Bradford Royal Infirmary

Our rating of the hospital stayed the same. We rated it as requires improvement because:

• We rated effective and well led as requires improvement. We rated safe, caring, and responsive as good.
• At this inspection we inspected four of the core services. We rated three of the services as good, and one as requires improvement. In rating the trust, we took into account the current ratings of the other services not inspected this time.

Are services safe?

Our rating of safe improved. We rated it as good because;

• Services provided mandatory training in key skills to all staff and made sure most staff completed it. Compliance with mandatory training had improved since our previous inspection.
• Staff understood how to protect patients from abuse and services generally 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. Safeguarding training levels had improved since the previous inspection.
• In children and young people’s services, there were enough nursing staff with the right qualifications, skills, training and experience to keep children, young people and their families safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank and agency staff a full induction.
• In maternity the service had enough staff with the right qualifications, skills, training and experience to keep women and babies safe from avoidable harm and to provide the right care and treatment. Caseloads among community midwives were within national guidelines and modified to account for the complexity of cases.
• Services managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned teams. When things went wrong, staff apologised and gave patients and their families honest information and suitable support. Managers ensured that actions from patient safety alerts were implemented and monitored.
• Staff completed and updated risk assessments for patients and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration. The trust had appointed a sepsis nurse in October 2018 who had rolled out a series of improvements. This included staff training, developing standard protocols and the establishment of a deteriorating patient group.
• Managers ensured that actions from patient safety alerts were monitored and implemented. Services used monitoring results well to improve safety. Staff collected safety information and shared it with staff, patients and visitors.
• Services used systems and processes to safely prescribe, administer, record and store medicines. staff followed current national practice to administer and check patients had the correct medicines. The prescribing of oxygen had improved since our last inspection.
• Most records were clear, up-to-date, stored securely and easily available to all staff providing care. Services used an electronic record system and all staff received full training on use of the system including bank and agency staff.
• The design, maintenance and use of facilities, premises and equipment mostly kept people safe.

However:

• Some services did not always manage infection prevention and control well. Ventilation equipment in maternity theatres did not adhere to national guidance, the service did not monitor or control infection risks in theatres consistently well. Compliance with infection prevention and control training in medicine for the period April 2018 to March 2019, was 74.3% for nursing staff and 70.8% for medical staff at this hospital. This did not meet the trust target of 85%. Infection rates on the neonatal unit had increased over the last two years. In the outpatients department we had concerns about the traceability of nasal endoscopes. Audit data indicated 65% compliance with completion of daily cleaning checklists and we saw some apparent gaps in cleaning records.
• The percentage of women who received one to one care in labour was poor. From November 2018 to October 2019 an average of 70% of women in established labour received one-to-one care. This varied from 57.2% to 82.5% over the period. This had been a concern at our last inspection.
• There were not always enough nursing staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment in medicine. Nurse staffing on the neonatal unit was not meeting national standards. Only 48.6% of shifts from September 2018 to October 2019 were compliant with national standards.
• Consultant cover on the neonatal unit was not meeting national standards. Paediatric consultant presence on the children’s unit was not in line with national standards and not all patients were seen by a consultant within 14 hours of admission.
• Records in maternity were not always complete. Updated risk assessments for each woman had not been completed. A records audit had not been completed in the 12 months prior to our inspection. Paper records on the neonatal unit were not stored securely. There was no formal system in place to ensure security of prescription pads in outpatients. Not all staff in maternity participated in the World Health Organisation safer surgery checklist.

Are services effective?

Our rating of effective stayed the same. We rated it as requires improvement because:

• Maternity services and medicine were rated as requires improvement for effective.
• Performance in national audits did not always demonstrate good outcomes for patients. The results of the 2018/19 chronic obstructive pulmonary disease audit showed that five out of the six metrics were worse than the national average and did not meet the national standard.
• Performance in the lung cancer audit for 2018 did not meet the national standard in three out of the five metrics but were better than the national and regional average. However, compared to the 2016 audit results, performance had decreased in four out of the five metrics.
• Stroke nurse responders were covering for vacancies and sickness on the stroke ward and were not able to leave the ward respond to a patient arriving at the hospital with an acute stroke. This contributed to a downgraded rating from B to C in the April to June 2019 national audit programme.
• There were higher than expected risk of readmissions in medicine. From February 2018 to January 2019, patients at Bradford Royal Infirmary had a higher than expected risk of readmission for elective admissions and for non-elective admissions when compared to the England average.
• The endoscopy unit had failed to achieve the Joint Advisory Group (JAG) for endoscopy accreditation in March 2018. There were concerns with patient flow and staff competencies.
• In maternity services there had not been enough oversight of or concerted efforts to improve the stillbirth rate in the 12 months prior to our inspection; the annual total stillbirth rate was more than double the regional average. This had been a concern at our previous inspection.
• In maternity we were not assured that managers always checked to make sure staff followed guidance, as some key audits had not been appropriately monitored or completed. The April 2019 to March 2020 maternity audit plan showed several audits were behind schedule, or their status was not determined.
• The maternity service did not always provide care and treatment based on national guidance and evidence-based practice; we saw some guidance was not fully implemented or was contradictory.
• Maternity staff did not always use the findings to make improvements and achieve good outcomes. For example, we found only one of 12 local actions from a key national audit had been implemented.
• There was no designated smoking cessation lead midwife in post, due to withdrawal of external funding; and an opt out referral to local authority smoking cessation services had a low success rate.

