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Archived provider: Weston Area Health NHS Trust Requires improvement

On 26 June 2019, we published a report on how well Weston Area Health NHS Trust uses its resources. The ratings from this report are:

  • Use of resources: Inadequate  
  • Combined rating: Requires Improvement  

Read more about use of resources ratings

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

Inspection Summary


Overall summary & rating

Requires improvement

Updated 26 June 2019

Overall trust

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

Safe, responsive and well-led were rated requires improvement and effective and caring were rated as good. The rating of well-led at core service level was requires improvement overall, and the rating for trust management, was also requires improvement. This led to a combined overall rating for the trust of requires improvement.

We rated well-led at the trust as requires improvement because:

  • While there had been improvements in the stability of the board, we had concerns about the capacity of them to meet all of the demands being placed on the trust. We saw that support for this issue was being procured through close working relationships with a neighbouring trust, as well as through the use of funding to support some additional posts. However, there remained the challenge of a lack of succession planning to provide any kind of leadership infrastructure which further jeopardised the performance of the trust.

  • The trust was not compliant with the requirements of the fit and proper persons regulation, with a board level director in a seconded role not subject to FPPR tests.

  • Mandatory and safeguarding training levels continued to fail to meet targets, with opportunities for training often hindered by the staffing challenges faced by the trust.

  • Capacity constraints meant that pharmacy was used as a supply service, meaning there was significant risk around clinical support to wards. This was a known risk and had been on the corporate risk register since July 2017 with no reduction in risk rating. Action had not been taken to reduce the significant workforce risk. There were limited internal process for monitoring the pharmacy service and results of medicines audits were not always shared with pharmacy. The department responded reactively to incidents and the lack of pharmacy or medicines audits meant they were not identifying concerns before they become an incident. However, an annual pharmacy report went to the Quality and Safety Committee (a sub-board committee) and a monthly pharmacy report was submitted to the Clinical Effectiveness Group which reported directly to the Quality and Safety Committee. We heard consistently of a negative working culture in all the areas we visited on this inspection with the exception of surgery, – experienced at operational level, and not addressed at leadership level. Staff survey results remained a concern, and, while an improving picture, still contained many areas of poor performance. Added to this was a lack of visibility of the senior leadership team with a feeling of being disconnected articulated by operational staff at all levels.

  • The executive and non-executive team evaluated an integrated performance report at the monthly board meeting. However, there was a lack of statistical process control to enable the leadership team to analyse performance in a proactive way. This meant that the reports provided for analysis of past performance but did not create a space to enable the forecasting of future activity.

  • The arrangements for identifying, recording and managing risks, issues and performance was not always effective or effectively managed.

  • Engagement with unions was poor, with little provision made for representatives to carry out their roles effectively.

However:

  • We were assured that the leadership team at the trust were fully sighted and conversant with the challenges of their roles. During our interviews with the senior leadership team we were assured there was a common recognition of the challenges facing the organisation and its ability to provide high quality care in a sustainable way. It was clear from our conversations, that the chief executive officer demonstrated the strengths, insight, integrity and resilience needed to perform his function.

  • Beyond the capacity challenge, the trust enjoyed a leadership team which was fully recruited and contained a diverse range of skills and experience. The trust had received funding from the NHS challenged provider fund which had funded additional posts to support elements of the capacity challenge.

  • The trust articulated and was engaged in some key strategic work within the local health economy. There was a clear interconnected vision and strategy for the quality of care and services for patients and the local population. Internally, the trust was working towards its strategy, and externally it was a key stakeholder in the development of the Healthy Weston programme, as well as driving the linking up of services with local trusts.
  • Staff at the trust were trained from induction onwards to understand and recognise the duty of candour. This approach was amongst the best we have seen and was clearly having a positive impact.  

  • The trust had been performing well above average for the NHS referral to treatment time target and met the standard overall.

  • There were effective arrangements for the work of volunteers who were highly regarded and valued in the trust.

  • Urgent and emergency services (also known as accident and emergency services or A&E) remained inadequate. This remained the same as our inspection in 2017. Safe and well-led remained inadequate. Caring remained as good and effective remained requires improvement, with responsive improving from inadequate to requires improvement. In safe, we found staff did not always assess and respond appropriately to patient risk and monitor their safety. The service did not have enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. There was not a cohesive or stable leadership team in the emergency department. This was compounded by a culture in which some staff did not feel supported. However, patient outcomes were generally in line with similar services, and staff cared for patients with compassion and provided emotional support when they were distressed.

