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Blackpool Victoria Hospital Requires improvement

Reports


Other CQC inspections of services

Community & mental health inspection reports for Blackpool Victoria Hospital can be found at Blackpool Teaching Hospitals NHS Foundation Trust.

Inspection carried out on 15 Nov to 14 Dec 2017

During a routine inspection

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

  • Although surgical and medical services had improved, urgent and emergency care services required improvement.
  • The emergency department had consistently failed to meet the Royal College of Emergency Medicine recommendation that the time patients should wait from time of arrival to being triaged (having an initial assessment undertaken) is no more than 15 minutes. This is important as it is a system that emergency departments use to make sure that the patients who may need immediate treatment are prioritised.
  • The emergency department and medical care services did not always have enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. This was because the planned establishment for nursing and medical staffing had not always been met.
  • The service had not always planned services in a way that met the needs of local people. The emergency department faced challenges to make sure that that the environment matched the needs of patients. We observed some patients were cared for in corridors.
  • People could not always access the service when they needed it. The emergency department had consistently failed to meet the four hour standard for admission, transfer or discharge.
  • Patient outcomes for urgent and emergency care continued to be poor and information submitted to the Royal College of Emergency Medicine showed that results were worse than the national average in most areas.
  • The service did not provide a suitable environment for high risk mental health patients within the emergency department. This was because the department did not have a designated area, which for example, was free of ligature points.
  • The service did not always ensure that each mandatory training area was completed to the trust target for the identified staff within the emergency department. Information provided indicated compliance with training was lower for medical staff.
  • Staff within the emergency department did not always have the correct level of training to prevent patients from abuse. Safeguarding training was not always provided in line with the Intercollegiate Document, 2014.
  • The service did not always manage medicines well. Controlled drugs were not always checked appropriately and patients’ own medicines were not reconciled in line with trust policy within the emergency department. The review dates for medicines were not consistently documented and there was a lack of adherence to the medicines self-administration policy within the medical wards.
  • The service had not always made sure that staff were competent in their roles and up to date competency records were not always available. This was because not all new staff within the emergency department had completed mandatory training before taking on the role and only 55% of nursing staff were up to date with annual appraisals.
  • The emergency department had a vision for what it wanted to achieve. However, not all of the aims had workable plans in place.

However,

  • Staff of different kinds worked together as a team to benefit patients. We observed positive examples of collaborative working.
  • Staff understood their role and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff continued to care for patients with compassion.
  • The service took account of patients’ individual needs.
  • Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

Inspection carried out on 21,22 September 2015

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

Blackpool Victoria Hospital is the largest acute hospital of the Blackpool Teaching Hospitals NHS Foundation Trust. It treats more than 80,000 daycase and inpatients and more than 200,000 outpatients from across Blackpool, Fylde and Wyre every year. The Urgent care service is one of the busiest in the country with more than 80,000 attendances every year in the emergency department. The hospital has 767 beds and employs more than 3,000 members of staff. It provides a wide range of services from Maternity to Care of the Elderly, and from Cancer Services to Heart Surgery.

The trust was one of the trusts identified for Professor Sir Bruce Keogh’s review of trusts in 2013 as the trust had a significantly higher than expected mortality rate from April 2012 to March 2013. CQC inspected the trust in January 2014 and found overall the hospital required improvement. Intensive/ critical care; children and young people and end of life services were rated as Good. Accident and Emergency; Medical care; Surgery and Outpatients services required improvement and Maternity and Family planning services were rated as inadequate.

This inspection was a follow up and was conducted on 21 and 22 September 2015. We only reviewed Maternity services, to review progress against the inadequate rating, we did not review the gynaecology service. We also reviewed the Urgent care services as continued intelligence had raised concerns with regards to the department. We also looked at the governance and risk management support for the services we inspected. We did not undertake an unannounced inspection as the team were confident they had gathered sufficient evidence at the announced inspection. We will apply ratings to the maternity and urgent care services but these will not affect the hospital overall rating of requires improvement.

