Royal Blackburn Hospital

East Lancashire Hospitals NHS Trust serves a population of 521,000. The trust has two acute sites: Royal Blackburn Hospital and Burnley General Hospital as well as three community sites. There is noticeable deprivation in both Blackburn with Darwen and Burnley. Alcohol-related diseases and adult smoking are among the most prominent health concerns in both areas. 44% of the population belongs to non-white ethnic minorities and life expectancy is 10 years lower for men and 7 years lower for women in the least deprived areas of both boroughs.

East Lancashire Hospitals NHS Trust was one of the 14 trusts reviewed as part of the Keogh Review in 2013 based on the trust having been an outlier for the previous two consecutive years on either the Summary Hospital-Level Mortality Index (SHMI) or the Hospital Standardised Mortality Ratio (HSMR). The review identified a number of concerns at the Trust particularly related to the quality governance assurance systems. The review panel also identified a number of areas of good practice and dedicated staff, but there was more for the Trust to do to communicate effectively to staff and share learning to ensure consistent approaches to quality improvement across the organisation, all of the time.

The trust was placed in special measures and CQC inspected the trust using the new comprehensive inspection model in July 2014. This resulted in the hospital overall being rated as Requires Improvement with improvement needed in urgent care; medical care; surgery and end of life care.

This inspection was a follow up and was conducted on 19, 20 and 21 October 2015. We did not inspect the community sites and only reviewed four core services in order to review the progress of the trust since coming out of Special Measures in July 2014. We have aggregate the ratings following this inspection with the previous ratings for the services not inspected to give a revised rating for this hospital. We also looked at the governance and risk management support for the services we inspected.

Our key findings regarding the trusts response to the last inspection report and current practice were as follows:

• The trust had a clear vision, objectives, values, operating principles and improvement priorities. These had been arrived at using a bottom up process and all staff we spoke with were engaged in the strategic direction of the Trust, its vision, demonstrated the values and were dedicated to achieving the best care for patients.

• The hospital services were supported by strong governance processes’ including well managed risk registers feeding in to the Board, ensuring a robust overview of the risks within the hospital. There was ongoing work to enhance the Board Assurance Framework and risk management in the Trust. Staff demonstrated their involvement in the solutions to the risks identified which had developed staff ownership of risk and solution and was enhancing achievement.

• A ‘Harm free care’ strategy, introduced 12 months ago had improved the way they dealt with and learnt from incidents. The strategy included actions such as completing rapid reviews of serious incidents, referral to a panel for discussion and sharing outcomes in senior meetings. We saw evidence of learning and change to practice from incidents and how this learning was shared across the service and trust wide.

• Mortality rates had improved and the latest Trust SHMI value as reported by the HSCIC had remained within expected levels at 1.08, for the third quarter in a row as published in July 2015. The latest published HSMR values (May 2015 report) were within expected levels. The indicative HSMR monthly rebased figure (Dr Foster intelligence) for the most recent 12 month period available (June 2014 – May 2015) was also within expected levels at 101.78.

• Over the past 12 months the Emergency Department/Urgent Care Centre’s had introduced a number of quality innovations that have improved patient experience, patient care, patient safety and patient outcomes. Some of the initiatives that had been introduced included the introduction of a Mental Health Triage Tool and Observation Policy; Rapid Assessment review; Introduction of a Sepsis Nurse Lead; Creation of a Dementia friendly environment and review and development of the Paediatric Emergency Department.

• Following the results of an audit in 2014, improvements were required to improve the care of patients with sepsis. Following the improvements the ED was now the second best provider regionally for the treatment of neutropenic sepsis, with 80% of patients receiving antibiotics within the hour.

• The hospital had consistently achieved better than the England average in respect of the 18 weeks target from referral to treatment between April 2014 and March 2015. Surgical procedures were sometimes cancelled at short notice but systems were in place to ensure patients were rescheduled within 28 days of the cancellation.

• Nurse staffing in ED, medical and surgical departments had improved since the last inspection. Although there was a reliance on agency staff; nurses had been recruited but they were not yet in post.

• The trust employed an Intensive Home Care Team who provided support to the ED and facilitated early discharges of patients from hospital. Established links with local GPs who provided medical support if required were available. Figures for September 2015 showed that out of 86 patients assessed, 69 were discharged into the community.

• Cleanliness and hygiene throughout the trust was of a high standard.

