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Provider: Northampton General Hospital NHS Trust Requires improvement

Reports


Inspection carried out on 11 June to 25 July 2019

During a routine inspection

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.


CQC inspections of services

Inspection carried out on 25, 26 and 27 July and 9 August 2017

During an inspection looking at part of the service

Northampton General Hospital NHS Trust is an 800-bedded acute trust with one main hospital, Northampton General Hospital (NGH). There are approximately 713 general and acute beds with 60 maternity beds, and 18 critical care beds. The trust employs 4,875 staff, including 531 doctors, 1,487 nursing staff and 2,857 other staff.

We carried out this inspection as part of our routine focused inspection programme. We completed a short notice focused inspection on the 25 to 27 July 2017 and an unannounced inspection on 9 August 2017.

We determined the extent of this focused inspection following a review of information gathered and the findings from our previous inspection. This included an analysis of the trust’s performance and information from stakeholders. The hospital was previously inspected under our comprehensive methodology in January 2014, when the overall rating was requires improvement.

We found the trust has taken significant action to meet the concerns raised from the January 2014 inspection, particularly in establishing an inclusive and supportive staff culture with a clear focus on patient safety.

We rated the four core services we inspected (critical care, maternity and gynaecology, children and young people and outpatients and diagnostic imaging) as good overall. Combining these core service ratings with the ratings for the other four services we last inspected in February 2017, the overall rating for the hospital was good. All five key questions were rated as good (safe, effective, caring, responsive and well-led). We have included some of the findings of the February 2017 inspection in this report to reflect our judgements about the trust overall.

We found that:

  • The trust’s leadership team were established and experienced members of staff and staff described the leadership team as approachable, cohesive, and inclusive.
  • Leaders had a shared purpose, strove to deliver and motivate staff to succeed. Comprehensive and successful leadership strategies were in place to ensure delivery and to develop the trust’s culture.
  • The trust had a model of clinical leadership that was understood by staff we spoke with and showed excellent engagement with the consultant, medical and nursing bodies.
  • The focus on safe patient care, despite the significant operational pressures during the days of the inspection, was clearly evident in all areas and from all staff we spoke with.
  • The trust was very proactive in engaging with staff. Almost all staff were very positive about the leadership of the board and senior managers. The level of staff support, respect and commitment to each other was clearly evident in all areas. Staff referred to the ‘Team NGH’ spirit and culture and were proud of this.
  • Overall, almost all staff expressed high levels of satisfaction and were proud to work for the trust. Staff reported feeling respected, valued, supported and appreciated.
  • The leadership teams were cohesive and inclusive and were focused on delivering safe, high quality care and treatment for all patients. Staff believed in the leadership of the hospital and were proud of the organisation and its culture.
  • Staff were friendly, professional, compassionate, and helpful to patients in all interactions that we observed. All patients told us that the staff had been caring towards them and all spoke positively about the staff in all areas inspected.
  • Patients and their relatives were supported during their stay within critical care services and staff provided opportunities to discuss care and treatment. This was delivered in a way that promoted dignity and confidentiality at all times.
  • There was a positive culture towards reporting incidents and learning from these to improve patient safety in all areas inspected.
  • There were effective systems in place to ensure that standards of cleanliness and hygiene were maintained. The design, maintenance, and use of facilities, premises, and equipment generally met all patients’ needs. The environment of the entire estate (despite some parts being over 275 years old) was extremely well maintained.
  • Medicines were generally stored and handled in line with the hospital’s medicines management policy.
  • There were effective processes in place to ensure that adults and children in vulnerable circumstances were safeguarded from abuse. Staff spoken to in all areas were aware of the processes to identify and respond to patient risk and there were systems in place to monitor and manage risks to patient safety.
  • Medical and nurse staffing levels met patients’ needs at the time of the inspection.
  • Policies were based on national guidance produced by National Institute for Health and Care Excellence (NICE) and the royal colleges. Pain of individual patients was assessed and managed appropriately.
  • Patients’ outcomes were being measured and were generally in line with national average. Action plans were in place to drive improvements.
  • The emergency department had a recovery plan to improve performance to meet the national standard for patients being seen by a doctor within four hours following arrival, which had been agreed with local commissioners and other stakeholders. Performance had declined and was below the national average.
  • There was clear evidence and data upon which to base decisions and look for improvements and innovation. The unit participated in the Intensive Care National Audit and Research Centre (ICNARC) audit and performed better or as expected in six out of eight indicators.
  • The critical care outreach team provided 24 hour cover seven days a week and assisted with the monitoring and treatment planning of deteriorating patients throughout the hospital, ensuring risks were responded to appropriately.
  • The children and young people’s service performed well in in a number of national audits including the National Neonatal Audit (2015) and the Epilepsy 12 audit (2014). Gosset ward was working towards achieving Bliss accreditation.
  • The maternity and gynaecology service completed the national maternity safety thermometer and monitored safety performance through clinical dashboards.
  • There were systems and processes in place to ensure that staff had the necessary qualifications, skills, knowledge and competencies to do their jobs. Effective multidisciplinary working was clearly evident throughout the departments and services.
  • There were appropriate processes and systems in place to ensure that information needed to deliver care and treatment was available to relevant staff in a timely manner.
  • Patient’s consent was obtained in line with trust policy and statutory requirements.
  • Services had been planned to take into account the needs of different people, for example, on the grounds of age, disability, gender or religion.
  • The hospital staff worked with a variety of stakeholders and commissioners to plan delivery of care and treatment. There was a focus in providing integrated pathways of care, particularly for patients with multiple or complex needs.
  • Access to services was generally effective and timely. Care and treatment was only cancelled or delayed when absolutely necessary.
  • Appointments were prioritised according to referral requests from GPs with urgent requests and cancer referrals booked within two weeks. The imaging department prioritised reporting higher risk examinations not seen by other clinicians.
  • The hospital consistently met the referral to treatment standards over time.
  • Waiting times for diagnostic procedures were lower than England average
  • Due to ongoing bed capacity issues in the hospital, the hospital had implemented safety driven bed escalation and management process to address patient flow concerns in the hospital. This kept patients safe, even at times of significant pressure on bed capacity.
  • Despite very high bed occupancy over time and on the days of the inspection, the commitment to the safety and quality of care and treatment for patients was clearly demonstrated by all staff at all levels.
  • The hospital had a well-defined process for the management of medically outlying patients. The hospital’s discharge team supported staff with complex discharge arrangements and senior managers were continually working to improve patient flow out of hospital.
  • The service managed complaints swiftly, openly and constructive as part of a co-ordinated patient feedback system.
  • The trust’s strategy and supporting objectives were stretching, challenging and innovative while remaining achievable and with full consideration of effective use of resources.
  • The trust had a well-developed staff health and wellbeing strategy and a variety of healthy lifestyle initiatives were available for all staff to access.
  • Full and effective fit and proper person checks were in place.
  • Generally effective governance arrangements were in place. There were structured meetings to review all aspects of performance, quality and risks and high risks were escalated through the services.
  • Service risk registers generally reflected the risks within the service and there was evidence of ownership, mitigations having being implemented and ongoing monitoring.
  • Performance in national audits and benchmarking with regional and national peers was consistently used to drive improvements in services.
  • There was a well-developed quality improvement programme at the hospital, which trained staff in quality improvement and service improvement methodology and achieved improved outcomes for patients.
  • Innovative approaches were used to gather feedback from patient services and the public, including people in different equality groups. Rigorous and constructive challenge from patients, the public, stakeholders, and regulators was welcomed and seen as a vital way of holding services to account.
  • The leadership team drove continuous improvement and staff were accountable for delivering change. Safe innovation was celebrated. There was a clear, proactive approach to seeking out and embedding new ways of working and new models of care.

