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Provider: Lancashire Teaching Hospitals NHS Foundation Trust Requires improvement

Reports


Inspection carried out on 02 July to 08 August 2019

During a routine inspection

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

  • We rated safe, effective and responsive as requires improvement; and caring and well led as good. At Royal Preston Hospital we rated two of the four services inspected as requires improvement and two as good. At Chorley and South Ribble Hospital we rated both core services inspected as good. In rating the trust, we took into account the current ratings of the services not inspected this time.
  • We rated well-led for the trust overall as good.
  • Our rating for Royal Preston Hospital was requires improvement overall which was the same as the last inspection. Our rating for Chorley and South Ribble Hospital was good which was an improvement from the last inspection when it was rated requires improvement.
  • Our ratings for urgent and emergency care and medicine at Royal Preston Hospital were requires improvement which were the same at the last inspection, although the ratings for effective and well led improved for urgent and emergency care.
  • Our rating for critical care at Royal Preston Hospital was good which was an improvement from the last inspection when we rated it as requires improvement.
  • Our rating for surgery at Royal Preston Hospital was good which was from the same as the last inspection when we rated it as good. Our ratings for effective went from good to requires improvement and our rating for responsive went from requires improvement to good.
  • Our ratings for urgent and emergency care and medicine at Chorley and South Ribble Hospital were both good which was an improvement from the last inspection when they were both rated requires improvement.


CQC inspections of services

Inspection carried out on 12 June to 19 July 2018

During a routine inspection

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

  • We rated safe, effective, responsive and well-led as requires improvement, and caring as good. We rated two of the trust’s eight services as requires improvement and four services as good. In rating the trust, we took into account the current ratings of the two services not inspected this time.
  • We rated well-led for the trust overall as requires improvement.
  • Our ratings for Royal Preston Hospital and Chorley and South Ribble Hospital were both requires improvement which was the same as the last inspection
  • Our ratings for urgent and emergency services and medical care, at both hospitals, were requires improvement which was the same as the last inspection.
  • Our ratings for surgery and services for children and young people at Royal Preston Hospital were good which was an improvement from the last inspection. Our rating for surgery at Chorley and South Ribble Hospital was good which was the same as the last inspection.
  • We previously inspected maternity jointly with gynaecology and outpatients jointly with diagnostic imaging so we cannot compare our previous ratings. We rated maternity and outpatients good at both hospitals.

Inspection carried out on 27 to 30 September 2016

During a routine inspection

The Lancashire Teaching Hospitals NHS Foundation Trust has two hospitals delivering acute services from Royal Preston Hospital and Chorley and South Ribble Hospital. There are 877 general and acute beds of which 56 are Maternity beds and 28 are critical care. There is 7,775 staff, of whom, 782 are medical staff, 2,192 are nursing staff and 4,801 are other designations.

There were 133,083 inpatient admissions with 562,446 outpatient attendances between July 2015 and June 2016. There were 129,157 attendances at Accident & Emergency between August 2015 and July 2016.

We inspected the trust as a follow up to the inspection in July 2014 where the trust was found to require improvement in the safe and responsive domains and good in effective, caring and well led domains. We visited Royal Preston Hospital and Chorley and District General Hospital between 27 and 30 September 2016.

We rated Lancashire Teaching Hospitals NHS Foundation Trust as requires improvement overall. This was because;

Access and flow was a significant challenge to the trust resulting in not meeting the 4 hour A&E target although the trust had not reported any 12 hour trolley breaches, In addition the trust not meeting Referral to Treatment targets and there were high numbers of patients placed in areas not specific to their needs. Capacity and flow challenges meant there was frequent use of escalation areas including the occasional use of the theatre recovery area. Planned operations were being cancelled due to bed shortages. Patient experiences were hampered by the need to move wards during their stay and the number of delayed discharges was having a negative effect on capacity and flow throughout the trust. There were a large number of patients whose discharge was delayed. Underutilisation of some areas at the Chorley site added to the problem.

There were pressures in the emergency department regarding access and flow that meant patients were not always seen in a timely way. We found that some medics were unaware of the requirement to gain senior review of patients prior to discharge for patients with chest pain or re-attendance within 72 hours.

