Archived: Poole Hospital

Poole Hospital is the hospital provided by Poole Hospital NHS Foundation Trust. The trust gained foundation status in 2007 and provides services to a local population of around 500,000 people, although this figure rises significantly between May and September each year, as Dorset is a popular holiday destination.

Poole Hospital has approximately 638 inpatient beds. The hospital provides the following services: urgent and emergency care, medical and older people’s care, surgery, critical care, maternity and gynaecology care, care of the young person, end of life care, and outpatient and diagnostic services. We inspected each of these eight core services at the hospital.

Poole Hospital is the trauma unit for East Dorset and the designated Cancer Centre for Dorset, providing medical and oncology services for the whole of the county, serving an approximate population of 750,000.

The Trust has an unusual case-mix, undertaking a very high proportion of non-elective work, with only 15 acute trusts across the country delivering a higher percentage of non-elective activity. Given the distribution of acute services within east Dorset, the Trust does not provide the usual range of elective services, with orthopaedics, urology, ophthalmology and interventional cardiology being largely provided by the neighbouring trust in Bournemouth.

We inspected this hospital as part of our planned, comprehensive inspection programme. We carried out an announced inspection visit to the hospital from 26-28 January 2016, and additional unannounced inspection visits from 8 -10 February 2016. The inspection team included a Chair, a CQC Head of Hospital Inspection, managers, inspectors, planners and analysts. Doctors, nurses, allied healthcare professionals, senior NHS managers and an ‘expert by experience’ were also part of the team.

We inspected the following core services at Poole Hospital: Urgent and emergency care, medical care, surgery, critical care, maternity and gynaecology, children and young people, end of life care, outpatient and diagnostic services.

Overall, we rated this trust as ‘requires improvement’. We rated it ‘good’ for providing effective, caring and well-led services and ‘requires improvement’ for safe and responsive services.

Our key findings were as follows:

Are services safe?

• Staff were encouraged to report incidents. The Trust overall had a culture of safety where incidents were mainly appropriately reported and followed up. Learning was shared and changes made as a result of this to improve the safety of services. However, clinical safety incidents were not consistently reported in the maternity service where midwives told us that they were not always able  to report incidents due to staffing pressures. The children and young person’s service had also not always ensured learning from incidents was embedded in practice.
• The rate of NRLS reported incidents per 100 admissions is 45% higher than the England average: 12.2 per 100 admissions, against an England average of 8.4 per 100 admissions. There was one never event reported in the trust and 88 serious incidents between August 2014 and July 2015.
• Patients arriving to the emergency department by ambulance were assessed and treated within national standard times. The trust time to treatment had been better than the England average since October 2013.
• Staff carried out risk assessments and management plans for patients in a timely way although this was not entirely robust within the care of the elderly wards. Some patient risk assessments and fluid charts on these wards were incomplete.
• The early warning score system needed to be used more reliably for the escalation of patients whose condition might deteriorate.
• In some operating theatres, staff did not follow the five steps for surgical safety reliably or accurately in order to minimise the risks to patients.
• The NHS safety thermometer is a monthly snap shot of the prevalence of avoidable harms, in particular new pressure ulcers, catheter-related urinary tract infections, venous thromboembolism (VTE) and falls. At the trust, from July to September 2015, 97% of care was harm free.
• Medicines were not consistently managed in some areas across the hospital. Medicines were not always kept safe at the correct temperature, or stored securely in line with current legislation, in the ED, critical care and surgery departments.

• Staff generally adhered to infection control procedures, but systems and processes for monitoring infection control standards in some services were not always reliable or appropriate to keep people safe. Premises and equipment were not always kept clean and cleaning was not always done in line with current legislation and guidance. Most wards and clinical areas were clean. However, areas in the delivery suite and ANDA were visibly dirty.
• In the Emergency Department, patients were sometimes at risk of harm as they did not always receive name-bands within an appropriate time; this meant they could have had the wrong treatment or care if they were unable to tell staff their name.
• Equipment was checked and stored appropriately in most clinical areas. However some of the equipment remained unchecked and unsuitable for immediate use in a post maternity clinic. Within the theatre complex, there was an insufficiently robust system for calling for emergency assistance. There were sufficient amounts of specialist equipment on, for example, the stroke unit, where adaptive cutlery and crockery was used.
• Staff understood their safeguarding responsibilities towards vulnerable adults and children, but in the ED, there was low take up of training for reception staff.
• Mandatory training compliance was sometimes below the trust target, and this was often as a result of staffing levels, as staff could not always be released to attend.
• There were not consistent numbers of staff in terms of staffing levels and skill mix as planned by the trust on medical and older people’s wards and in paediatrics. The Trust had tried to mitigate this risk by having on-going nurse recruitment which was successful in some areas. Midwives said they were regularly short-staffed and were not able to consistently provide one to one care to women during labour.
• Medical staffing levels were mainly appropriate. There were areas where further recruitment was necessary.
• In diagnostic imaging, staffing was a concern. There were five radiographer vacancies (25% of the workforce) affecting MR and CT scanning. Staff reported heavy workloads and concerns with the demands on the on-call rotas.
• Senior clinical staff were aware of the Duty of Candour regulation and the importance of being open and transparent with patients and families.

