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Provider: Barnsley Hospital NHS Foundation Trust Good

Inspection Summary


Overall summary & rating

Good

Updated 14 March 2018

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

  • We rated effective, caring, responsive and well-led as good and safe as requires improvement.
  • In rating the trust we took into account the current ratings of the five services not inspected 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.
  • We rated well-led at the trust level as good.
Inspection areas

Safe

Requires improvement

Updated 14 March 2018

Our rating of safe stayed the same although we saw improvement in the safe domain in both medicine and surgery. We rated it as requires improvement because:

  • The provision of safe care for adults and children with mental health conditions was not robust. Environmental and patient risk assessments were not consistently undertaken or actioned. We saw areas of risk that the trust addressed when we raised this with them following the unannounced inspection.
  • At the time of our inspection, we were not assured that there were processes in place for the safe and effective management of sepsis in children. There was no specific documented pathway for staff to follow and despite there being sepsis information on the early warning score documentation this did not include all the red flags and there was no variation for different ages of children. However, following our unannounced inspection the trust produced a paediatric policy and pathway that now needs to be embedded in practice.
  • There remained a number of nursing staff vacancies across the trust, notably the provision of registered sick children’s nurses (RSCN) in the emergency department had improved but after midnight still did not meet the Royal College of Emergency Medicine Guidelines. Staffing levels had improved in orthopaedics since the last inspection and medical staffing had improved, notably in the emergency department.
  • We were not assured that the children’s safeguarding team had an oversight of all safeguarding cases, as there was no effective reporting system in place to report to this team. The safeguarding training data provided by the trust was not broken down for staff in specific areas, so we could not confirm who had appropriate levels of training.
  • Mandatory training in key skills was available to all staff and the uptake was generally good but medical staff training figures was significantly under the trust target of 90%.
  • Records standards were generally of a good and consistent standard but this was not always the case in the emergency department.
  • Temperature monitoring of medicines storage rooms was inconsistent.

However;

  • Staff recognised and managed patient incidents well. There was a proactive approach to infection prevention and control, medicines were managed well and equipment was appropriately checked.
  • Staff responded appropriately to the deteriorating patient and interventions were timely.

Effective

Good

Updated 14 March 2018

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

  • There was evidence of good multidisciplinary working. Staff with specialist skills and knowledge worked well together to benefit patients.
  • Appraisals for both medical and nursing staff were above the trust target.
  • We saw that staff had an understanding of consent, and gained consent prior to performing care.
  • Care and treatment was based on national guidance and there was evidence of the effectiveness of this through participation in national and local audits, reviews of outcomes and actions taken to improve services.
  • Patients told us their pain was well-managed. Staff made sure patients had enough to eat and drink to meet their needs and improve their health, although the menus were not fully child friendly.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support adults experiencing mental ill health and those who lacked capacity to make decisions about their care.
  • Since the last inspection, laparoscopic surgery services had been established and the trust was monitoring audit outcomes.
  • The ophthalmology and orthopaedic services were participating in the Get It Right First Time quality improvement initiative and initial feedback from an external review for ophthalmology was positive.

However;

  • Staff had not received specific training to help them support children and young people with a mental health condition.
  • Staff on the children’s ward had not received any training to use equipment to provide high flow nasal oxygen and staff had to be moved from the neonatal unit to care for those patients. Plans were in place to introduce this training.
  • There were some issues with trainees in respiratory medicine relating to the training and support they received. The senior management team were aware of these issues and were working with Health Education England and with the respiratory team to improve the training and support for junior doctors in this speciality.
  • At the time of the inspection, some but not all of the surgical specialties had dedicated time for a clinical education / clinical audit meeting.

Caring

Good

Updated 14 March 2018

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

  • Patients told us that they received compassionate care and that staff supported their emotional needs. Play specialists were available to alleviate children’s anxieties. Patients provided us with positive feedback about their care during our inspection.
  • Staff involved patients and those close to them in decisions about their care and treatment. Patients and relatives we spoke with told us they felt well informed by doctors and nursing staff about their condition, treatment options and plan of care.
  • Spiritual and pastoral support was available to patients from the hospital chaplaincy service.
  • There was one example of staff arranging a brass band to play for a patient at the end of life as it had been a major part of their life.
  • The trust’s friends and family test (FFT) response rate was around the England average and showed consistently positive results.

