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Provider: Chesterfield Royal Hospital NHS Foundation Trust Good

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Inspection Summary


Overall summary & rating

Good

Updated 17 May 2017

Chesterfield Royal Hospital NHS Foundation Trust was one of the first hospitals in the country to become a Foundation Trust in January 2005, and serves a population of around 441,000 across the Bolsover, Chesterfield, Derbyshire Dales and North Amber Valley, High Peak and North East Derbyshire districts.

Chesterfield Royal Hospital is a medium sized District General Hospital based a mile outside the centre of Chesterfield in an area known as Calow. The hospital is the town’s largest employer with a workforce in excess of 3,500 staff and has a total revenue of £221.2 million.

Chesterfield Royal Hospitals NHS Foundation Trust is registered to provide the following Regulated Activities:

  • Assessment or medical treatment for persons detained under the Mental Health Act 1983
  • Diagnostic and screening procedures
  • Family Planning
  • Management of supply of blood and blood derived products
  • Maternity and midwifery services
  • Surgical Procedures
  • Termination of pregnancies
  • Treatment of disease, disorder or injury

Chesterfield Royal Hospital NHS Foundation Trust was inspected on 20 February 2017. This inspection was a focused inspection following a comprehensive inspection in April 2015. The purpose of this inspection was to review how the provider was leading the organisation.

Our key findings were as follows:

  • The trust had a clear vision of where it wanted to be which was articulated by staff.
  • There were clear lines of accountability and appropriate board sub committee’s in place.
  • Information being provided to the board was relevant, timely and the narrative statements in reports supported the quantitative data being presented.
  • The board used an integrated assurance system which provided the board with assurance of quality and performance. We reviewed the papers for the board and found papers to contain key information about performance and assurance. They were well organised and structured and actions monitored.
  • Risks were reported to the trust board through the board assurance framework and the significant risk register, with the top risks being reviewed by the board at every meeting.
  • Senior leaders were knowledgeable about the risks for the organisation.
  • The leadership team were very cohesive and worked well together. They were clear about the direction of the trust and were committed to delivering the strategic vision.
  • Staff told us there had continued to be a positive culture change in the organisation and staff were supported to develop. Leadership development had continued and the programme was highly valued by staff.
  • There were systems in place for staff to be able to speak up. We did not receive any concerns from staff during this inspection in relation to bullying or harassment. The staff survey results for 2016 echoed this and the percentage of staff reporting they experienced bullying or abuse by staff was much better than the national average.
  • The staff survey response rate was low with 34% of respondents completing the survey compared with 56% in 2015.
  • The results of the 2016 NHS staff survey were disappointing. Their overall staff engagement score was 3.71 which put them in the lowest (worst) 20% when compared with trusts of a similar type. There had been no improvement in this score for the past four consecutive years.

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

Importantly, the trust should:

  • The trust should take action to increase the response rate for the annual NHS Staff Survey.
  • The trust should take action to improve the overall staff engagement score in the NHS Staff Survey.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 4 August 2015

Overall we rated safety of the services in the trust as ‘requires improvement’. For specific information please refer to the individual reports for Chesterfield Royal Hospital and Community health services for children, young people and families.

We made judgements about nine services. Of those, three were judged to be good, with the remaining six requiring improvement, therefore the trust was not consistently delivering good standards of safety in all areas.

Staff knew how to report incidents. Our analysis of the trust’s incidents showed they reported a similar number of incidents compared with other similar trusts. Although there was evidence of learning within the services we inspected, more work was needed to ensure lessons were learnt across the entire organisation. The foundations on which to build this were in place.

Nursing staffing levels were within safe levels during the day time but many staff expressed concerns about the numbers of staff available at night. We observed the night nursing staff to be under pressure to deliver care in some areas. There had already been a review of staffing at night, and the levels on duty were the planned levels in most cases, but we raised our concerns with the trust during our inspection. The executive team took immediate action to review their night time staffing levels. We were also concerned about the availability of consultants to review patients in the high dependency unit. We raised this with the trust during our inspection and they took remedial action to mitigate the risks to patients.

Duty of Candour

  • The trust was aware of its role in relation to the Duty of Candour regulation that was introduced in November 2014. The intention of this regulation is to ensure that providers are open and transparent when things have gone wrong. It sets out specific requirements providers must follow.

  • Before this new regulation came into force, the trust had reviewed its “Being open,” policy and the tools that it already had in place on its website. This meant staff were able to access appropriate guidance and letter templates. When incidents were reported onto the trust’s system, an automatic reminder about the duty of candour procedures was provided. The executive team and senior managers in the organisation were aware of the duty of candour and could give examples of being open with patients.

Safeguarding

  • Overall, staff told us they felt confident reporting safeguarding concerns and were given support with this. Policies and procedures for safeguarding were in place and were being updated to reflect changes in national guidance. There was a non-executive lead for safeguarding adults but not for children.
  • Staff were able to tell us how they would report concerns through the trust’s procedures and they knew who they should contact.
  • We spoke with the professional leads for safeguarding and learning disability care. They provided support for staff Monday to Friday. They did not provide an out of hours’ service, but senior managers supported ward staff at night and weekends. There was a new system that alerted staff to patients with a learning disability, in line with national recommendations. This made sure staff were aware of their individual needs and were able to support them appropriately.

Incidents

  • There were 5649 incidents reported in the previous 12 months. The number of incidents reported was comparable to that of other similar trusts. Ninety seven percent of all incidents reported were classified as no or low harm. The top five categories of reported incidents were:

    • Patient accident (30% of all incidents)
    • Infection control (14 % of all incidents)
    • Documentation including electronic & paper records, identification and drug charts (9% of all incidents)
    • Medication (8% of all incidents)
    • Treatment, procedure (8.2% of all incidents)

  • Throughout the inspection we found staff knew how to report incidents using the trust wide electronic system. There were inconsistencies within the services about how much feedback staff received. In some areas, such as the emergency department and in medicine we found staff at all levels received feedback from incidents, but staff working in the maternity and outpatient services were less clear about how they received feedback when they had reported an incident. Giving feedback is important because staff need to see that the effort they make to report an incident is worthwhile, and that things change as a result. Without feedback, reporting can be seen as a bureaucratic process, rather than a mechanism to make things safer.

  • We found examples in all core services of lessons being learnt from incidents. There was further room for improvement, but the foundations on which to build this were in place.

Nursing, Midwifery and Therapy Staffing.

