All inspections: Blackpool Teaching Hospitals NHS Foundation Trust

Blackpool Teaching Hospitals NHS Foundation Trust is situated on the west coast of Lancashire and operates within a regional health economy catchment area that spans Lancashire and South Cumbria and supports a population of 1.6 million. The trust provides a range of acute services to the 330,000 population of the Fylde coast health economy and the estimated 11 million visitors to the seaside town of Blackpool. Since April 2012, the trust also provides a wide range of community health services to the 445,000 residents of Blackpool, Fylde, Wyre and North Lancashire. The Trust also hosts the National artificial eye service, which provides services across England.

The trust provides a full range of hospital services and community health services. These include adult and children’s services such as health visiting, community nursing, sexual health services and family planning and palliative care. The trust provides tertiary cardiac, haematology and adult cystic fibrosis services to 1.5 million population catchment area covering Lancashire and South Cumbria.

At our last inspection in October 2019, we rated safe, effective and responsive as requires improvement, caring as good and well-led for the trust overall as inadequate.

The trust had experienced significant challenges over the past 18 months due to the COVID-19 pandemic. There was significant redeployment of staff at the trust during that period to support staff in critical areas.

We carried out this unannounced inspection, from the 14 September to the 20 October 2021, of Blackpool Teaching Hospitals NHS Trust. We inspected core services at the Blackpool Victoria Hospital including urgent and emergency care, medical care, critical care and surgical care services because of continuing concerns about the quality and safety of these services. We also inspected the well-led key question for the trust overall. We rated urgent and emergency services as inadequate and surgery, medical care and critical care as requires improvement. We rated well-led for the trust overall as requires improvement.

Following this inspection, due to the concerns we had identified at Blackpool Victoria Hospital, we wrote to the trust asking for urgent action to be taken to ensure safe care and treatment.

Details for the summary for each core service inspected can be found later within the report, a summary of the trust wide well led is below.

We rated well led as requires improvement at Blackpool Victoria Hospital because:

There were several new appointments to the board but the plans they had developed had not yet had time to evidence their impact or sustainability. Not all leaders had the capacity to lead effectively. Not all senior leaders were visible or approachable in the organisation. Leaders were not always fully sighted with what was happening on the front line. They did not always identify their priorities and did not always develop plans to manage these in an effective and timely way.
The trust did not have a clear vision. Although the trust had not developed a new five year vision and strategy because of COVID-19, they had taken a pragmatic approach by putting the one-year overarching strategy in place within the organisation and had started to develop a five year one; however, there were several strategies that were out of date.
Not all staff felt supported, respected and valued by their local leaders. There was a lack of supportive inclusion for staff with protected characteristics. The trust was working towards an open culture where patients, their families and staff could raise concerns without fear. However, not all staff felt secure to raise concerns. The trust had work to do in relation to promoting equality, diversity and inclusion in daily work.
The arrangements for governance were not clear and did not always operate effectively. Not all staff in leadership roles were clear about their roles and accountabilities. Processes were not always effective and completed in a timely manner.
Risks, issues and poor performance were not always dealt with appropriately or quickly enough. There were systems to manage performance; however, these were not used efficiently. The risk management approach was applied inconsistently and was not linked effectively into planning processes. Significant risks were not always identified or escalated appropriately and there were insufficient processes to identify actions to reduce their impact.
The information that was used to monitor performance or to make decisions was inaccurate, and unreliable or not relevant. There was inadequate access to and challenge of performance by leaders and staff. The trust was delayed in implementing its digital strategy and had no implementation date at the time of our inspection.
There was minimal engagement with people who used services, staff, and the public. There was a limited approach to sharing and obtaining the views of staff. There was insufficient attention to appropriately engage with people, including those with protected equality characteristics. Feedback was not always reported or acted upon in a timely way.

However:

Senior leaders demonstrated the necessary knowledge, capability and integrity. They worked well as an executive team and with leadership teams across the trust.
The trust did have three key ambitions for what it wanted to achieve within a one-year strategy. The strategy was focused on sustainability of services and aligned to local plans within the wider health economy.
All staff we met were focused on the needs of patients receiving high quality and compassionate care.
The trust had sourced an external organisation to review and report on governance processes throughout the trust.
The trust was beginning to invest in continuous learning and improvement within the organisation, however there was still work to be done through the appropriate use of external accreditation and participation in research. There was knowledge of improvement methods and the skills to implement improvement was beginning to be shared among the organisation.

