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Eastbourne District General Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 6 June 2018

Our rating of services stayed 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.
  • The emergency care department was still rated as requires improvement because there was more work to be done to bring it to the same standard as the service on the Conquest Hospital site. This related particularly to the care of people with acute mental health needs and to the care of children and young people.
  • Mandatory training completion rates needed further work to ensure that the trust met it’s own targets.

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 Eastbourne District general 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. Openness and transparency about safety was encouraged. Staff understood their responsibilities to raise concerns and report incidents and near misses. 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.
  • There were robust safeguarding adults and children arrangements that were in line with current national guidance. Staff from Eastbourne Hospital were actively engaged in the local safeguarding arena and with other providers.
  • 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. This was very evident in the care of patients who had suffered strokes. The trust had been recognised for particularly high performance by the Stroke Association.
  • Consent was obtained in line with the current legislation and guidance. The trust had done much work on staff responsibilities in respect of the Mental Capacity Act 2005 and there generally good understood. All Deprivation of Liberty Safeguard applications were appropriate. Referrals to the Court of Protection were made when necessary.
  • 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.
  • Staff were very positive about their work and spoke with pride about the relationships with patients. We observed and heard about numerous occasions where staff had gone beyond the usual expectations their role for 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.
Inspection areas

Safe

Requires improvement

Updated 6 June 2018

Effective

Requires improvement

Updated 6 June 2018

Caring

Good

Updated 6 June 2018

Responsive

Requires improvement

Updated 6 June 2018

Well-led

Good

Updated 6 June 2018

Checks on specific services

Outpatients and diagnostic imaging

Requires improvement

Updated 27 January 2017

We found the outpatient and diagnostic imaging services at Eastbourne District General Hospital to be 'requires improvement'. This was because:

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

  • The diagnostic imaging department did not clearly demonstrate or document the process of investigating incidents or follow its own incident reporting policy. The radiology manager did not have a clear understanding of reporting incidents under IR (ME) R.

  • The diagnostic imaging department had not met the target for mandatory training, which included safeguarding training.

  • The trust referral to treatment time (RTT) had fallen below the 92% standard from March 2016 onwards.

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

  • Morale was described as low by some staff 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.

However

  • The outpatient department had systems and processes in place to keep patients free from harm. Incident reporting was now embedded in everyday practice and there was evidence of learning from incidents.

  • Infection prevention and control practices were in line with national guidelines. The department was clean and there was a newly refurbished reception area. Staff adhered to the trust infection prevention and control policies.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. Equipment checks were taking place and labels were used to clarify when equipment had been cleaned and was ready for re-use.

  • 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. Records were available for clinics; the number of temporary records was monitored daily using the clinical administration dashboard. Less than 1% of appointments were held where records were not available, which was in line with the trust target.

  • Records were accurate, legible, complete and were stored securely. The outpatient service was in the process of centralising the records store and planned to scan all paper records onto an electronic system.

  • Safeguarding arrangements were understood and followed by staff. Training, to an appropriate level, was provided and senior advice was readily available.

  • The hospital had a comprehensive audit programme in place to monitor services and identify areas for improvement. The outpatient and diagnostic imaging departments participated in a variety of local and national audits to demonstrate compliance with best practise, professional standards and National Institute for Health and Care Excellence guideline (NICE) guidelines.

  • The outpatient services had sufficient numbers of competent staff to provide their services. Staff completed appraisals regularly and managers encouraged them to develop their skills further.

  • There were differentiated outpatient pathways to meet the needs of different groups of patients. Particular consideration was given to meeting the needs of patients on cancer pathways.

  • We observed good radiation compliance as per national policy and guidelines during our visit. A radiation protection supervisor was on site for each diagnostic test and a radiation protection adviser was contactable if required. This was in line with ionising regulations, 1999 and the ionising radiation (medical exposure) regulations (IR (ME) R, 2000).

