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Provider: Bradford Teaching Hospitals NHS Foundation Trust Good

Reports


Inspection carried out on 13 Nov 12 Dec

During a routine inspection

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

  • We rated safe, caring, responsive and well led as good. We rated effective as requires improvement.
  • At this inspection we inspected four of the core services. We rated three of the services as good, and one as requires improvement. In rating the trust, we took into account the current ratings of the other services not inspected this time.
  • We rated well-led for the trust overall as good; this was not an aggregation of the core service ratings for well-led.


CQC inspections of services

Service reports published 24 June 2016
Inspection carried out on 11-13 January 2016 During an inspection of Community health inpatient services Download report PDF (opens in a new tab)
Service reports published 27 April 2015
Inspection carried out on 21 - 24 October 2014 During an inspection of Community health inpatient services Download report PDF (opens in a new tab)
Inspection carried out on 9 January 2018 to 8 February 2018

During a routine inspection

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

  • We rated safe, effective and responsive as requires improvement and caring and well led as good.
  • At this inspection, we inspected four core services and rated two of them as good and two as requires improvement overall.
  • In rating the trust we took in to account the current ratings of the services we did not inspect although because we inspected and rated maternity separately from gynaecology the previous rating for the combined services was not used.
  • We rated well-led for the trust overall as good and this was not an aggregation of the core service ratings for well-led.

Inspection carried out on 11 – 13 January 2016 and 26 January 2016

During an inspection looking at part of the service

Bradford Teaching Hospitals NHS Foundation Trust is an integrated trust, which provides acute and community health inpatient services. The trust serves a population of around 500,000 people from Bradford and surrounding area. The trust has around 900 beds and employs approximately 5,500 staff. The acute services are provided in two hospitals, Bradford Royal Infirmary and St Luke’s Hospital. The trust provides urgent and emergency care, medical, surgical, maternity, critical care and children’s and young people’s services at the Bradford Royal Infirmary site. Outpatient services are provided across both acute sites.

The community health inpatient services in Bradford are provided in three community hospitals; these are Westwood Park, Eccleshill and Westbourne Green. The community hospitals form part of the elderly care directorate and provide a less acute environment. These services are aimed at avoiding the need for patients to be admitted to an acute hospital for rehabilitation and restoring functional abilities following an acute hospital stay.

At the time of this inspection Eccleshill was temporarily closed. At the previous inspection in October 2014, Westbourne Green had been closed; as this was now open we visited this hospital and Westwood Park Community Hospital as part of this follow up inspection.

We carried out a follow up inspection of the trust between 11 – 14 January 2016 in response to the previous inspection as part of our comprehensive inspection programme in October 2014. We also undertook an unannounced inspection on 26 January 2016 to follow up on concerns identified during the announced visit.

Focussed inspections do not look across a whole service; they focus on the areas defined by information that triggers the need for an inspection. We therefore, did not inspect all the five domains: safe, effective, caring, responsive and well led for each core service at each hospital site. We inspected core services where they were rated requires improvement or inadequate. We also checked progress against requirement notices set at the previous inspection due to identified breaches in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. As a result of the October 2014 inspection, we issued a number of notices, which required the trust to develop an action plan on how they would become compliant with regulations. We reviewed the trust’s progress against the action plan as part of the inspection.

We inspected all eight core services at Bradford Royal Infirmary (BRI), although not all domains within each service. We also inspected medical services and outpatients at St Luke’s Hospital. We inspected the community health inpatient services at Westbourne Green and Westwood Park Community Hospital.

Since the last inspection there had been change and development in mainly three areas-

  • Leadership
  • Internal and external relationships, including partnership development
  • Governance arrangements

Changes had taken place in leadership across all levels, including the executive team and throughout various management posts. An improvement plan had been introduced by the leadership team designed to address the challenges faced by the trust, some of which were historical, some driven by increasing demand on services and some externally generated through review and regulatory requirements. In parallel with the improvement programme was recognition that the trust was facing financial challenges and forecasting a deficit of around £7 million. This was in the main as a result of agency costs and underperforming against quality improvement targets. Therefore, working more efficiently and effectively was also seen as a key challenge.