We rated one of the trust’s 14 services as inadequate overall and three as requires improvement. In rating the trust, we took into account the current ratings of the 10 services not inspected this time.

How we carried out the inspection

During our inspection we spoke with a variety of staff including consultants, doctors, therapists, nurses, healthcare support workers, pharmacists, patient experience, domestic staff and administrators and the trust’s board. During the inspection we also spoke with patients and relatives. We visited numerous clinical areas across the hospital site. We reviewed patient records, national data and other information provided by the trust.

We held several staff focus groups with representatives from all over the trust to enable staff who were not on duty during the inspection to speak to inspectors. The focus groups included junior and senior staff from pharmacy, junior and senior nursing staff, junior doctors and consultants, allied health professionals, staff representing equality diversity and inclusion, a separate focus group for staff from a black, Asian and minority ethnic backgrounds. We also had focus groups for the non-executive directors and governors.

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

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

We rated safe, effective, responsive as requires improvement, and caring as good. We rated six services as requires improvement, one as inadequate, nine of the trust’s services as good and one service as outstanding. We rated caring for community services as outstanding.

We rated well-led for the trust overall as inadequate.

Community adult services was last inspected in November 2017 and was rated overall as outstanding.

Our rating of this service stayed the same. We rated it as outstanding because:

The service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan and deliver care in a way to ensure flexibility, choice and continuity of care.
There were innovative approaches to providing integrated person-centred pathways of care that involve other service providers, particularly for people with multiple and complex needs.
People could access community health services for adults when they needed them, and technology was used innovatively to ensure people have timely access to treatment, support and care.
People were respected and valued as individuals and were empowered as partners in their care, practically and emotionally, by dedicated staff.
Staff were motivated and passionate in providing care that is kind and promotes dignity.
Patients felt cared for and valued their relationship with staff and their personal preferences and needs were always reflected in the care they received.
Staff found innovative ways to enable people to manage their own health and care when they could and to maintain independence as much as possible.
Staff of different kinds were committed to work collaboratively within their service but also with external organisations to benefit patients and provide good and effective care.
Staff consistently supported people to live healthier lives, including identifying those who need extra support, through a targeted and proactive approach to health promotion and prevention of ill-health, and they used every contact with people to do so.
The leadership, governance and culture promoted the delivery of high-quality person-centred care.
Leaders had the skills and abilities to run the service and were visible, approachable and supportive for patients and staff.

However:

Not all staff had received all relevant training in safeguarding children.
There were limited opportunities for staff to engage and share good practice or better ways of working across different localities.

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

The service provided mandatory training in key skills to all staff and most staff received and kept up to date with their mandatory training.
Staff understood how to protect children, young people and families from abuse and the service 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.
The service controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean.
The design, maintenance and use of facilities, premises and equipment in the service kept people safe. Staff managed clinical waste well. A large number of the directorates services were delivered in modern high specification primary care centres and children’s centres across the localities of the teams services.
Staff in the service completed and updated risk assessments for each child and young person and acted to remove or minimise risks. Staff identified and quickly acted upon children and young people at risk of deterioration.
Data provided by the trust showed that the service had less staff than it had planned for. In our interaction with staff we found that the service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix and gave staff a full induction.
Staff in the service understood the relevant consent and decision-making requirements of legislation and how this related to young people such as guidance for Mental Capacity Act 2005, Children’s Acts 1989 and 2004, Gillick competence 1985.
The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service. The directorate reported no incidents classified as never events and no serious incidents in the period from May 2018 to June 2019.
The service provided care and treatment based on national guidance and evidence-based practice.
Staff teams understood the needs of local people and had introduced systems so that staff deployment met the need of high and low population areas.
The staff in the service were aware of the diversity of populations and the challenges faced by some of its communities. Staff had access to multi-lingual sources such as translation services to support patient care.
The directorates leaders had the skills, knowledge and experience to guide and lead staff. management were respected, seen as supportive and effective in their roles.
Leaders in the trust and in the directorate had a vison for children and families’ services which focused on promoting well-being and nurturing. The service planned to move to a more holistic model of care which was connective with other services to promote well-being

