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St Richard's Hospital Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 22 October 2019

Our rating of services has identified that the unit has made improvements since our last inspection. We rated it as outstanding because:

  • There was an inclusive, effective and compassionate leadership structure. Leaders were competent and had high levels of expertise and experience, they continually demonstrated the capability to provide excellent sustainable care. It was apparent that deeply embedded systems of management and succession planning, aimed to ensure management represented the diversity of the workforce.
  • There was noticeably clear leadership of the service with a structure that was mirrored on both acute sites. The service had a vision for what it wanted to achieve and turned innovative strategies in to achievable actions. This vision focused on sustainability of services and was fully aligned with the wider health economy.
  • Leaders delivery of the trusts shared purpose was inspiring and motivated people to succeed. Staff were proud of the organisation as a place to work and spoke highly of the culture. Staff at all levels are actively encouraged to speak up and raise concerns.
  • There was a strong visible person-centred culture to providing care in the critical care unit. Patients were always treated with respect and dignity. All staff we spoke were passionate and dedicated to making sure patients received the best individualised patient-centred care possible.
  • The trust provided mandatory training in key skills, including life support training, to all staff and made sure everyone completed It.
  • There were defined and embedded standard operating procedures in place that kept people safe and safeguarded them from abuse. These systems were reliable and designed to minimise error.
  • The service-controlled infection risk in line with best practice. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean.
  • The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use all life support equipment. Staff managed clinical waste well.
  • Staff understood the impact that a person’s care, treatment or condition had on their wellbeing and on those close to them, both emotionally and socially. People's emotional and social needs were as important as their physical needs.
  • Relatives of patients told us they felt involved in decisions. We observed staff communicate with patients and their relatives in language they could understand regarding their care and treatment.
  • Staff had easy access to the information they need to assess, plan and deliver care, treatment and support to people in a timely way; particularly when people are referred or when they transition between services. The different systems to store or manage care records, were coordinated. People understood the information that was shared about them and were provided with a copy of this when appropriate.
  • Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date, stored securely and easily available to all staff providing care.
  • All staff were actively engaged in activities to monitor and improve quality and outcomes (including, where appropriate, monitoring outcomes for people once they have transferred to other services). Opportunities to participate in benchmarking and peer review are proactively pursued, including participation in approved accreditation schemes. Outcomes for people who use services are positive, consistent and regularly exceed expectations.
  • The continuing professional development of the staff's, competence knowledge and skills was recognised as being integral to ensuring high-quality care. Staff were proactively supported and encouraged to acquire new skills, use their transferable skills, and share best practice. Managers made sure staff received any specialist training for their role.
  • Staff, teams and services were committed to working collaboratively and had found innovative and efficient ways to deliver more joined-up care to people who use services.
  • The service was inclusive and took account of patients’ individual needs and preferences. There was a proactive approach to understanding the needs and preferences of different groups of people and to delivering care in a way that meets these needs, which is accessible and promotes equality. This included people with protected characteristics under the Equality Act, people who may be approaching the end of their life, and people who are in vulnerable circumstances or who have complex needs.
  • There was a fully embedded and systematic approach to improvement which made consistent use of a recognised improvement methodology. Improvement was a way to deal with performance and for the organisation to learn. Improvement methods and skills were available and used across the service and staff were empowered to lead and deliver change.
  • The service managed patient safety incidents well. Staff recognised incidents and near misses and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. Managers ensured that actions from patient safety alerts were implemented and monitored.
  • The service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix.
  • The service had enough medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed staffing levels and skill mix.