  • Consent was obtained and recorded in line with national guidance and the trust policy. Staff had a sound understanding of the Mental Capacity Act (2005) and how this impacted on their work.

  • 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.

  • Patient engagement had developed and hospital staff worked with the local Healthwatch, a patient experience group and local community to listen and work together to improve experiences.

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

  • Staff in outpatients felt engaged and involved with their work in local departments and throughout the trust. They had a daily safety huddle and the key points discussed were displayed for staff working later in the day to see and be informed of..

We noticed considerable improvements in the way the outpatient services were now being managed when compared to the findings from our previous inspection visits.

We reported serious concerns about both the availability and condition of individual medical records after both the September 2014 and March 2015 inspections. In March 2014 we saw that one clinic of 24 patients had run with seven sets of notes unavailable. We were told this was usual. The trust did not hold data relating to missing notes at the time of that inspection. From the current inspection visit we saw data was now collated that the service was meeting the trust target of less than 1% notes missing. A new tracker system had been introduced and records storage had been moved offsite with a retrieval system put in place. The trust was in the process of introducing an electronic records system with all current records being scanned into the system before it went live.

The premises looked cleaner and some areas had been refurbished. At this inspection, we saw all cleaning audits were in line with these specifications. Scores for cleanliness audits showed high levels of compliance in all areas. Staff were adhering to the trust policies on infection prevention and control.

At our last inspection we saw the diagnostic imaging department did not provide space and privacy for patients in gowns to maintain their dignity. The department had been redesigned so this issue had been resolved.

The trust had seen an improvement in their performance over time against the two-week standard for urgent GP referrals and data suggested the trust met the 93% operational target with performance of 96.1%. At this inspection, 12 of the 16 speciality groups were better than the England average for incomplete pathways (18-week targets) and four were worse than the England average for incomplete pathways.

Outpatients

Good

Updated 6 June 2018

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

  • Systems and processes were in place to assess, monitor and manage risks to patients. For example, safety checklists were used and monitored to ensure the safety of patients undergoing a surgical procedure.
  • Patient records were available, kept secure and up to date. The trust had made clear improvements to the way health records were managed across the organisation.
  • Staff recognised incidents and reported them through the electronic reporting system. Incidents were investigated by senior staff with lessons learnt shared across the trust. Staff were aware of the duty of candour and gave patients honest information and support.
  • There were business continuity plans in place for use in the event of a major incident. Learning from the use of the major incident plan included the addition of ophthalmology staff to the list of contacts in the event of a major incident.
  • Staff delivered patient care in line with evidence based care and best practice guidance. NICE guidance was used, monitored and audited in a number of clinical specialities, for example, Parkinson’s quality standard (QS164).
  • The service ensured that staff had the skills, knowledge and experience to deliver effective care, support and treatment. For example, through the use of practice based competency assessments for a variety of clinical procedures.
  • Multidisciplinary working was apparent across a range of specialities within outpatients. Doctors, nurses and allied health professionals worked together to provide integrated care that met the needs of patients.
  • People were respected and valued as individuals. Staff throughout outpatient services put patients at the centre of what they did. Staff we spoke with were highly motivated to provide care that was kind and promoted dignity. Patients and relatives told us that they were treated with dignity and compassion. We saw staff interacting in a caring and dignified way with patients with ill mental health and learning disabilities.
  • The outpatient department at Eastbourne hospital was undergoing an improvement programme for services provided to patients. This programme addressed issues such as how appointments were booked, queuing systems for specialist doctors, clinic duration and capacity and demand leading to positive results for patient services and patient experience.
  • Following our report in January 2017 it was highlighted that the outpatient service must develop play services in line with national best practice guidance. We saw dedicated areas for children in the main outpatient waiting areas.
  • We found there was strong and clear leadership capacity and capability. Leaders understood the challenges to quality and sustainability, and were taking action to address them.
  • There were clear and effective processes for managing risk and performance. Quality improvement work had begun within speciality clinics and there were plans to develop this across outpatients as a whole.
  • There were systems in place to support learning, improvement and innovation. The trust had participated in a national benchmarking programme for outpatient departments and the women’s health service had achieved successful accreditation from the British Society of urogynaecology in 2017. There was a continuous improvement programme in place across administrative services that included health records.

