During a routine inspection

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.

During a routine inspection

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