• Organisation
  • SERVICE PROVIDER

Sheffield Teaching Hospitals NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Requires improvement read more about inspection ratings
Important: Services have been transferred to this provider from another provider
Important: We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

All Inspections

5th October 2021 to 11th November 2021

During a routine inspection

Sheffield Teaching NHS Foundation Trust provides acute and community health services to a population of 640,000 people in Sheffield and the surrounding areas. The trust provides specialist services for the populations of Yorkshire & Humber, parts of Mid-Yorkshire and North Derbyshire. The trust operates from five sites:

  • Northern General Hospital
  • Royal Hallamshire Hospital
  • Jessop Wing Maternity Unit
  • Weston Park Hospital
  • Charles Clifford Dental Hospital

We carried out this unannounced inspection of Sheffield Teaching Hospitals NHS Foundation Trust of the acute and community services provided by this trust as part of our continual checks on the safety and quality of healthcare services. At our last inspection we rated the trust overall as good. Our inspection was prompted by concerns about the quality and safety of services. We also inspected the well-led key question for the trust overall.

We inspected urgent and emergency care, medicine and surgery at the Northern General Hospital and the Royal Hallamshire Hospital, maternity services in the Jessop Wing and community health services for adults at Beech Hill from 05 October to 07 October 2021. We undertook a further inspection of urgent and emergency care, medicine and surgery at the Northern General Hospital and the Royal Hallamshire Hospital, and maternity services in the Jessop Wing on 09 to 11 November 2021. We also conducted an inspection of the trust’s leadership and governance on 09 to 11 November 2021.

Whilst we inspected during the COVID 19 pandemic the risks and concerns identified by CQC during the inspection were not the result of the immediate pressures faced by the trust as a result of the COVID pandemic. The number of beds occupied during this period by patients diagnosed as COVID positive was a rolling average of 7.9%, the trust have reported the long lasting impact of the COVID 19 pandemic for the preceding 20 months. These included the significant impact on staffing, including sickness and the identification and redeployment of clinically vulnerable staff, the prolonged period of command and control arrangements and service remodelling.

We did not inspect critical care, end of life care, outpatients or diagnostics at either the Northern General Hospital or the Royal Hallamshire Hospital. We also did not inspect community services for adults, community end of life care, community dental services or the Sheffield dialysis unit. We are monitoring the progress of improvements to services and will re-inspect them as appropriate.

At this inspection we found the core service ratings for urgent and emergency care, medicine, surgery had deteriorated since our previous inspections in 2016 and 2018. The maternity core service remains rated as inadequate since the March 2021 inspection and the overall provider well-led rating has deteriorated from good in 2018 to requires improvement at this inspection.

Following our inspection of core services in October 2021, we formally wrote to the trust under our section 31 powers to share our concerns about our inspection findings. We asked the trust to take immediate action to improve the quality and safety of services. The trust provided details of the immediate steps taken to ensure patient safety and a further action plan to ensure and embed improvements. During our inspection of the trust’s leadership and governance in November 2021, we reviewed the action taken by the trust to improve the quality and safety of care patients were receiving on the inpatient wards. Our return visit found that the trust had not made significant improvement in some of the areas of concern identified in our October inspection which resulted in continued breaches of several regulations. As such we served the trust with a Warning Notice under Section 29A of the Health and Social Care Act 2008. The warning notice told the trust that they needed to make significant improvements in the quality and safety of healthcare provided. The principles we use when rating providers requires CQC to reflect enforcement action in our ratings. This means that the warning notice we served has limited the trust’s rating in the core service and well-led inspections.

