You are here

Provider: Great Western Hospitals NHS Foundation Trust Requires improvement

Community health services for children and young people are no longer provided by this trust. Urgent care services: the urgent care centre, previously inspected as part of community services, is now reported under urgent and emergency care.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 21 December 2018

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

Acute services at Great Western Hospital were rated requires improvement overall. The safe and responsive key questions were rated as requires improvement.

However, we rated the effective, caring and well led key questions as good. Trust-wide leadership was also rated good. Community services were rated good overall, with all key questions rated good. The overall rating for services for children and young people and outpatients improved since our last inspection; both services were rated good.

Our findings for each of the core services inspected this time is summarised below:

Urgent and emergency care

Our overall rating of this core service remained as requires improvement. There was no change to the rating for the safe and responsive domains, which remained as requires improvement. This was because the emergency department continued to be frequently crowded and patients did not always receive prompt care and treatment in the right setting. The rating for effective stayed as good because the emergency department used national audits to drive improvements in the quality and effectiveness of care and treatment.  Teams and services worked well together to ensure patients received coordinated care. The rating for caring, previously rated outstanding, went down to good. Feedback from patients and relatives remained consistently good and we observed compassionate and understanding care; however, we found no examples of outstanding care. The rating for well led stayed the same and was rated as good. The department had improved in several key areas, governance and quality improvement were prioritised and leaders had the knowledge and skills to run the department and they were respected by staff.

Medical care

Our overall rating for medical care remained as requires improvement. Safe remained as requires improvement. Some areas were not clean and hygienic. Staff did not always observe necessary precautions to prevent and control infection. There was a continuing shortage of nursing staff and heavy reliance on bank and agency staff. Staff were not up to date with their mandatory training. Effective remained as requires improvement. Patient outcomes, when benchmarked did not always compare favourably with the England average. Performance against national standards in stroke care remained consistently poor. Caring remained as good. Patients received a caring service from kind and empathetic staff. Responsive remained as requires improvement. Patients did not always receive care in the right setting due to a shortage of inpatient beds. Some patients were accommodated in wards and departments in a specialty other than that for which they were intended, and sometimes in departments which were not designed for inpatient care, or where single sex accommodation could not be provided. The rating for well led went down and we rated it as requires improvement. The service had failed to make significant improvement in several key areas since our last inspection.

Surgery

Our overall rating for surgery remained as requires improvement. Safe remained as requires improvement. Although we saw some improvements, for example in mandatory training compliance, there were a number of regulatory breaches. We had concerns about infection control practices, record keeping standards and a lack of documented patient risk assessments. Effective remained rated as good. There was coordinated multidisciplinary care and staff used evidence-based care pathways for patients admitted for surgery. Caring remained as good. Feedback we received from patients and relatives was consistently positive. Staff showed an encouraging, sensitive and supportive attitude to patients and their relatives. Responsive remained as requires improvement. There were insufficient surgical beds to meet demand and some patients were cared for in unsuitable settings. Our rating for well led improved. It was rated good because leaders had the knowledge, skills and integrity to lead the service effectively and they were well respected by staff. There were effective governance processes to ensure quality and safety were monitored and risks were managed.

Children and young people

Our overall rating of this service went up to good. We inspected only the safe and well led domains, both of which had improved, with a rating of good. Safe was rated good because, although there was still a shortage of registered children’s nurses, there was improved oversight of nurse staffing levels, using an acuity tool, and gaps in rotas were mostly filled by temporary staff. There was some improvement in mandatory training compliance for medical staff, although this still required further improvement. Well led was rated good because new managers were well respected by staff; there was a noticeable change in culture, and staff felt supported, able to contribute ideas and voice concerns if they needed.

Outpatients

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings. We rated this service as good overall. We rated safe as good because staff complied with safety systems to protect people from avoidable harm. We inspected the effective domain but did not rate it due to a lack of national data available to the CQC. We rated caring as good because patients were treated with kindness, compassion dignity and respect. We rated responsive as good because the service was performing better than the national standards for patients waiting times. We rated well led as good because there was a clear improvement strategy for outpatient’s services; staff were engaged and there was a positive culture where staff felt supported and valued.

