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Provider: Buckinghamshire Healthcare NHS Trust Good

On 18 June 2019, we published a report on how well Buckinghamshire Healthcare NHS Trust uses its resources. The ratings from this report are:

  • Use of resources: Requires Improvement  
  • Combined rating: Good  

Read more about use of resources ratings

Inspection Summary


Overall summary & rating

Good

Updated 18 June 2019

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

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

• At Stoke Mandeville Hospital we rated five of the trust’s services as good and one as outstanding. In rating the trust, we took into account the current ratings of the three services not inspected this time.

• At Wycombe Hospital we rated three of the trust’s services as good and one as outstanding. In rating the trust, we took into account the current ratings of the three services not inspected this time.

• In the community services we rated two of the services as good and one as requires improvement. In rating the trust, we took into account the current ratings of the one service not inspected this time.

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

Our full Inspection report summarising what we found and the supporting Evidence appendix containing detailed evidence and data about the trust is available on our website – www.cqc.org.uk/provider/RXQ/reports.

Inspection areas

Safe

Good

Updated 18 June 2019

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

  • The trust provided mandatory training in key skills to all staff and made sure everyone completed it.
  • There were comprehensive systems to keep people safe, which took account of current best practice. People who used services were at the centre of safeguarding and protected from discrimination.
  • In general, the services controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
  • The services generally had suitable premises and equipment and looked after them well.
  • Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary.
  • The trust was working hard to recruit and retain staff across all areas. The service had a dedicated team of medical staff providing the palliative care service with the right qualifications, skills, training and experience to provide the right care and treatment. In most areas where staffing shortages posed a risk for example in the community children and young people and families service the service took actions to reduce the risks to children, young people and families.
  • In most areas staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care.
  • The services followed best practice when prescribing, giving, recording and in most areas when storing medicines. Patients received the right medication at the right dose at the right time.
  • Patient safety incidents were well managed. Staff recognised incidents and reported them appropriately, Managers investigated incidents and shared lessons learned with the whole team and the wider service.

However,

  • There was no assurance staff working in the community had the knowledge and skills to identify the specific signs and symptoms for a child or baby suffering from sepsis.
  • There was lack of assurance that infection prevention and control was considered in clinics carried out in premises not owned by the trust.
  • Targets for completion of safeguarding training were not met for all staff groups and not all medical staff were required to complete adult safeguarding training.
  • In the community health inpatients areas, we did not see action was consistently taken when patients showed signs of a health deterioration.
  • In the community health inpatients areas, the service did not always have enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. Safer staffing levels were not always met which impacted on patient safety. Patients could not always have their needs met in a timely way and this impacted on their length of stay.
  • Medicines including emergency medications were not always stored safely and in line with manufacturer’s guidance and regulations.
  • Staff did not follow processes to keep patients safe and minimise the risks of medicines misappropriation when dispensing patients’ medicines in the day surgery unit.
  • Patients’ records were not always kept securely which may pose risks of unauthorised access to confidential information. In some areas records of care including risk assessments were not consistently completed which may pose patient safety risks.
  • Safety checks were not consistently completed such as World Health Organisation surgical safety checklists, the five steps to safer surgery. All three phases of checks were not completed as required.
  • The process for the transfer of patients to the wards was not always followed which meant patients were not accommodated in an area suitable for their needs.

Effective

Good

Updated 18 June 2019

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

  • The trust provided care and treatment based on national guidance and monitored evidence of its effectiveness.
  • The trust participated in a number of national audits. Overall outcomes were positive for those patients accessing the hospital. Managers monitored the effectiveness of care and treatment and used the findings to improve them.
  • Patients received information on how to manage their pain. Staff assessed and monitored patients pain regularly and offered them pain control. Staff used pain tools to support those unable to communicate their pain.
  • In most areas staff gave patients enough food and drink to meet their needs. Staff made adjustments for patients’ religious, cultural and other preferences. The trust had taken a proactive approach to pre-empting problems associated with food and drink in end of life care, through the development of ‘Palliative Feeding for Comfort Guidelines’ (February 2017) in collaboration with the clinical commissioning group. This ensured professionals worked together to ensure they considered the risks and benefits of eating and drinking for everyone.
  • The trust responded to patient’s needs and patients could access a variety of services seven days a week.
  • The trust had systems in place to work with staff to ensure they were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service. Although in some areas the appraisal rates did not always meet the trust target of 90%.
  • There was effective multi- disciplinary working which benefitted patients. Staff of different disciplines worked together as a team to support and provide good care.
  • There was a range of information and support available for patients and their families and carers.
  • Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They followed the trust’s policy and procedures when a patient could not give consent.