However;

In a number of teams, patients had long waits to start treatment. Arrangements to admit and treat patients were sometimes not in in line with national standards. Young people and families found it difficult to receiver treatment when they needed it and therefore did not received the right care promptly.
Whilst the service provided mandatory training in key skills to all staff and most staff received and kept up to date with their mandatory training. We found that the directorate still had some room for improvement to reach the trust completion target in some of its mandatory courses.
It was clear that supervision process needed to be reviewed and adjusted so that a clear chain of evidence concerning discussions about safeguarding occurred. Serious safeguarding concerns were still escalated and shared with the trusts safeguarding team.
Whilst records audits showed positive results we found some recording to be patchy in some services with elements of care planning missing.

We rated it as good because:

Since our last inspection the service continued to be provided by an integrated partnership between the trust and Trinity Hospice. There were enough staff to care for patients and keep them safe. Staff assessed risk to patients and acted on them. They managed medicines well.
The service planned care to meet the needs of local people and took account of patients’ individual needs. People could access the service when they needed it.
The service was planned, organised and delivered well. Care was delivered by competent practitioners who considered the needs of all patients and families in their care.
Since our last inspection the end of life care service’s vision and strategy had been set out for 2017-2020. The service had an action plan to monitor and deliver the vision and strategy working with external partners and the involvement of staff.
Staff provided a range of treatment and care for patients based on national guidance and best practice.

However:

Training in end of life care was not mandatory for all staff.
There was no non-executive director at board level for end of life care.

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

The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
Staff provided good care and treatment in line with nationally recognised guidance. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

Audits of the decontamination process were only carried out annually.
Medical emergency medicines and equipment were not taken on domiciliary visits. This had not been formally risk assessed.
Waiting times for a paediatric general anaesthetic in the south region were excessive.

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

The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
Staff provided good care and treatment. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

Our rating of this service went down. We rated it as requires improvement because:

Staff did not always develop holistic, recovery-oriented care plans in collaboration with patients, families and carers. Staff did not engage in clinical audit to evaluate the quality of care they provided.
Children who did not require urgent care waited too long to start treatment. The criteria for referral to the service excluded children and young people who would have benefitted from care.
Governance systems and processes did not always ensure that the quality and safety of the services provided was accurately assessed, monitored or improved. The service did not provide us with valid data about waiting times. The trust did not accurately identify which staff were eligible for some mandatory training topics, meaning that compliance figures were incorrect. Information on risk was not always easy to find in patients’ care records and staff did not document whether they had offered patients a copy of their care plan.

However:

The service provided safe care. Clinical premises where patients were seen were safe and clean. Patients who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
Staff provided a range of treatments that were informed by best-practice guidance. The team included the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
Staff understood the principles underpinning capacity, competence and consent as they apply to children and young people and managed and recorded decisions relating to these well.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
The service was easy to access for children who met the referral criteria.
The service was well led and the governance processes ensured that most of the procedures relating to the work of the service ran smoothly.

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

We rated safe and responsive as requires improvement. We rated effective, caring and well-led as good. Our rating for the trust took into account the current ratings of services not inspected this time.
Our decisions on overall ratings take into account factors including the relative size of services and we use our professional judgement to reach a fair and balanced rating.
There remained challenges with patient flow; performance in urgent and emergency care had gone down.
The emergency department had consistently failed to meet the Royal College of Emergency Medicine recommendation that the time patients should wait from time of arrival to being triaged (having an initial assessment undertaken) is no more than 15 minutes. This is important as it is a system that emergency departments use to make sure that the patients who may need immediate treatment are prioritised.
Safeguarding training was not always delivered at the level specified in the intercollegiate guidance within the emergency department and community dental practices.
In specialist community mental health services for children and young people, risk management plans were not properly updated on an ongoing basis.
There remained challenges with staffing in some areas of the trust, particularly in urgent and emergency care and medical care.
Mortality figures remained higher than expected, although we saw evidence that the strategy to reduce the mortality rates was having a positive effect.