Community health services for adults

We had not previously inspected this service. We rated this service good overall, with all domains rated good. Safe was rated good because staff complied with safe systems in all areas. They reported incidents and monitored patients in order to maintain and improve safety. We rated effective as good because patients received evidence-based care, delivered by well-coordinated multidisciplinary teams of competent staff. We rated caring as good because staff took the time to interact with patients and those close to them in a respectful, compassionate and considerate way. Patients and their relatives/carers were actively involved in their treatment and care. We rated responsive as good because services reflected people’s needs and ensured flexibility, choice and continuity of care. We rated well led as good because leaders were appropriately skilled and committed to service improvement. Staff felt valued and supported. There were effective governance systems to support safety and quality.

Community inpatients

We had not previously inspected this service. We rated this service good overall, with all domains rated good. Safe was rated good because staff followed safety processes to protect patients from avoidable harm. Staffing levels were monitored to ensure safe levels were maintained. We rated effective as good because staff used evidence-based practice to provide care and treatment. There was good team working between acute and community colleagues. We rated caring as good because staff promoted patient choice and acted as advocates for patients in their care. Relatives spoke highly of the emotional support provided to them and their loved ones to help them come to terms with their situation. We rated responsive as good because patients were supported to receive individualised care closer to their homes. We rated well led as good because there were effective governance processes which aligned with trust processes and risks were managed well. Staff felt supported and valued by managers.

Inspection areas

Safe

Requires improvement

Updated 21 December 2018

Patients did not always receive prompt care and treatment. The emergency department was frequently crowded and patients experienced unacceptable delays. There were frequent ambulance handover delays and patients were not always promptly assessed when they arrived in the emergency department. Crowding in emergency departments is associated with an increase in mortality.

Facilities and equipment were not always suitable for the services delivered. Demand often outstripped the availability of clinical spaces to assess, treat and care for patients in the emergency department, who were often cared for two-abreast in cubicles, or on the corridor. Mental health assessment rooms in the emergency department did not meet the safety standards recommended by the psychiatric liaison accreditation network. Staff in the observation ward did not feel safe and experienced delays when calling for assistance from security staff. Facilities in the surgical assessment unit did not meet national guidance. There was a lack of assurance in some areas that equipment was clean, well maintained and fit for purpose.

Systems to assess risks to patients and to monitor their ongoing safety were not consistently complied with. In the emergency department, there was a lack of assurance that staff carried out regular checks of patients’ safety in order to identify and appropriately manage deteriorating patients. Staff did not use a recognised proforma to assess patients with mental health needs who attended the emergency department, as recommended by the Royal College of Emergency Medicine. Patients with mental health needs were not always adequately monitored to ensure their safety. In surgery, risk assessments were not always documented, venous thromboembolism assessments were not routinely repeated for orthopaedic patients and there was not consistent compliance with the World Health Organisation’s Five steps to safer surgery checklist.

The service did not always control infection risk well. In medical care, some areas were not clean and hygienic. Staff did not always observe necessary precautions to prevent and control infection. Patients were not always appropriately isolated to prevent the spread of infection because side rooms were not available.

The service did not always have enough nurses with the right mix of qualifications and skills to keep patients safe and provide the right care and treatment. Medical wards were frequently short staffed. Staff worked under intense pressure and were frequently unable to take breaks or finish on time. Staffing levels and skill mix on medical wards did not always match the acuity of patients on the wards. There were particular concerns on Jupiter ward. High nurse staff vacancy rates in the emergency department meant there was heavy reliance on agency staff. This had not improved since our last inspection. Registered mental health nurses were not always available to support patients in the observation ward, in accordance with the trust’s policy.

Patients’ records were not always legible, complete, up to date or stored securely. In medical care staff did not consistently comply with record keeping standards or ensure that records trolleys were locked when not in use. In surgery, nursing documentation was not well organised or stored securely.

