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Stoke Mandeville Hospital Requires improvement


Inspection carried out on 6 September 2016

During a routine inspection

Stoke Mandeville Hospital is part of Buckinghamshire Healthcare NHS Trust and provides a wide range of services to Buckinghamshire and surrounding areas including 24 hour accident and emergency, maternity, cancer care and outpatient services. Services also include the regional burns and plastics units, the specialist spinal unit and is the base for eye care for the area.

Stoke Mandeville, treats over 48,000 inpatients and 219,000 outpatients a year and has 479 beds

We carried out a focused unannounced inspection visit on 6 September 2016. We inspected the medical, surgical and end of life care services provided at this location. During the inspection, we also followed up issues identified at the inspection in February 2014 and March 2015 relevant to the service types inspected.

Overall, medical care, surgery and end of life care were rated as ‘requires improvement’. All the services required improvement to provide safe care. Medical care and end of life care services required improvement to provide effective care and surgery required improvement to provide responsive care. We rated all of them ‘good’ for caring and ‘well led’ services.

Our key findings were as follows:

Are services safe?

By safe, we mean people are protected from abuse and avoidable harm

  • Staff felt confident and able to report incidents. The trust recognised the importance of learning from incidents to improve the care provided to patients. However, staff could not always describe where learning from incidents had changed clinical practice. Staff demonstrated a good understanding of duty of candour and gave examples where they had used this to support patients.

  • Staff did not always follow the trust’s medicine management policies and procedures.For example for controlled drugs orders and monitoring medicine fridge temperatures. Staffing shortages in the pharmacy department resulted in reduced support to departments and we found evidence of some unsafe practices, including out-of-date medicines.

  • In general, all clinical areas were visibly clean. There was some variability in infection control standards. The mortuary trolley was found to be dirty with no agreed cleaning schedule in place and deceased clothing was not appropriately stored while awaiting collection.On ward 8 we found some items of equipment had a layer of dust. Theatre staff did not always collect a new set of scrubs to change into when returning to the operating department from another area in the hospital, in line with the trust’s uniform policy and as good infection control practice. In most areas equipment was labelled to indicate it had been cleaned and was ready for use.

  • Systems were in place to enable staff to assess and respond safely to deterioration in patients’ health. The trust used an electronic warning system to prompt staff to take the necessary action to help prevent further deterioration in patients’ health. Staff completed relevant risk assessments for patients and shared information about patients’ care and treatment needs at handover meetings.

  • In the operating departments, the anaesthetic logbooks were not complete, to provide assurance staff had completed the daily safety checks and equipment was fit for purpose, prior to patients having surgery. On some of the wards, staff had not completed the daily checks on the resuscitation equipment in line with the trust policy, to ensure it was ready for use in an emergency.

  • Overall, staffing levels met the planned levels staffing. The trust achieved this using bank and agency staff for some shifts. Managers followed the trust escalation procedures when they identified staffing shortages for their department. In some areas this meant staff on occasions were under pressure to meet patients’ needs particularly when patients were assessed with high needs and required one to one care.

  • Staff completion ofstatutory and mandatory training was variable and not in line with the trust’s target in some areas, this included safeguarding children and vulnerable adults level 2, duty of candour, infection control, medicines management, basic life support and tissue viability.

  • Patient’s safety and daily staffing information was prominently displayed for patients, staff and visitors to read, as part of the trust’s open and honest approach.

  • Staff were knowledgeable about the hospital’s safeguarding policy and clear about their responsibilities to report concerns.However, not all staff were up-to-date with their level 2 safeguarding children and vulnerable adults training.

  • There was variability in the standard of record keeping.In some areas they were clearly written, and generally well organised. They included information about patients’ medical history and social situation, as well risk assessments, care plans and observations. They also included entries from different disciplines.This was not consistent and we also found records that had not been fully completed. This included no care plan or goals or documentation of how the patient had been involved in this and no record of discharge planning. Some DNACPR forms we inspected were not completed according to national guidelines.

Are services effective?

By effective, we mean that people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best possible evidence.

  • Staff planned and delivered people’s care and treatment in line with current evidence based guidance, standards and best practice across the medical and surgical services. While there was some evidence of evidence-based care for end of life care this was not constantly applied across the hospital. For example the trust did not have a protocol for withdrawal of treatment, which was not in line with national guidance

  • The hospital participated in national and regional audits and undertook a local audit programme. For the surgical services results from these audits showed patient outcomes were in keeping with the national average. The results of a number of national audits showed medical services performed worse than the national average. For example, the results of the myocardial ischaemia national audit project (MINAP) national audit 2013/14, National Institute for Cardiovascular Outcomes Research (NICOR) heart failure audit and National Diabetes Inpatient Audit (NaDIA) and national inpatient falls audit showed performance worse than the England average.