  • Nursing staff numbers was acknowledged as a major risk for the trust. In common with many other trusts in England there were difficulties recruiting appropriately qualified and experienced nurses. The trust had been actively recruiting nursing staff, and they had recruited nurses from overseas. The recruitment process had been reviewed, and changes had meant the time taken to recruit had been reduced. There were recruitment campaigns in place to try and fill vacant posts. The Royal College of Nursing told us problems with recruitment and staff turnover were a long standing issue for the trust.

  • Nurse staffing levels were assessed using a nationally recognised assessment tool. This had led to extra investment in the nursing establishment. At the time of our inspection many areas were in the process of collecting more data to inform a further nurse staffing review. The Director of Nursing and Patient Care reported information on nurse staffing levels to the trust board on a regular basis. Data on sickness absence rates, use of agency staffing, and staff turnover were reported to the trust board in the integrated performance report. We found generally, the staffing levels were in accordance with the levels that had been assessed as being required by the trust.

  • The National Institute of Health and Care Excellence (NICE) guidance on nursing staffing levels indicates that there should be a ratio of one registered nurse to eight patients in acute inpatient areas. The guidance does not differentiate between day and night time. We found the trust generally met the ratios of one to eight nurses during the day but there were less registered staff on duty during the night. Some wards had ratios of one registered nurse to 15 patients during the night. Whilst it is accepted that the needs of patients may be less during the night, staff didn’t feel they were always able to meet patients’ needs and some nurses told us they didn’t think it was safe. We visited the hospital during the night to look at nurse staffing levels. We didn’t find evidence that patients’ needs were not met; however, the administration of medicines was still in progress at 11.30pm. Staff told us they were often unable to take their breaks at night and intentional rounding records showed that checks on patients’ comfort were over an hour later than planned.

  • During our inspection we told the leaders of the organisation that staff were concerned about night staffing levels. Since then, we have received regular updates from the Director of Nursing and Patient Care about night staffing, and the actions the trust have taken. They undertook a look back exercise of night staffing incidents and staffing levels between October 2014 and March 2014, but did not find any correlation between these. They planned to undertake a further skill mix review and have begun implementing a red flag system for staff to escalate concerns about staffing levels. Senior nurses were focusing on the night shift and reviewing staffing and care contact time.

  • Guidance issued by the Royal College of Nursing suggests there should be a band six registered sick children’s nurse on duty within inpatient areas. Although this is not mandatory, it is recognised best practice. The trust was unable to provide a band six nurse on each shift and we did not see any plans in place to address this. There were the appropriate numbers of skilled nurses working in the neonatal unit.

  • A review of staffing levels in midwifery had taken place and the midwifery staffing establishment had increased. The national recommended birth to midwife ratio is one midwife to 28 patients. The trust had a rate of one midwife to 30 which was worse than the nationally recommended ratio but was comparable with other maternity services across the region. In addition, there was a supernumery midwife on duty on every shift who could support where the need was greatest. The supernumery midwife was not included in the midwife to birth ratio. There was an escalation process in place for maternity staffing, and the staffing position was monitored every four hours. The staffing rota was planned with the supervisor having supernumery status, but would help out with care at times of higher activity or patient acuity.

  • Therapy leads told us they used capacity modelling to ensure sufficient staffing. They told us it was difficult to measure the unmet need, especially with seven day working developing. All therapy teams said they had a stable workforce and there was a low turnover of staff. Therapy staffing was under funded currently and could not meet changes in demand. Dietetics was not able to meet the previously trust agreed new inpatient waiting times within their current staffing levels. There were insufficient resources for paediatric dietetic staff. Occupational Therapy and Physiotherapy had about 10% vacancies, and did not have good experiences with locums which created additional pressures on their own staff.

Medical Staffing

  • The trust, in common with many other trusts in England had difficulties in recruiting some medical staff.

  • Within children’s services there were not enough paediatric consultants to provide on-site cover until 10pm. It is well known that the peak admission time for paediatrics is the early evening, between 5-10pm, however the trusts peak time for activity was up to 6.30pm. Paediatric consultant presence was until 5pm, but we were told the consultants often stayed on duty to cover the workload. They were aware of the risks to patients and there was a registrar available 24 hours a day. An additional paediatric consultant who was due to come into post in October 2015 had been appointed. Consultant staff were on call out of hours and could all get to the hospital within 30 minutes. Locums were used to fill any gaps in the rota.

  • There was a lack of registrar grade doctors in some areas across the trust but the trust employed a higher ratio of consultants and junior doctors than the England average.

  • In the medical service there were fewer consultants employed than the England average, but there were more junior and middle grade doctors. This meant there was a risk that consultants were not always able to supervise the less senior doctors. However, the junior doctors we spoke with reported receiving good support from consultants, including out of hours.

  • There were sufficient numbers of intensive care consultants. We were concerned about the availability of consultants to review patients in the high dependency unit. We raised this with the trust during our inspection and they took remedial action to mitigate risks.

  • There were gaps in the number of junior doctors within the maternity service and this was on the divisions risk register. Locums were used to fill gaps.

Effective

Good

Updated 4 August 2015

Overall we rated the effectiveness of the services in the trust as good. For specific information please refer to the individual reports for Chesterfield Royal Hospital and Community health services for children, young people and families.

We made judgements about eight services. Of those, six were judged to be good, with the remaining two requiring improvement. We did not rate the effectiveness of the outpatient and diagnostic service as we are currently not confident that we are collecting sufficient evidence.

We found more work was needed to ensure the “Do Not Attempt Cardio Pulmonary Resuscitation” (DNACPR) forms were completed properly. Approximately 20% of the forms we looked at were incomplete. They did not indicate where discussions had taken place with the patient, and did not contain mental capacity assessments where a patient was recorded as lacking capacity to consent. The trust’s own audit showed performance had deteriorated since 2014.

The trust participated in a range of national audits, and in many cases the results were good. Where improvements were needed the trust had action plans in place.

Evidence based care and treatment

  • The endoscopy department had been awarded Joint Advisory Group (JAG) accreditation in February 2015. The accreditation process assesses the unit to ensure they meet best practice guidelines. This meant that the endoscopy department was operating within this guidance.

  • Guidance from authorities such as the Royal Colleges and the National Institute for Health and Care Excellence (NICE) were used to inform care. Some of the guidelines were in need of updating across the trust.

  • Some clinical guidelines, for example the anti-microbial prescribing guidelines, were available to junior doctors via mobile phone applications. This meant that that current guidance was instantly available for staff to reference.

