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Provider: East Sussex Healthcare NHS Trust Good

Inspection Summary


Overall summary & rating

Good

Updated 27 February 2020

Our rating of the trust improved. We rated it as good because:

We rated safe, responsive and well-led as good, caring and effective as outstanding. We rated three of the trust’s five services as outstanding and two as good. In rating the trust, we took into account the current ratings of the 13 services not inspected this time.

Inspection areas

Safe

Good

Updated 27 February 2020

Our rating of safe improved. We rated it as good because:

  • The service provided mandatory training in key skills to all staff and checked staff completed it. Overall, the majority of staff completed this training.
  • 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 used equipment and control measures to protect patients, themselves and others from infection.
  • Staff completed and updated risk assessments for each patient and removed or minimised risks. Staff used a nationally recognised early warning scores to identify deteriorating patients and escalated their care appropriately. Risk assessments considered patients who were deteriorating and in the last days or hours of their life.
  • Generally, the service had enough nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix. The service gave bank staff a full induction and where services had vacancies, managers were recruiting to posts. In community end of life care services, the service had access to enough staff within the out of hospital teams with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment and end of life care was prioritised to ensure patients’ needs were met.
  • Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date, stored securely and easily available to all staff providing care.
  • The service used systems and processes to safely prescribe, administer, record and store medicines.
  • The design, maintenance and use of facilities, premises and equipment kept people safe. Staff managed clinical waste well. When providing care in patients’ homes staff took precautions and actions to protect themselves and patients.
  • The service used monitoring results well to improve safety. Staff collected safety information and shared it with staff, patients and the public.
  • The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients, including children and young people, honest information and suitable support. Managers ensured that actions from patient safety alerts were implemented and monitored.

In the community adults service:

  • Completion rates for mandatory updates were below the trust’s target in two of the six subjects. In some cases, this was due to circumstances such as staff being on long term sick leave, and in most cases the staff were booked onto a session. Some of the clinic and office premises used by podiatry teams were not ideal for the purpose and confidential discussions had to be held elsewhere. Similarly, some offices used by district nursing and crisis response teams were noisy and did not allow for quiet working, private meetings or confidential phone calls to be made. Not all information we saw in homes during district nursing visits was up to date, and so did not reflect the treatment and care patients were receiving.

In the children’s and young people’s services:

  • The service did not always have enough staff with the right qualifications, skills, training and experience to keep children, young people and their families safe from avoidable harm and to provide the right care and treatment and this resulted in closures of some parts of the service for short periods. Staff did not always keep accurate records of medicines administered. There were no records of who held the correct patient group direction authorisations and we could not be sure that they were being used safely and correctly in line with trust and national guidance.

However:

In the outpatient’s service at the Conquest Hospital:

  • Not all mandatory training requirements were completed by all staff.

In the children’s and young people’s services:

  • The service did not always have enough staff with the right qualifications, skills, training and experience to keep children, young people and their families safe from avoidable harm and to provide the right care and treatment and this resulted in closures of some parts of the service for short periods.

  • Staff did not always keep accurate records of medicines administered. There were no records of who held the correct patient group direction authorisations and we could not be sure that they were being used safely and correctly in line with trust and national guidance.

In the community adults service:

  • Completion rates for mandatory updates were below the trust’s target in two of the six subjects. In some cases, this was due to circumstances such as staff being on long term sick leave, and in most cases the staff were booked onto a session.

  • Some of the clinic and office premises used by podiatry teams were not ideal for the purpose and confidential discussions had to be held elsewhere. Similarly, some offices used by district nursing and crisis response teams were noisy and did not allow for quiet working, private meetings or confidential phone calls to be made.

  • Not all information we saw in homes during district nursing visits was up to date, and so did not reflect the treatment and care patients were receiving.

Effective

Outstanding

Updated 27 February 2020

Our rating of effective improved. We rated it as outstanding because:

  • Care and treatment were provided based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance. Staff protected the rights of patients in their care.

  • Staff supported patients to make sure they had enough food and drink to meet their needs. Staff carried out regular assessments of nutrition and hydration. Patients were encouraged to eat and drink normally for as long as possible despite this need reducing as people approached the end of their life. Community staff worked with other agencies to support patients who could not cook or feed themselves.

  • 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 when necessary.

  • Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients.

  • The service 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. Staff providing end of life care had access to a range of specialist end of life care training.

  • Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care. In the community, Staff worked effectively with other professionals and stakeholders in the system to ensure patients received the most effective and timely care and treatment available. All those responsible for delivering care worked together as a team to benefit patients, whose care and treatment was seamless and uninterrupted. They consistently supported each other to provide good care and communicated effectively with other agencies.

  • Staff gave patients practical support and advice to lead healthier lives.

  • 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 those with mental health conditions.

However:

In community end of life care:

  • Not all staff were confident with the recording of mental capacity assessments and were not routinely doing this.

  • In the acute end of life care services:

  • There was not a major incident policy for the mortuary, although staff were developing one.

  • In the outpatients’ service at the Conquest Hospital:

  • Not all staff received an appraisal in line with the trust policy.

In the children’s and young people’s service:

  • At the Conquest Hospital Diagnostics, pathology and pharmacy provision were always available, although there was no seven-day service for physiotherapy, occupational therapy and play specialists.

  • There was not registered Mental Health nurse working within the department. The division had access to Child and Adolescent Mental Health Services (CAMHS) however there were pressures on the service meant children were not always seen or discharged in a timely manner.

  • We found online system anomalies that meant the most up to date policies were not always displayed.

