Royal Berkshire NHS Foundation Trust

Letter from the Chief Inspector of Hospitals

Royal Berkshire NHS Foundation Trust provides acute services to a population of 600,000 people across Reading, Wokingham and West Berks, and specialist services to a wider population across Berkshire and the surrounding borders. Royal Berkshire Hospital is the main inpatient site, with five other sites including West Berkshire Community Hospital, Windsor Dialysis Unit, Prince Charles Eye Unit, Royal Berkshire Bracknall Clinic and Townlands Hospital Outpatients.

During the inspection, we visited the Royal Berkshire Hospital, West Berkshire Community Hospital (Day Surgery Unit and Outpatient services), Windsor Dialysis Satellite Unit and Prince Charles Eye Unit.

We carried out this comprehensive inspection because the Royal Berkshire NHS Foundation Trust was initially placed in a high risk band 1 in CQC’s intelligent monitoring system. Immediately prior to the inspection the intelligent monitoring bandings were updated and the trust was placed in a low risk band 5. The inspection took place between 24 and 26 March 2014 and an unannounced inspection visit took place on 29 March and 2 April 2014.

Overall, this hospital requires improvement. We rated it good for being caring and effective but improvement was required in providing safe care, being responsive to patients’ needs and being well-led.

We rated the A&E service, end of life care and services for children and young people as good, but we rated outpatients, medical, surgical, maternity and critical care as requiring improvement.

Our key findings were as follows:

• Staff were caring and compassionate and treated patients with dignity and respect.
• The hospital was clean and well maintained; although there were some examples where cleanliness fell below expected standards.
• The workforce were committed and we noted an open culture during the inspection.
• Infection control rates in the hospital were similar to those of other trusts except the C.Difficile rates, which were higher than average and the trust was taking steps to improve.
• Staffing levels were not always sufficient to meet the needs of patients on all ward areas, with a consequent reliance on bank and agency staff.
• Medical records and the electronic patient record system and processes were not robust, which resulted in patient records not being available, reliance on temporary records and inability to access records as required in a timely manner, impacting on the ability to deliver care.
• ICU capacity was insufficient and operations were going ahead when no ICU bed was available, resulting in patients being cared for in the recovery area overnight.
• The observation ward in A&E was a room with three beds but it was not included in the four-hour decision to discharge, admit or treat A&E target as it was used as a ward, although it did not have any shower facilities. There were concerns about appropriate use and care of patients in this observation area.
• The major incident process associated with decontamination was not appropriate because of the distance and journey for patients through the hospital.
• Safeguarding processes and knowledge of the Mental Capacity Act was not sufficient.
• DNACPR forms were not consistently completed.
• The end of life care team worked collaboratively with key stakeholders.
• Paediatric care was generally positive.

We saw several areas of outstanding practice including:

• Caring interventions and support for families in in the Intensive Care Unit.
• The Children’s A&E department.
• Consultant geriatricians worked in the A&E department 8am to 8pm seven days a week.
• The responsiveness of the Palliative Care team.

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

Importantly, the trust must:

• Ensure that medical records are kept securely and records can be located and accessed promptly when needed to appropriately inform the care and treatment of patients.
• Maintain the privacy and dignity of patients placed in the observation bay in the A&E department.
• Ensure that the design and layout of the emergency department protects patients and staff against the risks associated with unsafe or unsuitable premises.
• Take appropriate steps to ensure that, at all times, there are sufficient numbers of suitably qualified, skilled and experienced staff employed to care for patients’ needs, and safeguard their health, safety and welfare.
• Accurately complete ‘Do not attempt cardio-pulmonary resuscitation’ (DNA CPR) forms, and document the discussions about end of life care with patients.
• Take proper steps to ensure that each patient is protected against the risks of receiving care or treatment that is inappropriate or unsafe by planning the delivery of care and appropriate treatment to meet patients’ individual needs, and have procedures in place to deal with emergencies which are reasonably expected to arise.
• Review the ICU capacity across the trust; employ suitably qualified, skilled and experienced staff; and have necessary equipment available to care for patients who require intensive or high dependency care.
• Ensure that planning and delivery of care meets patients’ individual needs, and ensure the safety and welfare of all patients.
• Increase staff knowledge of Deprivation of Liberty Safeguards (DOLs) and the Mental Capacity Act (MCA) through necessary training to improve safeguarding.
• Improve contemporaneous record keeping by all staff to avoid misplacing records of care and observations.
• Ensure the staffing levels and admission criteria in the Rushey Midwife-led unit is maintained to ensure safe care is provided to all women.
• Ensure that at all times there is a sufficient number of suitably qualified, skilled and experienced staff employed to provide safe midwifery care in all areas.
• Take action to improve the ventilation system on the delivery suite, to protect patients and others who may be at risk from the use of unsafe equipment.

Professor Sir Mike Richards

​Chief Inspector of Hospitals