Archived: Weston General Hospital

Updated 17 December 2019

Weston Area Health NHS Trust provides a wide range of acute and rehabilitation hospital services, as well as some community health services primarily to residents of the North Somerset area. It serves a resident population of around 212,000 people in North Somerset with over 70% of people living in the four main towns of Weston, Clevedon, Portishead and Nailsea. A further 3.3 million day-trippers and 375,000 staying visitors increase this base population each year.

The trust provides clinical services from three sites. The main site, Weston General Hospital, is located close to the town of Weston-super-Mare. There are two children’s centres providing community children’s services located in Weston-super-Mare and Clevedon.

Updated 17 December 2019

Our rating of these services stayed the same. We rated them as requires improvement because:

• There remained issues with nursing and medical staffing which did not ensure safe care at all times in the emergency department, medical care wards and the children and adolescent mental health services. The trust provided mandatory training in key skills to all staff; however, they did not make sure everyone completed it. In medical care and surgery we found the services did not always follow best practice when prescribing, giving, recording and storing medicines. Patients did not always receive the right medication at the right dose at the right time. We also found the process for supplying medicines for patient discharge in the discharge lounge could cause delays.
• There was a higher than expected risk of readmission for patients discharged after care and treatment in general medicine, gastroenterology, stroke medicine and geriatric medicine. We also found there were difficulties in identifying patients who were re-admitted with a surgical site infection. In the emergency department we found the service monitored the effectiveness of care and treatment but there was no effective system to report on results and limited substantial evidence to show that the service had taken action in response to poor outcomes.
• The trust tried to plan and provide services in a way that met the needs of local people, however they were restricted by the uncertainty of its future. Patients did not always have timely access to initial assessment, diagnosis or urgent treatment, and the people with the most urgent needs did not always have their care and treatment prioritised. We found the emergency department was frequently crowded; patients were cared for in non-clinical areas and some were accommodated overnight, without access to suitable bathroom facilities.
• Managers for the emergency care division, which included urgent and emergency care and medical care, had the abilities but did not always use the right skills to run a service providing high-quality, sustainable care. Some staff told us they felt undervalued by service leads. The service did not have effective governance systems to provide assurance of quality and safety. We also found there were compatibility issues with IT systems across the trust.

However,

• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. In medical care and surgery, we saw the services used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors. Managers used this to improve the service. The trust controlled infection risk well.
• Patients had enough food and drink to meet their needs and improve their health and provided health promotion information for patients to support them to manage their conditions and health choices. Staff also assessed and monitored patients regularly to see if they were in pain.
• Staff were kind and caring to their patients. The patients we spoke with were largely positive about the compassion and kindness of staff, and their dedication to giving good care, and we observed patients being treated with care and respect throughout their stay in hospital. In the child and adolescent mental health service young people could have open discussions about their personal, cultural, social and religious needs with staff, as they knew staff would respect their wishes and help meet their needs.
• The trust treated complaints seriously, investigated them, learned lessons from the results and shared these with all staff, although they did not always meet the deadlines to deal with complaints.
• In surgery we found the surgical leadership were clear about their roles and understood the challenges faced by the service. There were governance processes and oversight in the surgical division.

Updated 26 June 2019

Some domains had improved but the overall rating of this service stayed the same. We rated it as requires improvement because:

Medicines management needed improving. We found medicines had not been stored according to best practice guidelines and some had no expiry dates on them. Some patients had their medication delayed or missed when waiting in the discharge lounge. Medicines for discharge of patients in the discharge lounge could be delayed due to a lack of registered staff available to provide and explain medicines to patients.

There were not enough nursing and therapy staff to always safely care for patients and staff did not always follow trust policies when caring for patients. Acutely unwell patients did not always receive the appropriate level of monitoring.

Not all staff had attended mandatory training.

Service leads did not always use the best methods of engaging staff and inviting opinion. Some staff felt inhibited, undervalued and unsupported by senior managers.