  • The trust were working in accordance with the IRMER guidelines (Ionising Radiation Medical Exposure Regulations 2000). These regulations ensure that the use of X-rays are in the patient’s best interest and give clear definition to those who refer, take, or make, a clinical decision that radiographs are required for diagnosis.

Patient outcomes

  • Monitoring by CQC had not identified any areas where medical care services at Chesterfield Royal Hospital would be considered a statistical outlier when compared with other hospitals. The trust reported data for mortality indicators, the summary hospital-level mortality indicator (SHMI) and hospital standardised mortality ratio (HSMR). These indicate if more patients were dying than would be expected given the characteristics of the patients treated there. The figures for the trust were as expected.

  • The trust contributed to all national audits for which it was eligible for. We found the trust had action plans in place to take forward areas for improvement from the national audits. These actions were underway and, in some cases, had led to improvements in care.

Multidisciplinary working

  • Generally we found teams and services worked well together and we found some good examples of multidisciplinary working, particularly in the emergency department, the stroke unit and in children’s services.

  • Wards teams had access to the full range of allied health professionals, and team members described collaborative working practices. Medical and nursing staff of all grades described excellent working relationships between healthcare professionals.

  • Staff identified there were effective working relationships between children and adolescent mental health services (CAMHS) professionals and the paediatricians. CAMHS professionals visited Nightingale ward daily when a child with mental health concerns had been admitted.

  • There were transition arrangements in place for children moving into adult services.

Consent, Mental Capacity Act & Deprivation of Liberty safeguards

  • Staff sought consent from patients before undertaking treatments and patient consent was recorded in the records we reviewed. Patients we spoke with confirmed they had been given sufficient information to help them to decide to proceed with investigations and surgical procedures.

  • Mental Capacity Assessment, and Deprivation of Liberty Safeguards were included as part of mandatory training.

  • Patients admitted to adult wards at the trust who were deemed to be at risk of cardiac arrest were assessed within 24 hours of admission. Where a decision was taken that a ‘Do Not Attempt Cardio Pulmonary Resuscitation’ (DNACPR) order was appropriate then a DNACPR form was completed and placed at the front of the patient records. A trust wide audit of DNACPR forms dated January 2015 showed the percentage of forms that were complete was 10% (12 out of 123). The audit showed how performance in this area had significantly deteriorated over the previous year. The audit also showed 59% per cent of patients were deemed not to have capacity to contribute to the decision regarding DNACPR, but of these, only 24% of forms showed evidence that a capacity assessment had been completed. This meant patients had DNACPRs in place but it was unclear how the decision had been made on their behalf. During our inspection we reviewed 31 DNACPR forms across ten clinical areas. Our review showed 25 out of 31 DNACPR forms had been fully completed and included an assessment of the patient’s capacity to consent to the DNACPR where required. Approximately 20% of the forms we looked at were incomplete. They did not indicate where discussion had taken place with the patient and did not contain mental capacity assessments where a patient was recorded as lacking capacity to consent.

Caring

Good

Updated 4 August 2015

Overall we rated caring at the trust to be “good.” For specific information please refer to the reports for Chesterfield Royal Hospital and Community Health Services for Children and Young People. We made nine separate judgements about the level of caring in the organisation. All of the services were judged to be good.

Staff provided care with kindness and respect. We saw some good interactions with patients. Mortuary staff were respectful of patients who had deceased.

Compassionate care

  • Patients expressed a high level of satisfaction with the care and treatment provided when we spoke with them during our inspection. During our inspection we observed that patients were always treated with kindness and respect. Their privacy and dignity were maintained; for instance we saw that care interventions were carried out behind closed doors or curtains, and staff asked before they entered. We carried out an observation on Basil ward using the Short Observation Framework for Inspection (SOFI) tool. This helps us understand people’s experience of care when they are unable to communicate with us verbally. We saw that out of 21 observed interactions only two were assessed as poor interactions. Eight (38%) were assessed as being of good quality and the remainder as neutral. During the observation, none of the patients studied were assessed as being in a negative mood state at any time. We saw some examples of exceptional care. For example, we saw that on Durrant ward, a healthcare assistant had come to the ward in their own time to support a person living with dementia.

  • Mortuary services demonstrated an understanding and respect of patients’ cultural and religious needs. The bereavement service supported the trust to provide a sensitive and specialised service for relatives when a patient died. The bereavement service were involved in the immediate period following death and provided practical help and information to deceased relatives

Understanding and involvement of patients and those close to them

  • We saw that the “This is Me” assessment document produced by the Alzheimer’s Society was widely used to notify staff about the social history of people living with dementia and to alert staff to care preferences, and any special considerations relevant to their care.

  • We observed staff communicate with patients in an appropriate way. Staff adapted their communication to meet the needs of patients, for example one consultant in the emergency department used short simple sentences to communicate with a patient with no speech but effective hearing. However, one relative told us that staff had not recognised that a patient had a hearing impairment, despite being informed by relatives.

  • Most patients we spoke with felt they understood their care options and were given enough information about their condition. Detailed information was available for patients about their procedure and what to expect. They were given contact numbers of specialist nurses to ensure they had adequate support on discharge.

  • Patient diaries were used in the Intensive Therapy Unit (ITU) to help patients improve their memories of their stay. If a patient passed away, the diaries were given to families to assist in the bereavement process. Patients were not routinely offered a follow up appointment to support emotional and psychological recovery following an admission to the ITU. One consultant and a nurse were able to see patients if requested to do so, but this service was not supported in business plans.
  • The maternity service offered a “Birth Afterthoughts” service for women who expressed concerns about their birthing experience or for women who required specific emotional support following the birth of their baby.

  • Following late termination of pregnancy (after thirteen weeks gestation) patients who stayed overnight in hospital were cared for in side rooms adjacent to the maternity ward. At night the doors between the wards were left open so that midwives could provide support to the surgical nurse caring for these patients. A senior member of staff in the women’s health unit told us that patients could hear the babies cry on the ward and that this upset those patients who had had a termination of pregnancy. There was no plan in place to mitigate the emotional trauma this could have on patients.

Emotional support

  • Patients and their relatives and friends received emotional support during their stay in hospital. The hospital chaplaincy service and bereavement service provided support for patients and relatives.

Responsive

Requires improvement

Updated 4 August 2015

Overall we rated responsiveness at the trust to “require improvement.” For specific information please refer to the reports for Chesterfield Royal Hospital and Community Health Services for Children and Young People. We made nine separate judgements about the level of responsiveness in the organisation. Six services were judged to be good, and three required improvement.

