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Provider: Blackpool Teaching Hospitals NHS Foundation Trust Requires improvement

Reports


Inspection carried out on 03 June to 07 June 2019

During an inspection looking at part of the service

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

We rated safe, effective, responsive as requires improvement, and caring as good. We rated six services as requires improvement, one as inadequate, nine of the trust’s services as good and one service as outstanding. We rated caring for community services as outstanding.

We rated well-led for the trust overall as inadequate.


CQC inspections of services

Service reports published 17 October 2019
Inspection carried out on 03 June to 07 June 2019 During an inspection of Community health services for adults Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 03 June to 07 June 2019 During an inspection of Community health services for children, young people and families Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 03 June to 07 June 2019 During an inspection of Community end of life care Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 03 June to 07 June 2019 During an inspection of Community dental services Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 03 June to 07 June 2019 During an inspection of Community health sexual health services Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 03 June to 07 June 2019 During an inspection of Specialist community mental health services for children and young people Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
See more service reports published 17 October 2019
Service reports published 22 March 2018
Inspection carried out on 15 Nov to 14 Dec 2017 During an inspection of Community health services for children, young people and families Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 15 Nov to 14 Dec 2017 During an inspection of Community dental services Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 15 Nov to 14 Dec 2017 During an inspection of Specialist community mental health services for children and young people Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 15 Nov to 14 Dec 2017 During an inspection of Community health services for adults Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 15 Nov to 14 Dec 2017 During an inspection of Reference: Community health (sexual health services) not found Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
See more service reports published 22 March 2018
Inspection carried out on 15 Nov to 14 Dec 2017

During a routine inspection

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

  • We rated safe and responsive as requires improvement. We rated effective, caring and well-led as good. Our rating for the trust took into account the current ratings of services not inspected this time.
  • Our decisions on overall ratings take into account factors including the relative size of services and we use our professional judgement to reach a fair and balanced rating.
  • There remained challenges with patient flow; performance in urgent and emergency care had gone down.
  • The emergency department had consistently failed to meet the Royal College of Emergency Medicine recommendation that the time patients should wait from time of arrival to being triaged (having an initial assessment undertaken) is no more than 15 minutes. This is important as it is a system that emergency departments use to make sure that the patients who may need immediate treatment are prioritised.
  • Safeguarding training was not always delivered at the level specified in the intercollegiate guidance within the emergency department and community dental practices.
  • In specialist community mental health services for children and young people, risk management plans were not properly updated on an ongoing basis.
  • There remained challenges with staffing in some areas of the trust, particularly in urgent and emergency care and medical care.
  • Mortality figures remained higher than expected, although we saw evidence that the strategy to reduce the mortality rates was having a positive effect.

However:

  • We rated well-led at the trust level as good.
  • During the inspection in 2014, we were unable to identify a clear vision or strategy to support the trust. At this inspection, we found that a trust vision and five-year strategy had been developed in consultation with staff, patient representative groups and external stakeholders.
  • At the last comprehensive inspection in 2014, it was reported that there were poor incident reporting systems and failures to report near misses. At this inspection, we found that staff felt confident and were encouraged to report incidents via an electronic system.
  • There was a strong sense of integration across both the acute and community services. We identified outstanding caring and responsive practice in the community health services for adults.
  • Directors demonstrated an understanding of the quality of care across all sectors.

Inspection carried out on 15-16 January 2014

During a routine inspection

Blackpool Teaching Hospitals NHS Foundation Trust is a medium-sized acute trust providing healthcare for the population of Blackpool, Fylde, Wyre and parts of Lancashire and south Cumbria. The indigenous population is around 440,000. However, there is a transient tourist population in excess of 10 million people each year, either on one-day visits or staying for longer periods of time.

The trust serves a population that has mixed health needs. Parts of the population are among the most deprived in England (Blackpool Local Authority is the 10th most deprived of 326 local authorities in England). The population’s health is worse than expected in 23 of the 32 health indicators (for example: life expectancy, alcohol-related admissions, drug misuse, smoking related deaths and early deaths from cancer, stroke and heart disease). However, for the populations of Fylde and Wyre, they are better than expected: 9 of the 32 health indicators are better than the England average.

Within the Blackpool area, life expectancy is five years lower for men and three years lower for women compared to the national average.

In April 2012 the trust merged with community health services from NHS Blackpool and NHS North Lancashire as part of the Transforming Community Services programme. This has created a larger organisation with over 6,000 staff, in excess of 800 beds and an annual spend of approximately £360 million.

The trust provides a range of secondary care services usually found in all main hospitals along with tertiary cardiac surgery for the residents of Lancashire and south Cumbria (with an equivalent population of 1.6 million). The trust also provides some tertiary haemato-oncology services. Additionally, the trust manages the national artificial eye service on behalf of the whole country.

