We did not change ratings at trust level at this inspection. Please see summary of services at Great Western Hospital.
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.
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.
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.
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.
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.
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.
- 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.
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.
- 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.
We carried out an announced inspection between 21 and 23 March 2017 and an unannounced inspection at Great Western Hospital on 26, 27 and 28 March 2017 and 3 April 2017. This was a focused inspection to follow up on concerns from a previous inspection. As such, not all domains were inspected in all core services.
The inspection team inspected the following six core services at Great Western Hospital:
- Urgent and emergency services
- Medical care (including older people’s care)
- Critical care
- Services for children and young people
- Outpatients and diagnostic imaging
We also inspected:
- Urgent care services (provided as a community service).
We did not inspect end of life care or maternity and gynaecology services (previously rated good). We did not inspect the effective, caring or responsive domains for services for children and young people (previously rated good). The effective domain was inspected but not rated for outpatients and diagnostic imaging.
Overall we rated Great Western Hospitals NHS Foundation Trust as requires improvement.
We have deviated from the aggregation principles by not aggregating the ratings for (community) urgent care services to the overall trust rating. This is in recognition of the fact that, at the time of our inspection, the trust had only been running these services for six months. We also deviated from the aggregation principles for the well led rating at provider level. Please see the well led section below.
We rated the safe domain as requires improvement overall. Urgent and emergency services, medical care, surgery, critical care, services for children and young people, the urgent care centre and outpatients and diagnostic imaging were all rated as requires improvement.
- As a result of high demand we found the emergency department was frequently full, with patients in all cubicles and around the nurses’ station. There were occasions where the emergency department was deemed to be unsafe as a result of the number of patients within the department. However, this was improving. We also found that as a result of pressures for beds in surgery some patients had to use facilities which were not always appropriate for recovering from their surgery.
- The checking of temperatures for medicines needed to be improved. Daily checks of medicines were not always completed in the emergency department or critical care. We found in medical care that some areas did not have regular temperature checks. This meant that medicines used may not have been fit for use due to the temperatures they may have been stored at outside of the recommended temperature range.
- The storage of medicines needed to be improved. In medical care we found that some of the storage shelves did not allow for stock rotation, which increased the risk of medicines being out of date. In the urgent care centre medicines which should have been locked away were not. We also found in critical care that the fridges used to store medicines could not be locked. This meant that medicines could be removed without authorisation.
- Equipment used was not always checked in line with guidance to ensure it was fit for purpose. Daily checks of equipment did not always take place for emergency equipment. There were some days where checks were not recorded for the paediatric intubation trolley in the emergency department and the emergency equipment trolleys in critical care. We also found in the service for children and young people that heated water blankets did not have expiry dates or water change dates recorded.
- There were areas throughout the hospital which did not have sufficient numbers of suitably qualified staff on shift to keep people safe. This included the emergency department observation unit where we observed a patient walking out of the department without staff knowing. Within medical care, services for children and young people, surgery and critical care there were wards and theatres which went through periods of understaffing which meant that staffing numbers did not always meet national guidelines. In medical care we found that ambulatory care was sometimes left with no staff in it for short periods of time due to lone working arrangements.
- Mandatory training rates needed to be improved in the emergency department for medical staff, in the urgent care centre, medical care, outpatients and diagnostic imaging, critical care, and surgery. In services for children and young people all medical staff fell below trust targets for all mandatory training and paediatric basic life support training was below target in all staff groups.
- Safeguarding practices needed to be improved in the urgent care centre, outpatients and diagnostic imaging and in services for children and young people. In outpatients and diagnostic imaging only 20% of medical and dental staff had completed level two safeguarding adults training against a trust target of 80%. In the urgent care centre no one was level three trained for children’s safeguarding. In services for children and young people staff did not have ready access to relevant safeguarding information on a patient due a filing backlog.
- The security and completeness of records needed to be been improved. We found in medical care and critical care that patient records were not always stored securely. We also found that in critical care patient allergies and venous flushes were not always documented. In medical care we found that not all patient documentation was completed in full and handovers between wards was not consistency provided to a high standard. This meant that patients' full needs were not always met.
- There was a positive incident reporting culture and openness and transparency was encouraged. Opportunities for learning were sought when an incident occurred and learning was shared between teems. Where never events occurred in surgery we found they were investigated fully and actions had been taken to prevent them from happening again.
- We found all areas within the hospital, apart from a few exceptions, were visibly clean and tidy. We saw staff following National Institute of Health and Care Excellence standards for hand hygiene and we found that audit results were positive.
- We found that staffing levels for both medical and nursing staff were in line with recommended guidance in the emergency department, critical care and the urgent care centre. Within medical care there were sufficient doctors to provide safe care for patients.