We found that the trusts governance processes needed to be strengthened. There was a significant gap between the locally held risk registers and the directorate and corporate registers. Information was not well aligned and therefore did not provide assurance as to the escalation of risks or actions taken to mitigate those risks. There was a recognised lack of capacity in the governance team which was being addressed through recruitment.

We were not assured that all policies and procedures were current as many we reviewed were not up to date or had been appropriately reviewed. We were also not assured that staff were utilising the most recent versions of policy and procedures.

In respect of the Duty of Candour regulation we found that this was not addressed in all cases in a timely way. The quality assurance processes needed strengthening and currently provided reassurance rather than assurance. There were some concerns regarding the daily review of patients by consultant especially in the medical division.

The information we have received from the trust regarding mandatory training has not been easy to interpret and it has been difficult to identify training uptake at service level. This questions the reliability of information to the Board regarding the training levels of staff. Some examples include that in the emergency department that medical staff training in BLS, ALS and APLS was significantly below expected levels in nursing and medical staff. In paediatrics the percentage of staff with relevant level 2 safeguarding training was below expected.

There were a number of examples of poor medicines management found including a lack of risk assessment of patients who were self-medicating, we found incomplete records. We also found concerns with the consistency of accurate recording of the use of controlled drugs.

Medical staffing was a recognised significant challenge and plans were in place to improve the recruitment of relevant medical staff. The staffing skill mix was similar to the England average.

Across the organisation nurse staffing was found to be an ongoing challenge to the trust, although it was found that in all areas staffing levels were being actively managed to meet the needs of patients.

However, staffing in the paediatric department was not based on an acuity tool which meant we were not assured that the ward was always appropriately staffed. This was being managed through flexible working Nevertheless it was a concern due to the lack of clarity as to the required staffing level. We noted on the unannounced inspection that staff were working to a new draft escalation policy and had closed the ward to admissions on the previous day.

In the neonatal service this nurse staffing challenge was more noticeable due to them only being compliant with BAPM standards 80% of the time. On the unannounced visit we saw the shift was covered by nine staff when the expected number was 12. However, this hadn’t been escalated to senior managers. This was raised to Trust.

The trust had an Early Warning Score system in place however; we found the escalation of patients whose condition was deteriorating was not always appropriate and timely.

The safeguarding team was significantly understaffed due to sickness and vacancies affecting delivery. There were also concerns around the number of Deprivation of Liberty applications which were not responded to in a timely way by the local authorities.

We found the general physical environment was aged and worn. The discharge lounge at RPH was not conducive to promoting patient’s privacy and dignity. The designated discharge lounge area had patients waiting to go home sat amongst patients waiting for an outpatient appointment and confidentiality was difficult to maintain. Observation of patients could be improved and the facilities did not have readily accessible means for calling for urgent assistance should it be required.

We raised the following specific concerns which have been addressed;

  • Expressed breast milk on the post-natal ward was in an unlocked room, with unlocked fridge and no use of tamper proof tops.
  • The storage/recording of fetal remains was much improved on the unannounced visit. There is now a log in/log out system on the ward, porter also logs in and logs out when transferring samples to mortuary. Separate locked fridge for remains only.
  • Safe storage of IV fluids on emergency trolleys.

We saw several areas of outstanding practice including:

  • The trust had launched the Sleep Improvement in Adult Critical Care Programme. Disturbed sleep in critical care patients is associated with delirium, in which patients become confused, restless and experience hallucinations. This can delay their recovery from critical illness. The trust recognised this and identified the potential disturbances to sleep. To minimise disruption to patients during the night, they offered eye masks and earplugs, dimmed lights, anticipated empty infusion alarms, turned down the volume on medical equipment and phones and encouraged staff to talk away from the bedside. Staff were also reminded to check regularly for signs of delirium. The project and associated resources were shared with neighbouring critical care networks and at national meetings. An initial research study showed that making small changes caused a 50% reduction in patient delirium and significantly improved the quality of sleep experienced by patients. The study had won an initiative award at the National Nursing Times Awards.

  • The introduction in dermatology of a computerised diary colour codes patients by procedure enabling the service to plan a block of 12 week care in one go to suit the requirements of each patient. It also flags and calculates potential breeches giving better patient flow, facilitating comprehensive audit of care provision and outcome of treatment.

