Bolton NHS Foundation Trust

Updated 18 October 2023

Bolton NHS Foundation Trust provides a range of hospital and community health services in the Northwest Sector of Greater Manchester, delivering services from the Royal Bolton Hospital (RBH) site in Farnworth, in the Southwest of Bolton, close to the boundaries of Salford, Wigan, Blackburn and Bury; as well as providing a wide range of community services from locations within Bolton. ​

The Royal Bolton hospital provides a full range of acute and a number of specialist services including urgent and emergency care, general and specialist medicine, general and specialist surgery and full consultant led obstetric and paediatric service for women, children, and babies.​

At Bolton NHS Foundation Trust, the Integrated Community Services Division consists of domiciliary, clinic and bed-based services across the Bolton footprint to GP registered population.​

There are ​598 general and acute beds​; 78 maternity beds​ and 35 critical care beds​ with 225,561 bed days reported (up 235 from last year).​ There are 5,315 WTE staff, the total headcount of staff is 6,088​. The trust had a financial turnover of £478,339k in 2022/23, this was up 9% on the previous year ​.

We carried out an announced (staff knew we were coming) well led inspection of Bolton NHS Foundation Trust following an unannounced (staff did not know we were coming) inspection of the Childrens and Young People’s services provided by this trust.

This was because we received information giving us concerns about the leadership and management at the trust. There were specific concerns raised regarding the confidentiality and effectiveness of the Freedom to Speak Up (FTSU) process across the trust and the management of staff issues and processes including the inappropriate use of the Disciplinary Policy and Procedure.

We inspected the children’s and young people’s core service because they had not been inspected since 2016 and there had been opportunities for improvement following an incident which we felt required review to ensure the safety and quality of the services.

Our rating of services stayed the same. We rated them as good because:

• We have rated safe, effective, caring and responsive as good, with an improvement in the safe domain for the Children and Young People’s services however the trust well-led rating went down to requires improvement.
• In rating the trust, we considered the current ratings of those services not inspected at this time.
• Leaders mostly had the skills and abilities to run the trust. A new chair commenced in post on 01 June 2023. They understood the priorities and issues the trust faced. They were visible and approachable in the trust for patients, but staff gave a mixed review as to their visibility and approachability at the hospital and also reported visibility as less evident in the community services.
• We were informed of a significant breakdown of trust and relationships between some elements of the board and the Council of Governors with the potential to affect the effectiveness of how the board managed and governed. There were a number of concerns raised about the poor governance regarding the appointment and management of some key board members which the trust was reviewing.
• Throughout interviews and conversations with staff we were told that the lack of face-to-face meetings of senior leaders and governors during the pandemic had had a significant and lasting negative impact on relationships and promoted a culture of mistrust in some quarters.
• The trust had a vision and strategy until 2024 for what it wanted to achieve. However, at the time of the inspection the strategy and enabling strategies were under review and some staff questioned how current the trust strategy was. A clinical strategy was being developed. The vision and strategy were focused on sustainability of services and aligned to local plans within the wider health economy. Leaders and staff understood and knew how to apply them and monitor progress.
• Staff did not always feel respected, supported, or valued but they remained focused on the needs of patients receiving care. Some staff expressed reservations about raising concerns without a fear of retribution, did not always feel listened to and feedback was not consistent, whilst others described a just culture. This included concerns about the effectiveness of the Freedom to Speak Up function within the trust. The processes for the management of disciplinary and grievance issues required improvement. However, the children’s service had a culture where patients and their families could raise concerns without fear.
• We received conflicting views of the culture of the organisation with many staff we spoke with through the focus groups describing the organisation as having a “just” culture and not recognising the organisation described recently in the media. Whilst many other people had contacted us with quite the opposite opinion.
• Leaders operated governance processes that had recently been strengthened and were in the main effective. However, policy governance needed to be strengthened. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of their division.
• Leaders and teams used systems to manage performance however these were under review to make improvements. They identified and escalated relevant risks and issues and identified actions to reduce their impact. Some staff reported having limited ability to contribute to decision-making to help avoid financial pressures compromising the quality of care. It was acknowledged by the trust that governance lacked strength in some areas but was improving with the leadership of the new Chief Nurse.
• Elective recovery had shown signs of improvement however, in some pathways it continued to be more difficult to address. In particular, the breast cancer, urology and colonoscopy pathways.
• The trust collected reliable data and analysed it. Staff could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements. However, the connectivity across the organisation was a significant challenge. The electronic patient record system was not yet active in all areas. The information systems were not fully integrated but were secure. Data or notifications were consistently submitted to external organisations as required.