  • Medical care was rated as requires improvement overall. This remained the same as our inspection in 2017. Safe and well led remained as requires improvement but responsive improved to requires improvement from inadequate. Effective improved from requires improvement and caring remained as good. In safe, the service did not always follow best practice when prescribing, giving, recording and storing medicines. Patients did not always receive the right medication at the right dose at the right time. The service did not have enough nursing and therapy staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. Acutely unwell patients who needed side rooms did not always receive the recommended level of monitoring by nursing staff. However, the service took steps to control infection risks well most of the time. Staff kept equipment and the premises clean. When an infection was confirmed, they used control measures to prevent the spread of infection. Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary. The service also used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors. Managers used this to improve the service.

  • Child and adolescent mental health services were rated overall as inadequate. This was a drop from outstanding at our inspection in 2015. Safe and well led both went down from good to inadequate, effectiveness went down from outstanding to requires improvement, responsive went down from good to inadequate, and caring went down from outstanding to good. Staff did not protect young people from avoidable harm because they did not actively monitor the waiting list or revisit the risks of young people waiting to access treatment. There were not enough staff to meet the demands of the service. There was a high turnover rate and staff had felt the impact of this on their workload. The service had received an increase in referrals that was putting strain on its ability to see young people quickly. The service was not well led and there was a lack of ownership in local management. Staff did not document risk assessments of all the young people receiving care within the service.

  • Surgery was rated good at this inspection, which is the same rating as our last inspection in 2017. Safe, effective, and well led improved from requires improvement to good. Caring remained good, but responsive went down from good to requires improvement. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service controlled infection risk well. There were systems to monitor and maintain standards of cleanliness and hygiene, to prevent the spread of infection. The service had suitable premises and equipment and looked after them well. The World Health Organisation’s (WHO) five steps to safer surgery process was well embedded and followed within theatres. The service managed patient safety incidents well. The service used safety monitoring results well. However, the management of medicines could be improved to ensure best practice. The service provided mandatory training in key skills, however, not all staff were fully compliant with their training, particularly medical staff. Junior doctors were not confident the processes to support urology patents overnight and at weekends were functioning effectively.

  • On this inspection we did not inspect critical care, maternity, services for children and young people, or end of life care. The ratings we gave to these services on previous inspections in 2015 and 2017 are part of the overall rating awarded to the trust this time.

  • Our decisions on overall ratings take into account, for example, the relative size of services and we use our professional judgement to reach a fair and balanced rating.

Our full Inspection report summarising what we found and the supporting Evidence appendix containing detailed evidence and data about the trust is available on our website – www.cqc.org.uk/provider/RA3/reports.

Inspection areas

Safe

Requires improvement

Updated 26 June 2019

Our rating of safe stayed the same. We rated it as requires improvement because:

There remained issues with nursing and medical staffing which did not ensure safe care at all times in the emergency department, medical care wards and the children and adolescent mental health services. The trust provided mandatory training in key skills to all staff; however, they did not make sure everyone completed it. In medical care and surgery we found the services did not always follow best practice when prescribing, giving, recording and storing medicines. Patients did not always receive the right medication at the right dose at the right time. We also found the process for supplying medicines for patient discharge in the discharge lounge could cause delays. In the children and adolescent mental health service we found staff did not protect young people from avoidable harm because the service did not actively monitor the waiting list or revisit the risks of young people waiting to access treatment. We also found staff did not document risk assessments of all young people receiving care within the service.

However, staff understood how to protect patients from abuse and the service worked well with other agencies to do so. In medical care and surgery, we saw the services used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors. Managers used this to improve the service. The trust controlled infection risk well.

Effective

Good

Updated 26 June 2019

Our rating of effective improved. We rated it as good because:

Patients had enough food and drink to meet their needs and improve their health and provided health promotion information for patients to support them to manage their conditions and health choices. Staff also assessed and monitored patients regularly to see if they were in pain.

Services provided care and treatment based on national guidance and evidence of its effectiveness.

In most areas, disciplines of staff worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.

However,

There was a higher than expected risk of readmission for patients discharged after care and treatment in the specific areas of general medicine, gastroenterology, stroke medicine and geriatric medicine. However, it should be noted that the trust had the highest average age of admitted patients of all acute trusts which has a bearing on non-risk-adjusted data. We also found there were difficulties in identifying patients who were re-admitted with a surgical site infection if it was not incident reported.

In the emergency department we found the service monitored the effectiveness of care and treatment but there was no effective system to report on results and limited substantial evidence to show that the service had taken action in response to poor outcomes.