Most staff felt they could raise concerns but were doubtful that any actions would result.

However,

Records were kept in an organised way and staff had completed risk assessments for patients. These were transferred to care plans for staff to follow.

Staff were knowledgeable about safeguarding procedures and knew how to access support if they needed it.

Most staff were knowledgeable about what incidents to report. We found some staff were not clear about what they reported as an incident but incidents which were reported were investigated fully and improvement actions were identified. Staff used safety monitoring and audit results to inform their practice and make improvements. National standards and guidelines informed their practice and policies were developed using this information.

There was a strong ethos of team working and staff enjoyed working in the trust. Staff up to and including matron level, supported each other and were respectful in their contacts.

Matrons and ward managers supported their staff well and all staff felt they could approach any manager at this level.

Service leads used processes to provide an oversight of how staff were performing and outcomes for patients.

Staff were aware of individual needs of patients and developed systems to meet those needs wherever possible. This included patients with learning disabilities, mental health needs and dementia.

Specialist staff connected with staff in the community to create a smooth pathway of care for patients with ongoing needs.

Updated 26 August 2015

Services for children and young people were judged to be good overall.

The caring and of the service was rated as outstanding, and safety, effectiveness, responsiveness and leadership were rated as good. Treatment and care were delivered in accordance with best practice and recognised national guidelines. Children and young people were at the centre of the service and the priority for staff. Innovation, high performance and the highest quality of care were encouraged and acknowledged.

Children, young people and their families were respected and valued as individuals. Feedback from those who used the service had been exceptionally positive. Staff went above and beyond their usual duties to ensure children and young people received compassionate care. Children received excellent care from dedicated, caring and well trained staff who were skilled in working and communicating with children, young people and their families.

The leadership and culture of the unit drove improvement and the delivery of high-quality individual care.

All staff were committed to children, young people and their families and to their colleagues. There were high levels of staff satisfaction with staff saying they were proud of the unit as a place to work. They spoke highly of the culture and levels of engagement.

There was a good track record of lessons learnt and improvements when things went wrong. This was supported by staff working in an open and honest culture with a desire to get things right.

The unit was clean and well organised and suitable for children and young people. Staff adhered to infection prevention and control policies and protocols.

Updated 14 June 2017

We rated the service overall as good because:

• The care and treatment delivered, and the practices and protocols around them were safe.
• There was a strong culture around delivering safe care.
• People were protected from abuse and avoidable harm.
• Care was effective and patients had the outcomes that should be expected.
• Staff were well trained and experienced at delivering care.
• Staff were caring, compassionate, and treated patients as individuals.
• The services met the needs of vulnerable people, and those with specific mental and physical needs.
• There were good assurance frameworks to demonstrate how the quality and safety of care was reviewed and understood.
• There was a good culture of staff and patient involvement in the unit.
• There had been patient-focused improvements in the unit from the committed staff team.

However:

• With a high mortality rate at this trust, the service was not demonstrating learning from reviews into patient deaths.
• There were problems with patient flow in the rest of the hospital and this was affecting the ability to admit, transfer, and discharge patients in critical care at the right time.
• There was a lack of multidisciplinary or a collective approach to the leadership and management of the critical care unit.

Updated 26 August 2015

Overall we rated the end of life service provided by the trust as good.

Following the withdrawal of the Liverpool Care Pathway the trust had developed its own policies and strategies around delivering care consistent with the latest nationally agreed guidance. The team have developed a range of tools to support these objectives. This included individualised end of life care plans which included new documentation such as symptom based observation charts. Better information for patients and relatives had been developed and action taken to get improved feedback from bereaved relatives. There was a hospital Specialist Palliative Care Team (SPCT) that supported staff on the wards by responding to referrals. They also provided some training.

