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Provider: East Lancashire Hospitals NHS Trust Good

On 12 February 2019, we published a report on how well East Lancashire Hospitals NHS Trust uses its resources. The ratings from this report are:

  • Use of resources: Good  
  • Combined rating: Good  

Read more about use of resources ratings

Reports


Inspection carried out on 28 August to 27 September 2018

During a routine inspection

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

  • We rated safe, effective, caring and well-led as good. We rated responsive as requires improvement. Of the ten services we inspected we rated seven as good, two as outstanding and one as requires improvement. 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 ratings for Royal Blackburn Hospital and Burnley General Hospital were both good which was the same as the last inspection
  • Our ratings for surgery, at both hospitals, were good, which was the same as the last inspection. Our rating for urgent and emergency care at Royal Blackburn Hospital was requires improvement, which was a deterioration from the last inspection, when we rated it as good. Our rating for urgent and emergency care at Burnley General Hospital was good, which was the same as the last inspection. Our rating for medical care at Royal Blackburn Hospital was good which was the same as the last inspection. Our rating for medical care at Burnley General Hospital was also good which was an improvement since the last inspection.
  • Our rating for community end of life was outstanding. Our ratings for community adults and community inpatients were good. This was the first time we have inspected these services.
  • Our ratings for specialist community mental health services for children and young people was outstanding. This was the first we have inspected this service.


CQC inspections of services

Service reports published 12 February 2019
Inspection carried out on 28 August to 27 September 2018 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 28 August to 27 September 2018 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 28 August to 27 September 2018 During an inspection of Community health inpatient services Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 28 August to 27 September 2018 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 12 February 2019
Inspection carried out on 20-21 September 2016

During an inspection looking at part of the service

East Lancashire Hospitals NHS Trust serves a population of 521,000. The trust has two acute sites: Royal Blackburn Hospital and Burnley General Hospital as well as three community sites. There is noticeable deprivation in both Blackburn with Darwen and Burnley. Alcohol-related diseases and adult smoking are among the most prominent health concerns in both areas. Of the local population, 44% are non-white ethnic minorities and life expectancy is 10 years lower for men and seven years lower for women in the least deprived areas of both boroughs.

East Lancashire Hospitals NHS Trust was one of the 14 trusts reviewed as part of the Keogh Review in 2013 based on the trust having been an outlier for the previous two consecutive years on either the Summary Hospital-Level Mortality Index (SHMI) or the Hospital Standardised Mortality Ratio (HSMR). The review identified a number of concerns at the trust particularly related to the quality governance assurance systems. The review panel also identified a number of areas of good practice and dedicated staff, but there was more for the trust to do to communicate effectively to staff and share learning to ensure consistent approaches to quality improvement across the organisation, all of the time.

The trust was placed in special measures and CQC inspected the trust using the new comprehensive inspection model in July 2014. This resulted in the hospital overall being rated as Requires Improvement with improvement needed in urgent care; medical care; surgery and end of life care.

This inspection was a follow up and was conducted on 20 and 21 September 2016 and was a well-led review to follow up the focused inspection conducted on 19, 20 and 21 October 2015. We did not inspect the community sites and only reviewed four core services in October 2015 in order to review the progress of the trust since coming out of special measures in July 2014. We have aggregated the ratings following this inspection with the previous ratings for the services not inspected to give a revised rating for the trust. We also looked at the governance and risk management support for the services we inspected.

Our key findings regarding the trust’s response to the last inspection report and current practice were as follows:

  • The trust had a clear vision, objectives, values, operating principles and improvement priorities. These had been arrived at using a bottom up process and all staff we spoke with were engaged in the strategic direction of the trust, its vision, demonstrated the values and were dedicated to achieving the best care for patients.

  • The hospital services were supported by strong governance processes’ including well managed risk registers feeding in to the board, ensuring a robust overview of the risks within the hospital. However, there was ongoing work to enhance the Board Assurance Framework and risk management in the trust, where we found areas that required improvement. Staff demonstrated their involvement in the solutions to the risks identified which had developed staff ownership of risk and solution and was enhancing achievement.

  • The trust’s ‘Harm free care’ strategy, had improved the way they dealt with and learnt from incidents. The strategy included actions such as completing rapid reviews of serious incidents, referral to a panel for discussion and sharing outcomes in senior meetings. We saw evidence of learning and change to practice from incidents and how this learning was shared across the service and trust wide.

