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Provider: Wye Valley NHS Trust Requires improvement

Read our previous inspection reports for Wye Valley NHS Trust, published on 14 October 2014.

We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

Reports


Inspection carried out on 5, 6, 7, 8, 11, 17, 18 July 2016

During a routine inspection

Wye Valley NHS Trust was established in April 2011 and provides hospital care and community services to a population of 186,000 people in Herefordshire and a population of more than 40,000 people in mid-Powys, Wales. The trust also provides a full range of district general hospital services to its local population, with some links to larger hospitals in Gloucestershire, Worcestershire and Birmingham. During this inspection we only inspected the services provided by Hereford Hospital. We did not inspect community services provided by the trust. Therefore, the overall rating for community services remains as requires improvement, as per the September 2015 inspection.

There are approximately 236 beds of which 208 are general and acute, 22 maternity and six critical care beds within Hereford Hospital. The trust employs 2,601 whole time equivalent staff as of June 2016..

We carried out this inspection as part of our comprehensive programme of re-visiting trusts which are in special measures. We undertook an announced inspection from 5 to 8 July 2016 and unannounced inspections on 11, 17 and 18 July 2016.

Overall, we rated Hereford Hospital as requires improvement with three of the five questions we ask with safe, effective and well led being judged as requiring improvement. We rated Hereford Hospital as inadequate for being responsive as patients were unable to access all services in a timely way for initial assessments, diagnoses and/or treatment.

We rated caring as good. Patients were treated with kindness, dignity and respect and were provided the appropriate emotional support.

Our key findings were as follows:

Safe

  • There was a high vacancy rate which meant an increased use of agency and bank staff. The safer nurse staffing levels were planned in line with the national recommendations. The average trust fill rate for registered nurses remained below 95%, ranging from 74.5% on Wye ward to 109.4% on Monnow ward for June 2016. The trust strategy was to cover unfilled registered nurse shifts with a health care assistant where appropriate, to help mitigate staffing level risk. For June 2016 the hospital health care assistant fill rate was 116% for day shifts and 122% for night shifts. We found actual staffing levels met planned staffing levels on most wards during our inspection. We found no incidents relating to staff shortages directly affecting patient care at ward level.
  • Mandatory and statutory training compliance for June 2016 was at 86% which although had improved from 78% in July 2015, did not meet the trust target of 90%.
  • Patients’ weight was not always recorded on patients’ prescription charts, which could potentially lead to the incorrect prescribing of the medicine.
  • In maternity, the anaesthetic room used as a second theatre on the delivery suite was not fit for purpose. This could lead to increased risk of infection for mother and baby.
  • Staff were aware of their responsibilities regarding safeguarding procedures.
  • Staff understood their responsibility to report concerns, to record safety incidents and near misses. Staff received feedback on all incidents.
  • Staff had an awareness of the duty of candour process, however just prior to the inspection the trust had identified that it was not following all the requirements of the regulation in that it was not confirming their discussions with patients in writing and had put actions in place to address this.
  • Ward and clinical areas were visibly clean and staff were observed following infection control procedures.
  • There were systems in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients.

Effective

  • The Summary Hospital-level Mortality Indicator (SHMI) and the Hospital Standardised Mortality Ratio (HSMR) indicated more patients were dying than would be expected. This had been reported to the trust board and an action plan was in place to understand and improve results.
  • The caesarean section rate was significantly higher (worse) than the national average and the deteriorating rate was not recorded on the risk register.
  • Most care was delivered in line with legislation, standards and evidence-based guidance. However, some trust guidelines needed updating.
  • The service had a series of care bundles in place, based on the appropriate guidance for the assessment and treatment of a series of medical conditions. However, there was no hip fracture pathway within the hospital although we were told that this was being drafted.
  • The trust had processes in place to monitor some patient outcomes and report findings through national and local audits and to the trust board. Performance in national audits had generally mixed results compared to the national average. Actions plans were in place to address areas needing improvement.
  • Staff were clear about their roles and responsibilities regarding the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

Caring

  • Staff were observed being polite and respectful during all contacts with patients and relatives. Staff protected patients’ privacy and dignity.
  • Patients felt involved in planning their care.