There was an improvement plan and strategy in place for end of life services and leadership was provided on this. Members of the specialist palliative care team were clear about their objectives of their services, where improvements needed to be made and were well respected throughout the hospital. Staff were positive about the responsiveness of the team to referrals and the quality of advice and support that was provided.

We found there was inconsistency in the completion of the documentation relating to end of life patients. In some patient records there was limited recording of personalised care plans and little or no recording of spiritual needs. We found that not all ward staff were fully familiar with requirements of recording a patients end of life wishes. A new format was being implemented across the trust which was being positively received by staff but there were sections of the new documentation that were not being fully completed. There was also inconsistent knowledge amongst staff about the process and use for advanced care planning for patients who had life limiting illnesses but were not expected to die within the next few days. There was insufficient understanding on the wards that “end of life” includes those expected to die in the next twelve months, and so these patients were not being well identified or their needs assessed.

There was a problem for some patients of delayed discharge of, up to six weeks in some cases. Whilst the hospital staff were efficient in processing and preparing patients for discharge, problems with local provision of care packages caused delays. This meant that some patients died in hospital when their preferred location would have been home.

There were occasions when patients receiving end of life care were moved within the hospital and died shortly afterwards. These were the result of the pressures of high bed occupancy and the so called “black” escalation as result of the pressure of admissions through the emergency department. Staff tried to ensure that no patient died alone but we told that there were times when this had happened due to the pressure of work the ward staff were under.

Whilst many staff demonstrated they had excellent understanding of the aims, objectives and principles of end of life care, training for this area was no longer mandatory.

The specialist palliative care team provided input on the junior doctors course and also attempted to provide short “bite size” training for staff on the wards. On several of the ward there were nurse “end of life champions” who provided advice and support but the training they had completed was run three years previously and was not currently planned to be repeated.

There were many examples of excellent professional multi-disciplinary working with staff exchanging information and providing advice and support. The chaplaincy service was well organised and included in the palliative care multi-disciplinary team meetings. However we found that the expertise of the service was not fully utilised within the hospital and there was a lack of clarity for some staff around the role of the service and the defining of a patients spiritual needs.

Updated 26 August 2015

Overall we have judged safety, responsive, effective, caring and well-led to be good for maternity and gynaecology services. Patients’ and relatives’ feedback was positive regarding all care and treatment. Patients said they were consulted and involved with their care. We saw discussions of consultations and records of the patient’s choices and preferences documented in records.

Midwives followed comprehensive risk assessment processes from the initial booking appointment through to post natal care. There were clear escalation policies which were followed and all care was provided in line with national guidance and policy. The centre worked closely with St Michaels Hospital, Bristol which received the majority women with high risk pregnancies. The Head of Midwifery managed both services but was based at Bristol.

The national recommended ratio of Supervisor of Midwives (SoM) to midwives is 1:15, and this was not being achieved (Midwifery Rules and Standards, rule 12, Nursing and Midwifery Council, 2014). The ratio of SoM to midwives at Weston General Hospital was 1:21. This was due to SoM caseloads being shared between Weston General Hospital and St Michaels Hospital, Bristol. Three additional SoM were being trained.

During January 2015 Ashcombe Birth Centre was closed for three days, and the 10 post natal beds were used by medical patients for a further seven days. This was in response to intense trust wide service pressures. The beds were redeployed to medical patients during this time.

There was good communication between the medical and nursing staff, and maternity support workers. Team working was described as effective and good. The ratio of supervisors to midwives (SoM) did not meet recommended guidelines but plans were in place to address this. There were comprehensive risk, quality and governance structures in place. There was evidence to show incidents were interrogated for service improvements and systems were in place to share information and learning. Midwives said they were positively supported and there was a good and open culture.

Gynaecology was a small consultant led service; the majority of treatments provided were for hysterectomy and diagnostic procedures. There had been one never event for wrong site surgery during June 2014. This had been investigated and subsequent actions and learning put in place. Audit processes during 2014, had identified the service had not been compliant with regulations to submit termination notifications to the Department of Health. This had resulted from an administration staffing review. New procedures and staff training had been put in place.