  • Staff assessed and managed patient’s pain appropriately and had access to the acute pain service for advice and support. However, for patients receiving end of life care staff did not use a standardised pain assessment tool to ensure staff delivered a consistent approach to pain measurement or management.

  • Patients told us they had made an informed decision to give consent for surgery. The most recent informed consent audit showed medical staff were not completing all consent forms and patient care records to the expected trust and national standards.

  • There was some variability in staff awareness of their responsibilities regarding the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DoLs). Patient’s capacity was not always formally assessed and decisions were made on behalf of patients who were deemed to lack capacity.

  • Multi-disciplinary working was embedded across all the wards. Staff worked effectively within their team and with other teams to provide co-ordinated care to patients, which focused on their needs.

  • The hospital had systems in place to ensure they provided care for inpatients seven days a week. This included access to on-call theatre and diagnostic imaging staff in an emergency and consultants carried out ward rounds seven days a week. The hospital performed above the national and regional average for most standards set out in the NHS services, seven days a week guidance.

  • Staff had good access to training and professional development. The specialist palliative and end of life care staff were skilled and competent to perform their roles effectively. End of life care was not included in the hospital’s core training package for all staff which was not in line with national guidance. The trust did not provide standardised or formal training in end of life care for porter or mortuary staff.

Are services caring?

By caring, we mean that staff involve and treat people with compassion, kindness, dignity and respect.

  • In all areas, patients and relatives were positive about the caring attitude of staff, their kindness and their compassion. All patients we spoke with would recommend the service to their friends and family.This was supported by data collected for the Friends and Family Test.

  • Staff took time to ensure patients and their relatives understood their care and treatment. Patients told us they felt involved in their care and understood their treatment plans. Medical and nursing staff showed sensitivity when communicating with patients and relatives.

  • Staff we spoke with valued and respected the needs of patients and their families. Patients’ emotional, social and religious needs were considered and were reflected in how their care was delivered.

Are services responsive?

By responsive, we mean that services are organised so they meet people’s needs.

  • The trust worked in partnership with local commissioners to plan and deliver services, to meet the needs of local people. This recognised the local geography, population and neighbouring services.

  • There were services to improve the access and flow of patients through the hospital, to promote shorter lengths of stay. The trust is an integrated trust which provides acute and community services. This facilitated the development of improved pathways of care, for example the respiratory pathway and the creation of the division of integrated elderly and community care.

  • Patients had timely access to emergency treatment and the trust was taking action to minimise the waiting time for elective surgery.

  • Staff took account of the needs of different people, including those with complex needs, when planning and delivering services. Staff showed good understanding and made reasonable adjustments to meet patients’ individual needs. However, patient assessments, measuring the suitability of the environment for people with dementia and people with a learning disability, were consistently low scoring. There were adequate facilities to meet individual’s spiritual and cultural needs.

  • Ward staff and the discharge team started to consider and plan patient discharges from the date of admission. The trust worked with partners to improve the coordination of patient discharges and transfers to remove barriers to delays where possible. Trust data showed a significantly higher percentage (44.2%) of patients waiting for a residential home placement, contributed to the delayed transfers of care, compared with the national average of 10.2%.

  • In the surgical division, there was a significant backlog of patients requiring pre-operative assessment. The division had not achieved 90% of patients being seen and admitted within 18 weeks of referral.

  • The trust operated a rapid discharge home to die pathway which served to discharge a dying patient who expressed wanting to die at home within 24 hours. However, there were some external delays with funding and care packages for patients with complex needs and patients who expressed a wish to die at home, did not always get to do so.

  • Complaints were investigated thoroughly to improve the quality of care.

Are services well led?

By well led, we mean that the leadership, management and governance of the organisation assured the delivery of high-quality person-centred care, supported learning and innovation, and promoted an open and fair culture.

  • Staff enjoyed working at the hospital and told us they found managers and their team supportive. There was a clear sense of teamwork and collaboration between wards and members of the multidisciplinary team. Staff told us there was an open and transparent culture within the hospital.Most staff felt the leadership of the trust and within the division were visible and supportive.