The trust had committed to improving engagement both internally with staff but also externally with other stakeholders, patient groups and the general public. The trust had increased engagement with staff groups. More communication was taking place, from weekly Chief Executive bulletins to consultation with staff groups on shaping the future of the trust. There had been a strategy review, which had commenced with increased local and regional engagement. Greater collaborative working had taken place, particularly around integrated ways of working. The trust was exploring new models of care and better integration opportunities through the West Yorkshire Association of Acute Trusts. The trust was leading the ‘Well North’ initiative aimed at improving health across some of the most deprived areas in the north of England.

We saw an improving picture across the trust regarding leadership development and arrangements. There had been a revision of the governance systems across the trust from changes to the board assurance framework to arrangements on wards and in departments. There remained some fundamental issues such as the idenfitication of inconsistent practice at ward level that led us to believe that the assurance processes still need time to embed and become fully effective. It was too early to assess whether they would deliver the intended improvements in Trust Board assurance.

We had serious concerns about the reconciliation of medication, the monitoring of refrigerators used to store medications; the monitoring of resuscitation equipment and record keeping within the urgent and emergency care service. We wrote to the trust with our concerns and were given assurance that improvements were made immediately and that systems had been changed so that there were mechanisms in place to ensure effective monitoring took place.

Our key findings were as follows:

  • The trust was in the process of constructing a new hospital wing, which would enable the critical care unit to re-locate to a new 16 bed unit, accommodate a 56 bed paediatric unit, including high dependency and stabilisation suites.“ In addition a 31 bedded dementia friendly elderly care ward will also be provided. This will link across on the same level to an existing dementia friendly elderly care ward which has 28 beds. The wing was due to be open in November 2016.

  • The new wing would address many of the issues with the hospital environment identified in the previous inspection and the trust had commenced a full condition survey of the remaining estate. The trust was also in the process of redeveloping the urgent and emergency care department and gastroenterology service.

  • The new hospital wing represented £28 million of a £75 million investment in improving the hospital estate over the next five years. In the interim, the trust had taken action to address some of the issues with the environment, particularly critical care. However, wards 7, 9 and 15 remained very cramped with limited space around beds. We were concerned that in an emergency situation this would present a challenge.

  • The facilities and layout within the urgent and emergency care services (ED) was no longer sufficient or appropriate for the increasing demand on the service. Concerns continued over the lack of side rooms, which limited access to isolation facilities and the layout of reception did not protect patients’ privacy and dignity. The lack of side rooms also impacted on patient flow from ambulance arrivals. There was a cubicle for patients with a mental illness, but this was not a dedicated facility and was not suitable for its purpose.

  • We found that there had been improvements in some of the core services and this had resulted in a positive change in the overall ratings from the previous CQC inspection, notably incritical care services and outpatients and diagnostic and imaging.

  • However, the ratings remained the same in urgent and emergency services, medicine and surgery. This was because we either did not see significant improvement since our previous inspection or because we identified new areas of concern.

  • In relation to outpatient services, the trust had taken the necessary steps to ensure that the backlog of over 250,000 patient pathways on the non-referral to treatment pathway had been clinically reviewed and actions taken to reduce risks to patients, including prioritising appointments and the assessment of potential harm. An improvement plan had been developed and systems and processes had been changed. The trust had revised executive, clinical and managerial leadership arrangements for outpatients and invested in additional administrative staff and a rolling programme of staff training.

  • However, the new systems and processes had not yet been embedded within the outpatient service and further work was required to establish the new centralised patient booking system. Staff did not feel engaged with the changes and expressed frustration at the new systems. There were still a large number of patients waiting for outpatient appointments and there was a downward trend in referral to treatment times, which could delay access to treatment.

  • The trust had taken action to address some of the staffing concerns identified in our previous inspection. An integrated patient acuity monitoring system had been introduced to assess patient acuity and staffing levels on a daily basis. Nurse staffing levels had been reviewed across the trust and in December 2015 the Board of Directors approved a £2.5 million investment in staffing.

