Our rating of the trust stayed the same. We rated it as outstanding because:
We rated safe, effective, caring, responsive and well-led as outstanding.
We did not inspect all core services. The previous rating for those services we did not inspect were taken into account when working out the overall trust ratings for this inspection.
We rated well-led for the trust overall as outstanding.
The service managed patient safety incidents very well. Staff recognised incidents and reported them appropriately and could discuss the processes involved. Senior staff and leaders were well sighted on incidents and could provide details of specific events and the action taken to mitigate risk and prevent recurrence. There were both trust wide projects and objectives that focussed on safety and local ward and department targets; both were closely monitored to enable the trust to reach their goals. Outside of Patient First methodology, there was evidence that where unexpected occurrences happened (such as a listeria infection contracted from a catering company’s sandwiches), these were reacted to swiftly and effectively. Serious incidents were responded to appropriately; the trust showed a consistent and robust approach to the reporting and investigating of incidents. Timely actions were taken to mitigate risk and learning was embedded across the organisation.
The service used safety monitoring results exceptionally well and participated in the national safety thermometer scheme. Staff collected safety information and shared it with staff, patients and visitors. The trust used information to improve the service through their strategy and quality improvement methodology, Patient First. The trust aimed to reach a 99% score on the patient safety thermometer across all sites. The current score was 98.7 % harm free care.
The trust had a hospital standardised mortality rate (HSMR) of 92. Throughout 2018/2019 they have improved on this to move from the 28th centile nationally to being in the top 20% of trusts in England, in terms of HSMR.
The service-controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection. Standards of hygiene and infection rates were monitored to identify any risks and infection rates were low.
Staff kept appropriate records of patients’ care and treatment. Multi-disciplinary, electronic records were clear, up-to-date and available to all staff providing care.
Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. Specialist teams supported ward staff and patients in vulnerable circumstances. Staff were able to provide examples of where they had acted to protect vulnerable patients. The safeguarding team worked closely to identify future risks and ensure triangulation of all aspect of the service provision to ensure safeguarding concerns reported through routes, other than as safeguarding referrals by staff, were identified and acted upon. Safeguarding of people with mental health problems was a particular strength of the trust that had been developed following an incident three years prior to this inspection. The safeguarding team also fed into the Patient First Strategic objectives with areas such as noise at night being considered from a safeguarding perspective because reduced night time noise was seen to result in a reduced need for sedation of people with dementia and a consequent reduction of complications such as falls.
The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. The trust had invested in recruitment to maintain and increase staffing levels to ensure ongoing patient safety and high-quality care. There was a strategic objective to reduce medical staff costs through the appointment of more permanent staff and the introduction of innovative support roles. Recruitment of staff was a major challenge to the trust. However, there were systems, including the use of a flexible workforce that ensured there was a match between staff on duty and patients’ needs. We did not identify any areas where staffing challenges impacted negatively on patient care. We did see that the recruitment of additional consultants to the critical care units had enabled better senior medical staff coverage of both the critical care unit and out of hours anaesthetic requirements for the rest of the hospital.
The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance through programmes of audit. Outcomes were generally very good and exceeded the national averages. There was a multidisciplinary and quality improvement approach to improving outcomes. Data was collated and broken down to ward and department level so that local staff knew their own data and could use it to benchmark their own service over time and against similar wards or departments. Ward dashboards were used to show visibly the ward or department performance over time when measured against the True North Objectives. Staff were aware of changes to best practice guidance and talked knowledgeably about recent changes to recommended best practice. The trust had committed to employing and supporting research and academic development in all professions and this was reflected in the staff engagement with published research and using evidence-based practice. One example of this was recently published research which suggested the optimal timing for repositioning people at risk of pressure damage was not two hourly turns as this increased the risk of shearing damage to skin. The trust had not changed their policy in light of this but had invested in hybrid pressure relieving mattresses and were following any changes to the recommendations closely.
The trust made sure staff were competent for their roles. There was a programme of mandatory training and staff had opportunities to develop their skills and gain experience and qualifications to help them do their jobs effectively. Staff education was a real strength of this trust and staff of all grades and disciplines were encouraged to take part in further training and gain additional qualifications. The trust offered Clinical Improvement Scholarships as part of their Clinical Academic Programme in collaboration with Health Education England. The programme aimed to support practitioners to combine their everyday clinical roles alongside development of their research, leadership and continuous improvement experience. Projects completed so far include a physiotherapist developing improved access to optimum care and follow up where women had experienced severe perineal or pelvic floor injury during birth and an occupational therapist working on a two-year collaboration within the trust to prevent the deterioration of elderly patient’s frailty scores.
Staff always had access to up-to-date, accurate and comprehensive information on patients’ care and treatment. Electronic records were used effectively and there were electronic systems to ensure patients’ conditions were monitored. The effective use of a trust wide electronic patient observation recording system with an automatic escalation process and oversight by the critical care outreach team had significantly reduced the number of in hospital cardiac arrests by identifying patients whose condition was deteriorating at an earlier stage.