Not all staff were up to date with their mandatory training. Compliance with the trust’s target training completion rate was particularly poor for medical staff. In the emergency department we were concerned that many staff were not up to date with training in subjects which related to the care and treatment of children, including safeguarding children from abuse. In services for children and young people, staff in areas of the hospital, where children were cared for (outside of the children’s wards) did not meet trust targets for paediatric life support training.

However:

The service followed best practice when prescribing, giving, recording and storing medicines. Medicines were stored securely and accurate records were kept.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Whilst there were some shortfalls in training, safeguarding arrangements were otherwise robust and kept children and vulnerable adults safe.

The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.

Effective

Good

Updated 21 December 2018

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

The trust provided care and treatment to patients based on national guidance and evidence of its effectiveness. Clinical guidelines, policies and procedures were in line with national guidance and easily accessible for staff.

Managers in most core services monitored the effectiveness of care and treatment and used findings to improve. They compared local results with those of other services to learn and continue improving.

The service mostly made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service. Staff were encouraged to develop through accredited learning and training programmes developed by the organisation.

Staff of different kinds worked together as a team to benefit patients. Doctors, nurses, and other healthcare professionals supported each other to provide coordinated, and seamless care, including when care was provided across different specialties.

Patients’ consent to care and treatment was generally sought in line with legislation and guidance.

Staff gave patients enough food and drink to meet their needs and improve their health. The trust used a nationally recognised tool, the malnutrition universal screening tool (MUST), to identify patients at risk of being malnourished or dehydrated. They used special feeding and hydration techniques when necessary. The service made adjustments for patients’ cultural and other preferences.

Staff had access to up-to-date, accurate and comprehensive information on patients’ care and treatment.

However,

In medical care patient outcomes in some areas did not compare favourably with the England average. The trust performed poorly against national standards for stroke care and cardiac care.

In medical care we observed nurses from overseas, who were not yet registered in the UK, performing tasks which they had not been assessed as competent to perform.

Caring

Good

Updated 21 December 2018

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

Staff treated patients with compassion, dignity and respect. We saw polite and friendly interaction with patients. Staff took steps to preserve patients’ privacy and dignity, even in challenging physical environments. Patients with mental health needs were treated with understanding and without judgement. In the emergency department, even when they were very busy, staff were focused on the needs of patients, informed them of what was happening and took time to make them as comfortable as possible.

Staff provided emotional support to patients to minimise their distress. In community inpatient services, relatives spoke highly of the staff who helped them and their loved ones come to terms with their situation. In outpatients, staff provided emotional support to patients to minimise their distress, including when a life-changing diagnosis was given.

Patients and those close to them were involved in decisions about their care. Patients told us staff took time to explain treatments options in a way they could understand. In outpatients relatives told us they were made to feel part of conversations about their family member’s health need and treatment plans.

Responsive

Requires improvement

Updated 21 December 2018

Patients were not always able to access care and treatment in a timely way and in the right setting. The trust was consistently failing to meet national standards in relation to the time patients spent in the emergency department, the time they waited for treatment to begin and the time they waited for an inpatient bed. Patients did not always receive care in the right setting due to a shortage of inpatient beds. Some patients were accommodated in wards and departments in a specialty other than that which they were intended and sometimes in departments which were not designed for inpatient care or where single sex accommodation could not be provided. Referral to treatment times did not meet national standards for all specialities within the planned care division. In ophthalmology and urology, patients waited too long for treatment or follow up appointments. Some referral to treatment times (admitted performance) within 18 weeks, were worse than the England average.

Facilities and premises were not wholly appropriate for the services delivered. Demand for services in the emergency department frequently outstripped the availability of available clinical spaces to assess, treat and care for patients. Patients were accommodated two abreast in cubicles and in the corridor. This impacted on their comfort, privacy and dignity. There was a shortage of inpatient beds; demand often outstripped the availability of beds in the right specialty. Patients were frequently cared for on wards in specialties other than those they those which they were intended for. This impacted on patients’ experience but also on other areas of the hospital being able to function effectively. For example, day surgery often had overruns or late-notice theatre cancellations. Some inpatients were accommodated in departments which were not designed for inpatient care and in mixed sex accommodation.

