Dorset County Hospital

Updated 2 November 2023

We inspected the maternity service at Dorset County Hospital as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

Dorset County Hospital provides maternity services to the population of west and north Dorset, including Dorchester, Weymouth and Portland, and Purbeck.

Maternity services include an assessment area, antenatal and postnatal ward, a co-located midwife-led birth centre, delivery suite, and 1 maternity theatre. Between June 2022 and May 2023, 1519 babies were born at the trust. The home birth rate was 5%.

We will publish a report of our overall findings when we have completed the national maternity services inspection programme.

We carried out a 48-hour announced, focused inspection of the maternity service, looking only at the safe and well-led key questions.

The overall location rating for Dorset County Hospital went down as a result of the maternity services ratings. We rated Dorset County Hospital as requires improvement.

How we carried out the inspection

We provided the service with 2 working days’ notice of our inspection.

We visited maternity assessment unit which includes a triage service, delivery suite, the antenatal and postnatal ward, maternity theatre, and general theatres to see where maternity patients would be taken in an emergency if the maternity theatre was in use.

We spoke with 13 midwives, 2 support workers, 6 women and birthing people. We received 27 responses to our give feedback on care posters which were in place during the inspection.

We reviewed 10 patient care records, 10 Observation and escalation charts and 4 medicines charts.

Following our onsite inspection, we spoke with senior leaders within the service; we also looked at a wide range of documents including standard operating procedures, guidelines, meeting minutes, risk assessments, recent reported incidents as well as audits and action plans. We then used this information to form our judgements.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Updated 16 August 2016

Overall, we rated medical care as ‘good’.

We found that medical care (including older people’s care) was good for effective, caring, responsive and well led and ‘requires improvement’ for safe.

Staff managed most aspects of medicine administration, storage, disposal and recording safely. However, we found that hard copies of Patient Group Directions (PGDs) for medicines on the satelite renal dialysis unit were out of date or not authorised. Staff had not followed trust policy for updating PGDs. Resuscitation trolleys were not tamper evident, creating a risk of incomplete equipment in an emergency.

Patients and relatives told us staff were caring and compassionate, and treated them with respect. They felt involved in their care and recommended the hospital to others based on their own experiences. Staff helped them with pain relief. Medical services sought patient views both routinely on discharge and to help improve treatment pathways. Groups of patients took part in focus groups to share their specific experiences of care.

Staff had a good understanding of how to care for vulnerable patients including those living with a learning disability or difficulty, or with dementia. They used tools to assess patients’ mental capacity and understood the procedures to follow if patients were at risk of a Deprivation of Liberty if they were restricted or restrained.

Staff said their managers provided good support and felt the hospital was a friendly place to work. They had good access to professional development and most staff had completed mandatory training and appraisals. New nursing staff said the induction had been useful, although mentors did not always have time to provide adequate support. Junior doctors were satisfied with their training opportunities.

There was high level of bed occupancy and most wards had additional beds to help manage the increased demand for medical services. There were not always enough nursing staff, medical staff and therapists to support the needs of patients. The trust had carried out a staffing audit but had not completed the review to update staffing levels.

There was a culture of collaborative working and staff said they worked well together in multidisciplinary teams to coordinate patient care. We observed effective handovers between staff, which showed they considered patient’s individual risks and needs. However, we observed a nursing handover on Day Lewis ward, which lacked respect towards patients. Staff assessed patient’s health and welfare risks and agreed plans to support their care and treatment. They monitored changes, including deterioration in health, and took necessary actions.

Patient records were clearly completed and documented patient’s risk assessments and management plans. Staff did not always keep paper records in secure trolleys, to minimise access by unauthorised persons.

The divisional leads had an agreed vision and strategy for services and a clinical governance framework. They had recognised the need to improve their management of risks, and had started to use a new approach to monitoring service risks. Staff reported incidents, and understood how to use the incident reporting system. Staff carried out root cause analysis to investigate incidents and learn from them. The service had a high proportion of harm-free care. The services took part in national and local audits to check they provided care and treatment in line with good practice guidance. They developed action plans and worked with other health and social care providers to improve care pathways. For example, project teams worked to improved discharge arrangements, cancer care pathways and stroke care.

Wards were clean and the infection control team carried out regular audits to identify any areas for improvement. At the time of our inspection, the cardiac catheter laboratory had broken down and required repair by the suppliers. Other items of equipment were maintained safely under contract and staff reported maintenance staff responded promptly when requested. The equipment library also supplied aids and equipment within the agreed timeframe.

Updated 16 August 2016

We found that the services for children were good for safe, effective, caring, responsive and well led.