  • Staffing levels and skill mix had improved since our previous inspection. However, nursestaffing levels did not always meet best practice guidance across the ED, medical services, surgical services, theatres (including the obstetric theatres), maternity services and children’s and young people’s services.

  • Governance and assurance arrangements had been reviewed since the last inspection. However, we found that these were not robust enough to identify issues relating to issues such as medicines storage, medicine reconciliation and gaps in records in the ED. There was inconsistent daily checking of equipment such as resuscitation equipment in the ED and maternity services, which was not in line with the Resuscitation Council (2005) guidance.We wrote to the trust to ask for information about how they would address our concerns. The trust provided us with assurance that they were addressed promptly and we have seen evidence to support this, for example medicines reconciliation rates are now above the trust’s target. The trust has developed a robust plan to improve the quality of records in ED.

  • Our previous concerns about the safety of children who were cared for in the stabilisation room pending transfer out had largely been addressed. There were suitably qualified and trained staff to support critically ill children until the paediatric transfer team arrived. The service had been reviewed by the Royal College of Paediatricians and Child Health in August 2015 and an action plan had been developed to address the recommendations made in this report.

  • Our previous concerns about the care of patients requiring non-invasive ventilation (NIV) had been addressed. Patients requiring NIV were now grouped together in the respiratory unit on ward 23 and the service was compliant with British Thoracic Society Standards.

  • There was a dedicated infection prevention and control team with arrangements in place to prevent the spread of infection. However, we observed staff not following infection prevention and control practices on a number of occasions. The Methicillin-resistant Staphylococcus Aureus and Clostridium difficile rates for the trust were above the England average for the period August 2014 to August 2015.

  • Policies and procedures were not always up-to-date. We saw policies and procedures that were past their review date and in critical care some of the policies did not refer to current guidance and standards.

  • The trust used the five steps to safer surgery process in the operating theatres to improve patient safety and reduce the risk of clinical incidents. The five steps included the use of the World Health Organisation surgical safety check list. However, we observed patients receiving surgery when the surgical safety checklist process had not been followed. This meant there was a risk that safety issues might not be identified before a procedure took place.

  • There had been changes in the leadership and the management structure in children’s services, which had established a children’s board. There were clear governance structures to report to the Trust Board.

  • There was an improved culture in relation to incident reporting and feedback with learning from incidents across most services in the trust. However, there were inconsistencies within the operating theatre department.

  • Figures from May 2015 indicated no evidence of risk for the Hospital Standardised Mortality Ratio (HSMR) and the Summary Hospital-level Mortality Indicator (SHMI). There was one open mortality outlier for peripheral visceral atherosclerosis.

  • Improvements had been made within the urgent and emergency care services (ED) in a number of areas such as the initial streaming of patients, access for children’s emergency services and effective learning from incidents.

  • Generally documentation was found to be of a good standard across core services with risk assessments completed. However, within the ED, we found inconsistent recording in patient records; some were incomplete, lacking key safety and essential information such as completed pain scores and national early warning scores. This exposed patient to the risk of avoidable harm as clinicians may not have the necessary information to ensure appropriate care and treatment could be given in a timely manner.

  • The nutrition and hydration needs of patients were attended to and generally well documented.

  • There were systems in place for the safeguarding of adults and children. Training in safeguarding adults and children was part of the mandatory training programme. Not all staff had completed the appropriate levels of training appropriate to their roles.

  • Staff demonstrated a good knowledge of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards and decisions were generally appropriately documented in patients’ records, although needed further embedding in practice.

  • Overall figures for the completion of mandatory training had improved, for some courses such as basic life support and adults and children’s safeguarding Level 2 and Level 3 were below the trust target of 95% in medicine. Appraisal rates for staff were low in some areas.

  • Paediatricians ran a rapid access clinic from the child development centre, which provided clinical assessment to prevent admission where possible and to support early discharge home.

  • End of life services were effectively planned, designed and delivered, including spiritual and the diverse needs of patients. There was timely access to assessment, diagnosis, treatment and care.