Our key findings were as follows:

In urgent care services we found some areas had improved since the last inspection however, the results of national CEM audits showed that there were improvements to be made in a number of areas where they were in the bottom 25% of participating trusts nationally. Plans were in place to improve and these were having an effect and were regularly monitored. However, the time to mental health assessment remained a concern with many patients waiting over four hours for assessment although the trust was working with external partners providing mental health services to address this.

We also found that systems for checking essential equipment continued to require improvement since the last inspection when this was raised. The hospital managers took mitigating action before we left the site. However, there were some basic equipment shortages which were having a minimal effect on patients but are worthy of the hospitals attention.

We also noted an induction loop system to help hearing aid users was not working at the time of our inspection. Staff did not always utilise the language support for patient whose first language was not English and were satisfied for a relative to translate.

Leadership of the service had been improved through the employment of a matron with sole responsibility for the A&E department. The new matron however, had only been in post for two months. We noted that nurse appraisal rates were below the expected and the frequency of departmental meetings was very low. Although the team meetings had been reintroduced it was too early to understand the efficacy of them or the matrons role on the culture and understanding of risk and improvement in the department. However, there was a strong multidisciplinary team in the department and staff were positive and proud of the work they did.

The organisational vision and values had been cascaded but there was a lack of documented service level strategy although the direction of travel was planned with eight key actions highlighted by the A&E leadership team. A t

rust wide strategic review was underway at the time of the re inspection.

There was a current A&E strategy, developed  in December 2014, which was under review at the time of the inspection. The current work underway in developing a trust wide strategy would inform the future A&E strategy. 

The lead consultant and senior managers were aware of their challenges and there were escalation processes in place for dealing with additional demand.

The layout of the department continued to hinder the flow of patients, bed management ensured capacity was monitored and managed but when the department became busy patients waited on trolleys in the walkway whilst waiting for a cubicle. The service had escalation processes in place. The 4 hour wait standard was not always met but it was better than the England average. The percentage of patients leaving the department before being seen was slightly higher than the England average however the re-admission rate and percentage of patients waiting 4 to12 hours before being admitted were similar to the England average.

The separate, newly refurbished children’s department was not as busy as the adult side. Patient flow was good and it was rare for patients not to be treated within the four hour target. However, the average time each patient spent in the emergency department was above the England average between April 2013 to March 2015.

Staffing levels for both doctors and nurses had improved although bank and agency staff continued to be utilised. The emergency department was visibly clean. Patients nutrition and hydration needs had been assessed and patients had food and drinks where appropriate. Staff followed infection prevention protocols. There was a good skill mix of competent staff for both adult and paediatric patients. We saw effective collaboration and communication among all members of the multidisciplinary team and services were set up to run 7 days a week. Compliance with mandatory training did not yet meet the trust’s target but was on track to meet it by year end. Risks and complaints were managed well and there was evidence of learning from them. The trust was investing in the senior staff through leadership training and coaching. Staff were positive and proud of the work they did.

Patients described a positive experience and we observed staff treating patients with compassion, respect and dignity. The department Friends and Family test scores were consistently above the national average.

In maternity services the last inspection had identified areas which were inadequate and others that required improvement and an action plan had been developed to address these which has been monitored regularly. At this inspection we found improvements had been made in the number of incidents being reported and the number of post-partum haemorrhages had reduced at the trust. Staffing levels in maternity services were being safely managed and a new midwifery staffing model had been introduced which had impacted positively on the department.

We found that women using maternity services had a high regard for staff and clinical teams, who were caring and treated patients with dignity and respect. There was a good incident reporting culture and systems were in place to ensure lessons were learned. Policies and procedures were up to date and in line with NICE guidance.

The outcomes for patients were in line with the England average on most of the compared measures. Where they were worse this had been investigated and actions taken. There was a good system to triage patients who were admitted to the unit. Patients were offered choice of place for delivery and were included in the decision making for their care. There was good inclusion of the patients and systems for engagement with patients and staff were in place.

However, not all areas of the maternity unit or equipment met with infection prevention and control guidance. The systems for checking the maintenance of equipment and its readiness for use in an emergency were not robust. Training compliance in some key areas including skills and knowledge in emergency situations did not yet meet the trust’s target.