However:

  • We saw examples of patient care being completed in the corridor in the emergency department with no curtains or area for privacy provided. This was supported by the response from two of the six patients who said they did not want to be sitting in the corridor of the department. One patient felt that being cared for in the corridor impacted on their privacy and dignity.

Responsive

Good

Updated 14 March 2018

Our rating of responsive stayed the same overall; however in surgery it was noted to have improved and had outstanding features such as the use of technology and a proactive approach to understanding the needs of patients. We rated responsive as good because:

  • Services were planned in a way to meet the individual’s needs and the local population.
  • Children’s services were actively involved with the local Accountable Care System to plan care to reflect the needs of the local community. Waiting times for treatment and arrangements to admit, treat and discharge patients were in line with good practice.
  • The trust had applied measures to manage access and flow in the emergency department, these included providing consultants with the autonomy to admit patients through a strategy called ‘nine steps’ which created a clear pathway to be followed by clinicians.
  • There had been some improvements in meeting the Department of Health’s target of 95% of patients to be admitted, transferred or discharged within four hours of arrival in the emergency department. The trust’s own target of 94% was met for both quarter one and two in 2017.
  • The number of patients waiting between four and 12 hours from the decision to admit until being admitted had reduced significantly since December 2016 and was better than the England average. No patients had waited over 12 hours since January 2017.

  • Patients knew how to complain and staff knew how to deal with complaints they received. Complaints were investigated and learning was shared.

  • There was a lead nurse for dementia and a learning disability liaison specialist nurse. We saw that reasonable adjustments were made.
  • Between August 2016 and July 2017, the trust’s referral to treatment time (RTT) for admitted pathways for surgery was slightly better than the England average with a stable trend over the 12 months. The RTT for ophthalmology had particularly improved following the transfer of the service to the trust earlier in the year.
  • Since the last inspection, there had been changes to the configuration of surgical services to improve patient flow and reduce length of stay. Between June 2016 and May 2017, the average length of stay for elective and non-elective surgical patients was better than the England average.
  • Staff embraced the use of technology. A new IT clinical management system was in place. This contributed to improved and accessible information to manage clinical care. People’s individual needs and preferences were central to the planning and delivery of tailored services. Since the last inspection, managers had made changes to the configuration of services to improve patient flow and reduce length of stay.
  • The ophthalmology and orthopaedic services were participating in the Get It Right First Time quality improvement initiative and initial feedback from an external review for ophthalmology was positive.

However;

  • Despite the measures in place to manage flow through the hospital, we observed long waits for some patients referred directly to the acute medical unit from GP’s.
  • Six nursing staff we spoke with on three surgical wards with medical outlying patients told us they did not always know which consultant was responsible for which patient despite a daily list with this detail being circulated.

Well-led

Good

Updated 14 March 2018

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

  • We found effective leadership throughout the services at ward level and above. Senior leadership had been strengthened since the last inspection. Staff spoke highly of their line managers and told us they felt listened to.
  • The clinical business units had a clear strategy, which was linked to the trust’s strategic plan and aimed to meet the needs of the local population.
  • We found a positive culture with staff being open, honest, and willing to share information with us on inspection. Staff were loyal to the organisation, but were prepared to challenge leaders if they thought patient safety was compromised. We found good relationships between staff and they told us they pulled together to overcome challenges.
  • There was an effective governance structure in place supported by detailed performance reporting and risk management. Managers monitored performance and used the results to help improve care. Risks that could not be managed locally were escalated to the relevant clinical business units’ risk register. Risks could be escalated further to the corporate risk register if necessary.
  • There was a comprehensive monthly performance report for the clinical business units, which included robust performance measures and information about the quality of patient care. The report enabled the senior management team to have oversight of any areas where performance was lacking and required improvement and areas in which improvements had been made.
  • We found evidence of good engagement with patients and carers, staff and local organisations to plan and manage services. There was effective collaborative working with partner organisations.
  • The chief executive was relaunching the staff engagement group to address the variance in staff engagement across the trust.
  • We found a culture of continuous improvement and service development. There was a commitment to developing staff and improving services for patients.

However;

  • The children’s service did not have clear assurance that staffing on the children’s ward was appropriate as they did not use an acuity tool to assess staffing needs and were not using Royal College of Nursing (RCN) guidance for recommended ratios of staff to patients.