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Provider: Isle of Wight NHS Trust Inadequate

We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

Reports


Inspection carried out on 23 to 25 January and 20 to 22 February 2018

During a routine inspection

Our rating of the trust stayed the same. We rated it as inadequate because:

  • Overall trust wide we rated safe, and well-led as inadequate; effective and responsive required improvement. We rated seven of the trust’s 23 services as inadequate, and 11 as requires improvement. The findings of focused inspection of safe and well led in gynaecology services, an additional core service are in a separate report and not included in the overall trust rating.
  • We did not rate acute services in November 2016 as not all services were inspected at that time. The overall rating of acute services went down to inadequate since inspection in 2014. Five services were rated as requires improvement. Three services, emergency care, medical care and end of life care services, were rated as inadequate. Safe, effective and well led was rated as inadequate across acute services overall, with responsive as requires improvement.
  • The overall rating for mental health services remained as inadequate overall. Three of the seven services inspected were rated as inadequate, one was rated requires improvement. Safe, responsive and well led was rated as inadequate across mental health services overall, with effective as requires improvement.
  • Our rating of community services overall went down to inadequate. Community services for children, young people was rated inadequate overall with community services for adults requiring improvement. Safe and well led was rated as inadequate across community services overall, and effective as requires improvement.
  • The rating of ambulance services was requires improvement overall, however well led was rated inadequate across two of the three ambulance services and the 111 service. Safe and effective was rated as requires improvement for the ambulance and 111 services.
  • The GP out of hours service was rated requires improvement overall, with well led inadequate and safe, effective and responsive requiring improvement.
  • We rated well-led for the trust overall as inadequate

However:

  • All services were rated good for caring, with one service rated outstanding for this domain.
  • Two acute services, critical care and outpatients, were rated good overall.
  • There were improvements in some mental health services. Acute adult wards and PICU, and specialist community mental health services improved to a rating of good overall. Community mental health services for people with a learning disability or autism remained good overall. Long stay rehabilitation wards, had improved from inadequate to requires improvement.
  • The overall rating of ambulance services had improved, from inadequate in November 2016 to requires improvement


CQC inspections of services

Service reports published 6 June 2018
Inspection carried out on 23 to 25 January and 20 to 22 Febryary 2018 During an inspection of Community health services for children, young people and families Download report PDF | 1.09 MB (opens in a new tab)Download report PDF | 5.55 MB (opens in a new tab)
Inspection carried out on 23 to 25 January and 20 to 22 Febryary 2018 During an inspection of Emergency operations centre (EOC) Download report PDF | 1.09 MB (opens in a new tab)Download report PDF | 5.55 MB (opens in a new tab)
Inspection carried out on 23 to 25 January and 20 to 22 Febryary 2018 During an inspection of Community health services for adults Download report PDF | 1.09 MB (opens in a new tab)Download report PDF | 5.55 MB (opens in a new tab)
Inspection carried out on 23 to 25 January and 20 to 22 Febryary 2018 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 1.09 MB (opens in a new tab)Download report PDF | 5.55 MB (opens in a new tab)
Inspection carried out on 23 to 25 January and 20 to 22 Febryary 2018 During an inspection of Wards for older people with mental health problems Download report PDF | 1.09 MB (opens in a new tab)Download report PDF | 5.55 MB (opens in a new tab)
Inspection carried out on 23 to 25 January and 20 to 22 Febryary 2018 During an inspection of Patient transport services (PTS) Download report PDF | 1.09 MB (opens in a new tab)Download report PDF | 5.55 MB (opens in a new tab)
Inspection carried out on 23 to 25 January and 20 to 22 Febryary 2018 During an inspection of Specialist community mental health services for children and young people Download report PDF | 1.09 MB (opens in a new tab)Download report PDF | 5.55 MB (opens in a new tab)
Inspection carried out on 23 to 25 January and 20 to 22 Febryary 2018 During an inspection of Emergency and urgent care Download report PDF | 1.09 MB (opens in a new tab)Download report PDF | 5.55 MB (opens in a new tab)
Inspection carried out on 23 to 25 January and 20 to 22 Febryary 2018 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 1.09 MB (opens in a new tab)Download report PDF | 5.55 MB (opens in a new tab)
Inspection carried out on 23 to 25 January and 20 to 22 Febryary 2018 During an inspection of Community mental health services for people with learning disabilities or autism Download report PDF | 1.09 MB (opens in a new tab)Download report PDF | 5.55 MB (opens in a new tab)
Inspection carried out on 23 to 25 January and 20 to 22 Febryary 2018 During an inspection of Long stay/rehabilitation mental health wards for working age adults Download report PDF | 1.09 MB (opens in a new tab)Download report PDF | 5.55 MB (opens in a new tab)
Inspection carried out on 23 to 25 January and 20 to 22 Febryary 2018 During an inspection of Community-based mental health services for adults of working age Download report PDF | 1.09 MB (opens in a new tab)Download report PDF | 5.55 MB (opens in a new tab)
See more service reports published 6 June 2018
Service reports published 12 April 2017
Inspection carried out on 22-24 November 2016. During an inspection of Community health inpatient services Download report PDF | 373.11 KB (opens in a new tab)
Inspection carried out on 22-24 November 2016. During an inspection of Long stay/rehabilitation mental health wards for working age adults Download report PDF | 310.17 KB (opens in a new tab)
Inspection carried out on 22-24 November 2016. During an inspection of Substance misuse services Download report PDF | 281.79 KB (opens in a new tab)
Inspection carried out on 24 November 2017 During an inspection of Community mental health services for people with learning disabilities or autism Download report PDF | 266.73 KB (opens in a new tab)
Inspection carried out on 22-24 November 2016 &18 -19 January 2017 During an inspection of Community-based mental health services for adults of working age Download report PDF | 369.7 KB (opens in a new tab)
Inspection carried out on To Be Confirmed During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 336.44 KB (opens in a new tab)
Inspection carried out on 22-24 November 2017 During an inspection of Community health services for adults Download report PDF | 448.7 KB (opens in a new tab)
Inspection carried out on 22-24 November 2016. During an inspection of Wards for older people with mental health problems Download report PDF | 408.11 KB (opens in a new tab)
Inspection carried out on 22-24 November 2016 During an inspection of Community health services for children, young people and families Download report PDF | 411.94 KB (opens in a new tab)
Inspection carried out on 22-24 November 2016. During an inspection of Specialist community mental health services for children and young people Download report PDF | 294.3 KB (opens in a new tab)
See more service reports published 12 April 2017
Inspection carried out on 10-11 May 2017