There was openness and transparency about safety, and continual learning was encouraged. Staff were supported to report incidents, including near misses. Access to the children’s ward and neonatal unit was secure. Staff were clear about their responsibilities if there were concerns about a child’s safety. Safeguarding procedures were understood and followed, and staff had completed the appropriate level of training in safeguarding and other mandatory training.

The trust did not follow the Royal College of Nursing guidance on safe staffing levels for the paediatric wards. Whilst the trust did mitigate the impact of this overnight through effective rostering of competent staff, the system may not be sustainable. The unit was relatively small and not fully compliant with British Association of Perinatal Medicine (2010 Standards) requirements for a local neonatal unit as there was not a totally separate tier 1 rota, and the rota covered the children’s unit as well. However, there was no evidence of any negative impact of this arrangement. There were good levels of low and middle grade doctors and they were positive about the trust as a learning environment. The unit was also non compliant with the Royal College of Paediatric and Child Health Facing the Future: Standards for Acute General Paediatric Services (2015) as the unit did not have a consultant paediatrician available during the times of peak activity, seven days a week. Although a consultant was resident overnight

Care and treatment was planned and delivered in line with evidence-based guidance, standards and best practice. The individual needs of children and young people were assessed and care and treatment was planned to meet those needs. Care pathways and multidisciplinary records were used to support practice. Staff assessed patients’ pain effectively and obtained consent to treatment appropriately and in line with legal guidance. A paediatric early warning system was used for early detection of any deterioration in a child’s condition and an early warning system for neonates was used in the NNU.

Staff were trained and had the skills and knowledge required to undertake their role. Staff completed appropriate competence assessments. Appraisals and supervision took place and this helped staff to maintain and further develop their skills and experience. Services, including access to consultant paediatricians, were provided seven days a week.

Feedback from children, young people and parents about the care and kindness received from staff was positive. All the children and families we spoke with were happy with the care and support provided by staff. Staff worked in partnership with parents, children and young people in their care.

Inpatient services were tailored to meet the needs of individual children and young people. There were suitable facilities on wards for babies, children and young people and their families. A paediatric assessment unit, open 13 hours a day, improved patient access and flow through the hospital. There were no barriers for those making a complaint. Staff listened to the feedback given to them by parents. Play therapy staff ensured children were supported during their hospital stay.

There was a clear governance structure to manage quality and risk. There was strong visible clinical leadership that had brought about positive developments. Staff at all levels of the organisation were proud to work in this department. The unit had also involved a child inspector from social services in making improvements to the service.

There was a strategic plan for paediatric services 2016/17 and the service was part of the ongoing Dorset wide Clinical Services Review, and the acute services Vanguard project.

Updated 16 August 2016

We rated critical care at this trust as good for safe, effective, caring, and well-led care. Responsiveness of the service required improvement.

There was a strong culture of reporting, investigating and learning from incidents. Patients were protected from avoidable harm and abuse and the principles of duty of candour were well understood.

Consultants were notably present on the unit and junior doctors were well supported in developing critical care skills. Nursing staff felt well supported by doctors and there was excellent communication between doctors and nurses during handovers. Physiotherapy assessments happened within 24 hours of an admission and physiotherapists were an integral part of the care team on the unit.

The unit aimed to have a senior nurse shift coordinator who was supernumerary on at all times in line with national guidance. This was not always achieved when there was unscheduled staff absence. However, we saw that during these times there was a clear escalation process and patient safety remained the priority.

Medicines, including controlled drugs, were stored and managed safely with the exception of a small number of emergency medicines, which were located in the emergency trolleys. The emergency trolleys in non visible areas were not tamper-evident. This was corrected during the inspection, medicines were put in sealed boxes on the trolleys.

The unit was submitting on-going data to the Intensive Care National Audit Centre (ICNARC). Patients’ predicted mortality outcomes at this critical care service were in line with, or better, than similar units, with the exception of patients admitted with pneumonia whose predicted mortality was below similar units. There were consistently low rates of unit acquired infection and audits showed consistent compliance with best practice hand hygiene standards.

Treatment and care followed current evidence based guidelines with the exceptions of the critical care outreach services which was not available 24 hours a day seven days a week and did not have follow up provision for critical care patients. The trust was working towards having a 24 hour critical care outreach team.

Staff were sufficiently skilled in delivering critical care and 59% of the nursing staff held a post-registration award in critical care in line with national standards. The clinical nurse educator oversaw the education and training development of the nursing team though was frequently required to cover routine clinical work, which distracted from this. Appraisal compliance was low on the unit at 79% of the overall staff team in December 2015. However, the critical care outreach team staff had all been appraised within the last 12 months.