However:

  • The outreach team did not yet provide a round the clock service.
  • The high dependency unit did not meet the minimum bed space dimensions as recommended in national guidance.
  • The unit only had two isolation rooms and this has been identified by the trust and placed on the risk register.
  • Safety thermometer data was not displayed within the unit to keep patients and visitors informed about the unit’s performance.
Inspection areas

Safe

Outstanding

Updated 22 October 2019

Effective

Outstanding

Updated 22 October 2019

Caring

Outstanding

Updated 22 October 2019

Responsive

Outstanding

Updated 22 October 2019

Well-led

Outstanding

Updated 22 October 2019

Checks on specific services

Medical care (including older people’s care)

Outstanding

Updated 20 April 2016

Overall we rated medical care services as 'Outstanding'.

This was due to the responsiveness of the service in the care of individual patients, coupled with a clear understanding of the needs of the population that used the service. Pathways were designed in collaboration with external stakeholders and community providers. The staff listened to feedback and acted on what they were told to fine tune services in the best interest of their patients. The trust executive and board had an exceptional understanding of what their service was and who their patients were. This approach was fed down so the directorate had a really good understanding of what they were meant to be providing and who the service was for - and created services that met the identified needs. Medical leaders focussed on getting the basics right and building on that to provide excellent care.

For example, there were exemplary provisions made for patients living with dementia across the whole hospital. We received very high levels of very positive feedback from patients and relatives who had used St Richard's Hospital. The 'Sit and See' scheme allowed staff to experience the hospital from a patient perspective.

Patients at risk of deteriorating were monitored and systems were in place to ensure a doctor or specialist nurse was called to provide additional support. The trust had an open culture and was prepared to learn from clinical incidents. Across the Division of Medicine there were enough medical and nursing staff to keep patients safe. The trust found it difficult to recruit new nursing staff; but was able to effectively fill gaps across the division by using bank and agency staff.

We found care was provided in line with national and local best practice guidelines. Clinical audit was undertaken and there was good participation in national and local audit that demonstrated good outcomes for patients. Patient morbidity and mortality outcomes were within expectations for a hospital of this size and complexity and no mortality outliers had been identified. The improvements in the care of patients with strokes was notable.

There was a good knowledge of issues around capacity and consent among staff.

Patients received compassionate care and were treated with dignity and respect. Most patients and relatives we spoke with said they felt involved in their care and were complimentary about staff. One person told us, “The staff are very, very kind and helpful. You just feel completely confident that they know their stuff." The Medicines division had good results in patient surveys with results indicating an improvement in patient views over the last 12 months.

The Medicines division were effective at responding to the needs of the community. The trust’s performance management team understood the status of the hospital at any given time. Bed availability was well managed. Elderly care pathways had been well designed to ensure elderly patients were assessed and supported with their medical and social needs.

The medical services were well led. Divisional senior managers had a clear understanding of the key risks and issues in their area. Medical areas had an effective meeting structure for managing the key clinical and non-clinical operational issues on a day to day basis. The hospital had a risk register which covered most key risks. Staff spoke positively about the high quality care and services they provided for patients. They described the hospital as a good place to work with an open culture. The most consistent comment we received was that the hospital was a “nice” place to work and staff enjoyed working in their teams.

Services for children & young people

Outstanding

Updated 20 April 2016

The children and young people’s service was rated 'Outstanding' because it had a strong, open culture of safety and developed reporting and learning from incidents and complaints. There was also strong governance and an effective assurance framework which resulted in a cycle of monitoring and improvement.

The children and young people who used the serviced experienced good care that resulted in outcomes that were generally above national benchmarks. Where there was underperformance, it was recognised and addressed through robust action. Staff knew how the service was performing in specific areas and were motivated to make improvements. Innovation and ownership of the service was strongly encouraged.

There was a culture of joint working and learning from others. This worked across the trust with examples such as 'Harvey’s Gang' (which the trust is justifiably proud of) and with other local providers and children’s agencies. The result of this was that children and families had a seamless journey through separate services, both internally and externally. Outcomes for very young children living in challenging circumstances benefited from this joint working.

Most importantly, the staff and leaders of the service were self-aware, they knew the limits of care they could provide safely, they understood the areas they needed to improve on and were working on these. They were very proud of their work and felt sufficiently comfortable in their position to share their pride widely and loudly to build on their strengths.

