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Chorley and South Ribble Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 17 October 2018

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

  • The hospital had made improvements to compliance with mandatory training, life support training and safeguarding training in some areas but compliance in other areas such as urgent and emergency care was still not meeting the trust’s targets.
  • The emergency department at the hospital did not have the appropriately trained staff to assess and treat children. The hospital did not have staff with the appropriate level of life support training working on every shift within the department.
  • The access and flow of patients was an issue for the hospital which was demonstrated by the hospital not meeting national performance targets or performing worse than the England average. There were also a high number of bed moves at night.
  • The hospital did not always have enough staffing in every area. While there had been improvements since the last inspection some areas such as some medical wards and maternity did not always have enough staff.
  • The hospital was not always managing medicines well. There were different issues with medicines management in areas of the hospital such as patient group directions and controlled drugs.
  • While the number of staff who had received an annual appraisal had improved since the last inspection, in areas it was not at the trust target.
  • Staff lacked understanding and awareness of the Mental Capacity Act and the Deprivation of Liberty Safeguards in areas of the hospital.
  • Patient records were not always completed in line with best practice and were not always kept securely.
  • Some of the environment was cluttered and in disrepair and some items of equipment in the resuscitation trollies was past the manufacturer’s expiry date.
  • Risks were not always recorded accurately, with timely action to mitigate risks. Some of the governance processes have recently been developed so were not yet embedded.

However:

  • The hospital was managing safety incidents well. The environment and equipment were kept clean.
  • Services were provided in line with national guidelines and best practice and services were participating and carrying out local audits to improve practice.
  • Staff throughout the hospital were kind, compassion and caring to patients, their carers and family members. Patients were involved in decisions about their care and given emotional support.
  • Services were planned to meet the needs of people using the hospital and services were in general responsive to the individual needs of patients. The hospital engaged well with patients and members of the local community.
  • Staff were positive about their leaders across the hospital. There was a positive culture and staff were proud to work at the hospital.
  • Staff were committed to making improvements, although some of these processes were yet to be embedded. Staff were positive about the focus on continuous improvement and initiatives such as the safety triangulation accreditation review process.
Inspection areas

Safe

Requires improvement

Updated 17 October 2018

Effective

Requires improvement

Updated 17 October 2018

Caring

Good

Updated 17 October 2018

Responsive

Requires improvement

Updated 17 October 2018

Well-led

Requires improvement

Updated 17 October 2018

Checks on specific services

Critical care

Good

Updated 21 April 2017

We previously inspected the hospital in July 2014 and gave critical care services an overall rating of requires improvement. Following this inspection we have rated critical care services at Chorley and South Ribble Hospital overall as good because:

  • The critical care services were well led and staff were aware of the trusts vision and values.

  • We found that there were governance frameworks in place and risks were appropriately identified and monitored.
  • There was clear leadership throughout the service and staff spoke positively about their leaders.
  • Staff were able to report incidents and were knowledgeable about the types of incident they should report.
  • We saw evidence that learning from incidents and complaints was routine and this learning was disseminated.
  • Infection control was effectively managed and the department was visibly clean. Routine infection control audits were undertaken.
  • Nurse and medical staffing was sufficient to meet patient’s needs.
  • Patients received effective care and treatment that followed national clinical guidelines and was tailored to their individual needs.
  • This care was delivered by competent and professional staff.
  • The service participated in local and national audits.
  • Staff sought appropriate consent from patients before delivering treatment and care.
  • Staff treated patients with kindness, dignity and respect and provided care to patients while maintaining their privacy, dignity and confidentiality.
  • Patients spoke positively about the way staff treated them.

However:

  • Mandatory training uptake levels were low for some subjects, including safeguarding children and adult training.
  • Appraisal rates were low at 62% and this was a deterioration from the previous inspection.
  • Audits were not always followed up with action plans and a number of action plans had not been update for years in some cases.
  • The service, as a whole, was not meeting the Intensive Care Standards guidelines for 50% of nursing staff to have undertaken a post qualification course in critical care nursing.
  • There was limited monitoring of patient satisfaction.