Are services effective?

• The treatment and care provided in most services took account of current evidence-based guidelines. However, although evidence-based guidelines for the care and treatment of sepsis patients in the emergency department were followed, although some records had important pre-sepsis checks omitted.
• Services participated in national and local audits. There was appropriate monitoring of performance against national targets although this needed to improve medical services and for end of life care.
• Pain relief was given in a timely manner. Pain scores were used as part of the normal observations to record patients’ pain and to ensure that medicines for pain were effective. However, the use of pain tools designed for children were not being used within ED.
• Patients nutrition and hydration needs were met appropriately. Patients who required intravenous fluids had these prescribed, administered and recorded appropriately.
• Patients received drinks and food in a timely manner. There were protected mealtimes and staff to support patients who required extra help.
• Care and treatment for people following a stroke was below the national average and the trust had been slow to implement improvements.
• Patients were cared for by a multi-disciplinary teams working in a co-ordinated way. Staff reported good working relationships and clear lines of clinical responsibility with specialist teams who were called to review patients.
• Many services had developed across seven days a week. However, there were reported delays for patients who required mental health assessment out of hours and over the weekends: these services were supplied by a local mental health trust. Stroke inpatients also received significantly less physiotherapy than patients’ nationally.
• Many staff had access to specific training to ensure they were able to meet the needs of the patients they delivered care to and there were educational opportunities available for all grades of medical and nursing staff.
• Staff had clinical supervision and appraisal, although appraisal rates for medical staff in the Emergency department were low.
• Staff had immediate access to patient information. There were robust systems and processes to ensure that information was kept secure, but was available to all clinical staff that needed access to them.
• Most staff followed consent procedures and had overall good understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards which ensures that decisions are made in patients’ best interests.

Are services caring?

• All staff made a concerted and sustained effort to ensure that patients, carers and relatives were treated with kindness and support. We observed that staff were consistently kind and compassionate, putting the patient at the centre of care. Receptionists at the front door made a concerted effort to put any visitors or patients at ease, and this level of high support and regard continued throughout the hospital. Staff told us they were encouraged, no matter how busy, to stop to take time to help or reassure anyone in the hospital and this sometimes involved escorting people to unfamiliar areas, rather than just telling them how to get there.
• However, on the medical and care of the elderly wards, some concerns were expressed about personal care prior to our inspection, and staff understanding of people living with dementia. Further feedback from some patients and relatives on medical wards indicated they did not (always) feel informed or involved in decisions about their care. This inconsistency was also reflected in feedback we received at our listening /public engagement event immediately prior to our inspection.
• Many other patients, relatives and families told us they were kept informed of plans for on-going care and treatment. They said they had been given personalised support, adapted to their ability to take on complex or emotional information.
• Patients and their families were supported by staff to reduce anxiety and concern. They felt involved in the decision-making process and had been given clear information about treatment options: they then felt enabled to ask questions of senior medical and nursing staff and be supported to make the decision that was right for them or for their loved one. There was further emotional care from the chaplaincy and bereavement services, and counselling support where required for patients and families.
• Dignity and respect for patients was maintained at all times during treatment or examination. There were signs on curtains to remind staff and relatives that they needed to ask permission before entering.
• Overall, the trust consistently scored better than the England average for the Friends and Family test.

Are services responsive?

