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Provider: Western Sussex Hospitals NHS Foundation Trust Outstanding

We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

Inspection Summary


Overall summary & rating

Outstanding

Updated 20 April 2016

Western Sussex Hospitals NHS Foundation Trust became a foundation trust on 1 July 2013, just over four years after the organisation was created by a merger of the Royal West Sussex and Worthing and Southlands Hospitals NHS Trusts.

The trust serves a population of around 450,000 across a catchment area covering most of West Sussex. The three hospitals are situated in the local authorities of Worthing, Chichester and Adur. These areas have a higher proportion of over 65's compared to the England average. The three local authorities have a lower proportion of ethnic minority populations compared to the England average.

Adur and Worthing are in the middle 20% in England for deprivation. Chichester is in the top 40% of least deprived areas in the country.

The hospitals provide 953 inpatient beds which include 77 maternity beds and 32 critical care beds. Of these, 430 are at St Richard's Hospital. The trust employs over 5,600 staff (Whole Time Equivalent at end of August 2015). In the year 2013-14, there were more than 127,000 inpatient admissions and 533,000 outpatient attendances; over 135,000 patients attended the accident and emergency department. Its annual income is around £403 million. The trust has made a surplus every year up to 2014/15 since it was merged in 2009 and has paid back £21M of legacy debt. 

We inspected this trust as part of our comprehensive hospital inspection programme. Our inspection was carried out in two parts: the announced visit, which took place on the 9, 10, 11 December 2015 and the unannounced visit which took place on 21 December 2015.

Overall, we found that Western Sussex Hospitals NHS Foundation Trust was providing outstanding care and treatment to the community it served. We saw many examples of very good practice across all areas of the hospital. Where we identified shortcomings, the trust was aware of them and was already addressing the issues.

The trust is one of the 16 members of NHS Quest, a member convened network for Foundation Trusts who wish to focus on improving quality and safety within their organisations and across the wider NHS. The members of NHS QUEST work together, share challenges and design innovative solutions to provide the best care possible for patients. The trust was also a winner of a Dr Foster Better, Safer, Care at Weekends award.

There was a very strong governance structure and assurance framework. The Board executive and non executive directors were clear on their responsibilities and understood the hospital well. The governance was organised through four cross site divisions (medicine, surgery, women and children and core services), each had a consultant from that speciality as a Chief of Service.

Our key findings were –

The executive team provided an exemplar of good team working and leadership. They had a real grasp of how their hospital was performing and knew their strengths and areas for improvement. They were able to motivate and enthuse staff to ‘buy in’ to their vision and strategy for service development. Middle managers adopted the senior manager’s example in creating a culture of respect and enthusiasm for continuous improvement.

Innovation was encouraged and supported. We saw examples that, when raised directly with the Chief Executive and her team, had been allowed to flourish and spread across the services.

We saw respectful and warm relationships internally amongst staff teams, the wider hospital team and outwards to external stakeholders and the local community.

Across the hospital there was an embedded culture of learning from incidents. Staff were encouraged to have an open and honest attitude towards reporting mistakes and incidents that were then thoroughly investigated. There was strong evidence of learning from incidents both locally and across the organisation.

The hospitals were performing better, and sometimes much better than comparable trusts across England on many measures. Where this was not the case, the trust had clear action plans and investigations continued to bring about improvements.

An example of this was the 4 hour Emergency Department (ED) target where new and innovative approaches coupled with strong monitoring systems had resulted in the trust meeting the target over 95% of the time. They were amongst only a handful of trusts to meet the quarter four target.

In 2014/15 the trust improved their infection control ratings for the sixth successive year.

There was good management of deteriorating patients and systems in place to allow early identification and additional support when a patient’s condition became unexpectedly worse.

Monitoring by the Care Quality Commission had not identified any areas where medical care would be considered a statistical outlier when compared with other hospitals. The trust reported data for mortality indicators, the summary hospital level mortality indicator (SHMI) and hospital standardised mortality ratio (HSMR). These indicate if more patients were dying than would be expected given the characteristics of the patients treated there. The figures for the trust were as expected. Information about patients’ outcomes was monitored. The trust participated in all national audits it was eligible for. Where improvements were identified, the trust was responding and was making progress implementing its action plans in order to improve the quality of care they were providing.

Across all disciplines and in all core services we found a good knowledge and understanding of the policies and guidance relating to safeguarding vulnerable adults and children. Trust staff were involved in local initiatives, working with other key agencies to improve outcomes for babies and children from challenging or vulnerable families.

Staff of all grades and from all disciplines contacted us to tell us about their belief that the St Richard's and Worthing were very good hospitals. They talked with great pride about the services they provided and all agreed they would be happy for their family members to be treated there. They talked of their commitment to making sure they did their very best to provide optimal care for patients. They talked about initiatives to improve patient care that they had been involved in.