Care and treatment was not always delivered, taking into account patients’ individual needs, including those in vulnerable circumstances. Family members were sometimes asked to interpret and translate for patients whose first language was not English. This did not comply with national guidelines or ensure patient confidentiality.

Complaints were not always investigated and responded to in an acceptable timescale. In September 2018 it was reported to the board that of the 48 complaint responses were overdue. Most of these were within the unscheduled care division and were complex cases.

However:

The trust was performing better than the operational standard for people being seen within two weeks of an urgent GP referral, to receive treatment within 31 days of diagnosis and the standards for patients to receive their first treatment within 62 days of GP referral.

Staff supported patients with additional needs, such as patients living with dementia. In outpatients an alert was placed on the patient records and early appointment times allocated to reduce anxiety.

Patients admitted for planned surgery or for emergency intervention did not stay in hospital longer than they needed to.

There was good operating theatre utilisation. The percentage of cancelled operations at the trust had consistently been lower than the England average for the last two years.

The service treated complaints seriously, investigated them, learned lessons from the results and shared these with all staff.

Well-led

Good

Updated 21 December 2018

Our rating of well-led stayed the same. We rated it as good because:

Managers at all levels had the skills to lead effectively. Divisional managers were described by staff as visible, approachable and supportive. Recently appointed ward managers in children’s services were described as “a breath of fresh air”. The trust was taking steps to ensure succession planning and identifying future managers.

The trust had a vision for what it wanted to achieve and workable plans to turn it into action, developed with engagement of staff. The trust was in the process of refreshing its five-year strategy, and listening events had been arranged to engage staff in this process.

Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose, based on shared values. Staff were aware of, and could relate to, the trust’s values, service, teamwork, ambition and respect. They felt respected and valued by managers and their peers. Staff were nominated for trust-wide awards and divisions ran similar local systems to recognise their peers. There was a culture of candour openness and honesty.

The trust had a systematic approach to monitoring quality and safety, to drive improvement. There were clear governance processes from ward to board. Key safety and quality metrics were reported through a committee structure, reporting ultimately, to the board.

The trust had systems for identifying, monitoring and managing risks. Risks identified on divisional risk registers aligned to what staff and managers told us were their biggest concerns. Monthly risk meetings took place in divisions, where risk registers were reviewed and high risks escalated for review by the executive risk committee.

Leaders strived for continuous improvement and inspired staff to do so.

The trust had significantly improved systems to manage patient flow and reduce crowding, although this remained the most challenging area of risk. Performance against the national four-hour standard in the emergency department had improved and there were further plans and ongoing work to reconfigure the hospital’s ‘front door’ function to improve its safety and efficiency. There was also work in progress to embed processes designed to ensure timely discharge from hospital.

The trust had introduced a ward assessment and accreditation framework to help nurses assess their practices against standards to provide assurance of safety and quality. This had been adopted in some areas in medical care. In services for children and young people, an initiative to improve practice by learning from others’ good practice had been introduced. In medical care, occupational therapists told us the trust was an “empowering organisation” to work for; staff were encouraged to suggest ideas and get involved in projects to improve outcomes for patients. In response to some worsening scores in the 2017 staff survey, a programme called ‘engage to change’ had been introduced, which encouraged teams to put forward suggestions, design services and deliver improved outcomes. An example of a development which resulted from such a project, was the introduction of point of care testing in the ambulatory care unit.

However:

The trust was aware of the risks to safety and quality but in some areas the pace of change had failed to achieve significant improvements in performance in several key areas, since our last inspection.  The trust performed poorly in some national clinical audits. We were concerned that there had been a lack of significant improvement in stroke care, where performance had for some years been worse than the England average and the trust was awarded the lowest rating in the national stroke audit. There continued to be a significant shortage of nursing staff, and heavy reliance on temporary staff. Further improvement was required to ensure patients receive timely assessment and treatment in the right setting. Compliance with mandatory training across the trust needed to improve. There were continuing concerns about staff and patient safety in the emergency department observation unit.

The trust did not always manage and use information well to support its activities. In the emergency department there were significant problems around the availability of accurate and verified data to monitor departmental performance.