However, we also found:

  • The critical care unit did not comply with the Department of Health’s Health Building Note 04-02 critical care unit’s standards; however, this had been risk assessed and was under review. Refurbishment plans were in place to address this.
  • Mandatory training compliance did not always meet the trust target in some areas. Some staff in some areas were not up to date on annual safeguarding training. Overall, the trust compliance was meeting its target of 85%.
  • There were not always effective systems in place regarding the storage and handling of medicines in some areas we inspected. The trust took immediate action to address this once we raised it with them.
  • We found concerns about the fire exit in the fracture clinic. This had been addressed by the unannounced inspection and we found the service had also reviewed all fire exits throughout the service.
  • The maternity service had had higher than expected caesarean rates and perinatal mortality rates over time. Whilst actions and mitigating actions had been taken, these had not always improved outcomes. The service continued to monitor and assess these potential risks to patients.
  • Hospital wide bed capacity affected the ability of the critical care service to discharge patients to wards at the most appropriate time. Over eight hour delayed discharges were higher than the national average, however, action had been taken and improvement observed for patients waiting 24 to 48 hours.
  • Single sex accommodation in critical care was not always maintained due to hospital wide bed pressures. Action was taken to protect patients’ dignity at all times.

We saw several areas of outstanding practice including:

  • The geriatric emergency medicine service (GEMS) was outstanding in terms of providing awareness of and responding to the needs of patients within this group and developing a service that provided a multi-agency approach at the front door.
  • Physician associate programmes were being developed to provide a larger group of decision-making clinicians and provide developmental opportunities for staff.
  • The emergency department (ED) worked with external organisations to develop an on-site psychiatric liaison service within the ED, 24 hours a day, seven days a week.
  • The ED was actively working with local educational institutions to develop courses that were specific to areas that were difficult to recruit to such as geriatric and paediatric emergency medicine and the ED had a robust leadership development programme in place.
  • In the Sentinel Stroke National Audit Program (SSNAP) the hospital was rated as band A overall (A being the best and E the worst), in the April to June 2016 audit, which indicated a world-class stroke service.
  • We visited patients being cared for in two out of the three care homes that the hospital used to place patients that were fit for discharge and awaiting their return back to the community. There was a weekly consultant led ward round once a week for these patients and a hospital doctor also visited both homes on three other days of the week. We saw in all there was excellent level of clinical oversight and detailed records of all input from the service’s doctors.
  • Staff were focused on continually improving the quality of care and the patient experience. For example, we saw evidence that the service was committed to improving the care of elderly patients, such as those living with dementia. Colour-coded bays were evident on some of the wards we visited and finger food boxes had been introduced, which made it easier for patients to eat when they wanted and helped them to maintain independence. Directorate leads told us of plans that were being developed in collaboration with primary care and community services to support the care of elderly patients at home.
  • The end of life care service had piloted, evaluated and fully implemented an end of life companion volunteer scheme for dying patients who may not have any visitors. The service had support from the local community in caring for patient at the end of their life.
  • The ED had developed an end of life care room that was situated adjacent to the resuscitation area. There was a specific pathway and guidance for managing these situations when the patient was a child or young person. The ED had developed a specific continuation of care record for patients who were in the end of life care room; this included ensuring that they had received consultation and timely review for symptom control.
  • The trust had a duty of candour sticker that would be placed into the patient’s notes when the duty of candour had been applied. This included, for example, staff name, date, name of person/patient receiving information, account of incident, details of incident and if an apology was offered.
  • Two members of the critical care team had been nominated for the ‘Best Possible Care’ Awards. Patients and those close to them, as well as work colleagues, voted for staff members who had gone above and beyond to exceed expectations and had made a real difference to patient care.
  • The ‘Chit Chat’ group was set up by the maternity service in 2016 to facilitate antenatal education, parenting advice and peer support for women with additional needs, including learning disabilities or anxiety. Staff said these meetings were two weekly and very well attended. This group meeting initiative had been nominated for two national awards and had won one at the time of the inspection.
  • The maternity service reviewed and evaluated the provision of multi-disciplinary training when the service was chosen as one of the 10 pilot sites for enhancing patient safety. As part of the pilot, the service chose to concentrate on the fetal monitoring and team working and skills drills sections with the outcome that the service was able to deliver these training programmes completely internally (including Practical Obstetrics Multi-professional Training (PROMPT).
  • Gosset ward was working towards achieving Bliss accreditation. This means the ward had undertaken exceptional work through the involvement of parents to encourage bonding with these very special babies which has helped to build the evidence for Bliss accreditation.
  • Staff had developed an assessment tool to improve the monitoring and assessment of baby’s skin on Gosset ward. The ward was working with neonatal services from across the world (Canada and Turkey) to further develop the tool.
  • The recruitment of 1.7 WTE advanced neonatal nurse practitioners (ANNP) onto the medical neonatal rota was helping to address recruitment issues in relation to junior doctors.
  • The superintendent sonographer was very passionate about their service and had developed an excellent team which provided image quality assurance and peer review. They were able to detect team members’ weaknesses and pair them with other sonographers to help them develop. The ultrasound department conducted many audits and feed these back to ultrasound community in England.

