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Provider: East and North Hertfordshire NHS Trust Requires improvement

On 17 July 2018 , we published a report on how well East and North Hertfordshire NHS Trust uses its resources. The ratings from this report are:

  • Use of resources: Requires improvement  
  • Combined rating: Requires improvement  

Read more about use of resources ratings

Inspection Summary


Overall summary & rating

Requires improvement

Updated 17 July 2018

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

We rated safe, effective, responsive and well led as requires improvement and caring as good. We rated caring as good.

We rated two of the trust’s nine services we inspected as inadequate, five as requires improvement, and two as good. In rating the trust, we took into account the current ratings of the core services not inspected this time.

We rated well-led for the trust overall as requires improvement.

Inspection areas

Safe

Requires improvement

Updated 17 July 2018

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

  • The trust did not ensure everyone completed mandatory training. Theatre staff had also not received training in advanced life support.
  • Not all staff, who were caring for young people under the age of 18 years, had the correct level of safeguarding training.
  • Not all services complied with infection prevention and control guidance. Staff did not always keep themselves and equipment clean. We also identified a number of concerns relating to the environment at Mount Vernon Cancer Centre, which increased the risk of infection.
  • The trust did not always provide suitable premises and equipment and look after them well. For example, the procedure room based on 11B did not have any emergency equipment and we identified concerns with the current security arrangements for children on Bluebell ward.
  • Not all systems in place were effective in recognising and responding to deteriorating patients’ needs. This included harm reviews of patients waiting for a procedure, sepsis training and the use of early warning scores in the children’s assessment unit at Lister Hospital and the Urgent Care Centre at the QEII Hospital.
  • Staff did not always recognise and report incidents in a timely manner. There were also inconsistency with staffs’ understanding of their responsibility with regards to the duty of candour requirement.
  • Some areas did not have enough nursing staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • There was not effective governance arrangements in place to ensure controlled medicines and storage temperatures were checked daily, and that out-of-range temperatures were acted upon, when indicated.

However:

  • Most of the services within the trust prescribed, gave and recorded medicines in line with best practice. Patients generally received the right medication of the right dose at the right time. There were systems and process in place to provide Systemic Anti-Cancer Therapy (SACT) safely.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Midwifery staff exceeded the trust’s completion targets for all safeguarding training.
  • Staffing levels were regularly reviewed and staff were redeployed within the clinical areas, when needed.
  • The trust almost always had enough medical staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse, and to provide the right care and treatment most of the time.
  • Generally, staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care. However, there was limited evidence of actions taken following nursing assessments on the medical ward at Mount Vernon Cancer Centre.
  • Services generally used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors, and used the information to improve the service.

Effective

Requires improvement

Updated 17 July 2018

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

  • The trust did not always provide care and treatment based on national guidance and evidence of its effectiveness.
  • Managers did not always check to make sure staff followed guidance. For example, staff in the Urgent Care Centre at the QEII hospital did not follow the clinical pathways for potentially serious conditions, such as chest pain and head injuries.
  • Outcomes for patients were variable, with the trust performing better than the national average for some indicators but worse for others. The risk of readmission following elective surgery was worse than the national average, and the risk of readmission following unplanned plastic surgery was much worse than the national average.
  • The trust did not always ensure staff were competent for their roles. For example, there was a lack of training in the assessment and resuscitation of children and the recognition of sepsis in the Urgent Care Centre at the QEII Hospital.
  • Not all staff had received an appraisal.
  • Not all staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.

However:

  • Local and national audits were completed and action was generally taken to improve care and treatment provision, when indicated.
  • The trust generally managed patients’ pain effectively and provided or offered pain relief regularly. The maternity service met all national standards for obstetric anaesthesia.
  • Staff gave patients enough food and drink to meet their needs and improve their health. Services made adjustments for patients’ religious, cultural and other preferences and age appropriate nutrition was provided.
  • Multidisciplinary staff worked together as a team to benefit patients.
  • The services were working towards providing seven day services, and they were supported by easily available imaging and pharmacy services.

Caring

Good

Updated 17 July 2018

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

  • Staff cared for patients with compassion. Feedback from patients and parents confirmed that staff treated them well and with kindness.
  • Staff provided emotional support to patients and parents to minimise their distress. A range of emotional support was available to patients and their families.
  • Staff involved patients and those close to them in decisions about their care and treatment. Patients and their families were aware of the plans for their care and were involved in decision making at every step.