Our rating of services went down. We rated them as requires improvement because:

  • We rated safe as inadequate and effective, caring and responsive and well led as requires improvement.
  • We rated urgent and emergency care, medicine at the Royal Hallamshire hospital and Maternity services as inadequate overall. We rated the medicine at the Northern General hospital, surgery at both sites and community adult inpatients at Beech Hill as requires improvement.
  • In rating the trust, we took into account the current ratings of critical care, end of life, outpatients and community services including community nursing, end of life, dental and the Sheffield dialysis unit services which were not inspected this time.
  • The trust did not have enough staff to care for patients and keep them safe. Staff were not always up to date with training in key skills. The trust did not always control infection risk well. Staff did not always assess risks to patients, however, when they did, they were not always act on them and care records were not always up to date and contemporaneous. Staff did not always manage medicines well. The trust did not always manage safety incidents well and actions were not always robust.
  • Staff did not always provide good care and treatment. Pain relief was not always given on time. Staff worked together for the benefit of patients, but they did not advise them on how to lead healthier lives. Staff did not always support patients to make decisions about their care and access to information was not always easy. Not all key services were available seven days a week
  • Staff mostly treated patients with compassion and kindness, but they did not always protect their privacy and dignity when providing care. Staff did not always help patients to understand their conditions. Staff did not always provide emotional support to patients to minimise their distress.
  • The trust did not always plan care to meet the needs of local people, which, took account of patients’ individual needs, and made it easy for people to give feedback. People could not always access services when they needed it and experienced long waits for treatment.
  • Senior and executive leaders did not always operate effective governance systems to manage risks and issues within the service. Not all staff felt respected, supported and valued although. The trust not always engaged well with staff, patients and the community to plan and manage services.

However:

  • Staff understood how to protect patients from abuse. The service-controlled infection risk well.
  • The trust had enough medical staff to care for patients and keep them safe. Staff worked well together for the benefit of patients and advised them on how to lead healthier lives.
  • Staff treated patients with compassion and kindness.
  • Local leaders ran services using information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff were committed to improving services.

How we carried out the inspection

The team that carried out the well led inspection service comprised a CQC head of hospital inspection, three inspection managers, two inspectors and an inspection planner. In addition, there was an executive reviewer and three specialist advisors experienced in executive leadership of NHS trusts. The inspection team was overseen by Sarah Dronsfield, Head of Hospital Inspection

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

12 to 14 June and 11 to 13 July 2018

During a routine inspection

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

  • We rated responsive as outstanding and we rated safe, effective, caring and well-led as good.
  • The Northern General hospital was rated as Good overall as both urgent and emergency care and end of life had improved. Responsiveness was outstanding at this site which was an improvement.
  • In rating the trust, we took into account the current ratings of the other services not inspected this time.
  • 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.
  • We rated well-led at the trust level as good.

12 to 14 June and 11 to 13 July 2018

During an inspection of Community end of life care

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

  • We rated safe, effective, caring, responsive and well-led as good.
  • Staff caring for patients at the end of their life were aware of how and when to report incidents, including safeguarding concerns. We saw that staff received feedback and lessons learned were shared.
  • Staff practiced safe infection control techniques.
  • Staff caring for patients at the end of their life assessed patients and escalated their care to the specialist team when necessary.
  • Guidelines, pathways and policies were produced in line with national best practice guidelines and recommendations.
  • There was sufficient numbers of skilled staff to care for patients at the end of their life. The service was available seven days a week 24 hours a day.
  • Staff understood the importance of seeking patient consent before providing care and treatment and showed a good understanding of the mental capacity act and deprivation of liberty safeguards.
  • Relatives we spoke with gave consistently positive feedback. Staff spoke about the patients they cared for in a caring, compassionate and respectful way.
  • Patients and their relatives told us that they were involved in planning their care and that communication with staff was good.
  • Staff provided emotional support to patients and their loved ones.
  • Services were planned in conjunction with external partners, across the whole of the health system to meet the needs of local people.
  • We saw numerous positive examples of initiatives to meet the individual needs of patients at the end of their life.
  • There was a clear leadership structure and strategy for end of life care. Staff told us that their line managers were visible, approachable and supportive.
  • Local governance arrangements were robust and the team was aware of the risks to their service.
  • We saw numerous examples of engagement, improvements and innovation.

However:

  • The trust had implemented processes to record whether patients preferred place of death was achieved and if not why not, they had not completed any audits of this data. Therefore, whilst a system was now in place the trust was still not measuring if patients achieved their wishes. However, we found establishing patients’ preferred place of care was seen as a priority.