- Risks to patients were appropriately assessed in the emergency department where we found observations and treatment decisions were made in a timely way. We found that patients' records were legible, complete, up to date and accurate in the emergency department, surgery, and critical care.
We rated the effective domain as good overall. It was rated as good for urgent and emergency care, surgery, critical care. It was rated as requires improvement for medical care and the urgent care services. It was inspected but not rated for outpatients and diagnostic imaging.
- In the emergency department, medical care, surgery, critical care and outpatients and diagnostic imaging we found that patients' care and treatment were planned and delivered in line with guidance, standards, best practice and legislation. This included guidance from the National Institute of Care Excellence and the Royal College of Emergency Medicine.
- Information about patients' care and treatment was routinely monitored and action was taken to improve the effectiveness of treatment where shortfalls had been identified. In surgical services the trust had a better rate of re-admission compared to the national average. In emergency care the department performed well in the latest Royal College of Emergency Medicine audits.
- Staff had the skills required to carry out their roles effectively. In all services inspected we found that staff had qualifications, experience and had received competency training in line with their role requirements. Most services performed better than the trust target for completion of appraisals.
- Patients received care and treatment from different disciplines who worked together in a coordinated way. All departments communicated well with each other to ensure effective treatment for patients. This multidisciplinary working approach continued over weekends where there were 24 hour diagnostics, critical care outreach, physiotherapy, pharmacy, and mental health liaison services.
- Within all services we found that the nutritional and hydration need of patients were fully assessed and that actions were taken to address concerns as soon as they were identified. Within the trauma unit innovative systems were in place to improve nutrition and hydration for patients.
- In the urgent care centre policies, protocols and patient pathways were not in line with best practice legislation. Many policies were out of date, with some of them being several years out of date.
- In some areas of the trust outcomes required improvement. In medical care areas of the national stroke audit, MINAP audit and the national heart failure audit required improvement. In the urgent care centre outcomes were not routinely collected but were being introduced after the inspection.
- In critical care the provision of therapy services did not meet national standards. We found there was insufficient access to physiotherapy and dietetic services.
We rated the caring domain as good in medical care, surgery, critical care, outpatients and diagnostic imaging, and the urgent care centre. In urgent and emergency care we rated caring as outstanding.
- In all areas feedback from patients was consistently positive. We spoke withpatients their relative whotold us they recived care that was compassionate, they were involved as partners in care, and supported to cope emotionally with their care.
- Inspectors observed patients being treated with kindness and respect and saw that patients and their relatives were active partners in their care. They were well informed of treatment options and were involved in decision making.
- Emotional support was available to patients, either through the use of a psychiatric liaison nurse orstaff taking the time to sit with patients and talk to them. There were good examples of staff listening and acting appropriately to patients suffering from emotional distress.
- Privacy and dignity was compromised in the discharge lounge, the surgical assessment unit, theatre recovery, ophthalmology and the urgent care centre. Conversations with patients could be overheard in the urgent care centre assessment rooms, the discharge lounge and the ophthalmology department. We found that in the surgical assessment unit, the discharge lounge and theatre recovery privacy was difficult to maintain when a patient required the toilet or to use a bedpan.
We rated the responsive domain as requires improvement overall. It was rated as requires improvement for urgent and emergency care, medical care, surgery and outpatients and diagnostic imaging. It was rated as good for critical care and the urgent care centre.
- Patient flow through the hospital required improvement. The trust found it difficult to discharge patients from medical, surgical, and critical care services who required social care or patients who had a complex discharge.
- This resulted in the emergency department regularly being full to capacity, which meant that patients could not be seen in a timely way for assessment or treatment. The emergency department regularly breached targets for time spent in the department with most breaches being attributable to beds throughout the rest of the hospital not being available.
- Although medical outliers were managed well, the number of them was impacting the number of elective operations which could take place.
- Facilities were not always fit for purpose as a result of the numbers of patients being treated at the hospital. The medical expected unit was not always able to separate male and female patients, compromising privacy and dignity. In the emergency department patients were regularly cared for around the nursing station without screens to protect their privacy and dignity.
- For three months out of the past 10 the trust was performing worse than the national standard for two week urgent cancer referrals There were a high number of patients waiting for non-cancer outpatient appointments, with the most in ophthalmology. There were also delays in the sending out of letters for patients after their appointment.
- We found that in medical care and outpatients and diagnostic imaging translation services were available, but they were not always utilised. In medical care relatives were sometimes used with compromised confidentiality.
- A number of steps had been taken to improve patient flow. This included moving the ambulatory care service to increase capacity and the introduction of the medical expected unit. There were also effective patient flow meetings to establish who could be discharged.