• There was now a full bereavement service available at the hospital which was well received by users although it was noted not to be as well utilised by the ethnic minority groups. Work was underway with the local religious leaders to review this.

• Staff were caring, kind and respectful to patients and involved them in their own care. Improvements had been made in the monitoring of patients to identify if their condition was deteriorating which included revised systems for obtaining prompt medical assistance.

• Staff were proud of the work they did; they worked well together and supported each other when the services were under pressure. The trust ranked in the top 100 places to work in the NHS in an external health journal. Staff and patients told us they felt well engaged with and their views were valued.

• Staff explained that the last few years had been difficult but the stability of the current oard and executive team contributed greatly to the culture of continuous improvement.

• Leadership across the departments was very positive, visible and proactive. Managers had a strong focus on the needs of patients and the roles staff needed to play in delivering good care.

However,

• Temporary staff reported a lack of access to electronic patient records when required and the maintenance of the confidentiality of records particularly in communal areas required improvement.

• The risks associated with the use of a separate prescribing document for medicines delivered via a pump were raised with the trust at the time of the inspection. They took immediate action to address our concerns.

• Some improvements were required with regard to the management of records and medicines in the medical wards.

• The A&E department continued to find the 4 hour wait target challenging. Between July 2014 and August 2015 an average of 89% of patients were admitted transferred or discharged within four hours. Over the winter months last year there were 1644 occasions when ambulance handovers took longer than 30 minutes. This placed the trust in the highest quarter for ambulance handover delays in England.

• There was no designated area for patients not requiring an overnight stay, but who needed to undergo a period of observation or await test results. These areas can ‘contribute to patient safety, are highly efficient in terms of providing short term and ambulatory care, reduce admissions, and have been shown to improve crowding. Currently, staff admitted these patients to the Acute Medical Unit (AMU) which the trust had very recently doubled in number of beds from 40 to 80 to improve flow out of the ED. Two weeks prior to this inspection some medical wards had also moved to another area with the expansion of the acute medical unit. It was too early following this move to see any of the expected improvements.

• The audit of assessment of mental health patients in the ED (2014/15) showed that there remained room for improvement particularly in the assessment and recording of a patient’s mental state which was only assessed and recorded in 30% of cases. The ED worked closely with a neighbouring trust in providing care for patients with mental health needs which was provided in a timely way 24 hours a day, seven days a week when required.

• Medical staff recruitment in some areas remained a challenge; the ED department relied on locum staff to fill gaps, actions were being taken to develop doctors internally to reduce the need to recruit from outside the trust. There was currently one vacancy for an EOL consultant. The consultants should have provided six sessions in the hospital to support EOL patients but provided just less than five sessions per week.

• There was no paediatric consultant assigned to work in the paediatric area of the ED but consultants could be sourced from the main ED or the children’s ward. There was however a dedicated doctor in the paediatric area. Doctors could also be brought from the UCC or the main ED areas if required. The Royal College of Paediatrics and Child Health (2008) recommend that a paediatric consultant should be based in the ED.

• The results from data collected as part of national audits into the outcomes for patients with some clinical conditions showed the hospital was performing worse than the National average. Work was ongoing to improve these outcomes however this was not completed at the time of the inspection.

• The training and development of staff was below the trust’s target for nurses within the medical services.

We saw several areas of outstanding practice including:

• Several examples of innovation across the surgical division, including robotic surgery, theatre open days to break down barriers between community and operating theatres and the use of social media.

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

Importantly, the trust must:

• Ensure safe and accurate medicines administration and documentation particularly in terms of the recording of controlled drugs which patients have brought into the acute medical unit and oxygen prescribing and documentation on the medicine prescription and administration record.

• Ensure the safe access and use of electronic patient records in terms of all staff having access when required and maintaining the confidentiality of records particularly in communal areas.

In addition the trust should:

In Medicine;

• Consider how medicine storage fridge temperatures could be accurately recorded and action taken where they are not within the correct range.
• Improve staff uptake on the medical wards of mandatory training.
• Consider improving staff awareness of their role should a major incident occur.
• Improve the services for patients who had suffered a stroke including the input from speech and language specialists.
• Nursing staff on the medical wards should be up to date with an appraisal of their performance.

In End of Life;

• Work with commissioners to provide a seven day service.
• Consider re-audits of DNACPR records to ensure that all records are correctly completed and all discussions with patients and families are documented.

Professor Sir Mike Richards

Chief Inspector of Hospitals