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Provider: Queen Victoria Hospital NHS Foundation Trust Good

Inspection Summary


Overall summary & rating

Good

Updated 23 May 2019

We did not inspect all core services during this inspection, we inspected surgery (burns and plastics), outpatients and critical care. Overall, we rated the trust as good for safe, effective, responsive, well-led and outstanding in caring. All three core services we inspected were rated as good overall.

We rated safe, effective, responsive and well-led as good, and caring as outstanding. We rated all three of services as good. In rating the trust, we took into account the current ratings of the two services not inspected this time.

We rated the trust overall as good.

  • The trust had responded to concerns raised in our last inspection in critical care and improvements had been made. These included, for example, dedicated medical cover out of hours.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.
  • The service controlled infection risk well. Staff kept themselves, equipment and the premises visibly clean. They used control measures to prevent the spread of infection.
  • The service followed best practice when prescribing, administering, recording and storing medicines. Patients received the right medication at the right dose at the right time.
  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The service used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors. Managers used this to improve the service.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
  • Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for patients’ religious, cultural and other preferences.
  • There was a strong, visible person-centred culture and the service truly respected and valued patients as individuals. Staff were highly motivated and inspired to offer care that was exceptionally kind and promoted people’s dignity.
  • Feedback from patients, those close to them and stakeholders was continually positive about the way staff treated people. The trust performed ‘much better than expected’ compared with other trusts in CQC’s 2017 Adult Inpatient Survey. NHS Friends and Family Test data displayed on the wards showed almost all patients would recommend the service to family and friends. There were consistently high recommendation rates, which reached 100% in nine out of 12 months in 2018 on the Burns Unit, and eight out of 12 months on Margaret Duncombe Ward.
  • Staff saw patients emotional and social needs as being as important as their physical needs. Staff provided emotional support to patients and those close to them to minimise their distress and help them in their recovery from traumatic events or major surgery.
  • Patient safety and the patient experience were the focus of the trust’s strategy and service delivery.
  • Staff were fully committed to working in partnership with people and making this a reality for each patient. The service always reflected patients’ individual preferences and needs in the delivery of care.
  • Advice and guidance for non-urgent GPs referrals were in place, this allowed GPs access to consultant advice prior to referring patients into specialist clinics.
  • Safety huddles were held every morning in each outpatient department. All staff working in the outpatient clinics met at the same time every day to discuss current safety issues relating to the premises, patient care and other relevant issues that could impact on patient safety.
  • The trust’s leadership team had the skills, knowledge, experience and integrity that they needed to lead the trust. Executives were given the support they needed. Where an individual board member was lacking in experience, they were supported to gain relevant expertise.
  • The trust’s existing strategy and projected ‘strategic direction’ were aligned to local plans in the wider health and social care economy and were planned to meet the needs of the relevant population. The trust worked closely with other trusts, clinical commissioning groups and sustainability and transformation partnerships to identify and meet regional patient’s needs.
  • The trust monitored their progress against delivery of the strategy and local plans. The strategic objectives, were outlined in the unique and exemplar Board Assurance Framework (BAF). The trusts BAF brought together the strategic objectives and used them to evaluate board work and risk. This ensured objectives were reviewed and acted against, in terms of current risks and long-term strategy.
  • The different levels of governance and management functioned effectively to provide assurance. The board had a structure of committees which were chaired by non-executive members and reported directly to the board. Each committee reviewed evidence to gain information and assurances and escalated to the board in line with their terms of reference.
  • The trust had arrangements for identifying, recording and managing risks, issues and had identified actions to reduce the impact of them. The trust used a risk register system to manage risks of all levels. Core service level risks were held on a departmental risk register. Risks that were strategic or affected multiple core services were held on the trust risk register. The board reviewed and managed the trust risk register.
  • The trust had positive and collaborative relationships with external partners. It worked closely with other trusts in the region, clinical commissioning groups and the regional sustainability and transformation partnership to build a shared understanding of systemic challenges and identify and meet patient’s needs.
  • The two highest rated risks on the risk register were both rated 20. One was referral to treatment time delivery and performance and one was financial performance.
  • The trust had a referral to treatment time recovery action plan to eliminate 52 week waits across the three affected areas of the trust, and reach performance compliance by September 2019. The trust was on trajectory to meet this target.
  • The trust was beginning its journey to address financial performance. The board recognised that system-wide working and collaboration could be key to its financial sustainability and that they needed to utilise support within the system and determine their position and the corresponding financial strategy aligning to this.
  • The trust used secure electronic systems with security safeguards. It had a clear technology infrastructure plan for the hospital hub (main) site and had implemented current cyber security systems.
  • The trust had a focus on learning. They supported research internally and as part of external research projects. Learning from and participation in internal and external reviews was used to lead improvement and innovation. The trust was able to identify numerous research-based initiatives it had adopted over the past 12 months to improve patient care.