- High numbers of patients were streamed from the emergency department to the urgent care centre. We found that the urgent care centre was seeing patients quickly and seeing them within four hour targets.
- Reasonable adjustments were made to support patients in vulnerable circumstances throughout the hospital. Staff had a good understanding of the adjustments needed to support people living with dementia and learning disabilities.
We rated the well led domain as good overall. It was rated as good for urgent and emergency care, medical care, critical care, outpatients and diagnostic imaging and the urgent care centre. It was rated as requires improvement for services for surgery and children and young people. We have deviated from our ratings aggregation principles in recognition of the significant improvements made since our last inspection. There was good board oversight of quality, safety and the trust's financial situation, which had improved. Significant challenges in respect of capacity, access and flow were well understood. The trust was working with partners to address these challenges to ensure future sustainability of healthcare in Swindon.
- There was a clear vision and strategy within the services which was underpinned by realistic goals. The urgent care centre was working to develop its strategy in line with the unscheduled care division. This strategy was being acted upon with innovative workstreams through the emergency department, medical care, surgery, services for children and young people and outpatients and diagnostic imaging.
- Governance functioned effectively within all of the core services inspected and where reviews were underway (in services for children and young people and the urgent care centre) there were clear timescales and actions.
- Leaders of services throughout the organisation had a good understanding of the challenges faced by their departments and had the knowledge, skills and experience to lead effectively. Staff throughout the organisation spoke positively about their leaders and were confident to go to them if needed.
- Staff within services for children and young people felt disconnected from the rest of the trust. The leadership had not been embedded locally and there was no representation of services for children and young people on the board.
- Nurses in services for children and young people did not recognise the trust as a good place to work. We were told that they often had to work long hours without access to a drink and without having a break. Nurses did not know the strategy of the women’s and children’s division.
- In surgery there were areas where there was a lack of management oversight. Also, actions identified to mitigate risks on the risk register were not always effective.
- In the emergency department, and surgical services staff felt that the executive team was not visible enough and that attempts to engage with staff could be better.
We saw several areas of outstanding practice including:
- The work of the education lead in the emergency department to improve education through various initiatives and work steams, including improved appraisals, training as part of the governance days and introduction of structured workbooks and teaching sessions.
- The understanding and involvement of patients and those close to them in the paediatric emergency department we observed during triage. The nurse put patients at ease and made sure that the process was explained in a compassionate way.
- The understanding of the emergency department leadership team of performance, governance, risks and its impact on patient care.
- The use of an emergency department monthly governance day to engage staff with governance and learning from incidents, concerns or near misses.
- The use of social media in the emergency department to engage staff to be more engaged with governance, share learning and discuss concerns with senior members of staff.
- The work of the clinical trials team in the emergency department to increase trial recruitment from very few patients a year to several hundred patients a year and the impact this has had on patient experience in the department.
- The medical care service had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicine.
- The medical care service had introduced digital technology for patients living with dementia which enabled them to access personalised reminiscence material.
- The trauma unit within surgery provided a picture menu which showed photographs of all food options that the hospital provided. This could be used for patients with communication difficulties, such aspatients with learning difficulties so they could more easily identify what food they would like at mealtimes. This had been hugely successful on the ward and at the time of the inspection this was being rolled out across the hospital.
- The outpatient service had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicine.
- The outpatient service had introduced digital technology for patients living with dementia which enabled them to access personalised reminiscence material.
- The monthly staff newsletter in the urgent care centre contained information on departmental news, department performance and updates on policies and procedures.
- The trust had introduced acute neurology clinics, located close to the short stay/ambulatory care unit, for patients who attended the acute medical unit and would have needed to be admitted in the past for further opinions and tests. These patients could now be discharged with an appointment, either the following day or the day after. This initiative had led to a significant number of admissions being avoided and provided a positive experience for patients.
- The cardiology department inserted the first four lead pacemaker for a patient in the world. The medical staff were monitoring the patient’s recovery and rehabilitation as part of an international research project to assess the advantages of the new technology.
- A GP was employed in ambulatory care four days a week. The purpose of this new position was to improve communication with GPs to ensure basic tests had been completed prior to the patient attending the ambulatory care unit. It was anticipated that this would help to increase the flow of patients through the department and prevent patients attending the unit unnecessarily.
However, there were also areas of poor practice where the trust needs to make improvements.
Importantly, the trust must:
- Ensure that the emergency department observation unit is sufficiently staffed to keep people safe.
- Ensure that medical staff in the emergency department receive appropriate mandatory training to enable them to carry out the duties they are employed to perform.