  • Community health inpatient services were provided across three community hospitals. The services had made improvements since the last inspection in 2014. Nursing staffing levels had increased based on patient acuity and medical staff arrangements had been reviewed and formalised.

We saw several areas of outstanding practice including:

  • The trust was collaborating with another local trust to work towards recruiting and retaining a workforce that reflected the 35% black, Asian and minority ethnic (BAME) population in the Bradford area. Between June 2014 and September 2015, the trust had improved the BAME representation on the Trust Board of Directors from 0% to 29%.

  • The trust was leading the ‘Well North’ programme, which was a collaborative programme aimed at improving the health of some of the poorest communities in the most deprived areas in the North of England.

  • The Bradford, Airedale, Wharfedale and Craven Managed Clinical Network of Specialist Palliative Care had won the British Medical Journal, ‘Palliative Care Team of the Year’ award in 2015.

  • The trust had performed better than the England average for all indicators in the 2015 Hip Fracture Audit.

  • The trust had engaged with staff and the public to contribute to the design of the new building to create an environment which was reflective of the needs of local children’s and families.

  • The Bradford Learning Disability Eye Service had brought together community health, hospital eye services, education teams, patients and carers to improve access to ophthalmic services for people with a learning disability. The trust won VISION 2020 UK’s Astbury Award for excellence in collaboration in eye care.

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

Importantly, the trust must:

  • Ensure that infection prevention and control procedures are followed in relation to hand hygiene, the use of personal protective equipment and the cleaning of equipment.

  • Review and risk assess the environment on ward 24 and put in place actions to mitigate the risk of the spread of infection.

  • Ensure that the use of PGDs in ED are in line with trust policy.

  • Ensure that relevant staff working in surgery comply with the five steps to safer surgery process and that the WHO surgical safety checklist is consistently followed.

  • Ensure there are improvements in referral to treatment times and action is taken to reduce the number of patients in the referral to treatment waiting list to ensure that patients are protected from the risks of delayed treatment and care.

  • Ensure that robust arrangements are in place to ensure that policies and procedures (including local rules in diagnostics) are reviewed and updated.

  • Ensure that that patient information is held securely and patient confidentiality is maintained in relation to information so that risks can be identified assess and managed.

  • Ensure that there are alert systems in place to identify when actions are not effective and need to be reviewed.

  • Ensure that at all times there are sufficient numbers of suitably skilled, qualified and experience staff in line with best practice and national guidance, taking into account patients’ dependency levels.

  • Ensure that all staff have completed mandatory training, role specific training and had an annual appraisal

Information on what the trust should do in addition to the above can be found in the individual location reports.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 21 - 24 October and 4 November 2014

During a routine inspection

Bradford Teaching Hospitals NHS Foundation Trust is an integrated trust, which provides acute, and community in-patient health services. The trust serves a population of around 500,000 people from Bradford and the surrounding area. The acute services are provided in two hospitals, Bradford Royal Infirmary and St Luke’s Hospital. The trust also has four community hospitals; Westwood Park, Westbourne Green, ward F3 (at St Luke's hospital) and Eccleshill.

The community hospitals are part of the elderly and intermediate care service in the division of medicine at the trust and provide a less acute environment. These services are aimed at avoiding the need for patients to be admitted to an acute hospital for rehabilitation and restoring functional abilities following an acute hospital stay. At the time of the inspection only two community hospitals had in-patient services operating: Westwood Park and Eccleshill.

We inspected the trust from 21 to 24 October 2014 and undertook an unannounced inspection on 4 November 2014. We carried out this comprehensive inspection as part of the CQC’s comprehensive inspection programme.

We inspected the following core services:

  • Bradford Royal Infirmary – urgent and emergency care, medical care, surgical care, critical care, maternity, children’s and young people’s care, end of life care, outpatients and diagnostic imaging.
  • St Luke’s Hospital – medical care, outpatients and diagnostic imaging services and community children’s service, which were based at this hospital.
  • Eccleshill and Westwood Park - community health inpatient services.