The trust had made improvements to its complaints handling and the Patients Association had carried out a review and made recommendations which the trust were acting upon. Although it was better than the England average, half of the 16 people surveyed by the Patients Association thought their complaint had been poorly handled. We found some examples where the response letter sent to complainants could be further improved.

The trust had a policy and procedure in place to make sure patients living with dementia were identified and supported and there was trust wide action to improve the management and care of this group of patients. Refurbishments to ward areas had considered making them more dementia friendly in line with national best practice and we saw some good practice. However, the environment of the ward designated as a ward specialising in the care of people living with dementia was not dementia friendly.

Service planning and delivery to meet the needs of local people

  • The trust worked with other organisations in North Derbyshire to provide services that met the needs of its population.

  • Over 70,000 patients attended the emergency department each year. When it was built in the 1980s the design was to accommodate approximately 40,000 patients annually. Senior managers were aware of the challenges this created, and that the facilities were not appropriate for the current attendances. The risk was entered on the divisional risk register. The trust was working with partners on funding and the design of an urgent care village to replace the current department. At the time of our inspection a funding application was ready to go to the trust board.

  • The discharge lounge ran a “Home from Hospital” service in partnership with the British Red Cross. This enabled patients to be transported home by the Red Cross, to be settled at home and have any immediate practical tasks such shopping or snack preparation carried out. This showed how the hospital was committed to meeting the needs of local people by working in partnership with the voluntary sector.

Meeting people's individual needs

  • The trust employed a liaison nurse for patients with a learning disability and we saw her supporting patients and staff on the wards we inspected. We found some good work in the endoscopy unit where the learning disability nurse attended with patients to ensure they received the appropriate support and their needs were met. The trust also had a video for patients with a learning disability which showed them what to expect when attending the hospital for an x-ray. The video was available on the internet. The trust’s website had information in easy read formats.

  • The trust had a policy and procedure in place to make sure patients living with dementia were identified and supported. There was a trust wide plan in place to improve the management and care of patients living with dementia in the hospital. A dementia lead for the trust had been in post since July 2013.

  • There were arrangements to ensure all patients aged over 75 years were screened for dementia. Screening rates were running at almost 100%. Dementia assessment nurses carried out assessments in conjunction with medical staff. Reminiscence packs were available via the library to assist in the care of people living with dementia and we saw references to these in patients’ records.

  • An audit of the environment to assess the extent to which it could be considered dementia friendly was carried out in late 2012 using a validated tool developed by the King’s Fund organisation. This had led to agreement on the principles of design for future ward upgrades to ensure they met the principles of dementia friendly design. Although some areas had been upgraded, the ward that was designated as a ward specialising in the care of people living with dementia was not dementia friendly.

  • Dementia awareness training was part of the staff induction programme and it was also included in the trust’s mandatory training requirements. Training was also being provided to non-clinical staff. In addition, there was a specific training programme for health care assistants run in conjunction with a University. The trust was also using “Barbara’s Story,” a DVD of a patient’s experience living with dementia in hospital. The story was used to prompt discussion with staff, and linked to the trusts own values.

  • The emergency department recognised the specific needs of patients with mental health illness. In partnership with the local mental health trust they were able to provide 24 hour access to a mental health liaison team. There were no concerns raised about how this service was working.

  • Staff in the maternity service were aware of the learning disabilities liaison nurse and the safeguarding midwife, who both provided advice and support for people in vulnerable circumstances. They also supported people who lacked capacity to make decisions about their care. There was a specialist midwife with responsibility for complex care relating to alcohol abuse, drug abuse, safeguarding, and teenage pregnancy. Staff told us that they would refer women if required.

  • We held a focus group for the gypsy travelling community who were positive about their care experiences at Chesterfield Royal Hospital. They told us that staff at the hospital understood their cultural needs and that no matter where they were in the East Midlands this was their hospital of choice. They described how the hospital understood their approaches to cleanliness and their desire as a family to be actively involved in a person’s care.

  • There was a genuine commitment to reducing delayed discharges. We saw that the in the discharge lounge a “Home from Hospital” service was run in partnership with the British Red Cross. This enabled patients to be transported home by the Red Cross, to be settled at home and have any immediate practical tasks such shopping or snack preparation carried out. This showed how the hospital was committed to meeting the needs of local people by working in partnership with the voluntary sector.

  • Overall, we found that there were arrangements to ensure patients were cared for in single sex facilities, and had access to single sex washing and toilet facilities.

Access and flow

  • Like many trusts in England, the hospital was busy and the trust had faced challenges in access and flow especially during the winter months. Bed occupancy in the hospital had been consistently over 90% which was above the England average of 88%. In the medical division, bed occupancy was 95.5% in February 2015. It is generally accepted that when bed occupancy goes over 85% it can start to affect the quality of care provided to patients and the running of the hospital. There was a planned approach to dealing with the increases in admissions to hospital over the winter period and an additional ward was opened. We noted this ward had been staffed by moving some existing substantive staff onto this ward so there was not a total reliance on bank or agency staff.

  • Patients spent less time in hospital in medical care services that the national average. For emergency admissions the average length of stay was slightly below the England averages, but in stroke medicine it was much lower at 6.1 days against an average of 12 days.

  • We found that due to issues with patient flow, medical patients were transferred or admitted to beds that were designated for other specialities. During the period October to December 2014 there were up to 109 patients who had to be cared for in other areas. During one of the days of our inspection there were 29 patients on a different ward. This showed that medical care services were unable to care for patients within their allocated bed base. One medical ward had closed in 2014 with a reduction of about 30 beds, and a planned relocation of a ward in the future would result in the loss of another 12 medical beds. We were told that patients whose medical needs were not particularly complex and were stable were transferred to non-specialty beds. However, we reviewed the medical records of two outlying patients and considered both inappropriate transfers due to the complexity of their needs. For example, one patient was experiencing symptoms of a gastric bleed, and we noted that a requested doctor review took four hours.

  • During the period April – December 2014, 36% of patients experienced one ward move. This showed that not all patients were treated in the correct speciality ward for the entirety of their stay. We spoke with nursing staff and therapists who told us they felt that outlying patients received sub-optimal medical care. For example, they told us that doctors were difficult to contact and that consultant reviews were less likely to occur daily. We also found if a patient had to move into a non-speciality bed, they did not necessarily keep the same consultant. We raised this with the trust at the time of our inspection and this practice was stopped immediately.