However;

  • In some areas patients’ dietary needs were not always monitored and recorded to minimise risks of malnutrition.

Caring

Outstanding

Updated 18 June 2019

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

  • Feedback from patients and their relatives confirmed that staff treated them well and with kindness. We saw how staff took the time to interact with people who used the services and those close to them in a respectful and considerate way.
  • Staff cared for patients at the end of their life with compassion. There was a passionate caring ethos throughout the service. Without exception staff were caring, considerate and passionate about getting it right first time for patients.
  • There was a strong, visible person-centred culture in the end of life care service. Staff were highly motivated and inspired to offer care that was kind and promoted people’s dignity. Relationships between people who used the service, those close to them and staff were strong, caring, respectful and supportive.
  • Staff provided emotional support to patients to minimise their distress. Patients had their physical and psychological needs regularly assessed and addressed and we saw how patients had time to ask staff questions.

  • Staff providing end of life care recognised and respected the totality of people’s needs. Staff always took patient’s personal, cultural, social and religious needs into account. Patient’s individual concerns were identified and responded to in a positive and reassuring way. A patient and their relative described the hospice as an “Oasis of calm”.
  • Patients were empowered and supported to manage their own health, care and wellbeing and to maximise their independence.

  • Staff involved patients and those close to them in decisions about their care and treatment. They recognised the importance of relatives in the recovery of patients in their care.
  • Patients emotional and social needs were seen as being as important as their physical needs.
  • The bereavement team and medical examiner service understood the need to ‘get it right’ for every individual family and supported relatives in a sensitive and proactive way.

Responsive

Good

Updated 18 June 2019

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

  • The trust planned and provided services in a way that met the needs of local people. The trust looked at alternative models of care provision to try and reduce patients needing to be admitted to inpatient areas. The trust had adopted the ‘Purple Rose’ scheme to raise the profile of those at the end of life across the trust and ensure all staff had access to the information and resources they required in a timely way. In the emergency department the facilities, premises and the patient journey were being redesigned to increase capacity and to provide a better service for the local community.
  • The services took account of patients’ individual needs by making reasonable adjustments, providing specialised support. Staff from the palliative care team were activity involved in the trusts work in relation to people with protected characteristics.
  • People could access services when they needed to. Waiting times from referral to treatment were in line with good practice. The service reviewed any cancellations of surgery ensuring these were re-scheduled in a timely way. Teams worked collaboratively with internal staff groups and external agencies to provide care in the individuals preferred place when receiving end of life care. On occasions this had resulted in patients at the end of their life being discharged very quickly.
  • The trust was working towards improving clinic cancellations and appointment delays. Clinic room scheduling software had been introduced and telephone and virtual appointments had been implemented in some areas to make better use of appointment times for patients and staff.
  • The trust treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.

However:

  • Complaints received were not all dealt with, within the timescales stipulated in the trust’s complaints policy
  • The community health inpatients service had arrangements in place to meet the needs of people in vulnerable circumstances including those receiving end of life care. The ward environments however, did not always support the needs of those living with dementia. Buckingham Community Hospital, for example, was an older ward which did not have a dementia friendly environment to support patients to move independently around the ward.

Well-led

Requires improvement

Updated 18 June 2019

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

  • There was strong leadership in most areas, with managers having the right skills and abilities to run a service providing high-quality sustainable care. Local nursing leaders at ward level were experienced and knowledgeable about the needs of the patients they treated. However, at the executive level some essential roles, key to the trust moving forward were being covered by interim appointments.

  • Strategic priorities fed through to the divisions and on into each service delivery unit. Divisions and SDUs all had clear strategic vision for 2018-2020 and workable plans to achieve it. Some of the trust’s enabling strategies were still under development which would be key to turning the plans into action.

  • There was a governance framework that ensured responsibilities were clear, and that quality, performance and risk were understood and managed. However, at board level these had not always been effective, for example the trust’s current financial position had been contributed to by the board and executive team not being fully sighted on the risk relating to a change in contract and the impact of this.

  • 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. However, whilst there was a governance structure in place some aspects were reactive rather than proactive.

  • Services collected, analysed, managed and used information well to support all its activity, using innovative and best practice electronic systems and processes. Although information was not always presented and used in an informative way.

However:

  • The trust’s strategy, vision and values underpinned a culture which was patient centred. Local managers across the services promoted a positive culture that supported and valued staff.