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

Importantly, the trust must:

  • Improve the access and flow of patients through the trust.
  • Review and improve the governance processes for the organisation to ensure robust policies and processes are in place that support safe care delivery, risk management and the management and learning from incidents and complaints.
  • Ensure the medicines management policy is robust and adhered to particularly with regards to self-medicating and controlled drugs management.
  • Ensure that the mandatory training programme supports staff attending and maintaining their mandatory training requirements.
  • Ensure that the process and practice for the escalation of the deteriorating patient is reviewed and embedded across the organisation.
  • Improve the facilities utilised as a discharge lounge.
  • Review and improve the staffing levels to ensure safe care and treatment, particularly within maternity, children’s and neonatal services and where patients require intensive nursing at either level 2 or Level 3.
  • Ensure that Safeguarding resources are adequate and training meets national standards and is taken up by relevant staff.
  • Work with the Local authorities to improve the timeliness of authorisation of Deprivation of Liberty applications.

At Royal Preston Hospital the hospital must;

In Urgent and Emergency Care services;

  • Ensure access to the main entrance paediatric waiting area is limited to reduce the risk of children exiting the area through the automatic doorway.
  • Ensure intravenous fluids are stored securely and daily checks are completed with actions to address issues identified, completed.
  • Ensure mandatory training, including safeguarding, compliance reaches and consistently achieves the trust target.
  • Ensure clinical staff are aware of and adhering to the requirement for senior review of specific patient groups prior to discharge from the ED
  • Ensure appropriate signage is displayed in areas where close circuit television cameras are used.
  • Ensure action plans following CEM audits target areas of poor performance and improve practice.
  • Improve performance, particularly in relation to the department of health four hour target; wait times following a decision to admit, ambulance handovers.
  • Ensure version control for policies, procedures and guidance is robust and that these are kept up to date and reviewed regularly.
  • Ensure the department has a dedicated risk register with start dates, timelines, mitigating action and responsible person with review dates included.

In Medicine;

  • Ensure that all staff receive appraisals and complete mandatory training to enable them to carry out the duties they are employed to perform.
  • Ensure that records are kept secure at all times, so that they are only accessed by authorised people.
  • Ensure procedures in place around medicine management are robust and that policies are followed.
  • Ensure the risk registers are consistent and demonstrate mitigating actions and review dates

In Surgery;

  • Take appropriate actions to improve staff training compliance in areas such as safeguarding training and life support training.
  • Take appropriate actions to ensure that patients requiring escalation, as part of the national early warning score system (NEWS), are appropriately escalated by staff.
  • Take appropriate actions to improve compliance against 18 week referral to treatment standards.
  • Take appropriate actions to reduce the number of cancelled operations and the number of patients whose operations were cancelled and were not treated within the 28 days.

In Maternity and Gynaecology;

  • Ensure midwifery and support staffing levels and skill mix are sufficient in order for staff to carry out all the tasks required for them to work within their code of practice and meet the needs of the patient.
  • Develop a baby abduction policy and take action to ensure that there is a safe system for protecting babies from abduction.
  • Ensure all necessary staff completes mandatory training, including Level 3 safeguarding training and annual appraisals.
  • Ensure that the assessment and mitigation of risk and the delivery of safe patient care is in the most appropriate place.
  • Complete risk assessments for midwives carrying medical gases in their cars and develop a Standing Operating Procedure (SOP) or protocol for carrying medical gases by car.
  • Ensure that all staff receive medical devices training to ensure all equipment is used in a safe way.

In Critical Care;

  • Ensure that escalation procedures are followed appropriately across the hospital where patients’ National Early Warning Scores (NEWS) are greater than five and the patient may need to be assessed for admittance to the critical care unit.
  • Ensure that any patients admitted to Ward 2A, who are assessed as Level 2 high dependency patients, receive nursing care at a ratio of 1:2 in accordance with national standards.
  • Address action points on a gap analysis that showed that there was no availability for endoscopy for urgent gastro intestinal bleeds 24 hours a day.