Responsive

Requires improvement

Updated 17 July 2018

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

  • Patients could not always access services when they needed them. Waiting times for treatment were not in line with good practice across the trust. The end of life care service at Mount Vernon Cancer Centre was not always able to respond when people require urgent admission and some children were waiting longer than 52 weeks for appointments.
  • Patients, waiting for elective surgery, had their operations cancelled due to the lack of surgical beds as medical outliers were on surgical wards.
  • Patients experienced delays when attending the chemotherapy suite at Mount Vernon Cancer Centre.
  • Not all complaints were investigated in a timely manner in all services.
  • We were not assured that patients were always provided with translation services when they were required.

However:

  • Generally, the trust planned and provided services in a way that met the needs of local people. For example, the frailty intervention team worked closely with the emergency department team at Lister hospital, and the trust worked with the local NHS partnership trust to ensure the needs of patients with mental health concerns were met.
  • Services generally considered patients’ individual needs. For example, patients with complex needs, such as learning disabilities, would be cared for in a cubicle or seated area in the emergency department that was visible to the nursing staff. However, the medical ward at Mount Vernon Cancer Centre was not set out in a dementia-friendly way.
  • Overall times from referral to first treatment for patients with cancer were in line with the England average.

Well-led

Requires improvement

Updated 17 July 2018

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

  • Although there had been some improvements since our last inspection in October 2015, many of them were dependent on recommendations from external agencies rather than internal improvement programmes.
  • There had been little progress since our inspection in October 2015 for the end of life care service at Mount Vernon Cancer centre.
  • The services did not always have managers at all levels with the right skills and abilities to run a service providing sustainable care. There was confusion about who was responsible for the Urgent care Centre (UCC) at the QEII Hospital and managers were not involved in its operational management.
  • Not all services engaged well with staff. Managers spent very little time at the UCC at the QEII Hospital, and not all wards held team meetings where complaints, incidents and the learning from these could be discussed
  • Not all the services had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. Not all risks identified during our core service inspections were documented on the divisional risk registers.
  • There was not a fully embedded and systematic approach to continually monitor the quality of services and learn from when things went wrong. There were unacceptable levels of serious incidents and never events in the surgical division.
  • Some of the issues we raised during our inspection in October 2015 had not been improved. For example, cancelled operations, learning from serious incidents and staffing levels in the surgical division.
  • Some information the trust collected was not accurate or reliable. Different information management systems were used across the trust, which were not compatible with each other.
  • Not all staff were clear about the vision and strategy for their services.

However:

  • There had been some positive changes within the board and although some had not been in post for very long, improvements were evident.
  • Local managers across the trust generally promoted a positive culture that supported and valued staff, creating a sense of common purpose, based on shared values.
  • Staff spoke positively about their senior management teams. They told us they were visible and they felt well supported by managers. Most staff felt confident to raise any concerns they had.
  • Most services engaged well with patients, the public and local organisations to plan and management appropriate services, and collaborated with partner organisations effectively.
  • Governance processes across the services were generally well established. There was engagement and involvement of staff at an operational level.
  • The trust promoted training, research and innovation. For example, a nursery nurse had developed a daily observation and feeding prompt chart to ensure babies, who needed observations and/or feeding support, were reviewed as needed.
Checks on specific services

Community health services for children, young people and families

Good

Updated 5 April 2016

Overall we rated the service as good with the service being outstanding for caring and good in all other areas.

We found Children’s Community Services (CCS) provided a caring and effective multidisciplinary and multiagency service for children and young people (CYP) who required assessment, support and intervention to ensure their wellbeing and development.

Services were provided in a child friendly environment by a highly skilled and empathetic workforce across all children’s community settings. Services provided at the Child Development Centre (Danestrete) and the Children’s Zone (QEII) included visit’s to a child’s home, nursery, school or other locality setting. This enabled the development of holistic packages of care for each child and minimised the need for multiple appointments and duplication of history taking and documentation.

Children were truly respected and valued as individuals and encouraged to self-care and were supported to achieve their full potential within the limitations of their clinical condition. Feedback from children who used the service, parents and stakeholders were continually positive about the way staff treated people. Parents said staff went the extra mile and the care they received exceeded their expectations.

Services were well-led and staff were aware of the wider vision of the trust and felt supported in their roles.

We spoke to 43 staff which included nurses, doctors, therapist’s teachers, care support staff and administrative staff.  We also spoke to five children and eight parents.