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Provider: James Paget University Hospitals NHS Foundation Trust Good


Inspection carried out on 3 Sep to 2 Oct 2019

During a routine inspection

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

  • We found that there were no regulatory breaches and overall, we have found that the organisation was performing at a level which led to the overall rating as good.
  • Overall, we rated safe as requires improvement, effective, caring and well-led as good, and responsive as outstanding. In rating this trust we took into account the current ratings of the service not inspected on this occasion.
  • We rated the well-led part of the inspection as good.

CQC inspections of services

Inspection carried out on 3 July 2018 to 4 July 2018

During a routine inspection

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

Safe was rated as requires improvement with effective, caring, responsive and well led being rated as good.

Our inspection of the core services covered the James Paget Hospital only. 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.

James Paget Hospital

  • Medical care safety remained as requires improvement with effective, caring, responsive and well led rated good. All staff were aware of the different types of abuse and how to make a safeguarding referral. Support systems were in place from a designated safeguarding lead who was responsive and accessible. Patients had comprehensive assessments of their needs including clinical condition, pain relief, nutrition and hydration and rehabilitation. Staff understood their responsibilities to raise concerns and were open and transparent. Patients care and treatment was planned and delivered in line with current evidence based guidance and standards. There was a high degree of multi-disciplinary and collaborative working with holistic approaches to planning peoples’ discharge. Staff cared for people with dignity, respect and kindness. Patient feedback was consistently positive around the care they received. Leaders were visible, approachable and knowledgeable about quality issues and the challenges within their areas. They took measures at all levels to address risk and improve service provision. There was a strong focus on innovation and improving services across the division with many areas trialling new ways of working and developing initiatives responsive to patient need. However, mandatory and safeguarding training modules were below the trust target of 95%. Medicine supplementary paper prescription charts did not always contain the appropriate information such as allergies, height and weight to ensure the administration of medicines was safe and in line with best practice. Appraisal for nursing staff was significantly below target at 54.6% however a plan was in place to bring this up to target by August 2018.

  • Maternity services were rated good overall. Safe was rated requires improvement and the rating for responsive was outstanding. Effective, caring and well led ratings were good. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. Staff of different kinds worked effectively together as a team to benefit all women. Doctors, midwives and other healthcare professionals including those from other healthcare providers supported each other to provide good care. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They demonstrated knowledge as to how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care. Staff cared for patients with compassion. Feedback from patients confirmed that staff cared for t well and treated them with kindness. The trust planned and provided services in a way that met the needs of local people. The service delivered care to areas with high levels of deprivation and planned the service to help hard to reach groups access the service. The service took account of patients’ individual needs. The service offered hypno- birthing classes, birth rewind sessions, supported women with learning difficulties, mental health issues and where there were safeguarding concerns. The trust had managers at all levels with the right skills and abilities to run a service providing high-quality care. Incidents were not always fully investigated. There were 108 open incidents where medical notes had not been reviewed and the incident not fully investigated. This number was reduced to 30 at the time of our unannounced inspection. The service did not always control infection risk well. Not all areas we visited were visibly clean. We observed three members of staff that were not compliant with the uniforms policy. Curtains around beds on the ward and were not disposable and did not have dates displayed so it was not possible to tell if they had been changed in line with infection control requirements. The escalation process for the Maternity Early Obstetric Warning Score (MEOWS) was not always followed. Of 14 records reviewed there were two(14%) records where there was not appropriate escalation to the medical team when the score was triggered. The service provided care and treatment based on national guidance had a planned clinical audit programme in place for local and national audit.

  • End of life care went down from good to requires improvement overall. Safe remained requires improvement, effective remained good and caring improved from good to outstanding. Responsive and well led went down from good to requires improvement. The service had not addressed a number of areas, identified at our previous inspection, where improvements could have been made. The service did not meet the trust mandatory training compliance target, the target for safeguarding training or guidance from the Association for Palliative Medicine of Great Britain and Ireland, and the National Council for Palliative Care standard because the service did not employ a substantive palliative care consultant. The Trust did not have a pathway for community patients to access the inpatient specialist palliative care team (SPCT) without attendance at the ED.Staff did not consistently complete plan of care for the last days of life booklets. However, the service managed patient safety incidents, patient care records and medicines well and nursing staff provided care in line with national guidance. The service met the individual needs of local people including, dietary, religious and cultural needs. Patient feedback was consistently positive and there were many examples of staff going over and above patient expectations.