  • The Emergency Department/Urgent Care Centre had introduced a number of quality innovations that have improved patient experience, patient care, patient safety and patient outcomes. Some of the initiatives that had been introduced included the introduction of a Mental Health Triage Tool and Observation Policy; Rapid Assessment review; Introduction of a Sepsis Nurse Lead; Creation of a Dementia friendly environment and review and development of the Paediatric Emergency Department.

  • Following the results of an audit in 2014, improvements were required to improve the care of patients with sepsis. Following the improvements, the emergency department (ED) was now the second best provider regionally for the treatment of neutropenic sepsis, with 80% of patients receiving antibiotics within the hour.

  • The hospital had consistently achieved better than the England average in respect of the 18 weeks target from referral to treatment. Surgical procedures were sometimes cancelled at short notice but systems were in place to ensure patients were rescheduled within 28 days of the cancellation.

  • Nurse staffing in ED, medical and surgical departments had improved since the last inspection. Although there was a reliance on agency staff; nurses had been recruited but they were not yet in post.

  • The trust employed an Intensive Home Care Team who provided support to the ED and facilitated early discharges of patients from hospital. Established links with local GPs who provided medical support, if required, were available.

  • Cleanliness and hygiene throughout the trust was of a high standard.

  • There was a full bereavement service available at the hospital which was well received by users although it was noted not to be as well utilised by the ethnic minority groups. Work was underway with the local religious leaders to review this.

  • Staff were caring, kind and respectful to patients and involved them in their own care. Improvements had been made in the monitoring of patients to identify if their condition was deteriorating which included revised systems for obtaining prompt medical assistance.

  • Staff were proud of the work they did; they worked well together and supported each other when the services were under pressure. The trust ranked in the top 100 places to work in the NHS in an external health journal. Staff and patients told us they felt well engaged with and their views were valued.

  • Staff explained that the last few years had been difficult but the stability of the current board and executive team contributed greatly to the culture of continuous improvement.

  • Leadership across the departments was very positive, visible and proactive. Managers had a strong focus on the needs of patients and the roles staff needed to play in delivering good care.

However,

  • The risk management strategy was last approved in August 2016 included the risk management roles, responsibilities and processes. However, it did not clearly articulate where the trust saw its risk management processes at the beginning of the strategy and where it aimed to be at the end.

  • The risk descriptions on the Board Assurance Framework (BAF) were poor, describing only the condition with no detail on the cause of the risk or consequences. As a result of this, some actions were broad with no leads or timescales. Controls, assurances and gaps in both were comprehensively described within the framework.

  • The WRES data showed that black and ethnic minority staff (BME) were employed in higher proportions in lower pay bands (1 to 4) within the trust. BME staff were highly underrepresented in senior management roles.

  • The risks associated with the use of a separate prescribing document for medicines delivered via a pump were raised with the trust at the time of the inspection. They took immediate action to address our concerns.

  • The emergency department continued to find the four hour wait target challenging. Over the winter months last year there were 1644 occasions when ambulance handovers took longer than 30 minutes. This placed the trust in the highest quarter for ambulance handover delays in England.

  • There was no designated area for patients not requiring an overnight stay, but who needed to undergo a period of observation or await test results. These areas can ‘contribute to patient safety, are highly efficient in terms of providing short term and ambulatory care, reduce admissions, and have been shown to improve crowding. Currently, staff admitted these patients to the Acute Medical Unit (AMU) which the trust had doubled in number of beds from 40 to 80 to improve flow out of the ED.

  • The audit of assessment of mental health patients in the ED (2014/15) showed there remained room for improvement particularly in the assessment and recording of a patient’s mental state which was only assessed and recorded in 30% of cases. The ED worked closely with a neighbouring trust in providing care for patients with mental health needs which was provided in a timely way 24 hours a day, seven days a week when required.

  • Medical staff recruitment in some areas remained a challenge; the ED department relied on locum staff to fill gaps, actions were being taken to develop doctors internally to reduce the need to recruit from outside the trust.

  • The results from data collected as part of national audits into the outcomes for patients with some clinical conditions showed the hospital was performing worse than the National average. Work was ongoing to improve these outcomes however this was not completed at the time of the inspection.

  • The training and development of staff was below the trust’s target for nurses within the medical services.

  • Despite the duty of candour processes being in place, there were occasions where the 10-day timescale was not met by the trust.

  • Within the root cause analysis investigations that were reviewed we observed that a one-line summary of the incident was recorded as opposed to a true root cause.