However:

  • Not all nursing staff working in outpatient clinics where children were cared for were trained to child safeguarding level 3.
  • Not all complaints were answered within 30 days of their receipt as per trust policy and people were not made aware of the trust’s complaints response deadline.
  • Signposting was not dementia friendly and did not accommodate visual deficit needs.

Maternity and gynaecology

Requires improvement

Updated 27 January 2017

Overall, we rated maternity and gynaecology services as requires improvement because:

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

  • A lack of specialist training for nurses who cared for gynaecology patients presented a risk that may have impacted upon patient care.

  • Most of the maternity policies and procedures were outside their review date. This meant staff might not have been informed around all the relevant and current evidence-based guidelines, standards or best practice.

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.

  • Staff checked and maintained equipment to ensure that it worked safely.

  • Staff received up-to-date mandatory training in all safety systems. This included responding to childbirth emergencies such as post-partum haemorrhage (excessive bleeding after childbirth) and cord prolapse. Cord prolapse is when the cord comes out before the baby during labour, which can cause a reduced supply of blood and oxygen to the unborn baby.

  • 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 patients who used services were generally positive and met expectations.

  • Appraisal rates met trust targets.

  • Staff treated patients with dignity, respect and kindness. Patients felt supported and said staff cared about them.

  • Patients and staff worked together to plan care and there was shared decision-making about care and treatment.

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

  • 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 its 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.

Medical care (including older people’s care)

Good

Updated 6 June 2018

Our rating of the service was good. We rated it as good because:

  • Patients and relatives we spoke with gave positive feedback about the care they received on the unit.
  • Staff showed compassion when dealing with patients and protected their privacy and dignity.
  • Strong clear leadership seen, staff felt well managed and well led. Staff said matrons and senior nurses were visible and supportive within the department, they felt valued, listened to and respected and felt confident to raise any concerns with their line managers
  • The trust recognised the difficulties in matrons completing clinical and administrative work and they have introduced matron’s assistants. Matron’s assistants support matrons with the clerical side of their job such as monitoring training compliance, collecting, and collating data for clinical audits. Matrons and senior staff felt the matron assistant was a valuable resource, which meant had more clinical time to spend on the ward supporting nursing staff.
  • Staff knew how to contact the safeguarding team within the hospital and explained clearly how to make a safeguarding referral. We observed safeguarding folders, which identified the safeguarding lead and the referral process.
  • Staff felt able to raise concerns, report near misses and report incidents. There was openness at risk meetings and learning from incidents was shared across the team in a variety of ways.
  • Comprehensive risk assessments were carried out on patient admission and kept in the patient records. This included assessing the patient against the risk of falls, nutrition status, skin integrity and pain. Alongside the falls assessment an individual needs assessment is completed. This checks a patient’s dementia and delirium, blood pressure, medication review, visual impairments, continence care plan, call bells within reach and mobility and walking aids.
  • We saw staff monitor patient’s national early warning signs (NEWS) scores and discuss patients within safety huddle meetings that had consistently high scores.
  • We observed clear referral pathways for patients who were displaying or had mental health conditions. Staff knew where to access support and information. Staff knew about the psychiatric liaison team based in accident and emergency department and that the team were available 24 hours every day.
  • Managers investigated incidents and shared lessons learned with the whole team and the wider service. We saw incidents and lessons learned documented on team minutes and observed it happening within safety huddles. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • Data collection takes place on one day each month and reported within monthly governance meetings. All staff received a quarterly newsletter called ‘you said, we said’ and gives staff information of common risks and examples of learning from incidents.
  • Trust audits taking place were adult asthma, dementia, diabetes foot care, end of life care, falls, Parkinson’s disease action, pulmonary rehabilitation, and cardiology and staff were aware of audits taking place. Recent audits took place for JAG (joint advisory group on gastrointestinal endoscopy) accreditation, which they are currently awaiting the outcome.