  • The trust had no monitoring in place to track the times that patients moved wards. We spoke with four patients who told us they had been moved onto a different ward after 11pm at night. This was not in accordance with the trust’s own policy. We raised this with the trust’s senior leaders at the time of the inspection and the trust have since addressed this.

  • The trust generally met the national targets for patients to receive care and treatment in a timely way. The Department of Health target for emergency departments is to admit, transfer, or discharge 95% of patients within four hours of arrival at A&E. Between January 2014 and January 2015 the department generally met this target, unlike many trusts in the country, with occasional performance below the standard.

  • The trust met most of the referral to treatment time targets (RTT) (also known as the 18 week target). Medical care services met all targets; however the RTT for patients within the surgical division was below the 90% target, but remained just above the England average.

  • The referral to treatment time of non-admitted patients treated within 18 weeks was better at 97%. The percentage of cancer patients treated within 62 days from screening was also better at 98.1%, against the target of 90%.

  • On the critical care unit there was evidence of patients who were ready to be discharged to the wards but were unable to transfer due to a lack of beds; this led to patients having to remain in ITU or HDU unnecessarily. This was reflected in the units’ own ICNARC data. Occasionally, patients were discharged directly home from intensive or high dependency care.

  • The waits for the child development centre had increased to 14 weeks, but this was within the 18 week target. Staff told us that children who attended outpatients may have to wait for two to three weeks for blood samples to be taken. However, on occasion these children were referred to and seen on Nightingale ward which meant that blood samples could be taken immediately. The head of nursing told us that to date no actions had been taken to resolve this issue. Paediatric epilepsy service provision was identified as a risk. There was insufficient clinic capacity, and insufficient medical and nursing staffing. The service had an action plan and identified monitoring was in place. We saw the latest action plan which confirmed that two actions had been completed.

  • The trust did not audit ‘preferred place of care’ or ‘preferred place of death’. We discussed this with the end of life lead nurse for the trust who told us they were aware this information was not consistently documented as part of the patient’s plan of care, and that ‘preferred place of care/death’ was on the trust audit plan for 2015/16. As part of the trust’s ‘recently bereaved’ questionnaire family and friends were asked if their friend or relative ever stated where they would have liked to die; Only 17% of family and friends responded that their relative stated where they would like to die. For those patients with a rapidly deteriorating condition and likely to be entering the terminal phase of their illness the trust had a ‘fast track’ discharge policy. This facilitated a rapid discharge where possible, for patients who had identified their preferred place of care. The ‘fast track’ policy did not specify how soon patients should be discharged to their preferred place of care or death. Nursing staff told us ‘fast track’ discharges usually took up to 48 hours to arrange. Where delays in discharge had been identified staff told us this was largely due to the patient’s locality and obtaining equipment. The trust did not audit the length of time patients were waiting for a ‘fast track’ discharge and were unable therefore, to identify and address potential delays in the process.

  • The outpatients’ haematology clinic was overbooked. Space was limited with only three consulting rooms and a small waiting area. Staff informed us that at busy times there were up to 77 patients and “standing room only” in the waiting area. Appointments were allocated in ten minute sessions, with up to five patients allocated to the same time. This meant several patients were waiting to be seen at the same time. This could also affect other clinics if their patients were sent for blood tests prior to their consultation. There were plans for relocation to a new building which was planned to open in October 2016.

  • A recent significant demand for prostate MRI had led to pressures on the service, which had been identified on the risk register. The imaging and urology team had worked together to stratify the referral pathways enabling consistent service provision..

  • A weekly meeting with representation from across the local health and social care economy was held to expedite patient discharge in cases where there were delays, and to identify improvements. A delayed transfer of care rate of 3.6% was reported; slightly worse than a target of 3%. When we looked at patients’ records we saw that there was evidence of comprehensive discharge planning that commenced early during the patients’ admission. The trust were working with the health and social care community to provide different models of care and release capacity in the hospital. One example was with patients who had suffered a stroke. An early supported discharge system was in operation which allowed patients to return to their own homes while continuing to receive treatment and therapy. Nursing and therapy staff worked on the early supported discharge team and visited patients at home for up to six weeks, with daily input if needed.

Learning from complaints and concerns

  • Good quality complaints handling is vital to ensuring continuous improvement in the quality and safety of patient care. In 2013, the Patients Association published good practice standards for complaints handling, and all NHS organisations are expected to meet them. They provide guidance on how to investigate and respond to a complaint as well as how to manage complaints as an organisation. The trust had responded to the guidance and had updated the complaints, concerns, comments, and compliments policy in August 2014. This described how the trust managed and learnt from complaints, and made a commitment to deal with complaints promptly and effectively. It contained template acknowledgement and response letters.

  • There was an effective system to manage complaints, including guidelines for prioritising complaints. This indicated how quickly the trust would aim to provide a full response, from 30 to 35 days from receipt of the complaint, depending on its complexity. The assistance and complaints service (ACS) team had worked hard to close complaints that had remained open for a long time, and over 250 were closed between October and December 2014. However, complainants did not always receive a response in a reasonable timescale. In the year February 2014 to February 2015, it took on average 62 days to respond to a complaint. There were nearly 100 complaints still open and some had been open for longer than 80 days. The latest available integrated performance report showed that only about two thirds of complaints were resolved within the agreed timescales. Senior staff discussed complaints management, and the challenge of resourcing this in the April 2015 quality delivery group.

  • In the year 2014 – 15, the trust received 771 complaints. The trust received nearly twice as many inpatient and outpatient complaints but significantly less maternity complaints than neighbouring trusts (per patient contact). Medical services had the highest numbers of complaints and these were often complex issues so there were frequent delays, and these then caused back logs in investigations. Fifty per cent of complaints were about medical and surgical care and over 40% were related to outpatient appointments. Following an increase in the numbers of complaints the trust target was to reduce complaints by 10% in the year up to March 2015. Figures were better than previously, but a rise in complaints about a new patient appointments system meant the trust had received only 4% fewer complaints in the year.

  • Posters and leaflets about how to raise a concern or complaint were distributed around the hospital, but were not available in languages other than English. Ward staff would alert the assistance and complaints service (ACS) staff if a complainant needed an interpreter service.

  • The ACS office was situated in the main reception area. There were two front line staff who responded to face to face, telephone, and written enquiries. They had received training in conflict resolution, customer care and caring for people living with dementia. There was an escalation protocol relating to formal complaints which explained who staff should contact in given situations. There were two complaints advisors and a senior complaints advisor who each linked with one of the divisions and administered the complaints and their responses. They often met with patients either in the complaints office or they could meet patients on the ward if required.
  • Complaints were prioritised appropriately, and the ACS team supported ward and department staff in all aspects of complaints management. Complaints resolved on the spot were recorded and monitored. All complaints were reported on the trust’s electronic reporting system and the divisional quality governance coordinator discussed with divisional leads to allocate an investigator. Staff could only be allocated investigations through the electronic system after they had completed appropriate training.