  • There was a clear governance structure in place, which linked in with the trust’s overall governance structure.Meetings took place at all levels of the divisions and were well attended by members of the multidisciplinary team (MDT) staff reported on quality, safety and performance. However, minutes of all meetings at all level were not always recorded and therefore it was not always possible to evidence what had been discussed.We identified a number of concerns around staff not following practices designed to keep patients safe which had not been identified by the trust.

  • There was a local and a national audit programme and staff had knowledge of the audits that directly linked to their clinical area. The clinical governance teams had an oversight of audit performance and there was evidence of improvement in clinical audit results.

  • Systems were in place to gather patient feedback and departments and the division had used this feedback make changes to services. The trust had set up a patient panel to ask for opinions and suggestions in what mattered to them regarding developing plans for end of life care. The trust had not audited the views of the bereaved as recommended by the National care of the Dying audit hospitals) NCDAH) 2014/15.

We saw several areas of outstanding practice including:

  • Excellence reporting had been introduced in the operating departments to encourage staff to report and learn from examples of good practice.

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

Importantly, the trust must ensure:

  • Pharmacy staffing is provided to planned levels so that medicines management is safe and clinical pharmacy support is available to departments.

  • Staff comply with all aspects of the trust’s medicine management policy and associated standard operating procedures.

  • The management of controlled drugs is improved and staff comply with the misuse of drugs regulations.

  • All medicines are stored within the manufacturer’s recommended temperature ranges and that records are maintained to demonstrate that medicines are safe for administration to patients.

  • Daily checks of the anaesthetic machines and resuscitation equipment are completed and documented to confirm the equipment is safe for use.

  • All patients thought to lack capacity to make decisions about their care and treatments have a formal assessment of their capacity.

  • There is a clear process in placewith clear accountability for the cleaning of the mortuary trolley.

  • Suitable sealed storage is in place for deceased patients’ belongings in the bereavement office.

  • The new end of life care plans “Getting it right for me” and the associated “Getting it right for me patient held record” are used by clinical staff for all end of life care patients in the trust.

  • Patients who are subject to deprivation of liberty have current and valid authorisation documentation in place.

  • The end of life care strategy is completed and published and all clinical staff are aware of this strategy.

  • The use a standardised pain assessment tool across the hospital to ensure end of life patients have their pain accurately assessed and responded to.

  • A protocol for withdrawing treatment as recommended in the 2015 National Institute of Clinical Excellence guidelines is in place and clinical staff are trained in its use.

In addition, the trust should also ensure

  • The pharmacy service does not supply out of date British National Formularies.

  • Audits completed by the pharmacy service are used to drive improvements and progress should be demonstrated over time.

  • All staff working in theatres comply with the trust’s uniform policy, in particular changing their scrubs, if they leave and then return to theatre.

  • The standard of record keeping is monitored through regular audits and action taken for areas of non- compliance.

  • All staff understand the Mental Capacity Act (2005) and are confident to apply this in the clinical setting to safeguard patients.

  • Compliance with the trust informed consent audit shows continued improvement, with further action taken to address areas of non-compliance.

  • Minutes are recorded for all meetings held within the division of surgery and critical care, with an action log included to provide assurance that concerns are being addressed.

  • Medical records are maintained securely on care of the elderly wards.

  • Staffing levels are as planned to meet all patients’ needs.

  • Staff on ward 8 comply with infection control procedures to reduce the risk of infection.

  • The high proportion of delayed transfers of care attributed to patients waiting for a residential home placement is reduced.

  • Advanced care plans are fully documented in order to comply with patient’s wishes.

  • Porters, cleaners and mortuary staff receive standardised formal end of life care training.

  • The views of bereaved relatives is obtained to make care change to improve to the service

  • All staff are aware of the up to date list of telephone numbers for calling different faith ministers to visit the hospital out of hours.

  • Information leaflets regarding advance care planning, what happens when someone dies and how to register a death are printed and distributed in all the clinical departments, with a named lead responsible for ensuring they are accessible for patients and families and are up to date.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 24 March to 27 March 2015

During a routine inspection

Stoke Mandeville Hospital is one of seven hospitals that form part of Buckinghamshire Healthcare NHS Trust. The hospital is an acute district general hospital and provides a range of emergency and elective medical, surgical and specialist services, as well as maternity and outpatient services.

