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Provider: Cambridge University Hospitals NHS Foundation Trust Good

On 26 February 2019, we published a report on how well Cambridge University Hospitals NHS Foundation Trust uses its resources. The ratings from this report are:

  • Use of resources: Requires Improvement  
  • Combined rating: Good  

Read more about use of resources ratings

Inspection Summary


Overall summary & rating

Good

Updated 26 February 2019

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

  • We rated safe and effective as good, caring and well-led as outstanding and responsive as requires improvement.
  • We rated three of the core services we inspected at this inspection as good overall and one as outstanding.
  • In rating the trust, we considered the current ratings of the four core services we had not inspected this time. Whilst the trust had improved, there remained a rating of requires improvement for responsive.
  • Although the trust was outstanding in the caring domain and the well-led domain, the trust was rated as good overall because the responsive domain remained as a rating of requires improvement.
Inspection areas

Safe

Good

Updated 26 February 2019

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

  • We found a culture of openness and transparency about safety. Staff could raise concerns and report incidents, which were regularly reviewed to aid learning. Lessons learned were effectively shared at a local level.
  • The trust provided mandatory training in key skills to all staff and made sure everyone completed it. Compliance with mandatory training was good and staff were supported with time away from their clinical responsibilities to complete refresher training, to ensure they could care for patients safely.
  • Staff were aware of processes and standard procedures to keep people safe from abuse, and received training to assess, recognise and report abuse.
  • Staff responded appropriately to changing risks to patients who used the services; staff were confident about the process of escalating a deteriorating patient.
  • Nurse and medical staffing levels were planned and reviewed to ensure patients received safe care and treatment. Although there were vacancies at the time of our inspection, there were actions to mitigate this. Staffing at the time of our inspection was safe to meet patient needs and acuity, and the service had a proactive recruitment plan to maintain this.
  • Records were well managed, clear, up-to-date and easily available to all staff providing care. The electronic records system allowed staff to ensure records were completed fully and consistently.
  • The management of medicines had improved since our last inspection. There were systems in place to ensure the proper and safe use of medicines. Medicines were prescribed, stored and administered to people in line with current legislation and national guidance.
  • The trust controlled infection risk well. Staff kept themselves, equipment and the premises clean using effective control measures such as daily and weekly checklists, to prevent the spread of infection.

However:

  • Since our last inspection the trust had made improvements to improve the safety of paediatric patients within the emergency department, but during our inspection we identified that patients and relatives within the department could access the paediatric waiting and treatment area unchallenged by staff and that the area was not always supervised. Staff were not able to see the waiting areas and there was no closed-circuit television to observe the children and relatives. Although we observed the trust’s plans to reduce access to the paediatric area and strengthen the audio-visual aspects of the paediatric waiting area.
  • Observations were not always documented for patients with mental health conditions who required observation every 15 minutes within the emergency department.
  • The trust did not meet all the Royal College of Emergency Medicine standards, although they had action plans to improve compliance.
  • Throughout our inspection of surgery, we found that learning from incidents was not always shared between different divisions.

Effective

Good

Updated 26 February 2019

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

  • All core services provided care and treatment that was planned and delivered in line with current evidence based guidance.
  • Staff always had access to up-to-date, accurate, and comprehensive information on patients’ care and treatment.
  • Patients received comprehensive assessments of their needs including pain relief, mental health, physical health and wellbeing and nutrition and hydration.
  • Staff assessed and monitored patients regularly to see if they were in pain. Pain relief throughout the core services we inspected was well managed. Patients were prescribed pain relief to be given ‘when required’ could request this when they needed it. Pain score tools were used to assess and monitor pain.
  • Services throughout the trust monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them.
  • The trust ensured staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of services. Staff received regular appraisals to help with their development and support.
  • There was effective multi-disciplinary team (MDT) working throughout the core services we inspected to maximise patient experience and outcomes.
  • Staff were proactive in supporting patients to live healthier lives and we saw specific examples of staff using initiatives to promote people’s health.
  • Consent to treatment was sought in line with legislation and guidance. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.

However:

  • The severe sepsis and septic shock audit 2016 to 2017 demonstrated that the emergency department did not meet the national standards, although, the ED had implemented actions and had shown some improvements in 2018.

