13 to 21 Nov 2018
During a routine inspection
Our rating of the trust stayed the same. We rated it as requires improvement because:
We rated urgent and emergency care, and surgery as requires improvement. We rated medicine, critical care, and diagnostic imaging as good.
- We had concerns about nurse and medical staffing. There were high numbers of unfilled shifts for registered nurses in some clinical areas. Staff told us they gave medications late and completed poor or infrequent documentation as a result of poor staffing. Completion of paediatric sepsis pathway documentation was poor.
- We found that some concerns highlighted following our last inspections in 2016 and 2017 had not been addressed despite us telling the trust they must make improvements. Use of the World Health Organisation (WHO) checklist was not embedded and the environment in a theatres area was not compliant with national standards related to airflow.
- There were gaps in medical cover in the emergency department and the trust was not compliant with national standards for the out of hours medical cover in the critical care unit. We had raised concerns about out of hours medical cover in 2016 and 2017.
- Risk assessments were not always completed or reviewed. Patients were not always assessed for delirium in line with best practice. Risks that threatened the delivery of safe and effective care were not always identified promptly. For example, ward staff did not consistently report the impact of suboptimal staffing levels on patient care. This had been a concern at our previous inspection.
- Staff did not always recognise, report or record incidents and not all incidents were effectively investigated. This meant opportunity for learning from incidents was missed. We were not assured systems to communicate lessons learned from serious incidents and never events to all staff were always effective
- We had concerns about the assessment and management of patients with mental health needs. Patients waited several hours in the emergency department to be assessed, and the gaps in out of hours mental health liaison meant patients who had arrived during the night were often still waiting the next morning.
- In some areas, there was poor compliance with the trust’s infection prevention and control policy; this included staff not adhering to the uniform policy and there was an inconsistent approach to labelling of clean equipment. Some environments, particularly the walls and fixtures on two surgical wards were in poor order; they required repair and could not be cleaned effectively. Equipment cleaning schedules on wards were not comprehensively completed and visibly dirty equipment was stored with visibly clean equipment and consumables.
- Processes intended to keep staff safe had not always been followed. For example, there was no evidence checks on the lead aprons in the x ray department had taken place since 2012.
- There were both paper and electronic records in use. This meant in some areas, staff recorded information on paper forms then had to transcribe that to electronic records. There were potentials for error, and it took staff extra time to do this.
- We were not assured that storage of patient records on the wards was compliant with data protection regulations; there was a risk that patient’s confidential information could be accessed inappropriately. Paper patient records were not stored securely.
- Complaint investigation and response times did not consistently meet the trust target of 40 days; on average it took 56 days to investigate and close complaints.
- Governance over policies, procedures, other documents such as patient pathways was not robust; several were past the date for review and there was limited evidence of document control.
- Several clinical and non-clinical areas were in a poor state of repair and reflected the ageing buildings.
However;
- We found all staff to be caring and responsive to patients’ needs. Staff cared for patients with compassion. There was a strong focus in all the areas we visited to put patient need first. Staff at all levels worked to do their best for patients and treat them with dignity and respect. We saw staff calmly putting patients and their families at ease during difficult situations.
- Without exception, the staff we spoke with were friendly, warm and welcoming. We saw good examples of teamwork where clinical and non-clinical staff worked together for the benefit of patients. Therapy teams and other health and social care professionals worked well alongside nursing and medical staff for the benefit of patients.
- Feedback from patients we spoke with confirmed that staff treated them well and with kindness. Patients and their relatives told us that they were involved in planning their care and that communication with staff was good. Patients told us they felt safe and well looked after.
- Staff we spoke with had a good understanding of safeguarding processes and understood their roles and responsibilities under the Mental Health Act, and the Mental Capacity Act. Most staff knew how to support patients who lacked capacity to make decisions about their care; staff knew what action they needed to take in such situations.
- Staff worked hard to provide for the needs of vulnerable groups of patients such as those living with dementia or those with learning disabilities.
- Leaders of the core services were approachable, supportive and promoted a positive culture. Most staff told us the leaders were supportive, inclusive, visible, and approachable. They told us the trust felt like a better place to work in the last five or six months prior to our inspection.
- Management of medicines had improved since our last inspection. We saw areas where pharmacy staff were present on wards to provide support to ward teams.
- When something went wrong, staff were open and honest. They had good awareness of duty of candour.
- The environments had been improved in some of the areas we visited. Most of the areas we visited were visibly clean and tidy, and free from clutter.