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Chorley and South Ribble Hospital Requires improvement

Reports


Inspection carried out on 12 June to 19 July 2018

During a routine inspection

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 carried out on 27-30 September 2016

During a routine inspection

Chorley and South Ribble Hospital provides a full range of district general hospital services including urgent care centre, critical care, coronary care, general medicine including elderly care, general surgery, orthopaedics, anaesthetics, stroke rehabilitation, midwifery-led maternity care, and breast service.

The hospital has around 220 beds, large operating theatre complex, outpatient suites, and education facilities.

We inspected the hospital as a focused follow up to the inspection in July 2014 where the hospital was found to require improvement in the safe, responsive and well led domains and good in the effective and caring domains. We visited Chorley and South Ribble Hospital between 27 and 30 September 2016.

Following this inspection we have rated the hospital as requires improvement overall and the trust needs to make improvements. Staff were noted to be caring and patient focused and the caring domain was rated as good in all service areas.

We saw several areas of outstanding practice including:

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  • In outpatients the introduction in dermatology of a computerised diary colour codes patients by procedure enabling the service to plan a block of 12 week care in one go to suit the requirements of each patient. It also flags and calculates potential breeches giving better patient flow, facilitating comprehensive audit of care provision and outcome of treatment.
  • In the urgent care centre the housekeeper helped make sure elderly patients being discharged home had basic groceries provided such as bread or milk.

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

Importantly, the trust must:

Urgent Care services

  • Take action to help control risks associated with the room identified for mental health patients must be actioned and appropriately documented.
  • Ensure records of controlled drug use in registers are kept in line with trust policy.
  • Ensure mandatory training compliance reaches and consistently achieves the trust target.
  • Ensure clinical staff are aware of and adhering to the requirement for senior review of specific patient groups prior to discharge from the ED.
  • Ensure action plans following CEM audits target areas of poor performance and improve practice and that clinical staff are aware of and engaged with the process of clinical audit.
  • Ensure version control for policies, procedures and guidance is robust and that these are kept up to date and reviewed regularly.
  • Ensure the department has a dedicated risk register with start dates, timelines, mitigating action and responsible person and review dates included.
  • Ensure major incident plans are updated to reflect the current use of the department.
  • Improve communication and improve the negative culture centred on a lack of communication and feelings of mistrust amongst staff.

Medical Care (including older peoples care)

  • The trust must ensure that all staff receive appraisals and complete mandatory training to enable them to carry out the duties they are employed to perform.
  • The trust must ensure that records are kept secure at all times, so that they are only accessed by authorised people.
  • The trust must ensure procedures in place around medicine management are robust and that policies are followed.
  • The trust must ensure the risk registers are consistent and demonstrate mitigating actions and review dates.

Surgery

  • Take appropriate actions to improve compliance against 18 week referral to treatment standards.
  • Take appropriate actions to reduce the number of cancelled operations and the number of patients whose operations were cancelled and were not treated within the 28 days.
  • Take appropriate actions to improve staff training compliance in adult and children’s safeguarding training.

Critical Care

  • Improve the uptake of mandatory training particularly in safeguarding children and adults.

Maternity & Gynaecology

  • The hospital must ensure midwifery and support staffing levels and skill mix are sufficient in order for staff to carry out all the tasks required for them to work within their code of practice and meet the needs of the patient.
  • The hospital must ensure all necessary staff completes mandatory training, including Level 3 safeguarding training and annual appraisals.
  • The hospital must complete risk assessments for midwives carrying medical gases in their cars and develop a Standing Operating Procedure (SOP) or protocol for carrying medical gases by car.
  • The hospital must ensure that all staff receives medical devices training to ensure all equipment is used in a safe way

Outpatients and diagnostic imaging services

  • Ensure that clear processes and structures are in place for the management and reviewing of governance, quality and risks.
  • Review the processes for managing access and flow for outpatient services to ensure patients are not at risk.
  • Ensure staff complete mandatory training as per the trust policy.