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

We undertook this inspection to find out whether the Isle of Wight NHS Trust had made improvements to the inpatient and community mental health services following the comprehensive inspection of the trust in late November/early December 2016. At that inspection we rated the trust ‘inadequate’ overall and ‘inadequate’ overall for mental health services.

Following that inspection, we served a Section 31 Notice of Decision that imposed conditions on the trust’s registration. This required the trust to take action to address safety concerns at both its community and inpatient mental health services.

At this inspection (May 2017), we found that there remained a significant amount of work still to do for the conditions of the Notice to be fully met including:

  • further work on the ward environments to ensure they are fit for purpose

  • addressing staffing levels and the size of consultant caseloads

  • addressing the quality of patient records

  • providing staff with access to supervision

  • ensuring decisions are made about the future of some services, and

  • implementing good governance systems to ensure the board can effectively assure itself that the required improvements are being made in a timely manner.

However, there had had been some progress on a number of conditions in the Notice, most notably:

  • work had been carried out and was progressing on the physical ward environments, in order to make them more safe

  • there was positivity and enthusiasm from the staff on the Sevenacres site at being fully involved in planned improvements to their wards

  • there was an increased awareness of staff about the potential risks on the inpatient wards.

At the time of this inspection (May 2017), a new Chief Executive Officer had been in post just over a week and there had been a number of major changes to the senior leadership team and the way the trust was organised. In addition, the trust was also receiving input and support from a number of external organisations, including NHS Improvement.

Despite there still being much to do, we were assured that the new Chief Executive Officer had a good understanding of what was required to make the required improvements. The addition to the executive and senior leadership team, of experienced mental health and quality improvement specialists, should, given time, enable the trust to clearly progress the required improvements..

Following this inspection, we agreed with the trust to make some minor amendments to a number of conditions detailed in the Section 31 Notice of Decision. These amendments were related specifically to how and what information the trust would submit to us to allow us to continue to monitor the trust closely.

We will continue to closely monitor the trust’s progress in meeting the conditions detailed in the Section 31 Notice and we will inspect the trust again in the near future. The Section 31 conditions on the trust’s registration remain in place at this time and will remain so until we are assured those conditions have been met. We will not hesitate to take further action should we find that patients, staff and the general public are at risk of harm.

Inspection carried out on 22-24 November 2016

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

The Isle of Wight NHS Trust is an integrated trust that includes acute, ambulance, community and mental health services. Services are provided to a population of approximately 140,000 people living on the island. The population increases to over 230 000 during the summer holiday and festival seasons. St Mary’s Hospital in Newport is the trust’s main base for delivering acute services for the Island’s population. Ambulance, community and mental health teams work from this base, and at locations across the island. The trust also provides a GP led urgent care walk in centre and NHS 111 services which were not included in this inspection and will be subject to separate inspection and rating in 2017.

We carried out this short notice inspection of the Isle of Wight NHS Trust to follow up on some areas that we had previously identified as requiring improvement or where we had questions and concerns that we had identified from our ongoing monitoring of the service or if we had not inspected the service previously. We undertook site visits 22-24 November 2016 and an additional inspection of mental health services 18-19 January 2017.

We undertook a comprehensive inspection of the following core services across acute hospital, ambulance, community and mental health services:

  • Accident and emergency, medical care (including older people’s care) and end of life care.

  • Community health services for children, young people and their families, community adult services and community inpatient services.

  • Acute inpatient mental health, psychiatric intensive care unit, rehabilitation wards, community mental health, community learning disability services, community children and adolescent mental health services, older adults wards, and substance misuse services.