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

  • Review pharmacy provision to meet the needs of the critical care service and be in line with national guidance.
  • Continue to review and monitor over eight hour delayed discharges in critical care and report incidents and mixed sex breaches using the electronic reporting system.
  • Monitor staff mandatory training to ensure compliance with the trust’s target including annual refresher training for safeguarding adults at level two and safeguarding children level two and three.
  • Continue to monitor caesarean rates and perinatal mortality rates in the maternity and gynaecology service.
  • Review multidisciplinary support to critical care services to ensure national best practice is following, in relation to therapy support.
  • To monitor allergy testing ampules ensuring use within their recommended expiry dates.
  • The trust should consider improving the facilities for parents to stay overnight on paediatric wards.
  • Continue to monitor and review the impact of patients admitted to paediatric wards with mental health issues.
  • Continue to monitor and review the effect on children’s services due to the limited availability of psychologist support, particularly for children with long term conditions.
  • Continue to monitor controlled drugs are effectively stored in outpatient areas.
  • Continue to monitor fire exits are accessible at all times.

Professor Edward Baker

Chief Inspector of Hospitals

Inspection carried out on 16, 17 and 29 January 2014

During a routine inspection

Northampton General Hospital NHS Trust (NGH) is an acute trust with 800 bedded acute hospitals. At the time of our inspection of the acute services proved by the trust, it had an income of about £250 million and a workforce of 4,300 staff. It provided general acute services to a population of 380,000 and hyper acute stroke, vascular and renal services to people living throughout Northamptonshire, a population of 691,952. Between 2001 and 2012, there was a 9% growth in the population of Northampton, with significant increases in the 0 to 4 year and 60 to 64 year age groups (30% and 45% respectively). The trust’s main hospital site is Northampton General Hospital (NGH). It also provides services, inpatient beds at three community hospitals in Northamptonshire: Danetre Hospital in Daventry, Corby Community Hospital and Hazelwood Ward in Isebrook.

Before visiting, we looked at a wide range of information we held about the trust and asked other organisations to share what they knew about it. We carried out an announced visit on 16 and 17 January 2014, and during that visit we held group meetings with different staff members from all areas of the hospital. We looked at the personal care and treatment records of patients, observed how staff were caring for people and talked with patients, carers, family members and staff. We reviewed information that we asked the trust to provide. We also held a public listening event where patients and members of the public shared their views and experiences of the trust and we continued to receive and review information from various sources during and after our inspection. We carried out a further unannounced inspection at night between the hours of 8pm and 1am on 29 January 2014.

During our inspection, NGH appeared to be very clean throughout. In a national survey the trust was noted to have been performing well in relation to infection prevention and control.

The trust had a recent history of poor staffing levels on some wards. During our inspection, we saw that action had begun taken to address staffing issues. Staff told us that improvements in staffing levels were already having a positive impact on services. The trust was also experiencing a shortfall in consultant cover in the Accident and Emergency service and the labour ward, and had begun taking action to address this. It had also responded to recent concerns around staffing and care on two medical wards and had taken action, including increasing the staffing establishment to address those concerns.

Many of the executive post holders are either new to post or in interim positions. This had an impact on the trust’s leadership as staff reported that senior leaders, with the exception of the chief executive, were rarely visible on wards and were unaware of the positions and responsibilities of most executive post holders. There have been significant changes at the executive level of the trust for some time, and the chief executive was aware of the need for stability among this group in order to address the leadership concerns across the trust.

Areas of poor governance, specifically in relation to the management and maintenance of equipment, and to the dispensing of medications to patients on discharge, were identified during our inspection. Both areas were taken up with the trust and the trust has actively responded at the time of our inspection.

Our inspection revealed that end of life care was an area where the trust required more focus and commitment to improve.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.