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Inspection Summary


Overall summary & rating

Good

Updated 20 May 2016

East Lancashire Hospitals NHS Trust serves a population of 521,000. The trust has two acute sites: Royal Blackburn Hospital and Burnley General Hospital as well as three community sites. There is noticeable deprivation in both Blackburn with Darwen and Burnley. Alcohol-related diseases and adult smoking are among the most prominent health concerns in both areas. 44% of the population belongs to non-white ethnic minorities and life expectancy is 10 years lower for men and 7 years lower for women in the least deprived areas of both boroughs.

East Lancashire Hospitals NHS Trust was one of the 14 trusts reviewed as part of the Keogh Review in 2013 based on the trust having been an outlier for the previous two consecutive years on either the Summary Hospital-Level Mortality Index (SHMI) or the Hospital Standardised Mortality Ratio (HSMR). The review identified a number of concerns at the Trust particularly related to the quality governance assurance systems. The review panel also identified a number of areas of good practice and dedicated staff, but there was more for the Trust to do to communicate effectively to staff and share learning to ensure consistent approaches to quality improvement across the organisation, all of the time.

The trust was placed in special measures and CQC inspected the trust using the new comprehensive inspection model in July 2014. This resulted in the hospital overall being rated as Requires Improvement with improvement needed in urgent care, surgical and end of life services.

This inspection was a follow up and was conducted on 19, 20 and 21 October 2015. We did not inspect the community sites and only reviewed four core services in order to review the progress of the trust since coming out of Special Measures in July 2014. We have aggregate the ratings following this inspection with the previous ratings for the services not inspected to give a revised rating for this hospital. We also looked at the governance and risk management support for the services we inspected.

Our key findings were as follows:

  • The trust had a clear vision, objectives, values, operating principles and improvement priorities. These had been arrived at using a bottom up process and all staff we spoke with were engaged in the strategic direction of the Trust, its vision, demonstrated the values and were dedicated to achieving the best care for patients.

  • The hospital services were supported by strong governance processes’ including well managed risk registers feeding in to the Board, ensuring a robust overview of the risks within the hospital. There was on-going work to enhance the Board Assurance Framework and risk management in the Trust. Staff demonstrated their involvement in the solutions to the risks identified which had developed staff ownership of risk and solution and was enhancing achievement.

  • A ‘Harm free care’ strategy, introduced 12 months ago had improved the way they dealt with and learnt from incidents. The strategy included actions such as completing rapid reviews of serious incidents, referral to a panel for discussion and sharing outcomes in senior meetings. We saw evidence of learning and change to practice from incidents and how this learning was shared across the service and trust wide.

  • Mortality rates had improved and the latest Trust SHMI value as reported by the HSCIC had remained within expected levels at 1.08, for the third quarter in a row as published in July 2015. The latest published HSMR values (May 2015 report) were within expected levels. The indicative HSMR monthly rebased figure (Dr Foster intelligence) for the most recent 12 month period available (June 2014 – May 2015) was also within expected levels at 101.78.

  • Over the past 12 months the Emergency Department/Urgent Care Centre’s had introduced a number of quality innovations that have improved patient experience, patient care, patient safety and patient outcomes. Some of the initiatives that had been introduced included the introduction of a Mental Health Triage Tool and Observation Policy; Rapid Assessment review; Introduction of a Sepsis Nurse Lead; Creation of a Dementia friendly environment and review and development of the Paediatric Emergency Department.

  • Cleanliness and hygiene throughout the trust was of a high standard.

  • There was now a full bereavement service available at the hospital which was well received by users although it was noted not to be as well utilised by the ethnic minority groups. Work was underway with the local religious leaders to review this.

  • Staff were caring, kind and respectful to patients and involved them in their own care. Improvements had been made in the monitoring of patients to identify if their condition was deteriorating which included revised systems for obtaining prompt medical assistance.

  • Staff were proud of the work they did; they worked well together and supported each other when the services were under pressure. The trust ranked in the top 100 places to work in the NHS in an external health journal. Staff and patients told us they felt well engaged with and their views were valued.

  • Staff explained that the last few years had been difficult but the stability of the current board and executive team contributed greatly to the culture of continuous improvement.

  • Leadership across the departments was very positive, visible and proactive. Managers had a strong focus on the needs of patients and the roles staff needed to play in delivering good care.