In Children and Young People’s services;

  • Ensure that staffing levels in neonatal and children’s services are maintained in accordance with national guidelines.
  • Ensure that all relevant staff having regular contact with children, as defined by intercollegiate guidance, complete level three safeguarding training.
  • Ensure that indicators for managing the changing condition of ill children are consistently used and responded to appropriately on the children’s ward.
  • Ensure that the isolation room used on the children’s ward is free from access to ligature points
  • Ensure that patient records are kept securely in the children’s out patients department.
  • Ensure that checks on emergency resuscitation equipment, are completed and accurately recorded on the neonatal unit.
  • Ensure that secure access to the neonatal unit and children’s ward is maintained at all times by staff, parents and visitors.

In Outpatients and Diagnostic Imaging;

  • Ensure that clear processes and structures are in place for the management and reviewing of governance, quality and risks.
  • Review the processes for managing access and flow for outpatient services to ensure patients are not put at risk.
  • Ensure staff complete mandatory training as per the trust policy.

At Chorley District General Hospital the hospital must;

In Urgent Care services;

  • Take action to help control risks associated with the room identified for mental health patients must be actioned and appropriately documented.
  • Ensure records of controlled drug use in registers are kept in line with trust policy.
  • Ensure mandatory training compliance reaches and consistently achieves the trust target.
  • Ensure clinical staff are aware of and adhering to the requirement for senior review of specific patient groups prior to discharge from the ED.
  • Ensure action plans following CEM audits target areas of poor performance and improve practice and that clinical staff are aware of and engaged with the process of clinical audit.
  • Ensure version control for policies, procedures and guidance is robust and that these are kept up to date and reviewed regularly.
  • Ensure the department has a dedicated risk register with start dates, timelines, mitigating action and responsible person and review dates included.
  • Ensure major incident plans are updated to reflect the current use of the department.
  • Improve communication and improve the negative culture centred on a lack of communication and feelings of mistrust amongst staff.

In Medicine;

  • Ensure that all staff receive appraisals and complete mandatory training to enable them to carry out the duties they are employed to perform.
  • Ensure that records are kept secure at all times, so that they are only accessed by authorised people.
  • Ensure procedures in place around medicine management are robust and that policies are followed.
  • Ensure the risk registers are consistent and demonstrate mitigating actions and review dates

In Surgery;

  • Take appropriate actions to improve compliance against 18 week referral to treatment standards.
  • Take appropriate actions to reduce the number of cancelled operations and the number of patients whose operations were cancelled and were not treated within the 28 days.
  • Take appropriate actions to improve staff training compliance in adult and children’s safeguarding training.

In Maternity and Gynaecology;

  • Ensure midwifery and support staffing levels and skill mix are sufficient in order for staff to carry out all the tasks required for them to work within their code of practice and meet the needs of the patient.
  • Ensure all necessary staff completes mandatory training, including Level 3 safeguarding training and annual appraisals.
  • Develop a baby abduction policy and take action to ensure that there is a safe system for protecting babies from abduction.
  • Complete risk assessments for midwives carrying medical gases in their cars and develop a Standing Operating Procedure (SOP) or protocol for carrying medical gases by car.
  • Ensure that all staff receives medical devices training to ensure all equipment is used in a safe way.

In Outpatients and Diagnostic Imaging;

  • Ensure that clear processes and structures are in place for the management and reviewing of governance, quality and risks.
  • Review the processes for managing access and flow for outpatient services to ensure patients are not put at risk.
  • Ensure staff complete mandatory training as per the trust policy.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 9, 10, 11 July 2014

During a routine inspection

We inspected Lancashire Teaching Hospitals NHS Foundation Trust as part of the new comprehensive inspection programme. We had received some concerns about staffing and the use of overnight facilities that were not fit for that purpose.

We found the trust was not meeting three regulations

  • Regulation 22 HSCA 2008 (Regulated Activities) Regulations 2010 Staffing.
  • Regulation 23 HSCA 2008 (Regulated Activities) Regulations 2010 Supporting Workers.
  • Regulation 9 HSCA 2008 (Regulated Activities) Regulations 2010 Care and welfare of service users.

The inspection took place between 9 and 11 July 2014, along with an unannounced visit at Royal Preston Hospital on 21 July 2014 between 6pm and 8pm.

Overall, this trust required improvement, although we rated it ‘good’ for having caring, effective services, and we noted some outstanding practice and innovation.

Our key findings were as follows:

Access and flow

Bed occupancy for the trust was consistently above 90%,that is worse than the England average. It is generally accepted that the quality of patient care and how well hospitals perform starts to be affected when occupancy rates rise above 85%.