Responsive

  • The emergency department consistently failed to meet standards in terms of the amount of time patients spent in the department and waited for treatment.
  • Bed occupancy was consistently worse than the national average.
  • Patients were unable to access the majority of outpatient services in a timely way for initial assessments, diagnoses and/or treatment. The trust had put a system in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients on the waiting list.
  • The trust did not consistently meet all cancer targets for referral to treatment times.
  • Overall referral to treatment indicators within 18 weeks for admitted surgery patients was worse than the England average.
  • The percentage of patients that had cancelled operations was worse than the England average.
  • Delays in accessing beds in hospital were resulting in mixed sex occupancy breaches on the intensive care unit each month.
  • The trust did not have an electronic system in place to identify patients living with dementia or those that had a learning disability.
  • Staff adapted care and treatment to meet patient’s individual needs.
  • We saw examples of services planning and delivering care to meet the needs of patients.
  • Systems and processes were in place to provide advice to patients and relatives on how to make a complaint.

Well-led

  • The trust had governance oversight of incident reporting and management. The board assurance framework and corporate risk register identified most of the keys risks.
  • The executive team could demonstrate good understanding of the risks, issues and priorities in human resource management. However, overcoming some of these issues, such as recruitment, remained a significant challenge.
  • The trust implemented a new organisational structure in June 2016, with three service units reduced to two divisions, medical and surgical. Although staff felt the reconfiguration was positive and provided more support we were unable to assess the sustainability and effectiveness of the restructure as this had not yet been fully embedded into the trust.
  • The trust had a vision, their mission and their values. However, these were not fully embedded or understood by staff.
  • There was no equality and diversity strategy.
  • Following the trust being placed into special measures in October 2014, a comprehensive quality improvement plan was developed, which included a number of projects and actions. We saw that the action plans were reviewed regularly, with monitoring of compliance against targets and details of completed actions.
  • There was a sense of pride amongst staff towards working in the hospital and they felt respected and valued.
  • We were assured that appropriate steps had been taken to manage the ‘Fit and Proper persons’ legislation implementation.

We saw several areas of outstanding practice including:

  • Services for children and young people were supported by two play workers (one was on maternity leave at the time of inspection). The play workers regularly made arrangements for long term patients to have days out to different places, including soft play areas or bowling. An activity was arranged most months and the play workers sourced the activities from local businesses who donated their good and/ or services. This meant that patients with long term conditions could meet peers who also regularly visited the hospital. Patients found this valuable and liked the opportunity to meet patients who had shared experiences.
  • There was a children’s and young people’s ambassador group which was made up of patients who used or had used the service. We spoke with some members of the ambassador group who told us that they were involved in the service redesign when developments took place and improving the service for other patients.
  • The respiratory consultant lead for non invasive ventilation had developed a pathway bundle, which was used for all patients requiring ventilator support. The pathway development was based on a five-year audit of all patients using the service and the identification that increased hospital admissions increased patient mortality. The information gathered directed the service to provide an increased level of care within the patient’s own home. Patients were provided with pre-set ventilators and were monitored remotely. Information was downloaded daily and information and advice feedback to patients by the medical team. This allowed treatments to be altered according to clinical needs. The development had achieved first prize in the trust quality improvement project 2016.
  • The newly introduced clinic for patients with epilepsy had enlisted the support of a patient with epilepsy; their views had helped the clinic develop so that the needs of patients were met.
  • Gilwern assessment unit was not identified as a dementia ward, however, this had been taken into consideration when planning the environment. The unit had been decorated with photographs of “old Hereford” which were used to help with patients reminiscing. Additional facilities included flooring that was sprung to reduced sound and risk of harm if patients fell, colour coded bays and wide corridors to allow assisted mobility. Memory boxes were available for relatives to place personal items and memory aids for patients with a history of dementia, and twiddle mittens provided as patient activities. The unit provided regular activities for patients, which included monthly tea parties and games.

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

Importantly, the trust must:

  • The trust must ensure that all staff receive safeguarding children training in line with national guidance, in particular in the emergency department.
  • The trust must ensure that enough staff are trained to perform middle cerebral arterial Doppler assessments, to ensure patient receive timely safe care and treatment.
  • The trust must ensure there are enough sharps bins available for safe and prompt disposal of used sharps.
  • The trust must ensure that patients’ weight is always recorded on patients’ prescription charts, to ensure the correct prescribing of the medicine.
  • The trust must ensure that medicine records clearly state the route a patient has received medicine, in particular, whether a patient has been given the paracetamol orally or intravenously.
  • The trust must ensure all medicines are stored in accordance with trust polices and national guidance, particularly in outpatients.
  • The trust must ensure that all patients receive effective management of pain and there are enough medicines on wards to do this.
  • The trust must ensure all staff have received their required mandatory training to ensure they are competent to fulfil their role.
  • The trust must ensure all staff are supported effectively via appropriate clinical and operational staff supervisions systems.
  • The trust must ensure staff receive appraisals which meet the trust target.
  • The trust must ensure that patients are able to access surgery, gynaecology and outpatient services in a timely way for initial assessments, diagnoses and/or treatment, with the aim of meeting trust and national targets.
  • The trust must continue to take action to address patient waiting times, and assess and monitor the risk to patients on the waiting list.
  • The trust must ensure the time taken to assess and triage patients within the emergency department are always recorded accurately.
  • The trust must ensure effective and timely governance oversight of incident reporting and management, particularly in children and young people’s services.
  • The trust must ensure all policies and procedures are up to date, and evidence based, including the major incident policy.