However:

  • Current mandatory and statutory training for nursing and medical staff did not meet trust targets
  • Nursing staff shared concerns with the level of staffing on most medical wards. Senior staff told us most wards have full establishment of staff at the start of a shift. However, staff are taken from the ward they are based in to work in other areas that do not have a full establishment and staff shortages.

Urgent and emergency services (A&E)

Requires improvement

Updated 6 June 2018

We last inspected in October 2016 and rated urgent and emergency services as requires improvement overall. This reflected a rating of inadequate for safe, requires improvement for effective, responsive and well led and good for caring. Our ratings reflected low levels of consultant cover, variable compliance with hand hygiene, inconsistent pain management, limited paediatric services and delays to triage, assessment and treatment. We told the trust they must ensure consultant cover meets the minimum requirements of 16 hours per day, as established by the Royal College of Emergency Medicine.

Our rating of this service stayed the same. Whilst we noted significant improvements in the service from our findings on previous inspections, there were still areas where further work was needed. We rated it as requires improvement because:

  • There remained gaps and inconsistencies in the quality and completion of patient records. This included in the completion of baseline observations and information critical to monitoring patients for deterioration.
  • Records for patients with mental health needs required improvement to assure us of patient safety. In some of the records we looked at we found missing referrals, no evidence of consistent risk assessment and evidence of the discharge of a patient at significant risk of self-harm or suicide.
  • Most staff did not meet the trust’s 90% target for mandatory training completion and demand pressures on the service meant staff often found it difficult to attend training. Standards for the completion of safeguarding training were variable with all staff meeting the requirement for level 1 training. However, the trust had made demonstrable improvements in mandatory training rates since our last inspection.
  • Infection prevention and control standards were variable. Hand hygiene audits in 2017 indicated consistently good practice with 98% compliance. However there was inconsistent recording of infection control assessments in patient documentation and we did not observe consistent practice during our inspection.
  • Provision for patients with mental health needs was variable. A mental health liaison team provided urgent reviews within two hours of referral although there were gaps in the service out of hours. Mental health services were provided by another trust.
  • Consultant vacancies were listed on the service risk register and the latest available data noted 69% of patients were reviewed by a consultant within 14 hours of admission against Royal College of Emergency Medicine guidance.
  • The incident-reporting system indicated consistent oversight from the senior team and a detailed approached to establishing the causes. However records indicated persistent delays in completing investigations and contributing factors included those identified by quality audits, which the senior team had not resolved.
  • Options for food and drink had improved for patients in the clinical decisions unit but audits of the use of the malnutrition universal scoring tool (MUST) noted poor compliance with trust standards.
  • There was evidence of effective multidisciplinary working with the hospital intervention team the security team and specialties when these were available. However non-availability or delays in responding to referrals to specialties had resulted in negative patient outcomes including for patients who needed a stroke assessment. This was evidenced through a few incident reports, such as when a patient remained in the emergency department for 19 hours when multidisciplinary medical teams failed to identify an appropriate care pathway.
  • The trust’s urgent and emergency care Friends and Family Test performance (percentage recommended) was better in comparison to the England average. In the same survey the trust performed in line with the national average for 13 questions relating to how they involved patients in their care and worse than the national average in 11 questions.
  • Data for the period December 2016 to December 2017 indicated variable performance in RCEM audits. This included no month in which patients were admitted, transferred or discharged within four hours of arrival. In addition patients consistently spent longer in the emergency department than the national average. However no patients waited more than 12 hours from the decision to admit until being admitted and much work had been done by the site management and executive team to address patient flow throughout the hospital.
  • The trust had been sent a letter by the Secretary of State congratulating them on being one of the most improved emergency departments nationally.
  • We noted that whilst the rating remained the same, there were noticeable improvements in many aspects of care.
  • The trust had introduced an additional daily consultant shift, which meant consultant cover now met the RCEM requirements of at least 16 hours per day. This was a very significant improvement and meant that decisions about the care of complex patients were being made at the right level of seniority.
  • The senior team demonstrated a significant focus on improving sepsis screening and treatment. This included greater emphasis on evidence-based practice and training. Data provided by the trust showed improvements in the implementation of the sepsis pathway.
  • Facilities in the department included a dedicated area for patients with mental health needs and for children.
  • The department performed similarly to or better than national averages in the Emergency Department Survey 2016 and between November 2016 and December 2017 in the time from arrival to initial assessment.
  • Appraisals were consistently carried out, fit for purpose and focused on staff achievements and goals. Where individuals needed support this was provided.
  • The service had improved the triage process with significantly improved training and clinical competency checks for nurses and HCAs.
  • The healthcare assistant team had been awarded as ‘unsung heroes’ for their work in improving the patient experience and in most of our observations staff demonstrated a commitment to kindness, compassion and empathy. The team readily provided emotional support to patients when they were distressed or confused and used appropriate resources to support patients experiencing confusion as a result of dementia.
  • Some aspects of service planning were expanding to meet increased patient demand. This included an extension of the Hospital Intervention Team to 12 hours each day and a planned increase of overnight mental health team availability.
  • There was a dedicated practice development nurse in post who provided support to all members of the emergency department team. The practice development nurse also supported healthcare assistants to achieve the national care certificate and had helped to develop a new initial training and support programme for newly qualified nurses.
  • Training rates for the Mental Capacity Act (2005) exceeded the trust’s target of 90% and staff demonstrated good knowledge of this. However, monthly audits indicated low levels of compliance with trust standards relating to mental capacity assessments.