  • The mortality rates had improved and were now within expected limits.

  • The hospital had consistently achieved better than the England average in respect of the 18 weeks target from referral to treatment between April 2014 and March 2015. Surgical procedures were sometimes cancelled at short notice but systems were in place to ensure patients were rescheduled within 28 days of the cancellation.

We saw several areas of outstanding practice including:

  • Theatres ran interactive open days where they invited selective audiences, such as young people from the local high schools and people with learning difficulties. This initiative was to help break down some of the barriers between the community and hospital theatres. It also helped patients with learning difficulties become familiar with the theatre settings to help alleviate their anxieties around having surgery.
  • A band three member of staff from theatres ran a painting competition for children and young people who had learning difficulties and medical conditions. The resulting art work was displayed in the patients’ waiting area. This innovation was looking at working closely with these young people and easing their anxiety about undergoing surgery.
  • Each ward and theatre area held weekly staff meetings called ‘Feedback Fridays.’ These meetings were a two way process and covered all significant governance issues pertinent for their area, including lessons learned from incidents and complaints, the risk register for their individual areas and feedback from matron and governance meetings.

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

Importantly, the trust must:

  • make sure the records on the acute medical unit of controlled drugs which patients have brought in themselves are accurate.
  • take action to ensure that patients in the Rakehead centre are enabled and supported to make, or participate in making decisions relating to their care or treatment to the maximum extent possible.

In addition the trust should:

Urgent Care

  • Work to improve the levels of staff training in Mental Capacity Act and Deprivation of Liberty Safeguards training where these are low.
  • Review resuscitation trolleys regarding the provision of neck breathing resuscitation equipment.

Medicine

  • The trust should ensure that staff in the Rakehead centre adhere to infection prevention and control measures with regard to the use of personal protective equipment and the management of soiled linen.
  • In the Rakehead centre the trust should ensure that medicines are correctly stored and hazard signage is in place for the safe storage of oxygen.
  • The trust should ensure the provision of rehabilitation physiotherapy in the Rakehead centre is sufficient to meet the needs of patients.
  • The area in the Rakehead centre for the promotion of independent living should be accessible to patients.
  • The trust should ensure that the systems for assessing the mental capacity of patients and acting according to the outcome of that assessment are used in the Rakehead centre.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 20 May 2016

Effective

Good

Updated 20 May 2016

Caring

Good

Updated 20 May 2016

Responsive

Good

Updated 20 May 2016

Well-led

Good

Updated 20 May 2016

Checks on specific services

Maternity and gynaecology

Good

Updated 9 July 2014

The maternity and family planning services were found to be safe and effective, with caring staff. The service was responsive to the needs of the local population, providing a mix of standalone birth centres, an alongside birth centre (both of which are midwife-led) and obstetric-led birthing options for women. The service was also found to be well-led. There were established governance processes in place. Staff received feedback from incidents and there was evidence of learning as a result.

Medical care (including older people’s care)

Requires improvement

Updated 20 May 2016

At the last inspection medical services at Burnley General Hospital were rated as good. At this inspection some improvements were required in the Rakehead rehabilitation unit however services in other parts of the hospital were good.

Staff were involved in learning from incidents, complaints and results of audits. They were caring, kind and respectful to patients and involved them in their own care. There was good record keeping and on the wards infection prevention and control measures met guidance. Systems were in place to detect deterioration in a patient’s condition and measures were in place to obtain medical assistance. Nursing and medical staffing was adequate in all areas and there was a low reliance on agency staff. Staff felt part of the wider trust and were positive about improvements in the past 12 months.

In the Rakehead rehabilitation centre some improvements were required with regard to the provision of therapy services, infection prevention and control measures and medicine storage. Staff in this unit were not working within the guidance of the Mental Capacity Act and the Deprivation of Liberty Safeguards.

Urgent and emergency services (A&E)

Good

Updated 20 May 2016

At the last inspection in July 2014, we rated the service as requires improvement. Improvements were required in areas such as managing the public’s expectation of urgent care services, transfer times between sites and delays for assessments of patients with mental health needs.

At this inspection we found improvements had been made in four of the five domains (caring maintained a good rating).

Access and flow through the department was good. Targets set by the Department of Health were being met. Assessments were generally completed within 15 minutes. In July 2015 99% of patients were admitted, transferred or discharged within four hours and in August 2015 the figure was 98%. Less than 5% of patients left prior to being seen in July (3%) and August 2015 (3.5%).