- Ensure that daily checks are conducted on resuscitation equipment and medicine fridges in the emergency department to assess that they are safe to use.
- Continue to develop and initiate plans and work streams in line with the improvement plan to improve flow in the emergency department at pace to improve safety and patient flow in the department.
- Ensure the promotion and control of infection at all times and in all areas within medical care.
- Ensure the security of patients’ confidential and personal information at all times within medical care.
- Ensure the safety of patients at all times within medical care, including ensuring sufficient staff are on duty to monitor and provide care and treatment to the patients. The trust should ensure patients are not left unattended in the ambulatory care department as a result of staff lone working.
- Ensure that the privacy and dignity of patients in medical care is respected and ensure that breaches of the national mixed sex accommodation do not occur.
- Ensure that staff in medical care consistently meet the trust target for mandatory training.
- Ensure that handovers take place consistently in medical care when transferring patients between wards and departments. The trust should ensure that assessments were carried out promptly by doctors following patients being admitted to the medical emergency unit.
- Ensure that there are clear pathways in medical care, including staffing levels, regarding the care of patients who require non-invasive ventilation (NIV).
- Improve the number of staff on surgical wards who have completed all their mandatory training in line with the hospital target.
- Improve access to patient toilet facilities within the surgical assessment unit and theatre recovery area.
- Improve the response times to patients’ complaints within surgery.
- Improve the timely completion of discharge letters to GP’s, including reducing the large backlog of letters which have not been sent within surgery.
- Ensure all staff in critical care are compliant with mandatory training, role essential training and current assessment of staff’s paediatric competencies (nursing and emergency procedures).
- Ensure there are adequate allocated hours from allied healthcare professionals to meet national recommendations.
- Ensure there are adequate numbers of suitably qualified, competent and skilled nursing and medical staff in areas where children are cared for in line with national guidance.
- Ensure all staff involved with the care of children are up-to-date with paediatric basic life support and mandatory training.
- Ensure medical and dental staff in outpatients and diagnostic imaging have received training in level two safeguarding vulnerable adults
- Ensure medical and dental staff in outpatients and diagnostic imaging are up to date with mandatory training, including adult basic life support, fire training and paediatric life support
- Improve the rates of mandatory training within the urgent care centre to bring compliance levels in line with the trust’s target.
In addition the trust should:
- Ensure that there are suitable quantities of cardiac monitors and trolleys in the emergency department to ensure safe patient careat times of crowding.
- Ensure the provision of specialist support to patients attending the emergency department who misuse alcohol or substances.
- Ensure that the executive team is more engaged with staff in the emergency department and plan times of visits better to prevent a negative impact on staff morale.
- Ensure that equipment used for personal care within medical care services is fit for purpose and that staff are able to provide assistance promptly if the patients become unwell while using equipment. This relates to inaccessible showers.
- Ensure that clinical equipment in medical care, such as needles and blades, is stored securely. The trust should ensure the safe storage of medicines, including creams and ointments, at all times. This should include ensuring that medicines aree stored following manufacturers' guidelines.
- Ensure that where oxygen cylinders are stored in medical care, there is appropriate signage to inform staff and visitors to the area.
- Ensure that staff working in all departments in medical care have access to emergency equipment and medicines in order to be able to respond promptly to medical emergencies.
- Ensure within medical care that care documentation, including care plans, pain and risk assessments were completed in sufficient detail to inform staff of the individualised care and treatment that was required for each patient.
- Ensure that nursing staffing levels in medical care consistently meet the assessed and agreed staffing establishment for all wards and departments.
- Esure that within medical care performance against national audits is improved.
- The trust should ensure that within medical care the patient’s confidentiality was consistently respected when requiring assistance with interpretation and/or translation.
- Ensure that within medical care the complaints process was followed in a timely way and in accordance with the trust policy and procedure.
- Ensure that staff within medical care are consistently informed and knowledgeable about the risk registers for their wards and departments.
- Improve completion of NEWS within surgery.
- Ensure fabric curtains are replaced by disposable curtains to meet national standards.
- The critical care service should ensure processes to monitor and audit compliance with cleaning processes in critical care.
- Ensure effective processes to learn from mortality and morbidity meetings in critical care.
- Ensure staff in critical care check essential equipment daily in line with policy.
- Ensure that in critical care, patients’ allergies are always documented and that staff sign for all medicines they administer.
- Ensure the safe storage of medical gasses.
- Ensure all patient medical records in critical care are stored securely.
- The critical care service should ensure practice guidance is regularly reviewed and updated.
- Continue to support the clinical nurse educator role in critical care to comply with national recommendations.
- Review the training and competency assessment of medical staff in critical care to ensure there is always staff on duty who are competent in airway management.
