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Provider: Norfolk and Norwich University Hospitals NHS Foundation Trust Requires improvement

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 10 December 2019 to 15 January 2020

During a routine inspection

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

  • We rated safe, responsive and well led as requires improvement and caring as good. Effective went up from requires improvement to good. Ratings for four key questions, safe, caring, responsive and well led remained the same whilst effective improved. The rating for the well led question at trust level remained the same as requires improvement.
  • We rated two of the trust’s four acute core services as requires improvement (urgent and emergency care and surgery), one as good (outpatients) and one as outstanding (end of life care). Overall ratings for urgent and emergency care and surgery remained the same, and outpatients and end of life care had improved. In rating the trust, we took into account the current ratings of the four services not inspected this time.

On the basis of this inspection, the Chief Inspector of Hospitals has recommended that the trust is removed from special measures.


CQC inspections of services

Inspection carried out on 22 Jan to 27 Feb 2019

During a routine inspection

Our rating of the trust improved. We rated it as requires improvement because:

Safe, effective, responsive and well led were rated as requires improvement and caring was rated as good.

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.

On the basis of this inspection, the Chief Inspector of Hospitals has recommended that the trust remain in special measures.

  • Urgent and emergency care rating improved from inadequate to requires improvement overall. Safety and well led improved from inadequate to requires improvement. Effective and responsive remained the same at requires improvement and caring remained good. There were concerns regarding culture, leadership and the management of patient flow through the emergency department and staff recognising and responding to patient risks.
  • Medical care (including older people’s care) remained requires improvement overall. Nursing and medical staff were still not meeting the trust target for mandatory training, staff were still not consistent in the monitoring and recording of fridge temperatures for fridges where medicines were stored. Staff did not adhere to policies and procedures relating to mental capacity assessments (MCA) and deprivation of liberty orders (DoLS). Staff were not aware of any local vision for the service and the service was performing worse than the England average for referral to treatment (RTT) in two specialities. Governance process were not embedded or robust which allowed for inconsistencies across the speciality and while managers reviewed their open risks, they were not being actioned to reduce the level of risk in a timely way. However, the service had improved their infection prevention and control, management of resuscitation equipment and patient record storage. Staff told us the culture in the service had improved and the service had developed new ways of meeting patient needs for example the older people’s emergency department (OPED). Staff treated patients with care, dignity and respect.
  • Surgery rating went up from inadequate to requires improvement overall. The question of safety and well led went up from inadequate to requires improvement. Caring and effective stayed the same as good. Responsive stayed the same as requires improvement. There remained concerns with the environment and there were two further never events. People were unable to access all services in a timely way and not all staff were aware of their responsibilities under the Mental Capacity Act 2005. Further work on embedding a positive culture and effective management of risk was required by divisional leadership.
  • Critical care went down from good to requires improvement overall. Safety remained as requires improvement, effective, responsiveness and caring were rated as good and well led went down to requires improvement. There was no supernumerary nurse coordinator available out of hours, the critical care outreach team did not provide a 24 hour, seven day a week service and there were also no child friendly environments.
  • Maternity services were rated as requires improvement overall. We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings. We rated safe and well led as requires improvement. We rated effective, caring and responsive as good. We identified concerns with safety aspects including out of date consumable equipment and medicines within the community, a lack of level 3 safeguarding children training for medical staff and issues with the consistency of checking resuscitation trolleys and medicine refrigeration temperatures. We found that there was a lack of oversight for issues we identified in the community and that issues we had identified on our previous inspection had not been resolved.
  • Services for children and young people went down from good to requires improvement overall. The question of safety remained the same at requires improvement. Effective and caring remained the same and were rated as good. Responsive and well led went down in rating from good to requires improvement. There were long standing concerns with safety aspects relating to emergency equipment checks, fridge temperature checks, the completion of early warning scores and nurse staffing. A high proportion of children were waiting a long time for treatment, including after they had had their surgeries cancelled. The governance of the service was not robust and risks that we found on inspection were not always identified by the service for assessment and monitoring.
  • Outpatients remained rated as requires improvement overall. Caring remained the same at good. Safe, responsive and well led remained requires improvement. We do not currently rate the effectiveness of outpatient services. Records and medicines were not always stored correctly and waiting times from referral to treatment were not in line with good practice. However, the service controlled infection risk well, staff cared for patients with compassion, and managers promoted a positive culture.