Specifically, all consultants from St Richard’s Hospital and the overwhelming majority from Worthing Hospital who contacted us were very positive about how the trust provided service from this site. The majority of consultants employed across the trust responded to our invitation to submit written comments or to meet with us. They told us the executive team, and medical director in particular, were supportive, encouraging of new ideas and approachable. They told us about the work that had been done to improve the mortality figures overall and in specific areas. This included the changes to the pathways for patients who suffered a fractured neck of femur where changes to the care and treatment of this condition had reduced the number of elderly patients who died as a result of this.

Medical, nursing and midwifery staffing levels were safe and allowed staff to provide good care. Staffing acuity tools were in routine use and staffing was reviewed frequently – in some areas such as ED this was done four hourly. However, there were areas where the trust did not meet the recommendations of professional bodies such as the royal colleges. This included medical staffing in the critical care unit and the number of Supervisor of Midwives. In both these cases the trust was already taking action.

Volunteers from across the hospital were also keen to tell us about how much they enjoyed working at the hospital. They told us they were supported and accepted as a part of the hospital team. Those working in clinical areas described a sense of belonging and felt their work helping people to eat and drink or occupying elderly patients was valued.

We received an unprecedented number of letters and emails from people who used the service prior to, during and after the inspection visit. The overwhelming majority of these were very positive and told stories of staff going above and beyond the expected level of care. Staff we spoke with were exceptionally compassionate when talking about patients and we observed kindness not only towards patients but towards each other whilst on site.

The results of the Friends and Family Test supported the view of the many patients who contacted us. In most areas the hospital consistently scored above the national average.

The commitment of staff to providing good care coupled with good strategic and operational planning led to a service that was responsive to the needs of individuals. We saw flexibility and a willingness to make local changes to improve how people were cared for. There were numerous initiatives that improved patient experiences and allowed them equal access to care. These included Learning Disability nurses visiting the ED, interagency joint working in the hospital and community and the Harvey’s Gang project.

The trust had introduced a ward accreditation scheme which was being rolled out.

Outstanding practice

We saw much that impressed us but of particular note was;

The positive attitude of outpatient and diagnostic imaging staff was an outstanding feature of these hospitals. The outpatient nursing staff knowledge of vulnerable adult and safeguarding children and how they should proceed if concerns arose and compliance with training in this area. The management of medical records meant that more than 99% of full records were available to staff in clinics.

The level of 'buy in' from all staff to the trust vision and value base was exceptional. We were flooded with requests from staff wanting to tell us about specific pieces of work they were doing, how much they liked working for the trust and how supportive the trust executive team were of innovative ideas and further learning as a tool for improvements in patient care. The trust ambassadors worked to promote the positive work that the trust was doing to other staff and visitors.

Multidisciplinary working was a very strong feature across the hospital that resulted in better patient care and outcomes. There was clear professional respect between all levels and disciplines of staff. We saw real warmth amongst teams and an open and trusting culture. Exceptional examples of this included how 'Harvey's Gang' was growing and developing as more staff became involved in local initiatives such as the joint working 'Five to Thrive' project and Family Nurse Partnership which improved outcomes for the children of young and vulnerable parents.

The trust had won a Dr Foster Better, Safer Care at Weekends award.

The level of feedback from patients and their families was exceptional. We received many letters and emails before, during and after the inspection visit. It was overwhelmingly and almost exclusively positive. Amongst the hundreds of people who contacted us to say how good the hospitals were we received very few who felt unhappy with the care they had received.

We were contacted by many consultants working at the hospital, from across all specialities who wanted to tell us about how good it was to work at the trust. They wanted to tell us the executive team were approachable and supportive, that their ideas were listened to and that they felt the trust provided very good care to most people.

In ED the focus on access and flow, coupled with the work being done with local stakeholders such as GP's and CCG's had resulted in a department that was mostly able to meet the key performance targets. People were seen quickly and were not kept in the department overly long.

The attention and consideration of peoples' individual needs and genuinely patient centred care was evidenced across the hospital. The work of the learning disabilities nurse specialists, the neonatal outreach nurses and the SPCT were all notable. In the critical unit the staff remained focussed on the person and not the technology, with people being pushed out of the unit in a wheelchair, if they were well enough, to help them maintain a sense of normality. Staff encouraged fathers to stay overnight on the postnatal ward to provide support to their partner and to begin the bonding process with their baby.

The trust wide learning from incidents and complaints was well embedded. In all areas of the hospital, staff could give us example of where improvements had been made as a result of complaints, comments or incidents.

The executive team provided exceptional leadership and had a very good understanding of how the hospital was working in both the longer term (through a sound assurance framework) and on a day to day basis (through a regular ward and department presence and open door sessions). There was clear team work amongst the executive team and their positive leadership style filtered down through middle managers to local managers.

The Medicines division was involved in a trust wide NHS Quest initiative which focused on improving quality and safety. This involved the trust taking part in collaborative improvement projects for sepsis and cardiac arrest. Work was in progress on these initiatives at the time of our inspection.

The ‘Knowing Me’ initiative along with the other initiatives to improve hospital experiences for people with dementia.

The involvement of a learning disabilities nurse for patients admitted who had a learning disability improved the outcome and experiences for this group of patients.