The department maintained a culture of reporting, investigating, and sharing learning to promote improvement. The environment was visibly clean and tidy and audit results for cleaning and decontamination of equipment supported this.

Medicines were generally handled in accordance with legislation and guidelines. Patients were assessed for pain and offered pain relief when required. Records were complete, legible and contained the necessary information. The department had processes in place to safeguard children. Staff used national guidance to provide evidence-based care and treatment.

Patients received extra support from physiotherapists and Age UK. Age UK provided adult patients with support and advice relating to shopping, cleaning, food provision and pensions and referred patients for help with physiotherapy, mental healthcare provision and social services

Staffing was adequate and agency staff rarely used despite there being some vacancies, due to sickness, maternity leave and promotion. Medical cover was adequate despite vacancies in the division. Middle grade doctors provided on site cover 24 hours a day, seven days a week and consultants were available during the day or on an on call basis.

Children were cared for in the Children’s Minor Injury Centre between the hours of 10am and 8pm Monday to Friday, and midday until 8pm at weekends with the final admission received at 6pm each day. The centre was staffed by medics, advanced paediatric nurse practitioners and paediatric nurses. Outside of these hours at least one trained nurse with advanced paediatric life support training was always on duty, and staff had links with medics from the children’s ward based on site. Additionally, all nursing staff completed intermediate paediatric life support annually.

Staff felt supported and appraisal systems were in place. 14 out of 32 nursing staff had received their annual appraisal since May 2015. Training was managed by practice educators in the department, including core mandatory training and additional training including plaster skills and advanced life support. Nurses were trained to become ‘champions’ in specific areas such as dementia, sepsis and safeguarding.

Staff were caring and compassionate and patients told us they were treated with dignity and respect. There was a culture of being open, sharing learning and seeking feedback to promote improvement.

Risks, incidents, complaints and performance were reviewed through monthly clinical governance meetings. A risk register was in place which covered relevant topics. However some risks had been on the register for a number of years with no reference to when actions to mitigate them were instigated.

Staff spoke positively about their roles and felt supported and encouraged by leaders. Engagement took place with the public to source their views and manage their expectations of the UCC and how this differed from the trust’s main Emergency Department.

Surgery

Good

Updated 20 May 2016

We rated the surgical services to be good although there were some areas of outstanding practice.

Since our last inspection the trust had made significant improvements, particularly focusing on strengthening their governance structures. Robust governance structures had been implemented, risk registers were fully completed and all staff were familiar with the risks for their areas. Regular governance meetings took place where lessons learned from complaints and incidents were discussed. Leaders were very visible to staff.

We saw evidence that incidents were being reported and staff we spoke with were aware of the incident reporting system and how to use it. We saw evidence of learning from incidents and how this learning was shared across the service and trust wide. We saw evidence of change to practice following learning from incidents.

Cleanliness and hygiene throughout the surgical department was of a high standard. Staff followed good practice guidance in relation to the control and prevention of infection.

Patients cared for in the surgical division were receiving care in line with current evidence-based guidance and standards. Policies and procedures were in place and staff were aware of how to access them. Frequent audits were being completed and subsequent action plans implemented.

The trust participated in national audits including the hip fracture, bowel and lung cancer audits, which showed that overall the trust was achieving better than the National average.

At our last inspection we found that there was a lack of segregation in the theatre waiting area and subsequently patient’s privacy and dignity were not always considered as male and female patients, wearing theatre gowns waited together. To address this, the trust has developed separate male and female waiting areas.

The hospital had consistently achieved better than the England average in respect of the 18 weeks target from referral to treatment between April 2014 and March 2015. Surgical procedures were sometimes cancelled at short notice but systems were in place to ensure patients were rescheduled within 28 days of the cancellation.

Leadership across the surgical division was very positive, visible and proactive. Managers had a strong focus on the needs of patients and the roles staff needed to play in delivering good care.

At our last inspection we found discrepancies in how the local risk registers at ward level were being reviewed, there were concerns in relation to risks not being captured appropriately. However the trust has worked with the wards to ensure risk registers were well managed and maintained. Staff were familiar with the main risks for their area and local risk registers were on all staff notice boards.