However:

  • Mandatory training rates including safeguarding and Mental Capacity Act 2005 modules for all staff groups did not always meet the trust target of 95%. However, at the time of inspection compliance had improved. For example, the critical care unit had an aggregated compliance rate of 90%.
  • The service’s admissions policy for surgical and critical care patients relied heavily on the individual judgement of the on-call consultant as to whether a patient met the criteria for admission to the hospital. For example, there was no specific criteria for burns patients around the total body surface area affected by the burns. There were also no specific criteria for significant co-morbidities. However, the service had service-level agreements with a nearby large NHS acute teaching hospital trust for the provision of services such as general surgeons and geriatricians (specialist elderly medicine consultants) to support patients with existing co-morbidities.
  • There were high numbers of registered nurse vacancies predominantly in theatres and critical care and heavy reliance on temporary staff. However, the trust had systems and processes to mitigate the risk, for example, a limit to how many agency staff could be allocated to each theatre. These services used regular agency staff to provide consistency and continuity.
  • Nursing agency usage was higher than was recommended for a critical care unit. The Guidelines for the Provision of Intensive Care Services, 2015 recommended level was a maximum of 20% agency staff usage. There was a departmental policy of not having more than 50% agency on any one shift. This was an improvement which had been discussed and approved by senior clinical leads and the managers within the trust. Senior staff explained that due to the number of nurses, this would mean not more than two agency nurses per shift.
  • The critical care unit was not fully meeting the Guidelines for the Provision of Intensive Care Services 2015 but there had been an improvement since the last inspection. At the time of our last inspection critical care had no intensive care consultants but now had intensive care consultant cover Monday to Friday. However, the unit still lacked this cover out of hours and at weekends.
  • The trust had struggled to meet both the 18-week referral to treatment and cancer targets. Five specialties were below the England average for non-admitted pathways for referral to treatment times. The trust was acting to address this and was on a trajectory to meet the targets by April 2020.
  • The trust was not meeting its targets for cancellations of outpatient appointments in the seven days prior to the appointment. These rates varied within the reporting period, but neither the plastic surgery department, sleep disorder unit and ophthalmology met their target during the reporting period. On the day cancellations by the hospital had stayed the same for a period but also failed to reach their target.
  • The hospital did not meet the British Burn Association National Burn Care Standards. This was because, as a specialist trust, the hospital did not provide the usual range of hospital services such as general surgery, mental health liaison and paediatric medicine. To reduce these risks, the trust had service level agreements with a nearby acute NHS trust to provide these services in a timely way, 24 hours a day, seven days a week.
  • The trust was not expected to meet its financial plan in this year and the trust was projected to have a deficit of £5.9 million in 2018 to 2019. The trust was not used to operating within such a financially challenging environment. They were in the process of developing systems to manage the trust under these pressures.

Inspection areas

Safe

Good

Updated 23 May 2019

  • Risk to patients was identified and monitored. The critical care outreach team was available 24 hours a day to support patients on the unit or on the wards. The unit used a safety checklist for invasive procedures produced by the Intensive Care Society. The unit had a policy for insertion of central lines and guidance for the use of arterial lines.
  • Staffing levels and skill mix were planned, implemented and reviewed to keep people safe. We saw staff had enough time to look after patients safely.
  • Records we reviewed demonstrated that the National Early Warning Scoring (NEWS) system was being used consistently and correctly.
  • Safety huddles were held every morning in each outpatient department. All staff working in the outpatient clinics met at the same time every day to discuss current safety issues relating to the premises, patient care and other relevant issues that could impact on patient safety.
  • Openness and transparency about safety was encouraged. Staff understood and fulfilled their responsibilities to raise concerns and report incidents. Staff felt supported when doing so.
  • Staff managed medicines consistently and safely. Medicines were stored correctly and disposed of safely. Staff kept accurate records of medicines.
  • Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care. Records we reviewed had clear documentation and a high standard of record keeping in line with national guidelines.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • The service had suitable premises and equipment and looked after them well. Equipment received annual servicing and electrical safety testing to ensure it was safe and fit for purpose. The hospital had emergency equipment in clinical areas to allow staff to respond promptly to medical emergencies such as cardiac arrest and sepsis.