The level of staff engagement and involvement in service planning was exceptional, with the Trust Ambassadors giving a very clear message about staff ‘buy in’ and belief in the work they were doing.

The very strong governance systems allowed the trust to focus on safety and improved patient outcomes at all levels. Local managers could see how the wards and departments in their control were performing. The board involvement allowed proper assurance through involvement in governance meetings.

The trust executive had a very sound understanding of their hospitals. They did not need to look up how areas were performing as they were very aware of the areas of strengths and weaknesses.

However, we also saw things which the trust should review and take action where necessary;

The hospital should ensure all staff mandatory training is up to date.

The hospital should ensure the numbers of chemotherapy trained nursing staff on duty reflect the established number required at all times.

The hospital should ensure all staff receive an annual appraisal to ensure their continuous professional development needs are met.

The hospital should ensure there is an adequate supply of pressure relieving equipment for patients on all wards.

The hospital should ensure continuity on recording of medicines fridge temperatures on all wards, and that emergency medicines are checked in accordance with their own policy, to ensure they are always available for ready use in an emergency.

The hospital should review the levels of medical and nursing staff on each shift in critical care, in line with established national guidelines. The hospital should also consider the working practices of existing senior physicians during the pilot phase of a telemedicine model of care.

The hospital should review the security and storage of hazardous waste and chemicals on the critical care unit.

The trust should ensure grading of referrals occurs within acceptable timescales.

The trust should ensure that RTT is met in accordance with national standards.

The trust should ensure staff who work in the diagnostic imaging department and who provide care to children have the appropriate level of safeguarding training.

The trust should review the availability of supervisors of midwives.

The trust should review the resources available for emergency laparotomy to ensure it meets the recommendations of the national audit.

The trust should review how children with type 1 diabetes are managed to improve outcomes.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 20 April 2016

The trust was rated overall as good for safe provision of care. All services were rated as good for safety with the exception of critical care on both St Richard's and Worthing Hospital locations, which requires improvement.

Incident reporting systems were robust and supported by a strong no blame culture.

Equipment was largely accessible and well maintained although some shortages were reported by staff, however the management of waste, drugs and IV fluids and hazardous chemicals needs improvement.

Staffing levels were generally appropriate but consultant numbers in emergency departments and critical care were below recommended levels.

Incidents

  • The trust operates an electronic incident reporting system and we identified widespread awareness of how to use and report through the system in all staff groups.
  • Incident reporting is supported by a strong set of policies and procedures including incident process management, taking first hand accounts to evidence incidents and a supporting staff guide. We found the policies consistently applied across the trust.
  • The trust had reported 2 never events and 72 serious incidents in the period November 2014 to October 2015.  The incidents were of an even distribution across both locations and predominantly in medicine (patient falls and pressure ulcers). Our inspection identified that root cause analysis was appropriately undertaken following serious incidents.
  • The trust reports incidents at a rate below that of the national average per 100 admission. Across the trust we saw a culture of support and openness to the reporting of incidents although on one ward it was reported that staffing shortages are not reported by staff as incidents.
  • Across the trust and all core services we saw appropriate thematic review of incidents. The e system afforded the reporting staff member acknowledgement and feedback post reporting. The mechanisms for learning from incidents were well developed and embedded in routine practice. Formal meetings and a safety newsletter were all seen as effective, whilst the practice of daily huddles had been successfully embedded across all core services. Our discussions with staff during the inspection indicated a high awareness of incident learning points.
  • In some areas we saw that specific staff had been appointed to further support the incident process including a patient safety midwife and a service incident handler.
  • Mortality and morbidity was regularly assessed by all core services and we saw a double review process in place. Processes were designed to ensure cross site learning and we also saw evidence of discussion at wider network levels to further enhance learning.
  • Across the trust there was an awareness amongst staff of their responsibilities under the duty of candour regulation. In Children's services we saw a move to extend the duty of candour by reporting back to patients and carers below expected threshold levels. However, other areas within the trust indicated that medical staff training is required as some complaints letters do not explicitly address the requirements of the regulation.

