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Dewsbury and District Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 13 October 2017

The Mid Yorkshire Hospitals NHS Trust is an integrated trust, which provides acute and community health services. The trust serves two local populations; Wakefield which has a population of 355,000 people and North Kirklees with a population of 185,000 people. The trust operates acute services from three main hospitals – Pinderfields Hospital, Dewsbury and District Hospital and Pontefract Hospital. At Dewsbury, the trust had approximately 233 general and acute beds, four beds in Maternity and 8 in Critical care. The trust also employed  7,948 staff of which 1,517 were based at Dewsbury and included 126  medical staff 622 nursing staff.

We carried out a comprehensive inspection of the trust between 16-19 May 2017. This included unannounced visits to the trust on 11, 22 May and 5 June 2017. The inspection took place as part of our comprehensive inspection programme of The Mid Yorkshire Hospitals NHS Trust and to follow up on progress from our previous comprehensive inspection in July 2014, a focused inspections in June 2015, and unannounced focused inspection in August and September 2015. Focused inspections do not look across a whole service; they focus on the areas defined by the information that triggers the need for the focused inspection.

At the inspection in July 2014 we found the trust was in breach of regulations relating to care and welfare of people, assessing and monitoring the quality of the service, cleanliness and infection control, safety, availability and suitability of equipment, consent to care and treatment and staffing. We issued two warning notices in relation to safeguarding people who use services from abuse and management of medicines.

At the inspection in July 2015 and our follow up unannounced inspections, we found that the trust was in breach of regulations relating to safe care and treatment of patients, addressing patients nutritional needs, safe staffing, and governance. We issued requirement notices to the trust in respect of these breaches.

Our key findings from our inspection in May 2017 are as follows:

  • Nurse and medical staffing numbers were a concern. Staffing levels did not meet national guidance in a number of areas. Planned staffing levels were not achieved on any of the medical wards we visited during our inspection. We found examples of patient safety being compromised as a direct result of low staffing numbers. This included a failure to escalate deteriorating patients in line with trust and national guidance and a lack of understanding and implementation of sepsis protocols.

  • Access and flow within the hospital was a challenge with a number of medical outliers on wards, and a large number of patient moves occurring after 10.00pm. We found that as nursing staff were working under such pressure in medicine, they were not always able to give the level of care to their patients that they would have liked. We also found that nursing care plans did not reflect the individual needs of their patients, and not all patients felt involved in their care.

  • Not all staff had completed mandatory training and the trust was not meeting its target of 95% for all modules of mandatory training. Not all staff had completed the appropriate level of safeguarding training. Many services had not met the target rates for staff undergoing appraisals.

  • The completion of nursing documentation was inconsistent and did not always follow best practice guidance. We saw that patients whose condition had deteriorated were not always escalated appropriately. We found trust policies with regards to infection prevention and control were not always being followed. The trust had exceeded their target for the number of cases of clostridium difficile.

  • We were not assured that learning from incidents was being shared with staff. There was also a backlog of incidents awaiting investigation. This meant there were potential risks which had not been investigated, and learning undertaken. Information was not shared consistently. Consequently learning from incidents was not embedded with all staff. Staff we spoke to were not all familiar with the duty of candour and when it was implemented.

  • The trust showed poor performance in a number of national patient outcome data audits. The trust also had six active mortality outliers in which the division of medicine were involved.

  • There were issues regarding referral to treatment indicators and waiting lists for appointments. There was an appointment backlog which had deteriorated since the last inspection and was at 19,647 patients waiting more than three months for a follow up appointment. Managers told us clinical validation had occurred on some waiting lists, for example in areas of ophthalmology. However, this had not occurred on all backlogs or waiting lists for appointments across the trust. Between February 2016 and January 2017 the trust’s referral to treatment time (RTT) for admitted pathways for surgical services had been worse than the England overall performance.

  • We were concerned over the lack of oversight of endoscopy services despite a recovery plan being in place. There were large numbers of patients attending the endoscopy unit having their procedure cancelled on the day. Data also showed an increasing trend of patients waiting for diagnostic testing within endoscopy, of which 493 had breached the six-week threshold.

  • There was a lack of assurance that staff were competent to use medical devices and equipment. There was also little assurance that electronic equipment had an annual safety check.