However:

We rated well-led at the trust level as good.
During the inspection in 2014, we were unable to identify a clear vision or strategy to support the trust. At this inspection, we found that a trust vision and five-year strategy had been developed in consultation with staff, patient representative groups and external stakeholders.
At the last comprehensive inspection in 2014, it was reported that there were poor incident reporting systems and failures to report near misses. At this inspection, we found that staff felt confident and were encouraged to report incidents via an electronic system.
There was a strong sense of integration across both the acute and community services. We identified outstanding caring and responsive practice in the community health services for adults.
Directors demonstrated an understanding of the quality of care across all sectors.

This service has not been inspected before. We rated it as good because:

The service carried out infection control procedures in line with nationally recognised guidance. Premises and equipment were clean and well maintained. The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. Appropriate medicines and life-saving equipment were available.
The service provided care and treatment based on national guidance and evidence of its effectiveness. Staff of different kinds worked together as a team to benefit patients. Staff understood their roles and responsibilities under the Mental Capacity Act 2005 and with regards to Gillick competence.
Staff cared for patients with compassion. We observed staff treating patients with dignity and respect.
The service took account of patients’ individual needs. The appointment system met patients’ needs. The service dealt with complaints positively and efficiently.
Managers promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. There was a clearly defined management structure. The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.

However:

The dentists and dental care professionals had not completed level 2 safeguarding for children, in line with the intercollegiate document (2014).

We had not previously inspected this service. We rated it as good because:

Staff understood how to protect patients from abuse and had systems in place to assess and respond to patient risk. Equipment and premises were clean and appropriate medicines management arrangements were in place.
The service provided care and treatment based on national guidance and made sure staff were competent for their roles. Staff of different kinds worked together as a team to benefit patients and there were effective systems in place to support transition from children‘s to adult services. There was close working with the community adolescent mental health service team and the child and adolescent support and help enhanced response team.
Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness and we saw evidence of this.
We saw evidence of multidisciplinary and multi-agency working, with clinics and appointments being organised to best accommodate local families’ needs. There was an emphasis on recognising and addressing mental and emotional well-being.
The service had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients and key groups representing the local community. Managers promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.

We had not previously inspected this service. We rated it as outstanding because:

We saw outstanding practices in the way staff treated patients with compassion and respected their privacy and dignity. Staff were kind to patients and demonstrated they knew patients individually, particularly those who regularly used the services and involved them and decisions about their care.
There were effective systems in place to provide emotional support for patients.
There were innovative approaches to providing integrated person-centred pathways of care, particularly for people with multiple and complex needs.
The service had effective systems and processes in place to protect patients from abuse, assess, control infection risk and respond to patient risk.
The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
There was a range of effective care models in place. The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations.
Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
The service provided care and treatment based on national guidance and evidence of its effectiveness.
The trust planned and provided services in a way that met the needs of local people. There were a number of different initiatives across the service.
Staff across the services reported they felt supported, respected and valued.
We saw patients had timely access to care for most services.

However:

There was limited use of information technology systems in the community; staff did not have access to mobile working devices. There were issues with connectivity in the rural areas.

We had not previously inspected this service. We rated it as good because:

Whilst the service did not reach its mandatory training target, we saw strong levels of compliance.
The service had robust systems and processes in place to learn from incidents and effectively share learning and improve practices. Incidents were low.
We found safeguarding policies and procedures were in place and arrangements were in place for assessing patients’ need.
The service evidenced a multi-agency approach to engaging with clients.
Staff used national assessment and clinical guidelines which were based on national best practice.
Clinical sites and waiting areas were clean and safe.
We found the staffing levels of services were sufficient to meet the needs of patients.
The service met the needs of its population including individuals who were vulnerable.
The service was based on best practice contributing to local and national audits.
The service was well managed and managers were proactive in making disparate teams a collective.