  • A number of wards fell below 80% fill rate for registered nurses. However, the wards were sufficiently staffed during the night. Staffing throughout the medical and surgical services, together with the neonatal intensive care unit services had been identified as an issue for the trust and actions had been implemented to manage the risk.

  • Within the root cause analysis investigations that were reviewed we observed that a one-line summary of the incident was recorded as opposed to a true root cause.

We saw several areas of outstanding practice including:

  • Several examples of innovation across the surgical division, including robotic surgery, theatre open days to break down barriers between community and operating theatres and the use of social media.

  • Theatres ran interactive open days where they invited selective audiences, such as young people from the local high schools and people with learning difficulties. This initiative was to help break down some of the barriers between the community and hospital theatres. It also helped patients with learning difficulties become familiar with the theatre settings to help alleviate their anxieties around having surgery.

  • A band 3 member of staff from theatres ran a painting competition for children and young people who had learning difficulties and medical conditions. The resulting art work was displayed in the patients’ waiting area. This innovation was looking at working closely with these young people and easing their anxiety about undergoing surgery.

  • Each ward and theatre area held weekly staff meetings called ‘Feedback Fridays.’ These meetings were a two way process and covered all significant governance issues pertinent for their area, including lessons learned from incidents and complaints, the risk register for their individual areas and feedback from matron and governance meetings.

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

Importantly, the trust must:

  • The trust must review the duty of candour implementation and adhere to the 10-day timescale for all incidents.

Additionally, the trust should:

  • The trust should continue to work towards reducing the time taken to investigate and close a complaint to ensure they meet the trust target.

  • Root cause analysis reviews should contain a true root cause of the incident as opposed to a one-line summary.

  • The 10-day timescale for duty of candour processes should be adhered to.

  • Fill rates for registered nurse staffing should not fall below the recommended staffing requirements. The trust should continue to prioritise the recruitment and retention of nursing staff.

  • Continue to review the Board Assurance Framework (BAF) to ensure it is more robust and fully reflects the supporting information behind each strategic risk, including action plans with timescales for completion.

  • Review the work force equality standards data for the trust and continue to implement the action plan for improvements within this area.

Address the shoulds and musts for the locations

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 30 April, 1, 2 & 6 May 2014

During a routine inspection

East Lancashire Hospitals NHS Trust was established in 2003 and is a major acute trust located in Lancashire. The trust has seven main sites that are registered with the Care Quality Commission (CQC). Acute services are provided at the Royal Blackburn and Burnley General Hospitals and it is these sites that were inspected. The community hospitals and services were not included in this inspection.

We carried out a comprehensive inspection because East Lancashire Hospitals NHS Trust had been flagged as high-risk on CQC’s Intelligent Monitoring system. The inspection took place on 30 April, and 1, 2 and 6 May 2014.

Overall, East Lancashire Hospitals NHS Trust requires improvement. We rated it as good for providing effective care and caring for patients. It requires improvement in providing safe care, being responsive to patients’ needs and being well-led.

Our key findings were as follows:

  • The majority of staff were caring and compassionate.
  • Although many staff spoke of their “devastation” when the trust was placed in special measures in 2013, they now recognised this had been the catalyst for positive change. The trust had been supported by the NHS Trust Development Authority (NHS TDA) and the Emergency Care Intensive Support team and had recently started working with Salford Royal NHS Foundation Trust. These support mechanisms were helping the trust to make the changes required and significant progress had been made against the 30 urgent recommendations set out in the Keogh Mortality Review (July 2013).
  • There was much evidence that the culture of the trust was now positive, open and honest and the leadership team was more visible and approachable.
  • Despite the change in culture and the improvements that had been made, the trust was rated as ‘requires improvement’ for being well-led. The current executive team has had impact and is driving change. However, a number of key posts, including the roles of Chief Executive and Medical Director are filled on an interim basis. The new Chair has only recently been appointed. Many of the changes had taken place in the last few months, but new ways of working had yet to embed. Although work had commenced in making improvements straight after the Keogh Mortality Review, this had only really gained focus and pace since January 2014.
  • A new governance framework had recently been introduced and the quality strategy had been revised in line with the trust vision to provide safe, personal and effective care. Clear aims were identified in the strategy. However, it was too early to measure sustained progress against these.
  • Critical care, maternity and family planning, children and young people’s services and outpatients were rated as ‘good’ across all the sites where they were delivered. Medical (including older people’s) care surgery and outpatients services were also rated as ‘good’ at Burnley General Hospital. Accident and emergency (A&E) and end of life care were rated as ‘requires improvement’ at hospital locations as well as medical (including older people’s) care and surgery at Royal Blackburn Hospital. The elective nature of work at the Burnley General Hospital had the impact of providing a calmer atmosphere with less pressure on the availability of beds.
  • The trust had undertaken much work to improve mortality rates. However, these were currently slightly above the expected range.
  • The trust had taken action to improve the management of complaints, but there was a large backlog, which current actions were not sufficiently addressing and people did not feel they were being kept appropriately updated on the management of their complaint.
  • The trust had worked hard to improve the flow of patients through the trust sites. However, there were still instances where patients were inappropriately admitted from A&E without a full assessment. The trust had been struggling to meet the national standard which required that 95% of patients waited less than four hours to be admitted, transferred or discharged from A&E. The end of year position at 31 March 2014 was below the target, although performance was improving. While the target was not consistently met, the trust had met the target for three out of the four weeks in April 2014.
  • A new strategy for end of life care had been drafted. The trust identified that bereavement support for people was limited and was addressing this; however, some relatives were finding the lack of support challenging.
  • There had been one never event in January 2014, which was still under investigation at the time of the inspection. Staff felt comfortable in raising concerns, completing the necessary documentation and stated they received feedback. However, it was noted that the trust reported less serious events than that national average.
  • Staffing levels had improved for both nursing and medical staff. Nursing staffing levels were assessed through the use of the national Safer Nursing Care Tool and minimum staffing levels had been set which were in line with the national recommendation of one nurse to eight patients. Despite a recruitment campaign, there remained vacancies; the trust had been recruiting from abroad and used bank and agency to fill the gaps. Nursing staff said the levels had improved, although there were challenges in supporting larger numbers of new and junior staff. Medical staffing was an area of continuing concern in medicine despite increases in posts. Locum staff were being used to fill the rota.
  • In both the A&E and urgent care centre, there was not always an appropriately trained nurse to care for children.
  • There was now clarity about how issues from risk registers were escalated, however, the use in some wards and services was erratic.
  • Generally medicine management across the trust was in line with polices and guidance, however, in the A&E department and one of the theatres, poor management of medicines was observed.
  • Apart from issues regarding the cleanliness and general disrepair of some mattresses and birthing mats, staff worked in line with the infection control policy. Hospital infection rates were similar to comparable-sized trusts.
  • There was reliance from staff on the use of relatives to translate for patients without clear consideration of the privacy issues this may pose.
  • Some patients who required mental health assessment or admission to a specialist service waited too long in the areas which were not resourced to meet their needs.
  • Maternity services had improved the number of normal births, reduced the caesarean section rates and increased birthing choices for women.
  • Surgery was effective but routine checking of theatre equipment lists and the ‘sign out’ process for patients postoperatively was not robust.
  • The trust was working towards providing a seven-day-a-week service but there were some concerns regarding medical cover to achieve this.
  • Patients spoke highly of the breast care service.

We saw several areas of outstanding practice including:

  • The vast majority of staff spoke of the improvement they experienced in the culture in the organisation. The spoke highly of the executive team who were visible and approachable to staff. The felt proud to work in the trust and would now recommend it as a place to work.
  • The trust’s maternity services were received a national award for their ‘innovative work to improve maternity services, promote normal births and facilitate staff activities’. This work had improved normal birth rates, reduced caesarean section rates and increased birth choice for women.

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

Importantly, the trust must:

  • Ensure that new ways of working become embedded into practice and that improvements are sustained.
  • Ensure that risk registers are used consistently, with risks escalated as appropriate.
  • Seek to fill the interim posts with permanent staff to ensure some stability at the trust.
  • Continue to improve the management of complaints and that all those with outstanding complaints are clear on the timescales and targets for completion.
  • Continue to ensure that the flow of patients is improved from attendance in A&E to admission to wards and discharge.
  • Ensure that there are always sufficient numbers of suitably qualified, skilled and experienced staff employed in A&E at all times to care for very unwell children.
  • Ensure that people with mental health needs receive prompt, effective, personalised support from appropriately trained staff to meet their needs.
  • Ensure appropriate checks of equipment are undertaken and documented in theatre.
  • Implement the end of life strategy to ensure that there is an appropriately resourced bereavement service available.
  • Take action to prevent the cancellation of outpatient clinics at short notice and ensure that clinics run to time.
  • Ensure that there are appropriate translation services available and that patients’ privacy is considered if asking relatives to act as interpreters.
  • Ensure that all staff work in line with the medicines management policy.

Please refer to the location reports for details of areas where the trust SHOULD make improvements.

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.