7– 11 Dec and 23 Dec 2015

During a routine inspection

We inspected Sheffield Teaching Hospitals NHS Foundation Trust from 7 -11 December 2015 and undertook an unannounced inspection on 23 December 2015. We carried out this inspection as part of the Care Quality Commission (CQC) comprehensive inspection programme.

We included the following locations as part of the inspection:

  • Northern General Hospital
  • Royal Hallamshire Hospital, including Jessop Wing
  • Weston Park Hospital
  • Charles Clifford Dental Hospital
  • Community services including adult community services, community inpatients, community dentists, renal dialysis unit and end of life care.

We did not inspect the GP out of hours service based at the Northern General Hospital site.

We rated the trust as good. Royal Hallamshire Hospital, Northern General Hospital, Charles Clifford Dental Hospital and the community services were rated as good. Weston Park Hospital was rated as requires improvement.

Our key findings were as follows:

  • The trust was led by a stable and respected board.
  • We found the hospital was clean and staff adhered to infection control principles. The trust scored 99% for cleanliness in the patient-led assessments of care environments (PLACE) report for 2015.
  • There was a trust infection control accreditation programme in place. This programme set standards for infection prevention and control practice. Most clinical areas had achieved accreditation; plans were in place where this was not the case.
  • There had been four cases of MRSA reported by the trust between June 2014 and June 2015.
  • There had been 88 cases of C.difficile between June 2014 and June 2015. This was a rate in line with the England average per 10,000 bed days. The trust’s rate of C.difficile was below the trajectory target with 42 cases against a stretch target of 52 cases at the end of November 2015.
  • The trust had a well-established governance framework in place and incidents were reported and actions taken in response.
  • The trust used the safer nursing care tool, professional judgement and nursing hours per patient day to determine appropriate levels of staffing. There were some areas where staffing fell below planned levels on a regular basis, particularly in the Emergency Department and Weston Park Hospital wards, although the trust was mitigating risks as far as possible. Recruitment to vacancies was in progress. Staff were able to use bank or agency staff, where available, to fill staffing shortfalls.
  • The trust was committed to the development of advanced nurse practitioners to ensure patient care was maintained and the potential recruitment difficulties to junior doctor posts mitigated. This also allowed good advancement opportunities for nurses.
  • Mortality indicators showed no evidence of risk.
  • Patients were assessed for their nutritional needs. The trust had introduced HANAT (hydration and nutrition assurance toolkit) to encourage good nutrition and hydration best practice in the hospital environment.
  • We saw patients being cared for with kindness, dignity and respect and many services across acute and community patients told us they were very happy with their care.
  • We saw examples of effective multi-disciplinary working across both acute and community services
  • There was a well-established culture of continuous quality improvement. This was supported and assured by robust governance, risk management and quality monitoring. The trust used a Microsystems Coaching Academy which worked well to support small scale service improvements.
  • The trust’s vision and values were embedded in practice. These informed performance reviews and staff felt they were meaningful.
  • Clinical directorates had individual five year strategies that were linked to trust’s strategy, aims and objectives. The directorate strategies had consideration of the other clinical departments they worked with to deliver high quality care and the assistance required from corporate directorates and other partners. There was, however, no local end of life care strategy that provided an integrated acute and community vision of care for patients who were at the end of life.
  • The trust did not record the preferred place of death for those patients coming to the end of life and there were occasions when patients had to wait for up to two weeks to access a bed on the palliative care unit.
  • A culture of innovation and improvement was evident throughout all levels of the organisation.
  • There were concerns regarding the emergency department at the Northern General Hospital this included the clinical decision unit. Specifically we had concerns regarding the quality of care of patients during times when the department was busy.
  • There were concerns regarding the clinical decision unit specifically regarding the monitoring and escalation of deterioration patients in the seated area of this unit. We raised this with the trust at the time of inspection and a protocol was put in place.
  • The introduction of a new IT system had resulted in the trust not being able to record performance targets in the emergency department.
  • There were variable levels of compliance across both community and acute services for mandatory training levels. In the dental hospital staff had not received any training in Mental Capacity Act or Deprivation of Liberty standards.
  • We were concerned about the use of the teenage and young adult unit for patients who required an acute bed.
  • There was variation in the quality and completeness of Do Not Attempt Resuscitation (DNACPR) forms across all of the acute hospital sites.
  • In medicine there were concerns regarding the access to nursing guidelines that were held electronically and could not always be accessed by agency nurses. Care was conveyed between nurses using the handover sheets rather than referring to the nursing care plan.