- Explore the improvement of the patient bathroom facilities in critical care to include shower facilities so that these facilities are not shared with relatives.
- Review the arrangements for the provision of follow-up clinics in critical care to ensure these are sustainable.
- Ensure staff have access to appropriate equipment necessary in children’s services to carry out their roles and provide care effectively and efficiently.
- Ensure all staff involved in the care and assessment of children and young people have safeguarding training in line with intercollegiate guidance.
- Ensure that systems are in place to ensure case conference notes of vulnerable children are filed in their records in a timely manner.
- Consider the wellbeing of staff within children’s and young people’s services in terms of regular access to rest breaks and hydration.
- Consider mechanisms which could improve the connection of, and communication between, front line staff and divisional leaders within children’s and young people’s services.
- Consider options for improving the connection between the Women and Children’s division and the rest of the trust, together with considering the representation of children’s services at board level.
- Ensure patients within all of the diagnostic imaging waiting rooms can be monitored by staff.
- Ensure that departments within outpatients have access to resuscitation equipment in line with hospital policy
- Provide leaflets within departments in outpatients and diagnostic imaging that are available in different languages.
- Ensure access for bariatric patients in outpatients is improved so they can be assessed and treated without compromising their privacy.
- Make improvements on the follow up backlog waiting list to meet people’s needs and minimise possible risk and harm caused to patients through excessive waits on outpatient appointments and excessive waits on the reporting of images.
- Make improvements on the backlog in typing time times in outpatients and the delay in letters being sent to GPs.
- Ensure arrangements are in place to replace aging diagnostic imaging equipment identified at risk of failure
- Improve the storage of medicines within the urgent care centre and ensure that medicines are checked and managed by staff.
- Improve the quality of records audits in the urgent care centre to ensure that maximum learning is taken from them.
Professor Sir Mike Richards
Chief Inspector of Hospitals
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.
- 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.
Great Western Hospitals NHS Foundation Trust consists of one acute hospital (Great Western Hospital) and four community hospitals, of which three provide inpatient services. There are a total of 450 acute beds (including 12 critical care beds and 38 maternity beds) at the Great Western Hospital. Chippenham hospital as 37 beds spread over two wards, one ward of 25 beds at Warminster hospital and one ward of 26 beds at Savernake hospital. The trust provides acute and community healthcare services to a population of around 480,000 people from Wiltshire and the surrounding areas.
Overall, Great Western Hospitals NHS Foundation Trust was rated as requiring improvement. We rated it as good for caring and as requiring improvements in safety, effectiveness, being responsive to patients’ needs and being well-led. Maternity and Gynaecology services and End of Life care were rated as good overall with all other core services rated as requiring improvement. We rated safety within the Urgent and Emergency care services as inadequate. Within the community services, we rated services to children and young people as outstanding. All other community service was judged as good.
Our key findings were as follows:
- The trust was open and generally had a good culture for incident reporting. Safeguarding processes and practices were good.
- There was information available for patients and visitors on how to make a complaint. Clear processes were in place for the management of complaints and concerns. Investigations occurred, and lessons were shared.
- Patients were treated with compassion, kindness, dignity and respect. Staff within the Children and Young Peoples community teams were focused on the needs of the children and young people, putting them at the heart of everything they did. Care was delivered with empathy and honesty.
- There were concerns with staffing and how this impacted upon patient safety. Within the Emergency Department the design and layout meant that waiting patients, including children, were not adequately observed. The physical isolation of the observation unit and lack of environmental safeguards, posed unacceptable risks to patient and staff safety. Staffing levels did not always meet patient need. Staffing levels in the Emergency department (ED) did not take into account the requirement to care for patients who queued in the corridor or the sub-waiting room. There were also concerns about the level of staffing within the children’s ED and the ED observation unit. The midwife to patient ratio exceeded (was worse than) recommended levels and one to one care for women in established labour was not achieved 100% of the time.
- Some accommodation in the ED and minor injury units (MIUs) was cramped and not conducive to the exchange of private conversations or the protection of patients’ privacy and dignity.
- Compliance with level three safeguarding training within the maternity and gynaecology services was significantly below the trust standard.
- Not all staff were consistently adhering to good hand hygiene practices or using protective personal clothing.
- There was good multidisciplinary working to promote quality care. Patient outcomes, mortality and morbidity were generally monitored though action plans to address shortfalls were frequently incomplete so progress could not be assured.
- Whilst practice in some areas was good, consent to care was not consistently obtained in line with legislation and guidance including the Mental Health Act. Deprivation of Liberty Safeguards were not monitored and had expired without staff being aware.