Cleanliness and infection control, equipment and environment

  • The trust had an up to date infection control and prevention policy. Our report indicates a high level of compliance with personal protective equipment and hand hygiene. Hand gel and hand washing facilities were readily available for staff and visitors. However, on the critical care unit at Worthing we observed a member of staff breaching aseptic non touch protocols. Critical care at St Richard's had also sought to improve the compliance with recording antibiotic stop dates. Infection control training is up to date across the trust however the infection control and prevention team expressed some concern regarding the time afforded to junior doctors for infection control training.
  • The trust environment was largely clean and tidy. Patient Led  Assessments of the Care Environment (PLACE) audits strongly support our findings with a 100% score for cleanliness. We did however highlight in the report episodes when cleaners could not access cleaning materials at the weekend, some low level inconsistency in display of cleaning records and an incident relating to cleanliness in critical care at Worthing.
  • During our inspection we highlighted to the trust that the room designed for mental health patients within the emergency department at Worthing Hospital was not fit for purpose and created a hazard to patient and staff safety. The trust has since taken steps to address this.
  • Staff largely reported that equipment was readily available and supported their clinical function. All equipment is tracked, stored and maintained by an equipment library managed by (Electrical and Biomedical Engineering) EBME  who also hold a full asset register. We were advised by some staff that accessing electric beds and pressure cushions was an issue. The trust management was aware and had developed and implemented plans to address the situation. Prevalence rates for pressure ulcers across the trust were not remarkable.
  • The report also notes an aged resuscitaire fleet and aging scanning equipment for use within the maternity service at St Richard's Hospital. There is no bariatric lifting equipment available to the mortuary staff at St Richard's.
  • The trust estate largely afforded an appropriate environment for care. Bed spaces were consistent with guidance although the HDU at Worthing Hospital was cramped. Equipment was suitably stored in most clinical areas however we have identified the storage of equipment in corridors at St. Richards Hospital theatres and the storage of hazardous chemicals in both  critical care units as issues.
  • The site security arrangements were effective with personnel suitably trained.

Safeguarding

  • The trust had strong arrangements for the safeguarding both adults and children. For adults safeguarding there is an identified executive lead and a trust lead (who is also the designated adults safeguarding manager). The adult safeguarding team consist of a single nursing post, however the trust had identified the need for two additional nurse specialist roles including a mental capacity specialist.
  • The adult safeguarding team produces a comprehensive annual report to the trust board. The supporting governance structure has been strengthened to include  safeguarding strategy committee. The governance structure fully supports the identification and reporting of safeguarding issues.
  • The trust had a full adult safeguarding policy. During our inspection all core services reported that staff knew how to access and when to use the safeguarding policy and that staff knew who the safeguarding lead was. Staff had access to and have received appropriate levels of training although the level of training received by radiology staff could be enhanced.
  • The child safeguarding team is extensive and comprehensive including a named executive lead, trust lead, named doctor, nurse and midwife. Roles relating to sexual health and emergency department are also included.
  • The child safeguarding team also produced an annual report for the trust board that is comprehensive in content. The supporting governance structure allows for escalation, reporting and planning of safeguarding and had a clear link into the county safeguarding children board.
  • The trust had a full safeguarding children policy and core services demonstrated an understanding of how and when to access the policy. Training of staff was up to date and at an appropriate level.
  • The arrangements in maternity were particularly impressive with planned pathways and support for vulnerable women, female genital mutilation, first time mothers, teenagers and drug and alcohol dependency all in place. Staff also had access to safeguarding supervision.

Staffing

  • Across the trust wards and departments used appropriate acuity tools to plan and monitor staffing. The trust maintained surveillance of safe staffing levels. Our report indicated that staffing levels are largely maintained at appropriate levels. Women in maternity received 1:1 care when appropriate and the midwife to births ratio was strong at 1:25. Within the critical care environment patients again received the appropriate level of staff support.
  • Sickness and vacancy rates were relatively low and whenever gaps occur they were filled by bank staff and agency. Processes were in place such, as induction and checklists, to ensure the safe use of temporary staff.
  • Some areas remained a problem notably band 5 nursing in medicine and operating theatres staff. The trust took a proactive approach to recruitment and retention including the recruitment of overseas nurses. However, a number of core services commented on the lack of pace shown by internal human resource processes citing an extensive lag phase in getting staff into employment as a key cause of staffing pressures.
  • Consultant medical staffing was at a level that allowed appropriate ward rounds, on call coverage and support to junior doctors. However, in both the emergency department and critical care consultant coverage was below that recommended by respective colleges. Consultant cover in maternity was better than the national guidelines.
  • The medical staff mix was appropriate and the trust had recruited a number of resident on call consultants to ensure robust consultant support. In focus groups junior doctors were very positive about the experience of working at the trust and most core services reported junior doctors being very happy with the level of support received. However, junior doctors in orthopaedics suggested that rotas were short, handovers poor and that induction was not well managed.

Assessment of patient risk

  • Adult and paediatric risk assessment tools were in use across the trust and clearly documented inpatient records. Where required, escalation was made and the trust had developed a critical care out reach team to support deteriorating patients. Some concern was expressed about the number of referrals being made to a relative small team who also held responsibility for training ward staff in the identification of at risk patients.
  • The World Health Organisation (WHO) five steps to safer surgery checklist had been fully implemented by the trust. A programme of audit, peer review and mock inspection had been designed to support implementation and audits showed a very high rate of compliance.

Medicines

  • The trust had an up to date medicines management policy which clearly identified the role of senior trust officials in the management of the safe administration of medicines and was comprehensive in it's content.
  • Our inspection indicated that throughout the trust medicines were mostly stored in a secure manner and that storage conditions were suitably monitored. However, we did identify evidence that indicated that some medical wards were not compliant with trust guidelines for the storage of chemotherapy and intravenous solutions and that temperature monitoring of drugs fridges was not consistently completed.
  • Controlled drugs were securely stored and subject to audit.
  • There was comprehensive guidelines for the use of anticipatory medicines for those patients on an end of life pathway and National Care of The Dying Audit (NCDAH) indicated that the trust was significantly better than the national average for medicines prescribed against the five key symptoms.