We found staff could access care and treatment protocols based on national guidance and best practice. However, in the emergency department we had concerns about version control and out of date guidelines. This meant there was potential for medical staff to access out of date guidelines.

Caring

Good

Updated 26 June 2019

Our rating of caring stayed the same. We rated it as good because:

Staff were kind and caring to their patients. The patients we spoke with were largely positive about the compassion and kindness of staff, and their dedication to giving good care, and we observed patients being treated with care and respect throughout their stay in hospital.

In the child and adolescent mental health service young people could have open discussions about their personal, cultural, social and religious needs with staff, as they knew staff would respect their wishes and help meet their needs.

Responsive

Requires improvement

Updated 26 June 2019

Our rating of responsive improved. We rated it as requires improvement because:

The trust tried to plan and provide services in a way that met the needs of local people, however they were restricted by the uncertainty of its future. Patients did not always have timely access to initial assessment, diagnosis or urgent treatment, and the people with the most urgent needs did not always have their care and treatment prioritised.

We found the emergency department was frequently crowded; patients were cared for in non-clinical areas and some were accommodated overnight, without access to suitable bathroom facilities.

In the child and adolescent mental health service we found there were extensive waits for the service that put young people at risk and breached the 18-week referral to treatment target set by commissioners.

However,

The trust treated complaints seriously, investigated them, learned lessons from the results and shared these with all staff, although they did not always meet the deadlines to deal with complaints.

Well-led

Requires improvement

Updated 26 June 2019

Our rating of well-led stayed the same. We rated it as requires improvement because:

Managers for the emergency care division, which included urgent and emergency care and medical care, had the abilities but did not always use the right skills to run a service providing high-quality, sustainable care. Some staff told us they felt undervalued by service leads.

The service did not have effective governance systems to provide assurance of quality and safety. We also found there were compatibility issues with IT systems across the trust. The trust had recognised the need for improvement and submitted an information technology bid for £10m bid via the CCG Sustainability and Transformation Partnership (STP) to the Department of Health.

In the child and adolescent mental health service we found the pressure on the service working to full capacity had restricted the clinical leads ability to dedicate time to the management role. The service was not well led and there was a lack of ownership in local service management. Staff expressed concerns with safety, vacancies and capacity of the service and we were shown evidence of these concerns being raised that had not been acted on promptly and effectively, this included management of the waiting list, staff vacancies, staff numbers and support for staff.

However,

In surgery we found the surgical leadership were clear about their roles and understood the challenges faced by the service. There were governance processes and oversight in the surgical division.

Assessment of the use of resources

Use of resources summary

Inadequate

Updated 26 June 2019

Combined rating

Combined rating summary

Requires improvement
Checks on specific services

Specialist community mental health services for children and young people

Inadequate

Updated 26 June 2019

  • Staff did not protect young people from avoidable harm because they did not actively monitor the waiting list or revisit the risks of young people waiting to access treatment. There were not enough staff to meet the demand on the service. There was a high turnover rate and staff had felt the impact of this on their workload.
  • The service had received an increase in referrals that was putting strain on its ability to see young people quickly. This was due to the cutting of local services that young people would have previously have gone to before a referral to CAMHS was required. This reflected a national trend in the same direction. As a result, staff saw young people that were increasingly more complex and unwell in their presentation. This combined to create a service, which had previously been rated outstanding by CQC in 2015, that was struggling to cope with the demand and was therefore no longer operating at a level over and above its duty of care.
  • There were extensive waits for the service that put young people at risk and breached the 18-week referral to treatment target set by commissioners. The long waits due to the lack of staff within the service risked a negative impact on the health of young people and restricted who were offered a service. The pressure on the service had impacted the number of referrals being rejected and therefore young people were being re-referred into the service.
  • The service was not well led and there was a lack of ownership in local management. Staff expressed concerns with safety, vacancies and capacity of the service and we were shown evidence of these concerns being raised that had not been acted on promptly and effectively. Staff felt that the trust did not understand the service.
  • The governance arrangements did not support the delivery of a good quality service and the governance meeting functioned inadequately. The governance meeting had occurred only twice since June 2018 and the meeting minutes for the September meeting contained limited information. Staff felt business meetings were not regular enough to be useful and did not provide time for them to discuss issues. There were inadequate systems in place to demonstrate the effective running of the service, this meant that local management were not sighted on key performance indicators. The data systems in place at the time of the inspection meant that there was unreliable information being provided and data was not accurate.
  • The lack of effective management had impacted the service. Staff consistently reported that they did not feel respected, supported or valued at work. They reported high levels of stress, were not happy and did not feel engaged with the service.
  • There were not enough staff within the team to provide more intensive support to those experiencing crisis through the rapid access clinic. As a result, all staff held mixed caseloads that included young people requiring help in a crisis.
  • Staff were not up to date with mandatory training with overall compliance at 75% on the first day of the inspection with child safeguarding and fire training below 75%. Staff expressed concern that staff did not have the correct skills to support all the pathways provided. Staff did not all receive regular supervision to provide them with opportunity for reflective practice. There was limited specialist training open to staff working at the service.
  • Staff did not document risk assessments of all the young people receiving care within the service. There was no clear risk assessment tool being used by the staff and it was unclear where risk information was kept within the paper files. Staff did not document care plans for all young people in the notes we reviewed.
  • There was an unsafe culture in the use of paper records that had compromised the care of young people while impacting on their confidentiality. Notes were not stored safely and securely at all times.
  • Staff used an electronic records system to record and escalate incidents. However, we saw that not all incidents involving young people had been recorded. Learning from incidents was not robust enough to prevent repeated incidents occurring.