  • Urgent emergency ambulance, emergency operation centre, patient transport services

We also inspected and assessed the ‘well led’ domain, which covers the overall leadership and management of the trust.

Overall, we rated this trust as inadequate. We rated the safe, responsive and well led domain as inadequate overall. We rated effective as requires improvement overall. The trust was rated good for caring. We rated ‘well led’ as inadequate.

We rated mental health and ambulance services as inadequate overall. Community services were rated as requires improvement overall. Acute services urgent and emergency care and end of life care were requires improvement overall, medicine was rated as inadequate.

Immediately following our inspection, we issued a notice of decision under Section 31(HSCA 2014) to urgently impose conditions on the trust’s registration in relation to mental health services, as we had reasonable cause to believe a person would or may be exposed to the risk of harm unless we did so. We also formally wrote to the trust asking for a report on urgent action to address a number of other serious concerns across all services.

Our key findings were as follows:

  • Since our last inspection in 2014, some services had seen deterioration in safety and quality, including care for patients with mental health conditions.

  • The trust had not made sufficient progress to improve services as required at the last inspection and there was continued non-compliance with regulations that had been identified at the last inspection.

  • Inpatient mental health wards were not safe, and the ambulance station was not secure

  • There were deficiencies in organisational structures, processes and the trust leadership which prevented staff from providing good services

  • Staff in many services were disillusioned and suffering work overload; some described bullying and harassment. Morale was low among many groups of staff.

  • We found staff shortages, outdated practices, bureaucratic processes, limitations in information systems or use of information.

  • Staff felt senior managers had insufficient knowledge and experience. Some services had managers in interim roles and staff felt this impacted on their ability to be effectiveHowever staff spoke highly of the support they were given from their direct line managers and were proud of the strong sense of teamwork.

  • The trust did not have strong risk management and governance processes at all levels which affected the quality and safety of services. The executives were out of touch with what was happening at the front line.

  • There was a top-down culture with senior managers attempting to direct change. Senior managers did not appear to understand what was needed to make necessary changes or to implement their vision and strategies. Staff did not feel part of this process as managers had sought a high number of external reviews.

  • The trust recognised the need to work with partners to provide high quality and sustainable services for the island population. However there had been little progress in delivering that vision, so the trust and the wider system were not keeping pace with the actions and improvements needed to meet increasing demand for services and financial pressures.

  • The trust did not know whether all front line staff were reporting all incidents and learning from incidents was shared. There was a mixed understanding of the principles of the duty of candour and its application.

  • Patient care and safety was affected as all services had teams or wards that were significantly understaffed. Some trust wide key posts were vacant and the trust employed many locum medical staff

  • There was inadequate risk assessment of patients and risks were not adequately monitored or managed.

  • Key groups of staff were not up to date with safeguarding training. Staff did not always identify or report safeguarding incidents. Safeguarding and ‘looked after children’ teams were stretched and there were not sufficient monitoring of adult safeguarding.

  • The records systems across community services did not support patient safety.

  • Care and treatment did not reflect current evidence based practice in all services.

  • Staff did not regularly monitor patient outcomes and some services did not participate in national data collection schemes. Outcomes for stroke patients were poor.

  • Some staff did not have appropriate competence and skills, particularly in medicine services. Many staff across services did not receive regular appraisal or appropriate supervision.

  • Staff did not always seek patients’ consent for treatment, observation or examination.Staff awareness of the Mental Health Act (2005) and the Deprivation of Liberty Safeguards was variable and it was not always applied.

  • The trust did not plan or deliver services in a way that met people’s needs.

  • Patients’ privacy and dignity was not protected in mental health services wards and acute service escalation beds. Staff did not always report incidents where mental health wards had people of both sexes sharing bathrooms, which is a breach of the regulations.

  • Staff did not manage access and flow through services adequately. This led to delays in ambulance handovers and discharge from the emergency department. There were also multiple patient moves for non-clinical reasons across acute services, including end of life care patients and late evening or night time.

  • Staff did not plan patient discharge effectively leading to extended length of stays across acute and mental health inpatients services. Staff did not make sure end of life care patients were not discharged in a responsive manner and most were not transferred to their preferred place of death.

  • Partnership working between the trust and organisations such as the local authority and hospice was not always effective.

  • The trust missed targets in referral to treatment times and cancelled operations.

  • The trust needs to improve the collation, timeliness and quality of response to complaints, and put in place improved process for sharing the learning that comes from the complaints..

  • There was some evidence of staff responding to patients’ individual needs and the dementia passport worked well where it was used, but this was not consistent.

  • The trust board was not effectively monitoring how the needs of vulnerable patients were being met.

  • Staff treated people with dignity, respect and kindness during all interactions. They were compassionate and kind and showed empathy when caring for patients.

  • The Mental Health Act Code of Practice was appropriately followed, although the trust was an outlier for second opinion appointed doctor (SOAD) requests, when there were treatment changes for service users.