Overall, the trust was rated as requires improvement. Safety was rated inadequate, effectiveness, responsiveness and well led were rated as requires improvement and caring was rated as good. The ratings within the reports are based on the evidence gathered at the time of the inspection.

We found that the trust was dealing with the challenge of wide ranging changes within the organisation, which had been introduced over the last few months prior to the inspection. Changes included a new leadership with a new Chair and Chief Executive, and new organisational structures and governance arrangements. Going into the next 2015/16 financial year, the trust will be facing tighter budget and saving controls and may face a deficit Although, there was a robust impact assessment process in place, with consultation and involvement of staff; the Trust had not yet determined how this would impact on the quality and safety of services in the next financial year.

We found that the new governance arrangements and systems had yet to be embedded and their lack of maturity meant that they were generally untried and untested with regard to robustness and effectiveness. In some cases there was an unacceptable length of time taken to identify and address concerns over risk. We found this was the case with the considerable backlog of patients waiting for a review of their outpatient care pathway. There were over 205,000 patient pathways to be reviewed. A recommendation that the trust should assess thesepathways followed a review of Referral To Treatment Times (i.e. new referrals), It was not until May 2014, that the size of the backlog was fully understood by the trust. The Trust Board did not receive a briefing paper regarding this issue until October 2014.

We found serious concerns over the arrangements for stabilising children waiting for transfer to another hospital for paediatric intensive care as not all staff were appropriately trained and had experience of caring for the needs of such children. We also had serious concerns over the arrangements in place for caring for patients who required non-invasive ventilation at the Bradford Royal Infirmary site and whose care and treatment was not in accordance with national guidance.

There had been a commitment by the executive team to consult and involve staff, particularly the clinical body. However, further work was needed to engage staff over improvements. For example; a major challenge for the trust was the age of the buildings and some of the estate stock, particularly at Bradford Royal Infirmary. Improvements to the facilities were in progress with new builds on the Bradford Royal Infirmary site. Staff were aware of the ambition to improve the facilities through rebuilding. However, many of the staff we spoke with, particularly clinicians were unclear as to how it would impact on their service. For example, children’s and critical care staff did not know which services would be in the new builds

Our key concerns were as follows:

  • We had serious concerns over the high volume backlog of patients waiting for a review of their outpatient care pathway. There were over 205,000 patient pathways to be reviewed. The trust had taken steps to address this and was validating the information on patients in the back log. However, we had serious concerns over the length of time it had taken to put in suitable actions and the time it would take to assess the impact on individual patients.
  • Following the inspection we requested further information from the trust in accordance with Section 64(1) of the Health and Social Care Act 2008 (HSCA) regarding this backlog. The trust’s response indicated that actions were in place and that the backlog was reducing. The timescale for completing the review of all these patient pathways was March 2015.
  • We were concerned about the skills and experience of some staff, particularly in the stabilisation room used for children waiting to be collected for transfer to another hospital for paediatric intensive care. An outcome from a serious incident related to the stabilisation room had not been acted upon. We raised these concerns with the trust. The trust acted on the concerns raised.
  • At the Bradford Royal Infirmary, the hospital building and estates were old and many areas were no longer suitable to meet the needs of patients or staff. Space was compromised on the critical care unit and on the children’s wards, there were insufficient bathing facilities.
  • There was work in progress to increase and improve on the facilities within the hospital including the addition of a new wing to house the children’s service, critical care and improve endoscopy services. There was some anxiety amongst the staff working at the trust as to how the services would be reconfigured as part of the estate development.
  • There was a dedicated infection prevention and control team with arrangements in place for the prevention of infection. However, the layout in some medical wards and the critical care unit presented challenges. For example the inadequate number of side rooms (including a lack of ensuite facilities), meant that patients were not always suitably isolated. Access to hand wash sinks was compromised on the critical care unit. The trust was on target for its trajectory for Clostridium difficile infection rates but had breached the zero tolerance level for Methicilin-resistent Staphylococcus Aureus (MRSA).
  • There were staff shortages at Bradford Royal Infirmary, St Luke’s Hospital, and the community in-patient services. Staffing levels and skill mix did not regularly meet best practice or national guidance. We were particularly concerned about the low number of qualified staff working in children’s services, the recovery areas of the operating theatres and maternity services at Bradford Royal Infirmary, although there had been some improvements made in the urgent and emergency care department and medical services at this site. The trust was actively recruiting into vacant posts and staff were working additional hours to cover gaps on shifts. Some bank and agency staff were also used to cover shortages.
  • Not all staff had completed their mandatory training, particularly safeguarding training at Levels 2 and 3 or had received an appraisal. Access to training for some staff, particularly on medical wards had been affected by the staff shortages as they were unable to attend courses. We were concerned at the time of the inspection visit about the skills and experience in some areas, particularly in the stabilisation room used for children waiting to be collected for transfer to another hospital for paediatric intensive care. We found that children were exposed to risk as not all staff caring for the deteriorating child had all the necessary skills and experience required. In addition, we had concerns over the checking of equipment within the room, particularly ventilation equipment. We drew this to the attention of the trust immediately and after the inspection visit the trust addressed the risks by identifying staff on each shift with the necessary skills and experience to care for children in this room and by ensuring that competent staff were checking the equipment to the required frequency.
  • We were also seriously concerned about the care of patients being treated with non-invasive ventilation, who were placed in a number of hospital wards. Whilst under the nominated care of a medical consultant the lead practitioner was a physiotherapist. , Nurse staffing did not meet with best practice guidance. We drew this to the attention to the trust. Subsequent to the inspection the Trust provided us with information that they were acting on these concerns.

