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Inspection carried out on 19,20,21 October 2015

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

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 carried out on 1 May 2014

During a routine inspection

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 carried out on 20, 21 November 2013

During an inspection in response to concerns

We carried out a responsive inspection of Burnley General Hospital as a result of us receiving a number of concerns about the staffing levels on the Neonatal Intensive Care Unit (NICU). We also wanted to look at how patients using the close observation beds in the Central Birth Suite were supported. We combined this inspection with a planned unannounced visit to the Urgent Care Centre in order to check the urgent care pathway at this location.

We arrived unannounced at the NICU at 6.30 am on Wednesday 20 November and returned the following day to continue the inspection in the Urgent Care Centre. The Trust was not informed of our intended activities on the second day. Following the inspection, we spoke to 19 patients over the telephone who had recently been discharged from one of the services inspected.

We spoke to a number of parents of babies using the NICU and patients who had used the close observation beds, both during and after the inspection. The feedback we received from the majority of patients and parents was very positive and people in the main described good experiences and good outcomes from their stay or visit. Parents described the care and treatment they received as “very good”, “amazing” and “impressive”. People felt safe and confident in the ability and experience of the staff caring for their babies. Similarly, patients who had used the close observation beds were complimentary about the service they had received.

However, some parents also told us they felt there were not enough staff on the NICU and at times the staff seemed “stressed when rushed”. We found concerns about staffing levels throughout the NICU. This was evident through our discussions with parents who were using the service, from interviews with staff at all levels and from other information which suggested the staffing levels had been a cause of concern for some time. We were assured the Trust was implementing appropriate strategies to manage this situation and there was evidence the Trust management had closed the unit to new admissions when workload exceeded staffing numbers or skill mix.

We found the governance systems and in particular communication with the staff on the NICU to be limited and this had led to reports of “low” staff morale.

Patients who were using or had used the urgent care centre were positive about the care and treatment they received. On the day of our inspection there was a good flow throughout the department and patients were seen in timely manner. The staff spoken with told us they felt they had enough staff to care for patients.

We found the governance arrangements for monitoring the quality of the service provided in the urgent care centre were well organised and effective. This meant there were clear systems in place to ensure patients were receiving a good service and any problems were readily identified and addressed.

Inspection carried out on 26 September 2012

During a routine inspection

We spoke with five patients on ward 10 of the Lancashire Women’s and Newborn Centre, all had recently given birth in the birthing suite. We also spoke with midwives and senior managers and looked at a sample of records and policies and procedures.

All patients spoken with made positive comments about their care and support throughout their pregnancy and in particular during the birth of their baby. One patient told us, “The consultant and midwife were both brilliant and very supportive”. Patients were closely involved in decisions about their care and that of their baby. Each person had an individual midwifery care plan which was reviewed following any change of need or circumstance.

Midwives had a thorough understanding of safeguarding procedures for the protection of children and vulnerable adults. We saw evidence to demonstrate that midwives worked in collaboration with other agencies such as the Police and Social Services to ensure a coordinated response to safeguarding issues.

Midwives had access to appropriate supervision and were given opportunities to update and extend their training in line with their roles. We saw records of staff training during our visit.

There were established and effective systems in place to monitor the quality and safety of the service which included the analysis of patient feedback. We saw examples of how these systems worked together to monitor the performance of the Trust.

Inspection carried out on 20 March and 28 May 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.