We saw some areas of outstanding practice including:

  • ‘Post discharge medicines optimisation support to reduce readmission’, known as MOTIVE, resulted in a statistically significant reduction in 30-day readmissions. For every two patients referred by the hospital to the community pharmacist, three admissions per year were prevented.

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

For details of actions for specific services please see the core service inspection reports

Importantly, the trust must ensure :

Trust-wide

  • That the leadership improves at all levels from board to service level.

  • that there is an achievable strategic vision and staff are clear of their role and actively involved in delivery of meaningful plans to achieve this.

  • There is a systematic review and revision of hierarchical and bureaucratic processes, and clinical business unit leads are supported to work autonomously in the provision of high quality and sustainable and integrated services for patients.

  • There are improvements to the collection and use of information to support the monitoring of quality and safety.

  • Community records systems are fit for purpose, accessible to staff and support the delivery of safe services for patients.

  • There are clear, uncomplicated governance arrangements that support monitoring of quality, safety and performance across all services.

  • There are arrangements in place for identifying, assessing and managing risk at all levels and staff are appropriately trained in this.

  • The board develops and embeds an effective assurance framework to identify and take early action on any concerns arising in any services.

  • There is effective staff engagement and work to progress organisational development and culture change, so that candour, openness and challenges to poor practice are improved.

  • improvements are made to human resources processes, including clearly defined and consistent management of poor performance.

  • Staff and service leads are trained and supported in making quality improvements and innovations they identify are needed to support sustained quality services.

  • Improvements are made to the equality and diversity programme within the trust, so as to ensure equality for all staff and patients.

  • Improvements are made to partnership working with the local hospice and local authority, to facilitate effective access and timely flow along patient pathways.

  • There is a clear procedure and full range of checks are undertaken prior to the appointment of both executive and non-executive directors as set out in the fit and proper persons regulation of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

  • Improvements are made to collation, timeliness and quality of response to complaints, and the learning arising from complaints.

On the basis of this inspection, and the overall rating of inadequate, I have recommended that the trust be placed into special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 4–6 June and 21 June 2014

During a routine inspection

The Isle of Wight NHS Trust is an integrated trust that includes acute, ambulance, community and mental health services. Services are provided to a population of approximately 140,000 people living on the Island, and St Mary’s Hospital in Newport is the trust’s main base for delivering acute services for the Island’s population. Ambulance, community and mental health teams work from this base, and at locations across the Island.

We carried out this comprehensive inspection because the Isle of Wight NHS Trust is an aspirant Foundation Trust, prioritised by Monitor. The inspection took place on the 4, 5 and 6 June 2014 with an unannounced visit on 21 June between 4pm and 11pm.

We inspected the following core services:

Accident and emergency, medical care (including older people’s care), surgery, critical care, maternity and family planning, services for children and young people, end of life care, outpatients services and the ambulance service.

Community health services for children, young people and their families, community adult services and community inpatient services.

Primary Mental Health Services, learning disability services, Children and Adolescent Mental Health Services (CAMHS), older adults, Acute, PICU and S136 Place of Safety, rehabilitation inpatient services, drug and alcohol services, community mental health and crisis resolution services.

Overall, we rated the trust as ‘requires improvement’. We rated it ‘good’ for providing caring services, but it required improvement for the services to be safe, effective, responsive and well-led.

Overall acute and community services were rated as 'requires improvement'; ambulance and mental health services were rated as 'good'.

Our key findings were as follows:

Overall, we found that staff were caring and compassionate, and treated patients and people using services with dignity and respect. Staff were highly motivated, and treated people as individuals. However, NHS Friends and Family Test results rated the inpatient wards as lower than the national average, and people accessing community mental health services expressed some concern that they were less involved in their care, and had little information about services.

Staff followed good infection control practices, although for community inpatient services better MRSA screening was needed. The hospital was clean and well maintained, and infection control rates in the hospital were in an acceptable range.

The hospital monitored harm-free care in all in-patient areas, and had taken action which was reducing avoidable harms, such as pressure sores and falls.

Staff were aware of safeguarding procedures, and there were effective processes in all services to safeguard people from abuse or harm.

There were clear processes for taking people’s wishes into account, and seeking their consent where they had capacity to do so. People who did not have the capacity to consent did not always have their needs considered in a safe and proportionate way, as not all staff were informed about the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.

The Mental Health Act Code of Practice was appropriately followed, although the trust was an outlier for second opinion appointed doctor (SOAD) requests, when there were treatment changes for service users.

Patients were not always appropriately identified for 'do not attempt cardiopulmonary resuscitation' (DNA CPR) orders. When the orders were used, decisions were not always clearly documented or reviewed, and were not always discussed with the individual or their family. In some ward areas, staff told us that this was being avoided, as there was a reluctance to have these conversations.

Incidents were reported, and lessons were learnt and shared across services, to minimise risks and prevent reoccurrences, but this was variable. We found examples of incidents that had not been responded to promptly or adequately, some areas did not share lessons, and staff in community mental health services were under-reporting incidents because of limited staff capacity within the service.