In addition the trust should:

Urgent Care services

  • Have access to written information in languages other than English.
  • Encourage staff to use an approved method of translation rather than relying on web based public translation tools.
  • Improve access to regular teaching for medical staff.
  • Ensure staff meetings are regularly held with minutes taken to record discussions.
  • Introduce a mandatory daily handover between staff starting and finishing work, and document the details being discussed.
  • Rotas should be stored in an organised and accessible to the right staff at all times.
  • Improve root cause analysis to include the root cause of the incident.
  • Improve the attendance of staff invited to safeguarding meetings
  • Provide staff with results from hand hygiene and cleanliness audits for their department to help make sure they are able to monitor staff performance rather than results inclusive of multiple wards or directorates.

Medical Care (including older peoples care)

  • The trust should ensure that patients are discharged as soon as they are fit to do so.

  • The trust should ensure that patients are not moved ward more than is necessary during their admission and are cared for on a ward suited to meet their needs.
  • The trust should ensure that patients have access to pressure relieving equipment at all times.
  • Consider implementing formal procedures for the supervision of staff to enable them to carry out the duties they are employed to perform.

Surgery

  • Take appropriate actions to improve staff appraisal completion rates.
  • Take appropriate actions so that emergency equipment is securely stored.

Critical Care

  • Consider improving appraisal rates as these were lower than at the previous inspection.
  • Consider improving the management of the followed up of audit action plans.
  • Consider increasing the number of staff who had undertaken a post qualification course in critical care nursing in order to meet the Intensive Care Standards guidelines.
  • Consider improving the access to specialist critical care trained pharmacist services on weekends.

  • Consider increasing the monitoring of patient satisfaction as the service did not participate in the NHS friends and family test.

  • Consider improving the level of Physiotherapy staffing to meet the minimum expected standards.

Maternity & Gynaecology

  • The hospital should improve the recording of the review dates and version control of all policies and procedures.
  • The hospital should improve attendance at governance meetings.
  • The hospital should improve staff annual appraisal rates.
  • The hospital should increase staff training uptake for Female Genital Mutilation (FGM) training.
  • The hospital should work to better understand the variation inunplanned home birth rates to ensure safety of patients and babies.
  • The hospital should strengthen the risk registers to support the management of risk.

Outpatients and diagnostic imaging services

  • Consider monitoring and reviewing the procedures for caring for vulnerable patients attending for cancer therapy.
  • Consider improving the environment in the Outpatients department to ensure privacy and dignity is maintained.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 10 and 11 July 2014

During a routine inspection

Chorley and South Ribble Hospital is one of two hospitals providing care as part of Lancashire Teaching Hospitals NHS Foundation Trust. It provides a full range of district general hospital services, including emergency department, critical care, coronary care, general medicine, including elderly care, general surgery, orthopaedics, anaesthetics, stroke rehabilitation, midwifery-led maternity care, and breast service. There are no services for children and young people provided at Chorley and South Ribble Hospital.

Lancashire Teaching Hospitals NHS Foundation Trust as a whole provides services to 390,000 people in the Preston and Chorley areas, and specialist care to 1.5 million people across Lancashire and South Cumbria.

We carried out this comprehensive inspection as part of the new programme of inspection although the trust was not identified as a risk through our Intelligence Monitoring. We did not inspect services for children and young people.

We undertook an announced inspection of the hospital between 10 and 11 July 2014, and an unannounced inspection of Royal Preston Hospital between 6pm and 8pm on 21 July 2014. Our key findings were:

Mortality rates

  • Mortality rates were within expected limits.
  • Patients whose condition might deteriorate were identified and escalated appropriately.