A number of IT systems were in use to monitor and improve care quality including:
- A single results system for all GPs to access patient test results.
- An internal single system for results which is used by over 3,000 clinicians
- A clinical portal is being rolled out alongside other key developments such as e-Handover, self-check-in, and ‘watch list’ to improve, standardise and increase clinical effectiveness.
- Electronic patient observation, electronic prescribing and medicines administration are all well embedded
Staff cared for patients with exceptional compassion. Feedback from patients and our observations confirmed that staff treated them well and with kindness. Staff at all grades and from all disciplines, including executive staff, were able to recount specific stories where staff had gone over and above the usual expectations to meet patients’ needs and preferences. We heard numerous stories including where a member of nursing staff had been told by a very unwell elderly patient that their dog had been put into kennels and they didn’t know what would happen to it. The nurse completed their shift and then drove around all the local kennels to find the dog and persuade the owners to let them take a picture. The nurse returned, in their own time, to see the patient with a photograph of the dog that they could keep beside their bed. The patient died peacefully, knowing their dog was safe and being well cared for.
Staff involved patients and those close to them in decisions about their care and treatment. Patients said they were given sufficient information and support to make decisions about their care and treatment. The needs and preferences of patients took priority over performance data. We saw examples of where acutely unwell patients requiring high levels of care and who were not expected to live, but who wanted active treatment, were admitted to the critical care unit regardless of the impact on mortality figures. There was a strongly upheld view from all medical and nursing staff that the patients’ wishes were respected and that their needs came first in all decisions.
Staff provided emotional support to patients to minimise their distress, and patients could access a member of a multifaith chaplaincy team to discuss spiritual matters.
The trust planned and provided services in a way that met the needs of local people. They worked collaboratively with other healthcare organisations and patient groups to identify and meet local needs. The trust had an active patient experience and engagement committee which included staff, stakeholders and governors.
Generally, people could access the service when they needed it. Waiting times from referral to treatment usually met government standards and met the current commissioning targets. The arrangements to admit, treat and discharge patients were in line with good practice. The trust had a comprehensive suite of daily reports, for patient level operational review, including trend analysis.
The accident and emergency departments performed highly against the national averages. Western Sussex Hospitals accident and emergency four hour target performance was 92% in April 2019, compared to a national average of 85%
The service took account of patients’ individual needs. There were specialist teams to support those with additional needs, for example those living with dementia or those in vulnerable circumstances.
The trust board had the appropriate range of skills, knowledge and experience to perform its role. Non-executive directors were exceptionally well informed and had a sound understanding of the Patient First Strategy. They had received training in quality improvement and were able to articulate how reporting to the board was underpinned through the methodology. They knew the detail that allowed effective strategic oversight and challenge; for example, the chair was able to tell us how they had been informed about a serious incident involving a third-party catering provider and what the action had been to mitigate further risk.
The trust had a senior leadership team in place with the appropriate range of skills, knowledge and experience. The executive team were supporting another NHS trust to improve. In the relatively short time they had leadership of the other trust, there had been significant improvements without having any detrimental impact on the services at Western Sussex Hospitals NHS Trust. We noted the converse to be true; staff at Western Sussex had more opportunity to take on additional leadership responsibilities and more staff from all disciplines had increased developmental opportunities.
The organisational values were embedded, and staff could give examples of how they guided them in their work.
The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community. The trust had recently reset its strategy, mission strategic objectives and these were well understood by staff.
The trust used a systematic approach to continually improve the quality of its services and protect high standards of care by creating an environment in which excellence in clinical care flourished. The trust collected, analysed, managed and used information well to support all its activities. The trust was assured of its data quality. Performance dashboards were produced so that progress against any key performance indicators could be identified and tracked. There was appropriate oversight and challenge to the divisions through a system of senior review.
The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively. Patients were involved in production of pathways of care and other initiatives. There were arrangements for staff to register concerns or to highlight areas of exceptional practice or achievement.
There was exceedingly high ‘buy in’ from staff across the trust to the Patient First strategy and methodology. Staff felt engaged and proud to work for the trust. Results of a pulse survey in June 2018 showed that 93% of staff recommended the trust as a place to work and 97% recommended the trust as a place to be treated. The level of engagement was such that a large team of staff, including the chief executive and chief nurse, completed a climb of Ben Nevis to raise funds for improvements to facilities for patients living with dementia.
The trust was committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation. The trust had designed its quality objective to support the overall aim of becoming a learning organisation. There was a strong culture of quality improvement with staff trained in and carrying out quality improvement projects. Quality improvement using the Patient First methodology was highly visible throughout the trust and was known by all staff.
The trust remained on trajectory to deliver an underlying surplus of £2.5m at the end of the financial year. Delivery of this surplus will enable receipt of an additional £11.6m of Provider Sustainability Fund (PSF) and marginal rate rule for emergency admissions (MRET) income achieving the year-end control total of £14.1million.