There were risk registers to monitor and take action on risks, but these were also not consistent. Risks were not always appropriately identified or escalated, there were concerns raised by staff where no action had been taken or had been delayed, and some risk registers had not been appropriately updated for months or, as in community health services and community mental health services, for years.

Staffing levels were not sufficient in all areas, and there were ongoing challenges in recruiting staff to work on the Island. Nurse staffing areas had been reviewed, but there were insufficient appropriate qualified staff in children’s care in A&E, the acute services, community rehabilitation wards, district nursing and older adult mental health wards. Staff had reported concerns in these areas, and were disappointed that no action had been taken for some time. The succession planning in some services that would imminently be needed for sustainability, such as in maternity services, was not evident. The trust had recently signed off a recruitment plan, but the actions taken and updates were not well communicated to staff.  

Medical staffing was a similar challenge for many specialities, and the trust had employed locums to cover vacancies. Some services were run by locums who had changed over several years, and this had not provided consistency of leadership or treatment for patients and services users. The trust was actively trying to recruit to these areas, but many staff told us about the inadequate and bureaucratic human resources processes within the trust. The current support, in terms of recruitment and retention, was causing delays and frustrations at a time when recruitment needed to be timely and exact.

The majority of people who used the services and staff said they felt safe; however, there were examples of people stating that at times low staffing numbers affected people’s care and treatment.

In many areas, national guidelines and evidence-based practice were being used to treat patients. In pharmacy, ambulance and mental health teams there was innovative work to embed this practice, and outcomes of care were benchmarked and monitored to improve the effectiveness of services. This approach was inconsistently applied in community health services, community mental health services, and in the acute hospital. For example, the trust had considered the relevance of National Institute for Health and Care Excellence (NICE) guidance, but this was not consistently implemented, monitored or adhered to. People accessing community mental health services were not monitored or reviewed appropriately, to assess their progress or recovery.

There was good multidisciplinary and integrated working, with GPs, community teams and social care teams, to support people at home, avoid admission to hospital, and support early discharge. There was also work with housing and employment teams, and with the police, in mental health services, to co-ordinate people’s recovery, and support their independence and self-care. The trust was working to develop three locality-based integrated teams across the Island; teams and staff had said that this had already improved communication and joint working. However, community teams were under-resourced and there was ineffective caseload management and supervision; patients did not have appropriate assessment and care, and discharge was delayed for patients with complex needs.  

In March 2014, the trust mortality rates were within the expected range; there were care bundles and pathways for emergency care prior to hospital, and in use in the emergency department. Patients who were acutely ill were appropriately escalated, but care pathways and bundles were not always followed through during their inpatient stay, for example, for sepsis care. Seven-day working was developing for emergency care and pharmacy support, but this was less well developed in other areas.

The trust was working to provide services to people on the Island, where this was economically viable and appropriate, to avoid the need for people to travel to the mainland. There were good examples of innovative practice, and the use of technology and staff working flexibly to share knowledge and skills, although systems to share learning needed to improve. There was effective working with mainland services, for example, in cancer multidisciplinary teams, but the trust needed to ensure that communication worked well across all these services.

People received the right care at the right time. Ambulance services achieved national response times, patients were seen and treated in the A&E within four hours, people had surgery, diagnostic tests and outpatient appointments within national waiting times. However, in the acute hospital, the pressure on beds meant that patients were being moved several times for non-clinical reasons, and were not always on the correct ward for the care and treatment they required. Weekend discharges did not happen in some inpatient areas, or were not well co-ordinated with on-call community services. This had led to inappropriate arrangements of care, and possible readmission of these patients. There were long waiting times for assessment and treatment in community mental health teams.

The integrated nature of services helped to support the care of vulnerable people, for example, people living with dementia, and people with a learning disability. The specialist liaison was described as effective by staff. However, there were delays where staff had limited capacity, such as with the support that could be provided by the community psychiatric nurses in A&E to do timely assessments for people with a mental health condition. There was good access to advocacy services for people with a mental health condition.

There was a palliative care team to support patients who were coming to the end of their life. However, patients were not always being identified as being on an end of life care pathway in a timely manner, and did not always receive the care and support they required.

Complaints processes were understood by staff, patients and service users, and in many areas concerns and complaints were being used to improve services. The trust only responded to 44/93 (47%) of complaints (October 2013 to March 2014) within the 25 days target, or within agreed extended timescales.

The trust was developing IT systems towards an electronic records scheme. Where this was working well, it had a great impact, such as in A&E with GP practices. There was an ongoing programme to improve access and use IT across community services, and connectivity issues were a known challenge. Where implemented, the IT system was still not fully functional in community services, and incomplete electronic records created a risk. There were disjointed IT systems in mental health and learning disability services, and this caused delays to care and treatment. In some areas there were fewer computer stations, and staff were often waiting to use the system.

The trust had a statement of vision and values, and many staff were aware of this, but not in all areas. There was a five-year strategy to develop integrated services across the Island, working across health and social care, and to develop sustainable quality care. This would mean expanding community-based services, the centralisation of some services, and developing clinical networks where specialist expertise was in the interest of patients and the prevailing economics of providing a service.