However:

  • Mandatory training rates including safeguarding and Mental Capacity Act 2005 modules for all staff groups did not always meet the trust target of 95%. However, at the time of inspection compliance had improved. For example, the critical care unit had an aggregated compliance rate of 90%.
  • The service’s admissions policy for surgical and critical care patients relied heavily on the individual judgement of the on-call consultant as to whether a patient met the criteria for admission to the hospital. For example, there was no specific criteria for burns patients around the total body surface area affected by the burns. There were also no specific criteria for significant co-morbidities. However, the service had service-level agreements with a nearby large NHS acute teaching hospital trust for the provision of services such as general surgeons and geriatricians (specialist elderly medicine consultants) to support patients with existing co-morbidities.
  • Although nursing staffing levels were safe within critical care, the service was using up to 50% agency staff on any one shift and the Guidelines for the Provision of Intensive Care Services 2015, recommends a maximum of 20% usage of agency staff on any one shift.

Effective

Good

Updated 23 May 2019

  • The trust ensured staff were competent for their roles. Staff had the right qualifications and skills to carry out their roles effectively and in line with best practice. Staff received supervision and appraisals. Staff had access to learning and development opportunities.
  • There was a multidisciplinary approach to patient care. Doctors, nurses and other healthcare professionals supported each other to deliver effective care and treatment.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care. Records we reviewed demonstrated staff obtained and recorded patient consent in line with legislation and national guidance.
  • Staff had a scheduled approach to assessing and monitoring patients. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain.
  • Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for patients’ religious, cultural and other preferences.
  • Health promotion was provided to patients and staff. Leaflets were available on conditions such as deep vein thrombosis. Smoking cessation and alcohol consumption advice was given at pre-assessment.

However:

  • The service did not meet the British Burn Association National Burn Care Standard C.05: Additional Clinical Services. This was because, as a specialist trust, the hospital did not provide the usual range of district general hospital services such as general surgery, mental health liaison and paediatric medicine. To reduce these risks, the trust had service level agreements with a nearby acute NHS teaching hospital trust to provide these services in a timely way, 24 hours a day, seven days a week as needed.
  • The service did not fully participate with audits nationally. The service did not participate in the Intensive Care National Audit Research Centre audit program. However, they did participate in audit through the Southeast Critical Care Network.

Caring

Outstanding

Updated 23 May 2019

  • Patients were given timely support and information to cope emotionally with their care, treatment, condition in order to minimise their distress. We observed emotional support being given to a distressed patient.
  • Psychological and physical care was delivered in parity. We saw mindfulness-based cognitive therapy courses were available to help patients manage emotions following traumatic injuries, burns, facial conditions or cancer surgery. Mindfulness courses were popular with patients and well-attended.
  • The hospital provided a variety of equipment to support patients living with dementia for example bright coloured, dementia-friendly crockery.
  • Staff involved patients and those close to them in decisions about their care and treatment. Patients and visitors told us they felt well informed and included in the decision processes
  • Staff communicated well with patients, so they understood their care, treatment and condition. During our inspection, we heard many examples of staff going ‘the extra mile’ to provide compassionate care that exceeded expectations.
  • Relationships between people who used the service, those close to them and staff were strong, caring, respectful and supportive. These relationships were highly valued by staff and promoted by leaders. Staff described how they were always able to give patients the time they needed, and managers supported and encouraged them in this. They felt this was part of the person-centred culture of the trust.