Outpatients and diagnostic imaging

Requires improvement

Updated 21 April 2017

We inspected the hospital in July 2014 and gave outpatient and diagnostic imaging services an overall rating of requires improvement. Following this inspection we have maintained the overall rating because:

  • The outpatients and diagnostics service was predominantly managed through the diagnostics and support services division. However key outpatient departments such as orthopaedics and ophthalmology were under a separate management structure. The recent changes in the divisional structure had led to some lack of clarity in terms of performance and governance.
  • At our last inspection we found staff had not received clinical supervision, as required by the hospital’s own policy and procedures. At this inspection we found this was still the case. Some staff told us that they had regular morning briefings and managers were accessible but they had not received and the trust did not provide details of staff uptake of clinical supervision.
  • At our last inspection we found concerns within the ophthalmology department; clinics were sometimes cancelled at short notice and frequently ran late. At this inspection we found there were still issues regarding medical staffing and access to services in ophthalmology. In Ophthalmology there had been follow- up capacity pressures which had led to service governance concerns. The service had reported two serious incidents related to delays in accessing care and treatment.
  • The trust performed worse than the England average for referral to treatment times for non-admitted referral to treatment pathways in October 2015 and remained below the average each month to June 2016. Of the 16 separate specialties reported nine were below the England average.
  • For incomplete pathways of the 16 separate specialties reported, nine were below the England average, the lowest scoring being plastic surgery at 75%.
  • The percentage of people waiting less than 62 days from urgent GP referral to first definitive treatment was worse than the standard for three of the four most recent quarters.
  • Although there was a clear process for reporting and investigating incidents, staff told us they had not received outcomes of incidents submitted. We found that improvements were required by the trust to ensure that staff received regular feedback on incidents.
  • We found some areas did have significant vacancies such as radiology and ophthalmology. Staffing numbers and skill mix met the needs of the patients.
  • The environment in the general outpatient area was well maintained, although we found that some areas of outpatients were crowded. Patients were treated with dignity and respect by caring staff. However we observed patients having blood pressure monitoring in an open corridor. Patients spoke positively about staff and felt they had been involved in decisions about their care. Care provided was evidence based and followed national guidance. Across outpatients and imaging services we found there was good local leadership and staff were committed to meeting the needs of their patients. Overall staff worked well as a team and supported each other.

Urgent and emergency services

Requires improvement

Updated 17 October 2018

The service 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.

  • The service did not always have sufficient paediatric trained nursing and medical staff to keep self-presenting critical ill children safe. Risks to patients, including children, were not always assessed, monitored, managed and responded to in a timely way so that people were supported to stay safe. Compliance with life support training including adult and children’s basic, intermediate and advanced life support, was poor.
  • The service did not always ensure that mandatory training was completed by all staff. Records indicated that compliance with training for nursing and medical staff was low.
  • Staff did not always have the correct level of training to prevent patients from abuse. The service did not always ensure that safeguarding training was completed by all staff in line with ‘Safeguarding children and young people: roles and competences for health care staff Intercollegiate Document Third edition: March 2014. Records indicated that compliance with level two training for nursing staff and levels two and three for medical staff was low.
  • The service did not always manage medicines well. Controlled drugs were not recorded in line the Royal College of Emergency Medicine standards.

However:

  • Patients were cared for by staff who were compassionate, approachable and kept them informed of their treatment plans. Staff took account of individual patient needs and helped patients to maintain their dignity.
  • Staff of different kinds worked together as a team to benefit patients. We observed positive examples of staff working well together.
  • We saw good practice in relation to the care of patients with a cognitive impairment. Forget Me Not wrist bands were in use to aid the identity to support staff to care for patients living with dementia.
  • Staff understood their role and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • The service monitored safety and performance by regular safety triangulation accreditation reviews (STAR) and there was an action plan in place for each ward or service to address any performance issues identified.
  • The service had a vision for what it wanted to achieve and had plans to put them into action.
  • The service’s leaders worked at promoting a positive culture and staff were feeling more supported and valued, creating a sense of common purpose.

Maternity

Good

Updated 17 October 2018

We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings.

We rated it as good because:

  • All managers and staff displayed a caring approach to patients. All staff treated patients with compassion, dignity and respect.
  • Staff involved patients in decisions about their care and treatment including their emotional, physical and social wellbeing,
  • Patients and carers, we spoke with all gave positive feedback about the care they received from all staff.
  • Staff morale was good and staff reported feeling supported by their immediate line managers and colleagues.
  • Joint working between hospital and community services had improved since our last inspection.
  • Safeguarding systems were in place and guidelines followed well by staff. There was a system in place for protecting babies from abduction.
  • There were clear systems in place for reporting incidents and managing identified risks within the service.
  • Processes were in place for ordering and recording medications. Medicines were stored and dispensed correctly.
  • Infection control rates were better than the national average.