A comprehensive inspection of the acute services of Buckinghamshire Healthcare NHS Trust was conducted in March 2014. Following this inspection, urgent and emergency care and end of life care were rated as required improvement overall. However, urgent and emergency services were rated as ‘inadequate’ for responsive services at Stoke Mandeville Hospital, and end of life care was rated as ‘inadequate’ for providing effective services.

We therefore inspected this urgent and emergency care services and end of life care services as part of an unannounced focused inspection.

Overall, the urgent and emergency care services and end of life care services at this hospital ‘requires improvement’. However, each service had demonstrated improvement since the last inspection. The ratings from this inspection did not affect the overall ratings for the trust (from March 2014) which was ‘requires improvement’

Our key findings were as follows:

Urgent and Emergency Care Services

  • Overall we rated this service as ‘requires improvement’. This the same as the previous rating in March 2014. However the service had improved its rating in three of the five domains we inspected in providing a caring, responsive and well-led service.

  • During this inspection we found improvements in safety procedures, for example, more equipment had been purchased to monitor and treat patients. Medicines were appropriately managed and infection control procedures were being followed although this needed to be more consistent. Patients were assessed and treated within standard times and the modified early warning score was used effectively to identify deterioration in a patient’s clinical condition. The service still had to improve its assessment and documentation of patient risks, for example, for falls and pressure ulcer damage. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions for patients needed to be appropriately documented.

  • National guidance was being used to support patient care and treatment.. Local clinical audit programmes were developed to review and improve standards. National audits demonstrated that the Emergency Department performed similar to other trusts. Patients received effective pain relief and had appropriate nutrition and hydration.

  • Seven day services had extended and there had been improvements in senior medical presence and emergency nurse practitioner availability out of hours and at the weekend. There was still a need to increase this presence further to meet national guidelines. It was acknowledged that this needed to continue to improve as more staff were recruited. There was a recruitment plan to support this.

  • Multi-disciplinary teams worked well together, although there were still some delays to patients requiring review by medical specialty teams. The rapid access early assessment care team (REACT) worked effectively to discharge frail and elderly patients, with 70% of referrals being ready for discharge within 24 hours. There was a new psychiatric in-reach liaison services (PIRLS) that had improved the support of people in the Emergency Department who had a mental health condition.

  • Staff treated patients with care and compassion and with dignity and respect. Patients, relatives and carers, told us they had good experiences of care and their care and treatment was explained so that they could be involved. Staff made time to offer emotional support to patients who were anxious or distressed.

  • Services were being planned based on the needs of the local population and action was being taken, in conjunction with health and social care partners across Buckinghamshire, to respond to service demands. There were new services to speed assessment and treatment of emergency patients and avoid patient admissions to hospital. The new services included an initial assessment and treatment centre in the Emergency Department, assessment and observation unit (AOU), short stay acute medical unit, and ambulatory care service.

  • The service had improved its performance against the national emergency access target, that is for 95% of patients to be admitted, transferred or discharged within four hours. However, the target was not being met consistently. Escalation procedures identified specific trigger points for a hospital wide response to emergency pressures. Escalation was working in the Emergency Department although the hospital response needed to improve. We observed the Emergency Department to be busy but calm. Many patients were still waiting for excessively long periods in the Emergency Department although patients did not spend long waiting times on a trolley or in corridors.

  • The transfer of patients between Wycombe Hospital and Stoke Mandeville Hospital still required review to ensure patients were appropriately transferred.

  • The vision and strategy for the service was well developed and the trust was working with partners to improve the coordination of urgent and emergency care across the health and social care system in Buckinghamshire. The pace of change had been rapid over the last 12 months and there had been significant and clinically led service developments.

  • Staff engagement had improved and staff identified a culture of positive leadership and support.

  • The department had an effective governance structure and information was being used to monitor and improve the quality and safety of services. Risks were escalated and acted upon, but recorded actions were not timely to demonstrate ongoing work around patient flow and workforce planning.

  • The service could identify many examples of innovation and improvement and action was being taken to ensure the sustainability and resilience of services.

End of life care

  • Overall we rated this service as ‘requires improvement’. This was the same as the previous rating in March 2014. However the service had improved its rating in two of the five domains we inspected in providing an effective and caring service.
  • During this inspection we found improvements. Nursing and medical care had improved and patients received better symptom control and anticipatory drugs for pain relief. Patients nutrition and hydration needs were being assessed.