The trust must ensure that all risks are identified on the risk register and appropriate mitigating actions taken.

Please refer to the location report for details of areas where the trust SHOULD make improvements.

The trust was placed into special measures in October 2014. Due to the improvements seen at this inspection, I have recommended to NHS Improvement that the special measures are lifted.

Professor Sir Mike Richards

Chief Inspector of Hospitals


CQC inspections of services

Service reports published 20 January 2016
Inspection carried out on 22, 23 and 24 September 2015 During an inspection of Community health services for children, young people and families Download report PDF | 391.16 KB (opens in a new tab)
Inspection carried out on 22, 23 and 24 September 2015 During an inspection of End of life care Download report PDF | 308.15 KB (opens in a new tab)
Inspection carried out on 23 September 2015 During an inspection of Community dental services Download report PDF | 277.16 KB (opens in a new tab)
Inspection carried out on 22, 23 and 24 September 2015 During an inspection of Community health services for adults Download report PDF | 309.37 KB (opens in a new tab)
Inspection carried out on 22, 23 and 24 September 2015 During an inspection of Community health inpatient services Download report PDF | 389.38 KB (opens in a new tab)
See more service reports published 20 January 2016
Inspection carried out on 22 to 25 September 2015

During a routine inspection

Wye Valley NHS Trust provides hospital care and community services to a population of slightly more than 180,000 people in Herefordshire. The trust also provides urgent and elective care to a population of more than 40,000 people in mid-Powys, Wales.

The trust’s catchment area is characterised by its rural nature and remoteness, with more than 80% of service users living five miles or more from Hereford city or a market town. The trust has 387 beds and provides a full range of district general hospital services.

We inspected the trust in June 2014 and gave an overall rating of ‘Inadequate’, with particular concerns about the provision of services in both urgent and emergency services and medical care services. The inspection led to the trust being placed in special measures by the Trust Development Authority in October 2014. The trust developed a patient care improvement plan in order to implement improvements. An improvement director was appointed by the Trust Development Authority and commenced work in February 2015 to assist the trust to progress.

We undertook an announced inspection of Hereford Hospital, Bromyard, Leominster and Ross Community Hospitals between 22 and 24 September 2015. We undertook unannounced inspections on 25 September 2015 at Leominster Community Hospital and 1 October 2015 at Hereford Hospital.

We held focus groups with a range of staff in the hospital, including nurses, junior doctors, consultants, midwives, student nurses, administrative and clerical staff, allied health professional, domestic staff and porters. We also spoke with staff individually.

There were some areas of improvement from the previous inspection particularly within community services and urgent and emergency service. However, there were areas where significant improvement was required.

Overall, we rated Wye Valley NHS Trust as inadequate, with two of the five key questions which we always rate being inadequate (safe and responsive). Improvements were needed to ensure that services were safe and responsive to patient’s needs. We found that effectiveness and well led required improvement.

Five of the eight core services at Hereford Hospital were rated inadequate for safety.

The outpatient and diagnostic services at Hereford Hospital were rated overall as inadequate. All other services at Hereford Hospital were rated as requires improvement.

All community services were rated as good, with the exception of community inpatient services and community end of life care which were rated as requires improvement.

Overall we have judged the services at the trust as good for caring. Patients were treated with dignity and respect and were provided with appropriate emotional support. We found caring in community adult services to be outstanding.