  • There was a lack of internal audit and scrutiny in some services and limited assurance that all services were adequately measuring quality and patient outcomes. Some risk registers contained risks with review dates in the past. This led to concern that the risk registers were not always appropriately scrutinised.
  • There was no specific mental health assessment room in the emergency department. This did not meet not meet the Section 136 room guidelines (a designated place of safety) under the Mental Health Act 1983. Staff were not aware of the NHS Protect guidance on distressed patients.
  • Families who had been discussed at the multi-agency risk assessment panel (MARAC) were not flagged on the electronic system so could not be identified as being at risk of domestic abuse.

  • The critical care service was not compliant with the Guidelines for the Provision of Intensive Care Services (GPICS) standards in a number of areas. The unit used cameras to monitor patients in the side rooms. The use of the cameras was not in line with trust policy or national guidance.

However;

  • Nursing staff showed care and compassion towards patients. Patients and relatives were supported, treated with dignity and respect, and were involved in their care. We did receive positive feedback from some patients and recognition of how hard the nursing staff were working. Staff were also able to demonstrate compassion, respect and an understanding of preserving the dignity and privacy of patients following death.

  • There had been a significant piece of work undertaken to reduce the incident of falls. This had been very successful with the number of falls resulting in severe harm or death reducing by 72%. Falls bands were visible on patients.

  • Staff understood their responsibilities to raise concerns and report incidents. When an incident occurred it would be recorded on an electronic system for reporting incidents. We saw evidence that Root Cause Analyses (RCA) of serious incidents were comprehensive

  • We observed nursing and medical staff gaining consent from patients prior to any care or procedure being carried out. We observed the ‘Five Steps to Safer Surgery’ checklist being used appropriately in theatre and saw completed preoperative checklists and consent documentation in patient’s notes.

  • Policies and guidelines were evidence based and easy for staff to access. We saw many examples of good multidisciplinary working across different areas. We observed good interaction and communication between doctors, nurses and medical crews. Service planning was collaborative and focused around the needs of patients. There was sympathetic engagement with staff and patients around the reconfiguration of some services.

  • Managers were able to describe their focus on addressing issues with the referral to treatment indicators and reducing waiting times. There were referral to treatment recovery plans in place for various specialties. The Did Not Attend (DNA) rate was lower than the England average.

  • The trust had made changes to the way services are organised to the provision of surgery, concentrating emergency and complex surgery on the Pinderfields Hospital site. This met national guidance of separating planned and urgent care. The average length of stay for elective and non-elective medical patients was below the England average.

  • Staff used a community-wide electronic patient record system accessible to the multidisciplinary team caring for the patient including hospital staff, community staff and most GPs. They also had access to EPaCCS (Electronic Palliative Care Coordination System), which enabled the recording and sharing of people’s care preferences and key details about end of life care.

  • Staff reported a positive change in culture with the new management team and felt more engaged. Leadership at each level was visible, staff had confidence in the leadership. Staff spoke of an open culture. Management could describe the risks to the services and the ways they were mitigating these risks.

We saw several areas of outstanding practice including:

  • The trust had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicine.
  • The emergency department had introduced an ambulance handover nurse. This had led to a significant reduction in ambulance handover times.
  • The trust had a new electronic process with remote monitoring to alert staff to fridge temperatures being below recommended levels to store drugs.
  • Panic buttons had been installed for staff to use in the emergency department if they felt in any danger from patients, visitors or anyone walking into the department. The panic buttons had been installed in direct response to and following a review of a serious incident which occurred in the department.
  • We saw evidence of the risk assessment in patients` notes and falls bands were visible on patients. This enabled all staff in the hospital to identify patients at risk of fall no matter where they were in the hospital.

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

Importantly, the trust must:

  • Ensure that there are suitably skilled staff available taking into account best practice, national guidelines and patients’ dependency levels.
  • Ensure that there is effective escalation and monitoring of deteriorating patients.
  • Ensure that there is effective assessment of the risk of patients falling.
  • Ensure that the privacy and dignity of patients being nursed in bays where extra capacity beds are present is not compromised.
  • Ensure that there is effective monitoring and assessment of patient’s nutritional and hydration needs to ensure these needs are met.
  • Ensure that there is a robust assessment of patients’ mental capacity in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards.
  • Ensure that mandatory training levels are meeting the trust standard.

In addition the trust should;

  • Ensure appropriate precautions are taken for patients requiring isolation and that the need for isolation is regularly reviewed and communicated to all staff.

  • Ensure reported incidents are investigated in a robust and timely manner and the current backlog of outstanding incidents are managed safely and concluded.