Inspection carried out on 10 October 2017

During a routine inspection

Safe and well led were rated as inadequate, effective, and responsive were rated as requires improvement and caring was rated as good.

Our inspection of the core services covered Norfolk and Norwich Hospital only. 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.

On the basis of this inspection, the Chief Inspector of Hospitals has recommended that the trust be placed into special measures.

Norfolk and Norwich Hospital

  • Urgent and Emergency care was rated as inadequate overall. Safe, effective, caring and well led all went down, safe from requires improvement to inadequate. Effective from outstanding to requires improvement and caring from outstanding to good and well led went down from good to inadequate. Responsive went down from good to requires improvement. There were significant safety concerns within the department relating to premises, safety of patients with mental capacity concerns and infection prevention and control processes. We undertook immediate enforcement action in relation to the most significant concerns. The trust took the concerns seriously and responded appropriately with some immediate actions including a major redesign of the department and clinical decisions unit. Following whistle blower concerns we inspected again on 22 March 2018. At this inspection we found that the claims that the whistle blowers had made were substantiated. These included the number of patients waiting in corridors, delays in treatment, delays in admission of patients to beds on wards, an active policy of placing patients in trolleys on wards to await beds and manipulation of the delays through admitting patients who were approaching the 12 hour target rather than those who had already breached the target. However, we found that nurses and medical staff remained caring despite a low morale arising from not being able to provide the care they wanted to.
  • Surgery was rated as inadequate overall. Safe and well led went down from requires improvement to inadequate, responsive stayed requires improvement and caring and effective remained good. Daily checks were not always carried out and mandatory training was below the trust’s accepted target. There were concerns about the environment, equipment, medicines management and infection control procedures in the interventional radiology unit and the day procedure unit. The day procedure unit was utilised as an escalation area. The escalation criteria was not adhered to, with patients from multiple specialities admitted to this area, some with high level of acuity including palliative care patients and those living with dementia. Concerns were also raised by staff around the merge of vascular and urology specialties within Edgefield ward. Staff described training as adhoc and informal, staffing levels were not always in line with planned levels and we found gaps in monitoring of catheters, intentional rounding and completion of National Early Warning Score observations. People could not always access the surgical service as referral to treatment times and cancelled operations were not in line with national averages but were improving. Governance systems within the surgical service were not always embedded. However, the service monitored the effectiveness of treatment and staff cared for patients with compassion.
  • End of life care remained rated as requires improvement overall. Safe, effective and well led stayed requires improvement, responsive went down from good to requires improvement and caring remained good. The trust’s ‘do not attempt cardio-pulmonary resuscitation’ (DNACPR) forms did not meet national standards and were not always completed correctly. There were lack of assurances that the Mental Capacity Act and Deprivation of Liberty Safeguards were always being implemented for people who had DNACPR documentation. There was a significant lack of syringe drivers in the trust, which impacted on patient care. However, the trust now provided a specialist palliative care service which was in line with national guidance, which was an improvement since the last inspection.
  • Outpatients was rated as requires improvement overall. Caring was rated as good, safe, responsive and well led were rated as requires improvement. We previously inspected diagnostic imaging jointly with outpatients so we cannot compare our new ratings directly with previous ratings. Staff were not always trained to the appropriate level for safeguarding children, records and medicines were not always stored correctly and waiting times from referral to treatment were not in line with good practice. However, there had been improvements in the quality of documentation in patient records and staff understanding of the incident reporting process.
  • Diagnostic imaging was rated as requires improvement overall. Safe, responsive and well-led were rated as requires improvement and caring was rated good. We previously inspected diagnostic imaging jointly with outpatients so we cannot compare our new ratings directly with previous ratings. Staff were not always trained to the appropriate level for safeguarding children, there were significant reporting backlogs and risks had not always been identified or addressed. However, there had been improvements in staff understanding of the incident reporting process and progress had been made in the recruitment of new staff.
  • On this inspection we did not inspect medicine, critical care, maternity, gynaecology and children and young people services. The ratings we gave to these services on the previous inspection in the comprehensive inspection in November 2015 and responsive inspection in April 2017 are part of the overall rating awarded to the trust this time.

