Bedfordshire Hospitals NHS Foundation Trust

Luton and Dunstable hospital is part of Luton and Dunstable University Hospital NHS Foundation Trust and it is a medium size acute hospital comprising all acute services. There were approximately 679 beds at this trust including 544 general and acute, 76 maternity and 22 critical care and high dependency beds.

We carried out this inspection as part of our comprehensive inspection programme, which took place during 19 to 21 January 2016. We undertook two unannounced inspections to this hospital on 27 January and 4 February 2016.

We inspected eight core services, and rated three as good overall being surgery, maternity and gynaecology, and end of life care. Three core services were rated as outstanding being urgent and emergency care, children, young people and families and outpatients and diagnostics. Two services, medicine and critical care, were rated as requiring improvement.

We rated the Luton and Dunstable Hospital as good for two of the five key questions for effective and caring. We rated two key questions, responsiveness and well led, as being outstanding. For well led the trust had three outstanding ratings, four good ratings and one core service that required improvement, against our aggregation rules this would be rated as good, however, during our quality review in order to reflect the positive findings this was overruled and well led was rated as outstanding. We rated one key question, safety, as requiring improvement. Overall, we rated the hospital as good.

Overall, we rated the hospital as good.

Our key findings were as follows:

• Staff interactions with patients were positive and showed compassion and empathy.
• Feedback from patients was generally very positive.
• Staff morale was generally good and dedication and staff commitment to providing positive outcomes for all patients was high.
• Staff reported incidents appropriately, and learning from incidents was shared effectively.
• Staff we spoke with knew what duty of candour meant for them in practice and was evidenced by the way incidents had been managed.
• Most environments we observed were visibly clean and most staff followed infection control procedures. Equipment had been generally well maintained.
• Safeguarding systems were in place to ensure vulnerable adults and children were protected from abuse and staff followed these procedures.
• Appropriate systems for the storage and handling of medicines were generally in place.
• Nurse staffing levels were variable during the days of the inspection, although in all areas, patients’ needs were being met.
• Medical staffing was generally appropriate and there was good emergency cover.
• Working towards providing a seven day service was evident in most areas.
• Patients generally had access to services seven days a week, and were cared for by a multidisciplinary team working in a co-ordinated way.
• Patients’ needs were generally assessed and their care and treatment was delivered following local and national guidance for best practice.
• Outcomes for patients were often better than average.
• Pain assessment and management was effective in most areas.
• Most patients’ nutritional needs were assessed effectively and met.
• Staff generally had appropriate training to ensure they had the necessary skills and competence to look after patients. Staff were suitably qualified and skilled to carry out their roles effectively and in line with best practice.
• Services were generally responsive to the needs of patients who used the services.
• The emergency department consistently met the four hour target for referral, discharge or admission of patients in the emergency department which was recognised at a national level.
• The number of bed moves of more than one was low within the hospital compared to the national average.
• The trust’s average length of stay was lower than the England average for elective admissions.
• There was support for vulnerable people, such as people living with dementia and mental health problems.
• We saw there were systems in place to monitor medical outliers effectively throughout the trust.
• We found surgical services were responsive to people’s needs and outcomes for patients were good.
• The service regularly carried out operations on a Saturday to meet local need.
• Surgical care and treatment for patients having a fractured neck of femur was comparable to the national average.
• Cancellations of operations were similar to the national average
• The maternity service held stage two baby friendly accreditation
• We found there was a real commitment to work as a multidisciplinary team delivering a patient centred and high quality service in the children’s and young people’s service. Neonates, children and young people were at the centre of the service and the highest quality care was a priority for staff.
• The emergency department had an established and experienced leadership team who were visible and approachable to staff at all levels and had a clear and committed focus to drive improvements in patient safety and the quality of care and treatment throughout the department.
• Visionary leadership from the board to all areas of ED resulted in the ownership of the emergency pathway throughout the hospital. The leadership team in ED over the past five years had transformed the service from one of the worst performing ED’s in the country, to one of best performing nationally. This significant improvement in performance, despite a continuing rise in year on year attendances, had been recognised at a national level by senior NHS and government leaders.
• The specialist palliative care team had a clear vision in place to deliver good quality services and care to patients. There was a long term strategy in place with clear objectives.
• Waiting times for diagnostic procedures was lower than England average.
• The trust consistently met the referral to treatment standards over time.
• There were effective systems for identifying and managing the risks at the team, directorate and organisation levels. The management of risks within services was generally robust and risks had been addressed in a timely manner.
• Generally, there were effective procedures in place for managing complaints.
• There was a strong culture of local team working across most areas we visited.
• Leaders in all services were visible in and the majority of staff felt valued and supported.