However:

  • Women’s postnatal records were not always kept in a secure way. This meant that patient confidentiality could not always be assured.
  • Hazardous substances were not always stored securely a way which protected patients from possible harm.
  • Not all resuscitation equipment used by community midwives was within the manufacturer’s expiry dates. This meant that the effectiveness of this equipment could not be assured when it was needed.
  • There were significant staffing vacancies and sickness and absence rates due mainly to staff on maternity leave. Managers were aware of midwifery vacancy rates and a programme of recruitment was underway. Measures had been put into place to mitigate risk and manage staffing shortfalls.
  • Current processes for reviewing trust policies did not ensure they were reviewed in a timely way. A third of all trust policies were past their review date. The policies we saw which were over their review date remained relevant.

Outpatients

Good

Updated 17 October 2018

We previously inspected outpatients jointly with diagnostic imaging in September 2016, so we cannot compare our new ratings directly with previous ratings.

We rated the service as good because:

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • Care and treatment was delivered in line with best practice guidance. Patient outcomes were reviewed during clinic appointments to make sure patients were receiving appropriate care and treatment.
  • Staff demonstrated a consistently caring attitude to supporting patients that was compassionate and kind. Patients’ dignity was always maintained.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.
  • Patients could access care and treatment in a timely manner.
  • Staffing numbers and skills were flexibly managed to make sure there was sufficient staff to support the clinics as needed.
  • There was a clear strategy based on best practice and values that assisted the service in developing quality care and treatment.
  • The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.

However:

  • The assessment and recording of a patient’s mental capacity and staff understanding of the Mental Capacity Act 2005 was not always consistent.
  • Systems designed to flag patients needing extra support were not consistently used.
  • Information for patients was not always available in formats that met their needs
  • Patient records were variable not all records were clear and up to date.

Maternity and gynaecology

Requires improvement

Updated 21 April 2017

At the previous inspection in July 2014 we rated the service as good overall. Following this inspection we rated have this service as requires improvement overall because:

  • All staff reported a shortfall in staffing and an increasing quantity of work and activity within the service. Management told us that the midwifery staffing levels had not been formally reviewed since 2011. This was also a concern raised at the time of the last CQC inspection in 2014. Although it was noted that  since 2014, there had been an increase of 10 full time midwives.
  • The maternity service was currently waiting for the Birthrate Plus (a national tool available for calculating midwifery staffing levels) review and report, which will calculate the number of clinically active midwives required to deliver a safe high quality service.
  • Due to staffing issues and sickness absence rates, there was a heavy dependence on midwives working extra hours. The trust did not use agency staff but used their in-house bank staff on an ongoing basis. Midwives working over and above their normal working hours provided additional midwifery staffing. Community staff gave us examples of working a 24-hour shift and managers working a 60-hour week.
  • All midwifery staffing, including community were flexed to meet the needs of the service user. Managers were aware of the staffing shortfall and recruitment was underway. Staff informed us that the current measures in place were not sustainable and insufficient to mitigate the risk of harm. Due to the pressures of work, staff morale was low but staff of all professions supported each other well to work as a team. There was a desire to provide the best care they could to the patients and the inability to achieve this led to dissatisfaction amongst midwives.
  • Not all staff attended annual mandatory training or received their annual appraisal performance review in order to discuss and evaluate job performance and career development.

However:

  • There was an integrated service between the community midwives and the two birth centres at RPH and CDH.
  • Care at the Chorley Birth Centre was provided in a calm, relaxed and spacious environment that had been specifically designed and equipped to support normal births. The centre comprised of spacious en-suite birthing rooms, each with a birthing pool, specialised birthing equipment and separate family rooms.
  • There were clear systems for reporting incidents and managing identified risk within the service.
  • Clear protocols and prompt cards were in place for all staff with relevant training in the management of obstetric emergencies. Regular training sessions were held with the ambulance service regarding transfers from the birthing centre at Chorley to the obstetric unit at RPH.
  • CBC used a carbon fibre “Baby Pod” as a transport device for unwell babies who need transferring to RPH by ambulance. The unwell baby is comfortably secured in position by a vacuum mattress and soft positioning straps. The vacuum mattress is moulded around the baby and air is removed with the aid of a vacuum pump to hold the mattress in shape. All resuscitation procedures can be continued while the baby is securely positioned in the pod.
  • Medicines were delivered, stored and dispensed safely.
  • The wards were adequately maintained and equipment was readily available and fit for immediate use. Resuscitation equipment was available and fit for use by suitably trained staff.
  • We found that committed and compassionate staff delivered maternity and gynaecology services. All staff treated patients with dignity and respect. People we spoke to were positive about the care they had received.
  • Gynaecology staff informed us that referral to treatment times met the national recommendations, with rapid access to clinics available.