  • Patients and relatives gave examples of compassionate nursing care. They felt involved and informed regarding their care and treatment.
  • The specialist palliative care team was well led and staff were passionate about improving the quality of services. Staff across the hospital provided good emotional support for patients. The chaplaincy provided one to one spiritual support and worked closely with the bereavement officers to ensure relatives received a sensitive and individual service following the loss of a loved one.
  • The hospice day care services provided well considered emotional support for their patients and conducted patient satisfaction surveys to measure effectiveness.
  • Records were not always stored securely and in places could be accessed by patients and relatives. Do not attempt cardiopulmonary resuscitation (DNACPR) forms were not consistently completed.
  • Patients being taken to the mortuary frequently arrived without any identification wrist bands. Technicians were reliant on a nurse from the ward coming down to the mortuary to identify the patient.
  • Staffing levels in the mortuary were not safe. Technicians were often working long hours alone without support and they did not have appropriate equipment for bariatric 9obese)patients.
  • Patient areas were clean and staff followed infection control practices.
  • There were interim care plans in use following the withdrawal of the Liverpool Care Pathway in 2014. However, these care plans, called Hearts and Minds – end of natural life, were not consistently completed to provide holistic care for patients. Staff did not have a clear understanding of end of life care and ceilings of care, which would involve the cessation of all invasive treatments and non-essential medication, were not consistently applied. The trust was working on a care pathway called “getting it right for me” and had involved staff and patients to develop this.
  • The trust had participated in the 2013/14 National Care of the Dying Audit – Hospitals (NCDAH) and did not achieve five of their seven key performance indicators (KPI’s) but was similar to the England average for most of the clinical indicators of care. Local audit to monitor the effectiveness of services was not well developed.
  • There was evidence of good multi-disciplinary working practices on the elderly care wards, with doctors, nursing staff and allied healthcare professionals working together to ensure that patients at the end of their life were cared for in the correct setting. However, there could sometimes be discharge delays. The trust was still not monitoring patients preferred place of death although rapid discharge was being supported by the specialist palliative care team.
  • There was good support from the specialist palliative care team and referrals, once completed, were responded to within 24 hours. Support and advice was available 24 hours a day seven days a week. Training was available for staff in relation to caring for patients at the end of their life.
  • The hospital did not have a central register to identify a patient who was on an existing end of life care pathway and this could delay their care and treatment. However, a new electronic record, the Buckinghamshire Care Co-ordination Record was being implemented to ensure that patients who were receiving end of life care were identified more easily.
  • Patients at the end of their life were still being moved several times around the hospital despite trust guidelines recommending that patients on the end of life care pathway should not be moved.

  • The director of nursing holding responsibility for end of life care at trust board level. A new trust strategy was being developed but communication around this needed to improve. A review of the service had been undertaken and some key areas of work were in progress which included the new care pathway and the treatment escalation plan. A dashboard was being used to monitor some key indicators relating to care but audit to monitor the quality and safety of end of life care services needed to develop. The trust had held engagement meetings with staff and patients to establish how best to move the end of life care service forward.

We saw several areas of outstanding practice including:

  • The rapid early assessment care team (REACT) provided nursing and therapy support to facilitate the early discharge of frail and elderly patients admitted to hospital. Patient pathways were to community hospital or to the patient’s own home and equipment could be delivered on the same day to support patients at home. The team saw 3 to 4 patients a day and 70% were discharged within 24 hours.
  • There was a new psychiatric in-reach liaison services (PIRLS) that had been developed with the local mental health trust. This joint working had improved the support of people in the ED who had a mental health condition.
  • The specialist lymphodema nurses at the hospice recently received a second place award for oedema management; this accolade was given by the Journal of Wound Care.

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

Importantly, the trust must ensure :

  • Patient risk assessments and the documentation that supports these are routinely completed in the Emergency Department.
  • There is effective clinical engagement for a hospital wide focus to patient flow and escalation processes.
  • There are timely GP discharge summaries following a patient admission to the Emergency Department.
  • There is a timely replacement for the Liverpool Care Pathway and all staff follow the current interim policies.
  • Staff complete the end of life care plans (Hearts and Minds – end of natural life) appropriately so The National Institute for Health and Care Excellence (NICE) guidelines for holistic care are followed.
  • All staff consistently and appropriately complete the DNACPR forms and discussions between patients and relatives are recorded in patient records.
  • The overhead lighting lamps in the hospice are replaced to reduce the risk of patients coming into contact with hot surfaces.
  • Staffing levels in the mortuary are reviewed to give staff adequate rest time between shifts and to reduce the levels of lone working.
  • Mortuary staff have appropriate equipment for bariatric (obese) patients to reduce the risk of harm to staff from inappropriate manual handling.
  • Deceased patients are clearly and appropriately identified when being transferred from wards to the mortuary.
  • All staff involved in end of life care can identify a patient at the end of life (12 months) to ensure that referrals to the specialist palliative care team are made in a timely manner.

