We carried out a full follow up inspection between 20th and 22nd September with an unannounced inspection on 29th September 2016. This inspection was to follow up our comprehensive inspection in April 2015 where the concerns identified by the inspection team had resulted in my recommending the trust for special measures. A smaller focussed inspection in February 2016 followed up our most serious concerns and those areas rated Inadequate.
At this inspection we saw significant improvement across most of the areas we inspected. This included outstanding effectiveness in the critical care units and improvements in safety and leadership in maternity services and outpatients which we have now rated as good. These had been rated inadequate in 2015. There were similar improvements in medical care, surgery and urgent and emergency services with all services now rated as good overall. The improvement was in line with the trusts improvement plan and was assisted by constructive challenge from stakeholders at regular meetings.
Cambridge University Hospitals NHS Foundation Trust is one of the largest in the UK with around 1400 beds. The trust provides a major trauma centre for the east of England and specialist services in immunology, fetal medicine, IVF, neurosurgery, ophthalmology, genetics and metabolic diseases, specialised paediatric, cancer and transplant services.
The trust also provides district general hospital services to patients predominantly coming from Cambridgeshire, Essex, Suffolk and Hertfordshire. The demographics vary during the year due to the large student population of approximately 24,488.
The clinical departments are clustered together into five divisions:
Division A: Musculoskeletal; Digestive Diseases and ICU/ Periops
Division B: Cancer; Laboratory services; Imaging and Clinical support
Division C: Acute Medicine; Inflammation/Infection; Transplant
Division D: Neuroscience; ENT/ Head and neck/ Plastics; Cardiovascular-Metabolic
Division E: Medical Paediatrics; Paediatric Critical Care and Paediatric Surgery; Obstetrics and Gynaecology
During this inspection we inspected all key questions in all of the eight core services. The organisation had been through a significant change in senior leadership in the preceding 12 months which had resulted in a number of governance changes within the organisation. The trust was continuing progress against an overarching improvement plan in response to concerns found at our previous inspections.
Our key findings were as follows:
- The trust had received support from NHS Improvement since it was placed in special measures in September 2015 and had undertaken a review of governance structures across the organisation. This had included the implementation of the improvement plan and regular oversight of its implementation from regulators, commissioners and stakeholders.
- There was improvement in the quality and safety of all services with the exception of children and young people’s services which found the demand on the service challenging. This improvement was in line with the trusts improvement plan.
- There was improved learning from incidents across the divisions. Most staff we spoke with had a good understanding of the duty of candour.
- There had been an increase in permanent staffing levels resulting in very low levels of agency nurse usage across the trust. There remained use of bank staff and some locum consultants.
- The trust had developed a system of monitoring patient acuity on several occasions each day. This allowed senior managers and clinical staff to flex staffing levels to meet patient need.
- There were ongoing capacity issues within the trust resulting in cancelled and delayed surgeries. Children’s services were also under pressure though the imminent opening of additional beds should alleviate some of this pressure.
- Internal capacity issues were also seen in delayed discharges from the critical care units. There were also delays in transferring some patients from recovery post operatively to a ward for post-operative care.
- There were ongoing capacity issues within maternity services meaning the unit diverted high risk deliveries on 17 occasions between December 2015 and July 2016.
- Significant improvement had been made into reducing the numbers of patients waiting for outpatient appointments. However, further work was required to further reduce the waiting lists for appointments and some investigations.
- The trust failed to achieve the national target for treating, admitting or discharging 95% of patients within four hours. In December 2015, the trust met the target, however performance began to fall in January 2016 and fell to 83% in May 2016
- The revised governance systems were sufficient to ensure that the senior team had robust information on which to make decisions.
- There was a large audit programme. However, we saw results in medicine were below the England average and the stroke national audit scored ‘D’ – the second lowest score. There was very limited audit in end of life care though the trust had identified this and were developing an audit plan.