Inspection carried out on 11th, 12th, 13th and 25 August 2015

During a routine inspection

We carried out a comprehensive inspection between 11 and 13 August 2015 as part of our regular inspection programme. In May 2015 James Paget University Hospitals NHS Foundation Trust had been identified as having only one elevated risk and one risk on our Intelligent Monitoring system. This showed a decreasing pattern since October 2013.

The James Paget University Hospitals NHS Foundation is a university hospital providing the care to a population of 230,000 residents across Great Yarmouth, Lowestoft and Waveney, as well as to the many visitors who come to this part of East Anglia. The main trust site is in Gorleston and is supported by services at Lowestoft Hospital, the Newberry Clinic and other outreach clinics in the local area.

The James Paget Hospital officially opened on 21 July 1982, was established as a third wave NHS Trust in 1 April 1993 and became a Foundation Trust on 1st August 2006.

The trust has 458 inpatient beds and 26 day case beds located on the James Paget University Hospital. The trust provides critical, intensive and high dependency care, general and orthopaedic surgery and medicine, maternity, paediatrics and neonatal services.

We have rated this location as Good overall. We found that the staff were exceptionally caring and that they went the extra mile for their patients.

Our key findings were as follows:

  • All staff were caring and compassionate. They treated patients, relatives and carers with respect and dignity.
  • The trusts referral to treatment times (RTT) and four hour performance in the emergency department had improved since worse performance over the winter.
  • There was mostly enough nursing and medical staff to care for patients and protect them from the risk of avoidable harm though it did not always follow national guidance in relation to the care of children.
  • A number of medical vacancies had been identified, such as for consultant geriatricians which the trust had been unsuccessful in recruiting to.
  • There was an effective recruitment and retention strategy in place for nursing and medical staff with gaps in nursing staff acknowledged in medicine.
  • Clinical areas were visibly clean and we saw mostly good infection control practices. Infection control rates were low in the hospital.
  • The environment in some clinical areas including theatres and recovery was dated. A comprehensive estates strategy was in place to address these issues.
  • A new, purpose built day surgery unit opened during the course of our inspection which will enable more patients to be seen as day cases and potentially offer new pathways and services.
  • The emergency department made excellent use of technology and pathways, including for stroke, to effectively manage the care of patients.
  • For a number of clinical audits, the hospital performed in line with or better than the England average.
  • The vast majority of staff felt supported in their work, had received training and appraisals and most were aware of the trust vision and values.
  • Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) was not always consistently recorded or a care plan in place for patients receiving end of life care.

We saw several areas of outstanding practice including:

  • Care of patients requiring thrombolysis in the emergency department, with trained consultants and telemedicine access to a consultant neurologist.
  • Patient pathways for GP referrals that resulted in 97% of GP referrals not requiring services of the emergency department.
  • Spinal injuries nursing and state of the art equipment for patients with spinal cord injury was excellent.
  • A charity funded Eye Clinic Liaison Officer raised awareness about support for patients with macular degeneration.
  • The trust had been awarded integration status, with other health partners and social care to pioneer seven-day services. This included an Out of Hospital Teamchaired by the clinical commissioning group involving social care, the mental health trust and the hospital to identify ways to avoid crises in communities leading to hospital attendance. Data was showing a reduction in admissions.
  • The neonatal unit had developed a breastfeeding pack to encourage new mums whose babies were on the neonatal unit to hand express their breast milk. The pack contained information and tips on hand expressing along with a personal expressing log.

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

Importantly, the trust must:

  • Ensure that all equipment is checked at a frequency as per trust policy including, but not limited to emergency resuscitation equipment.
  • Ensure that all patient records are up to date and reflective of patient’s needs.
  • Ensure a named Non Executive Director for end of life care in line with Department of Health Guidance.
  • Ensure that all Do Not Attempt Cardio Pulmonary Resuscitation forms are completed fully and in line with national guidance.
  • Accelerate the implementation of the approved replacement for the Liverpool Care Pathway for people receiving end of life care

Professor Sir Mike Richards

Chief Inspector of Hospitals

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.

Joint inspection reports with Ofsted

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