Inspection carried out on 10-13 November 2015. Unannounced inspections 20 and 25 November 2015

During a routine inspection

The Care Quality Commission (CQC) carried out a comprehensive inspection between 10 and 13 November 2015. We also carried out unannounced inspections on 20 and 25 November 2015. We carried out this comprehensive inspection at Norfolk and Norwich University Hospital NHS Trust as part of our comprehensive inspection programme.

This organisation has two main locations:

  • Norfolk and Norwich University Hospital, a large acute hospital comprising all acute services.

  • Cromer Hospital which offers surgical and outpatients’ services.

    We also inspected Henderson unit as part of the unannounced inspection on 25 November 2015.

    The hospital opened in late 2001, having been built under the private finance initiative (PFI). Cromer and District Hospital was rebuilt by the Trust in 2013.

    The Trust provides a full range of acute clinical services plus further private and specialist services. The Trust has 1237 acute beds and provides care for a tertiary catchment area of up to 822,500 people from Norfolk and neighbouring counties. The hospital also has an important role in the teaching and training of a wide range of health professionals in partnership with the University of East Anglia, University Campus Suffolk and City College Norwich.

Previous unannounced responsive inspection by the CQC took place between 4 and 6 March 2015. The inspection focused specifically on accident and emergency services, capacity and demand, medical care and cancer services, surgery, and overall leadership of the trust. As this was a responsive inspection there are no ratings attached to our findings. However, concerns were raised about governance arrangements, Mattishall ward, the Fit and Proper Persons regulations and the bullying culture.

The trust had a relatively new executive team. The chief executive was appointed substantively in October 2015. At the time of inspection three other members of the team were interim positions; the chief operating officer, medical director, and director of finance.

The comprehensive inspections result in a trust being assigned a rating of ‘outstanding’, ‘good’, ‘requires improvement’ or ‘inadequate’. Each section of the service receives an individual rating, which, in turn, informs an overall trust rating.

The inspection found that overall, the trust had a rating of requires improvement.

Our key findings were as follows:

  • Staff were overwhelmingly caring in delivering care to patients. We witnessed some outstanding examples of care being given to patients and their relatives.

  • There were shortages of nursing staff that impacted on care provided throughout the hospital.

  • There were some areas where there were medical vacancies which impacted on care, most notably in the palliative care team and in the critical care complex.

  • Incident investigation and root cause analysis were not always completed by those with extended training.

  • The security on the children’s ward needed to be improved to ensure their safety.

  • There was a lack of understanding by staff around patients' abilities to consent to care and treatment.

  • The consultant body was cohesive, loyal to the hospital and proud to be working at the trust.

  • The service to patients having a heart attack was extremely good.

  • The communication with parents in the neonatal unit was very good. These included well written booklets.

  • The number of one stop clinics within the outpatients department was responsive to the needs of patients.

We saw several areas of outstanding practice including:

  • A specialist, midwife-led ‘birth reflections’ clinic was provided to support women who wanted to come to terms with their birth experiences.

  • A clinical reporting and scheduling system in cardiology (Intellect) has been developed locally allowing the service to be more coordinated and efficient.

  • There was an excellent primary percutaneous coronary intervention (PPCI) service which provided prompt, effective treatment in line with national guidance and demonstrated good working with other providers and professionals.

  • On Elsing ward we observed that the bays had been colour coded to assist patients moving around the ward and used single use knitted sensory bands. Holt ward had refurbished a room to 1950’s décor.