Critical care

Outstanding

Updated 22 October 2019

Our rating of this service improved. We rated it as outstanding because:

The leadership team had ensured that recommendations from our last inspection had been acted upon. Improvements to services were noted by the team across the critical care unit on both sites.

End of life care

Outstanding

Updated 20 April 2016

The overall rating for end of life care services for St Richard’s Hospital is 'Outstanding'.

The trust’s staff talked with enthusiasm about their proactive stance in getting people home to die if at all possible. This was supported by a strong rapid discharge policy that was sufficiently resourced to make it workable. The first national VOICES survey of the bereaved (2012) suggests that 71% of people wanted to die at home but that only 29% of people nationally who died in hospital felt they had sufficient choice about this. At the Western Sussex Hospitals NHS Foundation Trust, over 80% of people were supported to die in their preferred place of care. A strong culture of enabling rapid discharge supports people and their families in their desire to die in their home surrounded by the people they love and within a familiar environment that they retain more control over. The trust’s equipment library was a very good resource that enabled the rapid discharge of patients who wanted to be cared for at home in the last few days and hours of life.

A review of the data showed the trust had robust policies and monitoring systems in place to ensure it delivered good end of life care. However, it was the direct observation and conversations with staff, relatives and patients that made us judge the care outstanding. Individual stories and observed interaction provided assurance that staff of all grades and disciplines were very committed to the proactive end of life care agenda set by the board.

Staff provided a service that was caring. The specialist palliative care team (SPCT), mortuary and chaplaincy staff worked effectively and cohesively as a team to provide a seamless service. Most audits performed by St Richard's scored above England averages, which underpinned the rating given for this service. Feedback made directly to CQC, from relatives of people who had died at St Richard’s Hospital was overwhelmingly positive. They told us they, “could not have asked for more” and that staff in all areas of the hospital were caring, respectful and attentive. They talked about being involved and appreciated being supported to remain near their relative at all times.

The trust had prioritised the correct use of Do Not Attempt Resuscitation forms as a tool for engaging with patients and relatives about how they would like care to be delivered should there be an unexpected or expected but significant deterioration in the patient’s condition. Consultants had oversight of decisions made by junior doctors in consultation with family and we saw examples of clear challenge where a consultant was not content that sufficient thought had been given to the decision to withhold resuscitation that was requested by the relatives.

End of life care services were responsive. All teams worked hard to meet the needs of patients at the end of their life. There were some delays in discharges throughout the trust but these did not affect people needing end of life care where the trust managed to ensure that 79% of people were able to die in their preferred place of care.

The management structure, staff involvement and culture of the service were also outstanding. Staff feedback was exclusively positive throughout the inspection with all grades of staff supporting the trust focus on providing good end of life care. There was a positive vision for the future sustainability of the service.

Maternity and gynaecology

Outstanding

Updated 20 April 2016

Overall, we rated maternity and gynaecology services as 'Outstanding'.

People were protected by a strong comprehensive safety system, and a focus on openness, transparency and learning when things went wrong. This was demonstrated in safety thermometer results which showed the maternity service had achieved 100% since December 2014.

The service provided effective care in accordance with recommended practices. Outcomes were good and the service frequently performed better than the trusts own target. This was especially true of the work being done to reduce stillbirths and admissions to SCBU and NICU's. The service continually monitored outcomes for women and used incidents and complaints as opportunities for learning and improving services. There were high levels of multidisciplinary team working, both within the service and with external partners. Compliance with training was good and staff were offered additional opportunities for learning and development.

Care was compassionate and supportive and staff treated women and their families with respect and dignity. Outside the inspection visit we were contacted by many women who used maternity and gynaecology services who told us about their experiences. All those who contacted the CQC were extremely positive about the care and support they received. Performance in the FFT and the Maternity Services Survey 2015 showed performance above the national average.