Caring

Outstanding

Updated 26 February 2019

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

  • The trust had a strong, visible person-centred culture. Despite financial and staff challenges, staff were highly motivated and inspired to provide care that was kind and promoted the dignity of patients.
  • Feedback from patients and relatives was overwhelmingly positive about the way staff provided care and treatment. Patients told us that staff went that extra mile and their care and support exceeded their expectations.
  • Staff of all levels introduced themselves and took time to interact in a considerate and sensitive manner. Staff spoke with patients in a respectful way.
  • We observed many examples of staff responding with kindness when patients required assistance or support.
  • Patient’s emotional and social needs were as important as their physical needs.
  • Staff involved patients and those close to them in decisions about their care and treatment. We observed staff involving patients and their relatives during assessments and when taking physiological observations on the wards.
  • The trust provided support to patients’ relatives where appropriate by enabling open visiting where appropriate and having on-site accommodation available.

Responsive

Requires improvement

Updated 26 February 2019

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

  • The trust did not meet all the Royal College of Emergency Medicine standards, although they had action plans to improve compliance.
  • The trust continued to experience challenges with delayed transfers of care (DTOC). Staff understood the challenges and were acting to address shortfalls, which were mainly affected by external pressures of domiciliary care capacity.
  • Fast track discharge did not meet the NHS England recommended time of 48 hours and on some occasions, was much longer than this. The average time to discharge was eight days, which suggests that the trust was performing worse than the last inspection, where the average time to discharge was 3.8 days for patients living in Cambridge and 4.7 days for patients living outside Cambridge.
  • The service overall referral to treatment time (RTT) for admitted pathways for surgery was worse than the England average.
  • Between 2016 and 2018, the percentage of cancelled operations for elective procedures due to non-clinical reasons was higher than the England average in all quarters apart from the most recent one (April to June 2018).
  • Overnight intensive recovery (OIR) was intended to only be a 22-hour stay before patients were transferred to the appropriate ward, but there were frequent delayed discharges from OIR and main recovery to wards and the intermediate dependency area.
  • Although the trust treated concerns and complaints seriously, they were not always investigated, responded to, and closed in a timely manner.

However:

  • The trust was taking action to address patient flow and access throughout the hospital. The bed management team worked effectively with ward teams to ensure bed use was meeting demand and patient needs as best as possible.
  • The trust was performing positively against the national requirement for the total elective surgical waiting list to be lower in March 2019 than March 2018.
  • The trust had dedicated discharge planning coordinators to help support nursing and medical staff with discharge planning.
  • Services were planned with a focus on meeting the individual needs of patients. For example, there were initiatives to meet the needs of patients living with dementia or learning disabilities, particularly anxious patients or patients with mobility difficulties.
  • The trust planned and provided services in a way that met the needs of local people. Services provided reflected the needs of the population served. Services ensured flexibility, choice, and continuity of care where possible.
  • Staff were pro-active and understood the needs of different patient groups and planned care that met those needs. Staff were respectful of patient groups and promoted equality, which included patients approaching the end of their life, vulnerable patients and patients with complex needs.
  • Staff coordinated care and treatment with other agencies and services which ensured the needs of the patient were assessed and treatment was planned according to the individual’s needs.
  • Systems and processes were in place which enabled patients and relatives to make a complaint. Information about how to complain was available in department and ward areas throughout the trust. Staff understood their responsibilities and supported people to complained where appropriate.

Well-led

Outstanding

Updated 26 February 2019

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

  • Well-led for urgent and emergency services and end of life care was rated as outstanding.
  • There was compassionate, inclusive and effective leadership at all levels. The leadership team had the right skills and abilities to run a service providing high-quality sustainable care. Leaders worked collaboratively across departments and were knowledgeable about risks affecting and about priorities for the quality and sustainability of their services.
  • The trust had a vision for what it wanted to achieve and workable plans to turn it into action. These had been developed with involvement from staff, patients and external stakeholders. All staff we spoke with were aware of the trust vision and could describe it to us. There was a systematic approach to monitoring, reviewing and tracking progress within the trust.
  • Comprehensive and successful leadership strategies were in place to ensure and sustain service delivery and to develop the desired culture. Leaders had a deep understanding of issues, challenges, and priorities in their service, and beyond.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff reported feeling respected and valued.
  • The trust prioritised leadership development and succession planning to enable a culture that recognised the importance of having leaders with the right attitude, skills and abilities.
  • Leaders consistently involved staff, considered public feedback and welcomed stakeholder challenge to further develop services. Staff were committed to seeking and embedding new ways of working which improved care and services for patients.
  • The trust was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.
  • The trust used a systematic approach to continually improve the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care could flourish. There were effective structures, processes and systems of accountability in place to support the delivery of the strategy and good quality services.
  • There were systems and processes to ensure risks were monitored and mitigated wherever possible, and performance was monitored. Risks on risk registers were known to the leadership teams and matched what we found on inspection.
Assessment of the use of resources

Use of resources summary

Requires improvement

Updated 26 February 2019

Combined rating