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Provider: Northampton General Hospital NHS Trust Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 24 October 2019

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

  • We rated safe and well led as requires improvement, and responsive, effective and caring as good. We rated two of the trust’s eight core services as requires improvement and one as good. In rating the trust, we took into account the current ratings of the five services not inspected this time dating from 2017.
  • We rated well-led for the trust overall as requires improvement.
  • The trust provided mandatory training in key skills to all staff but did not ensure that everyone completed it.
  • The design, maintenance and use of facilities, premises and equipment generally kept people safe. However, staff did not always manage clinical waste or hazardous chemicals well.
  • The trust did not always have enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. However, managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank, agency and locum staff a full induction.
  • Staff kept detailed records of patients’ care and treatment. Records were clear, and up-to-date; however, they were not always easily available to all staff providing care in maternity.
  • Trust staff did not always follow its systems and processes to safely administer, record and store medicines.
  • The trust managed patient safety incidents well. Staff recognised incidents and near misses and reported them appropriately. Managers investigated incidents although they did not consistently share lessons learned with the whole team and the wider service.
  • When things went wrong, staff apologised and gave patients honest information and suitable support.
  • Managers did not always ensure that actions from patient safety alerts were implemented and monitored.
  • The trust provided care and treatment based on national guidance and best practice. However, some guidance on the trust intranet was not always up to date.
  • The trust planned and provided care in a way that met the needs of local people and the communities served. However, it did not always work effectively with others in the wider system and local organisations to plan longer term care needs.
  • People could not always access services when they needed it and as a result did not always receive the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were consistently worse than national standards. The trust did not achieve NHS constitutional standards in its urgent care service.
  • The trust treated concerns and complaints seriously, investigated them and shared lessons learned with all staff. However, complaints were not always managed in line with the trust’s own timescales. Not all clinical areas displayed information about how to raise a concern or make a complaint.
  • Leaders had the, skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They supported staff to develop their skills and take on more senior roles. However, not all staff reported that senior leaders were visible and approachable.
  • Staff did not all feel respected, supported and valued, staff feedback and experience showed a culture of bullying behaviour. However, staff were focused on the needs of patients receiving care. Not all staff felt that they were kept fully informed or had their views listened to and acted upon.
  • Leaders and teams generally used systems to manage performance effectively. However, quality measures were not consistently collected in the maternity service.

However:

  • Staff understood how to protect patients from abuse and services worked well with other agencies to do so. Most, but not all staff, had training on how to recognise and report abuse, and they knew how to apply it.
  • The trust generally controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean.
  • Staff completed and updated risk assessments for each patient and took action to remove or minimise risks. Staff identified and quickly acted upon patients at risk of deterioration.
  • Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary.
  • Staff assessed and monitored patients regularly to see if they were in pain and gave pain relief in a timely way. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain.
  • Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients.
  • The trust made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and development.
  • Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care.
  • Key services were available seven days a week to support timely patient care.
  • Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
  • Staff provided emotional support to patients, families and carers to minimise their distress. They understood patients’ personal, cultural and religious needs.
  • Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment.
  • The trust provided services that were inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers.
  • The trust had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. The vision and strategy were focused on sustainability of services and aligned to local plans within the wider health economy. Leaders and staff understood and knew how to apply them and monitor progress.
  • Leaders operated effective governance processes, throughout the trust and with partner organisations. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service.
  • The trust collected reliable data and analysed it. Staff could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements. The information systems were integrated and secure. Data or notifications were consistently submitted to external organisations as required.
  • The trust promoted equality and diversity in daily work and provided opportunities for career development for those with protected characteristics. The trust had an open culture where patients, their families and staff could raise concerns without fear.
  • Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients
  • All staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them. Leaders encouraged innovation and participation in research.
  • Staff identified and escalated relevant risks and issues and identified actions to reduce their impact. They had plans to cope with unexpected events. Staff contributed to decision-making to help avoid financial pressures compromising the quality of care.
Inspection areas

Safe

Requires improvement

Updated 24 October 2019

Our rating of safe went down. We rated it as requires improvement because:

  • Although nursing staff were generally compliant with mandatory training requirements, medical staff were not up to date in all areas.
  • Not all medical staff were up to date with safeguarding training; in some areas they were not compliant with targets for safeguarding training modules.
  • Clinical waste was not consistently managed well in all services. We saw used gloves and aprons in black bags in some medical wards that we visited and there was insufficient assurance that these were uncontaminated waste.
  • Hazardous chemicals were not stored safely on all wards. Although we found that cupboards containing cleaning chemicals were locked, on three wards we saw that the access code was written on the door jamb. This meant that unauthorised people could access hazardous chemicals.
  • We found that not all equipment was replaced at the end of its life, meaning that equipment was not always fit for purpose.
  • The environment was not suitable to meet patient’s needs in all areas. The paediatric emergency department was too small to accommodate the numbers of children attending the department. The Heart Centre was regularly used for medical outliers but did not have appropriate facilities to accommodate inpatients.
  • Safe systems for the storage, prescribing, administering and recording of medicines were not consistently in place in all areas. We found medicines removed from their original containers and stored in different medicine boxes and evidence that some out of date drugs had been administered to patients. Dates of opening on some short life medicines were not always recorded. Light and temperature sensitive medicines were not always stored in line with guidance. There was no process in place to check that patients had the correct medicines and we found evidence that some patients had been discharged without their medication or discharge summary. Not all staff were aware of medication alerts that had been issued nationally. Governance of patient group directives was not sufficient as we found that copies on the trust intranet did not have the required legal signatures. Controlled drugs were not consistently recorded in the controlled drug register when they had been issued. Not all areas had clinical pharmacy support.
  • There were not always sufficient numbers of staff to keep patients safe. The midwife to birth ratio was higher than the expected national birth rate and there were low staffing numbers on the maternity day unit and in maternity triage. There was a high vacancy rate for medical staff in medicine and there were high numbers of unfilled shifts for medical staff.
  • Records were not always easily available to staff in the maternity service. The community midwifery team were not always able to access electronic records or keep contemporaneous records due to connectivity issue in the community. In Medical care services, not all patient records were stored securely or kept in line with medical record keeping standards. We found some medical records trolleys left unlocked and some medical staff not writing their name or designation.

However:

  • Access to medical support was available seven days a week, including consultant cover and out of hours on-call arrangements. There were consultant led daily ward rounds on all medical wards.
  • Services controlled infection risks well and used control measures to prevent the spread of infection. Staff kept themselves, premises and equipment visibly clean.
  • There were systems to monitor and manage risks to patient safety. Comprehensive risk assessments were carried out for patients and staff identified, and quickly acted upon any risks to minimise or remove the risk.
  • Staff knew what to report as an incident and how to report them. All staff had access to an electronic incident reporting system and managers investigated incidents and shared lessons learned with staff.

Effective

Good

Updated 24 October 2019

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

  • Staff monitored the effectiveness of care and treatment and used findings of local and national audits to make improvements and achieve good outcomes for patients.
  • Managers made sure staff were competent for their roles through appraisals and supervision meetings. Training needs were identified and opportunities for developing knowledge and skills were provided. In the maternity service, “itchy feet” clinics were offered to support professional development opportunities amongst staff.
  • There was effective multidisciplinary working between doctors, nurses and other healthcare professionals, who worked together as a team to benefit patients. In the maternity service there was effective multidisciplinary working and communication between hospital and community staff, including midwives, GP’s and health visitors, meaning women received consistent coordinated person-centred care when they moved between services.
  • Staff supported patients to make informed decisions about their care and treatment and followed national guidance to gain patient’s consent. They understood how to support patients who lacked capacity to make their own decisions.
  • Staff gave patients enough food and drink to meet their needs. In the maternity service, both women’s and babies’ nutrition and hydration needs were identified, monitored and met.

However:

  • Services provided care and treatment based on national guidance and best practice and clinical guidelines were available for staff to follow to plan and deliver high quality care. However, in medical care four out of 15 guidelines reviewed on the trust’s intranet were out of date, meaning that there was a risk that staff were referring to out of date guidance.