  • The emergency department team and multidisciplinary colleagues had implemented a number of initiatives to improve the experience of patients living with dementia, including more resources and increased staff training
  • An established escalation process involved progressively senior staff as waiting times increased and capacity decreased. This enabled staff to use escalation areas and additional spaces for patients whilst they waited for diagnosis and treatment. Along with the introduction of GP streaming this reflected a targeted approach to improving access and flow.

  • Senior staff monitored and updated risks on the service risk register frequently and had initiated a number of strategies to reduce risks. This included a workforce development plan, additional consultant shifts and better utilisation of resource plans for access and flow.

  • Clinical governance systems were embedded in the operation of the service and reviews of incidents, complaints and risks were frequently carried out. However some governance processes did not demonstrate effectiveness or improvements in patient outcomes. This was demonstrated through consistently poor audit results despite governance interventions.

  • Demand for mental health services far outstripped capacity. However the mental health liaison team had introduced monthly multidisciplinary meetings and responsive debriefs with the ED team to review care and effective use of mental health pathways.
  • Staff with substantial expertise in safeguarding and child protection provided support to the emergency department (ED) team although the use of safeguarding tools and assessments was variable. The safeguarding team had recently been expanded and was addressing specific areas of the trust where shortfalls in practice were identified. A new training programme was being rolled out.

Surgery

Good

Updated 27 January 2017

We found the surgery services at Eastbourne District General Hospital (EDGH) to be good because:

  • The hospital had good medicine management processes in place, which related to the security and storage of medicines on all the wards we visited. In general, medicines in theatres were well managed but we observed the block signing of controlled drugs which was contrary to best practice guidance.

  • The trust was compliant with the intercollegiate document, safeguarding children and young people: role and competences for health care staff (March 2014). Staff we spoke to were able to demonstrate an understanding of their responsibilities to safeguarding vulnerable adults.