However:

• Services overall provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance.
• The policies and guidelines we checked were within their review date. This was an improvement from the last inspection.
• In children and young people’s services, staff monitored the effectiveness of care and treatment. They used the findings to make improvements and generally achieved good outcomes for children and young people.
• Staff assessed patients to see if they were in pain and gave pain relief in a timely way. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain.
• Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. Services made adjustments for religious, cultural and other needs.
• Services made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and development. Staff were experienced, qualified and had the right skills and knowledge to meet the needs of patients.
• Doctors, nurses, therapists and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care.
• Staff gave patients practical support and advice to lead healthier lives.
• Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. They knew how to support people who lacked capacity to make their own decisions or were experiencing mental ill health. They used measures that limit patients' liberty appropriately. Compliance rates for Mental Capacity Act (MCA) and deprivation of liberty safeguards (DoLS) training were above the trust target.

Are services caring?

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

• We rated caring good in medicine, maternity, children and young people’s services and outpatients.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. There was a family centred approach in children and young people services.
• Staff provided emotional support to patients, families and carers to minimise their distress. They understood patient's personal, cultural and religious needs. Staff took time to interact with patients and those close to them in a respectful and considerate way.
• Staff supported patients’ families and carers to understand the patient’s condition so that informed decisions about care and treatment could be made.
• All staff members displayed understanding and a non-judgemental attitude towards (or when talking about) patients who had a mental health problem or a learning disability.

Are services responsive?

Our rating of responsive improved. We rated it as good because:

• We rated responsive good in medicine, children and young people’s services and outpatients. Responsive was rated requires improvement in maternity.
• Services planned and provided care in a way that met the needs of local people and the communities. Services also worked with others in the wider system and local organisations to plan and coordinate care with other services and providers.
• People could mostly access services when they needed them and received the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were in line with national standards
• Services were inclusive and took account of patients, families and carers needs individual needs and preferences. Staff made reasonable adjustments to help patients access services.
• It was easy for people to give feedback and raise concerns about care received. Staff treated concerns and complaints seriously, investigated them and shared lessons learned. The service included patients in the investigation of their complaint.
• Since our last inspection of the service, maternity had implemented an eight-bed induction of labour suite and had extended maternity assessment centre opening hours to offer 24-hour provision.

However:

• Women could not always access maternity service when they needed it and receive the right care promptly. There had been 23 maternity unit closures over a one-year period; varying from approximately four hours to two days in duration. The birth centre had closed a further nine times. We saw women were routinely diverted to deliver at other trusts due to unit acuity and staffing.
• There had been numerous delays to the induction of labour service. In October 2019, we saw four women had given birth in areas of the service not intended for deliveries; such as the maternity assessment centre and induction of labour suite.
• The proportion of initial antenatal bookings undertaken before 13 weeks was below trust target.
• There were long waiting times for children waiting for autism assessments and waiting times from referral to treatment were not always in line with national standards. However, plans were in place to address these.
• Outpatient services were not always available seven days a week or during the evening.

Are services well-led?

Our rating of well-led stayed the same. We rated it as good because;

• Overall, leaders were visible and approachable for patients and staff. Leaders had the skills and abilities to run services. They understood and managed the priorities and issues in their areas. They supported staff to develop their skills and take on more senior roles. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care.
• Services had a vision for what they wanted to achieve and were developing strategies to turn it into action. These visions and strategies were focused on sustainability of services and aligned to local plans within the wider health economy.
• There was an open culture where patients, their families and staff could raise concerns without fear. Services promoted equality and diversity in daily work.
• Leaders operated effective governance processes. We saw senior leaders had recently implemented new roles to strengthen governance structures within the divisions. Staff were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of their service.
• Leaders and teams used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact. They had plans to cope with unexpected events.
• We saw that services collected reliable data and analysed it. Staff could find the data they needed, in accessible formats to understand performance, make decisions and improvements. The information systems were integrated and secure. Data or notifications were consistently submitted to external organisations as required.
• Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients.
• We found staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them. Leaders encouraged innovation and participation in research.

However:

• In maternity, we were not assured all levels of governance and management always functioned effectively and interacted with each other appropriately. Leaders did not always manage, prioritise or robustly monitor key issues the service faced. For example, with respect to identifying and acting on the stillbirth rate or monitoring incident reports of obstetric theatre use. Levels of one-to-one care in labour had not improved on average over the course of at least the last two to three years.
• Maternity services did not always collect reliable data and analyse it. We were not assured data was always available to understand performance, make decisions and improvements; key maternity service audits had not been completed or appropriately monitored.
• Maternity leaders and teams did not always robustly monitor and escalate relevant risks and issues and identify and implement actions to reduce their impact. There was limited evidence of leaders using the results of internal and national audits to improve key outcomes.
• Maternity services did not have a vision agreed for what it wanted to achieve. A strategic vision was being developed though and a women’s services action plan was in place; however, some key business risks such as replacement of the obstetric theatres were omitted.