However,

• Leaders and staff actively and openly engaged with patients, staff, the public and local organisations. Although, work by the established and developing equality groups would benefit from further corporate support. They collaborated with partner organisations to help improve services for patients.
• Staff were committed to learning and improving services and demonstrated a strong determination to provide quality care to patients. They had an adequate understanding of quality improvement methods and were promoting the skills and developing the capacity to use them. The trust had only recently invested in the Quality Improvement team to improve this. The management of complaints had improved. Learning was evident from serious incidents and mortality reviews.
• There was a palpable sense of strong family values across the trust from every level which supported the quality of care seen.

How we carried out the inspection

Prior to the inspection we spoke with each person who contacted us including former employees of the trust. During the well led inspection we conducted interviews with executive directors, non-executives and leaders for key roles. We also spoke with a variety of staff including consultants, doctors, therapists, nurses, healthcare support workers, pharmacy staff, patient experience staff, domestic staff and administrators.

We held 12 staff focus groups attended by over 320 representatives from all over the trust. This was to enable staff to share their views with the inspection team. The focus groups included junior and senior staff from pharmacy, junior and senior nursing staff, junior doctors and consultants, allied health professionals and staff from across the equality networks. We also had focus groups for the non-executive directors and governors. We received approximately 40 contacts from individuals wishing to share their experiences under protected disclosure.

We reviewed strategies and policies and minutes from meetings including the main committees and the Board. We reviewed the management of serious incidents, mortality reviews and complaints. We reviewed the processes used to identify and manage risk from Ward to Board.

Due to the nature of the concerns raised we also conducted a thorough review of the disciplinary process, the resolution (Grievance) process and recruitment process.

During the core service inspection, we also spoke with staff, patients and relatives. We visited the ward and other areas providing care to children and young people and reviewed patient records.

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.

Updated 11 April 2019

Updated 11 April 2019

Updated 10 August 2016

Overall we rated adult community services as good because:

• All community staff were aware of the trust’s incident reporting processes and there were mechanisms in place to learn from incidents.

• We found compassionate and respectful care was present in all interactions we observed.

• Patients accessing the service received effective care and treatment that followed national clinical guidelines including those from the National Institute for Health and Care Excellence (NICE). The service planned its services to meet the individual needs of the local population it served.

• Patients had access to the right care at the time and where targets in respect of this were not met, the service was working to improve and evidence of this improvement was well documented.

• There were robust governance frameworks and managers were clear about their roles and responsibilities.

• Risks were appropriately identified, monitored and there was evidence of action taken, where appropriate.

However,

• There were some instances where records were not fully completed in accordance with best practice.

• Staff did not always have timely access to computers.

Updated 10 August 2016

We rated the community children and young people services at the Bolton NHS foundation trust as ‘Good’.

This was because: -

• The level of incidents reported showed low risk of harm and safe systems for care and treatment of patients. Staff understood how to report incidents.

• There were enough suitably skilled, competent staff with the right mix of skills to meet patients’ needs.Patients were treated in clean and suitably maintained premises. Patient records were complete and accurate.

• The care and treatment was based on national clinical guidelines and staff used care pathways effectively. Audit records showed most patients experienced positive outcomes following their care and treatment and appropriate actions were taken to improve compliance with best practice standards

• Services were planned and delivered to meet the needs of local people. There were systems in place to support vulnerable patients. Most patients received care and treatment in a timely manner.

• Patients and their relatives spoke positively about the care and treatment they received. They were treated with dignity and compassion. They were kept involved in their care and they were supported with their emotional needs.

• The service delivery was based on the trust values and core objectives and staff had a clear understanding of what these involved. There was clearly visible leadership in place through local team leaders and staff were positive about the culture and support available.

However;

• Only 70% of staff in the Children's Community Nursing service had received their level three safeguarding children training.

• Some staff experienced difficulties in accessing trust-wide IT systems due to connectivity issues.

• There was a gap in compliance for nocturnal enuresis (bed-wetting) in children and young people because of an issue with alarms.

Updated 10 August 2016

Overall rating for this core service

Community inpatient services were rated as good overall. This was because;

• The service used the NHS safety thermometer to monitor its performance in relation to safety. Action plans were in place to improve harm free care.

• Incidents were reported and learning was shared. There was a good reporting culture. Incidents were investigated in a timely way.

• The environment was visibly clean and tidy. We saw staff using personal protective equipment such as aprons and gloves and observed them washing their hands appropriately. Hand hygiene compliance audits were high. Medicines were stored correctly and securely.

• A new nurse call buzzer was in place to improve patient safety.

• Overall mandatory training rates met the trust target. Adult safeguarding level two had been completed by 96% of staff. Staff we spoke with understood their responsibilities in relation to safeguarding adults.

• There were systems in place to ensure that patients were assessed and risks were monitored and minimised. There were clear admission criteria to ensure patients could be safely cared for outside of an acute hospital environment.