We saw the following area of outstanding practice:

  • The trust was actively trying to support breastfeeding and there was a network of experienced breast feeding mothers called star buddies, who supported new mothers wanting to breastfeed. The star buddies were mostly volunteers and attended antenatal classes to provide information and advice, as well as meeting women on the maternity ward. There was a monthly rota in place covering seven days and five nights of the week. The women we spoke to were impressed with this service and had found it helpful.

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

Importantly, the hospital must:

  • Improve the outcomes for patients through the improvements demonstrated through the national CEM audits in particular, reduce the number of patients attending urgent care services waiting for mental health assessment for over four hours.

In addition the hospital should:

  • Maintain all equipment in both urgent care and maternity is checked as per the policy and kept clean within the infection prevention and control guidance for each specific item.

  • Consider improving the monitoring of the impact of actions taken as a result of incident investigations in maternity services.

  • Maintain training for all staff working in the maternity department with basic life support, blood transfusion and CTG training by the year end.

  • Address the insufficient supply of basic equipment e.g. thermometers in A&E.

  • Review the computer equipment in ‘minors’ area of A&E to ensure consistent recording of patients’ treatment.

  • Try to improve patient confidentiality at the reception.

  • improve staff utilisation of translation support when dealing with patients in A&E who require communication support.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 15-16 January 2014

During a routine inspection

Blackpool Teaching Hospitals NHS Foundation Trust operates from three sites:

  • Blackpool Victoria, which is the main hospital site and the focus of much of its work.
  • Clifton Hospital, which currently has four wards, mainly for elderly care and rehabilitation (with one outpatient clinic).
  • Fleetwood Hospital.

This report relates to the acute core services at the Victoria Hospital site.

Blackpool Victoria is a large acute hospital that treats more than 80,000 day-case and inpatients and more than 200,000 outpatients from across Blackpool, Fylde and Wyre every year. Its Emergency Department sees more than 80,000 attendances every year. The hospital has 767 beds and employs more than 3,000 members of staff. It provides a range of services from maternity to care of the elderly, and from cancer services to heart surgery.

Blackpool Victoria is one of four hospitals in the North West that provides specialist cardiac services and serves heart patients from Lancashire and south Cumbria.

We found that the trust had undertaken work on improving clinical pathways. This was engaging clinicians, and these were well used. This was having a positive impact on the mortality data that was being measured. Some pathways (e.g. heart failure) require further work.

The hospital’s reporting of incidents was poor in some areas where some staff did not report near misses, and some staff reported incidents on behalf of others. This means that the hospital and trust could potentially miss out on valuable learning and therefore improve services.

The quality of patients’ clinical records was poor; handwriting was sometimes illegible and often difficult to read. Accessing information was challenging because of the filing of case notes. This may delay access to important clinical information and impact on continuity of care. Delays in access to case notes is already a challenge, particularly in outpatients.

We saw good participation in clinical audit and use of the data from this. This is an important way for the trust to develop its clinical services.

The trust has a higher than expected rate of primary postpartum haemorrhage (significant bleeding after childbirth). There is also a high rate of hysterectomy in these patients. This is under investigation by the trust.

We observed good caring by all levels of clinical and medical staff, and high levels of patient satisfaction for the way that staff delivered treatment and care.

The trust had made improvements to its services following feedback from its patients (e.g. ward 12) although some areas, such as stroke services, still required additional action. It had also improved facilities for patients in children’s and maternity services.

Many people we spoke to did not know how to share feedback or complaints with the trust. This is a valuable opportunity to develop services that is being lost to the trust.

Inspection carried out on 26 November 2013

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

This inspection was carried out to follow up on compliance actions made at the previous inspection in June 2013. These related to systems in place to manage and respond to complaints and concerns. During the previous inspection we found that complaints were not always dealt with in the trusts own timescales. People did not always feel their concerns or complaints were managed satisfactorily.

The Trust provided the Care Quality Commission with an action plan to address the non- compliance issues. They told us they were reviewing the trusts operation procedures for complaints. This included timescales and communication with people raising complaints.

Two inspectors, a specialist advisor (a professional with specialist experience in hospital governance) and an expert by experience (a person who has personal experience of the services being provided), visited Victoria Hospital unannounced on 26th November 2013.