Equipment was clean and well maintained but the layout of the unit was not optimal for the delivery of critical care. The unit was not compliant with Department of Health’s Health Building Notes (04-02), Risk assessments had been undertaken and there was ongoing review. The unit was not secure as there was a second entrance via another ward. There was not clear signage or mechanisms to stop visitors and staff from other wards walking on and off the unit.

Patients were not routinely discharged in a timely manner and delays occurred in over 40% of all discharges. Delays led to patients staying in mixed sex and sub optimal accommodation for significant length of time. Mixed sex breaches were not being reported immediately as they occurred which was not in line with national guidance.

Patients and their relatives were involved, where possible, in decisions made about their care and treatment. Staff were sensitive when required to deliver bad news and ensured that suitably skilled and experienced staff were available to support patients and relatives at these times.

Staff were responsive and worked collaboratively to meet patients’ health needs including those unrelated to their critical illness or condition. Staff made reasonable adjustments and used tools to support patients from vulnerable groups such as individuals with a learning disability.

Updated 6 November 2018

We previously inspected diagnostic imaging jointly with outpatients so we cannot compare our new ratings directly with previous ratings.

We rated the service as good because:

• Staff had completed training which allowed them to undertake their roles safely and effectively. There were training opportunities to allow staff to expand their skills and knowledge.
• Staff took appropriate action to minimise the risk of cross infection between patients.
• Staff followed professional guidance and working practices during investigation to keep patients safe.
• Risk to patient safety due to the type of investigation being undertaken were identified and managed appropriately.
• Patients received care from staff who treated them as individuals and ensured their physical and emotional wellbeing needs were met.
• Staff felt valued and supported in their role enabling them to provide high quality care. Patient feedback confirmed this was happening.
• Innovative practice was supported and promoted by staff who took responsibility to explore options to increase the quality of patient care.

However:

• Reporting of images were not completed in a timely way and did not meet the key performance indicators agreed by the department and the trust.

Updated 6 November 2018

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

• The trust provided mandatory training in key end of life skills to all new staff at induction and at regular updates. There were enough staff with the right skills and experiences to ensure the delivery of care. Staff had access to professional development, were competent for their roles, and had opportunities for a review of their performance. Appraisal rates exceeded the trust target.
• Medical staffing levels had improved since the last inspection in March 2016.
• Equipment availability had improved since the last inspection. There was greater oversight of competence for the use of specialised equipment.
• There was good multidisciplinary working. The specialist palliative care team worked closely with the local hospice and there was access to clinical expertise within the hospital.
• Leadership of the end of life care was much improved following out last inspection in March 2016. The trust had clear statement of vision and values for end of life care.

However:

• Mandatory training rates for the end of life team did not meet the trust target.
• Staff did not always keep appropriate records of patients’ care and treatment. Records were not always clear, up-to-date and available to all staff providing care. This included documentation of mental capacity assessments and or best interest decisions.

Updated 2 November 2023

Updated 6 November 2018

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings.

We rated the service as good because:

• 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 knew how to apply it.
• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
• Systems and processes were used by staff to assess, monitor and manage risks to patients.
• In most areas the service managed infection prevention and control risks well. Staff kept themselves, equipment and the premises clean. There was a robust process for ensuring equipment was cleaned effectively and control measures were used to prevent the spread of infection at Dorset County Hospital.
• Equipment was well maintained and readily available in all the departments we visited.
• The service had enough staff to keep people safe from avoidable harm and to provide the right care and treatment.
• Medicine optimisation was safe and well managed.
• Patients records were stored securely and outpatient staff had access to the information they needed to provide care.

However:

• While there were systems for governance and risk management, these were not always effective and did not always provide adequate oversight of quality, risk and performance. There was no overarching strategy or vision for the outpatient service.
• We found some improvements and innovations in individual teams. However, there was no coordinated approach to improvement across the service. We found areas where required improvements had not been made. We could not always find evidence of learning from audit or benchmarking against other services.
• National safety standards had not been embedded across the service and we had concerns regarding infection control procedures and the suitability of premises in some areas.
• There were significant delays in the typing of clinic letters and the trust had not made sustained improvement since our last inspection. The service was not meeting the national referral to treatment times in some areas.
• The outpatients service did not meet the trust target for compliance against mandatory training and had significantly low compliance in some key modules.

Updated 16 August 2016

Surgery was rated as good because services were effective, caring, responsive and well led however some aspects of safety required improvement

We rated safe as requires improvement because:

Staff did not consistently complete the ‘Five Steps to Safer Surgery’ checklist to minimise the risk of patient harm. Patient records were not stored securely but in open trolleys, presenting a risk of breaching patient confidentiality. Mandatory training targets had variations of 50-100% compliance against the trust targets.