Many staff were not aware of the trust strategy, but could verbalise the strategic direction of their own service; but in many areas these were not devised or written, or considered in alignment with the trust strategy. Mental health services, for example, had little knowledge of why the trust had a clinical network with Hertfordshire. There was a trust strategic overview of the integration of services, but there was less operational support and direction to cope with service demands, resource needs, and manage effective integration within and across the divisions.

The trust had comprehensive corporate governance processes: there was a committee structure, reporting and review processes to monitor key performance indicators, incident, complaints and business risks, at trust level, and across the three divisions of acute care, planned care and community care. However, the trust needed better clinical governance and assurance system to have an overview of the actual quality and delivery of services and practice. There were examples of risks, clinical audit, reporting and learning from incidents, and use of national and evidence-based guidelines that did not happen appropriately, or at all.

The Island had a slow pace of life, and this was the culture within the trust. Some of the issues faced by the trust are as they were in the wider NHS a few years ago. Pressures in terms of bed capacity were not high comparatively, but were recent issues for the trust. The responsiveness of services needed to be better prepared for the service demands and pressures that, with an older population on the Island, will increasingly be experienced by the trust.

Staff engagement did not happen effectively. The trust leadership team and senior managers were changing services and policies, but these were not effectively implemented. Communication came down from the trust leadership, but change happened without effective consultation or discussion. Staff at all levels and in all parts of the organisation told us that they were not being listened to, and there were predictable problems because of this. There were many examples where implementation of change did not happen effectively, and was not monitored appropriately, and this was increasing the risk to patients. There was low morale in the pathology services where service reorganisation and work pressures were affecting staff, and they felt that they had little knowledge, communication or ability to influence decisions.

Many staff in ambulance, community and mental health services described a disconnection with the trust, and considered they had a low profile compared to the acute service. They felt like it was an acute trust with satellite services, and the leadership of the trust did not reflect the complexity and integrated nature of its services.

There were several issues where we were concerned enough to ask the trust to take immediate action.

The paediatric emergency admission pathway required a single agreed point of entry for paediatric admissions. The current criteria of medical / surgical patients to the paediatric ward, trauma patients to A&E, and babies under 14 weeks to the neonatal unit, was confusing (and had caused confusion) for hospital and ambulance staff. There had been two serious incidents prior to this, with ambulances being redirect with children who required emergency care. During our unannounced visit, we found that the trust had implemented a single point of entry, and all children now had emergency care in the A&E.  The proposals had previously been discussed with the paediatric team but the immediate change had not been done in consultation with paediatric teams; it did not take account of children who had previously had direct access to the children’s ward and staffing levels on the paediatric wards.  The risks in terms of delays to treatment still remained for some children.

Staffing levels on the stroke rehabilitation and general rehabilitation wards were unsafe, and the stroke unit was a concern. There were inappropriate numbers of medical and nursing staff, and stroke patients received inconsistent care, and risks were not being managed appropriately. The ward also had medical and surgical outliers, and staff did not have the appropriate numbers, experience and skills to also care for acutely ill patients. There were patients requiring rehabilitation on other wards in the hospital who should have been on this ward. The admissions to the ward were not organised. The trust informed us that they had stopped medical outlier admissions to the ward, and were reviewing staffing levels. During our unannounced visit, we found that the trust had restricted medical outliers to the general rehabilitation ward, but outliers still remained on the stroke rehabilitation ward. Staff were still under pressure and had not had breaks. They could struggle to cope when a patient required one-to one-care, and an elderly patient was being wheeled around in a chair, as this was the only way nurses could observe them.

In adult community services, district nurses worked as lone workers from 8pm to 8am, and were at risk in terms of protection and security. This issue has been highlighted as a risk, but no action had been taken. The nurses were also identified as recently qualified or inexperienced (Band 5) nurses, who did not have the appropriate experience and skills for the decisions that they were being asked to make, such as to triage patients, and determine appropriate levels of care. The trust informed us that they had introduced an on-call senior district nurse and hospital at night team support for the district nurse on-call. During our unannounced inspection, we found that there was no district nurse on-call, and ambulance staff had only been informed at 8pm that night. There was no senior nurse on call, and the hospital at night team were not aware of the support they should be providing to the district nurse service. Patients who could be treated in the community, had delays to treatment and had to attend A&E.

The medicines kept in the ambulance station were kept at an inappropriate temperature. The temperature in the room was above 29 degree Celsius (and could get higher because of the radiator and computer equipment in the room). The drugs should be kept at 25 degrees Celsius or below; one drug should have been refrigerated. The ambulance station did not have a system for stock control, so even though drugs were within their expiratory date, the drugs stored the longest were not always the first to be used. The heat degradation would mean that the efficacy of the medication would be reduced. The trust told us that they had put an air conditioner in the ambulance station room, to keep the medicines cool. During our unannounced visit we found that medicines were appropriately stored at the correct temperature, and the stock had been reduced. However, we found that records of the temperature in the room were not kept, and there had not been a risk assessment done for the movement of IV fluids to another storage area.