Infection control

  • The hospital was clean throughout. Staff adhered to good practice guidance in the prevention and control of infection.
  • There were good rates of compliance with hygiene audits throughout the hospital

Food and hydration

  • Patients had a choice of nutritious food and an ample supply of drinks during their stay in hospital. Patients with specialist needs were supported by dieticians and the speech and language therapy team.
  • There was a period during mealtimes when all activities on the wards stopped, if it was safe for them to do so. This meant that staff were available to help serve food and assist those patients who needed help. We also saw that a coloured tray system was in place to highlight those patients who needed assistance with eating and drinking.

Medicines management

  • Medicines were provided, stored and administered in a safe and timely way.

Nurse staffing

  • Care and treatment was delivered by committed and caring staff who worked hard to provide patients with good services. However, nurse staffing levels, although improved, remained of concern and the trust was undertaking extensive recruitment activity.  However, adequate staffing levels were not consistently achieved in all core services.

We saw several areas of outstanding practice, including:

  • Clinical governance mechanisms.
  • Ultrasound-guided blocks for patients with neck of femur injuries.
  • Children’s safeguarding review meetings.
  • Rapid response for discharge to the preferred place of care coordinated by the end of life team. Staff told us there was a multidisciplinary approach to discharge planning that involved the hospital and the community staff working towards a rapid but safe discharge for patients.
  • The hospital was committed to becoming a dementia-friendly environment. An older people’s programme was developing this work and we saw several excellent examples of how it was being put into practice during our inspection. The proactive elderly care team helped staff to identify and assess the needs of older people. They also worked proactively with intermediate care services to ensure the safe discharge of older people and those living with dementia.
  • The hospital had also introduced activity boxes throughout the division to promote and maintain cognitive and physical function and reduce the unwanted effects of being in a hospital environment.
  • Two wards at Chorley had been designed specifically to meet the needs of people living with dementia. These wards had been nominated for a national Nursing Times award for the environment. Rookwood A and Rookwood B had also achieved the stage 2 quality mark for elderly-friendly wards from the Royal College of Psychiatrists.
  • The alcohol liaison service had been nominated for a national Nursing Standards award. Staff spoke highly of the service and the positive contributions they had made in supporting patients with alcohol-related conditions and their families.

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

Importantly, the hospital must:

  • Ensure that there are enough suitably qualified, skilled and experienced nurses to meet the needs of patients at all times.
  • Ensure medical staffing is sufficient to provide appropriate and timely treatment and review of patients at all times, particularly in the medical division and outpatients, including medical trainees, long-term locums, middle-grade doctors and consultants.
  • Ensure that Critical Care Unit admission criteria are clearly communicated and understood by all staff so that patients can receive timely and responsive care and treatment.
  • Improve patient flow throughout the hospital to reduce the number of bed moves and length of stay.

In addition the hospital should:

  • Engage with all key stakeholders, including staff, about the future critical care service needs and deployment of resources on the Chorley and South Ribble Hospital site.
  • Take action to improve the management of people with diabetes in line with national guidance.
  • Take action to ensure all prescription charts are fully completed with the required information.
  • Review and improve the impact of patient flow challenges on patients waiting for long hours in the Emergency Department before admission to an inpatient area.
  • Review and improve mechanisms for supporting and recording clinical supervision within the Emergency Department.
  • Audit the care that people received from the end of life service, including pain management and pain relief.
  • Ensure they receive feedback from patients within the outpatients departments to monitor and measure quality and identify areas for improvement.
  • Ensure that staff members have the opportunity to discuss any issues or concerns they may have on a regular basis within clinical supervision.
  • Take action to prevent the cancellation of outpatients clinics at short notice and ensure that clinics run to time.
  • Review the level of cancelled appointments within ophthalmology outpatients and review and address the identified concerns within this department.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 26, 27 November 2013

During a routine inspection

This was an unannounced inspection carried out over several days. During the inspection we visited a variety of areas including the hospital’s accident and emergency (A&E) department, the medical assessment unit (MAU) and a number of medical wards. We also made telephone contact with a number of people who had recently used the service.

We spoke with 17 people who were using or had very recently used the service. We also spoke with 29 staff members whose roles included nursing, domestic services, doctors and senior managers. In addition, the care records for 24 patients were inspected.