Learning from never events was not always shared effectively between specialities.

The trust needed to more to engage with staff and patients. Staff generally felt well informed but some staff did not consider they had a voice or could influence change. In the 2017 staff survey, scores in relation to engagement had worsened.

Checks on specific services

Community health inpatient services

Good

Updated 21 December 2018

We rated this service as good overall, with all key questions rated good. The service had not been inspected before under our current methodology, so we were unable to provide a comparison of ratings. We rated it as good because:

  • Staff were trained in, and followed safe systems and processes to protect people from avoidable harm.
  • Patients’ holistic needs were assessed and care and treatment provided by multidisciplinary teams, using evidence-based care pathways.
  • Staff acted as patients advocates and promoted choice. Staff provided emotional support to patients and their relatives to help them come to terms with their situation.
  • There was coordinated care, with close links with acute and community-based services.
  • The service was well led; leaders had appropriate skills and experience and supported staff well. There were effective governance arrangements.

However:

  • Nurse vacancies, resulted in reliance on temporary staff.
  • Documentation of best interest decisions needed to improve.
  • There was limited therapy provision at weekends.
  • Complaints were not always responded to within target timescales.
  • Some staff felt they had not been engaged early enough in the service’s improvement journey.

Community health services for adults

Good

Updated 21 December 2018

We rated safe, effective, caring, responsive and well-led as good, because:

  • We were assured the service was consistently meeting the requirements to provide safe care in all areas. Staff protected patients from abuse and maintained infection prevention and control standards. Staff were reporting incidents and lessons were learned from these. Safety information was collected and actions taken to improve services.
  • The service was providing effective care, with patients receiving evidence-based care and treatment. Staff from different services, both internal and external, worked well together. Staff were competent in meeting the assessed needs of patients.
  • Staff took the time to interact with patients and those close to them in a respectful, compassionate and considerate way. Patients and their relatives/carers were actively involved in their treatment and care.
  • Services provided reflected the needs of the population served and ensured flexibility, choice and continuity of care. Services were reviewed and improved when they were identified as not meeting the needs of patients. Complaints feedback was used to improve services provided and learning was shared amongst staff.
  • Leaders had the right skills and commitment to improve the quality of the service. The culture was centred around the needs and experience of patients. There were structures, processes and systems of accountability to support the delivery of the strategy and good quality services.

However:

  • Not all staff within community health services for adults were compliant with the trust’s mandatory training programme. There were shortfalls in some areas, including manual handling and adult basic life support.
  • The safety electrical checks on some equipment, including some medical devices, were out of date. However, the trust was aware of this and was taking action to address this risk.
  • Whilst there were systems for monitoring performance, waiting times were not being formally scrutinised until after our inspection.
  • Complaints were not always responded to within the target time frames set by the trust.

Community urgent care services

Requires improvement

Updated 4 August 2017

We rated the urgent care centre to be requires improvement overall. This was because:

  • We were concerned that following a serious incident the service did not explore all possible areas of improvement.
  • Not all staff had received the appropriate level of safeguarding training which put patients at risk.
  • Some medicines were not stored securely and some were not labelled correctly which meant it could not be identified when they were opened.
  • The quality of records required improvement and the records audit process was not robust
  • Compliance with mandatory training was variable so we could not be assured that staff were familiar with safe systems and processes.
  • The business continuity plan was not robust to account for different situations such as adverse weather.
  • There were incidents of inappropriate referral from the emergency department of patients who were too ill to be in the urgent care centre. Patients were sometime inappropriately streamed to the urgent care centre by the emergency department, NHS 111 and the ambulance service.
  • Due to the computer systems in the emergency department and the urgent care centre being different, patients may be waiting up to eight hours without being outside of target times.
  • Some patients did not have the waiting times explained to them which left them uncertain as to why they were waiting.
  • Staff were uncertain about the future of the urgent care centre and required more reassurance from managers during the transition period.