We had not inspected this service previously. We rated it as good because:

Patients were seen in a safe environment with a well-maintained building and range of meeting rooms.
Staff understood the safeguarding arrangements.
Staff held manageable caseloads and they kept their mandatory training up-to-date.
The team had minimal significant incidents.
Staff learnt lessons learnt from incidents and measures were put in place to prevent a reoccurrence.
Patients had access to a wide range of therapies and approaches to their mental distress.
Staff worked within national guidance in relation to the treatment of common disorders faced by children and young people.
Patients had access to a multidisciplinary team and there was appropriate interagency working including working with staff on hospital wards and community health staff such as school nurses and health visitors.
Staff had a reasonable understanding of the rules around parental control, the Mental Capacity Act and the Mental Health Act.
We observed positive interactions between staff and their carers and comments from patients and carers were positive.
Managers were developing a patient participation forum.
The service was responsive with waiting times well below the national average and no 18 week waits.
Crisis support was available to children and young people via the hospital emergency department into the evening and during the day at weekends.
Patients with physical disabilities could access the service as there was disabled access into building with level access, a lift and an adapted toilet.
The service had only received one complaint; information on how to complain was readily available.
Staff morale was reported as being good.
There was good leadership with a well-respected local manager who had developed local team objectives.
There were good governance arrangements with oversight of waiting times and other performance data.
A recent audit of care plans had already identified the shortfalls we identified.
Managers were committed to improve the service through new ways of working such as extending the service to work with young people up to the age of 18 and improving children’s health and well-being services across staff working departments in the trust.

However:

Staff were not always completing or updating patients risk management plans. In some cases, staff had not ensured that significant risks posed by patients to themselves or others were reflected.
Staff working with children with mental health needs in vulnerable circumstances had not had periodic ongoing disclosure and barring checks as the trust relied on ongoing self-disclosure.
Care plans were not always fully personalised or holistic and did not always provide sufficient information to inform children, their families and others of the care and treatment received and planned.
Staff did not make always make sure that care records were kept chronologically so it was sometimes difficult to follow the patient’s history and recovery journey.
Staff did not always evidence that care plans were produced with and alongside patients and they did not always capture the patient’s views or their voice. Care plans were not always signed by the patient and/or their carer.
At the time of the inspection, the service was not commissioned to be available to new referrals of patients aged 16+ up to 18, although this was planned to change in April 2018.
The team did not include professionally qualified learning disability nursing staff who specialised in working with children with learning disabilities, which meant that they could not always meet the complex needs of this group.
While managers understood the trust’s vision and values and trust objectives, operational staff did not feel they fully reflected the work that the service did.

Blackpool Teaching Hospitals NHS Foundation Trust is a medium-sized acute trust providing healthcare for the population of Blackpool, Fylde, Wyre and parts of Lancashire and south Cumbria. The indigenous population is around 440,000. However, there is a transient tourist population in excess of 10 million people each year, either on one-day visits or staying for longer periods of time.

The trust serves a population that has mixed health needs. Parts of the population are among the most deprived in England (Blackpool Local Authority is the 10th most deprived of 326 local authorities in England). The population’s health is worse than expected in 23 of the 32 health indicators (for example: life expectancy, alcohol-related admissions, drug misuse, smoking related deaths and early deaths from cancer, stroke and heart disease). However, for the populations of Fylde and Wyre, they are better than expected: 9 of the 32 health indicators are better than the England average.

Within the Blackpool area, life expectancy is five years lower for men and three years lower for women compared to the national average.

In April 2012 the trust merged with community health services from NHS Blackpool and NHS North Lancashire as part of the Transforming Community Services programme. This has created a larger organisation with over 6,000 staff, in excess of 800 beds and an annual spend of approximately £360 million.

The trust provides a range of secondary care services usually found in all main hospitals along with tertiary cardiac surgery for the residents of Lancashire and south Cumbria (with an equivalent population of 1.6 million). The trust also provides some tertiary haemato-oncology services. Additionally, the trust manages the national artificial eye service on behalf of the whole country.

The trust operates from three sites:

Blackpool Victoria, which is the main hospital site
Clifton Hospital, which currently has four wards, mainly for elderly care and rehabilitation (with one outpatient clinic), and
Fleetwood Hospital, which has outpatient clinics with some limited radiology on site.

The trust had a significantly higher than expected mortality rate from April 2012 to March 2013. As a result, the trust was included in Professor Sir Bruce Keogh’s review of trusts in 2013. The report “Review into the Quality of Care & Treatment provided by 14 Hospital Trusts in England” is available on the NHS Choices website. The report found that the pace of change at the trust had been slow, with the trust leadership trying to do too many things at the same time. It said that governance arrangements should be more robust. It also said there was a disconnect between the leadership team and the frontline service. We saw that the trust has put significant effort into developing clinical pathways in a number of areas as part of its response to this report.