  • Ensure staff are informed of lessons learnt from patient harms and patient safety incidents.

  • Ensure work is undertaken to reduce the number of patients requiring endoscopies being cancelled on the day of their procedure.

  • Ensure staff in maternity services are trained and competent in obstetric emergencies, to include a programme of skills and drills held in all clinical areas.

  • Ensure that staff triage training is robust and that staff carrying out triage are experienced ED clinicians.

  • Ensure the end of life time provide regular internal performance reporting to directorate or board management to demonstrate improvement in areas such as quality of care, preferred place of death, referral management and rapid discharge of end of life patients.

  • Ensure VTE risk assessments are completed and the target of 95% is achieved.

  • Ensure that records are completed fully and that records are stored securely.

  • Ensure care plans are individualised and reflect the needs of their patients.

  • Continue to address issues of non-compliance with referral to treatment indicators and the backlog of patients waiting for appointments.

  • Ensure that families who had been discussed at the multi-agency risk assessment panel. (MARAC) are flagged on the electronic system so they can be identified as being at risk of domestic abuse.

  • Ensure that there is a specific mental health assessment room that meets the Section 136 room guidelines (a designated place of safety) under the Mental Health Act 1983.

  • Ensure staff are aware of the NHS Protect guidance on distressed patients to ensure that patients with mental health problems would be treated appropriately.

  • Ensure a risk assessment is undertaken with regards to access to the staircase via the fire exit on ward 2.

  • Consider relocating the resuscitation trolley on ward 4 to ensure it can be easily access in an emergency.

  • Ensure that staff are following the medicines management policy and that fridge and room temperatures are appropriately recorded.

  • Improve the rate of missed medicines doses.

  • Ensure the use of cameras in critical care is reviewed and in line with trust policy and national guidance.

  • Ensure that children are recovered from day case surgery in a child friendly environment.

  • Ensure there are systems in place for the recording of transfer bag checks.

  • Ensure work to improve the completion of consent forms in line with trust expectations.

  • Review the risk registers and remove or archive any risks that no longer apply.

  • Increase local audit activity to encourage continuous improvement.

  • Ensure it continues to address capacity and demand across all outpatient services.

  • Consider ways of ensuring team meetings in main outpatients are regular and consistent.

  • Consider ways of ensuring environmental compliance issues with carpets in departments.

Professor Edward Baker

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 13 October 2017

Effective

Good

Updated 13 October 2017

Caring

Good

Updated 13 October 2017

Responsive

Requires improvement

Updated 13 October 2017

Well-led

Requires improvement

Updated 13 October 2017

Checks on specific services

Maternity and gynaecology

Good

Updated 13 October 2017

Following our previous inspection there were robust practices in place to check emergency equipment.

The service had successful bid for Department of Health Safety training and had allocated the funding appropriately.

We found good multidisciplinary working between midwifery and medical staff. We observed good and friendly interactions between staff, women and relatives. There was sympathetic engagement with staff and patients around the reconfiguration of maternity services.

The service had a comprehensive business plan, which included plans to increase staffing levels including specialist midwifery posts. The service had reviewed staffing using a recognised acuity tool and this identified a shortfall of 18 whole time equivalent midwives. The service had an agreed plan to fill these posts over three years.

However:

There was a lack of assurance that staff were competent to use medical devices. There was also little assurance that electronic equipment had an annual safety check. We were not assured of the competence of staff with regard to basic skills such as cannulation and perineal suturing.

Community midwifery caseload numbers were above the national recommendations. Attendance of community and birth centre midwives at obstetric emergency training was below the trust target of 95% at 86%. There was little information for women whose first language was not English, some staff were not aware this could be accessed on the trust intranet system.

The risk registers contained a large number of risks, and many had a review date in the past. This led to concern that the risk registers were not appropriately scrutinised.

Medical care (including older people’s care)

Requires improvement

Updated 13 October 2017

Nurse and medical staffing numbers were a concern. Planned staffing levels were not achieved on any of the medical wards we visited during our inspection. Medical staffing reported 21 consultant vacancies was heavily reliant on the use of locums to fill gaps in rotas. Access and flow within the hospital was a challenge with a number of medical outliers on wards, and a large number of patient moves occurring after 10.00pm.

We found examples of patient safety being compromised as a direct result of low staffing numbers. This included a failure to escalate deteriorating patients in line with trust and national guidance and a lack of understanding and implementation of sepsis protocols. We found that as nursing staff were working under such pressure, they were not always able to give the level of care to their patients that they would have liked. We also found that nursing care plans did not reflect the individual needs of their patients, and not all patients felt involved in their care.