• At the time of the inspection the hospital’s services, and those of other acute hospitals in Dorset, were subject to the Dorset Clinical Services Review to redesign and improve quality of care for people in the county.
• Bed occupancy in the hospital ranged between 86-98%. This was consistently above the England average. It is generally accepted that at 85% level, bed occupancy can start to affect the quality of care provided to patients, and the orderly running of the hospital.
• Performance in meeting national emergency access target for 95% of patients to be admitted, transferred or discharged from ED within 4 hours had varied through the year. The target was met between May 2015 and August 2015, and again in September 2015. Overall the trust performance had been in line of better than the England average but the average was approximately 91%.
• The trust reported 72 black breaches between November 2014 and October 2015. This is when ambulances are not able to hand over patients within one hour. A lack of physical capacity in the hospital was the main reported reason for this. The ambulance median time to treatment was around the standard of 60 minutes.
• The percentage of patients waiting 4 -12 hours in the department for a bed in the hospital had been decreasing since October 2014. However, the trust still remained below the England average.
• The acute medical admissions ward, rapid assessment consultant evaluation unit (RACE), and medical investigations unit had contributed to the trust’s ability to support older patients and manage the increasing pressures on beds.
• There were 32 medical outliers at the time of inspection. These patients were appropriately assessed, and there was a robust process to ensure junior and senior medical staff from the relevant speciality reviewed medical outliers regularly.
• In November 2015, 93% of patients with fractured neck of femur had surgery with 36 hours of being medically fit, 96% within 48 hours and 89% within 24 hours of being medically fit.
• The trust had identified patient flow through the hospital as a significant concern. In the period October to December 2015, the trust had mixed achievements in meeting the 18 week incomplete pathway for referral to treatment (RTT) standard. National standards detail that 92% of patients should start treatment within 18 weeks of referral for treatment. This data was for patients who were having elective surgical procedures carried out at the hospital. General surgery and trauma and orthopaedic service met this target. However, ENT and oral surgery services did not meet this target, with compliance rates ranging from 87% to 91%.
• The hospital’s cancellation rate for operations was similar to the England average. The percentage of patients whose operation was cancelled and were not treated within 28 days was lower (better) than the England average.
• The critical care unit had a low rate of elective surgical operations being cancelled because a critical care bed was not available. However, patients fit for wards were not always transferred out of critical care within 24 hours. Thames-Valley and Wessex networks leads carried out a review in July 2015. The trust was identified as an outlier on the NHSE national dashboard. A further review was planned for January 2016.
• In critical care, there were 39% of delayed discharges over 12 hours to wards due to lack of bed availability in the rest of the hospital, which meant patients could not be discharged to a ward at the earliest opportunity. This had resulted in patients that should be deemed as mixed sex breaches. There was an action plan in place which included meeting with director of operations to discuss this issue and identify solutions. This would be fed into the Best Practice Organisational Flow Group. The trust had recognised this was an on-going problem and was not meeting the NHS England key performance indicator.
• Maternity senior managers had not completed an assessment of needs to analyse how the service should be planned and delivered to local people. This meant the managers could not be assured the service provided appropriate care to meet the needs of the local population. The trust wide bed occupancy rates for maternity and gynaecology were higher than the England average and fluctuated between 65% and 83%. For example, from April 2015 to June 2016 the trust reported a bed occupancy rate of 82.8% compared with the England average of just over 60%.
• Pregnant women had prompt access to maternity services. The national and trust target for booking women for ante natal care by 12 weeks and 6 days gestation was 90%. The hospital consistently exceeded the trust and national targets for April 2015 to September 2015 with an average of 96.2% of women booked within the timeframe.
• Staff told us the 24 hour paediatric assessment unit improved patient flow. They felt having a facility whereby patients could be observed for longer than four hours allowed the paediatric team to reduce their admission rate to inpatient areas. GPs could refer children to the assessment unit, and following triage children were then admitted or they could return home. There was a system for recording waiting time within the assessment unit.
• The trust short notice cancellation rate for outpatient appointments was lower (better) than the England average. ‘Did not attend’ rates were also lower (better) than the England average and phone calls and texts were used to remind patients of appointments.
• The trust was meeting cancer waiting times for patients to see a specialist within 2 weeks and from decision to treat to first definitive treatment within 31 days. The trust also met the waiting times target for from 2 Week Wait referral to first definitive treatment within 62 days (April 2014 to October 2015) in 14 out of the 19 months. Overall performance for this period was 86.6% (target ≥85%).
• The hospital delivered patient centred end of life assessments in a timely way. The hospital specialist palliative care teams assessed newly referred patients within 24 hours as outlined in the Operational Policy for the Poole Palliative Care Service. The community specialist palliative care nurses assessed patients within three days of the referral.
• The trust operated a Rapid Discharge Home to Die (RDHD) pathway which served to discharge a dying patient who expressed wanting to die at home within 24 hours.. However, the trust had recognised through audit that patients were not always appropriately highlighted as suitable for fast track Continuing Health Care funding and there was a widespread deficit in knowledge about the CHC funding process.
• The trust was working in partnership with social care services to effectively support the discharge or patients, particularly patients with complex needs.
• Clinical staff did not always know how to access information to support them in meeting the needs of patients with a learning disability. There was not a specialist nurse, team or link nurse scheme to support where staff could receive advice and support to enable them to support these patients effectively.
• There was a clear and comprehensive complaints process. Staff understood how to manage complaints and there was evidence of learning from concerns and complaints. Patient feedback was sought and welcomed across the trust. This feedback was obtained from patient surveys and comment cards. The comments were largely positive.