We saw several areas of outstanding practice including:

Community dental service

  • A collaboration between the Sheffield Community Dental Services, NHS commissioners, Dental Public Health consultants and local general dental practitioners led to the development of the Residential Oral Care Sheffield service for residents living in care homes. This collaboration was cited as good practice by the British Society for Disability and Oral Health. This service now covers 80 out of the 88 residential care homes who participate in the scheme in the city of Sheffield.
  • The clinical lead was instrumental in developing a national benchmarking tool used by other community dental services and NHS dental commissioners for describing the complexity of patients treated by community dental services. An evaluation of the outcomes of the pilot project was delivered at the National Association for Dentistry in Health Authorities and Trusts in 2014.
  • Collaboration between the Clinical Lead of Sheffield Community Dental Services and the Head of Psychotherapy Services within Sheffield NHS Foundation Trust developed a dental nurse led Pain and Anxiety Service. This led to a reduction in the numbers of patients needing intra-venous sedation for dental treatment and the overall waiting times for intra-venous sedation.
  • Sheffield Community Dental Service provided a service for the Sheffield homeless under the auspices of the ‘Archer Project at the Cathedral’.
  • Sheffield Community Dental Service had developed a communication tool known locally as ‘the widget sheets’ enabling children with autistic spectrum disorders and other communication difficulties to accept dental treatment. An evaluation of this audit tool was published in the peer reviewed international scientific publication ‘Journal for Disability and Oral Health in 2014.
  • The development of a number of nationally recognised clinical benchmarking tools by Sheffield Community Dental Service was a result of exceptional leadership provided by the current Clinical Lead of the Service.

Community Adults

  • The active recovery service was a responsive service, which aimed to reduce un-necessary hospital admissions and facilitate the timely discharge of more complex patients from hospital. The team was multidisciplinary and multiagency with health and social care working closely together. The service had redesigned the traditional model of assessing to discharge to the more patient centred approach of discharge to assess resulting in reduced length of stay for patients and improved patient flow within the hospital.
  • The Single Point of Access (SPA) service managed referrals from patients and health professionals into all community health services. The service used a call routing system to direct patients to the right professional from the start. The team had extensive local knowledge and specialist expertise and were able to access to up to date information on service capacity. This meant that they could ensure patients were seen by the right professional at the right time at a venue of their choice.
  • We thought the person centred care planning was outstanding. The aim of this was to provide support for patients considered to be at high risk of hospital admission at an early stage. Community nurses and GPs worked together to develop patient and carers confidence in managing their own health. The community matron supported this. There were locality champions for person centred care planning in each of the four localities.

Northern General Hospital

  • The patient care and experience delivered by staff in the Bev Stokes Day Surgery Unit was outstanding, particularly in relation to patients living with learning disabilities and dementia.
  • The duty floor anaesthetist role in theatre developed in Sheffield was going to be used by the Royal College of Anaesthetists as a beacon of good practice.
  • The development of a relative’s room in the theatre complex.
  • On general intensive care unit /general high dependency unit there was the use of an electronic patient information system to ensure timely and accurate records, access to trust and local policies, procedures and guidelines The system ensured effective care was delivered and it was fully integrated and provided real-time information across teams and services.
  • An advanced clinical pharmacy service which included a consultant pharmacist and pharmacy prescribers had been developed to improve the safety and efficacy of medicines used in critical care.
  • The use of the Enhanced Recovery After Thoracic Surgery (ERAS) programme had resulted in marked improvements in the quality of care for patients on cardiac intensive care unit (CICU).
  • The laboratory team had introduced a ‘Patient Safety Zone’ project into the inpatient wards and in the community. The aim was to reduce labelling errors. Disturbance or distraction while taking blood samples has been identified as a major risk factor for errors. This initiative had been introduced to improve patient safety. Pathology staff showed us lots of publicity material, including branded biro pens.
  • In laboratory medicine, we observed large screens above the bench dealing with urgent samples. It contained a full list of patients waiting for results in the accident and emergency (A&E) department. The same screens were on display in A&E. This meant laboratory staff could see exactly who was waiting in A&E and gave context and ‘humanity’ to the samples they were analysing. Urgent results for A&E samples were available in one hour because of the use of this management tool.
  • Radiology provided an excellent service of ‘hot reporting’ for reporting x-rays for A&E patients; results were ready within 20 minutes.
  • Geriatric medicine had historically been part of acute medicine but was now combined with community services to provide an integrated service.