In addition the trust should ensure that :

  • Recruitment of medical and nursing staff continues to improve models of care, decrease the current workloads of staff in acute and emergency medicine and ensure appropriate medical staffing at night.
  • Infection prevention and control practices are consistently followed in the Emergency Department.
  • Risk registers are maintained and kept up to date in the Emergency Department and records of incidents, once reported, are completed in a timely way.
  • Infection control risks, in relation to storing patients’ belongings in the bereavement office, are addressed.
  • Interpreter services are provided to enable patients who do not speak English as their first language to receive the same level of care as other patients at the end of their life
  • Transfer arrangement between Wycombe Hospital and Stoke Mandeville Hospital are clarified for staff and patients.
  • Communication from senior management teams to all staff providing end of life care to improves.
  • Patients who received end of life care are not moved unnecessarily between wards.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 18-21 March 2014

During a routine inspection

Stoke Mandeville Hospital is one of seven hospitals that formed part of Buckinghamshire Healthcare NHS Trust. This hospital was an acute hospital and provided accident and emergency (A&E), medical care, surgery, critical care, maternity, children and young people’ services, end of life care and outpatient services, which are the eight core services always inspected by the Care Quality Commission (CQC) as part of its new approach to hospital inspection. The hospital also had the National Spinal Injuries Centre (NSIC), one of 11 centres of expertise in the UK, and we inspected this service too.

Stoke Mandeville Hospital had 479 beds and provided a wide range of inpatient medical, surgical and specialist services as well as 24-hour A&E, maternity and outpatient services. The hospital had the regional centre for burn care, plastic surgery and dermatology, as well as the NSIC. The hospital had recently become a national bowel cancer screening programme site. It saw 48,000 inpatients and 219,000 outpatients a year.

We carried out this comprehensive inspection because the Buckinghamshire Healthcare NHS Trust had been flagged as a potential risk on CQC’s intelligent monitoring system. The inspection took place between 19 and 21 March 2014 and an unannounced inspection visit took place between 6pm and 10pm on Saturday 29 March.

Overall, this hospital requires improvement. We rated it good for caring for patients but it requires improvement in providing safe care, effective care, being responsive to patients’ needs and being well-led.

Our key findings were as follows:

  • Staff were caring and compassionate and treated patients with dignity and respect.
  • The hospital was clean and well maintained. Infection control rates in the hospital were similar to those of other trusts.
  • The trust had worked to improve emergency care and had improved its mortality rates. Patients whose condition might deteriorate were identified and escalated appropriately and mortality rates were now within the expected range.
  • Patient’s experiences of care was good and the NHS Friends and Family test was higher than national average for most inpatient wards but was lower than the national average for A&E.
  • Patients were not always supported to eat and drink, where appropriate. However, standards to ensure that patients were properly hydrated had improved.
  • The trust opened a new acute medical admissions unit, surgical assessment unit and clinical decision unit for short stay patients in November 2013 to improve the flow of emergency patients through the hospital and speed their assessment, treatment and discharge. During our inspection visit however, we found the hospital to be busy and under pressure.  Capacity in A&E, on these wards and in the hospital was severely reduced.  There had been a reduction in the number of hospital beds due to Norovirus.  The trust described this as an exceptional circumstance as there were restrictions on one quarter of medical beds over a 10 day period in March 2014.  Patients in A&E were waiting a long time to be assessed and treated by inpatient teams, and admitted to a hospital bed.
  • The A&E doctors often identified patients informally for admission the decision to admit patients to the hospital was done by the inpatient speciality teams. There were delays with this approach. Patients were waiting on A&E trolleys for several hours. We witnessed several patients waiting over six hours before a decision to admit was taken and some patients had waited over 12 hours for a bed to become available on the ward. One 91-year-old patient waited over 13 hours on a trolley in A&E for a bed in the hospital.
  • There were concerns about nurse staffing levels. Wards and patient areas were staffed appropriately but there was a heavy reliance on nurse bank and agency staff and in some instances this affected the delivery and continuity of patient care. The trust was investing to improve nurse staffing levels.
  • Medical staffing in A&E had improved and senior staff were available out of hours and at the weekend. There were still concerns, however, about the presence of senior medical staff out of hours and at weekends, and the number of medical patients that a junior doctor had to cover out of hours.   There was a system for consultants to see new patient admissions over the weekend but some medical inpatient outliers were not seen over the weekend by a medical doctor unless their condition deteriorated. They were not assessed, or considered for discharge.  The trust was working to improve this situation. 
  • The multidisciplinary approach to patient discharge was improving, although there were still discharge delays for some patients with complex needs.
  • The support for patients living with dementia or who may have a learning disability was inconsistent.
  • Some patients could wait a long time for surgery.  Surgery was effective but some safety procedures for surgery were inadequate and patients could be unnecessarily fasted for long periods before surgery.
  • Critical care services provided safe and effective multi-disciplinary care. The caring and emotional support provided to patients was outstanding.
  • Maternity services provided safe and effective care but some women had their planned induction, or planned caesarean section delayed because of pressure on the availability beds on the postnatal wards.
  • Children received safe and effective multidisciplinary care but were not always seen by qualified paediatric staff in A&E out of hours or at weekends.
  • Patients receiving end of life care had good support from a specialist palliative care team but this level of support was not always available in the ward areas. There were examples of patients who did not have aspects of their care managed appropriately, this included pain relief, prevention of pressure sores, breaking bad news and managing distress.
  • Outpatient services were safe and changes were being made to speed up treatment for patients, and bring care closer to people’s homes. Clinic appointments, however, were often cancelled at short notice and patients could wait a long in busy clinics for their consultations.

We saw several areas of outstanding practice including:

  • The care and emotional support for patients in the critical care unit and NSIC was outstanding.
  • The ‘Evian Project’,  was a multi-professional group led by the consultant nurse in critical care. This has improved the hydration of patients in the trust.
  • The trust had a ‘Reflections at Birth’ initiative for women. Women were asked to complete a ‘birth reflections’ questionnaire one month after the birth of their child and their answers were used to inform management and improve the quality of the service.
  • Where appropriate, some children had pre-operative assessments done by phone to reduce the need for additional visits to the hospital.
  • The children’s outreach nurses supported early discharge for children. This included developing links with community nursing services, GPs, health visitors, education, occupational therapy and physiotherapy services.
  • The NSIC was a centre of expertise and was internationally accredited. Patients were involved in setting their own treatment goals and outcomes. The centre carried out extensive research.

However, there were also areas of poor practice where the trust needed to make significant improvements. We have said the trust MUST take the following actions:

  • Patients in A&E must be assessed by an appropriate specialist inpatient team in a timely way so that their treatment is not delayed. There should be clear standards to escalate patients who have long waiting times in A&E.
  • The decision to admit patients must be made earlier by the A&E team. Patients waiting over 12 hours in A&E need to be accurately and appropriately identified, and the number significantly reduced.
  • The accident and emergency (A&E) department must ensure that appropriate equipment is available and checked regularly to care for patients in the resuscitation bays, ‘majors’ area, initial assessment and treatment (IAT) and triage area.
  • The procedures and facilities in the treatment room on Ward 16B need to change to ensure that medicines can be prepared safely.
  • Medicines must be appropriate stored in locked cupboards and fridge temperatures need to be regularly checked, recorded, retained and acted upon.
  • The appropriate medicines for end of life care must be available to avoid treatment delays.
  • Care plans need to be developed for all patients.
  • Patients at the end of life must have person-centred, holistic plans of care to enable staff to assess and treat patients effectively.
  • ‘Do not attempt cardio-pulmonary resuscitation’ (DNA CPR) forms must be accurately completed and records of end of life discussions with patients must be documented.
  • Patients at the end of life should be treated according to the National Institute for Health and Care Excellence (NICE) ‘End of life care for adults quality standards’ (NICE, 2009).

There were also areas of practice where the trust should take action which are identified in the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

12 June 2014

Inspection carried out on 3 July 2013

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

During this inspection we inspected the regulated activities of diagnostic and screening procedures, treatment of disease, disorder and injury and surgical procedures.