The trust had been under pressure from high numbers of emergency admissions through its accident and emergency (A&E) departments, which affected the number of available beds, particularly in medicine. Patients were often placed in areas that were not best suited to their needs (outliers). The number of medical outliers often exceeded 30 patients and on occassions there were more than 50 people placed in areas not best suited to their needs.

Although the trust had good systems to make sure that patients were seen regularly by an appropriate doctor, patients often experienced a number of moves from ward to ward, sometimes during the night. Some patients could be be moved up to six times during their stay in hospital.

Surgical patients were also affected because operations were cancelled if intensive or inpatient beds were not available. We also found that discharge processes were slow and fragmented. Delays in discharge were made worse by the lack of intermediate care provision in the local area and delays in securing community-based care packages. The trust had begun to make changes to improve discharge processes and was also working with commissioners and the local authority to improve discharge support in the community. Although the trust was well aware of its challenges and was working on a solution, the required improvements were not yet visible.

Similarly, the numbers of delayed discharges from hospital remained a concern as the number of delayed discharges is higher than the England average.

Between April 2013 and March 2014, the trust cancelled 675 operations and 94 of these patients did not go on to receive their treatment within 28 days of the cancellation. This was significantly worse than the national average. For example, between July and September 2013, 20% of patients whose operation had been cancelled had not received treatment within 28 days compared to the national average of 3.7%.

However, since April 2014 and June 2014, 152 operations have been cancelled and only four patients (2.6%) had not received treatment within 28 days, which is better than the national average of 5.1%. This is a good improvement and the trust must sustain this level of performance to support patients receiving timely care and treatment.

The trust had reduced the number of day case patients waiting for elective surgery between April 2013 and February 2014. However, approximately 1,500 people were waiting for elective surgery as an inpatient at the time of the inspection.

Nurse staffing

Nursing staff were caring and compassionate and treated people with dignity and respect. Nurses were highly committed to giving people a high standard of care and treatment. Nurse staffing levels on most wards were calculated using a recognised dependency tool. However, recruiting nursing staff was an ongoing challenge for the trust. Nurse staffing levels, although improved, were still a concern. There was a heavy reliance on staff working extra shifts and on bank and agency staff to maintain safe staffing levels, particularly in the medical division. There were times when the wards were not appropriately staffed.

The maternity service had a number of vacant midwifery posts and it was also affected by staff sickness. The service relied heavily on community midwives, staff working extra hours and in-house bank staff to maintain staffing levels. The ratio of midwives to live births was 1:34, which is below the national recommendation of 1:28.

The nurse staffing figure in the paediatric assessment unit was below the Royal College of Nursing recommendation of two qualified nurses for assessment units. We found that children and young people had to wait for long periods to be seen by a doctor.

Medical staffing

The hospital was staffed by highly skilled, competent and well-supervised doctors. Medical staff were universally committed to providing good patient care. Consultants were present or accessible 24 hours a day and carried out daily ward rounds. However, there were issues regarding medical staffing and ophthalmology services at Chorley and South Ribble Hospital that were currently under review.

Mortality rates

The trust had a well-established mortality review process. Its mortality rates were within acceptable ranges for a trust of this size. Mortality data for expected deaths (4.1%) showed that the trust performed slightly better than was expected (4.3%).

Incident reporting and investigation

The trust had a robust systen for reporting incidents and near misses. Staff were confident and competent in reporting incidents and were supported by their managers to do so. The trust reported five potential never events during 2013/14. (never events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented.) Three were de-classified following investigation. The trust told us about a recent incident that they reported as a potential never event, which was unlikely to meet the full definition.

The trust had investigated all incidents requiring investigation and had taken robust steps to reduce the risk of reoccurance.

Nutrition and hydration

Dietary and nutritional requirements were considered as part of the care planning process. Specialist support was available for patients who needed help. The speech and language team actively supported patients with swallowing and eating difficulties.

There was a blue tray system in place to identify patients who needed help with eating and drinking. This system worked well and patients who experienced difficulties were well supported.

Most patients were complimentary about the choice of food and drink provided to them.