Royal Hallamshire Hospital

  • Staff in theatre had introduced a learning disability pathway. An operating list was dedicated to patients with a learning disability, if the patient needed more than one procedure this was carried out on the same operating list under the same general anaesthetic.
  • The use of duty floor anaesthetist role in theatre, developed in Sheffield, was going to be used by the Royal College of Anaesthetists as a beacon of good practice.
  • Radiology provided an excellent service of ‘hot reporting’ for reporting x-rays for minor injury patients; results were ready within 20 minutes
  • Histopathology was using cross-site digital pathology to speed up processing time for frozen sections.
  • On GICU and NICU there was the use of an electronic patient information system to ensure timely and accurate records, access to trust and local policies, procedures and guidelines The system ensured effective care was delivered and it was fully integrated and provided real-time information across teams and services
  • An advanced clinical pharmacy service which included a consultant pharmacist and pharmacy prescribers had been developed to improve the safety and efficacy of medicines used in Critical care.
  • The one to one team and specialist midwife clinics gave greater assurance that high risk women continued to have a choice on the care they received in pregnancy.
  • The rapid access clinic reduced readmissions of babies with feeding problems.
  • The GRIP project responsible for getting research into practice improved services for maternity and gynaecology.
  • The termination of pregnancy service gave women continuity of care in an appropriate caring environment. The seven day service gave women choice and improved accessibility.
  • The use of the Enhanced Recovery programme in both maternity and gynaecology improved the service for women.

Weston Park Hospital

  • Specialised cancer services provided a patient-centred holistic approach to patient care where the whole multidisciplinary team worked together to ensure the patient’s experience of the service was the best that it could be.
  • The teenage cancer unit had a number of innovations which had been paid for out of charitable funds. These included a ‘couples retreat’ for end of life patients and their partners. They could spend time away from home and explore issues about coming to the end of life.

Community end of life care

  • The intensive home nursing service provides support for patients and their families in the last days and hours of life. Relatives consistently praised the service and the staff who provided it.

Community inpatients

  • Feedback we received from patients was consistently positive about the way nursing and therapy staff treated them. Patients told us that staff go the extra mile. Staff and patients confirmed that the unit had a flexible approach to care.
  • Patients were supported emotionally. Activities such as singing, arts and crafts were arranged to prevent social isolation and boredom.

Charles Clifford Dental Hospital

  • An holistic approach to individual patient’s requirements was modelled within CCDH, and anxious patients had the option of utilising cognitive behavioural therapy (CBT), acupuncture, hypnosis, inhalation, or intravenous or oral sedation to assist with their dental treatments.
  • Staff were sensitive to the needs of vulnerable patients, making reasonable adjustments to ensure that effective two-way communication was achievable to allow patients to be fully empowered to make decisions about their treatment options.
  • The service worked with a local dental unit to provide an out of hours (17:00 – 20:00) oral surgery Consultant led clinic for patients who were unable to be released from work within core hours, enabling them to attend one evening each week.