  • Information about complaints was incorporated into the quarterly patient experience report at the quality delivery group. We looked at the quarterly reports for 2014-15. The main theme of negative comments from the friends and family test was comfort, most notably disturbance at night. Matrons developed a 14 point action plan to address this. While patients being moved to different wards at night was a concerning theme throughout our inspection, there was only one sub point relating to this. There had been some improvements in this by early 2015, although the main themes of negative comments remained food and disturbance at night. In March 2015 the trust launched its nutrition strategy, which outlined how the trust will improve nutrition over the next three years.

  • In July 2014, the Patients Association with the NHS Benchmarking Network developed a complaints survey. This helps NHS organisations monitor the way complaints are handled against the good practice standards. The findings for the trust were based on only 16 completed survey forms. Most respondents found it easy to make a complaint but 50% of respondents said that overall their complaint was handled poorly. The proportion of respondents who were very satisfied with their final response was better than the England average. However, nearly 40% were very dissatisfied. In November 2014, the association carried out an in depth review of six anonymised, closed complaints. On a scale of 1 to 5, where 1 is poor practice and 5 is excellent, the six cases received low scores of between 1 and 2.5. The panel identified some areas of good practice and made a number of immediate recommendations which the trust accepted and were working on.

  • We reviewed seven recently closed complaints, and found the responses varied in quality. A typical acknowledgement letter thanked the person for speaking with the assistance and complaints service, and explained the investigation and response process. The letter did not contain an apology that the person had needed to complain. Some of the investigations were prolonged and did not meet the trust’s timescales. Staff told us they contacted the complainant to explain any delay and agree a new deadline.
  • Most of the response letters were written in an impersonal style, and some failed to include an apology that the person had been dissatisfied with aspects of care. The letters used the formulation ‘your concerns have been investigated’ rather than an active voice taking responsibility for the investigation and its findings. Where the trust had apologised for the patient’s poor experience, this was often well into the substance of the letter, rather than in the introductory paragraph. In one lengthy letter to the relatives of a patient who had died, although the author offered condolences early on, the first apology was on the third page.

Well-led

Good

Updated 17 May 2017

We rated well-led as good because

  • The trust had a clear vision of where it wanted to be which was articulated by staff.
  • There were clear lines of accountability and appropriate board sub committee’s in place.
  • The board used an integrated assurance system which provided the board with assurance of quality and performance. We reviewed the papers for the board and found papers to contain key information about performance and assurance. They were well organised and structured and actions monitored.
  • Risks were reported to the trust board through the board assurance framework and the significant risk register, with the top risks being reviewed by the board at every meeting.
  • The leadership team were very cohesive and worked well together. They were clear about the direction of the trust and were committed to delivering the strategic vision.
  • Staff told us there had continued to be a positive culture change in the organisation and staff were supported to develop. Leadership development had continued and the programme was highly valued by staff.
  • There were systems in place for staff to be able to speak up. We did not receive any concerns from staff during this inspection in relation to bullying or harassment. The staff survey results for 2016 echoed this and the percentage of staff reporting they experienced bullying or abuse by staff was much better than the national average.
  • The trusts Use of Resources Metric score at the end of February 2017 was “1.” The Use of resources score is used by NHS Improvement to categorise providers against a list of metrics. Trusts are given of score of “1-4” with “1” being the best outcome.
  • Information being provided to the board was relevant, timely and the narrative statements in reports supported the quantitative data being presented.
  • Senior leaders were knowledgeable about the risks for the organisation.

However:

  • The staff survey response rate was low with 34% of respondents completing the survey compared with 56% in 2015.
  • The results of the 2016 NHS staff survey was poor. Their overall staff engagement score was 3.71 which put them in the lowest (worst) 20% when compared with trusts of a similar type. This was the fourth consecutive year where the score was in the lowest 20%.

Vision and strategy

  • The trust had a clear vision of where it wanted to be; “A first-class district general hospital (DGH) – the model for what a DGH can be in the service of its community – delivering sustainable high quality clinical care, offering an exceptional experience for our patients; and creating a great place for our staff to work.”
  • Their ambition was underpinned by four values; compassion, achievement, relationships, and environment. These values were encompassed in the trusts statement, “Proud to Care.” This was used in all trust communication and was promoted throughout the hospital and services. The vision and values of the trust were known by staff.
  • There were six core strategic objectives for the trust that were all underpinned by various strategies such as the quality strategy. In July 2016 the trust refreshed and launched its quality strategy which described how it will improve the quality of its services. There were a number of goals for improvement cited in this strategy. Each had their own improvement plan and actions were specific, measurable, achievable, realistic and timely (SMART). Performance against the improvement plan was reported bi-monthly to the Quality Assurance Committee (QAC) which was a sub-committee of the trust board. We saw progress was being made against the improvement plan.
  • The trust had a focus on wanting to improve the quality and safety of the care being delivered to patients.

Governance, risk management and quality measurement

  • An integrated quality governance team was led by the Director of Nursing and Patient Care.
  • The trust had clear lines of accountability and appropriate board sub committee’s that were chaired by non-executive directors. All of the sub committees had terms of reference in place.
  • We saw evidence of both the sub committees and the trust board reviewing their assurance and challenging where they did not have sufficient assurance.
  • The board used an integrated assurance system which provided the board with assurance of quality and performance. We reviewed the papers for the board and found papers to contain key information about performance and assurance. They were well organised and structured and actions monitored.
  • Risks were reported to the trust board through the board assurance framework and the significant risk register, with the top risks being reviewed by the board at every meeting. The BAF had recently been reviewed and revised. We saw that all risks were assigned to board committees and strategic risks were assigned to the board.
  • There were four divisions in the trust, all of which had monthly quality meetings. The agendas for these quality meetings were standardised so that each division reported on the same areas.
  • The leaders we spoke with during the inspection all felt there was the right balance of importance of both quality and finance at the trust board.
  • We spoke with one non-executive director and the trust chair and they both told us there was a great deal of rigour and challenge at the trust board in order to gain assurance. From our review of board papers and minutes of the relevant sub committees we could see how the board were sighted on risk and sought assurance appropriately.
  • Information being provided to the board was relevant, timely and the narrative statements in reports supported the quantitative data being presented.
  • Senior leaders were knowledgeable about the risks for the organisation.