Records and Information Technology

  • Our inspection indicated that record keeping across the trust was comprehensive and included risk assessment of patients. Records were kept in a secure manner and staff received training to support the maintenance of information governance. We saw evidence that records content was subject to regular audit.
  • The trust had a strategic direction for the implementation of information technology that aims to align systems across the trust locations. The trust is appointing a new director of information technology to further develop and deliver the programme of change.
  • The trust is implementing an new patient information system (ICIP). This system aims to deliver single sign in and access to other supporting systems including diagnostics. Implementation remains at a stage whereby records are held in duplicate form and staff have reported an increased workload. Staff have also said that training and support during implementation has been good.
  • The trust views innovative use of information technology as a key support to patient safety and we saw evidence to support this in the introduction of a risk and care pathway system that is accessible to clinical staff by mobile technology.
  • The trust has introduced IT to support medicines management. In addition to access to patients summary care record (to provide details of medicines management in the community) the trust has introduced an e prescribing system. Whilst this system offers a number of safety benefits some staff have expressed concern about  junior doctors not being able to access the system.
  • At the junior doctors focus group there was a general concern expressed about the number of systems that are required to be accessed during care.

Effective

Outstanding

Updated 20 April 2016

The trust was rated as outstanding for effectiveness. Services for Children and Young People and End of Life Care were both rated outstanding whilst all other core services were rated as good.

Outcomes for patients on end of life pathways considerably exceeded benchmarked standards whilst children's service outcomes were better than national averages. Hospital standardised mortality rate (HSMR) at the trust is within the top twenty percent of trusts nationally.

Across the trust we saw evidence of a full audit cycle and implementation of best practice policies and procedures.

Consent is well documented and managed and staff had a good understanding of the mental capacity act and it's implications.

Evidence based care and treatment

  • Staff had access to up to date policies, protocols and guidelines. Policies were accessible via the trust information technology and based on best practice or college guidelines. Policies were consistently applied across all sites.
  • There was strong evidence in all core services of involvement in national and local audit. Audit plans for core services were well developed, communicated within the teams and regularly monitored. We saw evidence of a number of cases of service change as a result of audit.
  • Pathways for high risk patients and conditions were well established including those for sepsis and deteriorating patents.
  • The location reports note that end of life care was of a particular high standard in terms of compliance with evidence based care, with excellent national audit results and the development of personalised plans for patients on an end of life pathway.

Pain Relief

  • The trust has a well developed pain team that acts in a proactive manner. The team is nurse led and has access to anaesthetic support.
  • The team has developed a comprehensive policies and protocols for the management of pain within the trust. Staff had ready access to these policies and were further supported by the provision of prompt cards.
  • Pain scoring tools are in use across the trust and we saw evidence of the local audit of pain relief.
  • Paediatric pain relief was well managed via a tailored pain policy and appropriate distraction techniques via play specialists were used. The paediatric chronic pain service was particularly impressive and  had achieved significant improvements to outcomes for patients.

Patient outcomes

  • All services participated in mortality and morbidity review meetings. The trust had been highly visible regarding it's aim to have excellent HSMR scores for both locations and were aware of variance between sites. At the time of our inspection the trust was not an overall outlier for in hospital mortality rate, the hospital standardised mortality rate (HSMR) or the summary hospital mortality rate (SHMI). The trust was however an outlier for gastroenterological and hepatological conditions although not at an elevated risk level.
  • Dr Foster data for the period November 2014 to October 2015 showed excellent performance for HSMR with the trust performing in the top 20% trusts in the country and both locations having HSMR scores below 91.
  • Throughout the report there is evidence of core services measuring and monitoring outcomes. We saw particularly strong outcomes in children's services where above national average results were being achieved for assessment of temperature on admission and readmission rates following asthma, epilepsy and elective surgery. In maternity services the trust was achieving excellent stillbirth rates, however elective ceaserean sections rates were above average.

    In surgery, outcome measures were largely positive, the pathway for hip fractures is noted to be different from that measured nationally. The pathway was noted to produce excellent results.

  • The end of life service was achieving exceptional outcomes. A well established rapid discharge team and tracking process has resulted in an outstanding 79% of patients dying in their preferred place of death.
  • Prior to the inspection we received information suggesting that incidents and outcomes within a department had not been fully investigated. We have discussed this with the trust and the trust has acted appropriately by obtaining positive assurance via an external review of the service.

Competent staff

  • All services had a structure that supported the maintenance of a competent workforce. Induction processes were well developed and extended to support bank, locum and agency staff.
  • We saw competency frameworks in place and these were supported by practice development nurses. The was good provision for new nurses with opportunity to work supernumerary on appointment, preceptorship and appropriate supervision.
  • Post registration and specialist  training was supported notably in critical care and maternity, however we have identified a shortfall in the number of supervisory midwives
  • Allied health professionals registration was monitored and maintained.
  • Appraisal processes are in place within the trust and have been targeted for improvement following national and local staff survey results. In some areas appraisal rates were below the trust target.
  • There was a good culture of multi disciplinary inclusion in ward rounds and safety huddle. This has been extended to include domestic staff attendance at daily huddles.