When we inspected the service on 6 February 2013 we found the provider to be non compliant with Regulation 22 'Staffing' and Regulation 23 'Supporting workers'. A compliance action was set for Regulation 22 and we took enforcement action by way of a warning notice in relation to Regulation 23. In March 2013 the provider sent us an action plan telling us what they were going to do to achieve compliance by the end of June 2013. In July 2013 we carried out a follow up inspection to check whether improvements had been made.

During this follow up inspection we visited the same wards as in February 2013 where we had identified non compliance and two additional wards.

During our visit in February 2013 we found staff on wards 6, 8, 9 and St Andrews were under considerable pressure to meet people's needs. Senior trust managers told us, since our last visit, they had reviewed staffing levels across all in patient areas using an adapted version of the 'Safer Nursing Care Tool' (SNCT). The SNCT is a recognised tool developed by the NHS Institute to inform nursing staffing levels. We were told the process of review had resulted in increased staffing and/or a reduction in beds in all the areas we had previously visited.

We found staffing levels had improved on all the wards we visited in accordance with trust's 'Nurse Staffing Levels 2013/2014'. However, the high use of bank and agency staff on certain shifts on wards 6,8,9,16a abd 16b meant the appropriate skill mix was not always maintained. On St Andrews ward we found there was sufficient staff, in accordance with the trust’s nurse staffing levels, to meet peoples’ needs. However, medical staff felt medical cover was not adequate.

We found staff morale had improved since our last visit. Staff were supported through appraisals. Statutory and non-statutory training uptake was below the trust's target of 70%. A system of trust wide supervision had been approved but not yet implemented.

Inspection carried out on 6 February and 3 March 2013

During an inspection in response to concerns

During our visit on 6 February 2013 we visited ward 6, the respiratory ward, wards 8 and 9, medicine for older people, St Andrews part of the National Spinal Injury Centre, Accident and Emergency (A&E) and the Clinical Decision Unit (CDU). We also visited A&E and CDU out of hours on Sunday 3 March 2013. We inspected the regulatory activities of treatment of disease, disorder and injury, diagnostic and screening and surgical procedures.

Most people were positive about the care they received. Comments from people on different wards included "couldn't ask for better" and "care is very good". However, some people expressed dissatisfaction with general communication especially in A&E with regards to waiting times.

We found discharge planning processes were clear on all wards. On wards 6, 8, 9 and St Andrews there were regular multidisciplinary team meetings to ensure all aspects of discharge were considered for patients before discharge.

We looked at equipment in A&E and CDU. There were systems in place to ensure maintenance was carried out. Staff said sometimes it was difficult to rapidly access specialist equipment.

We found appropriate staffing levels were not always maintained on wards 6,8 and 9. This meant some staff were under extreme pressure to meet people's needs. Support for staff in the form of supervision, training and appraisal was not available for all staff on wards 6,8,9 and St Andrews.

Inspection carried out on 18 July 2012

During a routine inspection

This visit focussed on in patient medical services for older people. We spoke to people on wards 8, 9 and 10.

People told us they were treated with respect and dignity. One person said that “everything had been well explained”. The people we spoke with said they were happy with the care provided. One person said “The care is good and staff work very hard”. People told us that they thought there was enough staff on duty and that call bells were answered promptly.

People thought the environment was clean.

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 17 May 2011

During a themed inspection looking at Dignity and Nutrition

People said their needs had been fully met; staff were quick to respond following personal requests and their care had been given in a respectful way. All the patients we spoke to identified they had been treated with dignity and respect during their hospital stay. Some patients said they had not received information about the facilities available at the hospital; whilst others said they did not have enough information about their care or treatment. None of the patients interviewed had been asked to provide feedback about their care and treatment in hospital to-date. Their experience is captured in a number of comments made to us:

‘I’m quite happy’.

‘The door is always closed when having personal care’.

‘They are very sensitive’.

‘They come straight away’.

‘We had to wait quite a while but they are busy’.

The patients we spoke to said they liked the food and had a choice from a selection of meals, food was hot and individual needs had been catered for. They said portion sizes were adequate and should they request additional food staff would provide it. None of the patients we spoke to said that they had missed a meal and all the patients confirmed they were given a hand wipe to clean their hands prior to the meal. Their experience is captured in a number of comments made to us:

‘The food is piping hot’.

‘I feed myself but they ask if I need help’.

‘Yes, there is plenty of choice’.

‘Very quiet, when I’m finished my dinner the dessert is cold’.

‘Sometimes I have to ask for help and sometimes I get it’.

‘We can choose from the menu’.