Our key findings were as follows:

  • Staff were kind and caring and treated people with dignity and respect.
  • Overall the hospital was clean, hygienic and well maintained.
  • Equipment was not always appropriately checked and maintained.
  • Recruitment was a significant risk for the trust.
  • The trust had high vacancy levels across both nursing and medical staff. With some areas having vacancy levels in excess of 40% for nursing staff at the time of the inspection.
  • Temporary staff usage was high and temporary staff did not always receive an effective induction.
  • Staff did not always have the appropriate training.
  • A recruitment programme was ongoing and changes had been made to speed up the recruitment process. Oversees recruitment had taken place.
  • Patient’s pain was well managed and women in labour received a choice of pain relief. Patients at the end of life were given adequate pain relief and anticipatory prescribing was used to manage symptoms.
  • Monitoring by the Care Quality Commission had identified mortality was above the expected range of 100 with a value of 114. The trust were implemented a series of actions to address this concern.
  • The trust were not consistently meeting the national targets set regarding patients access to treatment and there was lack of oversight of the risk this presented to patients.
  • The trust were not meeting the standard for patients admitted, referred or discharged from the emergency department within four hours.
  • The trust did not have effective governance oversight of incident reporting and management, including categorisation of risk and harm. Incident management was not effective as to allow for the timely mitigation of the risks relating to the health, safety and welfare of service users.
  • There was a lack of knowledge amongst trust staff with whom we spoke about when to make safeguarding referrals.
  • Staff generally felt they were well supported at their ward or department level.
  • Visibility of the executive directors had improved since the last inspection.

We saw several areas of outstanding practice including:

  • The trust had established a young people’s ambassador group. This was run by a group of patients who had used the service or continued to use the service. The group met regularly and were consulted on changes on changes and developments, for example they had recently introduced a ‘Saturday club’ and had been involved in the ED Patient-Led Assessment of the Care Environment audit (PLACE) aiding the redesign of the children’s waiting are; and had been involved in interviewing new staff in community services for children and young people. We spoke with some representatives from the group who were very passionate about their role and welcomed the opportunity to make a difference.
  • Compassionate care and emotional support provided by community adult service teams was excellent. Staff had a clear focus for providing best possible care and improving the well-being of patients they saw.
  • Community services for children and young people had submitted a proposal for a group project incorporating local health visiting teams, children’s centres, the local community and various members of the multi-agency team. The aims of the project were to: provide support and information to families on how to achieve healthy lifestyles; promote and support and encourage sensible weight management; enhance families ability to cook health nutritious meals; increase families social networks and therefore their social capital, leading to increased self-esteem and self-confidence; enhance links within the community by incorporating volunteers from within the community to help within practicalities of running groups on a regular basis; encourage links to other services within the community that promote lifestyle change, such as local gyms and swimming pool.
  • Health visitors in Leominster supported children in need at Christmas with a Christmas hampers project by utilising local community charities and food bank services to donate food hampers for families in need.
  • Health visitors at Ross Community Hospital had an allotment project to improve community engagement and encourage healthy eating. HVS had worked with a local charity to access allotments, for use by local communities to grow their own produce and share with families who had food and nutritional needs.
  • A member of the Leominster SNS team had won a prize from a national professional journal for producing a domestic abuse peer support programme.
  • The development of ‘Fresh Eyes Peer Review’, for complaints, which is an excellent example of a non-threatening, transparent, open and supportive initiative in organisational learning.
  • The education team had effective plans in place and appropriate clinical direction. The team had been well embedded for some years and that the team was a beacon of good practice within the trust.

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

Importantly, the trust must:

  • Ensure that where a person lacks capacity to make an informed decision or given consent, staff must act in accordance with the requirements of the Mental Capacity Act 2005 and associated code of practice.
  • The trust must ensure safeguarding referrals are made as appropriate.
  • The trust must ensure all staff have the appropriate level of safeguarding training.
  • The trust must ensure all staff have received their required mandatory training to ensure they are competent to fulfil their role.
  • The trust must ensure all staff are supported effectively via appropriate clinical and operational staff supervisions systems.
  • The trust must ensure staff receive and appraisal to meet the appraisal target of 90% compliance.
  • The trust must ensure there are enough suitably qualified staff on duty within all services, in accordance with the agreed numbers set by the trust and taking into account national recommendations.
  • The trust must ensure there are the appropriate number of qualified paediatric staff in the ED to meet standards set by the Royal College of Paediatrics and Child Health 2012 or the Royal College of Nursing.
  • The trust must ensure consultant cover meets with the Royal College of Emergency Medicine’s (RCEMs) emergency medicine consultants workforce recommendations to provide consultant presence in the ED 16 hours a day, 7 days a week as a minimum.
  • The trust must ensure processes in place are adhered to for the induction of all agency staff.
  • The trust must ensure ligature points are identified and associated risks are mitigated to protect patients from harm.
  • The trust must ensure risk registers reflect the risks within the trust.
  • The trust must ensure all incidents are reported, including those associated with medicines.
  • The trust must ensure effective and timely governance oversight of incident reporting management, including categorisation of risk and harm, particularly in maternity services.
  • The trust must review the governance structure for all services at the hospital to have systems in place to report, monitor and investigate incidents and to share learning from incidents.
  • The trust must ensure that all trust policies and standard operating procedures are up to date and that they are consistently followed by staff.
  • The trust must ensure all medicines are prescribed and stored in accordance with trust procedures.
  • The trust must ensure patient records are stored appropriately to protect confidential data.
  • The trust must ensure patient records are accurate, complete and fit for purpose, including Do Not Attempt Cardio-Pulmonary Resuscitation forms and prescription charts.
  • The trust must ensure risk assessments are completed in a timely manner and used effectively to prevent avoidable harm, such as the development of pressure ulcers within ED and pain assessments for children.
  • The trust must ensure that mortality reviews are effective with the impact of reducing the overall Summary Hospital-level Mortality Indicator (SHMI) for the service.
  • The trust must ensure there are robust systems are in place to collect, monitor and meet national referral to treatment times within surgery and outpatient services.
  • The trust must ensure there are systems in place to monitor, manage and mitigate the risk to patients on surgical and outpatient waiting lists.
  • The trust must ensure staff check the “site” of the operation to ensure this is appropriately marked, prior to the operation; and ensure that the “site” of the operation is documented on the 5 Steps to Safer Surgery checklist.
  • The trust must ensure all incidents of pressure damage are fully investigated, particularly within ITU.
  • The trust must ensure there is a policy available to ensure safe and consistent practice for parents to administer medicines to their children.
  • The trust must ensure there is a system in place to recognise, assess and manage risks associated with the temperature of mortuary fridges.
  • The trust must ensure clinicians have access to all essential patient information, such as patients’ medical notes, to make informed judgements on the planned care and treatment of patients.
  • The trust must ensure outpatients patients are followed up within the time period recommended by clinicians.

  • The trust must ensure that the categorisation of incidents is completed accurately and full investigations are carried out as appropriate, including the identification of themes to ensure relevant actions are implemented.

  • The trust must ensure that governance systems in place are effective. This includes ensuring practices are consistent, in line with hospital policies, and documents are approved through the clinical governance structure.

Following the inspection we issued Hereford Hospital with a warning notice under section 29a of the Health and Social Care Act 2008. On the basis of this inspection, we are recommending the trust remains in special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 3, 4, 5 and 19 June 2014

During a routine inspection

Wye Valley NHS Trust was established on 1 April 2011. The trust provides community services and hospital care (acute and community) to the population of Herefordshire. It also provides urgent and elective care to people in Powys Mid Wales. There are 18 locations registered with the Care Quality Commission (CQC); we visited Hereford County Hospital, Hillside Centre and Leominster, Ross on Wye and Bromyard community hospitals as part of this inspection.

We carried out a comprehensive inspection because Wye Valley NHS Trust had been flagged as high risk on CQC’s Intelligent Monitoring system (which looks at a wide range of data, including patient and staff surveys, hospital performance information, and the views of the public and local partner organisations). The announced inspections took place on 3, 4, 5, June with an unannounced inspection on 19 June 2014.

Overall, we found that services at Wye Valley NHS Trust were inadequate, with particular concerns about services in A&E and medical care. We rated it as ‘good’ for providing services that were caring, but A&E services were falling short of the level of care that would be expected. Improvement is required for the trust to provide effective care, and it was rated as inadequate for safety, for being responsive to patient needs and for being well-led.

Our key findings were as follows:

  • Across the trust the majority of staff in both acute and community teams were caring and compassionate. But in A&E we found that patients’ personal needs were not always met and they had limited access to fluids and food.
  • Privacy and dignity was maintained in most areas, but there were areas, such as in A&E and outpatients, where a lack of space or adequate sound proofing was preventing privacy at all times.
  • Overall, the trust was clean and well maintained across both acute and community locations.
  • Incident reporting was inconsistent. Not all staff were confident to report incidents. Some groups of staff did not have access to the electronic reporting system. Some explained that they would tell the nurse in charge and it would be up to them to decide whether to report it or not. There was a lack of feedback following incidents. This was seen across many service areas.
  • There were examples of poor systems for the management of medicines. These were not consistently in line with the trust’s policy, with examples of poor storage and administration. 
  • Forms for “do not attempt cardiopulmonary resuscitation” (DNA CPR) were not completed in line with the trust’s policy.
  • The trust had a higher than expected mortality rate for the demography of the patients admitted as measured by the Hospital Standardised Mortality Ratio.
  • The trust needed to confirm the future of stroke services. There was no appropriate access to specialist staff, inadequate escalation to stroke consultants and a low number of people receiving thrombolysis therapy.
  • Staff needed access to training to ensure that they have the correct competencies, skills and expertise to effectively care for and treat patients.
  • Mandatory training for staff was not up to date, with particular shortfalls in safeguarding of vulnerable adults and children and in the Mental Capacity Act. The trust recognised this and was taking action to address.
  • There were some examples of patients not having sufficient access to adequate nutrition and hydration.
  • There were shortfalls across the trust in medical, nursing and midwifery staffing, which affected day-to-day care. It was also preventing the development of seven-day services in some areas, for example, in endoscopy and stroke care.
  • There were significant issues with the flow of patients into, through and out of the trust, with high bed occupancy rates, sometimes rising to over 100%. The trust was failing to meet the four-hour target for patients attending A&E to be admitted, discharged or transferred. There were instances when patients remained on a trolley in A&E for over 12 hours. The trust was not able to accommodate medical patients in medical beds, and was having to use beds on the surgical wards, the surgical day unit, the clinical assessment unit and the discharge lounge. This resulted in delays in reviewing patients, elective operations being cancelled and difficulty finding beds for patients who needed to be admitted from outpatients. Due to the capacity issues, additional beds had been opened in one of the community hospitals, but it was difficult to access additional staff.
  • Equipment was not always accessible or appropriately stored.
  • Staff in children and young people’s services in both the acute and community settings felt they were not integrated with other services in the trust.
  • There were areas throughout the trust where risks were not escalated and therefore not effectively acted on. There was poor correlation between the risks discussed by staff and the trust’s risk register.
  • Audits were being undertaken, but in some areas there was a lack of evaluation of the effectiveness of care (outpatients and end of life care in the community).
  • In some areas nursing staff were undertaking responsibilities beyond their grade and level of experience.
  • Clinical supervision was not well developed.
  • Staff in community teams felt vulnerable when working on-call, particularly at night, and sometimes having long distances to travel with poor mobile signals.

We saw several areas of outstanding practice including:

  • Dedicated and committed staff going the extra mile for their patients.
  • Virtual wards, hospital at home and complex discharge coordinators, which had been established to prevent patients from needing to come into hospital and to promote timely and effective discharges.
  • There were excellent preoperative assessments, which included a public health element.
  • Community services for children were recognised to be good in all five key questions that we assessed.

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

Importantly, the trust must:

  • Ensure that all environments support the privacy and dignity of patients.
  • Ensure that all patients have access and support if required to appropriate foods and fluids.
  • Ensure that all staff have access to report incidents, feel confident to do so, receive feedback that lessons are learned and where appropriate, that learning is disseminated across the trust.
  • Ensure that reviews of patients are undertaken in a timely manner and that patients do not get lost in the system.
  • Ensure that action is taken to improve the flow of patients into, through and from the trust.
  • Ensure that improvements are made to discharge planning and arrangements, so that people are able to leave hospital when they are ready. Work must continue with partners to ensure that discharge arrangements have patients at the heart of the process.
  • Ensure that risks are recorded, escalated and acted on.
  • Improve end of life care in both the hospital and the community.
  • Ensure that medicines are managed in line with the trust’s medication policy.
  • Ensure that forms for recording “do not attempt cardiopulmonary resuscitation” are completed in line with trust policy.
  • Continue to improve mortality rates.
  • Confirm the future of stroke services, ensuring that there is appropriate access to care both now and in the future. 
  • Ensure that staff receive both mandatory training and training to ensure they have the correct competencies, skills and expertise to effectively care for patients. 
  • Ensure that staff are undertaking responsibilities within their grade and level of experience.
  • Ensure that the effectiveness of care is audited and findings acted upon.
  • Review the support for staff on call at night who may be travelling and unable to access help and advice if required.
  • Develop clinical supervision.
  • Ensure that equipment is available and appropriately maintained and stored.

Please refer to the separate reports for locations and community services for details of areas where the trust SHOULD make improvements.

Professor Sir Mike Richards

Chief Inspector of Hospitals

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.