Updated 17 December 2019

• Managers had ensured the service was fully recruited to, promoting optimal capacity of the team. Temporary staff had also been recruited to support with reducing the waiting times for people on the waiting list. The time young people were waiting between assessment and referral had reduced.

• The risk of people on the waiting list was monitored by staff and managers maintained oversight of this. Care records contained clear and comprehensive risk assessments, and risk management plans were present where required. Managers had delivered specific training on care records and risk assessments.

• We were assured sufficient priority and resources had been allocated by the trust to address issues around paper care records.

• The trust had recruited a clinical nurse lead to govern and maintain oversight of clinical activity within the team.

• Managers had good oversight of incidents that had occurred and were able to give us examples of how practise may be changed to prevent repeated incidents reoccurring.

• Managers had developed process and policies to ensure the service was managing risk appropriately. Governance structures were in place to monitor the key areas of the service to identify risk. Managers were actively reviewing the service to develop ways of improving efficacy and quality of service delivery.

• Managers maintained oversight of the performance, quality, safety and efficiency of the service.

However:

• Although the risk of people on the waiting list was being monitored, staff had concerns about the process by which this was being completed.

• The use of paper care records continued to cause risk.

• Although managers had started to implement governance structures to review the quality of the service, they were not yet fully embedded to enable us to evidence their effectiveness.

Updated 26 August 2015

We rated outpatient and diagnostic imaging services as good in the safety, caring and well led domains. We rated the responsive domain as requiring improvement. We have reported on the effectiveness of outpatients and diagnostic imaging services. However, we are not currently confident that, overall, CQC is able to collect enough evidence to give a rating for effectiveness in the outpatients department.

Patients found staff to be friendly, professional and caring and were happy with the outpatients and imaging services provided by the hospital. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. There was learning from incidents and this led to improvements in patient safety.

There was participation in relevant local and national audits, including clinical audits and other monitoring activities such as reviews of services, benchmarking and service accreditation. Information about effectiveness was shared and was understood by staff. It was used to improve care and treatment and people’s outcomes. Staff had the skills they needed to carry out their roles effectively and in line with best practice. They were supported to maintain and further develop their professional skills and experience.

We observed people being treated with dignity, respect and kindness throughout our inspection. Staff anticipated people’s needs and addressed them in a compassionate manner. People’s privacy and confidentiality was respected at all times. Waiting times and delays were kept to a minimum and managed appropriately.

Appointment cancellations were high but the department did not monitor this and as such the reasons for this were not understood.

Most services ran on time and patients were kept informed of any disruption to their appointments. The leadership of the outpatients and imaging departments promoted safe, high quality, compassionate care. They encouraged cooperative, supportive relationships among staff so that they felt respected, valued and supported.

Updated 26 June 2019

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

• Safe care was being provided in many areas of the surgical service. Staff understood how to protect patients from abuse. Patient risk was well considered and there were clear processes for escalation and support should a patient deteriorate. The world health organisation’s five steps to safer surgery was observed to be completed well and was embedded in practice. Patient safety incidents and patient safety performance was monitored, managed and learning identified to make improvements to the service.

• There was effective care within the surgical service. Care and treatment were based on national guidance and evidence of its effectiveness. The effectiveness of care and treatment was monitored, and the trust were generally performing similar when compared to other trusts. Patient’s nutrition, hydration and pain was well managed. Teams worked well together to deliver care which benefitted the patient.

• The care provided to patients was done so with compassion, dignity and respect. Patients spoken with were largely positive about the dedication and kindness of staff. Staff provided emotional support to patients when needed and involved them in decisions about care and treatment.