  • In general services had a positive, inclusive and collaborative culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff we spoke with said they were proud to work at the hospital.

  • Services engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively.

  • Services was committed to improving by learning from when things went well and when things went wrong.

Assessment of the use of resources

Use of resources summary

Requires improvement

Updated 18 June 2019

Combined rating
Checks on specific services

End of life care

Good

Updated 10 July 2015

Overall this core service was rated as ‘good’. We rated community end of life care as ‘good’ for providing a safe, effective, caring, responsive and well led services.

Our key findings

Are services safe?

  • Incidents were reported and there was evidence of learning and improvement as a result. Safeguarding procedures were understood.
  • Patients were supported to understand the medication they were taking and how this could be best used to control their symptoms.
  • Medicines to support patients at the end of life were available in the community. Patients had the equipment they required to support their care safely in their own home.
  • Staff followed good infection control procedures.
  • There were sufficient specialist staff to support patient.
  • Staff used records appropriately and were well informed about the potential risks for patients and how these were to be managed.
  • Do not attempt cardio-pulmonary resuscitation (DNA CPR) forms were being used and this was monitored through audit.

Are services effective?

  • In line with national recommendation the Liverpool Care Pathway was no longer being used and the trust had developed a new pathway that was about to be trialled. Consideration was being given to the Priorities for Care of the Dying Person set out by the Leadership Alliance for the Care of Dying People.
  • New treatment escalation plans had also been developed in line with national guidance. Patient’s pain was well managed and the clinical nurse specialist (CNSs) worked in partnership with patients to ensure that this was achieved.
  • Patients nutrition needs were discussed and reviewed by the CNS as part of their holistic approach.
  • The trust had participated in the 2013/14 National Care of the Dying Audit – Hospitals (NCDAH) and did not achieve five of their seven key performance indicators (KPI’s) but was similar to the England average for most of the clinical indicators. Local audit to monitor the effectiveness of services was not well developed. The trust had acknowledged this gap and audit needed to be introduced.
  • Training in end of life care was available to all staff and specialist staff was further supported to develop their skills. A
  • There was a single point of access for all referrals for specialist palliative care and anyone, including parents, could refer a child to the children’s palliative care team.
  • Staff worked together to provide a multidisciplinary service and GP services to provide holistic care and prevent emergency admissions.
  • Staff had the information they required to care for patients and were conscious and informed about the requirement to seek consent.

Are services caring?

  • Staff demonstrated a caring and compassionate approach.
  • Patients and their families were positive about the care and support they received and the way they were treated.
  • Staff were courteous and treated patients and their families with dignity and respect. Patients and their families were involved and encouraged to be partners in their care and in making decisions.
  • People and staff work together to plan care and there is shared decision-making about care The CNSs provided emotional support and would refer patients to other professionals if additional support was required.

Are services responsive?

  • The trust had developed an action plan to improve its end of life service and a project lead had been employed to move this forward. The trust had engaged with staff, patients and their relatives as part of this project.
  • The CNSs took a holistic approach to their role and the service was available to all.
  • The children’s hospice at-home team offered individually tailored care, adapted to the child and family’s needs.
  • An interpreting service was available although family members often acted as interpreter.
  • The CNS managed their own diaries to ensure that patients were visited at time suitable for them. The children’s palliative care team worked in a similar way liaising with families and scheduling support at a time that would best meet their needs.
  • Support and advice was available 24 hours a day and staff were clear on how to access this support.
  • The community teams worked together to support patients and their families and to ensure that they had the support and equipment they required.

Is the service well led?

  • There was a clear vision for the service and the end of life care strategy was being reviewed to ensure that it reflected the service as a whole.
  • The trust was actively making changes to the service to ensure it better reflected current guidance, although while there was some monitoring of the quality of the service, this required further development to include audit and the monitoring of outcomes for patients.
  • The director of nursing was the lead for the service at board level and had clear insight into the challenges they were facing and the changes being made.
  • At a local level there was respect for the lead consultant in palliative care.
  • The matron’s role had been expanded and their responsibilities increased, and they were receiving support with their development to assist them in their role.
  • There was an open culture that placed the patient and their family at the centre.
  • There was a team approach to caring for patients in the community, with joint working between specialist staff, the adult community healthcare team and the community hospitals.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Community health inpatient services

Requires improvement

Updated 18 June 2019

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

  • Buckinghamshire Community Hospital’s environment did not support patients to move independently within the ward. Staff documented risks and deterioration to patient’s health, however these records were not always accurate, and we could not see appropriate action was always taken in response to an identified patient decline. The service was not sufficiently staffed to meet patient needs which impacted on patient therapy and hospital length of stay. Documentation relating to medicines storage did not always meet best practice guidelines.
  • Systems in place to recognise, document and escalation risks relating to governance, quality and performance were not effective in identifying key risks to service delivery. Previously identified staffing concerns for inpatient services had not been fully addressed and impacted on patient care.

