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Provider: Dorset County Hospital NHS Foundation Trust Good

On 06 November 2018 , we published a report on how well Dorset County Hospital NHS Foundation Trust uses its resources. The ratings from this report are:

  • Use of resources: Good  
  • Combined rating: Good  

Read more about use of resources ratings

Inspection Summary


Overall summary & rating

Good

Updated 6 November 2018

Effective, caring, responsive and well-led were rated as good and safe as requires improvement. Apart from safe, for which the rating stayed as requires improvement and caring which remained good, the other key questions improved from requires improvement to good. We took all ratings into account in deciding overall ratings other than those for diagnostic imaging which we do not include in the overall ratings.

  • We rated well-led at the trust as good. There was effective, experienced and skilled leadership, a strong vision for the organisation, and embedded values. The leadership had the capacity and capability to deliver high-quality sustainable care. Leaders understood the challenges to quality and sustainability and they were visible and approachable. There was a clear vision for the trust and strong values. The strategic plans fitted with local integration plans for Dorset county, and the strategy was aligned to the wider health and social care economy. Staff felt valued and supported and positive and proud to work for the organisation. There were cooperative and supportive relationships throughout the trust. There was good governance and structures to assess the care provided and give assurance around quality. There were processes for managing risk, issues and performance. Information and data was of good quality. The views of people using the service were considered, as were those of staff and stakeholders. The trust was strong on continuous improvement and innovations. However, the trust needed to review and improve how it gave assurance around learning from preventable deaths. The arrangements for the Freedom to Speak-up Guardian did not reflect the recommendations of the National Guardian’s office. The responses to complaints and how the trust demonstrated to those who complained that it learned from their issues needed improvement.
  • Urgent and emergency services (alternatively known as accident and emergency services or A&E) improved from requires improvement overall at our last inspection in 2016 to good in 2018. At our previous inspection, safe and well-led were requires improvement with the other key questions rated as good. Safe remained this time as requires improvement with issues with patient triage times, paediatric nursing levels, some mandatory training, and completion of records. There were also some unresolved issues with the room used for assessment of mental health patients. However, staff protected patients from avoidable harm, most areas were being kept clean, incidents were addressed, and there were good staffing levels and skill mix in the nursing teams. The other key questions were rated as good, with well-led improving from requires improvement to good. There were strengthened arrangements for leadership, priorities were well understood, and there was a strong culture. However, there were some issues with governance of risks, some need for improvement in IT systems, and a lack of engagement with the public around the way services were designed and run.
  • Maternity services were rated as good. We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings. Safe was rated as requires improvement with all the other key questions rated as good. In safe we found not all staff had updated their mandatory training, not all equipment was cleaned correctly, medicines were not always managed well, and there were issues with the levels of nitrous oxide, which had not been addressed since our previous inspection. There was an inconsistent approach to the use of safety guidelines and there were some issues with emergency planning and untoward events. However, incidents were well managed, there were good staffing levels, patients were protected from avoidable harm, there were comprehensive birth plans for women, and staff were given time to undertake specialist midwifery training. The other key questions were rated as good.
  • End of life care was rated overall as good. This improved from a rating of requires improvement at our last inspection. Safe improved to good, effective remained requires improvement, caring and responsive stayed as good, and well-led improved significantly from inadequate to good. In effective, resuscitation decisions or mental capacity assessment and decisions were not always well recorded, and care planning was not always completed as required. However, otherwise, the service provided care in line with national guidance, staff were competent and there was good multidisciplinary working.
  • Outpatients was rated as good overall. We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings. Safe was rated as good. Effective we do not rate. Caring and responsive were good, although well-led was rated as requires improvement. In well-led the governance systems were not always effective for assurance purposes, and there was no coordinated approach to service improvement. We had some concerns about infection control at the physiotherapy clinic in Weymouth Community Hospital, and clinic letters were significantly delayed. Neither of these areas had improved since our last inspection. However, the services had good managers, there was a positive culture, and good engagement with patients, the public and staff.
  • Diagnostic imaging was rated as good overall. We previously inspected diagnostic imaging jointly with outpatients so we cannot compare our new ratings directly with previous ratings. Safe, effective, caring and well-led were rated as good. Responsive was rated as requires improvement. In responsive, handovers were not as good as they should be, and reporting times for patients attending A&E were poor. However, the service met the individual needs of patients and some reporting times were good.
  • On this inspection we did not inspect medical care, surgery, critical care, or services for children and young people. The ratings we gave to these services on the previous inspection in 2016 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.
Inspection areas

Safe

Requires improvement

Updated 6 November 2018

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

  • Mandatory safety related training rates did not meet the target of 85%.
  • Some staff in the maternity service did not always follow infection prevention and control practices when cleaning patient equipment.
  • Equipment checks and stock replacement was not undertaken to a consistent level.
  • Medicines storage and management of waste arising from the use of pain relief gas was not maintained to a sufficient standard in maternity.
  • In diagnostic imaging services, there were no staff trained to level three child protection in line with national guidance.
  • In the emergency department, the median time from arrival to initial assessment was worse than the overall England median for the period from December 2017 to March 2018, although its performance during the reporting period, improved from 16 minutes down to 11 minutes.
  • For children’s care, staffing levels in the accident and emergency department did not meet the expected standards.
  • Staff did not always complete patient records to a consistent standard in the accident and emergency department and in end of life care services.
  • Although the service had made some safety improvements to the room for patients with mental health needs in the emergency department, there were remaining safety risks and a lack of risk assessments, particularly regarding ligature points and safety of furnishings.