During this inspection, we inspected services in A&E, surgery, critical care, medicine, maternity and family planning, children’s care, end of life care and outpatients.

We spoke to a large number (over 100) of patients in all areas, to the families and carers of some of these patients and to visitors to the hospital

We found that the people using the service were highly complimentary about the level of care they received from all of the staff they met.

Mortality

Mortality figures remained higher than expected for the trust, but these figures were falling (improving). The trust has undertaken some significant work on improving and clearly defining the clinical pathways (including steps to be taken at each stage and those staff responsible for doing it)to achieve this, and was monitoring patient care.

Staffing

Staff, were very committed and were making considerable efforts to provide good patient care. The quality of care in the children’s care service was high. The trust had increased levels of medical and nursing staff and this was recognised by staff; allied health professionals, such as physiotherapists and occupational therapists, felt that their staffing had not increased in a way that reflected their contribution patient care.

All the staff we spoke with said they enjoyed their job, liked working for the organisation and valued their role.

Complaints

The complaints process has improved. The newly-named Patient Relations Service has improved this process. However, we have spoken to many people using the service who do not know how to make a complaint, and so we conclude there is still much work to do here.

The trust's target was to respond to formal complaints within 25 days. This target was not always met. However, the divisional management team were working to address this and the number of complaints processed within 25 days had improved since April 2013. Following CQC's review of Outcome 17 in June 2013, the trust had reviewed its complaints process and the new arrangements were being implemented at the time of this CQC hospital inspection

We saw that Patient Relations Service leaflets were available, but these were not always visible in some of the areas we visited.

Leadership

The visibility of the executive team has increased significantly. We spoke to many people who had met (or knew of) many of the executive directors. However, visibility does not equate to engagement, and we did note that there still appears to be a disconnect in some areas between the board and the operational service, particularly among medical staff.

In a number of areas there were differences of opinion between the executive team and the clinical workforce. In part, this may be due to a more positive view of some challenges, but we were concerned that it may also be a symptom of this disconnect.

We were unable to identify a clear vision or strategy to support the new enhanced acute and community trust. We saw that there are considerable opportunities for the new trust to improve. However, this requires a clearly articulated vision.

Service developments

The trust has received external accreditation for its Bowel screening, Trauma unit, Radiology and Haematology (stem cell transplant) services.

The trust uses the palliative care amber care bundle (a process to support the quality of care of patients who are at risk of dying in the next one to two months but may still be receiving active treatment).

We saw examples of excellent integration between acute and community services. The staff we spoke to from the community all praised the method of integration, and they valued the welcome from other colleagues. Staff from both the community and the acute teams explained that the integration had improved their knowledge and understanding of the overall processes. We felt that the work put into the integration of the teams from acute and community had been highly effective and the trust should be proud of its work in this area.

Processes of care

There were challenges in patient flow. We saw that patients were staying for long periods, the trust was reliant on escalation beds and there was limited use additional medical staff. There were opportunities to significantly improve the pathway in this area. This would improve both the experience of the service for patients and could reduce the time they spend in hospital.

We noted that the accident and emergency service is largely meeting the national waiting time target of four hours. However, we did note that this success is down to an increased response within the last hour of the waiting time. This may mean that the systems in use are less efficient and some patients could wait longer than needed in the service.

We saw that cancelled operations had led to ineffective use of resources and challenges to patient flow. This meant that patients were not accessing the treatment and care they needed in a timely manner.

Medical records

There are challenges with medical records that may also interrupt patient flow and impact on safety. It was difficult to find information in the medical records. We noted that an electronic patient record solution is in development, but this may take some time and current challenges require an interim solution. For safe and effective clinical care, patients' medical records need to be easily accessible, legible and simple to follow.

Safety

The trust had a significantly higher rate of primary postpartum haemorrhage (haemorrhage after childbirth) and this had led to some patients having a hysterectomy. Good practice guidelines on access to interventional radiology by the Royal College of Obstetricians and Gynaecologists (RCOG) were not followed and the trust has requested a review by the RCOG at the time of our inspection. This was a significant safety issue which the trust had not identified to us at the outset.

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.

All Inspections

Mortality

Staffing

Complaints

Leadership

Service developments

Processes of care

Medical records

Safety