• A daily safety huddle involving key members of the multidisciplinary team was in place to highlight particular patient safety concerns.

• Nursing staffing fill rates were generally good. Nursing staff were supported by staff from the local authority.

However,

• Risk assessments were not always completed in a timely way, for example the risk of developing a pressure ulcer.

• There was not sufficient structure to intentional rounding documentation to ensure this essential patient safety task was completed in an effective way.

• The environment required the planned upgrades to ensure patients could be cared for in a safe way.

We rated effective as good because;

• Audits of care were completed and showed that 100% of patients had an individualised care plan.

• Care and treatment followed evidence based practice and national guidance. A consultant provided a ward round twice weekly.

• Pain was monitored and pain relief given in a timely way.

• There was access to additional training to improve staff knowledge in areas such as falls and dementia care.

• Multi-disciplinary working was well-established. The service worked well with colleagues from the local authority.

However;

• Appraisal rates did not meet the trust target.

We rated caring as good because;

• Friends and family test scores showed a high percentage of patients would recommend the service.

• Patients and those close to them were involved in their care and treatment. A care co-ordinator acted as a point of contact.

However;

• Scores for privacy and dignity on the patient led assessment of the care environment (PLACE) were much lower than the England average although details from the trusts own survey showed that patients felt they were treated with dignity and respect.

We rated responsive as good because:

• Services were planned around the needs of local people. There was additional capacity at times of high demand for intermediate care beds.

• Individual needs were understood and considered when delivering care and treatment. There was additional facilities and support for patients living with dementia.

• The service monitored admissions and discharges. This information was shared with staff at the hospital to improve access and flow.

• There were low numbers of complaints about Darley Court. Lessons were learnt from complaints and shared within the division and the wider trust.

However,

• The environment required improvements to better meet the needs of patients living with dementia.

We rated well-led as good because:

• Governance and risk management systems were in place that supported the delivery of care. Risks were managed and regularly reviewed to minimise the impact to the service.

• Leaders used comprehensive performance dashboards to monitor how the service was doing. The service had good systems in place to review data about patient referrals and outcomes.

• Leaders were supportive and enthusiastic about the service they provided. They valued every member of the team.

• The culture was open and honest. Staff engagement was good.

• The service was working closely with local partners to improve, develop and ensure a sustainable service for the future.

However,

• Issues with IT meant that leaders could not always look at data relating solely to Darley Court.

• There had been no recent patient experience survey.

Updated 10 August 2016

We rated specialist community mental health services for children and young people as requires improvement because:

• The trust did not provide eligible staff with mandatory training in safeguarding vulnerable children at level three. NHS England identified that this training is essential for the role of a community CAMHS practitioner.

• The trust did not provide eligible staff with mandatory training in the Mental Health Act (MHA), MHA Code of Practice (2015), Mental Capacity Act or legal frameworks specific to children and young people aged below 16 years, such as the Children’s Act (2004).

• The trust had a MHA policy in place. However, staff did not always follow the MHA Code of Practice (2015).

• CAMHS had a lone working policy in place. However, staff did not always follow this in practice.

• Once assessed by the single point of access team (SPoA), children and young people had to wait approximately 23 weeks to receive active treatment from a CAMHS practitioner.

• Children and young people’s care plans did not always capture their views.

• The local population comprised of approximately 30% of people who identified as black or a minority ethnicity (BME). CAMHS received very few referrals from children and young people who identified as a BME.

• Outcome measures to monitor the progress children and young people were making whilst receiving treatment were not routinely completed.

• In some key areas, CAMHS were not working proactively with other teams within Bolton NHS Foundation Trust to improve the service they delivered to children and young people.

• During inspection, we found a sharps box (a box used to dispose of contaminated items such as used needles and syringes) that had not been disposed of since 2014. This increased the risk of the spread of infection within the service.

• The main units clinic room did not have a mixed water tap.The Department of Health guidelines (Infection control in the built environment 2013) states that mixed water taps are essential for reducing the risk of scalding to people using the facility.

However;

• Staff completed comprehensive risk assessments for every child and young person that used the service, and these were regularly reviewed. There was an effective on-call system to respond to any emergencies within the service.

• Staff were effective in the prescribing and monitoring of children and young people on medications.

• Staff were well qualified to perform their role.

• CAMHS had improved its working relationship with other agencies, external to the trust, that were also involved with children and young people using the service. This included delivering training to local primary and secondary schools to raise mental health awareness.

• Staff treated children, young people and their parents/carers with kindness, dignity and respect.

• Children, young people and their parents/carers had produced short films for the CAMHS website to raise awareness of what it was like to access CAMHS and the different kinds of support they offered.

• The service demonstrated a commitment to quality improvement and innovation. The patient participation group had successfully secured funding from the Health Education Innovation England Fund (2015/16) to develop a self-help mobile phone application.