  • The nursing team within the emergency department demonstrated outstanding care, leadership and treatment of patients.

  • The innovation around trialling new ways and models of care including medicines administration within the emergency department, as well as the vision for the service was outstanding.

  • The outcomes for trauma were outstanding and the best in the region.

  • The local audit programme for nurses and medical staff within the emergency department was outstanding.

  • The governance risk management, learning arrangements and staff willingness to continually strive to be better for the patients in the emergency department were outstanding.

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

Importantly, the trust must:

  • Ensure that patient acuity is properly assessed and there are adequate medical, nursing and midwifery staff to care for patients in line with national guidance.
  • Follow infection control principles when cohorting patients.
  • Ensure that all children’s inpatient wards and units have adequate security measures in place to reduce the risk of children absconding and unauthorised adults gaining entry.
  • Ensure that incidents are investigated in a timely way by trained investigators, graded, and reported in line with current national guidance.
  • Ensure that the management of outliers on Cley ward are properly assessed and provided with safe care.
  • Ensure that the management of referrals into the organisation reflects national guidance in order that the backlog of patients on an 18-week pathway are seen.
  • Ensure that patient records are legible, accurate, complete and contemporaneous for each service user, taking into account the use of both hard and electronic records.
  • Review ‘do not attempt cardio-pulmonary resuscitation’ (DNACPR) forms to ensure they are completed fully and in line with trust policy and national guidance.
  • Review its Mental Capacity Assessment and Deprivation of Liberty Safeguarding (MCADOLS) process and the way this is documented within patients’ notes – Regulation 17(2) (c).
  • Ensure that staff within the radiology department have access to appropriate support, supervision and appraisal.
  • Ensure that compliance to mandatory training is met and ensure consistent compliance across all clinical staff groups. Ensure that training is relevant to meet the needs of those in specific roles such as staff in the mortuary.
  • Ensure that medicines are stored and administered in line with national guidance.
  • Review and improve the environment of the children’s emergency department to ensure that the environment is fit for purpose and safe for children to receive care.

  • Review the staffing of the children’s emergency department to ensure that there are sufficient numbers of registered children’s nurses on duty at all times.

  • Ensure that there is an increased awareness of the complexities of end of life care, including a defined strategy and vision, increased involvement and referrals to the specialist palliative care team (SPCT) and improvement in performance indicators specifically recognition of the dying patient.

In addition the trust should:

  • Closely monitor transfers to Mattishall ward and the environment should be improved in line with the development plan for the unit.
  • Reconsider the ambulatory care pathway in the AMU.
  • Review the availability of adequate equipment for patients to sit out of bed if clinically able to do so.
  • Review the permanent clinical leadership in AMU.
  • Ensure a robust process for checking of emergency equipment.
  • Review its risk management and escalation policies with respect to how clinical staff raise concerns and ensure these are acted upon appropriately.
  • Reduce readmission rates for children and young people with long-term conditions.
  • Review the provision of information technology for community midwifery teams.
  • Review mechanisms for supervision and appraisal for all staff so that they are supported effectively.
  • Develop an action plan to address the lack of improvement in the completion of discharge information in the specific safeguarding children paperwork for use within the maternity departments.
  • Review the provision of adequate seating in the antenatal clinic.
  • Reduce the number of cancelled gynaecology clinics.
  • Review the ratified guidelines within the obstetric assessment unit and ensure that it is located in an area where it can operate effectively.
  • Put procedures in place to reduce the number of closures of the obstetric unit.
  • Review the staff understanding of the vision and strategy for their areas.
  • Review fluoroscopy changing areas and process to ensure patient privacy and dignity is maintained.
  • Ensure that doctors within the emergency department adhere to 'bare below the elbow' policy requirements.
  • Improve the culture amongst the consultant body within the emergency department.
  • Improve the culture of the organisation towards the emergency department to reduce the feeling of blame for targets not being achieved.
  • Review the bed management process and site management processes within the organisation to increase capacity and flow.
  • Improve systems and processes for the declaration of black alert to ensure that it contains tangible changes designed to improve the service, i.e. daily consultant or nurse led discharges.
  • Review the emergency department triage process to ensure that all patients are offered pain relief where it is required.
  • Review the plans for expanding the main emergency department and make a decision swiftly on the future expansion of the service.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 4th and 6th March 2015