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

Importantly, the trust must:

  • The trust must ensure patients do not wait longer than the recommended standard for assessment and treatment in the emergency department.
  • The trust must ensure that on initial assessment in the “pit stop area” in the emergency department patient’s vital signs are taken and recorded consistently.
  • The trust must monitor performance information to ensure 95% of patients are admitted, transferred or discharged within four hours of arrival in the emergency department.
  • The trust must ensure the safe storage of intravenous fluids.
  • The trust must ensure doctors follow policy and best practice guidance in relation to the prescription of oxygen therapy.
  • The trust must ensure that guidance is followed in the documentation of foetal heart rate monitoring.
  • The trust must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced staff on duty at Weston Park Hospital.
  • The trust must ensure the divisional risk registers reflect issues in the emergency department demonstrate evidence of actions and reviews.
  • The trust must ensure there is a clear strategy for the end of life care which is implemented and monitored.
  • The trust must ensure that staff implement individualised, evidence based care for patients at the end of life.
  • The trust must ensure that DNACPR records are fully completed.
  • The trust must ensure that staff complete mandatory training in accordance with the trust policy

Professor Sir Mike Richards

Chief Inspector of Hospitals

8 – 11 December 2015

During an inspection of Community dental services

We rated the community dental services at this trust as outstanding. This was because:

  • Staff protected patients from abuse and avoidable harm. A specialist dentist working in the service had contributed to the development of theresource website ‘child protection and the dental team’, initially funded by the Department of Health and now hosted by the British Dental Association. This resource is used nationally by general dental practice teams for the effective management of safeguarding children in dental practice. Systems for identifying, investigating and learning from patient safety incidents were in place. Infection control procedures were in place. The environment and equipment were clean and well maintained and medicines and emergency equipment was available at each site we visited to deal with medical emergencies. However, due to the age and design of the Manor clinic the delivery of optimal care to patients who were confined to a wheelchair was difficult.

  • The dental services were effective and focused on patients’ and their oral health care. We saw several examples of innovative care approaches including the provision of care to the most vulnerable members of society. Those vulnerable members included Sheffield’s homeless community who were treated through the The service could meet patients’ needs because of the flexible attitude of all service members. In collaboration with commissioners of dental services and dental public health consultants, Sheffield community dental service developed a domiciliary service called Residential Oral Care Sheffield (ROCS). Senior dentists and the oral health promotion team in the service work in partnership with local general dental practitioners to deliver effective dental care to 90 care homes in Sheffield.

  • Patients, relatives and carers said they had positive experiences of care within the service. We saw good examples of staff providing compassionate and effective care. We also saw effective interactions taking place between individual staff members. We found staff to be hard working, caring and committed to the care and treatment they provided. Staff spoke with passion about their work and conveyed their dedication to what they did.

  • Staff responded to patients’ needs at each clinic we visited. The service kept treatment delays for routine dental treatment within reasonable limits through effective resource management. Effective multidisciplinary team working ensured the service provided patients with care that met their needs and at the right time. We saw specialist dental teams delivering dental care to mental health services, the homeless of Sheffield, the spinal injuries unit and special schools.

  • The community dental service was well led. Organisational, governance and risk management structures were in place. The service’s operational management team was visible and the working culture appeared open and transparent. Staff were aware of ‘PROUD’ and the organisation’s vision and way forward and they said they felt well supported and that they could raise any concerns.

  • The Sheffield community dental service had achieved national profile status in community dentistry through a number of innovative projects. The clinical lead was instrumental in developing a ‘case mix’ tool kit that is used to describe the complexity of the patients treated in the community dental services. Commissioners of dental services when commissioning community dental services use this tool kit as a national benchmark. Commissioners also use the tool kit as a key performance indicator when judging the effectiveness of a community dental service.

07 - 11 December 2015

During an inspection of Community health services for adults

Overall rating for this core service Outstanding

Overall we found services for community adults to be outstanding.

There were robust methods of reporting, investigating and learning from incidents and near misses that staff understood and embedded in their daily work. There was a risk register in place that ensured potential risks were known, assessed and appropriate controls were implemented. Pharmacists worked with community teams and had written and reviewed standard operating procedures to improve safety around medicines.Compliance with mandatory training was generally high and we observed good infection control practices. We found that staffing levels met the needs of patients.

We found care and treatment was evidenced based with pathways of care based on National Institute of Clinical Excellence (NICE) guidelines. There were excellent examples of multi-professional teams working closely together for the benefit of patients. Referrals to community services were managed by the Single Point of Access (SPA) service, which established the most appropriate service for the patient. Staff had good access to records using laptops with 4G and used an electronic patient record system allowing information to be shared between professionals. Staff we spoke to had a good level of knowledge about the Mental Capacity Act and Deprivation of Liberty Safeguards.