Responsive

Good

Updated 23 May 2019

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

  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff. However, complaints were not always dealt with within the timeframe in the trust policy. There was openness and transparency in how complaints were dealt with.
  • The trust planned and provided services in a way that met the needs of local people, as well as patients from further away that required specialist services. The facilities and premises were suitable for the services being delivered. The trust operated ‘hub and spoke’ clinics for some specialties and held satellite clinics in locations across the south east region. This allowed patients who lived far away from the trust to benefit from the service’s specialist skills and expertise closer to their home.
  • The trust worked with partner services to provide holistic care. For example, the trust had a good working relationship with a local trust to provide support for patients with a mental health condition. We saw input from mental health professionals within the patient records we reviewed.
  • The trust took account of patients’ individual needs. The trust had several options available to support people with communication difficulties.
  • The trust had a variety of innovative methods of supporting patients living with dementia.
  • Advice and guidance for non-urgent GPs referrals were in place, this allowed GPs access to consultant advice prior to referring patients into specialist clinics.

However:

  • In two surgical specialties, plastics and oral surgery, people could not always access the service when they needed it. The trust experienced a decline in referral to treatment performance in 2018. In partnership with NHS Improvement’s intensive support team, the trust reviewed their waiting list systems and processes an implemented initiatives to reduce the waiting lists. These included Saturday clinics, use of a locum breast consultant, outsourcing of some operating lists, and improving theatre efficiency and utilisation. As a result, the trust was on its trajectory to meet its target for wait times by April 2020.
  • There were no wheelchair-accessible toilets in the Rowntree Theatre Unit, where patients attended for procedures such as minor skin excisions under local anaesthetic. This meant staff would need to transfer wheelchair-users to an accessible toilet elsewhere in the hospital.
  • There was no hearing loop in some of the outpatient departments. Hearing loops are audio systems that help people with a hearing impairment hear more clearly.

Well-led

Good

Updated 23 May 2019

  • Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care. They were knowledgeable about the issues and priorities for the quality and sustainability of the service, understood the challenges and how to address them. All staff we met spoke positively about the leadership, both at local and executive level. They described leaders as being visible and approachable and supporting them to deliver the best possible patient experience.
  • Staff understood candour, openness, honesty, and transparency. The trust’s values were embedded and promoted by all staff. Managers promoted a positive culture that supported and valued staff, creating a sense of common purpose based on the shared values. Any behaviour which was inconsistent with the values was dealt with swiftly and effectively, regardless of seniority.
  • The trust engaged well with patients, staff, the public and local organisations to plan and manage services. They collaborated with partner organisations effectively. The trust had several forums and groups that promoted staff engagement, both face-to-face and through newsletters and social media. The chief executive held regular staff forums, including breakfast meetings in the theatre department, which staff valued. The trust promoted staff wellbeing through mindfulness sessions and groups to support them with emotional eating and stopping smoking.
  • The service was committed to improving by learning from when things went well and when they went wrong, promoting training, research and innovation. We saw examples of projects and changes to drive continuous improvement.
  • The trust used a systematic approach to continually improve the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish.
  • The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. Staff we spoke with understood the risks to the service, and we saw the service acted to reduce risks.
  • Senior staff regularly reviewed risk registers and updated them with actions taken to reduce risks and any changes in risk ratings. The service monitored a range of performance and outcome measures each month. They acted to address performance that fell below targets, such as referral to treatment times.
  • The trust was managing substantial risks in relation to financial challenges and referral to treatment times.
  • The trust collected, analysed, managed and used information well. Relevant information was displayed on notice boards within clinical areas. This included performance data such as safety thermometer data, staffing data and NHS Friends and Family recommendation rates.

However:

  • The board’s financial position changed in 2018; it had previously met its financial plans but was expected to have a deficit in 2018/19. The trust was operating under new financial pressures and it did not have past experience of managing the related challenges. The board was still establishing how it will move forward under these pressures.
  • The trust did not have an agreed and structured continuous improvement programme which could support both operational and financial performance improvement, although we understood the trust was in discussion with other trusts to learn from their experiences.
  • We found that the board committee which scrutinised finance and performance was not attended by the whole executive team, although the entire board received the board papers and Director of Nursing and Medical Director were able to attend the meetings.
  • The trust had not met multiple referral to treatment performance targets across core services in 2018. There were internal and external reasons for the reduced compliance including; regional increase in demand, significant vacancy levels across departments and the identification of patients who had erroneously been left on a waiting list previously. The trust was working internally and with external organisations including NHS Improvement and commissioners to manage and balance the backlog, increasing demand and capacity. The trust had implemented initiatives and progressed to improve patients’ waiting times. They were on trajectory to meet their targets by 2019 for 52 week breaches and March 2020 for open pathways.