The A&E had a non-clinical screener for patient attenders. The receptionist in A&E was determining where patients went for assessment. Triage was not undertaken by a nurse or doctor. The trust told us that this practice had ceased, and assessment and triage was now undertaken by a trained nurse. During our unannounced inspection we found that triage was being undertaken by a nurse, but patients were waiting over an hour to be assessed and triaged. Patients were being assessed in order of attendance, and there had been no triage of patients in terms of priority.

We have served a warning notice under Regulation 10 (Assessing and monitoring the quality of service provision), because there was a lack of effective implementation and monitoring of quality and risks in services.

We saw several areas of outstanding practice including:

Trust-wide  

The Integrated Care Hub was an excellent example of efficient multidisciplinary teams working closely together to ensure the best outcomes for patients. This integrated call centre opened in 2013 and provided access to the 999 emergency calls service, the NHS 111 service, the GP out-of-hours service, district nursing, adult social care, tele-care services, non-emergency patient transport services, and mental health services. The Integrated Care Hub co-ordinated access to emergency, urgent and unscheduled care for the Isle of Wight. There were 64 staff located at the Integrated Care Hub, including switchboard, call handlers, dispatchers, clinical advisors, and operational and clinical managers. Key services were accessed out of hours through the Hub. The Hub was effective in ensuring that patients had timely access to appropriate services, avoiding unnecessary admissions to hospital, and delivering better outcomes for patients.

The pharmacy service was operational seven days a week. The service was innovative, and worked effectively within multidisciplinary teams to improve patient care. For example, electronic prescribing had reduced medication errors, and was being used to ensure that venous thromboembolism risk assessments occurred. The service offered an advice line, and was involved in the pre-admissions initiation of antibiotics with ambulance services.

The trust was developing integrated information systems, and was working towards electronic patient records. There was connection between the A&E and ambulance services, and local GPs.

Acute and Ambulance Service

There was evidenced based care for orthopaedic patients having hip and knee operations.

A widely shared care network for managing children with the most complex and rare conditions had enabled families to be supported and treated closer to their homes. It also enabled access to the best possible advice for these families. For example, the children’s ward was a Level 1 Paediatric Oncology Shared Care Unit, and could also offer care to visitors to the Island with oncological problems.

Ambulance staff used electronic tablets to enable operational staff to complete their e- learning.

The ambulance service was participating in a trial in early intervention in sepsis, jointly with another ambulance service. The aim was to identify patients who might have sepsis, and to reduce their mortality through early intervention prior to admission to hospital.

The Individual Learning Plan (ILP) had been developed and implemented to support the development of staff competency in the ambulance service. This was introduced in 2014, and staff were given learning objectives and were required to demonstrate learning as part of their continuous professional development.

Community Mental Health Services  

The Integrated Sexual Health service provided a good service to wider groups in the community, and improving access to the service for harder to reach patients. The services provided access for the full range of the demographic population of the Island, including young people, the homeless and vulnerable adults.

The staff in the Community Stroke Rehabilitation Team provided an excellent service, by working towards patient-specific rehabilitation goals, facilitating early discharge from hospital, and always putting the patient at the centre of their care.

Innovative practice and collaborative working were identified in the children’s physiotherapy department, with a specialist therapy provider that enabled funds to benefit more children.

A productive series community programme was embedded in the orthotics department.  This had demonstrated sustained improvements in the treatment and care of children.

Changes to the local authority safeguarding arrangements in 2013 and resulted in large increases in safeguarding and child protection referrals.  These were being managed effectively to reduce risks to children.

The trust had introduced an Alzheimer’s café, and created a garden for dementia patients.

A Parkinson’s care co-ordinator had been created to meet the needs of larger numbers of patients with Parkinson’s disease.

Staff demonstrated a good background knowledge of families and children, as well as areas of higher risk in different localities across the Island.

Effective multidisciplinary working and communication, both within the service and with other health and social care professionals, was evidenced.

Mental Health Services

Primary mental health services teams provided and referred people for a range of evidence-based psychological therapies, on both a group and individual basis.

The service had developed new and innovative services to protect vulnerable people, and reduce the use of the Mental Health Act. One example of this was 'Operation Serenity', where there was joint working with the police, to treat people at home, or in the community. This had reduced the use of the S136 Place of Safety, and decreased the number of people having to be detained under the Act.

The Learning Disability Service was innovative in its use of assistive technology, to help people with communication difficulties, to encourage their choices and preferences.

The Drug and Alcohol Service had introduced a range of health promotion measures, and had integrated its work with GPs. Service outcome measures were used to improve the service.

The outside garden space on Afton Ward for older adults was funded and developed by staff. The garden was gender-specific, and had a quiet and restful area, as well as areas that encouraged activity and learning. It was described as inspirational by people and their families.

On the acute, PICU and Rehabilitation wards (including S136 Place of Safety) there was effective debriefing for staff following incidents, and staff shared lessons learnt in team meetings. Reflective practice was provided to staff through a skilled psychologist.