- The ED was not consistently meeting the national standard for 95% of patients to be discharged, admitted or transferred within four hours of arrival at A&E or for consultant-led referral to treatment time (RTT) targets in five of the six surgical specialties. Bed occupancy rates were higher than the England average. Both the acute and community hospitals faced a high number of patients who were fit for discharge, but without transfer of care packages.
- Whilst not designed for that purpose, the day surgery unit (DSU) was frequently used to accommodate patients overnight.
- As a result of the second class post imposed due to financial pressures some patients missed appointments whilst others did not receive MRSA washes or preparations for endoscopy procedures in time.
- At the time of the inspection, the trust was in breach of its licence from Monitor following a significant departure from the financial plan in late 2014 resulting in a deficit of £9 million against a planned surplus of £1million. The consequent actions, including independent reviews of governance arrangements, identified significant shortfalls that are in the process of being addressed. Governance processes within some divisions was found to be weak.
- The trust were committed to maintaining the quality of care whist also striving to manage demands for services and the flow of patients into, through and out of hospital. At the time of the inspection the necessary improvements had not been made and sustained.
- The trust was open about the issues faced and took feedback well. The significant scrutiny from regulators and commissioners was adding to the challenges for the leadership team.
We saw several areas of outstanding practice including:
- The diagnostic imaging team had some areas of outstanding practice, one of which, the palliative ascites drainage, was highly commended by the British Medical Journal (BMJ) in 2015. Innovative practice was seen with the introduction of the intra operative breast radiotherapy project.
- In the critical care unit we were given examples of staff ‘going the extra mile’ for their patients, including a patient attending a family wedding in London, with transport being arranged by the unit and staff escorting the patient for the day.
- The consultants provided specialist pre and post pregnancy counselling and support service to women. This and other specialist clinics developed to manage high risk pregnancies had been recognised as best practice. The lead consultant had won an All-Party Parliamentary Group Maternity Services Award during 2011. This service style had since been adopted by other Maternity Services across the country and show-cased at Harvard, USA.
- The midwives successful audit and interdepartmental training to prevent cerebral palsy in pre- term babies born at the hospital
- Children were treated with respect and their ability to give consent for their own treatment was taken seriously.
- The multi-disciplinary working within the community. For example the neurology community team worked with a patient, their carers, social services, housing authorities and other clinicians including the palliative care team to arrange the adaptation of accommodation for a patient with motor neurone disease.
- The wheelchair service who committed to providing wheelchairs for patients diagnosed with motor neurone disease within two weeks by prioritising the adaptations that were required to be completed. They also provided a priority service for patients who were receiving end of life care.
- The community respiratory team, how they worked with others, lead training initiatives for GPs and physiotherapists and held brief informal training updates to nursing teams during their lunchbreaks. There were weekly teleconferences and meetings every six weeks between colleagues to discuss the latest guidance. The lead nurse also chaired quarterly meetings of a respiratory network of health professionals who worked in respiratory services.
- The tissue viability team led by a nurse consultant demonstrated an outstanding level of evidence-based practice and innovation in the management of pressure ulcer care. Regular, quarterly pressure ulcer audits contributed to a quality improvement collaborative for pressure ulcers work plan and the organisational action plan for pressure ulcer reduction. An estimated £40,000 a year was expected to be saved due to the reduction in the length and frequency of nursing visits, with time saved to be used to visit more patients. Great Western Hospital is the first provider nationally to roll out the use of these systems.
- Specially trained health visitors and school nurses took part in an on-call unexpected child death rapid response team. When a child or young person who lived in Wiltshire died unexpectedly, the police would be contacted alongside the rapid response team. Whilst the police would investigate the circumstances surrounding the death, the staff within the rapid response team were responsible for providing emotional support to the parents. By using health visitors and school nurses that had been specially trained, it utilised their skills at communicating with parents to support them at the worst moment in their lives.
- The children and young people's community teams had excellent multi-disciplinary and multi-agency working. This extended across the local communities they served, health and social care as well as the ministry of defence to support children of military families.
- The leadership across the children and young people's community team was very visible and staff were full of praise for their immediate team leaders and wider management team within the community. They felt supported and valued by their team leaders and managers.
- The looked after children team had produced a health passport for all their children and young people. This contained full details of each individual child's health and medical history. Details of appointments, immunisations were also included. Young people were able to take these passports with them once they left the care of the local authority to help them make a good start in their adult lives.
- The children and young people speech and language therapy team (SALT) were linked directly to local schools. This was to make sure children and young people received more intensive support and received early intervention when necessary.
- The Governance Database developed and used by the Integrated Community Health Division (ICHD) was a spreadsheet used by staff to record audit information and outcomes, serious incidents and investigations that took place and training records. There was also information about staffing levels, complaints and safeguarding issues. Staff at all levels were aware of and used the database regularly.