Leadership of the trust

  • Since our last inspection in 2015 there had been a change in Chief Executive of the trust and a new Chief executive was appointed in October 2016.
  • The trust Chair had been in post since 2015 and was very clear about her role in holding the executive team to account.
  • The leadership team were very cohesive and worked well together. They were clear about the direction of the trust and were committed to delivering the strategic vision.
  • Leaders in the organisation were visible and staff told us they were approachable. From our discussions with senior leaders we found evidence they shared the values of the organisation and were supportive of its vision and strategic aims.
  • The trust Board met regularly in both public and private. It was made up of the required numbers of non-executive members. The non-executive directors brought a good mix of skills to the board and we saw evidence in the trust board minutes of how they challenged and held the executives to account.
  • The Medical and Nursing director worked well together and had been in post for some time. They were well established within the organisation and staff spoke highly of their leadership. The Chief Executive wanted to strengthen the clinical leadership and there were plans to introduce a deputy medical director post for the organisation.
  • The trust had been a Foundation Trust since 2005 and had an established Council of Governors. We didn’t speak with the Governors at this inspection because we had no evidence to indicate our previous assessment had changed. The Governors were valued by the trusts executive team and there were good relationships in place where the Governors felt able to hold the trust board to account. The minutes of meetings from the Governors demonstrated challenge being given back to the trust executive team.

Culture within the trust

  • When we inspected the trust in 2015, we identified the culture of the organisation had changed to one where the focus was more on quality and safety. We noted the trust needed to work harder on its engagement with staff, and to ensure its most valuable resource were well motivated advocates for their organisation. At this inspection we spoke with staff who told us there had continued to be a positive culture change in the organisation and staff were supported to develop. Leadership development had continued and the programme was highly valued by staff.
  • The Chief Executive, who was new in post at the time of this inspection told us about plans to strengthen middle management in the trusts.
  • The trust held a “Leadership Assembly” which was a regular event with senior and middle managers and leaders to cascade key messages to leaders within the organisation. The aim was to ensure messages from the trust board were passed through the organisation. We saw how key messages had been cascaded and staff were positive about this approach.
  • At our last inspection in 2015 some of our findings when we spoke with staff were at odds with the staff survey results. It was clear that staff were proud of their hospital and they liked working there. Many staff described a friendly, family feel to the hospital and felt they worked in supportive teams. We found the same during this inspection, with the staff at our focus groups speaking very positively about working at the trust. We did not hear any negative comments from staff at the focus groups we held. Furthermore, we have not received any comments from staff wanting to raise concerns with us after our inspection
  • The trust had signed up to the ‘Speak Out Safely’ campaign which aims to encourage staff to raise concerns. There was a hot line in place for staff to share concerns. Staff had been encouraged by their leaders to be open with the inspectors during the inspection. The trust had also appointed a Freedom to Speak Up Guardian.
  • We did not receive any concerns from staff during this inspection in relation to bullying or harassment. The staff survey results for 2016 echoed this and the percentage of staff reporting they experienced bullying or abuse by staff was much better than the national average.

Equalities and Diversity – including Workforce Race Equality Standard

  • As part of our inspection, we reviewed how well the trust was adopting the Workforce Race Equality Standard (WRES) and realistically working towards achieving workforce race equality. The WRES and Equality Delivery System (EDS2) became mandatory in April 2015 for NHS providers. Providers must collect, report, monitor and publish their WRES data and take action where needed to improve their workforce race equality. The trust published their WRES report on their website.
  • The trust had published their equality objectives on the trust website, which included for example establishing E-learning for E&D, regular reporting of workforce demographics and developing links with local E&D groups. The paper included updates of progress in relation to the objectives up to January 2017, indicating progress in promoting the E&D agenda across the trust, supported at board level.
  • The trust had completed an EDS2 ratings evaluation with an outcome rating of ‘developing’. The evaluation had included a range of equality and diversity (E&D) areas under the headings - Better health outcomes, improved patient access and experience, a representative and supported workforce and inclusive leadership.
  • Chesterfield Royal Hospital NHS Foundation Trust (CRH) had a workforce which reflected the ethnicity of the local population with 95% as white British and 5% from visibly black and minority (BME) community backgrounds.
  • The trust had a WRES lead at deputy director level and we saw evidence in trust board minutes of equality and diversity as a standing agenda item.
  • A People Committee established in July 2016, chaired by a non-executive, had a broad remit, which included equality and diversity and was an outcome of the trusts Peoples Strategy. The strategy included being inclusive and recognising diversity as a key value. Staff told us they were aware of these initiatives and said they had not experienced any discrimination, personal or within career development opportunities. However, Trust data and staff survey results (National NHS Staff Survey 2015) indicated 7% of staff had experienced discrimination at work in the previous 12 months.
  • There had been no disciplinary action involving BME staff for the 12 months prior to our inspection.
  • The trust did not have specific BME or lesbian, bisexual, gay or transgender groups (LBGT). However, actions had taken place to identify those who may benefit from such a group through requesting expressions of interest within staff communication systems.

Public engagement

  • The Friends and Family Test (FFT) scores were about average when compared with other trusts. This test is based on a question asked of patients in all NHS trusts in England, “How likely are you to recommend this ward/clinic to friends and family if they needed similar care or treatment.”
  • The trust set themselves local targets for the FFT and they were above the target for all areas with the exception of the emergency department.
  • Following some investment over the previous 12 months, the trust had implemented real time patient feedback. Patients were able to provide live feedback in a variety of ways from paper based to electronic devices on wards and via SMS’ Staff could view electronic feedback through the hospital intranet. The questions in the real time survey included questions linked to the quality strategy ambitions. We saw detailed reports on the patient experience were reported to the trust board. Most importantly, these report described how the organisation had made changes as a result of patient feedback. It reinforced the trusts commitment to listen to patients and carers experiences of their care and treatment at the hospital.

  • Each of the divisions had completed more in depth patient surveys and were developing plans to address the themes.
  • Patients were invited to tell their stories at the beginning of trust board meetings and we saw evidence of this in meeting minutes. Patients had also attended divisional staff meetings. Staff told us they found these provided a powerful insight into patient experience.
  • The patient engagement team worked with the local Healthwatch and attended their patient forums in order to gain more information from people who used services at the trust.
  • The trust had an Assistance and Complaints Service for patients and aimed to resolve as many as possible close to the point of the issue arising. The trust knew what their top themes of complaints and concerns were so they could aim to focus their work. The trust broke down the top themes from patient feedback by division and we saw this information was presented very clearly to enable staff to make improvements. We also saw evidence of how they had made changes as a result of patient feedback.
  • The trust were using benchmarking data to compare understand their patient experience position in comparison to other trusts, particularly to those trusts rated as outstanding by the Care Quality Commission. Data showed the trust were in a good position compared with the national picture.