Mandatory training and appraisal figures were below the trust target in the division of medicine. There had been a deterioration in training rates since the last inspection. Safeguarding and resuscitation training compliance were a particular concern. We found poor completion of documentation, particularly in relation to risk assessments relating to falls and monitoring of nutrition and hydration. This had been highlighted at the previous inspection.

Issues in relation to the monitoring and assessment of patient’s nutrition and hydration needs had been identified at the previous inspection. A project plan had been put in place to address the issues in April 2016; however there was a lack of progress against this. We found poor documentation in relation to nutrition and hydration, with only 28% of the records we reviewed being fully completed. We lacked assurance that all patients were receiving pain relief in a timely way and we did not find care plans for pain management in place.

We found trust policies with regards to infection prevention and control were not being followed. We found commodes that were heavily stained and bathroom areas for patients that were not visibly clean. The trust had exceeded their target for the number of cases of clostridium difficile. We found that trust guidance was not being followed with regards to isolation of patients with an infection.

We were not assured that learning from incidents was being shared with staff. There was also a backlog of incidents awaiting investigation. This meant there were potential risks which had not been investigated, and learning undertaken. Information was not shared consistently. Consequently learning from incidents was not embedded with all staff.

The trust showed poor performance in a number of national patient outcome data audits. The trust also had six active mortality outliers in which the division of medicine were involved.

We were concerned over the lack of oversight of endoscopy services despite a recovery plan being in place. There were large numbers of patients attending the endoscopy unit having their procedure cancelled on the day. Data also showed an increasing trend of patients waiting for diagnostic testing within endoscopy, of which 493 had breached the six-week threshold.

We were concerned that the number of new appointments at local leadership level were not able to fulfil their roles as they were working clinically for much of the time. Directorate meetings were variable in their structure and content meaning information was not shared consistently. Consequently learning from incidents was not embedded with all staff.

However:

We did receive positive feedback from some patients and recognition of how hard the nursing staff were working. There had been a significant piece of work undertaken to reduce the incident of falls. This had been very successful with the number of falls resulting in severe harm or death reducing by 72%. Service planning was collaborative and focused around the needs of patients.

Policies and guidelines were evidence based and easy for staff to access. We saw many examples of good multidisciplinary working across different areas. Overall there was good evidence of seven day working clinical standards being met with some areas above regional averages.

The average length of stay for elective and non-elective medical patients was below the England average. Staff reported a positive change in culture with the new management team and felt more engaged. The risk registers reflected the risks to the service.

Urgent and emergency services (A&E)

Requires improvement

Updated 13 October 2017

Not all staff had completed mandatory training and the trust was not meeting its target for all modules of mandatory training. Not all staff had completed the appropriate level of children’s safeguarding training.

The completion of nursing documentation was inconsistent and did not follow best practice guidance. Pain scores were inconsistently recorded in adult and children’s written records. We saw that patients whose condition had deteriorated were not always escalated appropriately.

Families who had been discussed at the multi-agency risk assessment panel (MARAC) were not flagged on the electronic system so could not be identified as being at risk of domestic abuse. There was no specific mental health assessment room in the department. This did not meet not meet the Section 136 room guidelines (a designated place of safety) under the Mental Health Act 1983. Staff were not aware of the NHS Protect guidance on distressed patients.

Staff told us the lack of a palliative care team out of hours had created difficulties in obtaining hospice beds and arranging transfer

However:

We saw evidence of the risk assessment in patients` notes and falls bands were visible on patients.

Panic buttons had been installed for staff to use if they felt in any danger from patients, visitors or anyone walking into the department. The panic buttons had been installed in direct response to and following a review of a serious incident which occurred in the department.

The paediatric area was relatively new. It was very clean and well equipped with well- planned processes. There were four cubicles, one private consultant room and two Triage rooms. The facility opened in March and is open 24 hours per day.

We observed good interaction and communication between doctors, nurses and medical crews. Nursing staff showed care and compassion towards patients. We observed nursing and medical staff gaining consent from patients prior to any care or procedure being carried out.

The Admission Avoidance team and The Hospital Avoidance team (HATS) demonstrated the department not only engaged in multidisciplinary working but also multi-agency working. Staff told us the senior managers were visible and approachable.