However:

  • The trust had taken our feedback seriously, and had a critical friend visit from the CCG as well as inviting CAMHS experts from NHSI to come in to support with improving the service. Additionally, processes were amended so that any patient going on to the waiting list would be risk assessed as to their current status and whether they needed to be seen as an emergency. Advice to patients and families was also updated to ensure they were aware of how to seek help during the time they spent on the waiting list. The trust had developed an action plan to address the issues. The plan included:

  1. The urgent care assessment team (UCAT) had started to risk assess all patients on the waiting list, as well beginning to see patients as  part of the urgent referral process, to reduce the workload on the remainder of the team
  2. Additional management capacity had been created in CAMHS to support the team. There was a demand and capacity review being undertaken to assess workload at an individual and service level
  3. There were weekly and monthly reports coming to the Medical Director, Director of Nursing and Director of Operations  to monitor waiting list times and risk assessment of the waiting list.
  4. There were strengthened governance arrangements with the assistant general manager reporting back any governance risk issues, to the directorate governance committee.

  • Staff demonstrated knowledge of safeguarding processes. There were cover arrangements in place for sickness, vacancies and annual leave. Staff followed personal safety protocols.
  • Staff completed a mental health assessment of young people entering the service. Where a young person had been in hospital there was well documented care programme approach record. Care pathways guiding staff on the treatment to provide according to a young person’s presentation were used and reflected National Institute for Health and Care Excellence (NICE) guidance. Staff used recognised rating scales to show progression through treatment.
  • Young people accessing the eating disorder pathway received a comprehensive physical health assessment. Staff encouraged young people to lead healthy lives.
  • Staff demonstrated a clear attitude of respectful, compassionate care. Young people could have open discussions about their personal, cultural, social and religious needs. Staff were skilled at using a range of communication tools.
  • The service had a clinician of the day service to respond to young people and families phoning into the service. Staff followed up young people who did not attend an appointment to ensure their safety.
  • The service received a critical friend report from a professional external to the service to help them identify performance issues and a potential way forward.

Community health services for children, young people and families

Good

Updated 26 August 2015

Overall community health services for children and young people were found to be good. We found that services were safe, effective, caring, responsive and well-led.

Weston Area Health NHS Trust provided specialist community services for children, young people and families in Weston-Super-Mare and surrounding areas. As part of this inspection we talked to professionals delivering these services. We also met and spoke with children, young people and their parents. We visited services at Drove Road in Weston-Super-Mare and at The Barn in Clevedon.

Overall we judged the safety of community health services for children and young people as good. Risk was managed and incidents were reported and acted upon with feedback and learning provided to most staff.

Care was effective. Care was evidence based and followed recognised guidance. There was excellent multidisciplinary team working within the trust and with other agencies.

Care and treatment of children and support for their families was delivered in a compassionate, responsive and caring manner. Parents spoke highly of the approach and commitment of the staff who provided a service to their families.

Backlogs and waiting lists for initial assessments for children and young people and there were concerns expressed about the flexibility of appointments and the number of cancelled appointments. This meant the responsiveness of the service required improvement. However, the service responded well to the individual needs of children, young people and their families.

There were clear lines of local management in place and structures for managing governance and measuring quality. However, most staff felt isolated from the main trust and highlighted a lack of engagement and visibility from senior managers.