• Although responsiveness requires improvement, the service was restricted by the future plans for the trust and thus for the surgical service. Theatre productivity was a priority for the transformation team and was reviewed regularly. Patients had access to the service when they needed it for planned and emergency surgery. There were strict guidelines to minimise cancellations for patients, particularly patients with cancer. The trust had learnt from the problems identified in the previous year and had arranged for additional bed capacity to support when the day surgery unit was used for escalation for inpatients.

• The surgical leadership team were clear about their roles and understood the challenges for the service, although the vision and strategy were once again impacted by the trust’s future. There was a positive culture observed. Governance processes were established, and staff were clear about their responsibilities within this. There were effective systems for identifying risks and risk were well understood by staff and leaders.

  However,

• In some area’s safety could be improved and brought in line with best practice. Mandatory training compliance for medical staff was not meeting trust targets and there were inaccuracies with reporting of this data. Medicines were not always managed appropriately, to include storage and medicines reconciliations. Staffing was challenged although being managed to keep patients safe. However, there were concerns from the junior doctors with the processes to support urology patients overnight and at weekends, which require further review and resolution.

• There were a few areas which would help to improve the effectiveness of the service. Appraisals needed further focus to enable them to meet trust targets for all staff groups. Consideration could also be given to patients being re-admitted to hospital with a surgical site infection and how this is identified to allow investigation.

• Responsive was rated as requires improvement. The responsiveness of the service was impacted by the theatres not being fully utilised as there were not enough surgeons to run theatre lists. Data provided from the trust also showed late starts in theatre were occurring frequently, and patients were not always discharged from recovery in a timely manner. Some environments could also be improved to include the day surgery unit and the theatre receiving unit, both of which were limited by their environment but being managed by the teams.

• The leadership team had undergone frequent changes with interim arrangements, which made it difficult for consistency across the surgical directorate. We found although risks were well understood and identified, the risk registers did not have clear actions to see a trail of the management of risks. There were also compatibility issues with IT systems used across the surgical service.

Updated 17 December 2019

• Governance systems were still not operating effectively. We had limited assurance that the main governance forum in the emergency department provided good oversight of quality and risk at departmental, directorate or trust level, in order to support informed decision-making. The risk register was not up to date and was not an effective tool to manage risks or provide assurance that controls were effective. Incident management had improved and serious incidents were investigated and acted upon within appropriate timescales. However, there remained a significant backlog of other incidents and actions arising from incidents.

• Although junior doctors were mainly positive about the support and supervision they received from senior medical staff, some still told us that the quality of supervision was variable depending on which consultant was in charge. Concerns were expressed about a lack of support and supervision at weekends. Middle grade doctors were unhappy about a lack of teaching and educational opportunities and a number of staff had left or were considering leaving for these reasons.

• There was limited assurance that the nursing workforce had the skills and experience to provide safe care and treatment. A training needs analysis was underway but this still showed numerous training gaps. Training sessions were being provided but these were ad hoc and did not form part of a coordinated and structured training plan. There was still no structured or formal system of nurse supervision, although some progress had been made in identifying teams to be led by senior nurses.

• Overall, the service has made good progress in addressing concerns; however, changes were not fully rolled out or embedded and progress was limited by management capacity. This was in the context of a service experiencing intense pressure due to increasing demand for services, poor patient flow in the hospital and continuing staff shortages.

However:

• Governance systems, meetings structures and terms of reference had been reviewed and a new governance lead had been appointed.

• The service had done a lot of work to address our concerns with regard to nurse supervision and training. A competency framework had been developed, a training needs assessment was underway, and a practice education nurse had recently been appointed. There had been a concerted effort to ensure all staff were trained in non-invasive ventilation.

• The service had introduced a quality improvement/training forum, where mortality and morbidity reviews took place and audits were presented.

• There was a programme of clinical audit and a review of clinical guidelines was underway. Action plans had been developed following national audits and there was evidence of actions being progressed.

• The service had identified mentors from a neighbouring trust to support senior medical staff to develop leadership and supervisory skills.