  • The identification, reporting and investigation of incidents had improved significantly since our previous inspection. We saw minutes of meetings where incidents including never events were discussed and learning fed back to staff via ward meetings and newsletters, which were available in hard copy and circulated by email. There were readily observable changes made across the trust in relation to never events that had occurred, with learning widely disseminated. Learning from Morbidity and Mortality meetings needed further development. Records were brief and suggested limited discussion and challenge.

  • The recently introduced electronic observation recording system had led to improvements in the management of deteriorating patients. Earlier recognition and identification resulted in more timely review by the critical care outreach team, who had oversight of all NEWS Scores for all patients in the hospital. Where the NEWS score was elevated to a higher level there was automatic review by the medical emergency team.

  • The incidence of both pressure damage and falls had shown a sustained improvement over time. Ward and departmental safety thermometer results showed improvements across the service. Medicines management had been added to the safety thermometer as an additional performance measure.

  • Where compliance with VTE risk assessment and prevention had been a concern in our previous inspection report, there was now evidence of high rates of compliance with 95% of patients having a properly completed VTE risk assessment in July 2016.

  • Infection prevention and control measures had improved since our previous inspection. The ‘Bare below the elbow’ policy was enforced more rigorously through the daily safety huddles. Hand hygiene audits showed sustained high levels of compliance with results maintained above 97% since February 2016.

  • The trust rate of surgical site infections (SSIs) was better than the national average.

  • Equipment checks were now given a higher priority. Daily checks of essential equipment were taking place with records available to confirm senior oversight of equipment checks occurring.

  • Care pathways used in surgery referred to national guidance from the National Institute for Care and Excellence (NICE) guidance and other bodies such as the British Orthopaedic Association guidelines. We observed staff following national best practice guidance in theatres.

  • Consent was obtained in accordance with the trust policy and guidance from the professional regulatory bodies. Staff had an understanding of what informed consent entailed. They had received training in the Mental Capacity Act 2005 and knew how this impacted on their work.

  • Friends and Family Test results showed a higher than average response rate and the scores were higher than the England average. Over 98% of surgical patients would recommend the hospital.

  • The hospital staff tried to ensure that the individual needs and preferences of patients were met. There was a system in place to identify patients who might be a little confused and need careful support in decision making.The coloured butterfly markers allowed staff to differentiate these patients from those with more advanced dementia.The dental team provided exemplary planning of care for patients with learning difficulties who needed dental surgery. Every adaptation was offered to make the appointment as comfortable and relaxed as possible.

  • A robust governance system was being introduced. At the time of our inspection visit it was partially rolled out with a clear timeline for continued introduction of key aspects of the framework.The triumvirate management structure for the division gave clear lines of reporting, clear accountabilities and responsibilities and was known to staff. All those we spoke with were clear who their immediate manager was; this was not the case on the last inspection visit in 2015.

  • The majority of staff reported positive changes in their workplace culture and spoke of approachable and supportive middle managers. We saw real warmth in the relationships between ward leaders and nurses and from the HoN towards their wider team. One team of staff felt their manager was less approachable and they felt less supported but this appeared to be about an individual middle manager’s approach.

  • Black and minority ethnic (BME) reported that they felt supported and accepted as part of the hospital workforce. We saw respectful and confident interaction between BME staff and white British staff on the wards we visited.

    However

  • The trust systems for the management of patient records were new and not yet fully embedded.Patient records had been moved off site and were retrieved when needed but staff reported some delays in this. There were times still when patient records were not available for pre-assessment clinics and consultations.

  • There was a high vacancy rate of 12% for surgical nursing staff and the service was highly reliant on bank and agency staff for both nursing and medical staffing. Recruitment continued to provide challenges and whilst the trust had taken many steps to address this, the problem of recruiting sufficient permanent staff continued. The nursing staffing levels had improved since our previous inspection visit in September 2014. Theatres staffing met the recommendations of the AfPP and ward level planned nursing staffing versus actual staffing was usually met, albeit with temporary staff.