We looked at what systems had been put in place to improve the management of complaints. We visited three departments within the hospital to speak with staff and look at what information was available to patients to raise concerns or complaints, we also carried out a random selection of telephone interviews with people who had raised concerns and complaints with the Trust in order to determine what that experience was like for those people. Most people told us they had been informed of timescales in the response to their complaints. Some people told us the timescales were not always met. One person told us, “They did let me know about the timescales, they didn’t meet them but they did let me know this would be the case and why”.

Staff members we spoke with told us they were aware of the hospitals complaints processes and some gave examples of how they had directed people to the appropriate contact. This included P.A.L.S (Patients and Liaison Service) who provide confidential advice and support in health related matters.

Inspection carried out on 11 June 2013

During an inspection in response to concerns

We carried out this review in response to concerns centred on issues we had been made aware of from the Trust and also members of the public. The concerns centred around three areas inlcuding, consent to care and treatment, communication and complaints. This responsive inspection took account of the three areas and the content reflects the evidence found in respect of the Trusts compliance with those regulations.

As part of the inspection process we spoke with a number of patients on the wards. We also spoke with relatives in order to gain the views of people who experienced services including planned, emergency surgery and treatment.

Patients we spoke with told us they were given the opportunity to make informed choices about their care and treatment. They told us staff respected their preferences and decisions. One person told us, “I had everything explained to me including the benefits and risks. I had the time to discuss this with my wife. The nurse also spent time with us. It gave me more confidence to make a decision”. Another person told us, “I had all the information I needed to be able to give my consent to my operation”. Two other patients we spoke with told us they had been provided with the information they required to make an informed choice to consent to care and treatment.

Patients told us they had been looked after well and had confidence in the service offered. One person said "everyone is very kind and caring"; "nothing is too much trouble for them". One person said the "staff know what they are doing". Another added that the various staff had "explained everything" and all "knew what each other were doing".

The staff told us they enjoyed working in their particular departments, and they felt supported, both by their colleagues and the senior management team.

We saw the trust had made changes to the way complaints and concerns were being handled and managed. Patients we spoke with in the cardiology centre were satisfied with information they had been provided with and told us they felt comfortable in raising issues with senior staff if they were not satisfied with their care or treatment. Information received by the Care Quality Commission highlighted a number of concerns regarding the way the trust managed complaints and concerns. This included complaints not being responded to in the trusts own timescales. People felt they did not know what action had been taken to improve areas within the context of their individual concerns.

We saw that the trust had a number of internal and external audit systems in place to monitor the quality of the service provided. We were reassured that they responded appropriately when they were given information of concern. They reviewed their own processes as a result of concerns raised and made amendments to their systems if required.

Inspection carried out on 19 March 2013

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

We carried out this inspection to follow up areas of non compliance found during a Dignity and Nutrition Inspection (DANI) on 1st August 2012. In addition we looked at how hospital discharges were being managed and how patients privacy and dignity was being respected.

People we spoke with told us they were satisfied with the care and treatment they had received. They told us they were supported and staff were respectful. Comments included, “I had everything explained to me, staff were very supportive”. Also, “I was anxious about going home as I live alone. They have got carers coming in for the first few weeks. I am happy with what they have done for me”.

We saw there were systems in place for patients to receive a planned discharge. Records we looked at had been completed and other professionals and external agencies had been involved in the planning for patient discharge.

Patients requiring clinical assessment and intervention for nutrition had records in place to manage this process. Where patients were ‘nil by mouth’, there was evidence of clinical decision making as to how this would be managed. In one instance we saw a patient had been assessed for ‘nil by mouth’, on admission. Improvements had been made to record nutritional assessment for patients. The Malnutrition Universal Screening Tool (MUST) had been completed in all instances where there had been a need for the patient

Inspection carried out on 1 August 2012

During a themed inspection looking at Dignity and Nutrition

People told us what it was like to be a patient in Blackpool Victoria Hospital. They described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older patients’ in hospitals were treated with dignity and respect and whether their nutritional needs were met.

