Requires Improvement’. This was because:

  • The service did not have a programme of regular audits for end of life care.

  • The trust provided formal training for some staff in end of life care. However, junior staff told us they were not confident at recognising an end of life care patient.

  • The trust did not meet the requirements of the key performance indicators of the National Care of the Dying Audit (NCDAH) 2016.

  • The trust had not implemented the standards set by the Department of Health and National Institute of Health and Care Excellence’s (NICE) guidance.

  • There were inconsistencies in the documentation in the recording of spiritual assessments, Mental Capacity Act assessments and recording of ceilings of care for patients with a Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) form completed.

  • Patients did not always have access to a specialist palliative support for care in the last days of life, as the trust did not have a service seven days a week

  • We found the service did not have clarity in its leadership. It was disjointed without a clear line of objectives that the staff could understand or follow.

  • There was no formal referral criterion for the specialist care team for staff to follow.

  • The risk register for the service was insufficient and did not reflect the needs of the service.

  • The trust did not collate service user’s views with a patients or bereaved relatives’ survey.

However:

  • The specialist palliative care team were a dedicated team who worked with ward staff and other departments in the hospital to provide holistic care for patients with palliative and end of life care needs in line with national guidance.

  • Staff recognised that provision of high quality compassionate end of life care to its patients was the responsibility of all clinical staff that looked after patients at the end of life. They were supported by the palliative care team and end of life care guidelines.

  • Staff at the hospital provided focused, dignified and compassionate care for dying and deceased patients and their relatives. Most of the clinical areas in the hospital had an end of life care link staff member.

  • Facilities were provided for relatives and the patient’s cultural, religious and spiritual needs were respected.

  • The hospital had systems and processes in place to keep patients free from harm.

  • Infection prevention and control practices were in line with national guidelines.

  • Areas we visited were visibly clean, tidy and fit for purpose. The environment was light, airy and comfortable.

  • Medical records and care plans were completed, contained individualised end of life care plans and contained discussions with families. The DNACPR forms were all completed in accordance national guidance and the trust policy.

  • The hospital had sufficient supplies of appropriate syringe drivers and staff were trained in their use.

  • Out of hours telephone support for palliative medicine was provided by the local hospice.

  • A current end of life care policy was available and a steering group met regularly to ensure that a multidisciplinary approach was maintained.

Since the inspection visit in September 2014 there have been a number of improvements to the end of life care provided at the Conquest Hospital. There are still areas where further improvement is needed but greater consideration was being given to identifying and meeting the needs of this group of patients. Some significant changes to the safety of the service that were evident included much better understanding of the rationale for reporting incidents and a more robust investigation process. We saw evidence across the hospital that there was now a commitment to sharing learning when things went wrong. The trust now had a single type of syringe driver for use with patients.

Patients with an end of life care plan were now identified at bed meetings and there was a commitment from senior staff that these patients should be cared for in single rooms, without being moved around, whenever possible. We attended the bed meetings and saw this happened in practice.

Completion of DNACPRs was now good. The records showed that there had been discussion with the patients and/or their relatives. There was consultant review of any decision made by a more junior doctor regarding resuscitation. Work still needed to be done to support staff around ‘ceiling of care’ discussions but overall there were significant positive changes in practice relating to the identification of people approaching end of life, the use of DNACPRs.