Consent and Mental Capacity Act (MCA)

  • Consent was guided by trust policy that was informed by Department of Health guidance leading to a standardised approach with appropriate provision for child consent. We saw evidence of consent audit.
  • Staff were aware and had a good understanding of mental capacity act (MCA) , Deprivation of Liberty Safeguarding (DOLS) and patient best interests decisions.

Caring

Outstanding

Updated 20 April 2016

The trust was rated as outstanding for caring.

A number of core services achieved this rating. We saw evidence of a consistent approach to compassionate care, an empathy and understanding towards patients and a supportive environment. In addition we saw numerous examples where departments and individuals had significantly exceeded expected standards for their patients.

Compassionate care

  • Prior to and during the inspection we received an unprecedented level of communication with the inspection team from patients carers and the public. The feedback was overwhelmingly positive with numerous examples cited of not only excellent care but a supportive, caring and compassionate approach to patients. This feedback was spread across all core services.
  • Our observations during the inspection supported much of the feedback we received. Notably on critical care units were we saw a high level of awareness of patient and carer anxiety and staff actively supporting and addressing this. This included staff supporting longer term patients by providing risk assessed wheelchair access to areas of comfort such as the chapel.
  • An ethos of compassionate care extended beyond clinical staff and this was typified by the approach of the critical care ward administrator at Worthing whose caring approach to both patients and staff did much maintain this high standard of care.
  • The trust had introduced sit and see audits whereby staff observed and provided feedback on care provided by colleagues.
  • Compassionate communication was regularly observed during the inspection including the use of lip reading, maintenance of communication with sedated patients and child appropriate communication techniques.

Understanding and involvement of patients

  • Across all services feedback from patients and carers indicated that they felt fully informed and involved in the planning of care. We saw staff ensuring that their was time for patients to ask questions. In both surgery and critical care this included patient access to support post discharge.
  • The Friends and Family Test provided strong supporting evidence although in a number of areas response rates were low. In addition to this local patient surveys were undertaken and we saw an impressive analysis of feedback comments in surgery.
  • Arrangements for adolescents in transition from paediatric services to adult services had been extensively considered and designed accordingly. The trust has developed the 'Ready Steady Go' programme to support this transition.
  • For patients on an end of life care pathway facilities for close family to stay overnight were made available. The needs of patients and carers from protected characteristics had been considered and provided for.

Emotional support

  • Patients and carers had access to psychological support in the form of chaplaincy and bereavement services. For children's services mental health and play specialist support was available.
  • Members of the end of life care team received monthly psychology supervision as part of there development framework.

Responsive

Requires improvement

Updated 20 April 2016

The trust is rated as requires improvement for responsiveness. Surgery, Critical Care and Outpatients are all rated as requiring improvement.

Our report indicates some excellent practice in the design of services for patient needs notably in children's services and also the accessibility of end of life care.

However, flow of patients through critical care and the waiting times for treatment in surgery and outpatients all require improvement.

Service planning and delivery to meet the needs of local people

  • The trust holds a strong working relationship with it's commissioners. Planning has included joint strategic needs assessment and a detailed assessment of the population served. In addition key trust staff hold leadership roles in the multiagency development of strategic and service plans across the health economy.
  • The development of Southlands Hospital was suitably planned in conjunction with a review of inpatient bed configuration.
  • We saw evidence of service planning based on patient pathways within core services. Of particular note was the planning and introduction of the frail elderly pathway.
  • Historically, the trust's two main locations have sought support for the provision of cancer services from different tertiary centres. Whilst the trust continues to plan to ensure that patients receive the most appropriate onward referral our report indicates that some patients have to travel considerable distances for diagnostics.

Meeting individual needs

  • The trust had a well developed a strategy for the supportive care of patients living with dementia that was exceptionally well embedded within the delivery of service. Our report indicates areas where the needs of this cohort of patients were particularly well understood and the use of indicators to both identify patients and reduce the likelihood of unsettling bed moves was well established. In addition we saw both the use of tailored communications techniques and reminiscence boxes to provide further support and stimulation.
  • The trust employed a lead nurse for learning disabilities. The practical applications implemented to support such patients were widespread across the trust and our report identifies the use of patient passports and easy read communication tools that in addition to aiding the care process afforded opportunity and access to information relating to the overall patient experience.
  • Children's services were well designed to provide for the needs of all age groups. Appropriate environment and support was afforded to teenagers and those transitioning to adult services. The trust initiative 'Harvey's Gang' which provides support to children being treated for cancer at the trust is both unique and exemplary.
  • The trust managed a volunteer workforce that included seventy chaplaincy volunteers who provided support to patients on an end of life pathway, particularly those unable to attend the trust chapels. Facilities and support for people of all faith were considered and links with attendance by the local Imam. Our report indicates that pre-prayer washing facilities available to Muslim people could be improved.