Staffing levels of registered nurses, particularly overnight left a poor contingency for absence. There was poor availability of therapy staff to support postoperative patients.

However, staff knew how to report incidents, and used the investigation of incidents and never events to share learning with colleagues. They were aware of their responsibilities under the Duty of Candour, adult safeguarding and used the safety thermometer data to inform patients, staff and visitors.

Patients received care and treatment based upon national guidance, standards and best practice recommendations. The surgical services were consultant led and delivered and there was good evidence of multidisciplinary team coordination to support patients. The surgical services participated in a number of national audits such as the Hip Fracture Database, where they had performed well. The trust had robust systems to monitor patient’s nutrition and fluid balance. The patients told us that their pain levels were regularly assessed and they received adequate pain relief.

Staff treated patients with kindness and showed regard to their dignity and privacy. The trust’s results of the Friends and Family Test showed a higher than average response rate. The surgical wards displayed 90-100% of people recommending the ward they had been a patient in. The patients described receiving good care, thoroughly explained and which they had been involved in any decisions relating to them.

The trust had developed services to support the needs of the patients’, the daily single point of access multidisciplinary (MDT) meeting helped to provide a coordinated approach to complex patient discharges. The one stop breast clinic provided timely and accurate diagnosis for patients awaiting breast cancer diagnosis.

The trust had taken steps to improve the Refer to Treatment targets and the majority of the surgical specialties were only just below target. Cancellation of patients’ operations was better than the England average.

Although the trust had a discharge lounge, there was no obvious drive for earlier discharges and poor usage of the discharge lounge by some of the wards caused the holding of post-operative patients in recovery, prolonging theatre lists. The lack of beds could also mean the opening up of the day case unit overnight and the admittance of orthopaedic patients into other surgical wards.

According to the surgical dashboard, surgery had failed to screen all emergency admissions over 75 years for dementia since April 2015 although of those screened 100% of patients were then appropriately assessed.

Staff were aware of the trust’s strategy and vision; there was good engagement from staff that were passionate about improving services and providing a high quality service to patients. Most staff felt the leadership of the trust and within surgical services were visible and supportive. Staff told us they felt proud of their service, the patients’ outcomes and feedback and the response rates for the NHS staff survey was higher than national average Patients were encouraged to be engaged in changes to services, i.e. patient hip and knee pathways.

Updated 6 November 2018

• Since the last inspection improvements had been made following a change in the leadership arrangements. This had benefitted the department with greater support and focus on risk management, service delivery, quality and performance. A flat leadership structure helped to foster a well-integrated team, which worked together in a mutually respective manner for the benefit of patients.
• The culture was enabling and encouraged inclusivity and participation. Staff were supported to develop and grow, and their contributions were valued.
• The staff had worked hard to address some of the areas previously identified as having the potential for improvement. This included having oversight and continuous monitoring of the environment, adherence with infection control practices and national targets.
• The emergency department had enough staff with the right qualifications, skills, experience and training to keep patients safe from avoidable harm and abuse, and to provide them with the care and treatment they needed. All staff understood their responsibilities to safeguard patients from avoidable harm, abuse and neglect.
• Staff were provided with supervision opportunities and were encouraged with professional development. Training and access to professional guidance and other experts within the multidisciplinary team helped staff to promote safe and effective treatment and care. Most people’s needs under the control of ED staff were met.
• Well-developed systems and processes were embedded in the practices of staff regarding risk assessment, and treatment and care reflected professional standards. Monitoring of performance, patient outcomes and quality of the services provided enabled staff to reflect on practice and to improve.
• There were reliable systems for reporting incidents, for investigating and learning from these. People were made aware when an error or mistake occurred in an open and transparent manner.
• The quality and standards of patient care were reported positively by people we spoke with. We observed many examples of kind and caring staff interactions, and people were given information and were involved always.
• Services were organised to provide appropriate access, treatment according to need and ease of flow thereafter. Peoples individual needs were assessed and addressed in a safe and effective manner.

However:

• Greater attention was needed for aspects of patient record completion, to ensure entries were made in a timely manner. The completion of mandatory training subjects was not always achieved, and complaints sign off did not always happen within the trusts timescale.
• Professional standards were not always met for the availability of consultant cover and paediatric nurse provision. Performance targets were not consistently met and there was work to be done around some of the results from national audits.
• Some improvements were needed to the environment to help enhance the delivery of services, this included the mental health assessment room, size of the resuscitation areas, and visibility of waiting areas.
• Apart from the patients’ complaints process, the department had not involved patients in contributions to the discussion about departmental improvements.