Cleanliness

Both hospitals were clean and well maintained. Staff adhered to the trust’s infection prevention and control policy. We saw good hygiene practice in all of the clinical areas we inspected. Infection rates for MRSA were in line with the England average but Clostridium difficile and MSSA were higher than the England average. However, audits of compliance with standard hygiene practices took place regularly and showed high levels of compliance.

Equipment was clean and regularly maintained so that it was ready for use.

Staff training

We found that some wards and departments were not meeting the trust’s target of 80% for staff training. Some staff said that they could not go to training sessions because of staffing pressures in their area of work. This was a particular concern in the childrens service, where there were not enough nurses trained in advanced paediatric life support to provide one trained nurse for every shift in paediatric areas, to meet best practice guidance. The trust had acknowledged that the numbers of staff undertaking mandatory training needed to be improved and had implemented a number of initiatives, including eLearning packages. As a result, there had been a month-on-month improvement in mandatory training completion.

Medicines management

Medicines were dispensed, stored and administered safely. However, the out-of-hours arrangements led to patients experiencing delays in securing prescribed medications. In addition patients also experienced delays in receiving medicines to take home with them. This often meant that discharges were delayed and patients were sometimes discharged from hospital quite late in to the evening.

We saw several areas of outstanding practice, including:

  • Data from the College of Emergency Medicine consultant sign-off audit showed that 100% of patients at Preston A&E Department were seen by an Emergency Department doctor; the national average was 92%. Also 25% of patients were seen by a consultant, well above the national average of 13% in 2012/13.
  • The trust was committed to becoming a dementia-friendly environment. An older people’s programme was developing this work and we saw several excellent examples of how it was being put into practice during our inspection. The proactive elderly care team helped staff to identify and assess the needs of older people. They also worked proactively with intermediate care services to ensure the safe discharge of older people and those with dementia. Activity boxes and blankets had been introduced throughout the division to promote and maintain cognitive and physical function and reduce the unwanted effects of being in a hospital environment. Two wards at Chorley had been designed specifically to meet the needs of people with dementia. These wards had been nominated for a national Nursing Times award for the environment. Rookwood A, Rookwood B, Barton, Bleasdale wards and Ward 21 had also achieved the stage 2 quality mark for elderly-friendly wards from the Royal College of Psychiatrists.
  • The trust had won the Clinical Innovation category at the North West Excellence in Supply Awards for developing a disposable female urinal.
  • The alcohol liaison service had been nominated for a national Nursing Standards award. Staff spoke highly of the service and the positive contributions they had made in supporting patients with alcohol-related conditions and their families.
  • Our specialist adviser assessed that speech and language therapy input for neonatal babies was likely to improve the long-term outcomes for these children and considered this to be outstanding practice.
  • The end of life team coordinated rapid response for discharge to the preferred place of care. Staff told us there was a multidisciplinary approach to discharge planning that involved the hospital and the community staff working towards a rapid but safe discharge for patients.
  • Ultrasound-guided blocks were used in A&E for patients with neck of femur injuries, which provided quicker pain relief.

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

Importantly, the trust must:

Staffing

  • Ensure that there are enough suitably qualified, skilled and experienced nurses to meet the needs of medical patients at all times.
  • Ensure that there are enough suitably qualified, skilled and experienced midwives to meet the needs of patients at all times.
  • Ensure that medical staffing is sufficient to provide appropriate and timely treatment and review of patients at all times within the medical division and outpatients.
  • Ensure that medical staffing is appropriate at the location, including medical trainees, long-term locums, middle-grade doctors and consultants.

Supporting staff

  • Ensure that staff receive advanced paediatric life support and moving and handling.
  • Take steps so that the trust can confirm the status of mandatory training completed by staff, particularly in the child health directorate.

Care and welfare of patients

  • Improve patient flow throughout the hospital to reduce the number of bed moves and length of stay, particularly in the medical division.
  • Take action to prevent cancellation of outpatients clinics at short notice and ensure that clinics run to time, particularly within ophthalmology outpatients.
  • Take action to make sure that admission and referral pathways to the High Dependency Unit are clearly communicated and understood by all staff so that patients receive timely and responsive care and treatment.
  • Review the level of cancelled appointments within ophthalmology outpatients and review and address the identified concerns within this department.

Professor Sir Mike Richards

Chief Inspector of Hospitals

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.


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.