We saw several areas of outstanding practice including:

• The emergency department had a robust process for managing the access and flow in the department which was a multi-disciplinary approach to patient care and had helped to achieve the four hour target consistently since 2012 which was recognised at a national level.
• The dementia nurse specialist for the hospital was licensed to deliver the virtual dementia tour to hospital trust staff. The virtual tour gave staff an experience and insight to what it is like living with dementia and this was very popular and gave staff an understanding of people’s individual needs.
• We saw strong, committed leadership from senior management within the surgical division. The senior staff were responsive, supportive, accessible and available to support staff on a day to day basis and during challenging situations.
• Implementation of Super Saturday for elective surgery lists helped to reduce waiting lists. Two separate general surgeons were on call to meet patient needs.
• The hospital had an Endometriosis Regional Centre, which was accredited for advanced endometriosis surgery within the region.
• Paediatric services had developed new models of care for the child in the right place, with the right staff, across tertiary, secondary and primary care boundaries.
• There was an exemplary holistic approach to assessing, planning and delivering care and treatment to patients in the children, young people and families’ service.
• There were a range of examples of how, as an integrated service, children’s services were able to meet the complex needs of children and young people. The level of information given to parents was often in depth and at times complex. Staff managed to communicate with the parents in a way they could understand.
• The neonatal unit had been at the forefront of introducing new treatments and procedures including nitrous oxide therapy, high frequency ventilation and cooling therapy which had resulted in a significant reduction in its mortality and morbidity. The use of innovative ways of working with almost 24 hours a day, seven days a week consultant cover due to the introduction of new consultants and meeting European Working Time Directives had led to the team being able to treat more complex babies.
• There was a range of examples of working collaboratively and the children’s and young people’s service used innovative and efficient ways to deliver more joined-up care to people who used services. We observed the service prided itself on meeting the transitional needs of young people living with chronic conditions or disabilities through engagement with adult and community services to improve transition from children and young people’s services to adult services.
• The outpatients’ division had very clear leadership, governance and culture which were used to drive and improve the delivery of quality person-centred care. Divisional leads were frequently involved with patient care and problem solving to ensure smooth patient pathway through departments.
• Involvement of clinical staff in the development and design of the orthopaedic hub and breast screening unit have enabled clinical needs to be met and promoted a positive patient experience.
• Joint ward rounds with pharmacy staff and ward based clinicians promoted shared learning promoting an improved patient experience and possibly improved outcome.

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

• The trust took immediate actions during the inspection to address areas of concern regarding the staffing levels, medicines’ management and bed space concerns in the high dependency unit.
• The trust took immediate action during the inspection regarding ensuring all executive team members complied with the fit and proper person requirement.

In addition the trust should:

• Ensure that all staff complete mandatory training in line with trust targets, including conflict resolution training.
• Ensure that all relevant staff have the necessary level of safeguarding training.
• Ensure all staff have had an annual appraisal.
• Ensure that information for people who use this service can obtain information in a variety of languages and signage reflects the diversity of the local community.
• Ensure that all services take part in relevant national audits to allow them to be benchmarked amongst their peers and to drive improvements in a timely way.
• Ensure the high dependency unit contributes to the Intensive Care National Audit and Research Centre (ICNARC) database, to allow benchmarking against similar services.
• Ensure the time to initial clinical assessment performance information is monitored to give an effective oversight of performance.
• Ensure that all handover documents are completed within the emergency assessment unit.
• Ensure there are consistent processes to enable patients to self-administer their medicines.
• Ensure that there is a standardised consultant led board rounds implemented within the medicine service.
• Ensure that patients receive the recommended input from therapists.
• Ensure environmental repairs are completed in ward areas and kitchen areas.
• Ensure that defined cleaning schedules and standards are in place for all equipment.
• Review the consent policy and process to ensure confirmation of consent is sought and clearly documented.
• Ensure patients have their venous thromboembolism (VTE) re-assessment 24 hours after admission
• Continue to ensure lessons learnt and actions taken from never events, incidents and complaints are shared across all staff groups.
• Review the security systems at maternity ward entrances to further improve the safety of women and their babies on the unit.
• Improve the timing of reporting incidents to the National Reporting and Learning System (NRLS).
• Establish parameters for the gynaecology performance dashboard to enable the service to identify areas of compliance that needed addressing.
• Establish appropriate support is available to parents in the maternity unit following the death of their baby.
• Ensure effective collection and oversight of the end of life care service with regards to rapid discharge performance and preferred place of death for patients’.
• Provide adequate waiting area facilities for patient on beds or trolleys within diagnostic areas.
• Provide appropriate facilities to ensure privacy and dignity is maintained for patients who wear gowns for clinical investigations.
• Review plaster technician facilities to ensure appropriate storage and treatment areas are available across the trust.

Professor Sir Mike Richards

Chief Inspector of Hospitals