Surgery

Good

Updated 20 April 2016

Overall we found that surgical services at St. Richard’s Hospital were 'Good'.

This was because patients were protected from avoidable harm. There were robust systems to report, monitor, investigate and take action on incidents. There were effective governance arrangements to facilitate monitoring, evaluation, reporting and learning. Risks were identified and acknowledged and action plans were put into place to address them.

We saw patients’ care needs were assessed, planned and delivered in a way that protected their rights and maintained their safety. Surgical care was evidence based and adhered to national and best practice guidance. The trust’s policies and guidance were readily available to staff through the trust’s intranet. The care delivered was routinely measured to ensure quality and adherence to national guidance and to improve quality and patient outcomes. The trust was able to demonstrate it continuously met the majority of national quality indicators. Patient surgical outcomes were monitored and reviewed through formal national and local audits.

There was clear leadership, and staff knew their reporting responsibilities and took ownership of their areas of influence. All staff spoke with passion and pride about working at St Richard’s Hospital and spoke enthusiastically about their role and responsibilities. We found staff attendance at mandatory training was good and staff were knowledgeable in how to safeguard and protect vulnerable patients.

Patients told us they were treated with dignity and respect and had their care needs met by caring and compassionate staff. During our inspection we observed patients being treated with kindness, respect, professionalism and courtesy. This positive feedback was reflected in the Family and Friends Test and patient survey results.

However, we found some areas had scope for improvement. We considered that existing mitigating strategies and the expertise of clinical staff meant that risks to patients were minimised:

The trust did not meet the referral to treatment (RTT) times for a number of surgical specialties. The ophthalmology, musculo-skeletal and ENT specialties were of particular concern.

We found there were some environmental challenges where lack of facilities such as adequate storage, clinic room and toilet facilities presented a potential risk to patients and impacted on their care and treatment.

Staff were not monitoring ambient room temperatures in rooms where drugs were stored. There is a risk that certain medicines become less effective if stored at incorrect temperatures.

The availability of junior doctors out of hours was raised as a concern as staff felt they could not always access medical support promptly.

Urgent and emergency services

Outstanding

Updated 20 April 2016

Overall we rate the emergency department as 'Outstanding'.

This was because the trust had demonstrated a very responsive and hospital wide approach to meeting treatment time targets. The hospital met, and sometimes exceeded, the national target of seeing, treating, admitting or discharging 95% of patients within four hours, ending the year in the top 20 trusts in the country. Departmental leaders and staff had implemented highly effective systems to maintain flow and escalate problems as soon as there were indications of delays in patient flow.

There were clear arrangements in place to protect patients from abuse and avoidable harm. Medical and nurse staffing was at safe levels through effective recruitment and there were no 'No Events' or 'Serous Incidents' reported within the emergency department. There was a strong organisational culture of reporting errors and incidents. Incidents and complaints were investigated thoroughly, and lessons learnt were shared. Infection prevention and control practice was well established and staff followed the trust policy and national guidance.

Patients were efficiently assessed, monitored, and cared for to prevent or respond to deterioration in their condition.

Patients were asked about their wishes and supported to make decisions about their care and treatment. We saw staff consistently offered care that was kind, respectful, and considerate, whilst promoting patient privacy and dignity at all times. Staff supported patients promptly in managing pain and anxiety and we observed staff discussing treatment and pain management with patients in ways they could understand.

The 2014 Western Sussex Trust staff survey showed the numbers of staff experiencing physical violence was worse than the national average score for acute trusts. In discussion with the trust this was identified as a result of the large numbers of patients with advanced dementia. The trust had worked with staff to address the risks by introducing a new elderly care pathway so these patients had a reduced length of stay in ED and could quickly be transferred to a calmer ward environment or discharged to the familiar surroundings of their home.

CCTV was not installed within the paediatric area of the emergency department and doors were not locked, potentially allowing the public access with the risk of possible harm to children.

Outpatients

Good

Updated 22 October 2019

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