- The division had recently developed a four day community induction programme. Once staff had completed the GWH trust induction they were expected to undertake the community induction. This applied to new staff, staff who had a new role within the trust and staff employed in the last year that had not had a chance when they started to attend the specific community induction. The programme was very detailed and staff told us they had really appreciated the induction as it gave them an insight into the services offered and lone working, fire safety and medical cover for example.
- Two consultants provided bespoke training on some of the community hospital wards. This was well received and attended by staff. They felt this enhanced the feeling of working in partnership to ensure the best care and support is provided for the patients.
- The community services participated in ‘IWantGreatCare’, this was a continuous, real-time collection, monitoring and analysing quantitative and qualitative patient and relative feedback and could act as an early warning system.
- People’s individual needs and preferences were central to the planning and delivery of services. The service was flexible, provided choice and ensured continuity of care in the wider community. The involvement of other organisations and the local community was seen to be integral to how patient care was planned and ensured the service met people’s needs.
- End of life care had become part of the induction and mandatory training programme, these programmes of learning had been devised by the palliative consultant and end of life nurse.
However, there were also areas of poor practice where the trust needs to make improvements.
Importantly, the trust must:
- Ensure staff receive up to date safeguarding, mandatory training appraisals and training on the Mental Capacity Act.
- Improve governance processes to demonstrate continuous learning, improvements and changes to practice as well as board oversight and assurance.
- Ensure there are sufficient numbers of midwifery staff to provide care and treatment to patients in line with national guidance.
- Ensure effective infection prevention and control measures are complied with by all staff.
- Ensure safe storage of medicines, including intravenous fluids.
- Improve the access and flow of patients in order to reduce delays from critical care for patients being admitted to wards and reduce occupancy to recommended levels.
- Review nurse staffing levels and skill mix in the emergency department (ED), including children’s ED, the ED observation unit and minor injury units, using a recognised staff acuity tool.
- Take steps to ensure there are consistently sufficient numbers of suitably qualified skilled and experienced staff employed to deliver safe, effective and responsive care.
- Ensure all staff who provide care and treatment to children in the emergency department are competent and confident to do so.
- Make clear how patients’ initial assessment should be carried out by whom and within what timescale within the ED.
- Monitor the time self-presenting patients wait to be assessed in the emergency department and take appropriate action to ensure their safety. This must include taking steps to improve the observation of patients waiting to be assessed so that seriously unwell, anxious or deteriorating patients are identified and seen promptly.
- Ensure that clinical observations of patients in the emergency department are undertaken at appropriate intervals so that any deterioration in a patient’s condition is identified and acted upon.
- Risk assess and make appropriate improvements to the design and layout of the emergency department observation unit to reduce the risk of patients harming themselves or others.
- Clarify the use of the observation unit, setting out its purpose, admission criteria and exclusion criteria to ensure that patients admitted there are clinically appropriate and receive the right level of care.
- Ensure best (evidence-based) practice is consistently followed and actions are taken to continually improve patient outcomes.
- Ensure chemicals and substances that are hazardous to health (COSHH) are secured and not accessible to patients and visitors to the wards.
- Ensure sharps bins are used in accordance with manufacturer’s guidance to prevent the risk of a needle stick injury.
- Ensure staff members are aware of the risk of cross infection when working with patients with isolated infectious illness.
- Ensure risk assessment tools in place to identify risks of thrombosis, pressure damage, moving and handling, nutritional and falls are consistently completed and appropriate action taken.
- Ensure National Early Warning Scores used to identify from a series of observations when a patient was deteriorating are appropriately actioned when high indicator scores were seen.
- Ensure that patients with mental health issues on medical wards are appropriately managed.
- Ensure appropriate review and action are undertaken when Deprivation of Liberty Safeguards have been put in place.
- Ensure consistent compliance with the Mental Capacity Act. Ensure all appropriate surgical patients have their mental capacity assessed and recorded to ensure consent is valid, and the hospital is acting within the law.
- Ensure patients’ records are fully completed and provide detailed information for staff regarding the care and treatment needs of patients.
- Ensure the provision of single sex accommodation.
- Ensure all areas of the premises and equipment are safe and secure, and patient confidential information is held securely at all times.
- Ensure patients being admitted overnight to the day surgery unit have appropriate facilities which meet their needs, maintains their privacy and dignity, and reflects their preferences.
- Provide a responsive service to reduce waiting times and waiting lists for surgery procedures. Theatre efficiency, access and flow, delays, transfers of care, and bed occupancy must be improved to ensure patients are safely and effectively cared for.