Caring was good. We found staff were genuinely caring and passionate about the care they provided to patients. Patients we spoke to all said they were extremely happy with the care they received and felt they were always treated with compassion. Patient’s relatives said they thought the care provided had been excellent and staff had been caring and responsive. We observed staff treating patients with dignity and respect. Patients and their relatives were involved in their care. We observed treatment and support options being discussed with patients and their families before gaining consent and agreement. Emotional support was made available for example; mental health services aligned to the active recovery team provided talking therapies for patients and could signpost patients to other agencies. We saw staff putting on overshoes when entering patients home in wet weather. We thought this was extremely considerate.

Community services were exceptionally responsive. There was close working with commissioners to provide services along coordinated pathways of care. We saw good examples of community services working closely and planning services with the acute hospitals to provide integrated care to patients. The active recovery team had redesigned the traditional model of assessing to discharge to the more patient centred approach of discharge to assess. The first ward to implement discharge to assess had a sustained reduction in length of stay of 7 days. Access to services via the single point of access was excellent, ensuring patients were seen by the right professional at the right time at a venue of their choice. Staff were aware of cultural differences. Patient information leaflets were available in different languages and there was good access to interpreting services. Community nursing teams had a dedicated member of staff who was the dementia link. Staff we spoke to had completed dementia training and could describe how they would provide extra support for patients living with dementia. There was shared learning from complaints and we saw evidence that changes were made in response to complaints.

Community services were extremely well led. Senior managers could articulate their vison and strategy and shared this with staff. There was strong leadership at both senior and local level. Staff spoke highly of their managers and felt well supported and listened too. Senior managers were often seen and staff said they were approachable. Staff engagement was outstanding. The trust used different methods of engaging the staff such as the ‘listening into action’ events and ‘you said we did’ initiatives. Staff were consulted with and encouraged to lead on service development and change and they felt empowered and valued. There was a positive culture of service improvement and we found innovative services along pathways of care, which reached across both hospitals, and community services.

07-11 December 2015

During an inspection of Community end of life care

Overall rating for this core service Good

We rated the community end of life service as good. We found patients were receiving care which was safe, effective and caring. However, we rated well-led as requires improvement.

Staff were encouraged to report incidents and near misses. They said it was easy to report incidents when they returned to their team bases. They said they were trained to carry out root cause analysis and discuss the lessons learned with colleagues at team meetings. Incidents were analysed across the palliative care and therapeutics directorate and discussed at their operational business and governance meeting.

Community nursing teams were able to access guidance for medicines management of community patients in last few days of life. A community infection control accreditation programme had been developed which set standards for infection prevention and control. The programmed aimed to assess and optimise infection prevention and control practices throughout community services.

Patient’s pain and their nutrition and hydration needs were being effectively assessed.

We found many examples of good practice, for example, the introduction of electronic laptops which enabled community teams to record information at the time it was being delivered in patients’ homes and send GPs electronic messages. The intensive home nursing service provided city wide care including respite care for people in the last days of life. Patients, relatives and staff working in other services spoke very highly about the service and the staff who provided it.

The trust had developed a range of mechanisms for responding to patients’ needs during the working day and out of hours and relatives told us the intensive home nursing service responded to their needs quickly, offering examples of service which had been put in place the same day.

The service had developed guidance for the service to replace the Liverpool care pathway and were supporting staff to complete the end of life template developed by primary care. However, the guidance for staff caring for people at the end of life had been introduced recently and not all staff were clear how they should incorporate this into their clinical practice. Some staff were enthusiastic about using the end of life template on the electronic record system but the template did not include information about people’s spiritual or emotional needs. The trust had developed guidance for staff assessing the spiritual needs of patients approaching the end of life.

The trust did not monitor whether patients died in their preferred place of care. This meant the service did not monitor one of the key indicators for the service. The information system used by the trust could capture this information and recording was encouraged however the information was not being collected and monitored.