However:

  • The services managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The pharmacy team were constantly looking at innovative ways to improve and promote medicine safety as well as ensuring patients received the right medicines.
  • There were embedded practices for keeping people safe and protected from avoidable harm. Staff understood their responsibilities to safeguard vulnerable people and used risk assessments and observational tools to protect patients from abuse. The service worked well with other agencies to achieve this. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • In most areas, the service managed infection prevention and control risks well. There was a clear process for ensuring equipment and the premises were cleaned effectively. Control measures were used to prevent the spread of infection.
  • Skill mix and caseloads of the specialist palliative care team were planned and reviewed to ensure people always received safe care and treatment. Urgent medical attention and advice could be sought and provided at different times of the day including out of hours.

Effective

Good

Updated 6 November 2018

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

  • Care and treatment was delivered in line with legislation, standards and evidence-based guidance.
  • The services monitored the effectiveness of care and treatment and used the findings to improve them. They generally compared local results with those of other services to learn from them.
  • The service made sure staff were competent for their roles. Managers monitored competence through appraisals, sharing learning and providing support for development.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
  • Patients in the accident and emergency department had a detailed assessment of their physical and mental health needs, which included the need for pain relief, nutrition and hydration. Treatment and care was planned and delivered in line with professional standards and guidance.
  • The accident and emergency department took part in national and local audits to monitor the effectiveness of adherence with best practice and patient outcomes. Actions were taken where local audit results identified the need for improvements.
  • Staff providing treatment and care had the right skills and experience to do so and had on-going access to development opportunities. They had access to clinical support and had their performance reviewed.
  • There was good multidisciplinary work and arrangements for patients to receive ongoing care. An assessment of patients’ needs and the referral or discharge arrangements was well established, and involved other clinical input as required.
  • Staff understood the principles of consent was and followed correct practices.

However:

  • Staff did not always make timely entries in patient records or there were gaps in records for care and treatment. Resuscitation decisions were still not always recorded appropriately and in line with national guidance. Best interest decisions and mental capacity assessments were not always carried out and documented where expected for patients receiving end of life care.
  • Diagnostic waiting times for investigations were below national standards, and the reporting of images was not always completed as the trust required.
  • Not all staff had received timely appraisals in line with trust policy.
  • There were significant delays and no longer-term plan for the timely completion of clinic letters following attendance in the outpatients’ departments.

Caring

Good

Updated 6 November 2018

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

  • Staff cared for patients with compassion. Observations and feedback from patients confirmed staff treated them well and with kindness.
  • Staff provided emotional support to patients to minimise their distress. Staff showed awareness of the emotional impact a patient’s care, treatment or condition would have on their well-being.
  • Staff involved patients and those close to them in decisions about their care and treatment. They explained procedures in a way they could understand.

Responsive

Good

Updated 6 November 2018

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

  • The trust planned and provided services in a way that met the needs of local people.
  • The maternity service worked hard to provide continuity of care and support on transition between antenatal, labour and birth and postnatal care during hospital stay. This was reflected in the integrated working patterns of midwives across the community and onto the unit.
  • There was good access to emergency and urgent care. People attending the department received care personalised to their needs, and accounted for their choices and decisions. The triage process focused on assigning patients to the right area and included consideration of ‘fitness to sit’ while waiting to be reviewed.

However:

  • The physical environment of some areas presented limitations and challenges to managing increasing demand.
  • Patients on occasion waited for up to 12 hours for a mental health assessment in the emergency department.
  • The trust policy was ambiguous about response times for complex complaints, and it was therefore unclear as to whether complaints were followed up within an appropriate timeframe.
  • Patients could not always access outpatient services as quickly as would be expected. Some services did not meet the national target for referral to treatment time.

  • Handover from other services did not always provide the radiology service staff with all the clinical information required for the staff to meet all the patients’ needs.

Well-led

Good

Updated 6 November 2018

Our rating of well-led improved. We rated it as good because:

  • The trust had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. Staff felt supported and valued in their role by their managers.
  • There were systems for performance management of staff through the annual appraisals which were aligned to the trust’s values. There were processes and procedures for managers to follow if staff did not meet performance expectations
  • The governance arrangements across most areas provided assurance that quality was central to the delivery of care to patients.
  • The service leads acted to proactively identify risks to the service which could impact on the quality for the care required. Staff took responsibility to ensure risks were minimised wherever possible without compromising the quality of care.
  • The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.
  • The service engaged with patients seeking feedback to improve the quality of the services provided.
  • There were good systems of accountability from pharmacy management to support governance and management of medicines throughout the trust.
  • Medicines safety risks were identified, actioned and shared appropriately within the trust and with external partners. Learning actions from medicines incidents and audits were shared and reviewed by service leads.
  • Medicines optimisation was thought of as part of an integrated system across the county, with the pharmacy department working closely with other providers to ensure patients received safe and effective medicines support.

However:

  • The outpatient department lacked a coordinated approach for the governance of risk management and quality improvement. It did not always demonstrate how this service learned from activities such as audit or measuring against similar services.
  • The IT systems were not always easy for staff to use, and information across the different systems could not always be linked.
Assessment of the use of resources

Use of resources summary

Good

Updated 6 November 2018

Combined rating