Staff engagement

  • We met with staff side representatives during our inspection. Quarterly Staff Forum and monthly Staff Partnership Committee meetings were held. Representatives told us there was good engagement and cooperation with the trust. We were given examples where the board had listed to staff views, for examples proposals to change the pay date each month did not proceed after concerns from staff.
  • Staff side representatives confirmed to us they were actively involved in human resource policy decisions. One suggestion for improvement was that communication through middle management could be improved, however staff side representatives told us that senior manager were willing to listen to staff views.
  • Staff forums were held on a quarterly basis. Minutes from the meeting identified actions to be taken and identified the staff responsible. A range of topics were discussed including staff uniforms, concerns about patient bed moves and car parking.
  • The Staff Friends and Family Test was launched in April 2014 in all NHS trusts providing acute, community, ambulance and mental health services in England. Seventy four per cent of staff would recommend the organisation as a place to receive care.
  • A new staff recognition and reward scheme was introduced called ‘Applause’. The new scheme aimed to make it more accessible for groups of staff that were not always recognised for their contribution. The new scheme included ideas thank you cards, local schemes so that divisions could say thank you in their own way.
  • There was a staff health and well-being group who met regularly. A range of activities were available for staff to become involved in, these included yoga, hydration, a running group, the 5k Bolsover run and resilience training for staff.
  • Staff attendance was constant at 95% for the rolling year.
  • Staff turnover rates for the trust were 11.6% for the year 2016/17. The overall staff vacancy rates at January 2017 were 4%, this had increased since November 2016 when it was 3.5%.
  • The overall staff sickness rate in December 2016 was 4.9%.
  • Total spend on agency staff decreased to £930k in February, from £1,022K in January. This total spend comprised of £506k on medics (reduced from £626k in January), £293k on nursing (increased from £228k) and £132k on other staff groups (decreased from £169k).This equated to 7% of the pay bill.
  • Consultant appraisal rates were 78% in March 2017 and appraisals for all non-medical staff were 68% in March 2017.
  • The staff survey response rate was low with 34% of staff completing the survey compared with 56% in 2015.
  • The results of the 2016 NHS staff survey were disappointing. Although there were improvements in some areas the trust continued to be a way off their ambition to be in the top 20% of trusts for staff engagement. Their overall staff engagement score was 3.71 which put them in the lowest (worst) 20% when compared with trusts of a similar type. Possible scores range from 1 to 5, with 1 indicating that staff are poorly engaged (with their work, their team and their trust) and 5 indicating that staff are highly engaged. This was the fourth consecutive year which the staff engagement score was low. Actions the trust had taken to improve the engagement score had failed to make the required improvements.
  • The trust had a plan for how they addressed the staff survey and presented it to the trust board in March 2017. The plan set out a range of initiatives to address the findings but to also engage staff around the importance of giving their views.
  • The trust were planning to implement Listening Into Action during 2017/18 pending approval they had been accepted onto the programme. Listening into Action is a nationally recognised method for engaging and empowering staff in improving the quality of patient care and experience.

Innovation, improvement and sustainability

  • The Trust had been set a target level of agency spend for the financial year of £11.599m by NHS Improvement. The total agency spend at January 2017 was £1.9m worse than trajectory. Whilst the Trust had found the agency cap challenging and there was further progress to be made the Trust could evidence a 18% (£2.6m) reduction in agency spend compared to the equivalent 2015/16 financial position. This represented a reduction against both nursing (£0.6m) and medical agency (£2.1m) spend.
  • The trust has been running a number of GP practices as part of its portfolio. The trust has created an ‘arms-length organisation’ (ALO) to help facilitate its transition into an organisation that provides a full range of healthcare services and specialties for people across the community. Officially registered with Companies House as ‘Derbyshire Primary Care and Commercial Services’ the arms-length organisation is classed as a limited company within the NHS.
Checks on specific services

Community health services for children, young people and families

Good

Updated 4 August 2015

Overall rating for this core service Good l

Chesterfield Royal Hospital NHS Foundation Trust provided a range of community health services for children, young people and families in Chesterfield and north Derbyshire. The services were managed from Chesterfield Royal Hospital and clinics were held in The Den, a dedicated facility for children and young people.

We inspected the following regulated activities that the trust is registered with CQC to provide:

• Diagnostic and screening procedures

• Treatment of disease, disorder or injury

During our inspection we spoke with 30 people using the service, including children, young people and their families. We spoke with 44 staff including nurses, doctors, speech and language therapists, occupational therapists, physiotherapists, administration staff and health care support workers. We visited clinics at various locations including The Den at Chesterfield Royal Hospital, and Buxton Health Centre. We accompanied community nurses visiting children and young people in their own homes or at school. We looked at a total of 15 records of care and treatment.

There were reliable systems, processes and practices in place to keep children and young people safe and safeguarded from abuse. Staff understood their responsibilities to raise concerns and to record and report safety incidents, although near miss incidents were not always reported. Lessons were learned from incidents and action taken to improve the service. Staff demonstrated a sound awareness of safeguarding issues and knew the procedures to follow if abuse was alleged or suspected.

Staffing levels and caseloads were planned and reviewed so that children and young people received safe care and treatment. There were identified problems with staffing levels in some teams. Appropriate action was being taken to monitor the risks and to resolve the issues.

Children and young people had care and treatment in line with legislation, best practice and evidence based guidance. The outcomes of care and treatment were monitored through local and national audits. Results of audits were used to improve outcomes for children and young people using the service. There was collaborative and effective multi-disciplinary and multi-agency working to understand and meet the needs of children and young people using the service. This included the arrangements for young people moving to adult services. Children, young people and their families were treated with dignity, respect and kindness and were involved in their care and treatment.

Staff had the relevant skills, knowledge and experience to deliver effective care and treatment. Staff were supported through supervision and annual appraisal, though not all staff had received an appraisal in the last year. Services were planned to take account of the needs of the local population and of the individual needs of children, young people and their families. The leadership, governance and culture promoted and supported the delivery of high quality person centred care. There was a clear and effective governance structure for this service.