Professor Sir Mike Richards
Chief Inspector of Hospitals
Overall rating for this core service GOOD
Overall we rated all these adult community services as good. The trust provides a range of community services including district nursing, physiotherapy, continence, podiatry, wheelchair services, learning disability services, dietetics, diabetes, respiratory,adult speech and language therapy, neurology and tissue viability. During the inspection we looked at community services for adults, community outpatients and diagnostic services.
We rated all the five domains of this core service as good and found that some aspects of the effective and well led domains were outstanding.
The community services had a commitment to providing harm free and safe care. There were procedures in place to improve pressure care treatment through staff training and also the use of new innovative treatment techniques.
We found there were robust procedures in place for reporting incidents and staff we spoke with were aware of the processes to follow. We saw the learning from incidents was cascaded and improvements were initiated.
Equipment was well maintained and clinics and patient waiting areas were kept clean hygienic and safe.
Staff were completing mandatory training. The integrated health team was 80% compliant with mandatory training. which met the trust target of of 80%. Infection prevention and control mandatory training was completed by 85% of the team.
There were relevant and current evidence based guidance and best practice in use by clinicians across all the various services. We considered some of this to be outstanding practice. We found some outstanding practice where clinicians accessed information and knowledge through colleagues, clinical networks and professional associations.
Staff we spoke with said they considered that the trust valued training and they, “felt invested in”. Staff told us the training was generally of a high standard, was well planned, organised and professionally delivered.
Staff received annual appraisals and there were excellent levels of support from colleagues and managers. All staff we spoke with said they were well supported and supervised by their line manager. However there were inconsistencies around the arrangements for clinical supervision.
There were numerous examples of positive, professional multi-disciplinary working. We considered some of these to be examples of outstanding practice. This occurred within the integrated teams, between the county wide specialist teams, with GP surgeries and with hospital based clinicians. Staff were able to demonstrate knowledge of the various other professionals they worked with, how they shared information and also sought advice and support from different specialists.
Patients were treated with kindness, dignity respect and compassion by the clinical staff and also by reception and other staff working when they visited the community hospitals.
Various developments and changes in the planning and delivering of community services had taken place over the previous 18 months. There was a drive to implement integrated Integrated Teams to work closely around primary care to make care accessible to patients as locally as possible. The Integrated Teams provided a seven day service between 7am and 10 pm. The out of hours service between 10pm and 7am was commissioned to a private provider.
We saw and heard about various initiatives in place to improve the service to patients, including pressure care treatment, multi-disciplinary working with acute colleagues and early intervention treatment for stroke patients.
Patients living in the community were able to access care and treatment in a timely way, though there were some breaches of the 18 week national referral to treatment target in certain services. Action plans were in place to address the shortfalls in breaching these targets
Staff were well informed about the strategy for community services. They were able to explain the values and objectives, such as working closely with primary care services, providing a holistic service, promoting healthy lives and working in an integrated team of professionals.
There was a governance framework in place which gave clear guidelines over lines of responsibility. There were clear processes in place to monitor quality and risk and deliver an improving service. We found that there were some outstanding examples of auditing and action planning against identified shortfalls or areas for improvement by the different Integrated Teams and specialist county wide services.
The leadership and culture reflected the vision and values of the trust and encouraged staff engagement with delivering quality community based services. We found examples of outstanding leadership being provided by heads of locality and the clinical leads for the specialist services.
There was a culture of teamwork that permeated through the community adults service.
There were examples of services taking action to promote improvement and best practice and to improve the service delivered to the community. We saw examples of outstanding and innovative ideas being put into action.
During the inspection we spoke with approximately 70 staff, including managers, clinicians, administrators, technical staff and domestic staff. We also spoke with the trust director for community services.
We spoke with 39 patients and relatives. We visited locations across the geographical area where services were run and also where they were managed and coordinated. We observed care and support being provided by clinicians both in clinics and in the patients own homes. We ran drop in session in the three community hospitals where staff could talk to inspectors.
We looked at a sample of patients records and also trust documentation, including training records, policies, monitoring data and risk registers.
We took feedback from the public via our website and through public listening events. We also received feedback through the healthwatch organisation who had sought the views of patients.
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.
Overall rating for this core service Good
We rated Great Western Hospitals NHS Foundation Trust as good overall for community inpatient services. This trust provided inpatient care and support at three community hospitals. There were 37 beds on two wards at Chippenham Community Hospital, 26 beds on one ward at Savernake Hospital in Marlborough and 25 beds on one ward at Warminster Community Hospital. Care and support were provided by nurses, healthcare assistants and therapy services including physiotherapists and occupational therapists. Medical cover was provided by visiting consultants and local general practitioners.
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.