However:

  • Most staff had received up-to-date mandatory training, including safeguarding. Premises and equipment were visibly clean and available for patient use. Medicines were managed safely. The service monitored key safety performance and incidents were reported and investigated.
  • Patients received effective care and treatment which met their needs. The trust participated in benchmarking programmes to drive improvements to the service. Staff development was encouraged, and appraisals were up to date. Patient’s received care from integrated multidisciplinary care teams. Patients were supported to make decisions about their care.
  • People were supported, treated with dignity and respect, and were involved as partners in their care. Patient feedback results were good, and most patients we spoke with were happy with their care. Staff were compassionate and helpful in their interactions with patients.
  • Patient needs were met through the way services were organised and delivered which included those in vulnerable circumstances. Patient complaints were investigated, and responses provided.
  • The leadership, service vision and culture sought to promote the delivery of high-quality person-centred care. Teams felt supported by managers and were supportive of each other. Staff and patient engagement was sought and innovation encouraged.

Community health services for adults

Good

Updated 18 June 2019

Our rating of this service

improved. We rated it as good because:

  • The service provided mandatory training in key skills to all staff, and staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staffing levels and skill mix were planned and reviewed to ensure patients received safe care and treatment.
  • The service controlled infection risk well. Staff kept themselves, equipment and the premises clean, and kept appropriate records of patients’ care and treatment.
  • Risk assessments were carried out for people and risk management plans were developed which ensured staff delivered safe care and treatment.
  • Patients received the right medication at the right dose at the right time. There were processes to ensure care and treatment was delivered in line with current evidence-based national guidance.
  • The service used safety monitoring results well. Staff collected safety information and shared it with staff.
  • Staff assessed patients’ nutrition and hydration needs using appropriate assessments, where applicable and managed patient’s pain effectively.
  • The service ensured staff were competent for their roles and had access to up-to-date, accurate and comprehensive information on patients’ care and treatment.
  • Staff in different professional groups, including local GPs, worked together as a team to benefit patients, and patients were given advice on improving their general health and wellbeing.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff treated patients with compassion and provided emotional support to patients to minimise their distress. Patients and those close to them felt involved in decisions made about their care and treatment.
  • The service planned and provided services in a way that met the needs of local people ensuring patients had flexibility and choice. In all areas we saw that staff tailored their services in response to the complex needs of vulnerable patients.
  • The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. They promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • The service 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.
  • There were effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
  • The service engaged with patients, staff, the public and local organisations to plan and manage the delivery of care in the community and collaborated with partner organisations effectively.
  • The trust was committed to improving services by learning from when things go well and when they go wrong.

However:

  • The trust did not include responding to the deteriorating patient as part of their mandatory training programme.
  • Not all teams were able to complete staff appraisals within the trust timescales.
  • Complaints received were not dealt with according to the trust complaints policy

Community health services for children, young people and families

Good

Updated 18 June 2019

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

  • Children, young people and families were protected from poor care and abuse by staff who had the relevant skills and received appropriate support. This was by mandatory training, safeguarding awareness, competency assessments, supervision and appraisals. Where there were staff shortages the service took actions to reduce the level of risk to patients.
  • The service had a culture of learning from where things had gone wrong, this included learning from incidents and complaints.
  • The service mostly provided care and treatment based on national guidance. Staff followed processes to ensure management of medicines was carried out in a sure way that met national guidance.
  • There was effective multidisciplinary working both across the trust and with partner organisations.
  • The leadership of the service supported monitoring and improvements to the services they delivered. The service engaged well with patients, partner organisations and staff. Staff reported a supportive working environment that looked after their wellbeing as well as supporting them in their personal career development.

However,

  • Health visiting performance was below the national average. Health visiting and some aspects of the Looked after Children’s performance did not meet national targets. People could not always access services in a timely manner. Waiting times from referral to treatment were not in line with good practice.
  • Although the service had systems for identifying risks, not all risks were formally identified which meant there was no plan to eliminate or reduce them.
  • Although the service collected information, not all information was analysed and used to support all its activities.