Caring

Outstanding

Updated 27 February 2020

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

  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Feedback from patients was consistently very positive, and patients felt staff went the extra mile to provide care the care they needed. In the end of life care services at both hospitals, staff providing end of life care truly respected and valued patients as individuals and thoroughly understood and respected patients’ personal needs and preferences.

  • Staff provided emotional support to patients, families and carers to minimise their distress. They understood patients’ personal, cultural and religious needs and used innovative ways to help people meet them. In children’s services, staff understood the impact a child’s condition and treatment had on their wellbeing both emotionally and socially.

  • Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment.

  • Relationships between people who used the service, those close to them and staff are strong, caring and supportive. These relationships are highly valued by staff and promoted by leaders.

  • Staff provided high quality emotional support to patients, families and carers to minimise their distress. People’s emotional and social needs are highly valued by staff and are embedded in their care and treatment.

Responsive

Good

Updated 27 February 2020

Our rating of responsive improved. We rated it as good because:

  • Care was planned and provided in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care. End of life services were flexible, provided choice and ensured continuity of care and there was a proactive approach to work with others in the wider system and local organisations to plan care that met the needs of patients, their families and the wider community. In community services, the involvement of other organisations and the local community was integral to how services were planned and ensured that services met people’s needs. They reliably and consistently coordinated care with other services and providers.

  • People could access the service when they needed it and received the right care in a timely way. Where there were waiting lists, staff had processes to minimise these and their impact. Patients could access the specialist palliative care service when they needed it and had access to services in a way and at a time that met their needs. There were arrangements that ensured specialist advice was available at all times. In the outpatients department at the Conquest Hospital, waiting times, delays and cancellations were minimal and manged appropriately.

  • The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. Services were tailored to meet the needs of individual people and were delivered in a way to ensured maximum flexibility and choice. Staff coordinated care with other services and providers.

  • People were supported to give feedback and raise concerns about care received. There were systems to treat concerns and complaints seriously, investigate them and share lessons learned with all staff. The service included patients in the investigation of their complaint.

However:

In the community adults service:

  • The frailty team did have a lengthy waiting list at the time of the inspection. Managers had a plan to address this.
  • In the outpatients’ service at the Conquest Hospital:

  • Not all waiting times from referral to treatment were in line with national standards.
  • In the main outpatient department, there was no designated waiting area for patients on stretchers. Not all clinic areas had seating available for bariatric patients or those that had difficulty in sitting.
  • In the Children’s and Young People’s service at the Conquest Hospital:

  • The service was not always able to deliver care in a way that met the needs of local people and the communities served.
  • Staff were not clear of the formal process or guidance surrounding children missing appointments. Missing appointments for some children may be an indicator that they are at an increased risk of abuse.

Well-led

Good

Updated 27 February 2020

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

  • Leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. They supported staff to develop their skills and take on more senior roles. In end of life care, leaders had an inspiring shared purpose and strove to deliver and motivate staff to succeed
  • The service 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.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear.
  • Leaders operated effective governance processes, throughout the service 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.
  • Leaders and teams used systems to manage performance effectively. They 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.
  • 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.
  • The leadership team drove continuous improvement. Staff were committed to continually learning and improving services. Safe innovation was celebrated. There was a clear proactive approach to seeking out and embedding new and more sustainable models of care. They were developing an understanding of quality improvement methods and the skills to use them.

However:

In the children and young people’s service:

  • Staff were aware of some changes within the department, although we heard they were not always part of improvement plans.

  • The transition pathways from children’s to adults’ services was still not fully realised, although action had started to be undertaken.

  • In the acute end of life care services:

  • The risk register was not kept up to date.

Assessment of the use of resources

Use of resources summary

Requires improvement

Updated 27 February 2020

This was the first time we inspected use of resources at this trust. We rated use of resources as requires improvement because:

The trust had exited special measures for quality and finance in 2018 and 2019 respectively, and at the time of our assessment, the trust could evidence good productivity in several areas. In particular, the trust benchmarked well on clinical services and had significantly reduced its reliance on agency staff. However, the information available at the time of the assessment showed that despite improvements, the trust’s costs remained higher than the national median and there remained opportunities to improve the way it used its resources regarding workforce, clinical support services and corporate functions. Although the trust had reduced its deficit including through working with its local health system partners, it still needed to increase the level of recurrent efficiencies it achieved and reduce its reliance on central cash support.

Combined rating

Combined rating summary

Good

Updated 27 February 2020

Our combined rating of quality and resources was good and this was the first time we have produced a combined rating for this trust. We rated it as good because:

We rated safe, responsive and well led as good and caring and effective as outstanding. Use of resources was rated as required improvement.

Checks on specific services

Community end of life care

Good

Updated 27 February 2020

Our rating of this service improved. We rated it as good because:

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, supported them to make decisions about their care, and had access to useful information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not generally have to wait too long for treatment.

  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work.  Staff generally felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

Community health services for adults

Outstanding

Updated 27 February 2020

Our rating of this service improved. We rated it as outstanding because:

  • The service had enough skilled staff to care for patients and keep them safe, although they had vacant posts to be recruited to. Staff had training in key skills although not all staff had attended mandatory updates within the required period. Staff understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and generally kept good care records. They managed medicines well. The service managed incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, and gave patients pain relief when they needed it. Managers monitored the effectiveness of the services and made sure staff were competent. Staff worked exceptionally well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week, or if they were not, there were plans in place to ensure they would be.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and usually did not have to wait too long for treatment. Where there were waiting lists, managers had processes to ensure each was considered and prioritised according to urgency. Where appropriate and possible, people on the waiting lists were signposted to other services for more immediate assistance.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients, the community and other stakeholders to plan and manage services and all staff were committed to improving services continually.