Access and flow

  • The access indicators for patients on an end of life pathway were outstanding. 95% of referred patients were seen within 48 hours, 98% had a clear documented discussion recognising the end of life pathway and 70% received a chaplaincy review. This in addition to the 79% of patients dying at their preferred place of death produces a remarkable level of performance.
  • The emergency departments and the emergency floor bed capacity have been very well designed to facilitate the rapid movement of patients to the most appropriate clinical environment. Trust performance against the 4 hour access target is in the top 20 trusts nationally and has been robust in it's attainment. Indicators for total time within the emergency department and ambulance handover are again of the highest order.
  • Flow from critical care was however problematic. Our report includes evidence of patients being maintained in recovery post operatively due to lack of critical care bed capacity. In addition a high percentage (29%) of patients wait longer than 24 hours to be discharged from critical care and 10% of patients are discharged at night.
  • The trust was not meeting the national referral  to treatment targets. At the time of inspection only 85% of admitted and non-admitted patients met the target whilst only 88% on an incomplete pathway met the target, a picture consistent with the preceding six months. In addition an increasing number of surgical patients had been waiting extended times for outpatient and inpatient care. The trust is currently reporting on a recovery plan to another regulator, however this plan is behind schedule.
  • In outpatients departments we have reported high levels of patients appointments being cancelled (14%) by the hospital of which a further group (4%) were cancelled at short notice. Clinics were also being set up at short notice to address patient waiting lists but were affording little notice time for patients.

Learning from incidents

  • Across all core services we saw complaints being responded to in a timely manner with responses letters of appropriate tone and content. We saw a number of mechanisms in which learning is shared ranging form the daily huddle through to formal feedback meetings. Our report also provides evidence where the trust has changed practice following complaints.

Well-led

Outstanding

Updated 20 April 2016

The trust is rated as outstanding for well led.

In addition to individual services achieving outstanding ratings for being well led the trust overall has achieved an exceptionally high level of consistency and standardisation of governance and management processes across all sites. This, associated with excellent clinical involvement in leadership, was driving a high performance culture and ensured clear and robust connection from ward to board.

The board is highly focussed on patient safety and experience and this was the basis of the clear strategy that the trust has developed in conjunction with its workforce and stakeholders. The strategy and patient safety focus was recognised across the workforce and this is reflected in services that are exceptionally well designed to meet the needs of patients. 

There was a sense of pride within the workforce and engagement in improvement and strategy was strong and this was reflected in excellent interactions between staff and patients and between staff themselves. The culture of the organisation was very open and transparent. Staff felt valued and the trust had implemented methods to ensure that high performance is recognised and celebrated.

Innovation and improvement programmes were highly encouraged and evident across the trust. Improvement programmes addressed patient safety issues and as well as efficiency issues and the number of highly innovative approaches to improving the patient experience was notable.

Both the chair and chief executive had extensive experience and provided highly focussed and credible leadership. The staff viewed the leadership of the trust as visible and accessible.

Vision and strategy

  • The trust has a comprehensive five year strategic plan that is active until 2019. The plan has been developed in conjunction with stakeholders and identifies the key vision of  Patient First  and values of 'We care'. The vision extends into patient care, quality, safety, local people, teamwork, service improvement and sustainability.
  • The plan clearly identifies the key strategic options for divisions and each service line whilst providing an overall strategic framework for delivery. Staff at divisional level had been engaged in the development of strategy and divisional and service line plans aligned with the overall strategy.
  • During our inspection we discussed the trust vision with staff who largely indicated a strong connection and recognition with 'Patient First' and 'We care' . Teams in core services were largely aware of local strategy and felt engaged in it's development and delivery.
  • The delivery of strategic change will undoubtedly require levels of service re-configuration. In one area where this has been initiated we identified a team that had become disenfranchised with change. The trust had recognised this and has initiated a supportive development program for the service.

Governance, risk management and quality measurement

  • The trust has a well established governance structure.  This structure is appropriately constructed to support the provision of assurance to the trust board. Sub board committees cover suitable areas and are led by non-executive directors. Our review of recent board papers indicated comprehensive content.
  • The trust board receives sub board reports at an appropriate regularity. Risk, quality and performance data is presented in a form that allows for differentiation between locations.
  • Each division was led by a clinical chief of service and director of operations with accountability for integrated performance to the chief operating officer. Integrated performance meetings are held monthly and led by the chief operating officer. Each division reviewed a comprehensive balanced scorecard.
  • Risk management processes were well established within the divisions. On all core services we saw local risk registers and an awareness of how risk should be documented. Processes for escalation of risk were clear and we saw evidence of core service action plans.
  • The governance framework across locations was standardised extending from daily departmental level 'safety huddles' through to formalised meetings that subsequently informed divisional and  board reports.