  • The trust’s referral to treatment time (RTT) for admitted pathways for surgical services had been worse than the England overall performance since July 2015.

  • There were 735 mixed sex breaches on surgical wards at EDGH during a 12-month period. The reason for these was not documented in most cases.

Intensive/critical care

Good

Updated 27 March 2015

The intensive care service used procedures to ensure that patients received safe and effective care. Clinical outcomes were monitored and were similar to units of similar size. Practice changed where required improvements were identified. Staff were caring and compassionate, working to maintain privacy and dignity of their patients. However, some improvements were needed in bed management processes to ensure that patients did not remain in the intensive therapy unit (ITU) longer than required and patients requiring critical care were managed in an appropriate setting. Clinical leadership on the unit was strong and supported staff development. However, changes to the clinical unit management team led to a lack of engagement with ITU staff, making it difficult for clinical staff to develop plans for the future.

Services for children & young people

Requires improvement

Updated 27 January 2017

We rated this service as requires improvement because:

  • There was no play service provision at the hospital.

  • Incident reporting, whilst improved from 2014, was still inconsistent and did not reflect the number of incidents that should have been reported

  • The hospital had no paediatric recovery nurse

  • Paediatric nurse cover overnight in the emergency department was limited.

  • A number of pathways and policies were still in development

  • Waiting times for outpatients appointments for some patients were excessive

  • The appointment system was not working well and patients were not being sent letters regarding upcoming appointments

  • Transfers to the Conquest hospital were taking place very late from the SSPAU

  • There were no explicit criteria to guide staff as to whether a child should be transferred by ambulance or fit to go by private car.

However:

  • The Friston Unit was clean, uncluttered and had a good play area for children.

  • We saw a good example of staff adhering to the duty of candour

  • We were given positive accounts about the compassionate care children had received from parents and children themselves

  • All staff were aware of the vision and strategy for the trust and how services for Children and Young People fits in.

  • Initiatives had been introduced to help keep children out of hospital.

  • There were plans in place to have a paediatric nurse in the emergency department and on the wards on a rotational basis.

  • Links between acute and community services were good.

  • There was clear line management and staff were aware of their responsibilities.

  • Service development was being encouraged.

End of life care

Requires improvement

Updated 27 January 2017

Overall we rated the end of life care service at Eastbourne District General Hospital 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 (2005) assessments and recording of ceilings of care (best practice to guide staff, who do not know the patient, to know the patients previously expressed wishes and/or limitations to their treatment) for patients with a completed Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) form.
  • Patients did not have access to a specialist palliative support, for care in the last days of life in all cases, as the hospital did not have a service seven days a week.
  • The specialist palliative care team at the hospital did not have a weekly multidisciplinary meeting to discuss all aspects of patient’s medical and palliative care needs.
  • The hospital did not have a rapid discharge process for end of life care patients to be discharged to their preferred place of death.
  • The hospital did not monitor or record end of life care patient’s referrals to the chaplaincy team.
  • 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 that we saw were all completed in accordance with national guidance.
  • 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 medical team at the local hospice.
  • A current end of life care policy was evident and a steering group met regularly to ensure that a multidisciplinary approach was maintained.

We identified some improvements in the service but judged that it still needed further work and investment to ensure it could continue to meet the needs of the patients it served. There was better end of life care planning and recording of individual care needs and preferences.

We could see that discussions with patients and their relatives were now taking place around dying. All the DNACPR forms that we saw were correctly completed with clear reasoning and recording that the decision to withhold resuscitation had taken place. Previously, DNACPRs were poorly completed, with limited information as to why the decision had been made and whether there had been any family involvement.

The bed management arrangements had been revised since our previous visit and site managers were now clear that where a patient was receiving end of life care there was an expectation that they would be nursed in a side room. Movement of these patients was restricted and made only when all other possibilities had been considered.