There was effective use of the wellness recovery action plan (WRAP) for patients on the acute, PICU and Rehabilitation wards (including S136 Place of Safety). Discharge planning started on admission and the discharge tree was used on the PICU. The wards had excellent relationships with housing and employment services.

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

Importantly, the trust must ensure:

Trust-wide

The clinical leadership of services improve, and there must be operational support and co-ordination to cope with service demands and to manage effective integration.

Staff engagement is effective, so that service changes and developments are owned and effectively implemented, to reduce risks to patients and people that use services.

Complaints need to be responded to within 25 days, or agreed timescales.

Acute and Ambulance Services

Staff receive training on the Mental Capacity Act 2005 and the Deprivations of Liberty Safeguards. The principles must then be applied to ensure that where people do not have capacity to consent, the correct procedures are followed.

Staff are competent in how to recognise when a patient is on an end of life journey, so that decisions are made and their care managed appropriately; the trust must ensure that staff have received the appropriate training, and understand the tools available to them. This includes the use of the AMBER care bundle, and the use of syringe drivers.

'Do not attempt cardio pulmonary resuscitation' (DNA CPR) orders must be completed in their entirety, in a timely manner, for all patients where this decision has been made. There must be clear documentation as to how this decision was reached.

Risk assessments in relation to patient care must be completed, and used to inform the patient’s plan of care.

All patients have a named consultant for the duration of their stay, with clear referral and acceptance criteria when there is a change in consultant for clinical needs.

The provision of care is reviewed for patients who have had a stroke, to ensure that the pathway is fully reflective of national guidance.

National guidance is reviewed, gap analysis completed, and improvement plans put in place and monitored where required, to ensure that practices are in line with nationally-recognised guidance.

The trust must ensure there is a lead nurse qualified in the care of children (RN(children)) and sufficient registered (Children) nurses are employed to provide one per shift in emergency departments receiving children as per Standards for Children and Young People in Emergency Care Settings 2012.

There is a single point of access for children in an emergency situation. Short-term measures should be safely implemented while long-terms plans are developed.

The nursing staff provision is reviewed within the Accident and Emergency Department and the Stroke ward, to ensure that they are staffed to the agreed establishment and skill mix, in line with current guidance.

There is an effective and safe procedure for the obtaining, recording, handling, using, safe keeping, and dispensing of medicines used by the ambulance service.

Community Health Services  

There are effective operation systems to regularly assess and monitor the quality of the services provided, in order to identify and manage risks. Risks as a result of the implementation of the IT project were not monitored at all times. Staff did not report all risks and near misses, and the trust was not responding to risks and near misses, particularly with regard to the levels of medical, nursing and therapy staff.

There are effective and reliable measures, and support is in place to protect the safety of staff working alone and out of hours in the community.

Community nursing staff receive regular training and updates for Doppler assessments, and ensure that patients with leg ulcers get regular and timely reviews of risk assessments.

There are sufficient qualified and experienced nursing and medical staff on the wards, including out of hours, to meet patients’ needs. This includes the stroke TIA clinic, the needs of patients who are medical outliers, and those placed in the additional four beds used in Rehabilitation. Short-term measures need to be in place whilst longer-term measures are arranged.

There are clear admission policies to community inpatient wards, and adherence to these must be monitored. Patients placed on the stroke rehabilitation and general rehabilitation wards must meet the criteria for admission, so that they can benefit from the services offered.

Staff receive regular supervision and this includes bank staff.

Doctors are offered adequate training, and sufficient staffing needs to be in place to enable medical and nursing staff to attend all teaching and development sessions.

Infection prevention and control measure are followed. The risks from damaged equipment must be removed; local infection control audits must include a review of equipment; yellow clinical waste bins outside the ward must be kept locked at all times; sharps boxes must always be left closed; and patients must be given appropriately handover checks and screening for MRSA on the wards.

There are adequate levels of equipment (including stroke chairs, wheelchairs and other equipment), in good repair to meet patients’ needs; and all equipment must be regularly checked and appropriately maintained.

Trip hazards from electric leads in the ward corridors are eliminated.

Staff have the correct understanding of ‘intentional rounding’ practices and recording on the stroke ward.

Standards for pressure area care are followed. Patients with pressure ulcers must have appropriate and timely reassessment on the stroke ward, action must be taken and recorded in response to patients’ skin changes, and all patients must have use of a pressure-relieving mattress where assessments indicate this is required. The use of inco sheets for pressure ulcer care needs to be reviewed.

Staff request and record patients’ written consent to the display of their details on the computerised screen on the wards.

Wards display a contact point for access to information and complaints regarding the use of CCTV on the wards.

The trust must update the DNA CPR policy, and ensure wards audit their adherence to this policy.

Mental Health Services  

Risk management and care planning in people’s records in the Community Mental Health Team must be improved. Records were not reviewed consistently or updated in a timely manner.

The caseload management and line management supervision of caseloads in the Recovery and Rehabilitation Team are regularly undertaken to identify issues that may impact on care delivery and quality.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.