- The electronic patient record (Epic) had now been in place for some 2 years. Many of the concerns we had identified at previous inspections had been addressed and staff were more familiar with the system though care planning was not always individualised and personalised.
- Staff were very caring and on some occasions went to great lengths to support and care for patients.
- There was an open culture. Staff reported incidents and there was increased evidence of learning from incidents.
- Staff spoke positively of local (divisional) management. Managers in all areas were well sighted on risks as well as developing new pathways and delivering care.
- Patients spoke highly of the care they received. Friends and Family Test results were generally positive across the trust however, there were very poor response rates in some areas.
Importantly, the trust must:
- Ensure medicines including controlled medicines are securely stored at all times.
- Ensure that end of life care is properly audited (such as preferred place of death and DNACPR) and actions taken in response to those audits.
- Ensure that complaints are responded to in a timely way wherever possible.
- Ensure resuscitation decisions are always documented legibly and completed fully in accordance with the trusts own policy and the legal framework of the Mental Capacity Act 2005.
In addition the trust should:
- Ensure it improves the environment for children in the ED to ensure children’s safety at all times.
- Review staffing in the emergency department with respect registered nurses (child branch) to ensure children’s needs and national guidance are met.
- Review staffing of the specialist palliative care team against national guidance.
- The trust should ensure that all staff complete mandatory training and safeguarding training to ensure it complies with the 90% compliance target.
- Continue to work to improve delayed discharges and discharges that occur between the hours of 10pm and 7am in the critical care and intensive care units.
- The trust should ensure the actions from the safeguarding review they have conducted for level three training for staff in adult areas caring for patients under the age of 18 years are implemented.
- The trust should review the level of children’s safeguarding training healthcare assistants undertake to ensure it is in line with the Intercollegiate Role Framework for Looked After Children and the trusts own Safeguarding Children’s Policy.
- Review consultant hours in maternity in line with national guidance.
- Continue to improve referral to treatment time performance including for cancer services and reduce the number of cancelled operations.
- Consider improvements to the response rate for the Friends and Family Test which are poor across the trust.
- Ensure that systems are in place to reduce the risk of confidential information leaks.
- Work to reduce the number of diversions of high risk deliveries in maternity services.
- Continue to reduce the time for end of life patients to be discharged to their preferred place of care.
- Ensure that all equipment is appropriately checked and safety tested where required.
We saw areas of outstanding practice including:
- Ward J2 ran weekly ‘music and movement’ classes to help meet the holistic needs of patients during their long-term recovery. A volunteer specialising in music and movement ran the classes and staff encouraged patients and their relatives to attend. This had received excellent feedback from patients and relatives.
- The teenage cancer unit provided outstanding facilities for young people diagnosed with cancer and receiving treatment for cancer. The teenage cancer unit provided a welcoming, age appropriate environment for young people to receive treatment, but also meet other young people and relax and socialise.
- The ED team had developed a mobile phone application called “Choose Well.” The application offered guidance on waiting times and hospital services across Cambridge in order to improve the patient experience and offer choices in health care.
- The emergency department had secured £100,000 of funding from the Small Business Research Initiative (SBRI) to support the development of a crowd prediction modelling tool to enable the trust to understand and map patient flow through the department.
- The charitable trust was in the process of setting up a trauma ICU centre in Burma in which a number of the ICU/NCCU staff were involved, as well as the Burma nurse specialist visiting later on in the year.
- The initiative for ‘Family Facetime’ proposed the purchase of two technology tablets to enable mums on the Obstetric Close Observation Area (OCOA) who are too unwell to visit their baby on the neonatal intensive care unit to receive a video link via Facetime with their baby.
- The bereavement follow up scheme saw a reduction in complaints of approximately 50%.
On the basis of this inspection I am recommending that Cambridge University Hospitals NHS Foundation Trust is removed from special measures.
Professor Sir Mike Richards
Chief Inspector of Hospitals