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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

Reports


Inspection carried out on 30 October to 29 November 2018

During a routine inspection

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.


CQC inspections of services

Inspection carried out on Announced inspection 20th to 22nd September 2016. Unannounced inspection 29th September 2016.

During an inspection to make sure that the improvements required had been made

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

Inspection carried out on 21- 24 April 2015 and 7 May 2015

During a routine inspection

The Care Quality Commission (CQC) carried out a comprehensive inspection between the 21 and 24 April 2015. We carried out this comprehensive inspection as part of our regular inspection programme. Cambridge University Hospitals NHS Foundation Trust had been identified as having only two elevated risks and one risk on the Care Quality Commission’s (CQC) Intelligent Monitoring system in December 2014. However in May 2015 the Intelligence Monitoring system showed that there were five elevated risks and four risks.

Cambridge University Hospitals NHS Foundation Trust is one of the largest hospitals in the United Kingdom with around 1096 beds. The trust provides a major trauma centre for the east of England and specialist services in immunology, foetal medicine, IVF, neurosurgery, ophthalmology, genetics and metabolic diseases, specialised paediatric, cancer and transplant services. These services were inspected as part of the core services within this report. The trust also provides district general hospital services to patients predominantly coming from Cambridgeshire, Essex, Suffolk and Hertfordshire. The demographics vary due to the large student population of approximately 24,488.

All the clinical departments at CUH 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

Whilst we inspect core services these crossed divisions. We were able to disaggregate some of the performance information for the trust across our core services.

During this inspection we found that the trust had significant capacity issues and were having to reassess bed capacity at least three times a day. This pressure on beds meant that a number of elective patients were cancelled as there were no beds available. We found that staff shortages meant that wards were struggling to cope with the numbers of patients within the hospital and that the critical care areas were not staffed in line with national guidance. We reported this to the hospital trust management and undertook enforcement action to apply a condition on the trusts registration to ensure that there were sufficient staff in place to care for critically ill patients. We have since been assured that there are systems in place to ensure that staffing levels are in accordance with national guidance and have removed this condition form the trusts registration.

We have rated Addenbrooke’s and The Rosie Hospitals location as inadequate although we found that the staff were exceptionally caring and that they went the extra mile for their patients. However we have rated the overall trust as inadequate as there was a lack of management oversight and robust governance systems in place to highlight the concerns we found during this inspection.

Our key findings were:

  • There was a significant shortfall of staff in a number of areas, including critical care services and those caring for unwell patients. This often resulted in staff being moved from one area of a service to another to make up staff numbers. Although gaps left by staff moving were back-filled with bank or agency staff, this meant that services often had staff with an inappropriate skills mix and patients were being cared for by staff without training relating to their health needs .Despite this staff were exceptionally caring.
  • Pressure on surgical services meant routine operations were frequently cancelled and patients were waiting longer than the 18-week referral to treatment target for operations. Pressure on the outpatients department meant long delays for some specialties and not all patients being followed up appropriately, particularly in ophthalmology and dermatology. There were some outstanding maternity services but significant pressures led to regular closures and a midwife to birth ratio worse than the recommended level.
  • Disconnected governance arrangements meant that important messages from the clinical divisions were not highlighted at trust board level.
  • Introducing the new EPIC IT system for clinical records had affected the trust’s ability to report, highlight and take action on data collected on the system. Although it was beginning to be embedded into practice, it was still having an impact on patient care and relationships with external professionals.
  • Medicines were not always prescribed correctly due to limitations of EPIC, although we were assured this was being remedied.

However, we also found:

  • Caring staff who did everything they could for patients in their care.
  • Effective and robust multidisciplinary working across the trust.
  • The emergency department and major trauma centre were efficient and effective.

There were areas of poor practice where the trust needs to make improvements.