Caring

Good

Updated 24 October 2019

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

  • Staff treated patients with compassion and kindness. Staff took time to interact with patients and those close to them in a respectful and considerate way. Staff responded compassionately to pain, discomfort and emotional distress in a timely and appropriate way. Patients felt that their privacy and dignity was respected.
  • Staff provided emotional support to patients. For example, the maternity service provided bereavement support for women and those close to them who had suffered a pregnancy or baby loss.
  • Staff supported and involved patients, families and carers to make decisions about their care. Staff talked to patients in a way they could understand, and nurses introduced themselves and explained what was about to happen before providing care.

Responsive

Good

Updated 24 October 2019

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

  • Services were inclusive and took account of patients’ individual needs and preferences. Staff made sure patients living with mental health problems, learning disabilities, and dementia received the necessary care to meet all their needs. There were specific rooms in the emergency department which were made to look less clinical and homelier that were prioritised for use by patients with additional support needs. Staff in the maternity service had access to specialist healthcare professionals with expertise in dealing with women in vulnerable circumstances, including a learning disability liaison nurse and psychiatric liaison team.
  • There were generally systems to manage patient access to, and flow through services. There was an electronic display in the emergency department which provided an overview of bed availability and flow of patients coming through the department. There were regular bed meetings for all services daily, to discuss patient discharge plans.
  • In the maternity service there was a 24-hour telephone triage service which enabled review of urgent health issues such as pain, vaginal bleeding or suspected broken waters. This ensured that women could be assessed and reviewed promptly.

However:

  • Although the trust treated complaints seriously, not all clinical areas displayed information about how to raise a concern or make a complaint. Leaflets or posters about making a complaint were not readily available in the maternity service. Learning from complaints was not consistently shared with all staff. Services generally took longer than the trust target to investigate and close complaints.
  • Systems for reviewing medical outlier patients were not effective, meaning that not all medical patients on outlier wards were reviewed daily by a consultant.
  • Managers did not monitor waiting times or procedure cancellation rates in maternity clinics. We could not be sure women could always access services when they needed to or receive treatment within agreed timeframes.
  • The trust did not meet some targets in line with national guidance such as time from arrival in the emergency department to receiving treatment and percentage of patients spending less than four hours in the emergency department.
  • Children’s facilities in the accident and emergency department were not suitable for the numbers of children treated.

Well-led

Requires improvement

Updated 24 October 2019

Our rating of well-led went down. We rated it as requires improvement because:

  • Not all staff we spoke with felt that there was a culture of respect throughout the trust. Concerns of bullying had been raised with the freedom to speak up guardian. We witnessed some poor staff interactions in some medical areas that we visited.
  • In medical care services, governance processes had failed to identify some safety issues which presented a risk of harm.
  • Although matrons and ward leaders were visible and approachable, not all staff were able to identify divisional and senior leaders.

However:

  • There were governance processes including regular audits, performance monitoring, mortality and morbidity reviews and information sharing at meetings. There were clear lines of accountability throughout the trust.
  • Leaders generally had the skills and abilities to run services, understanding the priorities and issues services faced.
  • There was a clear vision and strategic plan for the trusts which set out realistic objectives for the future development and sustainability of the department.
  • Systems to manage performance were used effectively. While relevant risks were identified and escalated so that actions to reduce the impact of risks could be taken, it was not always clear how the existing controls related to the risk as stated in the risk register.
  • There was an active quality improvement agenda throughout the trust which encouraged staff engagement in service development and improvements.
Assessment of the use of resources

Use of resources summary

Requires improvement

Updated 24 October 2019

We rated it as requires improvement because:

The NHS trust has realised some productivity improvements, however there remain unmet efficiency opportunities within workforce and clinical services. Performance against constitutional operational standards also remains below national standards and national median. The NHS trust delivered the control totals and plan for 2018/19, with an improvement against the previous year. Its planning for further improvement to a breakeven position in 2019/20, however the level of efficiencies required to achieve the plan had not been fully developed at the of time assessment.

Combined rating

Combined rating summary

Requires improvement

Updated 24 October 2019

This is the first time that we have awarded a combined rating for Quality and Use of Resources at this NHS trust. The combined rating for Quality and Use of Resources for this NHS trust was requires improvement.