During an inspection looking at part of the service

The Care Quality Commission (CQC) undertook an unannounced responsive inspection between 4th and 6th March 2015. The inspection rationale related to an increase throughout 2014 of negative intelligence regarding various areas within the Trust. Therefore the inspection focused specifically on accident and emergency services, capacity and demand, medical care and cancer services, surgery, and overall leadership of the trust.

The Trust operates across two primary sites, one in Norwich, the second in Cromer. The Norfolk and Norwich University Hospital was rebuilt in 2001 and is based on the Norwich Research Park. Cromer and District Hospital was rebuilt by the Trust in 2013.

The Trust provides a full range of acute clinical services plus further specialist services and a small private practice. The Trust has 1,099 acute beds and It provides care for a tertiary catchment area of approximately 1,024,000 people from Norfolk and neighbouring counties. The hospital also has an important role in the teaching and training of a wide range of health professionals, especially in partnership with the University of East Anglia.

Previous inspection by the CQC took place on the 2nd and 3rd December 2013 and had resulted in one compliance action in respect of Regulation 17 HSCA 2008 (Regulated Activities) Regulations 2010 Respecting and involving people who use services. During the responsive inspection we also followed up on the current status with regard to this compliance action. The trust had completed and implemented an action plan and significant improvements had been made. We judged that the Trust was now meeting this requirement and therefore have removed this compliance action.

There were serious concerns raised regarding board effectiveness and a bullying culture within the leadership team. The Trust since Q2, 2014 has been breaching on national targets, ED waiting times, Cancer services and referral to treatment time. This has increased pressure on the leadership and staff teams to meet targets and raised concerns that patient care may be affected.

Our key findings were as follows:

  • The trust had taken action in respect of capacity management in the emergency department on a day to day basis however a cohesive strategic plan for access and flow of patients was lacking.
  • Capacity and target pressures have led to the Board being too operationally focussed and reactive and there was an inconsistent management approach to staff at a local level.
  • There was evidence of a dysfunctional executive team where the current dynamics and tensions were affecting individual’s ability to apply due diligence and proper governance.
  • The trust had implemented a new governance framework in December 2013 and we found that there was no process in place, and a lack of challenge and scrutiny by the board, to provide assurance to the board that this framework was effective.
  • There was no clear process in place, at board level, to manage allegations made by whistle blowers and other third parties.
  • The trust had not considered the arrangements it needed to put in place in order to demonstrate that it met the requirements of the fit and proper person regulation and there was a lack of decision making present regarding the appointment of new directors.

The trust needs to make the following improvements:

  • The trust should review its governance arrangements to ensure that sufficient assurance is given to the board on the effectiveness of such arrangements.
  • The trust should ensure that they develop measureable plans to regain a unified direction and minimise impact of the divisions within the leadership team upon the staffing body and ultimately patient care.
  • The trust should ensure that appropriate and swift action is taken to address the bullying culture which is alleged to be present within the trust and ensure effective monitoring and follow up takes place.
  • Ensure that it has effective arrangements in place to ensure that all directors, or those performing the functions of a director, are fit and proper in line with regulation 5 of the Health and Social Care Act Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
  • The trust should ensure that there is a clear strategic escalation plan in place for access and flow of patients through the emergency department and that there is a consistent management approach in response to high demand pressures.

The inspection included review of the accident and emergency services, medical care, cancer and surgery services and this is reported in the location report. At a provider level, i.e. trust senior level, we reviewed the key question is the service well led as we had received a number of concerns in this respect. We will be carrying out a comprehensive inspection in 2015 where we will follow up the findings and consider any improvements made.

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.


Organisation Review of Compliance