There had been a number of changes to the structure and leadership of the service in 2015. Integrated pathway managers were appointed who were responsible for improving the pathways for patients between the hospital and community services. However, plans for achieving this had not been developed. Some services which had worked together were now managed in different directorates and staff were unclear about how they would communicate and develop together in future. Each directorate had a different method of reporting with different metrics, measures and definitions. Managers acknowledged the need for improved systems to monitor the effectiveness of services.

7-8 December 2015

During an inspection of Community health inpatient services

Overall rating for this core service. Good 

We rated Beech Hill as good overall, however we rated the unit as requires improvement for safe. The unit used an electronic reporting system for incidents and near misses. All staff we spoke with knew how to use the system. We found that medicines were securely stored on the unit. All areas of the unit looked visibly clean, well maintained and infection prevention and control measures were embedded on the unit. Staff took a proactive approach to safeguarding. We saw effective handovers and shift changes; however, we had some concerns about staffing levels. Rosters for night duties indicated that there was one registered nurse and one care support worker on each ward, with a second care support worker who worked between the two wards. Rosters also showed that the minimum planned staffing levels were not always met. The wards were on separate floors. Senior staff we spoke with told us that increased numbers of patients were being referred back to the acute hospitals because they were not medically fit. Staff were not using a recognised early warning tool to recognise a deteriorating patient. This was because there was an expectation on the unit that patients were medically fit. Therefore staff used their observations and clinical judgement. We also found that resuscitation equipment was not always checked in line with the trust’s policy and it was not always possible to identify if equipment was clean.

We rated effective as good because people’s care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation. Patients were receiving adequate pain relief, nutrition and hydration. There was participation in relevant local and national audits, including clinical audits and other monitoring activities such as reviews of services, benchmarking, peer review and service accreditation to improve services for patients. There was a centrally hosted clinical computer system, which allowed all members of the MDT to access and share records. Staff received a comprehensive trust induction programme and timely appraisals. Staff were also supported with professional development. Consent to care and treatment was obtained in line with legislation and guidance, including the Mental Capacity Act 2005. We saw evidence that patients were supported to make decisions and, where appropriate, their mental capacity was assessed and recorded. Deprivation of Liberty was recognised and acted on in a timely and appropriate manner.

We rated caring as outstanding. We found that feedback we received from patients was consistently positive about the way nursing and therapy staff treated them. Patients told us that staff went the extra mile. Staff and patients confirmed that the unit had a flexible approach to care. We saw that the staff were highly motivated and inspired to offer care that was kind, promoted people’s dignity, and involved them in planning their care. Patients said that staff were lovely, could not do enough for them, attended to every wish and were caring, compassionate, sensitive and supportive. Relationships between patients, those close to them and staff were strong, caring and supportive. Patients and their families’ personal, cultural, social and religious needs were seen as a priority by all staff. Activities such as singing, arts and crafts were arranged to prevent social isolation and boredom. Patients said that they felt ‘safe and secure’.

We rated responsive as good. We found that the services were planned and delivered in a way that meets the needs of the local population. The needs of different people were taken into account when planning and delivering services. Staff told us that they respect the equality and diversity of their patients. Patients and families we spoke with confirmed this. The facilities and premises were appropriate for the services being delivered. We spoke with the matron and found that there was an openness and transparency in how complaints were dealt with. Complaints and concerns were taken seriously, responded to in a timely way and listened to. Improvements were made to the quality of care as a result of complaints and concerns.

We rated well led as good because the trust had a clear statement of vision and values, driven by quality and safety, which was recognised and integrated within the unit. Staff we spoke to were aware of and based their care around the trusts PROUD values. There was good interaction between the board and the unit. Senior staff shared details of the board and governance meetings with staff on the unit. Senior staff were visible, approachable and supportive to staff and patients. Leaders were actively engaged with staff, people who used services and their representatives and stakeholders. Therapy staff told us that they were proud of how the team worked together to achieve targets and ’go the extra mile’. There was a strong focus on continuous learning and improvement at all staff levels. Staff shared innovations and improvement work that they were involved with.

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.