However:

  • Managers had recognised where services could be improved and various work streams were in place to mitigate and improve them.
  • Staff understood their responsibilities to raise concerns and report incidents. Learning from incidents was shared with them.
  • Staff held the appropriate qualifications and training to perform their role. Staff were given opportunities to develop and improve their skills and to progress within the service.
  • Staff worked well with other services, such as NHS 111, the ambulance service, GP’s and, particularly ambulatory care, to ensure that treatment was effective.
  • Feedback from patients was positive about the way staff treated them. Patients were treated with dignity, respect and kindness during all interactions.
  • Staff encouraged patients to be partners in their care and supported them to make decisions. Staff responded compassionately when people needed help.
  • Confidentiality was respected at all times.
  • The department consistently met or exceeded the national standard which requires that 95% of patients are discharged, admitted or transferred within four hours of arrival at the urgent care centre.
  • There was suitable support provided to patients with complex needs such as patients living with dementia or a learning disability. Staff understood the reasonable adjustments needed to ensure vulnerable people were cared for appropriately.
  • The urgent care centre was accessible by patients with a disability and chaperone and translation services were available.
  • Governance and performance management systems were being proactively assessed and established. The centre had set up a dashboard and governance processes in line with processes in the wider trust and were using them to monitor performance
  • The urgent care centre used risk registers to identify where the biggest risks were and they were taking steps to mitigate known risks.
  • Leadership the urgent care centre were proactive and well respected. The leadership within the unscheduled care division had the skills needed to integrate the urgent care centre with the division.
  • Despite the amount of change going on within the urgent care centre, staff morale was positive; staff felt respected, valued, and supported by their leadership team.

Community health services for children, young people and families

Outstanding

Updated 19 January 2016

Overall rating for this core service

Outstanding

We found that services were safe, effective, caring, responsive and well led. The staff were competent, compassionate, enthusiastic and well supervised in their role. During the inspection, we met with managers, staff, children, young people and parents in a variety of community settings. We observed staff delivering care being in schools, outpatient clinics and in the child’s own home. There was an open reporting culture for any incidents that took place. Staff were encouraged to raise incidents and managers gave them feedback when appropriate. Staff were aware of their responsibilities to safeguard children and young people from abuse and worked closely with different agencies where appropriate. Recruitment had been a concern within the health visiting service, but we did not see any evidence that this had a negative effect on the care provided.

Care provided to children and young people was evidence based, using NICE guidance, Department of Health research and from advice from specialist centres. Local, regional and national audits were undertaken. Managers shared the outcomes with staff and, where services needed to improve, we saw action plans in place and plans to re-audit. Multidisciplinary and multi-agency working was embedded across the teams. We saw evidence that staff received regular supervision and appraisals.

We received excellent feedback from children, young people and their parents/carers about the care and treatment they received and the staff who provided it. Staff were skilled at communicating with children and young people and treated them with respect and dignity. Staff were friendly, warm, caring and professional. Staff always put the children and young people at the heart of everything they did and always involved them in their care and treatment. Specially trained health visitors and school nurses took part in a rapid response team to support parents in Wiltshire who had experienced the unexpected death of their child. We saw staff were responsive to the needs of children, young people and their families. Interpreting services were used for families where their first language was not English. Robust clinical governance structures were in place. Staff felt supported by their team leaders and managers within the community services.

End of life care

Good

Updated 19 January 2016

Overall rating for this core service GOOD 

We judged the overall service provision of end of life care as good. We found the service to be safe, effective, caring, responsive and well-led.

There were systems in place to keep patients safe. There was a good provision of equipment, including syringe drivers and mattresses for patient use in the community. We saw pre-emptive prescribing of anticipatory medications and availability of the ‘just in case’ medications.

End of life care was delivered through evidence based research and guidance. Education programmes had been developed and delivered, new documentation had been successfully introduced to the trust improving the pathway for patients

Patients and relatives spoke highly of the teams of nurses in the community; they were seen as very responsive to their needs. Out of hours there were good resources for staff to access including a 24 hour advice line managed by specialist palliative care nurses at a local hospice.

End of life care was seen as a priority for the trust. There was a clear overarching strategy for the service and plans to improve the delivery of care had already begun to take place with good results. The staff were able to collate evidence and influence change to improve services for patients.