Leadership of the trust

  • The trust chair has been in post for five years and has appropriate experience and a clear understanding of the role. The team dynamic is well understood and there is a board development programme in place. The chair is supported by five non executive directors all of appropriate experience. Non executive directors hold a portfolio of sub board committees. The non executive directors expressed a strong sense of confidence in the executive team.
  • The trust has a stable executive team with highly experienced chief executive and chief operating officer. Recently appointed directors of nursing and finance have refreshed the executive team. There is a strong sense of both purpose and team collective responsibility in the executive team.
  • There is a clear sense of clinical leadership from the medical director and engagement of clinicians in the development of clinical strategy. The medical director attends and updates the medical staff council on a regular basis.
  • Our contact with staff within the core services indicated that the trust leadership was open, accessible and visible within the organisation. Staff views of divisional level management were almost extensively the same, however one area reported that the approach to change management in its service had been driven by a style that lacked due consultation and consideration.
  • The trust governors enthusiastically endorsed the patient first strategy and believe that the board has a passion for patient safety. Governors have attended governance training and have a planned programme of further training. A full understanding of holding non-executive directors to account is developing and governors believed that non-executives are operating effectively.
  • The trust board lacked diversity in its composition. Likewise the governors focus group indicated that both the engagement and diversity of governors could be enhanced to be more reflective of the workforce.

Culture within the trust

  • Throughout the core services there is an exceptionally high sense of team work with a strong sense of pride. Staff report the culture of the organisation to be supportive and inclusive of all grades of staff.
  • The patient safety focus of the trust strategy had integral to staff behaviour and was indicated by the widespread and consistent use of safety huddles.
  • We held focus groups for staff of all grades across the trust and staff reported a no blame culture and gave no indication of any level of bullying and harassment. They also indicated an openness in reporting and managing incidents within the trust. Staff largely considered there to be ample opportunity for development and training and that their value was recognised.The trust has relatively low figures for both sickness and turnover.
  • Prior to our inspection we received information indicating that there was a corporate culture of bullying and that as a result incidents were not being reported or addressed and there was a high turnover of consultant staff. Following this we held extensive interviews with consultant staff  and we reviewed the trust processes for consultant appointments. We could find no corroborating evidence of a trust wide bullying culture following our interviews with staff across all the core services.
  • Focus groups for staff from BME backgrounds largely supported the view the trust was a good place to work. They did not provide indication that discrimination was tolerated from other staff or from patients. The 2015 staff survey did however indicate that BME staff were 6.3 % more likely to experience discrimination and the focus groups indicated that cultural assumptions are made by colleagues and managers.
  • The workforce race equality scheme report identifies that within the trust there is a low number of BME staff holding non medical posts above band 8 and also that the likelihood of being shortlisted for a post is lower for BME applicants. The focus groups provided supportive information in that BME staff do feel that they are less likely to be promoted and that non BME staff of less experience gain promotion. In addition it was indicated that job opportunities are not universally communicated. Staff feel there is little direct encouragement to apply for the trust leadership programme. 2015 staff survey data indicated that whilst BME staff are less likely to believe that the trust provides equal opportunities the differential between responses from white and BME staff is significantly smaller than the national average and has improved since 2014.
  • BME staff reported that the breaking though programme, although initially good, had lost impetus. In addition the transition by the trust from a BME forum to a Celebrating Cultures group had not been fully recognised and it's initiation had lacked consultation.
  • The trust has an equality and diversity policy. Equality and diversity training is well attended (77%) and the trust issues a quarterly Equality and Diversity Newsletter. A Diversity Matters Group is a sub board committee that is chaired by the chief executive.

Staff and public engagement

  • The trust maintains communication with the organisation via emails and a number of newsletters. Staff reported that communication within the trust was largely very good and that they felt informed.
  • Long service and excellence are celebrated by the organisation at an annual staff awards ceremony.
  • The trust holds staff conferences to support and develop the Patient First strategy of the trust. Staff evaluation of the conference indicated a high level of satisfaction with content.
  • The trust has initiated a Clinical Leaders Programme and has comprehensively evaluated the course. The overall views of attendants was exceptionally positive.
  • The trust has a 'trust ambassadors scheme' which is  a voluntary group who promote and communicate good practice. The ambassadors we interviewed were highly motivated and keen advocates for patients and role models for the trust values.
  • The consultant focus groups and our interactions during the inspection provided indication of a very engaged clinical workforce. The trust has measured and reviewed consultant engagement at board meetings using an independent verification process. This was reported in an annual report alongside revalidation and appraisal data.
  • The trust has a well designed website that signposts services and provides service information. It also provided detail on becoming a trust member.
  • The trust has held open stakeholder forums and open public forums in addition to a public annual general meeting.

Innovation and sustainability

  • The trust is a member of NHS QUEST a group of sixteen foundation trust hospitals who work collaboratively to achieve excellence in quality.
  • The trust has a well developed programme management office and a comprehensive approach to the development of improvement plans across the trust. The programme is jointly led by the chief operating officer and director of finance. All schemes are equality and quality impact assessed.
  • Across all core services there was a culture of improvement and innovation and we have reported numerous examples of projects and initiatives that have contributed to service improvement.