Surgery

Good

Updated 13 October 2017

Senior nursing staff had daily responsibility for safe and effective nurse staffing levels and staffing guidelines with clear escalation procedures were in place. Appropriate risk assessments were completed accurately for falls, pressure ulcers National Early Warning Scores (NEWS), sepsis screening and malnutrition. Staff were aware of escalation procedures.

We saw evidence that Root Cause Analyses (RCA) of serious incidents were comprehensive and highlighted immediate actions taken, chronology of events, findings, care and delivery problems, root causes, recommendations, lessons learned and action plans.

We observed the ‘Five Steps to Safer Surgery’ checklist being used appropriately in theatre and saw completed preoperative checklists and consent documentation in patient’s notes.

Patients had good outcomes as they received effective care and treatment to meet their needs. The trust had made changes to the way services are organised to the provision of surgery, concentrating emergency and complex surgery on the Pinderfields Hospital site. This met national guidance of separating planned and urgent care.

Leadership at each level was visible, staff had confidence in the leadership. There were clear governance processes in place to monitor the service provided. The division handled 97% of complaints within trust timescales (95% target).

However:

Medical staff did not reach the trust 95% target for mandatory core training completion, this included safeguarding.

Across the division, NEWS audits (March 2017) showed that 59% of observations were recorded which were worse than the 67% compliance rate in the previous audit. There were 108 missed medications recorded between March 2016 and February 2017 across the surgical division.

Between February 2016 and January 2017 the trust’s referral to treatment time (RTT) for admitted pathways for surgical services had been worse than the England overall performance.

Intensive/critical care

Requires improvement

Updated 13 October 2017

The service was not compliant with the Guidelines for the Provision of Intensive Care Services (GPICS) standards in a number of areas, for example, supernumerary nurse staffing, out of hours medical cover and continuity of care and multidisciplinary staffing. The environment and facilities did not comply with national standards. The unit used cameras to monitor patients in the side rooms. The use of the cameras was not in line with trust policy or national guidance. The service could not provide assurance that staff’s training and competence with equipment was up to date.

The actual nurse staffing did not meet the planned nurse staffing numbers. The service used agency staff regularly and there was limited evidence to support their induction on the unit. The process for the multidisciplinary team and critical care outreach team to receive feedback from incidents on the unit was unclear.

The service did not have an audit lead or audit strategy.

There was limited evidence that the service measured quality. There was no evidence that senior staff had reviewed some risks and their controls had been reviewed.

However;

Patients and relatives were supported, treated with dignity and respect, and were involved in their care.

Leadership of the service was in line with GPICS standards. Staff spoke of an open culture and were proud of the team work on the unit. The service was actively involved in the regional critical care operational delivery network and the acute hospital reconfiguration.

Staff understood their responsibilities to raise concerns and report incidents. Staff assessed, monitored and completed risk assessments and met patients’ needs in a timely way. Patient outcomes were mostly in line with similar units. Fifty five percent of staff in the service had a post registration qualification in critical care. This was in line with GPICS minimum recommendation of 50%.

Services for children & young people

Good

Updated 13 October 2017

Staff understood their responsibilities for reporting incidents. There were incident reporting mechanisms in place and staff received feedback. Staff had the skills required to carry out their roles effectively. Children’s services had employed advanced nurse practitioners.

Care was planned and delivered in line with evidence-based practice. Children and young people could access the right care at the right time. There were processes in place for the transition in to adult services, although they were not as well developed as at Pinderfields, due to commissioning arrangements. A lead nurse for the trust had recently been appointed.

There were effective governance processes and the leadership team understood the risks to their service.

However:

Staffing for children’s day case surgery did not meet Royal College of Nursing (RCN) guidance and there were no specific plans in place if the staff member on duty called in sick at the start of a shift.

Although there were safeguarding systems and processes in place, staff were not meeting the trust target for safeguarding training and did not receive regular safeguarding supervision.

Equipment had no indication of when electronic testing was due and relied on staff contacting medical physics. Service leads told us that there had been a decision to reintroduce the labelling of equipment.

End of life care

Good

Updated 13 October 2017

Nurse and consultant staffing levels for the specialist palliative care team were at full complement and reviewed daily to keep people safe at all times. Any staff shortages were responded to quickly and adequately. Staff delivering end of life and specialist palliative care understood their responsibilities with regard to reporting incidents. Staff we spoke with told us that when an incident occurred it would be recorded on an electronic system for reporting incidents.