The inspection team was led by two Care Quality Commission (CQC) inspectors joined by a practising professional and an Expert by Experience, who has personal experience of using or caring for someone who uses this type of service.

To carry out the inspection, we identified two wards, where there were a percentage of

older patients, in order to focus the dignity and nutrition inspection (DANI). As part of the inspection process we spoke with a number of patients and visitors on both wards. We also spoke with members of the executive management board for Blackpool Teaching Hospital Trust. A range of staff members were spoken with on both wards throughout the site inspection. We did this to gain the views of patients who received care and treatment and people who visited the hospital or worked there.

Patients we spoke with were positive about the care and treatment they were receiving. They told us they liked the food in hospital and told us there was “plenty of choice,” available to them. Comments included, “It’s a busy ward all the staff seem to be involved in meal times, it’s really organised.” Also, “I can’t always manage my food, but the staff are around to help.” A visitor told us, “My wife never had a good appetite, but they go out of their way to try and encourage her with food.”

Patients told us they liked the way staff made them feel at ease if they were receiving treatment, or were talking to the doctor. They told us they felt staff respected their privacy and dignity. Comments included, “Nurse speaks ever so softly when she is asking if I want the bathroom, it’s nice because you don’t want everyone to hear.” Also, “When I need some treatment or the doctor comes to talk to me they always pull the curtains around the bed,” and, “I like my own room it’s more private, the nurses always knock even though I always have the door open, I like to see what’s going on.” We saw evidence of these practices occurring during the observations we made on both wards.

In addition to gaining the views of patients who used the hospital services, we asked other agencies including Local Involvement Network (LINkS) about Blackpool Victoria Hospital. They told us they had been involved in a recent patient experience meeting, which included visiting a ward. They told us comments received from patients had been positive. Patients spoken with were very satisfied with the choice of food and the quality of meals available to them.

Inspection carried out on 21 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 24 April 2012

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

We did not visit the provider as part of our inspection and there were no comments received from people in receipt of their service. We looked at all the information we hold about the provider and asked them to send us information confirming how they had achieved compliance with consent to care and treatment. They sent us comprehensive evidence of the action they had taken in ensuring staff have undertaken training in Mental Capacity Act (MCA). This evidence demonstrated staff at all levels have received training to gain the necessary knowledge and skills to act in peoples best interests and to act in accordance with the consent of people, in relation to their care and treatment. Action taken to gain compliance included, identification of a dedicated lead in Mental Capacity Act (MCA) training. Evidence of a comprehensive training programme, evidence of access to e-learning, regular reviews on the impact of training and regular board updates.

Inspection carried out on 26 September 2011

During an inspection in response to concerns

Patients we spoke with during our inspection were very positive about the information they had received prior to under going surgery. All confirmed they had received information about what to expect during their stay in hospital and about the treatment they were to receive.

Patients told us that they felt fully informed about their care and treatment and that all

doctors had taken the time to answer any questions they had. Patients said that their pre-operative assessment and physical examinations were carried out in private and helped them understand the surgical procedure they were being admitted to hospital for and were positive about their experiences.

Patients said that the new building was relaxing and clean but some did not like the lay out of the four bedded bays. However patients told us there was insufficient natural light in the bay and the lighting provided was insufficient that in the for the bathroom there were no electric shaver points.

Patients said that staff were available when needed and had a relaxed and professional

approach to their jobs which put them at ease. They told us that they were supported by staff who were helpful and recognised if they had anxieties about their treatment. They confirmed that staff helped them understand their treatment and allay their anxieties.

Patients said that staff were attentive and were readily available to provide care and

support when needed.

"Everybody has been brilliant; they have told me everything I wanted to know"

"I thought the information I had was good".

"The leaflets were helpful, but then the staff explained everything I needed to know".

"They went through all the forms again so I understood what was happening and I had

already agreed to have the operation. They treat you really well in that way and I knew what to expect"

"The wards are new and clean – it's very comfortable in here."

"The staff are excellent; they do speak to people in a respectful way".

"Night staff are friendlier, the day staff seem to be a bit rushed to spend too long a time with you"

"The nurses have explained everything and carried out the procedure very well, they are all very caring".