Importantly, the trust must ensure that:

  • All patients awaiting an outpatient’s appointment are assessed for clinical risk and prioritised as to clinical need.
  • Effective governance and management arrangements are put in place in outpatients.
  • Systems or processes must be established and operated effectively to enable the outpatients department to assess, monitor and improve the quality and safety of services.
  • Services around end of life are reviewed to allow for fast track or rapid discharges to be undertaken in a timely way.
  • Patient dependency in the intensive care unit is reviewed and staffing monitored against this on a day to day basis to ensure compliance with the Faculty of Intensive Care Medicine / Intensive Care Society core standards for ICU (Ed1) 2013.
  • There is adequate staffing to provide safe care for patients requiring non-invasive ventilation.
  • Data collection for the ICNARC case mix programme is monitored and that data collected is reliable, accurate and representative of the functioning of both critical care units.
  • Patients are discharged from critical care units to the wards in a timely manner and minimises the number of patients being discharged after 10pm.
  • It encourages collaborative working and sharing of clinical governance data between the general critical care unit and the Neuro Critical Care Unit.
  • Medicines are managed in line with national guidance and the law.
  • All patients who may lack capacity have a mental capacity assessment and, if appropriate, a deprivation of liberty safeguards (DoLS) assessment and that patients’ consent is properly sought before treatment.
  • All emergency equipment is checked in line with policy.
  • Risk assessments are completed and correctly recorded.
  • All environments are safe and that high levels of nitrous oxide in delivery suites are addressed.
  • Consistent foetal heart rate monitoring is provided in maternity services.

We saw areas of outstanding practice including:

  • The allergy clinic had a one-stop allergy service that provided diagnosis and management of a wide range of allergic disorders. This clinic was dynamic and comprehensive.
  • Virtual clinics had been set up in a number of areas, each consisting of a multidisciplinary team of staff including nursing and consultant grade staff. The purpose of the clinic was to review patient diagnostic tests and notes to make treatment decisions without the need for the patient to attend an appointment. Patients were then called and treatment options explained over the phone.
  • The chaplaincy and bereavement service offered a one-stop appointment where bereaved relatives could see all trust staff that they needed to see in one visit. Bereaved relatives were also invited back six weeks after the death to enable staff to provide emotional support and answer any questions. The six-week follow-up had been devised at Addenbrooke’s and rolled out nationally.
  • The specialist palliative care consultants at Addenbrooke’s had won National and International recognition as an area of excellence in palliative care for their work in developing the “Breathlessness Intervention Service”.
  • The online educational resource – cambridgecriticalcare.net – developed by the neurological critical care team is a repository of educational resources aimed not only at local trainees, but trainees nationally and internationally.
  • Patients previously treated within critical care were invited to a twice-yearly focus group to help drive service improvement. Through this focus group, real change had been implemented, including improving the transition of care from the critical care area to the ward, establishment of a quiet/interview room for doctors to speak to relatives on the critical care unit, and the re-design of the relatives’ room.
  • On the general critical care unit, a junior doctor jointly with the IT department developed an application for a mobile tablet called “My ICU Voice” to enable patients who had a tracheostomy to communicate with staff.
  • Team working in the critical care unit was outstanding. Given the limited resources, all members of the multidisciplinary team worked collaboratively to ensure patients received kind and compassionate care. Nursing staff were observed doing everything they could to ensure patients’ carers were well informed of their loved ones’ condition.
  • There was well-managed and coordinated medical handover and follow-up of patients following admission, with all specialties being represented for effective care management planning.
  • The “supervisor of midwives” network at the trust was outstanding and was an important contact for patients and staff. The purpose of supervision of midwives is to protect women and babies by actively promoting safe standards of midwifery practice.
  • The Birthing Unit in The Rosie Hospital had facilities that were outstanding and state of the art. They included 10 birthing rooms, all with en-suite bathrooms, mood lighting and music systems, a fold-down double bed, birthing balls, slings, birthing stools, floor mats and comfortable seating and access to a sensory garden.
  • The Neonatal Intensive Care Unit is at the forefront for provision of care for babies. The neonatal transfer team (ANTS) was the first such team to formally and consistently enable parents to travel with their sick babies.

  • The ACTIVE Children and Young People’s Board enabled current and former young patients, and any other children who were interested, to meet and share ideas. The ACTIVE Children and Young People's Board was involved in producing child-friendly information and in projects such as Teens in Hospital, which was looking at ways of improving the experience of young people, especially those on adult wards.

On the basis of this inspection, I have recommended that the trust be placed into special measures.

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.