We viewed body store protocols and spoke with body store and porter staff about the transfer of the deceased. Staff told us that the equipment available for the transfer of the deceased was adequate and we saw that this included bariatric equipment.

The trust had developed a care of the dying patient (CDP) care plan that provided prompts and guidance for ward based staff when caring for someone at the end of life. We observed the use of these and saw that information was recorded and shared appropriately and that the plans were completed.

We saw that the specialist palliative care nurses worked closely with medical staff on the wards to support the prescription of anticipatory medicines The guidance the specialist nurses provided was in line with the end of life care guidelines and was delivered in a way that focused on developing practice and confidence in junior doctors around prescribing anticipatory medicines.

Staff used a community-wide electronic patient record system accessible to the multidisciplinary team caring for the patient including hospital staff, community staff and most GPs. They also had access to EPaCCS (Electronic Palliative Care Coordination System), which enabled the recording and sharing of people’s care preferences and key details about end of life care.

We observed the use of syringe drivers on the wards and saw that regular administration safety checks were being recorded. Ward staff told us that syringe drivers were available when they needed them.

For those palliative care patients who were already known to the service and admitted to the hospital for care and treatment, 93% were followed up by contacting the ward within 24 hours to assess the need for specialist palliative care assessment.

Staff were able to demonstrate compassion, respect and an understanding of preserving the dignity and privacy of patients following death. Body store staff told us there was always a member of staff on call out of hours. This service was available for families who requested to visit during an evening or a weekend.

We observed staff caring for patients in a way that respected their individual choices and beliefs and we saw that records included sections to record patient choices and beliefs so that these were widely communicated between the teams.

The quality of leadership for end of life care had improved since the last inspection. Structures, processes and systems of accountability, including the governance and management of joint working arrangements were clearly set out, understood and effective.

However:

Staff we spoke to were not all familiar with the Duty of Candour and when it was implemented.

An end of life care plan had been introduced, but there was no regular audit to determine what percentage of end of life inpatients had the care plan in place. There was no regular internal performance reporting to directorate or board management to demonstrate improvement in areas such as quality of care, preferred place of death, referral management and rapid discharge of end of life patients.

The weekly specialist palliative care team (SPCT) multidisciplinary meeting included SPCT nurses and palliative care consultants but no other discipline such as allied health care professionals, pharmacy or the chaplaincy.

We were unable to assess the level of performance in achieving fast track discharges for end of life patients due to lack of evidence; no audit work had been done to measure performance in this area since the last inspection. The service reported that 73% of all new referrals were seen within 24 hours of being referred to the team.

Outpatients

Requires improvement

Updated 13 October 2017

There were issues regarding referral to treatment indicators and waiting lists for appointments. There was an appointment backlog which had deteriorated since the last inspection and was at 19,647 patients waiting more than three months for a follow up appointment. Managers told us clinical validation had occurred on some waiting lists, for example in areas of ophthalmology. However, this had not occurred on all backlogs or waiting lists for appointments across the trust.

No specialties were above the England average for non-admitted referral to treatment (RTT) (percentage within 18 weeks). The trust had a trajectory to be achieving the indicators by March 2018. The trust did not measure how many patients waited over 30 minutes for imaging within departments.

Although senior managers could describe the duty of candour, it was not well understood across all staff groups. Mandatory training completion rates and targets were not always met. Appraisals completion rates did not always achieve the trust target.

In main outpatients, team meetings did not always happen monthly. Managers were aware of this and told us they were addressing consistency of team meetings in main outpatients.

However:

A trust incident reporting system was used to report incidents and staff we spoke with were aware of how to report incidents.

Areas we visited were visibly clean and tidy. Medicines checked were stored securely and medicines checked were in date. Staff told us records were available for clinics when required. Actual staffing levels were in line with the planned staffing levels in most areas.

Staff provided compassionate care to patients visiting the service and mostly ensured privacy and dignity was maintained. Diagnostic services were delivered by caring, committed and compassionate staff.

Managers were able to describe their focus on addressing issues with the referral to treatment indicators and reducing waiting times. There were referral to treatment recovery plans in place for various specialties. The Did Not Attend (DNA) rate was lower than the England average.

Risk registers were in place and managers took risks to the divisional governance meetings. Management could describe the risks to the service and the ways they were mitigating these risks. Most staff we spoke with told us managers and team leaders were available, supportive and visible. Staff we spoke with told us there was effective teamwork within teams and there was a culture of openness and honesty.