Staff were proud of the work they did; they worked well together and supported each other when the service was under pressure from increased demand. The trust ranked in the top 100 places to work in the NHS in an external health journal. Staff and patients told us they felt well engaged with and their views were valued.

We saw several examples of innovation across the surgical division, including theatre open days to break down barriers between community and operating theatres and the positive use of social media.

Services for children & young people

Good

Updated 9 July 2014

Children, young people and neonates (newborn infants) received safe and effective care from appropriately trained and competent staff. We saw that staff treated patients with dignity and respect, showing compassion and empathy to them and their families or carers.

Staff were positive about working in the family care division of the trust and told us they felt supported and valued in their roles. Parents and carers were satisfied with the care and treatment delivered to their children and told us they felt included and involved.

The environment was clean, bright and airy with sufficient equipment to deliver the necessary treatments. Toys were available in waiting and treatment areas. However, on the neonatal intensive care unit NICU, there were no facilities for parents/carers to have a hot drink or sit on the ward away from the cot side. There was a refurbished waiting area outside of the unit which provided seating, toys and a cold water fountain.

The care and treatment provided to children and young people was based on national guidelines and directives. Policies and procedures were reviewed regularly and updated as necessary. The care and treatment was audited to monitor quality and effectiveness and, as a result action had been taken to improve the service.

Staff were provided with regular and appropriate training and an annual performance development review. There was no process for staff to receive formal supervision throughout the year but, during our discussions with staff, we were told the managers were approachable and provided support when required.

Services for children and young people were caring. Patients and their families/carers were treated with dignity and respect. Surveys took place to gather feedback from patients and their families/carers. Interpreter services were available when required.

End of life care

Good

Updated 20 May 2016

The EOL care service at the Royal Blackburn hospital was rated good overall with no domain requiring improvement. Although there were few deaths at the hospital, the SPCT team managed end of life care effectively. Staff attended full team meetings with the consultants from the EOL team and with the palliative care lead nurse.

The clinical leadership in the specialist palliative care team was effective. There was a strategy and a vision for the end of life service and effective reporting mechanisms to the trust board. All directorates were engaged in the delivery of good quality end of life care.

Staff were enthusiastic and caring and enjoyed working for the trust. They said that the last few years had been difficult but the stability of the current board and executive team contributed greatly to the culture of continuous improvement. The nursing staff ensured that they were up to date with policies and procedures for EOL care and asked for advice from the SPCT if necessary. Staff we spoke with were aware of the EOL care lead and the trust EOL strategy.

Systems were in place to keep people safe and incidents were reported by staff through effective systems. Lessons were learnt and improvements were made. An integrated care plan had been launched which was comprehensive and staff had been trained to use it. The plan identified priorities for patients in the last few days and hours of their lives. Patients and their relatives were involved in the planning of their care.

The service had a well-developed education programme for medical staff, nurses and unregistered staff in EOL care. Staff in the SPCT and on the wards were committed to providing good compassionate care for patients and their relatives. There were good audit systems in place and the outcomes of these were used to improve the service.

The bereavement services were responsive and death certificates were issued in a timely way to meet the needs of different religions. Porters were respectful of patients when they took them to the mortuary.

However, consultant cover for out of hours and seven day working was not always available. The specialist palliative care telephone advice line for out of hours was answered by a nurse and referred to a doctor if necessary. This doctor was not always a consultant in palliative medicine and could be a GP. This did not fully meet the National Institute for Health and Care excellence (NICE) quality standards for end of life care.

Outpatients

Good

Updated 9 July 2014

Patients were treated with dignity and respect by caring staff. Patients spoke positively about their care and felt they had been involved in decisions about their care. Staffing numbers and skills mix met the needs of the service. There was a clear process for reporting and investigating incidents. Themes and trends were identiifed and action taken to minimise risks. The outpatients departments we visited were clean and well-maintained.

Patients and staff told us that clinics were sometimes cancelled at short notice and we found that clinics frequently ran late. Patients spoke of the anxiety and incovenience this caused them. Staff were auditing this and were considering ways to address it. Changes to the patients’ ambulance transport services had caused confusion for staff, resulting in them not knowing which patients had transport arranged. Patients could wait for long periods for transport if their appointment was late.

There was good local leadership and a positive culture within the service. Staff worked well as a team and supported each other. Staff said they had confidence in their managers and all disciplines worked together for the benefit of patients.