Are services well led?

• The trust had published its vision, values, mission statement and objectives, and had taken action to assess and improve staff understanding of these. Staff used “The Poole Approach” (a delivery method of ensuring patients and relatives were at the heart of their care) as a daily strategy for internal and external communications.
• Staff felt that the executive team provided a strong, visible and supportive presence within the trust. Staff were positive about all the directors in the trust. However, many staff identified that some senior staff who attended bed meetings were viewed as obstructive and unsupportive. They also described difficulties in accessing these staff. For example, some senior nurses described having to wait in a corridor for up to an hour for requests for extra staff to be signed and agreed.
• The Director of Nursing provides end of life care leadership at trust board level and had good oversight of end of life care issues across both specialist palliative care and the acute medical wards.
• The trust was part of the on-going Dorset wide clinical service review and the Developing One Dorset vanguard to integrate acute care. Most services had developed interim strategic plans within this context. However, there was not a service-wide strategy or vision for paediatric services or for maternity services. The paediatric service had lacked leadership at a senior nursing level until an acting matron was appointed in January 2016. Senior managers did not consistently demonstrate an understanding of current service risks.
• Some services had effective clinical governance arrangements to monitor quality, risk and performance, but some local risk registers did not always reflect all of the concerns described to us by staff, or provide sufficient detail on actions being taken. The risk registers did not include key issues such lack of staffing on the paediatric wards or the maternity concerns regarding delays to care and the inability to consistently provide one to one care in labour. A few issues, such as lack of paediatric staffing, had not been formally raised to the executive team.
• Staff told us they were proud to work for their trust and some had done so for many years.
• Patient feedback was mainly through surveys and there was less evidence of other engagement opportunities.
• There was active participation in research and quality improvement projects, and the Outpatient and Diagnostics departments had highlighted much innovative practice.

We saw areas of outstanding practice including:

• The trust had developed a set of values called "The Poole Approach". The Poole Approach was established in the early 1990s as a philosophy of care. It pledges that staff at Poole Hospital will strive at all times to provide friendly, professional, patient-centred care with dignity and respect for all. These values were well embedded with staff working in the hospital. Staff were consistently kind and compassionate, putting the patient at the centre of care. Receptionists at the front door made a concerted effort to put any visitors or patients at ease, and this level of high support and regard continued throughout the hospital. Staff told us they were encouraged, no matter how busy, to stop to take time to help or reassure anyone in the hospital.
• The rapid assessment consultant evaluation (RACE) unit provided a high multi-disciplinary quality of care specifically for older patients, over the age of 80. The unit provided a seven day service and was reducing the number of elderly patient admissions and the length of stay for elderly patients that were admitted.
• For neonates, children and young people receiving palliative care, the trust had designed a special unit called the Gully’s Place Suite. This was a purpose-designed space which provided privacy and dignity for parents and families of babies, children and young people who required palliative and end-of-life care.
• Nuclear medicine was an exceptionally well led multidisciplinary service, despite an increasing workload, with no breaches of waiting times. Patients interviewed confirmed an outstanding level of care, information provided to patients, and concerns responded to appropriately. The department has also safely introduced two new radio pharmaceuticals based on scientific evidence. Medical physics have developed a new dental phantom; a commercial product.
• Non-invasive cardiology in CT and MRI imaging have reduced the need for invasive tests on patients with low and medium risk of coronary disease whilst ensuring high risk patients are transferred quickly to the neighbouring NHS hospital. There is excellent team working between cardiology and radiology to provide this service.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must ensure:

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• ​Action is taken to improve the cleanliness of clinical areas at St. Marys hospital and this is monitored to ensure good infection control practices.
• Delivery rooms meet with Department of Health regulations
• A review of the midwifery staffing to ensure sufficient staff are available to provide one to one care in labour.
• Medicines are stored at the appropriate fridge temperature and are recorded daily.
• Medicines are stored safely and securely including intravenous fluids. This should be in line with current legislations, trust’s policies and standard operating procedures.
• Appropriate dates are placed on medicines once opened.
• Patient group directions are correctly completed and in-date for staff to use.
• Flooring is accessible for cleaning purposes and  equipment is clean and protected from dust.
• There is a robust process for calling for emergency assistance in the theatre complex.
• There is appropriate support for patients with a learning disability including better flagging and referral for patients to specialist
• Equipment on the wards is in date and stored in a safe manner.
• The five steps to safer surgery checklist is appropriately completed.
• Review the emergency theatre arrangements to ensure patient safety and wellbeing is not adversely affected.
• The staffing levels and skills mix is assessed in all areas and staffing is delivered as planned.
• Patient records are secure stored so as not to breech patient confidentiality and to prevent unauthorised access, particularly in medicine and maternity departments.
• All staff participate in mandatory training.
• Risk register includes all factors that may adversely affect patient safety.
• Learning from incidents are embedded in practice.
• Implement a flagging alert system to identify Looked After Children within the trust
• Ensure secure access arrangements to the paediatric unit are in place out of hours.
• Implement policies and protocols for children and young people for absconding or for restraint.
• Patients and members of the public are informed of the safety thermometer results.
• Where relevant, DNA CPR forms must be endorsed by a consultant grade doctor.
• There is a clear and measurable action plan which details how they will improve patient outcomes with regard to the organisational targets and key performance indicators as measured in the National Care of the Dying Audit.
• Service leads review how they use data to improve patient outcomes.
• An end-of-life care policy is developed that addresses the withdrawal and withholding of life-sustaining treatment for critical care patients.
• That end of life care patients are given sufficient opportunity to identify their preferred place of care.
• There are no mixed sex breaches in critical care.

Action the hospital SHOULD take to improve

• Consultant presence in the delivery suite meets the Royal College of Gynaecologists and Obstetricians guidelines.
• Clear guidelines for staff regarding the maximum numbers of women accepted the induction of labour.
• Conduct a needs analysis to ensure the service is meeting the needs of the local population.
• Develop clear plans to deliver the maternity service strategy.
• Encourage improved working relationships between senior midwives and their managers.
• Patients in the department are correctly identified with name bands in a timely way.
• Review necessary improvements to achieve referral to treatment time targets.
• There is a robust process used for monitoring requests for agency and bank nurses and whether they are fulfilled or not.
• A patient is given the opportunity to wash or clean their hands before meals.
• Staff check equipment regularly, and equipment is maintained or replaced in line with trust policy.
• Staff complete risk assessments and actions required to reduce risks to a patient, in a timely way.
• Appropriate arrangements happen with the local mental health trust to improve patient assessment and out of hours support.
• Staff are offered regular supervisions and appraisals to promote staff development.
• Training provision should ensure all staff have an accurate understanding of the trust’s deprivation of liberty safeguards policy.
• Improvements in the care pathways for stroke and heart failure are embedded and sustained.
• A decrease in the number of bed moves, and patients moved overnight.
• An increase in the number of complaints responded to within 25 working days.
• Delayed discharges from CCU should be improved including out of hours discharges from the unit.
• Resuscitation trolleys in the critical care unit should be tamper-evident.
• Mandatory training updates for critical care staff should meet trust targets ensuring staff complete updates in essential and core training.
• Development of a safety checklist for patients undergoing invasive procedures such as insertion of central venous catheters.
• Access to a follow-up clinic for patients discharged from the critical care unit should be further developed and to include better access for psychological and other support.
• The hospital improves the access and flow of patients in order to reduce delays from critical care for patients being discharged to wards.
• There is dedicated dietetics support for patient in critical care.
• Policies and procedures should be regularly reviewed to provide up to date guidance for staff including withdrawal of treatment policy.
• Support and develop the paediatric service so it can deliver service-wide strategy and vision.
• Outpatient clinics are planned to meet the specific needs of children.
• Play therapists are used by the outpatient department to help children cope during outpatient procedures.
• Documents within electronic records for patients are filed appropriately once scanned to enable clinicians to find relevant information effectively.
• Departmental and team meetings are held at an agreed frequency to enable good communication between managers and staff.
• Seven day service provision in diagnostic imaging is reviewed and monitored to ensure stability of staffing.
• Managers in diagnostic imaging provide forums for staff engagement.
• All staff within outpatients and diagnostic imaging are aware of the department strategy.
• There is an agreed set of performance indicators for end of life care to measure service quality in a timely manner.
• There is a process for monitoring whether patients who express a wish to die at home are able to do so and that any delays in discharge are recorded and reviewed.

Professor Sir Mike Richards

Chief Inspector of Hospitals