The overall feedback from patients was very positive, with the vast majority of people expressing satisfaction with their experience of the service. People’s comments included:

‘’My general impression of the time I spent at the hospital is that I received a service that was knowledgeable, skilful and caring in every way.’’

‘’I cannot fault any of the staff. They are all very caring and nothing is too much trouble. It is really lovely here.”

Most people told us that they had received the care they needed and that staff had taken the time to explain their treatment options and offer advice where necessary. People also felt that they had been treated with respect and dignity and that staff had provided treatment in a kind and caring manner.

During the inspection we looked at the care people received and how their welfare was promoted. We found that people received safe and effective care that met their needs.

We inspected the area of cleanliness and infection control and found that the Trust had good arrangements in place to help ensure that people were cared for in a clean, hygienic environment and protected from the risk of infection.

We assessed staffing levels. We found there were safe staffing levels in all the areas we visited and that the Trust had implemented a number of positive measures to maintain safe staffing levels.

Arrangements for the monitoring of quality and safety were assessed. We found that there were good processes in place that enabled managers to monitor standards, identify risk and respond appropriately to adverse incidents.

We looked at how the Trust enabled people to raise concerns and their processes for responding to complaints. We found that the Trust were implementing a number of positive improvements to help ensure that people’s complaints were responded to in a timely and appropriate manner.

Inspection carried out on 17 October 2012

During a routine inspection

During this inspection we looked specifically at the maternity services provided at the hospital. The hospital has a midwifery led birth centre. The centre provides a number of labour rooms well equipped with birthing pools and birthing balls, for example.

We spoke with four patients who were receiving care, and ten staff members including midwives, health care assistants and managers.

Everyone we spoke with gave very positive feedback about the service and the way they had been cared for. Comments included;

‘’They have been absolutely fantastic. Everything has been just how we wanted it. My midwife was wonderful she even helped us mix aromatherapy oils. You get the feeling nothing is too much trouble.’’

‘’I was worried and they really listened to me and brought my antenatal appointment forward.’’

‘’When I had my baby, I felt so confident with them. I just felt like I could trust them straight away.’’

We looked at five areas during the inspection including the ways in which patients were enabled to make decisions about their care and the quality of care provided. Other areas included arrangements for the safeguarding of patients from abuse and staff training. We also looked at how the Trust monitored the safety and quality of the service.

We found positive evidence of compliance with all areas we inspected.

Inspection carried out on 8 November 2011

During an inspection in response to concerns

Throughout our visit we spoke with a number of patients and in some cases, their families. During these discussions we received extremely positive feedback from everyone we spoke with.

People spoke very highly of staff and expressed satisfaction with their (or their loved one’s) treatment and care. Comments included;

‘’We cannot fault any aspect of care. From arrival to date it has been exceptional.’’

‘’The staff here are brilliant – they are not just here to make up the numbers – they are all good caring people.’’

‘’They really care here. The Sister told me I can phone anytime if I have any concerns.’’

‘’Staff here seem to really know what they are doing and keep you in the picture.’’

‘’It is fantastic here – First class care!’’

‘’Staff are excellent, very friendly – very responsive.’’

‘’I am so glad she is here with these people. I think she has every chance of recovering well because of the way she is being looked after.’’

None of the people we spoke with had any concerns about the standard of care they were receiving and people told us that they would be comfortable in raising any concerns they may have in the future. One relative said ‘’I have no complaints whatsoever, but if I did I wouldn’t have any hesitation in speaking up. I think they (the staff) would want to know.’’

Prior to our visit we also spoke with a number of organisations including the Lancashire Link Local Involvement Network. Local involvement Networks are in place across the country and their role is to ensure people have a say about their experiences of services and how their health and social care services are planned.

No organisations we consulted had any concerns about Chorley and South Ribble Hospital.

Further comments made by people in relation to specific outcome areas are included throughout this report.