The trust operates from three sites:

  • Blackpool Victoria, which is the main hospital site
  • Clifton Hospital, which currently has four wards, mainly for elderly care and rehabilitation (with one outpatient clinic), and
  • Fleetwood Hospital, which has outpatient clinics with some limited radiology on site.

The trust had a significantly higher than expected mortality rate from April 2012 to March 2013. As a result, the trust was included in Professor Sir Bruce Keogh’s review of trusts in 2013. The report “Review into the Quality of Care & Treatment provided by 14 Hospital Trusts in England” is available on the NHS Choices website. The report found that the pace of change at the trust had been slow, with the trust leadership trying to do too many things at the same time. It said that governance arrangements should be more robust. It also said there was a disconnect between the leadership team and the frontline service. We saw that the trust has put significant effort into developing clinical pathways in a number of areas as part of its response to this report.

During this inspection, we inspected services in A&E, surgery, critical care, medicine, maternity and family planning, children’s care, end of life care and outpatients.

We spoke to a large number (over 100) of patients in all areas, to the families and carers of some of these patients and to visitors to the hospital

We found that the people using the service were highly complimentary about the level of care they received from all of the staff they met.

Mortality

Mortality figures remained higher than expected for the trust, but these figures were falling (improving). The trust has undertaken some significant work on improving and clearly defining the clinical pathways (including steps to be taken at each stage and those staff responsible for doing it)to achieve this, and was monitoring patient care.

Staffing

Staff, were very committed and were making considerable efforts to provide good patient care. The quality of care in the children’s care service was high. The trust had increased levels of medical and nursing staff and this was recognised by staff; allied health professionals, such as physiotherapists and occupational therapists, felt that their staffing had not increased in a way that reflected their contribution patient care.

All the staff we spoke with said they enjoyed their job, liked working for the organisation and valued their role.

Complaints

The complaints process has improved. The newly-named Patient Relations Service has improved this process. However, we have spoken to many people using the service who do not know how to make a complaint, and so we conclude there is still much work to do here.

The trust's target was to respond to formal complaints within 25 days. This target was not always met. However, the divisional management team were working to address this and the number of complaints processed within 25 days had improved since April 2013. Following CQC's review of Outcome 17 in June 2013, the trust had reviewed its complaints process and the new arrangements were being implemented at the time of this CQC hospital inspection

We saw that Patient Relations Service leaflets were available, but these were not always visible in some of the areas we visited.

Leadership

The visibility of the executive team has increased significantly. We spoke to many people who had met (or knew of) many of the executive directors. However, visibility does not equate to engagement, and we did note that there still appears to be a disconnect in some areas between the board and the operational service, particularly among medical staff.

In a number of areas there were differences of opinion between the executive team and the clinical workforce. In part, this may be due to a more positive view of some challenges, but we were concerned that it may also be a symptom of this disconnect.

We were unable to identify a clear vision or strategy to support the new enhanced acute and community trust. We saw that there are considerable opportunities for the new trust to improve. However, this requires a clearly articulated vision.

Service developments

The trust has received external accreditation for its Bowel screening, Trauma unit, Radiology and Haematology (stem cell transplant) services.

The trust uses the palliative care amber care bundle (a process to support the quality of care of patients who are at risk of dying in the next one to two months but may still be receiving active treatment).

We saw examples of excellent integration between acute and community services. The staff we spoke to from the community all praised the method of integration, and they valued the welcome from other colleagues. Staff from both the community and the acute teams explained that the integration had improved their knowledge and understanding of the overall processes. We felt that the work put into the integration of the teams from acute and community had been highly effective and the trust should be proud of its work in this area.

Processes of care

There were challenges in patient flow. We saw that patients were staying for long periods, the trust was reliant on escalation beds and there was limited use additional medical staff. There were opportunities to significantly improve the pathway in this area. This would improve both the experience of the service for patients and could reduce the time they spend in hospital.

We noted that the accident and emergency service is largely meeting the national waiting time target of four hours. However, we did note that this success is down to an increased response within the last hour of the waiting time. This may mean that the systems in use are less efficient and some patients could wait longer than needed in the service.

We saw that cancelled operations had led to ineffective use of resources and challenges to patient flow. This meant that patients were not accessing the treatment and care they needed in a timely manner.

Medical records

There are challenges with medical records that may also interrupt patient flow and impact on safety. It was difficult to find information in the medical records. We noted that an electronic patient record solution is in development, but this may take some time and current challenges require an interim solution. For safe and effective clinical care, patients' medical records need to be easily accessible, legible and simple to follow.

Safety

The trust had a significantly higher rate of primary postpartum haemorrhage (haemorrhage after childbirth) and this had led to some patients having a hysterectomy. Good practice guidelines on access to interventional radiology by the Royal College of Obstetricians and Gynaecologists (RCOG) were not followed and the trust has requested a review by the RCOG at the time of our inspection. This was a significant safety issue which the trust had not identified to us at the outset.

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.


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.