Medical care (including older people’s care)

Requires improvement

Updated 17 October 2018

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

  • Training levels for mandatory safeguarding training were below the trust target of 90%. At the time of inspection this was 82% across the medical division, included for both Royal Preston Hospital and Chorley and South Ribble Hospitals.
  • The service did not always have suitable premises and equipment and looked after them well. We saw out of date and incorrect equipment on three resuscitation trolleys.
  • There was a generalised lack of awareness of the requirements of the Mental Capacity Act and staff did not follow trust processes for assessing capacity. Discussions with families about patients with do not attempt cardio pulmonary resuscitation records were not always recorded in line with the Mental Capacity Act (2005).
  • Staff did not always keep appropriate records of patients’ care and treatment.
  • Numbers of nursing staff did not always meet the planned levels needed to providing safe care for patients.
  • People could not always access the service when they needed it. Referral to treatment times were consistently below the England average.
  • Whilst the trust now had managers at senior levels with the right skills and abilities to run a service providing high-quality sustainable care, significant leadership changes in the medical division over recent years had impacted overall progress
  • There was no service strategy, although leaders had a vision for what they wanted to achieve and were clear in articulating these.
  • The medical service had not used a systematic approach to continually improving the quality of its services or effectively managing risks. Governance arrangements were not embedded and risk registers complicated.

However:

  • Safeguarding procedures were clear and staff followed these correctly.
  • Staff were aware of the types of incident which could occur and reported these if they occurred. Managers completed incident investigations and shared learning with staff.
  • The service used safety monitoring results well. Staff followed procedures for management of medicines
  • The service planned for emergencies and staff understood their roles if one should happen. Staff followed escalation plans during periods of high patient demand.
  • The service made sure staff were competent for their roles and appraisal rates met trust targets and staff worked well together in a multidisciplinary approach
  • We heard staff communicating with patients in ways which respected their dignity, providing support and reassurance. Patients we spoke with were full of praise for the staff and treatment they received.
  • The service took account of patients’ individual needs, particularly in positive approaches to support patients living with dementia.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff we spoke with were positive about future developments.
  • The trust collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards. Managers had access to data to monitor performance and identify improvements.
  • The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively

Surgery

Good

Updated 17 October 2018

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

  • We previously rated this service in April 2017, when we rated responsive as requires improvement. At this inspection we rated responsive as good. We also rated safe, effective caring and well-led as good.
  • Compliance rates with mandatory safeguarding training and staff appraisals had improved since the last inspection.
  • Staff across different disciplines worked together well to meet patients’ care and treatment needs.
  • Staff treated patients with compassion, dignity and respect and feedback from patients about staff was positive.
  • The service had improved compliance against 18-week referral to treatment standards and at this inspection referral to treatment time was similar to the England average.
  • We saw positive examples of the service engaging with the wider community including people with additional needs.

However:

  • The average length of stay from February 2017 to January 2018 for all non-elective and all elective patients was higher than the England average.
  • The service cancelled elective orthopaedic surgery for two weeks in April 2018.

End of life care

Good

Updated 14 November 2014

Care for patients at the end of life was supported by a consultant-led specialist palliative care team. Staff effectively followed end of life care pathways that were in line with national guidelines. Staff were clearly motivated and committed to meeting patients’ different needs at the end of life. Nursing and care staff were appropriately trained and supervised and they were encouraged to learn from incidents.

The palliative care team staff were clear about their roles and benefited from good leadership. We observed that care was given by supportive and compassionate staff. People spoke positively about the care and treatment they received and they told us they were treated with dignity and that their privacy was respected. The nursing staff and doctors spoke positively about the service provided from the specialist team.