We observed much good practice, especially in the following areas:

  • Medical staff reported that the training was excellent at Bradford Royal Infirmary, including the teaching facilities within the trust. The trust had received good trainee doctor feedback.
  • Generally, treatment and care followed best practice and national guidance and outcomes for patients were positive.
  • Patients reported good experiences and were treated with kindness and their dignity and privacy protected. Patients and their relatives reported that they felt involved in decisions about their care. Women on the maternity unit reported good experiences and were happy with the care they received. Staff generally received feedback from complaints so that improvements in their service could be made.
  • The support from the chaplaincy service was excellent. However, the facilities for spiritual support were inadequate and were having an impact on the experience of those wishing to access this service.
  • Generally the community inpatient services offered a good experience for patients, although there were some concerns over nursing staffing levels and access to medical staff out of hours and at weekends.

We saw several areas of outstanding practice including:

At Bradford Royal Infirmary:

  • The hospital was providing twelve internships for people with learning disabilities. This gave people valuable work experience and encouraged integration within the community.
  • The surgical services had introduced a complementary system of ‘green bands’ worn by patients on their wrists displaying personal and procedure information. This was an effective additional safety measure to the World Health Organization (WHO) Five Steps to Safer Surgery checklist.
  • Working in collaboration with Macmillan Cancer Support, the hospital specialist palliative care team (HSPCT) were awarded the International Journal of Palliative Nursing multidisciplinary teamwork award for the positive impact that their work had on the care they provided.
  • The HSPCT were the first team in the country to link the AMBER care bundle to the Gold Standard Framework for end of life care register, which showed an increase of 38% to 57% in the identification of patients in their last year.
  • The palliative care liaison service work with ethnic minorities had won a Department of Health and Social Care award under the category ‘Improving Lives for People with Cancer’ and was awarded with a commendation.
  • The elderly care wards, particularly Ward 29 and Ward 30, had made improvements to the care of older people, including those living with dementia. The environment had been adapted and was an exemplar for friendly environments for people living with dementia.
  • In diagnostic imaging, all ultrasound stenographers were independent reporters. There were a high proportion of advanced practitioners, which had helped improve access to services.

At St Luke’s Hospital:

  • There had been improvements to the wards to make them friendlier for people living with dementia.
  • In diagnostic imaging, all ultrasound stenographers were independent reporters. There were a high proportion of advanced practitioners which had helped improve access to services.

The areas of poor practice where the trust needs to make improvements are listed at the end of this report.

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.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.